California has taken perhaps the most proactive stance in the nation in enforcing laws to ensure people with mental illnesses have fair and timely access to care. But even in this state, it’s proving difficult to ensure mental patients truly have equal access to treatment.
Parity laws, including a sweeping measure passed by the federal government in 2008 and an older California law, require insurers to provide mental health and substance abuse benefits on par with the coverage they offer for other medical care. And a separate state law requires insurers to provide patients with access to mental treatment within a specific timeframe – 48 hours for an urgent visit and 10 business days for a non-urgent one.
After the 2013 fine, Kaiser patients continued to face not just ongoing delays – they also faced arbitrary limits on treatment in direct violation of the state’s parity statute, officials found. The law was intended to prevent such things as annual caps on patient visits that would not typically be faced, for instance, by patient with another chronic illness such as diabetes or heart disease. Yet, according to the 2015 report, some Kaiser staffers told mental health patients that they were not entitled to long-term individual therapy -- ever.
“No one ever sees a therapist once a week in the Kaiser Health Plan,” according to a 2014 email a Kaiser psychologist sent to a patient, which was cited in the state’s most recent report. “Not a covered benefit for the past 20-something years and will not be a benefit in the future.”
Dr. Mason Turner, Kaiser Permanente’s Associate Director of Regional Mental Health for Northern California, said that the organization has fixed the problems identified by the state.
“Between the time the DMHC made their [initial] findings and now, we've made substantial improvements, hired many more staff, and really put into place a lot of mechanisms to address the initial concerns that were brought up,” Turner said in April.
The access problems, he said, were caused by an increase in demand, which rose in part because of the influx of new enrollees under the Affordable Care Act. In response, he said, Kaiser increased the ranks of therapists by 25 percent and arranged to contract with outside therapists when necessary.
The actions against Kaiser highlight both how far California has come in ensuring equal treatment for mental health patients and how far it has yet to go.
On one hand, after many years of “abysmal” enforcement, “now we have regulators who seem to be enthusiastic,” said Randall Hagar, director of government relations for the California Psychiatric Association.
Hagar gives credit to managed health care department director Shelley Rouillard, who spent 20 years in consumer advocacy before joining the department in 2011 and becoming director in 2013. On the other hand, critics say, Rouillard and her staff are making slow progress at best.
“This is one of the ‘pace car’ states, and it's still slow going,” said Carol McDaid, who runs the Parity Implementation Coalition, an advocacy group made up of addiction and mental health consumer and provider organizations.
Holding Insurers Accountable
Soon after they fined Kaiser in 2013, California officials realized the problems with unequal coverage of mental health were much broader.
For years, California, like most states and the federal government, relied on consumers to bring complaints alleging that their rights had been violated under parity laws. State regulators grew concerned that the approach was too passive -- few consumers were complaining, perhaps because of the stigma attached to mental illness.
So as a first step, the department of managed health care last year began requiring insurers under its watch to show -- at least on paper -- that they were complying with federal parity law.
The results were not encouraging: Of 26 managed care insurers, from Aetna to Western Health Advantage, zero were able to prove that they were fully in compliance. Most filed incomplete or flawed documents, state officials said.
“It is rather shocking,” Rouillard said.
Part of the problem, Rouillard said, is that the federal government did not release the final regulations dictating how its parity law should be enforced until November 2013 – five years after the law was passed.
In addition to the flawed and incomplete paperwork, her department found insurers trying to control costs in ways that could be discriminatory -- for example, by limiting the number of days a patient could receive inpatient care for a mental health condition.
“Mental health services are still sort of a second class benefit as far as the health plans are concerned,” Rouillard said.
At this point, Rouillard says the managed care plans she regulates are in varying stages of compliance with the federal parity law. Just one plan, Health Net, has so far been able to prove on paper that its benefits fully comply. Rouillard says she expects the other plans to follow suit by the end of the year, and in 2016, the department plans a more intensive review.
Charles Bacchi, president and CEO of the California Association of Health Plans, disputed that insurers see mental health a second-tier benefit. “We're committed to providing this coverage for our enrollees. It's very important, and it's something that we're working hard to do,” he said.
But the law poses a huge challenge for health plans, he said, in part because the science underpinning diagnosis and treatment of mental illness is constantly evolving. In addition, health plans are trying to adapt not just to parity law but to the implementation of the Affordable Care Act, which has transformed the national insurance landscape.
Even so, he said, “I think by the end of this year, all the plans will have filed the right documents and will have approval from the department, and this will be something that's in the rearview mirror.”
‘A Societal Problem’
Finding that her situation did not improve even after the first investigation of Kaiser in 2015, psychologist Ginne made a request of her managers -- copied to Rouillard -- that December. She asked that six of her sickest patients be transferred to other providers who could see them more frequently.
One of them, an elderly man with dementia and depression, was hallucinating “fully-formed humans,” Ginne said in an interview. One day, he wandered down the block at 5 am in his pajamas, panicked, and flagged down a truck driver who called the police.
“He was a danger to himself,” Ginne said.
According to Ginne, the backup in appointments meant she could see him for individual therapy only once every few months. The man had been assigned to regular group therapy for depression, which Ginne felt was inappropriate for his condition.
When her supervisors did not transfer the man to another individual therapy provider, Ginne reported the case to Adult Protective Services, because she said she believed him to be imminent danger.
“That's such a bad solution,” she said, shaking her head. Ultimately, he and his wife decided to quit therapy entirely.
Rouillard said that many managed care plans have a long way to go to ensure fair and equal access to mental health care for Californians. But she also said there’s only so much her department can do.
Access to care at companies like Kaiser is also an issue of capacity – and that’s not within the department’s purview, she said.
“There just aren't enough therapists to see everyone who needs help,” she said. “It isn't just a plan problem; it's a societal problem. And that is really the crux of the matter. We're trying to address a problem that is beyond our ability to fix, and that is a challenge.”