Maria Spivey was driving the #1 bus in San Diego one spring day two years ago, when her cellphone started ringing and ringing. She figured it was her 17-year-old daughter Chloe.
"There was no way I could stop and answer the phone," she remembers. So she kept going.
"When I get to the end of the line," she told herself, "I'll take a break. I'll call Chloe."
When she got to the terminal, the calls became more insistent. Now it was her partner, Charles.
“‘You need to get home,’” Spivey remembers him telling her. “’Get home now.’”
She rushed home to find police cars parked in every direction outside her house. Charles opened her car door.
"Chloe's gone," he told her.
Chloe had killed herself.
“I think I almost fell to my knees,” Spivey says, holding back tears. “But I didn’t want to lose complete control. My kids were watching me.”
At first Spivey blamed herself.But later, she blamed Kaiser Permanente. Spivey says the HMO failed to take care of her daughter. When Chloe started having trouble with depression and anxiety in middle school, Kaiser told her she couldn’t get weekly individual therapy.
“There's no one-on-one,” Spivey remembers being told.
Chloe had attempted suicide once before, when she was 16. Even then, Kaiser did not schedule her into individual therapy. Instead she was put into a weekly group for teens with drug abuse problems.
“They didn't discuss depression, anxiety, PTSD," Spivey says. No one asked if she was feeling suicidal. “Chloe told me more often than not, ‘Mom, this is not what I need.'"
History of Complaints
Complaints like these had been building up at Kaiser for years. Mental health clinicians at Kaiser who were members of the National Union of Healthcare Workers started to organize across the state. They sent thousands of pages of internal Kaiser documents to state regulators.
The clinicians said Kaiser was understaffing its psychiatric department. They said patients were being shuttled into groups or forced to wait four to six weeks for individual therapy appointments.
The Department of Managed Health Care, the main regulator of health insurers in the state, found merit in these claims and fined Kaiser $4 million, which Kaiser initially contested, then agreed to pay in 2014.
But the union was still not satisfied. It said patients were still waiting too long for appointments, and in 2015, they went on strike.
Kaiser eventually reached a contract agreement with the union, building more time into therapists’ schedules for patient care, and offering “competitive” salaries and benefits, said Yener Balan, Kaiser’s executive director of behavioral health quality, in a statement. It also hired hundreds of new therapists last year and is "aggressively" recruiting more.
“Kaiser Permanente is actively working to meet the challenges that everyone in the mental health treatment community is facing,” Balan said. “As one of the largest mental health providers in California, we recognize that we are in a position to lead, and that is what we are committed to do."
While the union is pleased with the changes, union president Sal Roselli says there’s still more work to do.
“We want to make Kaiser the poster child to take to other [insurance] providers, in terms of how to do it right,” he says.
Kaiser May Be 'Victim of Their Own Data'
Kaiser is the only insurance company that’s been fined in California for forcing patients to wait excessively long for mental health visits. But is it really the only one with problems?
Last year in Sacramento, Shelley Rouillard, the head the state's Department of Managed Health Care, testified before a senate committee on mental health that Kaiser's integrated system -- where the insurer and medical provider are one entity -- made it something of an easy target.
“Kaiser probably has much better data than anyone else,” she told state lawmakers. "And so to some extent they may be a victim of their own data.”
Other insurers don’t have a centralized call center that tracks appointment wait times, like Kaiser. They have fragmented networks of self-employed therapists. There’s no way to count how many calls a patient makes before they find one who’s available. Or how many patients simply give up.
Right now in California, insurance companies monitor themselves to make sure they have enough clinicians. Insurers are responsible for surveying therapists in their directories to make sure they are accepting new patients. But these surveys do not simulate the typical patient experience -– as therapists’ answers about whether they are taking new patients can vary dramatically if the person calling is a patient or the insurance company who pays them.
For example, a KQED survey of 100 psychologists in the Blue Shield network in San Francisco found that only 28 were actually taking new patients, a rate Rouillard said was “not acceptable.”
Mental health clinicians and advocates criticize the Department of Managed Health Care for going easy on insurance companies.
The fines are too low and too infrequent, says Meiram Bendat, a plaintiffs’ lawyer in Los Angeles. “They’re a slow bureaucracy that takes way too long to respond to consumer complaints.”
Difficulty of Enforcement
Rouillard says the mental health parity laws her agency is tasked with enforcing are extremely complicated, so it makes more sense to work with the companies to correct problems.
“We want the plans to do the right thing from the beginning," Rouillard says. "It's worth it to spend the time to help them understand what the law is and what their responsibilities are and for us to work with them to get it right.”
Right now, the agency is reviewing health insurance plans’ mental health benefits. Where there are violations of the law -- say a plan charges a higher copay for mental health services compared to other medical services -- the agency tells the insurer to fix the plan so the copays are the same. Of 25 insurance companies reviewed this year, 24 had a violation like this, according to the department. Later this year, department officials will visit insurance companies on site to audit patient files.
“It's been a good process,” Rouillard says. “It’s been a little long and dragged out, but we’re getting there and we’ll see on the back end how well it really works.”
Other states are taking a much more aggressive approach.
In New York, the state attorney general has been suing insurers, using subpoena power to demand data from companies about what kind of care patients are actually getting, not just what the companies say they’re giving.
“It doesn’t seem like there’s any lack of winnable cases available,” says Keith Humphreys, a psychiatrist at Stanford who served as a policy advisor to the Obama administration. “The reason we see that in New York is not that New York is an unusual place -- but that you had a public official who was engaged enough and talented enough to expose it.”
He calls the New York attorney general a hero.
The investigations pursued in New York and by California's Department of Managed Health Care have depended largely on consumers submitting complaints about their health plans. This can be a tall order for people suffering from a mental illness, who may be too distraught, or even cognitively impaired by their condition to navigate the web of agencies, and the web of forms. Advocates believe the number of complaints submitted to regulators represent only a fraction of potential violations of mental health laws.
Maria Spivey says when her daughter Chloe was struggling, she didn’t have the energy to file a complaint with state regulators. She didn’t know how -- or even that it was an option.
“I didn’t have time to waste on Kaiser and what they weren’t doing for Chloe," she says. "I was trying to save Chloe and find people that would help me.”
Spivey is now one of several plaintiffs in a lawsuit against Kaiser. She wants to see Kaiser make a more meaningful overhaul to its mental health system -- to provide one-on-one therapy to all patients who need it, as soon as they need it.