Large HMO Cited in Mental Health Care Cover-up

Nancy A. Melville

April 03, 2013

California's Department of Managed Health Care (DMHC) has cited Kaiser Permanente for using a deceptive dual record-keeping system to cover up violations of the state's "timely access" law, which restricts the amount of time mental health patients should have to wait for an appointment, as well as for other violations.

In a report filed last month, the DMHC concludes that many Kaiser mental health patients faced extensive waiting periods for appointments, well beyond the 10 days for a regular appointment that the law requires.

The health maintenance organization's (HMO's) official electronic medical record (EMR) system showed no such violations, but a parallel set of paper appointment records that were kept by the organization differed, showing more details on the appointment history, according to the report.

Specifically, when a mental health patient requested an appointment and no slots were available, patients were placed on waiting lists on paper or were requested to call back when the next window to book appointments opened, but no electronic record of contact was established.

The patient contact was only recorded in the EMR system when the patient called back and was finally able to make an appointment, resulting in an inaccurate record that did not reflect the enrollee's initial request or the true waiting period, according to the DMHC.

"These are definitely serious matters," Shelley Rouillard, the DMHC's chief deputy director, told Medscape Medical News.

"The department's primary concern is that the enrollees get the care they need, when they need it, and in a timely way in accordance with the law, and clearly Kaiser was having problems in this area," she said.

Potential for Substantial Harm

In addition to the timely access violations, the DMHC concluded that Kaiser had provided its members with "inaccurate educational materials" that suggested limits on mental health coverage that violated state and federal mental health parity laws.

"The Plan's failure to provide consistent and effective health education services, as shown in the inaccurate materials distributed to enrollees, may have discouraged some enrollees from seeking and accessing medically necessary behavioral health services," the DMHC wrote.

Kaiser was informed of the complaints in 2012, but the DMHC said a follow-up showed that adequate corrections had not been made. The violations have been referred to the department's enforcement division.

"This is an unusual step to take in terms of immediate enforcement action," Rouillard noted.

 
We often find issues that require corrective action, but in this case, we felt that because there was a potential for substantial harm to beneficiaries who weren't able to get in to see a mental health provider in a timely way, and because some of the materials Kaiser was putting out in terms of health services were misleading, that this was serious enough for us to take immediate action. Shelley Rouillard
 

"We often find issues that require corrective action, but in this case, we felt that because there was a potential for substantial harm to beneficiaries who weren't able to get in to see a mental health provider in a timely way, and because some of the materials Kaiser was putting out in terms of health services were misleading, that this was serious enough for us to take immediate action."

Clinician Whistle-blowers

The violations were discovered through a standard survey or evaluation process that the DMHC uses to review compliance by all California health plans.

After the review was underway, complaints regarding timely access violations were brought forward by a group of Kaiser Permanente's own mental health clinicians, who were represented by the National Union of Healthcare Workers (NUHW). Those complaints were considered and incorporated in the evaluation, Rouillard said.

Among the psychologists lodging complaints was Andris Skuja, PhD, who said the violations had been observed for years before the clinicians referred their concerns to the DMHC.

"Over a number of years, we tried many internal mechanisms with Kaiser to address some mounting concerns we had about the adequacy of treatment," Dr. Skuja told Medscape Medical News.

 
We weren't able to do work on what would be considered a best practices basis, and the bottom line was we had to go to the DMHC to protect patients because Kaiser wouldn't. Dr. Andris Skuja
 

"We weren't able to do work on what would be considered a best practices basis, and the bottom line was we had to go to the DMHC to protect patients because Kaiser wouldn't."

At issue are the mental health needs of patients that, in some cases, may be dire, Dr. Skuja added.

"For some patients, waiting a few more weeks or longer for an appointment may be fine, but for others, the need for sooner care may be crucial," he said.

"Their lives may be unraveling, and it's affecting their job, their relationships, and their health, and it was heartbreaking to see that people weren't getting the care they needed in a timely way."

Kaiser Responds

In a statement provided to Medscape Medical News, Kaiser Permanente agreed that the DMHC report "did identify some areas where initial nonurgent appointment wait times and data tracking need to improve."

The organization asserted that the use of paper records was not a deliberate attempt to be deceptive.

"We informed the DMHC (in the review) that a small number of facilities used paper waiting lists or requested a member to call back when the next window to book appointments opened, by staff who were trying to accommodate patients' wishes, not manipulate data."

"We respect the DMHC and their survey process, and we take these findings seriously," the company added.

 
We had a full and frank discussion with the DMHC, and we agree with the DMHC that we need to reduce wait times and improve our monitoring of wait times for these appointments. Kaiser Permanente
 

"We had a full and frank discussion with the DMHC, and we agree with the DMHC that we need to reduce wait times and improve our monitoring of wait times for these appointments."

Kaiser addressed the fact that some of the harshest criticism of the company's practices and DMHC violations has come from the NUHW.

"NUHW's generalizing allegations are inaccurate and distort the reality of mental health services we provide our members," the company said in its statement.

"While we are making progress in hiring new providers where they are needed, we have also proposed to NUHW a number of other positive solutions to improve our members' access and experience, such as scheduling, intake, or assignment changes at the departmental level. Unfortunately, NUHW has thus far blocked or refused to work with us on many such proposals."

Kaiser added that "it is important to note that Kaiser Permanente is currently in extended and ongoing contract negotiations with NUHW. Also, NUHW and Service Employees International Union–United Healthcare Workers (SEIU-UHW) have a statewide election next month."

Need for Stronger Sanctions

Union disputes notwithstanding, the fact that the violations were reported by clinicians themselves is nevertheless important, because patients — particularly mental health patients — simply may not be in a position to complain, or to complain in large enough numbers to matter, said Randall Hagar, director of government relations for the California Psychiatric Association.

 
Someone with severe depression or anxiety or even a psychotic disorder is just not going to have the motivation to complain about a wait for an appointment. Randall Hagar
 

"Someone with severe depression or anxiety or even a psychotic disorder is just not going to have the motivation to complain about a wait for an appointment," he told Medscape Medical News.

"They will possibly be afraid of retaliation and the stigma."

Instead of complaining or pushing the issue, some patients may simply wind up in the emergency department.

"We do know there has been a huge increase in the number of mental health patients using the emergency room in recent years, and my suspicion is it's because people can't get the right kind of care up front," Hagar said.

Although Kaiser may face fines for the violations, Hagar notes that such punishments often are not enough to motivate any meaningful action.

"Advocates for improvement say that it is typically cheaper for the plans to continue to violate than to provide the services, because the fines are just not adequate," he said.

"I think most psychiatrists would agree that we need to have more teeth in our enforcement and fines," Hagar added. "If it could be made more expensive for them to commit these violations, I believe you'd see fewer of them."

Better monitoring of violations is also essential, he said.

"What we need are better mechanisms to bring these matters to people's attention sooner."

The issue comes down to the basic responsibility care providers have in getting patients the care they need, when they need it, said Jo Linder-Crow, PhD, chief executive officer of the California Psychological Association.

"In general, when people are in crisis and reaching out for help, there is a standard of care, and you want to provide that care, if it's therapy for example, in a timely manner. Access to care and timely care is something all of us care about," she told Medscape Medical News.

"We certainly hope the DMHC will take care of this for the benefit of patients."

None of the sources quoted have disclosed any relevant financial relationships.

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