Kaiser Mental Health Clinicians Strike

[drusso]

Why don't employed MD's take more direct actions like this?

http://nuhw.org/news-and-press/kaiser/

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Members don't see this ad.

 

[NJPAIN]

Bravo!!!!

 

[Disciple]

Looks like they had the same complaints that many Kaiser physicians probably do.

Not being able to treat outside of algorithms/system protocols, too many patients, and proposed cuts to pensions.

Predictions on how Kaiser doctors will respond when it's their turn?

 

[melancholy]

great to hear this if this is the case. poor mental health access and focus on group vs individualized care including individual therapy is turning me into a psychiatrist and therapist...

 

[willabeast]

great to hear this if this is the case. poor mental health access and focus on group vs individualized care including individual therapy is turning me into a psychiatrist and therapist...

It has always been so

 

[Disciple]

great to hear this if this is the case. poor mental health access and focus on group vs individualized care including individual therapy is turning me into a psychiatrist and therapist...

I'd heard that, but is that really how it is? Group therapy focused?

 

[melancholy]

Kaiser has success in many areas due to its ability to work with large populations and pool the data to use towards quality improvement, but also is able to manage multiple health conditions efficiently through the use of many classes and groups. In the case of mental health, there certainly is benefit for the right patient in a group setting for depression, anxiety, bipolar, DBT, PTSD, dual diagnosis, etc. however I think sometimes the groups are used in substitution of individual follow-up appointments to "buy time" in a sense. (not to say this is always the case). They have scheduled classes as well as drop-in groups for various conditions and the support can often be helpful, but I still think the individualization is key and for our "unique" patient population who often has psychiatric co-morbidities (some week I feel that easily over 50% of my new female patients have hx of child sexual abuse or domestic violence + PTSD + depression/anxiety), this approach doesn't work so well.

Don't get me started about the move to go towards watching PT videos, then a telephone appt or a group class, then possibly an individual PT appt for a handout (i exaggerated a little bit, but you get the idea).

 

[Disciple]

drusso, 101N, Algos

There's how you do it for a large population without spending a lot.

 

[Disciple]

Kaiser has success in many areas due to its ability to work with large populations and pool the data to use towards quality improvement, but also is able to manage multiple health conditions efficiently through the use of many classes and groups. In the case of mental health, there certainly is benefit for the right patient in a group setting for depression, anxiety, bipolar, DBT, PTSD, dual diagnosis, etc. however I think sometimes the groups are used in substitution of individual follow-up appointments to "buy time" in a sense. (not to say this is always the case). They have scheduled classes as well as drop-in groups for various conditions and the support can often be helpful, but I still think the individualization is key and for our "unique" patient population who often has psychiatric co-morbidities (some week I feel that easily over 50% of my new female patients have hx of child sexual abuse or domestic violence + PTSD + depression/anxiety), this approach doesn't work so well.

Don't get me started about the move to go towards watching PT videos, then a telephone appt or a group class, then possibly an individual PT appt for a handout (i exaggerated a little bit, but you get the idea).

Interesting, I didn't know that's the way it was going with the PT.

Since the ACA, and particularly the Medicaid expansion, have you noticed your patient population changing much?

How easy, or difficult is it for the patients you described to have access to a Psychiatrist?

 

[Aether2000]

Yepper. And that is one reason why Kaiser docs are paid less. Robbing Peter to pay Paul.

 

[Ducttape]

hmm... maybe we should be seeing patients in groups. im sure there are hipaa concerns, but...

meet up with a group of 5 patients per half hour, all with M48.06, all meet up in a room, discuss functionality, physical exercises, how to manage pain, discuss med (non-opioid) options, set up future care (injection, etc.).

 

[Aether2000]

I like it! And then the logical extension of this would be to have multiple fluoro machines in the OR and have multiple patients loaded up at once....imagine having the ability to walk from patient to patient in one room. We could do an entire month's worth of procedures in a few hours....

 

[Ducttape]

would be kind of cool billing 99214+25+64483+64484+90853, x10...

(last code would be group psychotherapy)

 

[Disciple]

I like it! And then the logical extension of this would be to have multiple fluoro machines in the OR and have multiple patients loaded up at once....imagine having the ability to walk from patient to patient in one room. We could do an entire month's worth of procedures in a few hours....

I think this is being done already. Physician owned specialty hospitals. Block time, ORs 1-4.

 

[Disciple]

hmm... maybe we should be seeing patients in groups. im sure there are hipaa concerns, but...

meet up with a group of 5 patients per half hour, all with M48.06, all meet up in a room, discuss functionality, physical exercises, how to manage pain, discuss med (non-opioid) options, set up future care (injection, etc.).

Sure, it could be done.

But I thought you were all about quality.

"Cheap", "quality", have to pick one.

 

[Ducttape]

Im not sure group pain management would qualify as "quality"...

 

[drusso]

I think that seeing patients in groups would be very cost effective--especially if a physician were not involved. There is no way to recognize this kind of service in private practice.

 

[melancholy]

Interesting, I didn't know that's the way it was going with the PT.

Since the ACA, and particularly the Medicaid expansion, have you noticed your patient population changing much?

How easy, or difficult is it for the patients you described to have access to a Psychiatrist?

Sorry missed this post.

we are getting more members from the expansions and quite a bit more patients who had county insurance or patients that now have managed medi-cal through our HMO. alot more work trying to look for outside records and confirm past treatment plans and such.

there was some weird rule that you needed to fail two SSRI's before a therapist would refer to a psychiatrist, but previously i was able to just request a referral for a psych med consultation and it was not too much of an issue. due to turnover from retirement and other reasons and still being behind with hiring, it can take over a month still to see a psychiatrist I believe, so most are seen by a PhD, LCSW, or MFT first to bridge the gap. once patients see the psychiatrist, the model is to do telephone appointments and secure email to correspond generally for medication trials, etc.

 

[melancholy]

would be kind of cool billing 99214+25+64483+64484+90853, x10...

(last code would be group psychotherapy)

back when i was in training at UC Davis, one of our PM&R doctors was running a chronic pain group where a psychologist would pick a topic to discuss (pacing, very basic CBT strategies, etc.) and the doctor would also talk about various types of CAM treatments, mindfulness meditation, etc. it was an interesting approach. i think he found some way to code/bill for it and he was typing notes in the group setting. he later then would bring patients individually if needed into a separate room if an intervention such as prolotherapy or other injection was needed. i believe the prolo may have been cash pay at a lower rate offered to the patients.

 

[SSdoc33]

back when i was in training at UC Davis, one of our PM&R doctors was running a chronic pain group where a psychologist would pick a topic to discuss (pacing, very basic CBT strategies, etc.) and the doctor would also talk about various types of CAM treatments, mindfulness meditation, etc. it was an interesting approach. i think he found some way to code/bill for it and he was typing notes in the group setting. he later then would bring patients individually if needed into a separate room if an intervention such as prolotherapy or other injection was needed. i believe the prolo may have been cash pay at a lower rate offered to the patients.

might as well melt all of the patient's jewelry together and mold it into a golden calf to worship. same basic idea.

whenever i hear the words mindfullness or wellness it automatically makes me anxious and angry. idiosyncratic reaction?

 

[melancholy]

might as well melt all of the patient's jewelry together and mold it into a golden calf to worship. same basic idea.

whenever i hear the words mindfullness or wellness it automatically makes me anxious and angry. idiosyncratic reaction?

obviously some of the topics that came up in these Shared Medical Appointments were much more alternative, but some people are more attuned to benefiting from mindfulness based strategies than others for certain as one size doesn't fit all, however you never know unless you try and see what people are drawn to. I think he even did a session on laughter medicine. The psychologist would do more standard lectures related to behavioral strategies to managing chronic pain.

 

[SSdoc33]

obviously some of the topics that came up in these Shared Medical Appointments were much more alternative, but some people are more attuned to benefiting from mindfulness based strategies than others for certain as one size doesn't fit all, however you never know unless you try and see what people are drawn to. I think he even did a session on laughter medicine. The psychologist would do more standard lectures related to behavioral strategies to managing chronic pain.

to me, chronic pain is really a phychiatric/psychological issue. we all know that pain from a disc herniation doesnt last decades, cause you to look for disability, etc. unless there is some concomitant psychiatric pathology. behavioral therapy/ supratentorial treatment is definitely the way to go in this population. i think that i have just become so jaded that when a patient has chronic pain but no hard findings to support it, i just shut down because i am not the right doc for them. im not going to tout the mindfulness psychobabble because im not a psychiatrist/psychologist and have no desire to be one. you have something wrong with your body, im your guy. something wrong with you brain, go see someone else.

 

[melancholy]

to me, chronic pain is really a phychiatric/psychological issue. we all know that pain from a disc herniation doesnt last decades, cause you to look for disability, etc. unless there is some concomitant psychiatric pathology. behavioral therapy/ supratentorial treatment is definitely the way to go in this population. i think that i have just become so jaded that when a patient has chronic pain but no hard findings to support it, i just shut down because i am not the right doc for them. im not going to tout the mindfulness psychobabble because im not a psychiatrist/psychologist and have no desire to be one. you have something wrong with your body, im your guy. something wrong with you brain, go see someone else.

you're absolutely right that there are psychiatric co-morbidities majority of the time that predispose these patients from having ongoing issues with chronic pain. if someone doesn't have a dx of depression, anxiety, PTSD, sexual abuse, fhx of alcohol dependence or substance use, or their own substance use or alcohol or drug issues, i inquire deeper because there is usually a reason.

I'm just relating what one of the attendings where i trained at used to do in regards to the discussion on group vs individual therapy efficacy.

I think you gotta stick with your guns and do what you do best, but be enough of an amateur to identify issues and send patients to the right people (who do good work) to get the help they need. It all has to go happen in conjunction and everyone is different....

 

[jonnylingo]

Regarding shared medical appointments:

At Swedish Medical in Seattle:




Also done at Cleveland Clinic:

http://my.clevelandclinic.org/patients-visitors/prepare-appointment/shared-medical-appointments

 

[kstarm]

to me, chronic pain is really a phychiatric/psychological issue. we all know that pain from a disc herniation doesnt last decades, cause you to look for disability, etc. unless there is some concomitant psychiatric pathology. behavioral therapy/ supratentorial treatment is definitely the way to go in this population. i think that i have just become so jaded that when a patient has chronic pain but no hard findings to support it, i just shut down because i am not the right doc for them. im not going to tout the mindfulness psychobabble because im not a psychiatrist/psychologist and have no desire to be one. you have something wrong with your body, im your guy. something wrong with you brain, go see someone else.

I am not very good with these issues either. I wonder what our responsibility should be in addressing them, or what new fellows should know. With 50-70% of patients with chronic pain having comorbid mental health issues (bipolar, depression, anxiety, etc) should we be expected to have more skill in addressing this? Is referring to psych all we need to know? This is clearly an underlying issue that is playing a significant role in their pain perception.

I think of primary care and the relatively little amount of time that is spent learning MSK medicine and pain management when some of the most frequent complaints they see patients for is pain and MSK related. I wonder if there will ever be a shift in how we educate our physicians. Until recently only 3% of US and Canadian medical schools had any dedicated pain curriculum.

 

[melancholy]

I am not very good with these issues either. I wonder what our responsibility should be in addressing them, or what new fellows should know. With 50-70% of patients with chronic pain having comorbid mental health issues (bipolar, depression, anxiety, etc) should we be expected to have more skill in addressing this? Is referring to psych all we need to know? This is clearly an underlying issue that is playing a significant role in their pain perception.

I think of primary care and the relatively little amount of time that is spent learning MSK medicine and pain management when some of the most frequent complaints they see patients for is pain and MSK related. I wonder if there will ever be a shift in how we educate our physicians. Until recently only 3% of US and Canadian medical schools had any dedicated pain curriculum.

I think being able to identify potentially the most pressing co-morbidities or triggers that are impeding progress with your treatment plan is the main focus. Since you may have had more of a relationship with the patient and may have a better understanding of their treatment course and what may be going on in their lives, you would potentially be able to provide more useful information to a mental health provider (as an example) to help guide their evaluation and treatment. Perhaps also identifying what sort of conditions may be amenable to different types of treatment modalities such as biofeedback, etc. Finding something that can motivate the patient to get their butts off the chair and moving.

 

[101N]

I am not very good with these issues either. I wonder what our responsibility should be in addressing them, or what new fellows should know. With 50-70% of patients with chronic pain having comorbid mental health issues (bipolar, depression, anxiety, etc) should we be expected to have more skill in addressing this? Is referring to psych all we need to know? This is clearly an underlying issue that is playing a significant role in their pain perception.

I think of primary care and the relatively little amount of time that is spent learning MSK medicine and pain management when some of the most frequent complaints they see patients for is pain and MSK related. I wonder if there will ever be a shift in how we educate our physicians. Until recently only 3% of US and Canadian medical schools had any dedicated pain curriculum.

Pain training has to change. If you look back from where we are now you see a parallel rise in pain dx and opioid Rx'ing starting about 1990. This is also the same time Wolfe made 'suffering' a medical disease by coining the term fibromyalgia syndrome, and Portenoy, et al, had the brilliant idea to use opioids for it. This isn't coincidence. Both have since realized their mistakes, but too late, the horse has left the barn.

 

[SCIronMike]

Looks like they had the same complaints that many Kaiser physicians probably do.

Not being able to treat outside of algorithms/system protocols, too many patients, and proposed cuts to pensions.

Predictions on how Kaiser doctors will respond when it's their turn?

I've been at Kaiser for a little more than 4 years now. I still think it is a great place to practice and can't imagine leaving. I think the patient load is very reasonable and compensation is fair. I very much doubt pension cuts will happen. The medical group is profitable and has continued to do well under the ACA.

 

[Disciple]

I've been at Kaiser for a little more than 4 years now. I still think it is a great place to practice and can't imagine leaving. I think the patient load is very reasonable and compensation is fair. I very much doubt pension cuts will happen. The medical group is profitable and has continued to do well under the ACA.

This is from a different forum, but does this concern you at all?

Interesting discussion. I am not an anesthesiologist, but I used to work for TPMG for several years and had to leave due to move to So Cal. First of all, you guys have to know that different Kaisers are very different. TPMG is very different from SCPMG- one is a corporation, the other is a partnership. In 3 years, you hopefully become a shareholder at SCPMG and start getting a K1 instead of W2 thus all the tax benefits. At TMPG, you are a W2 employee forever. I have a very close anesthesiologist buddy at TPMG about 15 years in and it's all supervision. He hates it and counts days to retirement. By the way, at TPMG, earliest you can retire is 55 not 50 and I believe you have to do 30 years for full retirement benefits. Not sure about SCPMG, but probably similar.

Overall, there are lots of benefits to being at Kaiser and lots of drawbacks. Once you become a shareholder, it's VERY hard to get rid of you. You also practically can not be sued. All patients sign arbitration agreement and vast majority of issues get settled quickly. Pension is also very nice and at TPMG it was roughly worth 3-4 M$ for someone making 3-400k. You get to keep your medical plan for life if you retire from KP. Now- you are cog in a wheel, absolutely no say in terms of how you practice. This is very rough mentally. Also, since everyone is on salary, docs quickly become very lazy. All docs, not just particular speciality. Goal in life become not to see parents at all costs. Another huge issue- your staff does not work for you and is all unionized. Your bonuses also depend in part on staff evaluations, so technically you work for them. Maybe not such a huge deal for anesthesia since you are not office based, but I am sure OR nurses get to evaluate anesthesiologists. I also hear that SCPMG now has a 16 billion $ pension fund short fall. How do you think they will be dealing with it?

 

[SCIronMike]

This is from a different forum, but does this concern you at all?

About half of the info is there is inaccurate. Yes, we are a partnership at SCPMG. I get a schedule K1. We can take early retirement at 58. Retirement is mandatory at 65. Your pension vests at 10 years of service. it is 2% per year for the first 20 years, and then 1% per year for each year after that. I've never felt that I've been told how to practice other than to be mindful of the cost of brand name medications and certain diagnostic tests. Yes there are certain lazy docs, but the vast majority are good partners. Yes, all of our staff are union employees, but other than a couple bad apples, they are REALLY great. My bonus has nothing to do with how my staff evaluates me. It has to do with patient satisfaction scores, patient access to our care, and documentation / closing charts. We also have a draw each year of the medical group is profitable. In every year that I've been there (4 years now), SCPMG has been extremely profitable. I seriously doubt there is any pension fund short fall. Even if the pension evaporates, we still put $51k / year into our Keogh and 401k plans. That alone should generate enough to retire on at typical rates of return.

 

[clubdeac]

About half of the info is there is inaccurate. Yes, we are a partnership at SCPMG. I get a schedule K1. We can take early retirement at 58. Retirement is mandatory at 65. Your pension vests at 10 years of service. it is 2% per year for the first 20 years, and then 1% per year for each year after that. I've never felt that I've been told how to practice other than to be mindful of the cost of brand name medications and certain diagnostic tests. Yes there are certain lazy docs, but the vast majority are good partners. Yes, all of our staff are union employees, but other than a couple bad apples, they are REALLY great. My bonus has nothing to do with how my staff evaluates me. It has to do with patient satisfaction scores, patient access to our care, and documentation / closing charts. We also have a draw each year of the medical group is profitable. In every year that I've been there (4 years now), SCPMG has been extremely profitable. I seriously doubt there is any pension fund short fall. Even if the pension evaporates, we still put $51k / year into our Keogh and 401k plans. That alone should generate enough to retire on at typical rates of return.

Sounds like the VA

 

[SCIronMike]

Sounds like the VA

I think we get paid quite a bit more than the VA though.

 

[clubdeac]

I think we get paid quite a bit more than the VA though.

I don't think so Feel free to PM me and we can have a pissing contest

 

[hyperalgesia]

I think we get paid quite a bit more than the VA though.

Kaiser pension is 2x VA for the first 20 years and we get no keough. Federal govt pension is 1% throughout (unless you got in a very long time ago). Kaiser is a better for the career path generally speaking.