Any Kaiser Docs?

[R. Matey]

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Statistically, most of these patients are likely to have MDD, anxiety disorders, PTSD, SUDs, etc. I don't know any evidence-based treatment protocols that have providers treating these disorders with individual therapy every 5 weeks? At least on the front end. Kaiser is also a managed care organization. Thus, it is especially in their interest (not to mention the patients!) to advocate for and render best practices. I'm sure their current practices are costing them money by extending treatment to ridiculous lengths, reducing clinician ability to render highest quality care, and likely contributing to overutilization of higher levels of care (IP, PHP, case management, ER visits) to deal with the disorder and its inevitably associated peripherical issues and flare-ups.

Generally agree with this, though keep in mind that Kaiser operates differently in different regions in according with state laws regarding access and mental health parity. It sounds like Kaiser is a behemoth in CA meaning that it can run the table in terms of access and quality of treatment where it might be smaller fry in other places. That said, it sounds like I might have it a lot better than others who are similar positions nationwide. Where I am, the problem is getting in the door; coming back through is a lot easier.

 

[erg923]

Generally agree with this, though keep in mind that Kaiser operates differently in different regions in according with state laws regarding access and mental health parity. It sounds like Kaiser is a behemoth in CA meaning that it can run the table in terms of access and quality of treatment where it might be smaller fry in other places. That said, it sounds like I might have it a lot better than others who are similar positions nationwide. Where I am, the problem is getting in the door; coming back through is a lot easier.

To my point above: Does Kaiser have Population Health analysts and/or any research Clinical Psychologists to look at this? I mean, its is managed care org, right? It's not a hard question to answer with data, and I'm sure they have a big enough N to do a robust analysis of my hypothesis?

Lastly, I thought that indeed the primary issue with Kaiser MH care was/is the "follow-up issue"...panels too big for most therapists? That's what I have always heard, and indeed what the strikes have been about, no?

Further, anyone CAN initiate care/specialist care follow-up into a system by going to their ER, right? For example, if I have a broken leg, I am hooked up with an ortho consult and subsequent follow-up by this ER visit.

 

[R. Matey]

I thought that indeed the primary issue with Kaiser MH care was/is the "follow-up issue"...panels too big for most therapists, etc.? That's what I have always heard, and indeed what the strikes have been about, no?

Right, in CA. As I said, I'm not in CA and the issue is more access in the first place in my region. What is "Kaiser" is actually a conglomerate of different health plans that operate differently depending on the regional health plan. due to state insurance regulations and competition from the market.

I'm sure there's research on it, but I just did a cursory glance looked and it wasn't coming up quickly and I have other things to do. Look at the websites of the research centers in SF, Denver, Portland, and Seattle--all do research on mental health related questions.

 

[erg923]

So...managed care org running (multi-state) hospital systems= not good (or is it the other way around)? 🙂 I would have to agree.

 

[erg923]

So...managed care org running (multi-state) hospital systems= not good (or is it the other way around?) 🙂 I would have to agree.

Kaiser and the VA (seemingly) probably have what we would call "leakage".... or an unnecessarily increased MH spend happening. If someone were to do a deep-dive into the data anyway...

When patients are denied or are otherwise not able to access the lowest level of care for their condition (i.e. evidence-based OP mental health therapy/treatment), this will inevitably "leak" into the system as (most likely) utilization of higher cost services to address them (e.g., ER visit, IP admissions, etc.). If there is an "access problem"...people are also highly likely to come into the system via higher cost services such as ER and/or IP admissions, and with an increased risk of morbidity/mortality from their conditions. They don't just go away. Especially if they have your insurance plan.

There are multiple proven ways to address and reduce this.

 

[Fan_of_Meehl]

Ye

Yup, large groups are something I'm starting to see more and more of in the VA.

Yeah...it's funny how all the folks who croon all day about the importance of 'evidence-based care' in administration positions (who push groups to handle overpopulated provider panels) appear not to be familiar with the most recent VA/DoD Expert Consensus Guidelines for assessing/treating PTSD which basically only recommended group therapy for PTSD over no treatment at all.

 

[R. Matey]

There are multiple proven ways to address and reduce this.

 

[erg923]

1. Do the data work to see where you are. This is key. It is complex, but not all that "hard" if you have a few people (particularly psychologists) who understand public health, health statistics and its integration with psychological science. Most large managed care orgs would have at least 3-5 such people on staff with this skillset somewhere already. Out of, I don't know, 20,000 employees?

2. Decrease barriers to evidence-based care/therapy at the lowest level of care (usually traditional OP services, but also explore Peer Support Services, Community-Based Services offerings and/or anything else supported by CMS). This may require hiring more clinicians.

3. Increased secondary care spending such as case management follow-up and social services.

4. Use established population health management protocols to monitor spend amongst high utilizing members and cross reference with diagnosis. Design EBT programs and protocols from this data and work with your INN providers regarding resource needs and utilization.

5. Establish known alternative treatments and a list of available providers for when higher levels of care are not deemed needed/appropriate.

 

[Fan_of_Meehl]

1. Do the data work to see where you are. This is key. It is complex, but not all that "hard" if you have a few people (particularly psychologists) who understand public health, health statistics and its integration with psychological science. Most large managed care orgs would have at least 3 such people on staff somewhere. Out of, I don't know, 20,000 staff??
2. Decrease barriers to evidence-based care/therapy at the lowest level of care (usually traditional OP services, but also explore Peer Support Services, Community-Based Services offerings and/or anything else supported by CMS). This may require hiring more clinicians.
3. Increased secondary care spending such as case management follow-up and social services.
4. Use established population health management protocols to monitor spend amongst high utilizing members and cross reference with diagnosis. Design EBT programs and protocols from this data and work with your INN providers regarding resource needs and utilization.
5. Establish known alternative treatments and a list of available providers for when higher levels of care are not deemed needed/appropriate.

This is such an underrated and important perspective. It seems that no one is doing this at VA. An intelligent multi-level and systems-focused analysis of the problems with MH access and service delivery is long overdue but will never occur due to political and organizational factors.

 

[cara susanna]

Oh God, I WISH we had mental health case management. Dare to dream!

 

[AbnormalPsych]

Kaiser clinicians, from what I am aware of, have no cap on their case loads. The people I am familiar with see 1-2 new intakes per day, daily. And there is a big wait list for these. Case loads just build and build and build. Again, name of the game here is just access to care.

As an HMO Kaiser doesn't really make much money (or any) at each service.

So hiring more clinicians is just lighting money on fire. They will squeeze every drop out of available resources before they must hire more.

 

[Fan_of_Meehl]

Kaiser clinicians, from what I am aware of, have no cap on their case loads. The people I am familiar with see 1-2 new intakes per day, daily. And there is a big wait list for these. Case loads just build and build and build. Again, name of the game here is just access to care.

As an HMO Kaiser doesn't really make much money (or any) at each service.

So hiring more clinicians is just lighting money on fire. They will squeeze every drop out of available resources before they must hire more.

Makes you wonder what they'll do once there are two clinicians seeing ten groups of five hundred patients each...daily. The 'system' may not respect 'caps' on caseloads but the realities of time and space certainly will...I mean, at SOME point.

 

[MAClinician]

1. Do the data work to see where you are. This is key. It is complex, but not all that "hard" if you have a few people (particularly psychologists) who understand public health, health statistics and its integration with psychological science. Most large managed care orgs would have at least 3-5 such people on staff with this skillset somewhere already. Out of, I don't know, 20,000 employees?

2. Decrease barriers to evidence-based care/therapy at the lowest level of care (usually traditional OP services, but also explore Peer Support Services, Community-Based Services offerings and/or anything else supported by CMS). This may require hiring more clinicians.

3. Increased secondary care spending such as case management follow-up and social services.

4. Use established population health management protocols to monitor spend amongst high utilizing members and cross reference with diagnosis. Design EBT programs and protocols from this data and work with your INN providers regarding resource needs and utilization.

5. Establish known alternative treatments and a list of available providers for when higher levels of care are not deemed needed/appropriate.

Massachusetts did #2 and #3 for their Medicaid clients, first with the children’s system and more recently with the adult-serving system. Commercial/private insurers were also required in the last two years to provide similar services for children as the Medicaid services. The desired effect of increasing access to care (mental health care in general, not specific to psychologists) has not been obtained to the level the state had hoped. #4 has also been tried in the form of providing collaborative trainings with “cohorts” from various providers (typically masters level) over a year or two, with the goal that the original participants will train their coworkers in these models. Some providers have been more successful than others. I am less familiar with services for adults with commercial or private insurance so I can’t speak to what has been done or is planned.

It is a challenging problem to say the least.

 

[beginner2011]

Oh God, I WISH we had mental health case management. Dare to dream!

In my major metro VA I would hazard a guess that the case management burden among psychotherapists (SW and Psychology) is the primary contributor to turn-over. It's surprising to me that facilities don't hire case management staff separately from psychotherapy staff.

 

[DrSoon2016]

Kaiser clinicians, from what I am aware of, have no cap on their case loads. The people I am familiar with see 1-2 new intakes per day, daily. And there is a big wait list for these. Case loads just build and build and build. Again, name of the game here is just access to care.

As an HMO Kaiser doesn't really make much money (or any) at each service.

So hiring more clinicians is just lighting money on fire. They will squeeze every drop out of available resources before they must hire more.

My caseload is huge. I see 9 a day, so 45 a week, and see my pts every 3-5 weeks. I probably have 200 on my caseload

To respond to what someone said earlier, Kaiser therapists (and myself for sure) do exposure therapy but it requires some additional work like squeezing in a pt during a lunch time. Why do you think that Kaiser doesn't make much money from behavioral health? There is such A high demand for therapy services, but such a reluctance to hire more people, so I wonder why it financially does not make sense to them to hire more therapists? Any ideas?

 

[AbnormalPsych]

Why do you think that Kaiser doesn't make much money from behavioral health? There is such A high demand for therapy services, but such a reluctance to hire more people, so I wonder why it financially does not make sense to them to hire more therapists? Any ideas?

I'm pretty sure I just posed a hypothesis for this.

Let's test it out.

How much are your patient's paying in co-pay at each session? Times that by the number of sessions per year. You are making well over 6 figures with kaiser from data I've heard/seen, with thousands more in benefits. Add in the $ for the lease or property taxes for your building that you are part of, support staff, utilities, overhead, etc dedicatied to you as part of your clinic. Which number is greater?

Kaiser is an HMO. Patients or their employers pay for their insurance plans each year then have access to services for dirt cheap. What am I missing? How is it possibly a money maker for Kaiser to spend that much money to hire someone who will bring in wayyyyyyyy less than that each year? They lose money with every hire.

 

[DrSoon2016]

K

I'm pretty sure I just posed a hypothesis for this.

Let's test it out.

How much are your patient's paying in co-pay at each session? Times that by the number of sessions per year. You are making well over 6 figures with kaiser from data I've heard/seen, with thousands more in benefits. Add in the $ for the lease or property taxes for your building that you are part of, support staff, utilities, overhead, etc dedicatied to you as part of your clinic. Which number is greater?

Kaiser is an HMO. Patients or their employers pay for their insurance plans each year then have access to services for dirt cheap. What am I missing? How is it possibly a money maker for Kaiser to spend that much money to hire someone who will bring in wayyyyyyyy less than that each year? They lose money with every hire.

Good point . I wonder why Kaiser chooses to pay so much for therapists instead of paying a decreased salary and hiring more.

 

[R. Matey]

Kaiser is an HMO. Patients or their employers pay for their insurance plans each year then have access to services for dirt cheap. What am I missing? How is it possibly a money maker for Kaiser to spend that much money to hire someone who will bring in wayyyyyyyy less than that each year? They lose money with every hire.

In my area, they just hire a bunch of mid-levels.

 

[foreverbull]

1. Do the data work to see where you are. This is key. It is complex, but not all that "hard" if you have a few people (particularly psychologists) who understand public health, health statistics and its integration with psychological science. Most large managed care orgs would have at least 3-5 such people on staff with this skillset somewhere already. Out of, I don't know, 20,000 employees?

2. Decrease barriers to evidence-based care/therapy at the lowest level of care (usually traditional OP services, but also explore Peer Support Services, Community-Based Services offerings and/or anything else supported by CMS). This may require hiring more clinicians.

3. Increased secondary care spending such as case management follow-up and social services.

4. Use established population health management protocols to monitor spend amongst high utilizing members and cross reference with diagnosis. Design EBT programs and protocols from this data and work with your INN providers regarding resource needs and utilization.

5. Establish known alternative treatments and a list of available providers for when higher levels of care are not deemed needed/appropriate.

I suppose you could say Kaiser (and Sutter Health for that matter, another big health system in my area) are pretending to address #2 in a VERY halfhearted fashion by referring some clients out to private practitioners in NorCal and offering to pay for it. But the reimbursement is egregiously low for psychologists (they also allow midlevels) to do so—to the tune of $60-$75/session for a private practitioner in one of the highest cost of living areas in the country. And it is not EBP, typically. So again, clients who come to me can’t usually find anyone who is paneled to provide it (in Kaiser’s case via Beacon/Magellan) or agreed to this rate and isn’t full, so they still have to pay full fee out of pocket when they are fully insured with Kaiser or Sutter Health. VERY frustrating situation.

To your earlier point about costs and availability of services, I think about systems like Lyra, employer based coverage for free sessions. Employees under an employer who pays for Lyra are all allotted 25 sessions/year and Lyra pays private practitioners full fee, including for no shows. For the majority of folks with lesser severity MH issues, this is a good amount; maybe even more than enough. For those who need more, it’s assessed on a case by case basis and they may have to start paying out of pocket fully or a portion at least. This model is pretty good, in my opinion, because you can stretch 25 sessions out to a year if every other week OR do the weekly intensive format for 6 months (Lyra requires practitioners to be using CBT as their major approach, and requires clients to fill out weekly rating scales, but doesn’t require structured therapy per se). The only requirement is that the practitioner has to be a psychologist with Lyra (there’s a largely informal brief interview process).

The latter really seems like a great model, although to be fair, offering this to folks in a system like Kaiser would probably hurt their bottom line in the short term at the very least, but not necessarily in the long if it prevents ER and IP usage of enough Kaiser insured patients—and if physical health improves in the long run as well, although that is abstract and hard if not impossible to measure. Again, goes back to prioritizing mental health as more than a “bare minimum” approach.