Roughly 4,000 behavioral health workers at Kaiser Permanente will walk out of their jobs Monday in a five-day statewide strike over what they describe as chronic understaffing that is limiting patient access to mental health services at the nation’s largest managed care organization.
“We are constantly under pressure to see new patients,” said Kenneth Rogers, a Kaiser psychologist who’s on the bargaining team for the National Union of Healthcare Workers. “We have only a limited amount of time to see any kind of patients, but the more new patients we have to see, the less time we have for the return patients. ... If there were more staff, there would be more clinicians to see more new patients, and they would take that pressure off the existing therapists’ patient load.”
Union spokesman Matt Artz said that the ratio of mental health clinicians to Kaiser members has remained essentially unchanged since 2015 despite findings from the California Department of Managed Health Care showing that patients were having trouble accessing care that year. NUHW said that Kaiser has maintained roughly one full-time equivalent clinician for every 3,000 Kaiser members in California.
The union represents 325 Kaiser health care workers in the Sacramento region, 58 in Fresno and 32 in Modesto and 66 in San Joaquin County, Artz told The Sacramento Bee. The NUHW site posted a strike schedule at various locations, including Kaiser’s medical centers in Sacramento on Morse Avenue, South Sacramento on Wyndham Drive and Roseville on Eureka Road; the Fresno Medical Office Building on North First Street; the Modesto Medical Center on Dale Road; and the Stockton Medical Office Building on West Lane.
John Nelson, KP’s vice president of communications, said the union’s principal demands at the bargaining table have not been about improving care and access but have instead focused on gaining even higher wages and benefits. NUHW’s bargaining team, he said, has demanded changes to performance standards that would reduce, not increase, the availability of mental health care for our members.
“The union wants to reduce the amount of time caregivers spend seeing patients,” Nelson said in a prepared statement. “The current goal is an average of 75 percent of their time, which the union agreed in 2015. Striving for this industry standard is one of the key ways we’ve been able to increase access to care for our patients.”
Rogers said, in order to appreciate how this union proposal will ensure psychotherapists can effectively treat patients, you have to understand how Kaiser scheduling works. Right now, he said, Kaiser clinicians must spend 75 percent of their time seeing patients.
“If you’re a teacher, you might teach high school students, and you might teach five out of eight or nine periods,” he said. “You get some periods for prep time. The Kaiser clinicians get very little prep time – 75 percent is a lot of time to see patients.”
Rather than requiring clinicians to see patients 75 percent of the time, Rogers said, clinicians are seeking to have their schedules booked 80 percent of the time. Some patients will cancel appointments at the last minute, Rogers said, and that will leave time to work on notes or perhaps slide in a patient who calls with an acute problem.
“You’ll have that (new) patient who doesn’t report a high acuity initially but then calls back later and they’re in serious trouble,” Rogers said. “And, there isn’t any room for flexibility based upon the way the organization treats its book. You’ve booked up everybody. There’s no room at the inn, so to speak, so you have to make a determination: Can you squeeze in a phone call? Sometimes you don’t even have time for that.”
If the patient is at risk of harming themselves or others, Rogers said, he works to get them to emergency services. If the patient’s mental state is heading downhill but is not life-threatening, he said, he can send them to an intensive group therapy.
However, Rogers said, that is happening often enough that patients aren’t getting the quality of care they deserve. That shouldn’t happen at an organization with Kaiser’s resources. Recently, Kaiser reported a $2.9 billion profit over the first nine months of 2018, NUHW pointed out, and a $3.8 billion profit for 2017.
Rogers said: “If I’m on a desert island, and there are only two bananas, I understand we have to all split that up, and people are going to be getting less, and we have to figure out a way to be economical. This is an island with many, many, many bananas, and they’re telling me the solution is cutting the bananas in half. It’s just absurd, just absurd.”
Nelson said that Kaiser therapists are not routinely sending people to the emergency room or to group therapy.
“We are meeting the established regulatory standard for first appointments for mental health and wellness on average more than 90% of the time, statewide,” Nelson said. “We also monitor return visits and are ensuring that we follow therapists’ care plan recommendations for the timing of these visits. As documented by the therapists themselves, we are meeting their recommendations between 86-94% of the time.”
The California Department of Managed Health Care issued a report in June 2017 saying it would continue to monitor Kaiser’s performance for 18 months to assess whether it was providing timely access to care for patients with behavioral health problems. DMHC regulators said that, in July 2017, they reached an agreement with Kaiser to correct violations and enlist an outside consultant to help it do so. The agency has been monitoring Kaiser since 2013 when it levied a $4 million against the HMO for violating the California’s Mental Health Parity Act and standards for timely access to care.
Kaiser, in its response to the latest DMHC report, stated that it had greatly enhanced access by aggressively recruiting and hiring therapists, increasing the hours for contract clinicians, canceling or reducing vacations of staff, and increasing the productivity of staff.
“We have been working productively over several years now to improve care and the care experience for our members,” Nelson said. “Over the last three years in particular we have demonstrated that by working together we can advance the quality and reach of our mental health care and create a more professionally supportive work environment.”
The California Office of the Patient Advocate awarded KP’s Northern California division its highest rating of five stars for behavioral health, making it the only health plan in the state to achieve this, Nelson said.
The organization has implemented “televisits” for patients who find that more convenient, he said, and it is using patient feedback to measure therapist performance. It also has increased the number of therapists on its staff by 30 percent since 2015, despite a nationwide shortage of such professionals, Nelson said, and it has spent $175 million on building new clinics.
“It’s particularly disheartening that the union leadership would call this strike during the holiday season, when many of our patients with mental health needs may be at their most vulnerable,” Nelson said. “Strikes are not an effective bargaining tactic. They put patients, members and employees in a difficult situation, unnecessarily.”
Labor expert Kate Bronfenbrenner of Cornell University told The Bee by phone that strikes are particularly effective when exercised at a time when company management will feel a pinch point and therefore understand the union members’ power.
Artz and Rogers said that a settlement would avert next week’s strike but that the company has not budged on its position over 16 or so sessions. The NUHW and Kaiser’s negotiators have been working since June to reach an agreement, they said, but the contract expired in September.
Rogers said he didn’t have to spend anytime organizing this strike, as he did with past job actions: “The clinicians at our clinic ... came to me and said, ‘Look, we’ve got to go.’ I didn’t talk anybody into it. As their elected representative, I sent the message, but I didn’t organize it. It’s to a point where people are like, ‘We can’t do this. We can’t handle this. There’s too much.’ ”
The key issue here are working conditions and patient access, Rogers said, but the union is also seeking wage increases because the raises alone in the 2015 contract did not make up for going roughly five years without wage increases. The prior contract expired in 2011.
Members in NUHW’s Southern California unit also want to see the company restore traditional pension for members hired after the 2015 contract was instituted, Artz said. That’s because Kaiser imposed terms on new hires in that unit stripping away the traditional pension and leaving them with only a 401(k)-style plan, according to NUHW documents from Aug. 1, 2014.
In the end, after five years without a deal, NUHW’s Southern California members conceded this takeaway in order to forge a contract, said NUHW President Sal Rosselli, but they did so only because management told them they would be negotiating similar deals with other unions. Kaiser didn’t, Rosselli said.
Kaiser said it has offered NUHW-represented workers guaranteed wage increases that will ensure it can remain competitive in recruiting top talent. In 2015, Nelson stated, NUHW members received generous wage increases, pay scale adjustments, and bonuses ranging from $5,000 to $10,000.
The company is disappointed in the union’s position, Nelson said, but remains committed to addressing patient needs during the five-day strike that will end Friday night.
“Should the union seek to carry out a strike, our teams have plans in place to deliver care and services to our members,” Nelson said.
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The California Department of Managed Health Care recommends that consumers file a grievance with their health plan if they’re having trouble accessing the care they need. If the health plan is not resolving a grievance or there’s been in action on it for 30 days, consumers can contactthe DMHC Help Center by calling 1-888-466-2219 or going to www.HealthHelp.ca.gov. If your health plan is acting in a way that poses an imminent or serious threat to your health, contact the DMHC Help Center immediately.