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How a large health organization addresses high demand

December 22, 2014
by Julie Miller, Editor in Chief
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In California, the National Union of Healthcare Workers has outspokenly complained about the largest integrated health system in the state, Kaiser Permanente (KP), saying it fails to adequately staff mental-health departments, which forces patients to wait weeks or months for appointments. The union also says in written materials that too many patients are driven to group therapy rather than individual treatment.

Union officials have been voicing concerns for years, and members threatened to go on strike in December. The demand for behavioral health services nationwide is only increasing, and the delivery system must find solutions to meet the needs of patients. One of the biggest hurdles can be the work force shortage.

According to John Nelson, spokesperson for Kaiser Foundation Health Plan, there are 2,000 psychologists on staff in California. He tells Behavioral Healthcare that the health workers in Southern California have agreed to a process that allows patients in the KP system to access out-of-network community providers when demand is high. However, he says, Northern California workers have not agreed to a similar arrangement.

“The bottom line is that there is shortage of skilled, qualified therapists and psychologists and other clinical practitioners in the mental health field,” he says.  “I don’t know that it’s more acute in California, but it’s certainly an issue here.”

Nelson says, being both a health plan with 9.5 million members and a provider of physical and behavioral care, KP must hire enough providers to care for its own covered members in the health plan. When there’s a shortage of qualified candidates, the process can be a challenge from the start. It can take six months from the time a position is open to the time a new KP clinician is onboard.

Even so, Nelson says, from 2011 to early 2014, KP has increased the number of therapists by 273 in California, from 1,105 in 2011 to 1,378 in early 2014, for a 25 percent increase. Comparatively, California health-plan membership grew by 8 percent. 

“We think we’ve actually made good progress, and we are hopeful that the professionals would join us in trying to make more progress,” he says. “Unfortunately the union’s position is around try to put pressure on us by criticizing and not being instructive and helpful.”

Appointment window
California is known for its high penetration of managed care, and the state governing body monitors consumer protections such as network adequacy and timeliness of appointments. The state also enacted the nation’s first set of regulations in 2011 to reduce waiting times for patient access to treatment, which includes behavioral healthcare.

“For initial non-urgent mental health appointments, a patient must be scheduled within 10 working days or 15 calendar days from the official day that the patient seeks a medical appointment,” Nelson says.

He also says that the union’s claim that people are forced into group treatment isn’t true because data shows that 70 percent of KP’s mental-health appointments are individual, one-on-one therapy services—not group. What’s more, he says, group therapy is effective for certain patients and shouldn’t be discounted as inferior.

The bottom line, according to Nelson, is that the union is not trying to work cooperatively on solutions. The onus is on providers to go to their managers to discuss options for scheduling appointments when they’re getting booked up and patients might not receive care within the 15-day standard. Bargaining tactics aren’t the answer, he says.


California regulations state the following time limits for access to care:

  • Urgent care appointments—within 48 hours if the service does not need to be pre-authorized or within 96 hours if the service requires preauthorization by the plan.

  • Appointments with psychiatrists—within 15 business days of patient request.

  • Appointments with other licensed mental health professionals—within 10 business days of patient’s request for an appointment.

  • Speaking to a health plan representative to get an appointment—no more than 10 minutes, during normal business hours.

  • Receiving a call back from a mental health professional—If patients are unable to directly reach their mental health professional, the law requires a live operator or recorded message to communicate how long it will take to get back to the patient.

  • Triage and screening—Health plans are required to provide 24/7 triage or screening services to patients by phone. Waiting times for triage or screening services may not exceed 30 minutes. However, the waiting time must be appropriate for the problem and if that problem is urgent, a plan’s screening and triage must respond more quickly.




The article contains multiple inaccuracies and offers readers a severely one-sided perspective about a very important subject matter -- namely, the behavioral health services provided by the nation's largest HMO, Kaiser Permanente. The article contains five direct quotes from John Nelson, Kaiser's spokesperson; however, the article fails to offer even a single quote or perspective from more than 2,600 psychologists, licensed clinical social workers, marriage and family therapists who work inside Kaiser's behavioral health clinics each and every day.

Additionally, the article fails to mention key facts like the following:

• Just three months ago, Kaiser agreed to pay a $4 million fine to the California Department of Managed Health Care for committing multiple violations of California law, including Kaiser's failure to provide timely access to thousands of behavioral health patients, the HMO's violations of the California Mental Health Parity Act, its falsification patients' appointment records, and others. The fine is the largest mental health fine ever issued by the agency.

• Kaiser is currently operating under a "Cease and Desist Order" imposed by the Department of Managed Health Care. This legal sanction orders Kaiser to "cease and desist" from committing further violations of California's behavioral health laws.

• Kaiser's patients have filed four class-action lawsuits against the HMO for violating California's timely-access standards and other laws with respect to mental health services. The lawsuits allege that Kaiser's delayed care has contributed to tragic outcomes for patients, including suicides. In September of 2014, the most recent class-action suit was filed; it alleges that Kaiser is illegally dumping severely mentally ill patients onto cash-strapped county health systems.

• The professional associations of mental health clinicians have backed NUHW’s request for investigations of Kaiser's behavioral health services. All three of the associations -- the California Psychological Association, the California Chapter of the National Association of Social Workers, and the California Association of Marriage and Family Therapists -- submitted letters of concern to the Department of Managed Health Care that supported NUHW’s request for a government investigation of Kaiser. Subsequently, government investigators conducted a 15-month investigation and fined Kaiser $4 million.

• In 2013, Kaiser agreed to pay $9 million to the family members of autistic children as a result of an out-of-court settlement to a class-action lawsuit. The suit alleged that Kaiser withheld multiple therapies from children with Autism Spectrum Disorders. Earlier, the Department of Managed Health Care had ordered Kaiser to "cease and desist" from withholding behavioral health therapies from autistic children.