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Commentary Regarding the DMHC 2017 Survey and Report of Kaiser Permanente

The California Department of Managed Health Care has released the Final Report Routine Survey of Kaiser Foundation Health Plan, Inc. A Full Service Health Plan.  It is not favorable.

Very few news articles have been written about this report.  See: http://www.pressdemocrat.com/news/7164140-181/state-regulators-once-again-critical

Fewer press releases have made their way to the public.  So unless someone in the public is looking for it, they probably will not ever know it exists.  Unfortunately for patients this could jeopardize their health.

The California Department of Managed Health Care requested that Kaiser Plan submit information regarding its health care delivery system for both full service and behavioral health services.  The DMHC survey team conducted their onsite survey for Southern California from May 16, 2016 through May 20, 2016 and again on March 30, 2017.   The Northern California onsite survey was conducted June 20, 2016 through June 24, 2016.  As per page 3 of this report: “While onsite the Department reviewed plan documents and files for both full service and behavioral health services.

For the Full Service survey, the Department’s review period for files was from March 1, 2014 through January 15, 2016. For the Behavioral Health survey, the Department’s review period for files was from December 1, 2014 through January 1, 2015. “ (DMHC Kaiser Survey 2017) 

The bulk of the 2017 report focuses on the chronic problem of Kaiser Behavioral Health Issues which was early on brought to the attention of the media by the NUHW union.  (1)(2)(3)  On February 24, 2015, the Los Angeles Times published an article stating “ For the second time in two years, California regulators slammed HMO giant Kaiser Permanente for causing mental health patients, including some who were severely depressed or suicidal, to endure long delays for treatment. The state Department of Managed Health Care said in a report Tuesday (clarification, year - 2015) that some Kaiser patients continue to wait weeks to see therapists and psychiatrists. The agency also criticized Kaiser for giving patients misleading information about the extent of their mental health coverage.” The article concludes with”: The report was a follow-up to a 2013 survey that found four major deficiencies in Kaiser's handling of mental health patients. The agency fined Kaiser $4 million that year and ordered it to improve its performance. “(4)

The fine did not seem to have much effect in modifying the negative but potentially financially lucrative Kaiser Permanente Behavioral Health Division Business Practices which have historically gone on for well over two decades.

An article by the Press Democrat states “.....less than a year after the California Department of Managed Health Care, or DMHC, levied a $4 million fine against Kaiser for what it termed serious deficiencies in providing timely access to mental health services. It was the second-largest fine in the history of the regulatory agency, which was created in 2000.

Following a routine survey conducted in the first half of 2012, state regulators found that Kaiser was not accurately tracking patients' access to the HMO's therapists. The agency also said Kaiser could not ensure that patients were offered timely initial appointments with therapists for non-urgent matters, in violation of state regulations.”  (5)

On March 14, 2014, Courthouse News provided an article: Kaiser illegally fails to treat serious mental illness on par with treatment for physical illness, a class claims in a lawsuit filed last week. (6)

On Oct 2, 2013 a Class Action suit was filed against Kaiser in Alameda County, California.  
Case RG13697775 - denied access to mental health services, dissuaded from pursuing mental health services, provided with delayed access to mental health services and/or provided with inaccurate and confusing information from Kaiser regarding mental health services available  (7)

In 2004 a report on a Kaiser Behavioral Health survey was prepared by Russell Holstein, PhD.  Holstein conducted a survey of  Kaiser behavioral health facilities throughout the various areas where Kaiser was then in operation.  One psychiatrist from the Southern California Regional Office  “advised that the survey would reveal that like any HMO, Kaiser was an “overburdened system.”  

Dr. Holstein suggests that “Kaiser attempts to look good by offering virtually no waiting list for new appointments. However, Kaiser comes off exceptionally badly, even as compared to other managed care plans, in the way they overburden the treating clinicians with new cases. The requirement that therapists have to handle seven or more new intakes per week makes weekly psychotherapy, other than group, a virtual impossibility. As each treating psychologist is expected to integrate seven or eight new patients into their case loads, the statement by one of the Northern California respondents that, “Kaiser treating clinicians are more like greeters than treaters” makes sense. “  Holstein continues with the  “clean survey was sabotaged. Administrators did not provide access to intake or treating clinicians so the survey could be done.

The clinicians who did answer the questions raised serious concerns about under treating and poor accessibility to individual psychotherapy. Because of this, it is reasonable to assume that Kaiser is withholding information about its policies. This assumption is given more credibility in light of the report by union officials following the Colorado job action in 1998 that clinicians were gagged to talk about certain Kaiser policies (Miller, personal communication). As it became clear the only way to do this survey at most Kaiser facilities would be with a Court Order requiring clinicians to answer truthfully and a Gag Order on administrative and public relations personnel “ 

He also states in this report “Kaiser has a philosophy of wanting their clinicians to relate to patients in a way that generates the greatest satisfaction with services, rather than the greatest benefit to the patient. This leads to the cynical conclusion that Kaiser Permanente is committed to providing less than the standard of care but in a way that “cools the mark out.” (Goffman, 1952) This phrase has to do with con artistry. It relates to how to deal with a person who has been the victim of a con so as to calm them and make them less incendiary, perhaps even appreciative. This is a notion that should chill any clinician who has concern about providing adequate services to patients. And with this, there is one significant question that needs clarification. How is it that a large facility such as Kaiser does not create significant clinician outrage at their being required to offer phantom services? “ 

Furthermore, Dr. Holstein goes on to say in the report section titled: “Does Kaiser Violate the Law?
Kaiser Permanente walks a very fine line with regard to violation of law. While there is a clear violation of morality by not offering services Kaiser patients need, the question as to whether they violate the law probably will not get addressed by regulators. This is despite the fact Kaiser indicates in its plan documents that individual psychotherapy of up to 20 or more visits a year is something patients are entitled to. The failure to actually provide individual psychotherapy does not get Kaiser within the purview of State regulators. The main reason for this is clear. State regulators receive complaints from health consumers. Yet, mental health consumers are probably the least likely individuals to complain about the inadequacies of mental health care, so these concerns fail to come to the attention of regulators.“(8)

Finally, The following is from "Nicholas A. Cummings Collected Papers Vol. I" - Pages 128 - 129
Note:  Nicolas A. Cummings led the Behavioral Health Division and worked it into a money making enterprise.  He also is the person that made sure psychiatric services were provided by HMO's. That sounds good doesn't it?  Read the following to learn the motives behind the actions:

The Beginning of the Kaiser Permanente
Mental Health Benefit

"Kaiser Permanente soon found, to its dismay, that once a health system makes it easy and free to see a physician, there occurs an alarming inundation of medical utilization by seemingly physically health persons.  In private practice the physician's fee has served as a partial deterrent to over-utilization, until the recent growth of third party payment for health care services.  The financial base at Kaiser Permanente is one of per capitation, and neither the physician nor the Health Plan derives an additional fee for seeing the patient.  Rather than becoming wealthy from imagined physical ills, the system could be bankrupted by what was regarded as abuse by the hypochondriac.

Early in its history, Kaiser Permanente added psychotherapy to its list of services, first on a courtesy reduced fee of five dollars per visit and eventually as a prepaid benefit.  This was initially motivated not by a belief in the efficacy of psychotherapy, but by the urgent need to get the so-called hypochondriac out of the doctor's office.  From this initial perception of mental health as a dumping ground for bothersome patients, twenty years of research has led to the conclusion that no comprehensive prepaid health system can survive that does not provide a psychotherapy benefit.

Early investigations confirmed physicians fears they were being inundated, for it was found that 60% of all visits were by patients who had nothing physically wrong with them.  Add to this the medical visits by patients whose physical illnesses are stress related (peptic ulcer, ulcerative colitis, hypertension, etc.), and the total approaches a staggering 80 to 90% of all physician visits. Surprisingly as these findings were 25 years ago, nationally accepted estimates today range from 50 to 80% (Shapiro, 1971)  Interestingly, over 2,000 years ago Galen pointed out that 60% of all persons visiting a doctor suffered from symptoms that were caused emotionally, rather than physically (Shapiro, 1971). (9)

It would do the Administrators of the California Department of Managed Health Care great good to read the above cited volume written by Nicolas A Cummings as well as reviewing the published material from decades of offenses against patients specific to the Kaiser Permanente Behavioral Health Program.  Cummings stated that 60% of patients did indeed have nothing physically wrong with them, that the majority of their complaints are emotionally based.  Other authors have produced higher numbers. Those patients need Behavioral Health assistance if they so chose and to promise patients that such care will be provided for when it will not be is immoral.   Those patients with physical Behavioral Health issues certainly also need care in a timely manner.

The 2017 DMHC Survey of Kaiser (10) is well written, well documented and sourced.  This information is clearly presented for public viewing without identifying any specific patients.  DMHC has done a good job of putting this together.  This time, after decades of patient abuse, DMHC must, not should, but must find an adequate punishment so that Kaiser thinks more than twice about continuing such behavior.  Certainly a fine more than the cost of doing business would be appropriate.  Restitution to famlies who have lost loved ones or have suffered serious problems due to the Kaiser lack of promised Behavioral Health Care would also be appropriate.  

The other issues within this report truly should be presented in a separate report because of the attention given to the Behavioral Health Division.  To do otherwise takes away from the seriousness of the other problems and makes it difficult for members of the public to locate other information that they may be concerned with.

The Response to this Survey from Kaiser is as expected.  (11)


Sources:

(1)  May 13, 2015.   Union Protests Kaiser's Firing of Whistleblower
 http://oldarchives.courthousenews.com/2015/05/13/union-protests-kaisers-firing-of-whistleblower.htm

(2)  May 14, 2015.  Union Accuses Kaiser of Firing Whistleblowing Psychologist
 https://archives.sfweekly.com/thesnitch/2015/05/14/union-accuses-kaiser-of-firing-whistleblowing-psychologist

(3) Sep 16, 2016.   Kaiser continues to increase number of mental health workers
http://www.mercurynews.com/2015/09/17/kaiser-continues-to-increase-number-of-mental-health-workers/

(4) Feb 24, 2015.  California again slams Kaiser for delays in mental health treatment
http://www.latimes.com/business/la-fi-kaiser-mental-health-20150225-story.html

(5) June 14, 2014.  Kaiser's mental health care at heart of dispute
 http://www.pressdemocrat.com/csp/mediapool/sites/PressDemocrat/News/story.csp?cid=2371274&sid=555&fid=181#page=1

(6) Mar 31, 2014 - Kaiser’s Psych Care Pushed Patient to Sue
http://www.courthousenews.com/Kaisers-Psych-Care-Pushed-Patient-to-Sue/
http://www.courthousenews.com/2014/03/31/dion

(7) October 2, 2013 .  California Class Action Case RG13697775
http://legalstuff.kaiserpapers.org/pdfs/Futterman-v-KFHP.pdf

(8) 2004, TRIAGE AS TREATMENT - Phantom Mental Health Services At Kaiser-Permanente
http://behavioral.kaiserpapers.org/phantom-mental-health-services-at-kaiser-permanente.html

(9) "Nicholas A. Cummings Collected Papers Vol. I" - Pages 128 – 129
https://www.ebay.com/i/222496068699?chn=ps&dispItem=1
https://books.google.com/books?id=nozE2JQku_sC&pg=PR14&lpg=PR14&dq=Nicholas+A.+
Cummings+Collected+Papers+Vol.+I&source=bl&ots=mb2tNKbGCr&sig=hNjLD3SBkAkDR5YSW8RKrvnk0kE&hl=
en&sa=X&ved=0ahUKEwjozonx7PPUAhUBU2MKHdcAATkQ6AEIMjAD#v=onepage&q=Nicholas%20A.%
20Cummings%20Collected%20Papers%20Vol.%20I&f=false


(10) DMHC June 12, 2017 Survey of Kaiser - https://www.dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/055_r_full%20service-behavioral%20health_061217.pdf

(11) Kaiser's Response to the DMHC 2017 Kaiser Survey
http://dmhc.ca.gov/desktopmodules/dmhc/medsurveys/surveys/055_r_full%20service-behavioral%20health_pr_061217.pdf




 

















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