Assembly Standing Committee on Health

Good afternoon. We will begin now the Kaiser Permanente's Behavioral Health Care System informational hearing set for May 6th in Room 1100 as a part of the Assembly Health Committee. I want to thank everyone for joining today. Behavioral health disorders have come to represent a complex challenge for California, the enormity of which is evidenced on our streets, in our schools, in small rural communities and in our largest cities. Kaiser is a key partner in the delivery of behavioral health care in this state as it insures over 9 million Californians.

However, over the last 14 years, there have been several enforcement actions taken by the Department of Managed Health Care specific to Kaiser's failure to provide timely access to behavioral health, to communicate services clearly to enrollees, to handle enrollee grievances, and more. This culminated in the most recent settlement agreement between the Department of Kaiser between the Department and Kaiser in October 2023 and the corrective Action Work Plan, released initially in August of last year and revised this March.

This work plan focuses on eight corrective action areas, oversight, access, network and referrals, grievance and appeals, future strike contingency, mental health parity, member communications, and continuous improvement and comprehensive review. That is a lot of work, some of which I understand has already begun.

But we simply cannot accept repeating the cycle that has played out before and failed to provide necessary behavioral health care to Californians that need it, as is guaranteed under law. I want to note that other health plans also have deficiencies that lead to enforcement actions by the departments. But this pattern is exhibited by the largest health plan in the state and that deserves attention. Members of the Committee, I want to just open up for any initial comments that we might have.

Thank you, Assembly Member Patel, for joining. And I'm sure other Members, as is this time slot tends to be, will come in across the duration of our hearing. We'll start with our first panel, which is an overview of DMHC enforcement actions against Kaiser and the Corrective Action Work Plan. Today with us we have Mary Watanabe, Director of the Department of Managed Health Care, Dan Southard, Chief Deputy Director for the Department of Managed Health Care, Sarah Ream, Chief Counsel, Department of Managed Health Care.

We'll begin with our first panel, which will provide an overview of the timeline of the Department of Managed Health Care enforcement actions against Kaiser, culminating in the Corrective Action Work Plan. Director Mary Watanabe and Chief Deputy Director Dan Southard and Chief Counsel Sarah Ream are here to answer any questions as well. Director, please go ahead.

Hi. Good afternoon. I'll skip my name and introductions of my team. I appreciate the opportunity to provide an overview of the significant actions the DMHC has taken over the last 12 to 14 years to hold Kaiser accountable for providing timely access to behavioral health services.

The Department's mission is to protect consumers' health care rights and ensure a stable health care delivery system. We do this by regulating 140 health plans that cover nearly 30 million Californians, and now it's 97% of state regulated commercial and public health plan enrollment in the state.

Before I talk specifically about Kaiser, I believe it would be helpful to start with a brief overview of the ways that the DMHC monitors health plan compliance with the law, including timely access to behavioral health services. The DMHC conducts routine medical surveys or audits of health plan operations every three years.

We also may conduct a non-routine survey at any time when a specific issue or problem requires a focused review of a health plan's operations. We also monitor complaints to our help center and may conduct a non-routine survey or take enforcement action if we find patterns of noncompliance.

The DMHC takes enforcement actions against plans that violate the law. These violations are often discovered by our help center. We also received approval from the 2021 state budget to conduct focused behavioral health investigations of all full service commercial health plans regulated by the Department with the intent to investigate an average of five plans a year.

The purpose of the investigations is to understand the challenges members face accessing behavioral services with a focus on identifying and evaluating barriers experienced by enrollees and providers. We've completed two phases of the behavioral health investigations which include nine health plans, and we've issued final reports detailing the results of the investigations and required corrective action plans.

The third phase of the investigations is expected to be completed this summer and we anticipate completing all investigations by 2029. Now I will provide a brief overview of the actions we've taken over the last 12 to 14 years related to Kaiser's behavioral health system.

In 2012, we conducted a routine survey of Kaiser's behavioral health services and identified deficiencies related to the delivery of behavior health services. The findings resulted in a $4 million fine against Kaiser, and in 2015 we released a follow up survey report that determined some of the deficiencies had not been corrected.

Then in 2016, through another routine survey, we identified a repeat behavioral health deficiency, which was included in our enforcement investigation into the deficiencies that were discovered during the 2012 and 2015 surveys. In 2017, we reached a three year settlement agreement with Kaiser.

Kaiser agreed to improve its behavioral health quality assurance program and take action to improve care related to the deficiencies. The settlement agreement required Kaiser to hire an expert consultant to help develop quality assurance measures to assess whether members had access to behavioral health care.

Despite these actions, the DMHC continued to receive complaints regarding timely access to appointments, including ongoing complaints from the National Union of Healthcare Workers, or NUHW. And in 2021, the DMHC's help center received a 20% increase in behavioral health complaints for Kaiser.

In response to the increased complaints, on May 16th of 2022, we initiated a non-routine survey of Kaiser's behavioral health delivery system in both Northern and Southern California. The non-routine survey identified 11 deficiencies in Northern California, eight deficiencies in Southern California, and one statewide deficiency.

The main areas of deficiency were during the non-routine survey related to the plan's inability to provide timely, urgent, non-urgent, and follow up behavioral health appointments. We posted the non-routine survey report on our public website on February 22nd of this year.

In August of 2022, we also initiated a targeted enforcement investigation to examine if Kaiser was providing timely access to appointments during the NUHW member strike that started on August 15th of 2022 in Northern California. This strike lasted 10 weeks.

State law requires health plans to provide enrollees with medically necessary care within timely access and clinical standards at all times, including during a strike. While the non-routine survey examined Kaiser's behavioral health operations in both Northern and Southern California, the enforcement investigation was focused on the strike response in Northern California.

On October 12 of 2023, we announced a settlement agreement with Kaiser in which Kaiser committed to undertaking a systemic overhaul of its behavioral health care delivery system to improve member experience, access to care, and quality oversight.

The settlement agreement included a $50 million administrative penalty or fine that requires and requires Kaiser to make significant investments totaling 150 million over five years into innovative programs to improve the delivery of behavioral services for all Californians beyond Kaiser's existing obligations under the law.

Kaiser paid a $40 million penalty on October 19th of 2023, with the remaining $10 million suspended upon completion of corrective actions. Kaiser will be required to pay the suspended $10 million penalty should it fail to meet the obligations of the settlement agreement.

And I'll just note, the settlement agreement resolves both the 2022 non-routine survey findings and the 2022 enforcement investigation related to the strike response in Northern California. As part of the settlement agreement, Kaiser was required to submit a Corrective Action Work Plan.

The Corrective Action Work Plan is Kaiser's self drafted initial blueprint describing in more detail how they plan to address the issues in the settlement agreement, including a timeline with key dates and deliverables. Kaiser submitted an initial Corrective Action Work Plan to the Department on February 1st of 2024. It lacked detail and specificity about the steps the plan will take to address the corrective action areas. The DMHC conducted meetings with Kaiser to further discuss the measures Kaiser will implement in each of the corrective action areas.

Kaiser submitted a final Corrective Action Work Plan on August 15th of 2024, which was accepted and posted to our website on January 23rd of this year. An updated Corrective Action Work Plan was posted to the website on March 12th of this year, which incorporated the findings of the non-routine survey.

The DMHC will closely monitor Kaiser's progress in meeting the terms of the settlement agreement and the Corrective Action Work Plan during mandatory quarterly meetings where Kaiser is required to submit quarterly written reports and updates on the progress it has made. The first meeting was held on April 3rd of 2025.

We are currently working with Kaiser on the content and format of the first quarterly report and expect to post it to our website soon. In addition to the actions I just described, we will continue to assess Kaiser's compliance with all applicable laws and regulations through our normal review of consumer complaints and regulatory filings.

We'll conduct an in depth on site review of Kaiser's behavioral health delivery system through the non-routine follow up survey and behavioral health investigations where we will validate that Kaiser has implemented what they have reported in the quarterly meetings.

Ultimately, the metrics by which the DMHC will hold the plan accountable is whether the plan is complying with the law, which we refer to as the Knox-Keene Act. As part of Kaiser's corrective actions, they voluntarily proposed to develop a process to reimburse members who attempted to but were unable to obtain timely and clinically appropriate behavioral health services within Kaiser's network.

We're currently working with Kaiser on the reimbursement plan, and the plan will periodically report the status of its implementation and completion of the reimbursement plan to the DMHC, and we'll post more information on our website when it's available. Finally, in October of 2024, the DMHC opened an investigation to better monitor Kaiser's activities during the strike of NUHW members in Southern California.

Enforcement investigations are confidential pursuant to federal and state laws, but I can say that we have met with Kaiser on at least a weekly basis since the Southern California strike started and I, along with members of my leadership team, attended an on site investigation to monitor Kaiser's response to the strike at the end of October.

As of yesterday, the DMHC help center has received 153 complaints since the strike started nearly seven months ago. Less than a third of those complaints involve a complaint about timely access to care. Most of the complaints are from enrollees who want to see their striking provider rather than another provider offered by the plan. In comparison, during the 10 week strike in Northern California in 2022, we received nearly 500 complaints to our help center and the majority of these were related to timely access to care.

We take all complaints related to access to care very seriously, including complaints and calls to our help center and the numerous letters and complaints we've received from NUHW. We investigate and look into every issue that is raised. This may include reviewing medical records or other documents, listening to phone calls, or interviewing witnesses.

We may discuss specific cases and issues that have been raised during our weekly meetings with Kaiser and request additional data where appropriate. I am personally attending these meetings along with Dan, Sarah, and a team of our Office of Enforcement. In conclusion, I'd like to encourage consumers having problems accessing behavioral health services to contact our help center.

You can find more information on our website at dmhc.ca.gov. Just a reminder, this allows us to help individual consumers get the care they need and provides valuable information about whether Kaiser is complying with the law. That concludes my presentation. I believe I've covered your questions in my presentation. I'd be happy to go through the questions or we can just open up to your questions.

Thank you. I actually will just start with a baseline question because I think it is foundational to perhaps this discussion in the next panel as well. And just wanting to be able to, for the sake of transparency, have conversations to, for everyday Californian for their ability to understand. When we talk about timely access to care. You've referenced that often, both in terms of some of the deficiencies that were found and a critical piece of the corrective action as well as the complaints that you heard since the strike. What does that look like for the average person?

Yeah, I'll just say we have very specific requirements in the law about how quickly you should get an appointment. I will just say, when I've talking to the average person I'll say generally you shouldn't wait more than two weeks to get an initial appointment.

There's also requirements around urgent and emergent appointments, which should be within a few days. We've also had a number of laws recently that have required a follow up appointment within 10 days. And then I would just note that SB 855 also required plans to arrange for care out of network if they can't provide an appointment in network.

If they fail to do that, the enrollee can go out of network on their own. So we've significantly expanded the consumer protections in law around timely access and the requirement on the plans to either ensure they can meet those standards or arrange for care out of their network.

Thank you. And just another baseline related to this, what you raised in terms of the number of the nature of the complaints that have been received in both of those points in time related to the strike. What does continuity of care, what should continuity of care look like in behavioral health?

Dan Southard, DMHC. I think for... Excuse me. Continuity of care in the behavioral setting is utilizing the acceptable standards of care. I think generally when we're talking about that, that the enrollee is able to see the same provider on an ongoing basis. So generally that's what we're looking for in a continuity of care issue.

Maybe I'll just add, I know one of the questions that comes up a lot when we talk about parity and mental health parity is around continuity of care and continuing to see your provider. Obviously during a strike, when your provider is on strike and unable to see you, you'll have to see someone else.

For any of us that have our own lived experience, either ourselves or with a family member, you can probably understand if you have cancer, diabetes, a chronic condition, and your medical provider is out on leave or on vacation, it may not be as big of a disruption to see someone else that's trained in that specialty versus if you have a mental health condition, you've had trauma, assault, violence, to see another provider during a strike, during a disruption.

While that may meet the requirements of the law, I want to acknowledge that that relationship with your provider is very important. I think it's an issue we hear a lot about in this context. And again, I think this is separate from mental health parity and the very strong federal and state protections we have. This is the reality of what you need when you have a behavioral health crisis is probably very different than what you need when you have a medical condition and why that relationship with your provider is very important.

We likely will never have the workforce we need for everybody to always be able to see the same provider, particularly when we have work stoppages, which is why the timely access standards say the plan has to offer an appointment within the timely access standards. It doesn't guarantee it is necessarily with the same provider or everybody's favorite pediatrician.

But they need to make sure that you are seen and able to be treated. But I just wanted not to acknowledge that there is some differences. I think if you've been through this and you have a behavioral health condition, starting that over with somebody different can be very challenging. We acknowledge that.

Thank you, Director. And that was largely the point that I was wanting to just make sure that we were clear on and had some transparency around that. To the point of timely access to care, I did want to focus on the nature of, well, on the word access in that sentence as well. Another foundational question.

When we are looking at access to care in the behavioral health setting, what in your estimation is the preferred approach and either by statute kind of or regulation in terms of ensuring that that access to care in the initial visitation essentially is provided by a provider that has the ability to assess the, assess the kind of care that is needed?

Yeah, I'll start and Dan and Sarah can jump in here. But I think, you know, the requirements is someone that is clinically appropriate to assess and treat your condition needs to be the person that you see. This often will come up of, you know, does it have to be in person versus virtual?

I think we've seen a lot of success with virtual models for behavioral health, But I think we have reiterated the importance of the enrollee choice. It really is up to the enrollee. If they want an in person appointment, they need to be, the plans need to be able to provide that. I don't know. Dan, Sarah, if you would add anything else about any other requirements around.

Sarah Ream, Chief Counsel for the Department. I would reiterate what Mary said and add on that to the extent we in our help center and other places, we often not often, we sometimes have enrollees come to us and they've identified a particular provider, typically an out of network provider that they would like to see.

And while I certainly I understand that, I feel for them. The timely access does not require that the enrollee necessarily have access to the particular provider that they would prefer. The health plan's obligation is to timely arrange an appointment with a provider who is appropriate for treating that condition, who is appropriately licensed, trained and whatnot.

So we do see some friction there in that what the enrollees may prefer isn't always what is required by law.

I'll just add on quickly how we assess that. So Mary talked a little bit about our routine and non routine surveys. We look at access during those surveys. We look at access issues during our help center complaints. And then something we haven't talked about yet today is our annual timely access.

So on an annual basis, health plans or their vendor have to survey a subset of their statistically relevant subset of their providers to determine if at least 70% of them are offering an appointment within the timely access standards.

And this is the first year we'll be producing data related to the 70% rate of compliance and then holding plans accountable to that.

Thank you. I appreciate that. I also just want to recognize that the these foundational questions that I'm asking are really taken from the, was it 36, letters of of testimony that was were offered by members at Kaiser who were trying to seek care.

I just want to say to those 36 individuals who were willing to share their stories that were deeply, deeply just painful to read. I can't imagine what it must be like to have to go through the pain of the experience of those that caused members of the public to write in.

I just want to kind of bring their voices and kind of baseline concerns into the room as we proceed through this hearing and honor that because it should be.

There was another kind of theme in there related to access that had less to do with the identification of a particular provider, but more the format of the type of intervention that was offered, group treatment versus in person or one-on-one treatment, provider treatment.

And just for the sake of you all are our agency with the expertise just to be able to provide some baseline information for the public around how DMHC understands the kind of the method of offered treatment as compared to the diagnosis or the assessment. That's Initially made as it relates to access. Like what counts as access?

Yeah, no, and I'll just say, I mean generally it is up to the treating provider to determine the appropriate treatment kind of modality and the appropriate course of treatment. Again, I think we expect the plans to have some oversight of that process.

I will tell you that the use of group therapy is something that we have been taking a very close look at. I will say this was a subject of our investigation, our non routine survey.

I think particularly during the pandemic when we didn't necessarily always have the ability for people to be seen in person and with the increased demand there was, we were hearing a lot of complaints about people being forced into group treatment with large numbers, maybe not the appropriate modality.

So that's something that I think we've been monitoring very closely as well. Again, this is where the complaints to our help center are also very informative. They are a little bit of an early indication of systemic issues.

And so if we start to see complaints about enrollees either, you know, funneled into virtual visit when they don't want to, into maybe intensive outpatient programs when they need something for a higher acuity, or into group therapy, that's something that we look into very closely.

Again, one of the things we do when we get those complaints is we look at the medical record. Sometimes these are voluminous amounts of paper and documents that we get as well as talking to the enrollees to understand their complaints. So I think again we look to the treating provider of what they're recommending.

That should be documented in the medical record. But it just would reiterate the importance of people coming to our help center if they feel like they're not getting the care they need.

As part of the strike in 2022, we amended our contact center's call IVR system to include a prompt number eight, which remains in effect since that time frame to bypass the waiting time in our call center to get to someone quickly who's in need of a timely appointment.

So that remains as well as part of our help center activity.

That's very helpful, thank you. And I'll move now, if it's okay, into the DMHC's role around the. Well first, another baseline question. So obviously you all chose to move forward with doing a non routine survey. In everyday Californians speak, that seems to be a lot of jargon.

But also my sense is it is pretty significant thing for DMHC to do. So just kind of within the context of, of your work overall. Can you give us a sense of how often DMHC is required to be triggered to do a non routine survey and what triggers that for you and in this instance, what triggered it?

Yeah, and I'll just say we don't do it very often. So every three years we go out and do a full blown audit of health plan operations. So, when there's new laws on an annual basis, plans are required to file documents with us.

There's a lot of paper, it's a lot of policies and procedures saying here's how we're going to comply with this new law or how our ongoing compliance works. But every three years we go out and say, okay, how did that actually work in practice? How did you implement that across your operations?

And so we do that every three years for all of the plans we regulate. What happens is if there is a significant enough issue that comes to our attention that we aren't going to wait till that three year cycle comes up, that's when we do a non routine survey.

And I think what we saw before we conducted the 2022 non routine surveys, we saw a significant uptick 20% increase in complaints to our call center. Our help center is significant. And that was specific to Kaiser Behavioral Health Issues. We also had NUHW raising their hand, sending us letters saying we've got problems.

We had been meeting with them since about 2020. I will just say one of the things we try to do is separate what's a bargaining, a contracting employment issue versus what are real access issues. And so we've pushed really hard to get evidence. We need proof.

We can't just, you know, kind of go in in the dark looking for something. So we're really looking for evidence and a reason to justify doing the non routine. And we felt that we had enough to do that in 2022. So we initiated the non routine survey. It's not something that we do very often.

It's certainly not something we take lightly when we do that. It's an indication that we think there's a problem and we're going to look for it. Similarly, open an investigation. We have investigations all the time that are usually related to trends or patterns of things we see at our help center.

Sometimes there's something we read in the media, we'll all start to get emails, our staff will get emails or we'll get letters about an issue and we'll open an investigation.

But this is, this was a very significant point in time that we had both the non routine of Northern and Southern California and an enforcement investigation specific to the strike and all related to behavioral health. Sometimes it's more related to general operations, but this was was targeting behavioral health.

And just to remind everyone, this is in the 2022 time frame. Right. So 2022, a year after the. We were amidst still the impact of the pandemic.

We knew that we were in a behavioral health tailspin, if you will, where, you know, youth, adults were all significantly struggling with their ability to cope with the impacts of the pandemic, the economic insecurity, the life insecurity that was coming in that moment. So I want to thank you for making sure to take that swift action.

And just another foundational question for us. I stated in my opening remarks that Kaiser is a key partner and delivers behavioral health care in the state to over 9 million Californians. Can you give a sense for the panel and the public what I'm going to use a jargon term like market share.

What portion of Californians is Kaiser responsible for through obviously who it insures and then also with the commitment and partnership that the state has with it.

Yeah. And I don't have their breakdown by Medi Cal and commercial individual, small group, large group. But I will just maybe say if we've got close to 40 million Californians, we have 30 million nearly under the DMHC's jurisdiction. So it's about a third of the lives under our jurisdiction. One in four Californians nearly are Kaiser Members.

I think it's one of the many reasons why we took the actions we did. It's also why it's not insignificant that Kaiser has committed to making transformational change. As you noted, they are not the only ones that have issues delivering behavioral health services.

But if Kaiser can truly transform the way they deliver behavioral health services that impacts one in four Californians. That's a very big deal to me. And again, we're requiring them to make investments of 150 million that go beyond just Kaiser. We want them really to be a leader. They are the largest plan in California.

They should be leading in innovation in the behavioral health space. And that's what we're hoping that they'll do with the $150 million.

I think I am in full agreement with you that I aspire to ensure that Kaiser is actually set up to be a leader in this space. And here we are in a hearing that belies that aspiration. I just also wanted to dive in a little bit now to the corrective action work plan.

I think it was very helpful for you to kind of outline the nature of the corrective action work plan. This is a work plan that the Kaiser puts together. We presented it, Committee Members have copies of it. We've digested it thoroughly.

In Health Committee, how would you describe the nature of the corrective action work plan that was submitted to you initially, in terms of the being smart, in terms of providing specific measurable attainable. Well, I don't know. I can't remember what smart tiff.

But you get smarty, smarty, smart goals attainable and actually focused on being able to ensure that we had ability to measure progress against the plan, the stated actions.

Yeah, I mean I'll say in February, I think it was of last year they gave us an initial plan and I will just tell you it was not transformational in my mind. It did not go far enough. It was not the transformational change that I think their Members want to see.

It's why we took months to go literally area by area to talk about what transformational change looked like that resulted in the corrective action work plan that we posted. I think it was in January, which certainly I think gets us closer to transformational change.

The metrics that I think we're all really looking for, the kind of those, those smart goals, I think you see the blueprint of what they've committed to doing to address the areas of deficiency. But I think the actual metrics is what we're going to see in the quarterly reports and I'm looking forward to sharing those soon.

And so I think one of the fundamental things that we have been looking for Kaiser the health plan to do going back to 2012, this is really what a quality assurance plan is, is can the health plan tell us whether their Members are getting timely access to care through the medical groups?

Do they have the oversight to see what is happening both with their medical groups and with their external network? And so a lot of what we're looking at is what are the metrics that the health plan is looking at? What's that escalation process? What's that visibility and accountability?

And so I think you see some of that in the corrective action work plan steps they're taking to correct areas that were identified through both our non routine and the investigation. But more specific measures and metrics you'll see, I think in the quarterly reports.

I appreciate that and we'll look forward to that. And what's the timing for that again?

So we're working with them now. The first one we're still working through kind of the format and what it will look like. So we're closed probably in the next Couple of weeks, we'll have it posted to our website. If I haven't said this already, if you go to dmhc.ca.gov, just search Kaiser settlement.

It'll take to take you to the webpage we have on our website with where we're posting publicly all the documents that we can share, at least the public versions on our website.

Thank you. I think one of the challenges that I had when I was reviewing both the graphic related to the milestone timeline and the corrective action work plan, so that's me, is that there really aren't any dates tied down.

We have a habit in the Legislature for sure with being very specific about dates for completion of particular aspects of implementation.

I'm not really clear what the start date and the end date is associated with this timeline, which makes all the milestones kind of a bit, you know, they're associated with a particular quarter, which makes the milestones pretty amorphous in terms of understanding what the. A confirmation of date. Is there any.

Can you share any visibility or insight into perhaps what might be included in the, in the quarterly report that might get to a level of specificity that would be more transparent for the public?

Yeah, no. So I'll say in the quarterly reports, I think what, what you'll see is more of what has Kaiser done to date to, to make changes to come into compliance that align with what you'll see in the timeline.

I will just note the settlement agreement has, has a date which is essentially two years from when the settlement agreement was signed for Kaiser to make these changes that can be extended. We had a, you know, a strike in the middle of this. We were delayed in approving the, or moving forward with the corrective action work plan.

I will say as a regulator, I'm a little, I'm more, I think I have a little more comfort with quarters because what we've noticed is we went into this with very good intentions collectively.

And as we dig in and actually start to implement, and as Kaiser starts to implement, we're asking for more changes, we're asking for more data. So there is. If we said by this date you have to have this done, it doesn't allow the flexibility for us to say, okay, we want to see you do more here.

We want more data. We have more questions. And again, just, I think unintended things that happen to that may push out those dates. So I think the quarters allow some flexibility. Again, it is Kaiser's blueprint for how they're going to implement this.

And so I think we're tracking on a quarterly basis how they're doing in meeting the timeframes that are in the timeline. And then we do have dates specifically specific in the settlement agreement. And Dan, Sarah, jump in if I, if I miss any of the items here.

Yeah, I just did want to just focus particularly on Area 3, network and referrals, which I know tie into and we tie into the next panel that we will have.

When I talked to Kaiser in one of the conversations I had with them, they spoke to the fact that they'd essentially try to address issues of access by providing non employee providers or kind of opening up the network to contracted providers, essentially.

I think there's in addition to there being a kind of squishiness, sorry to use that word, very technical in terms of the timeline associated with these quarters and the start line and start to date and the end date associated with the corrective action work plan.

Numbers and specific metrics around what that overall portfolio of providers looks like matters to the patient care and patient service bottom line as it relates not only to access but also to continuity of care, which we already indicated is in the behavioral health space a very specific and particular need to behavioral health.

So in the area of Area 3 network and referrals, do you have any recommendations around creating stronger specificity to what has been included in the corrective action work plan that you'd like to speak to?

Yeah, and I'll say, I think when we had the settlement agreement and started working with them on the corrective action work plan, it was maybe didn't necessarily contemplate a strike, let alone a nearly seven month strike.

And so I think we actually have spent the last seven months becoming very, very familiar with their external network, their oversight and visibility into the external network. It was one of the gaps I think we had identified in the settlement agreement is just the lack of visibility of what happened when Members were referred to the external network.

It's something we spent a tremendous amount of time talking about, looking at, trying to understand because of the need to refer so many people to the external network during the strike.

So it's something also I think as we're looking at these quarterly reports, wanting to understand there's a reference to a supply and demand dashboard that you'll see in here.

That's a significant change for Kaiser, the health plan to be able to monitor what that supply and demand dashboard looks like, how many appointments are requested or scheduled on a weekly basis.

So a lot of that I can't understate the amount of time the three of us sitting here, as well as a whole team in my office of enforcement have spent.

We started out with meetings twice a week with Kaiser to walk through this, see the data, have them walk through how they were going to offer a timely appointment to everybody that had to be rescheduled, what that external network looked like, what the contingency network looked like.

So we spent a lot of time going through that and look to see more of that in the quarterly reporting because I think it really is critical for access going forward.

And just looking at the, the changes Kaiser's made since our 2012 and 2013 actions to now, I think some of that they've shared with you in their letter and elsewhere just how they've expanded their network.

And for the sake of us just being clear on both kind of the enforcement aspects for DMHC beyond the fines and what just from an implementation standpoint is DMHC's response to ensure that when a milestone is on this timeline, even quarterly, when it's kind of blown through and starts to kind of be a repeat offender, if you will, quarter over quarter, what are the steps for ensuring that Kaiser comes into compliance for DMHC?

Yeah, I mean, I think at the end of the day, some of this is we default to what's in the settlement agreement. The settlement agreement kind of lays out what Kaiser is required to do. The corrective action plan is the blueprint of how they're going to get there and then the detail of how they're coming in.

Implementing all that is really in those quarterly reports. So again, if Kaiser doesn't implement and correct one of the deficiencies, they may have to pay that additional $10 million. There could be additional enforcement action. So it's, that's one of those things we're talking through in the quarterly meetings to make sure they are on track.

And sometimes because of the strike, things got moved up. You know, things might have been been rearranged a little bit, but that's part of what we're talking through in the quarterly meetings. I don't know if you'd add anything just as it relates to the settlement agreement or other tools we have.

We. Other tools we have include the whole Panel P of enforcement remedies that are in the Knox Keen Act itself. So if, if we were to see new violations by Kaiser, the Department could conceivably bring a new enforcement action against Kaiser outside of the settlement agreement. I don't think we anticipate that we would need to do that.

We certainly hope we don't. But that would be another tool in our toolbox that we could, we could bring to bear if we had to.

Yeah, I think that one of our just challenges of life and particularly within the space is that in order for there to be an enforcement action, right, many years, many, many months and years have to pass. Then there's lawsuit and the settlement of that lawsuit.

And in the meantime, one in four Californians are not getting the care that they, that they need. So there is a timeliness associated with the application of the remedy. And I appreciate the receipt of settlement dollars to be able to support this.

I'm just trying to get at kind of just from again, the everyday Californian who is one of those 36 members of the community who took time to write in a letter of testimony here. What is our collective remedy as things are developing in real time for us to understand whether or not action can be taken and to be able to fix what we know is already a concern.

And I think I can, I can shed some light on that. So I don't. Mary had mentioned our help center, which is staffed by attorneys and non attorney expert staff. And that is really where in real time the rubber meets the road for enrollees.

So if an enrollee is having difficulty accessing care, they can call, they can write, they can email, submit a complaint and they are in real time assisted by our help center staff to get an appointment, get an appropriate appointment, get the continuity of care appointment.

So it is not a situation where folks are falling by the wayside while we implement the settlement agreement and the, the cap, the roadmap we are providing with all enrollees for all health plans providing real time assistance.

Now those help center complaints and those help center interactions help inform our enforcement actions and where we need to go if we're going to do a non routine survey or when we go out and do our routine surveys, I think as Dan said, those are the information that we glean from those help center complaints serve as a bellwether to possible systemic issues.

But just because they're a bellwether doesn't mean they're sitting on the side not being resolved. They're being resolved as they come in. People are getting the relief they need as they need it. So that's something I think we're very proud of.

And it's sort of the settlement agreement, the cap and the help center complaints that work that we do sort of dovetail together to help ensure that California that enrollees in Kaiser and all the other plans are getting the care they. Need when they need it.

Thank you. And I think that that. Thank you for spending some time on that. I'm as I'm sure all of our Committee Members do and every Member of the Legislature does, we get constituent complaints and have a very active constituent services component of what we do as legislators.

And largely those are calls that come in when people like if you're calling in because you've been able to somehow find your Assembly, know your Assemblymember exists, know that they have constituent services. You are on your very last, very last, you know, lifeline for being able to seek support.

So I appreciate that we now have a tool in our toolbox as legislators and as a part of our constituent services to let them know that DMHC has this help center to be able to address these concerns. And I'll certainly make that a part of my communications out and I hope other Members do as well.

You were going to say something.

I just want to add, anytime a health plan denies a service, they're required to include a copy of our independent medical review complaint form in that denial letter in addition to a self addressed envelope to the DMHC's help center. So it's available to them through that process as well.

Great, that's very helpful. I'm going to ask my last question and see if our Committee Members have any questions. So I wanted to speak just get a sense there was $150 million in investment commitments made. Do you have a sense as part of the settlement?

Do you have any updates about that $150 million, where those resources are going, what kind of commitments or investments have been made?

Yeah, we'll have something to share soon. It's over five years so we'll probably have more to share on kind of what you year one looks like. But again I think we've detailed in the settlement agreement some of the areas we're looking for.

But this is really about testing some new models, being innovative, supporting the state's behavioral health delivery system, not just Kaiser. So looking especially I'm excited about maybe some innovative workforce approaches too. So anyways, more to come on that I think we're getting closer to that as well as on the quarterly report.

So just we're getting close on a number of pieces. There's some things we're trying to wrap up quickly.

Thanks. I sit on the benefit of sitting on the budget Subcommitee as well. But so I'm hearing you clearly basically that those settlement dollars not only go to addressing the specific concerns related to this particular provider, but really are intended to be able to support the broader state infrastructure around behavioral health needs.

Yeah, this $150 million is not for Kaiser to fix their systemic issues with behavioral health. This is for, or we call them community investments because it really is investing in some innovative approaches that support the just creative and innovative approaches to delivering behavioral services across the state.

I'm hoping that these are things that could be scaled and implemented beyond Kaiser. But they'll be making those investments over five years.

Okay, thank you. I'll turn it off. Over to my Committee Members. Dr. Patel.

Want to thank you, Madam Chair, for bringing this very crucial hearing to us. Having a Kaiser hospital, major Kaiser Hospital, as well as several clinics in my district. And as you stated, probably a quarter of my constituents are Kaiser Members, especially those that work in public service.

Want to thank you for making sure we understand the terms of the settlement agreement and the process is set forward and even what the fine money is going to provide for us and improvements going forward. I'm trying to understand how we got here. I mean, you provided us this long roadmap of several interventions and fines and agreements.

Is there a continuing workforce shortage in this space? And did we ever get an understanding of why Kaiser wasn't able to meet the behavioral health needs? Are there not projections of these kinds of things that they can access actuarial data as populations shift? What was the root cause? If there is one or several?

Yeah, and I don't know that I could necessarily answer that. Kaiser may have done that analysis. I'll tell you again, going back to some of the themes we saw, going back to the 2012, 2013 enforcement actions, again as Kaiser, Kaiser's an integrated model.

But Kaiser the Health Plan is who we regulate and ultimately hold accountable for patient access. And so Kaiser the Health Plan needs to know what is happening within their medical groups, with their Members.

And so we saw a clear lack of oversight and accountability and visibility into how many people needed behavioral health services, how many providers were seeing patients. What was that demand? I don't know if they were doing projections. I think we can all acknowledge having lived through the pandemic.

The need was huge for our youth that were doing remote school, the trauma of a pandemic. So we saw this huge uptick in demand. I'm optimistic and excited about the stigma that seems to have also gone away. But it's led to this huge demand. And so I don't know that collectively we had anticipated that.

We certainly seem to have a workforce shortage, particularly of those at the masters and above level. It's why I think we really were requiring Kaiser to invest in innovative models. We've had, I know, conversations and other hearings about community health workers, the use of people, peers.

So I think there's definitely an interest in how do we use those with a lower level of education where we can get that people through the pipeline faster. But I don't think it's just Kaiser. This is across the board. I think we recognize a workforce shortage. Again, encouraged by some of the positive experiences.

We're hearing about virtual appointments, which also I think can expand capacity, but wanting to make sure that's appropriate and what the enrollee needs. So again, I think it's, we want to make sure the plans have the oversight for how the care is being delivered and really have the visibility into what's happening.

That's, I think, one of the biggest lessons learned from all of our actions.

I certainly appreciate that and would welcome any kind of materials that I could push out on my Assembly page to make sure the patients in and the members in my community know what's ahead of them and what they can expect going forward. Thank you.

Thank you.

I want to thank you for coming. I think I see you weekly at this point, Director. Definitely want to appreciate you all coming to speak to our kind of the State of behavioral healthcare system as it relates to Kaiser.

I know that you all share a lot of that information as well in our budget sub hearings where we get to dive a little bit more deeply into DMHC's overall practice and regulations and how you all support our behavioral health community in the State of California.

I want to thank you for taking the time to be here with us today. Thank you. We're going to move on now to our second panel which is Perspectives on Access and Quality of Care in Kaiser's Behavioral Health System. We'll have Milton Brown, a Kaiser enrollee. Lauren Fink, Senior Director of Public Policy with the Kennedy Forum.

Cassandra Gutierrez Thompson, LCSW, a Kaiser therapist and NUHW Member. And Sofia Mendoza, NUHW President here. First up, I wanted to share that I'm very thankful that these Members of our behavioral health community and providers were open to coming to this hearing and to participating fully.

And I wanted to share that although we did invite Kaiser to be here to an informational hearing entitled Kaiser Permanente's Behavioral Health Care System. We unfortunately don't have a representative from Kaiser Permanente to hear this feedback and to answer questions of this Committee. We were sent, however, a nice little two page letter sent on May 6th.

I'll read from it a little bit.

We do want to provide you and the Members of the Committee with current and accurate information about our behavioral health care goes on and on and then goes on to say that we know in the past we fell short of providing high quality evidence based care in a way that is timely, convenient and easy to navigate.

And just goes on to say a lot of the things that we would be able to read in the recent quarter that we will be would be able to read in the corrective action plan or the recent quarterly review. And I have to say I'm supremely disappointed.

One in four Californians, as we've just heard, are supposedly served by Kaiser in this very important space of behavioral health care. And DMHC was willing to participate and openly participated in an additional hearing.

We have Members and providers here who are open and willing to do so, but yet we don't have the benefit of hearing directly from Kaiser.

And I just want to say for the record, providing a two page letter to this Legislature, where we have an opportunity to actually hear directly from them, engage in conversation about their efforts to be able to support Californians is this to me with that.

I want to thank the panel that is here for taking the time to be able to speak. We have first Milton Brown an enrollee. Thank you Mr. Brown for being here and we'd love to hear your testimony.

Please press the mic.

Thank you so much for giving me a chance to share my experience about my—that my family had with Kaiser. So, I, for 30 years, have been a expert in treatments for suicidal behaviors and a Researcher for 15 years. I was a Professor of Psychology for 20 years.

I run a private practice clinic for suicidal teens and adults, and the biggest trauma of my adult life was when my daughter almost died by suicide. And my secondary trauma was fighting Kaiser to follow the standards of care, follow the law, to save my daughter's life.

I've counted six egregious violations that deviate from the standard of care, including principles recommended by the American Association for Suicidology. So, they're not just my personal opinions. So, my daughter received inpatient care soon after her suicide attempt. And when she was released, she was doing a bit better.

She still had suicide ideation, but she was still doing a bit better. 11 days later was the next psychotherapy contact. So, 11 days without a session. I believe the law states 10 days is necessary, at a minimum, unless the situation is urgent, which I called this immediately. I asked for sessions immediately following her discharge.

I called it urgent because she still had some suicide ideation and psychology research says very definitively, shortly after a suicidal person is released from a treatment facility for suicide risk, they are at the highest risk. It's stronger than any other risk factor that exists ever in psychology research. But 11 days it took.

So, that was very, very disappointing. Kaiser broke the law. The—she was transferred into the intensive Outpatient Program within Kaiser. The full program is supposed to be sufficient, supposedly. Five weeks daily therapy. Well, they offered her four. They said, we can't complete the fifth week because of the strike. Not our fault. Well, it is their fault.

I said, well, can you get her in the next IOP? It's a week later. They said yes. Okay, that's something. And then promptly they rescinded that official statement, denial, changed their mind, no explanation at all. Again, breaking the law when lives are at stake.

I don't think if it was a cancer patient that they would settle for 80% of chemotherapy, but for, for emotional disorders, I guess that's okay with them. After those four weeks of the five, for the IOP that she received, it took a month for her to get the next psychotherapy treatment piece.

And again, upon leaving an intensive program, the risk for suicide is highest upon exiting a program. So, she was left hanging for a month. Every single time, I said, I want immediate appointments, please, somebody who's qualified in suicidal behaviors. It took a month. Way beyond the 10 days required by law.

And again, I call that urgent because that's what suicide research indicates. It's an urgent situation because it's very fragile situation and the response is supposed to be 48 hours. They basically ignored that. They broke the law again.

They, she got a—so, one month after her IOP, she got an outpatient therapy appointment, and I looked at her treatment records just to see what was going on. Well, they said she has a mental disorder. Which one? No documentation about any specific mental disorder. And I know that suicide risk is a collection of risks from disorders, so my daughter had risk of dying because she had panic disorder, post-traumatic stress disorder, and major depressive disorder.

And her psychiatrist at the inpatient facility said she was the most dangerous, the most lethal suicide-attempting teen he had ever seen.

So, a combination of those behaviors in her history, her recent history, with those diagnoses, that I know were a part of her profile that they didn't bother to assess, she was at risk for dying and they didn't have a treatment plan for those disorders because they didn't even have them in the chart. An egregious violation.

Violation of the law. She was undertreated, absolutely, and part of the reason I know that is because she had a second suicide attempt. So, the idea of spending less money to see if the lesser interventions work means, well, somebody in this category could die. And then you'll know, maybe. Or if they attempt suicide, maybe they don't die.

It's a flip of a coin sometimes. And then, you'll know if the lesser, more, less costly interventions work. So, I said finally, enough is enough. Get her the standard of care. There are several treatments, like what I provide at my clinic. We provide dialectical behavior therapy. It cuts suicidal behaviors in half.

So, the people who could die, in that group, about half of them can be saved. I said, please get her DBT. It took four months to get that approved. So, now they—add that to all the other time. Apparently, Kaiser is willing to let her die and deprive her of what I knew from the very beginning.

I said from the very first day, get her DBT. And they, over six months later, said, okay, fine. And with that huge delay, they were basically willing to let her die. Egregious, egregious, egregious. So, my case is not unique. A lot of Kaiser Members come to my treatment clinic.

A portion of them get authorized by Kaiser, and Kaiser supposedly will pay for it. And most of them, it was about a year till they even found out that this treatment that saves a lot of lives, even exists.

So, Kaiser has a watered-down program and client—members—don't know that there is something for real available until they find it out on their own.

And, and then they beg and plead to get Kaiser to cover DBT, done for real outside of Kaiser, and then some of them succeed. And a lot of the Members, they know, they find out on their own, not because Kaiser told them that there's a lifesaving treatment like this, they find out on their own and they say I don't want to wait.

It's not going to be approved, and they pay for it on their own and it is very expensive. It hurts the families. Now, they have two layers of hurt combined.

So, my question is, how many people have to die for Kaiser to finally wake up and do what's right?

Thank you, Mr. Brown, for sharing your testimony today and for speaking to your daughter. And I do hope that she's able to.

She's doing much better. Thank you.

Thank you. Thank you for sharing that as well and for your advocacy for her and for so many others. I don't have any questions at this time. I think we are going to just thank you for acknowledging the parents' perspective and underscore that there are parents in California who are struggling, like you are, for their children, I among them, and I want to thank you for bringing that testimony forward.

We're going to move on to Lauren Finke now and Sophia Mendoza and then we'll hear from Cassandra Gutierrez Thompson. We'll hear from all of the panelists and then bring it back to the Committee for some questions.

Good afternoon, Chair and Members. My name is Lauren Finke. I'm Senior Director of Policy at the Kennedy Forum. We were founded by former Congressman, Patrick Kennedy, who's the author of the Federal Parity Act. We're national experts on mental health and substance use disorder access and parity compliance laws.

We actively engage with state and federal agencies on parity implementation and collaborate with state regulators, legislators, and advocates nationwide. We develop best practice guidelines focused on consumer protections, corrective enforcement actions, and ongoing regulatory oversight, which will be the focus of my testimony. While others testifying today can speak specifically about their experience with Kaiser, I will try to highlight how implementation and enforcement of the state's laws can improve oversight, transparency, and compliance for Kaiser's mental health delivery systems.

So, I'll start with regulatory best practices. California has among the nation's most comprehensive mental health and substance use disorder access laws and regulations implementing them.

The DMHC's role in ensuring transparency and communication on these processes, and progress made, is the surest way to understand if these laws are being implemented with fidelity, now and in the future. Without it, we risk an environment where health plan violations of Californians' rights, including those of Kaiser enrollees, can continue to persist.

Parity enforcement is often mathematical and very paperwork heavy. Ensuring standardized processes is important, as are targeted and clear benchmarks, and transparency on how plans are progressing toward those benchmarks.

The DMHC has powerful tools at its disposal, many of which it has used. The health plans have found—when health plans are found non-compliant, they can employ a number of these mechanisms and can—and can ensure consumers are made whole when any violations that have occurred, they can ensure that they've been made whole with their experiences.

So, several best practices for oversight. First is ensuring consumers are made whole. This should include mandatory reprocessing of improperly denied claims, limiting plans from imposing certain utilization management or other restrictions until they can prove full compliance.

For example, when a health plan has insufficient mental health clinicians in their network, which was found with Kaiser, regulators could require the plan to reimburse members for out of network providers until the regulator certifies network adequacy.

Such a bill introduced this session would require similar processes for Kaiser and I should not—regulators can do this for all plans as part of the regular regulatory scope. Second is strong corrective enforcement and corrective action plans with clear public accountability measures.

Effective plans include clear timelines, measurable benchmarks, defined corrective steps with associated data reporting, independent auditing the model progress. Without seeing such documentation publicly, we feel there is significant capacity regarding the status of Kaiser's open corrective action work plans that prevent the public and Legislature for—from—easily tracking progress. Third is proactive engagement with stakeholders, including enrollees.

Regulators should conduct regular meetings with consumer advocacy groups and pursue organized investigations that include the consumer voice when, when targeting systemic issues. This includes the IMR process. It's really not enough to rely on help center complaints and appeals for Kaiser enrollees.

Proactive enforcement should be the priority here and the consumer voice is important for ensuring that that is a key part of it. I also would love to speak a little bit on legislative oversight recommendations.

The Legislature has sent a number of letters requesting the status of enforcement actions, both to Department and to Kaiser. And so, several approaches that we believe will strengthen oversight over the over Kaiser—first, standardized reporting on enforcement activities.

When inquiring about the status of budget allocations and implementation of legislation, the Legislature should expect responses that point towards clear goals and markers for success and an understanding of where we sit in the current landscape. Second is establishing transparency benchmarks.

The Legislature can require ongoing publishing of regular standardized reports on key comparing compliance metrics, under the federal law.

So, that would include out-of-network utilization rates for mental health providers, provider reimbursement comparisons within a plan, prior authorization denial rates, network adequacy measures, timely access and compliance data. And ultimately, the success of regulatory oversight should be measured by whether Californians can accept access to the mental health care they need, when they need it, without facing discriminatory barriers, as we've heard today.

The issues highlighted by enrollees and providers should be investigated for global systemic compliance issues, instead of only one-off resolution. So, transparency really the name of the game for effective oversight and implementation. Happy to answer any questions. Thank you.

Thank you. Go ahead. Please, go ahead.

Yeah.

Good afternoon, Chair and Committee Members. My name is Cassandra Gutierrez Thompson and I'm a licensed Clinical Social Worker and a proud Member of the National Union of Healthcare Workers. I work in Kaiser's ADAPT program in Southern California and we provide short-term treatment for patients with mild to moderate anxiety and depression.

And I'm here to speak candidly about systemic issues within Kaiser that dangerously compromise mental health care and the wellbeing of both patients and clinicians. In my role at ADAPT, therapy sessions are limited to 30 minutes.

This model creates a factory-like setting where both Clinicians and patients feel like they're on a conveyor belt together, rushed and pressured to watch the clock. This approach is not aligned with clinical standards, that most therapy sessions are 45 to 50 minutes long, which provides the needed depth for effective therapy. Kaiser's compressed format undermines the therapeutic process.

Patients get shortchanged of the healing they deserve. Kaiser hires good clinicians, but it's really hard to stay a good clinician in this broken system. ADAPT Clinicians face relentless schedules, often seeing 14 to 16 patients back-to-back, without adequate time for documentation or attending to patient needs. This pace forces us into unethical dilemmas—either compromise patient care or neglect our own wellbeing.

We don't even have time for bathroom breaks. Many dedicated therapists burnout, which is one reason why Kaiser continues to have a problem recruiting and retaining clinicians. Patients seeking therapy are routed through call centers lacking clinical assessment, often leading to inappropriate placements.

For instance, individuals with PTSD, OCD, or other complex conditions that are not appropriate for ADAPT, in the program I work in, are still placed on my calendar, only for me then to have to apologize that I won't be the therapist who works with them.

The patients get shuffled, they have to wait for another appointment and then they have to retell their story to someone else, which is not only retriggering, but it delays them actually getting served.

Even worse, sometimes we're pressured to keep these higher acuity patients and are told to only treat their depression and anxiety, which dangerously ignores their more complex needs. Furthermore, and I'd like to say too that technically Kaiser can check a compliance box if they saw that patient within 10 days, but again, that patient was not truly served.

Furthermore, Kaiser expects therapists to be lifespan generalists, treating patients from infancy to old age, across all the diagnoses. This one-size-fits-all approach is unrealistic, and it diminishes the quality of care. This model denies patients from getting the true specialized help they often need.

And in 2022, the California Department of Managed Healthcare, DMHC, noted that Kaiser Permanente's over reliance on group therapy sessions, right, rather than clinically appropriate one-on-one sessions, in order to meet timely access standards for mental health care.

Well, in a cruel twist, rather than minimizing the use of groups, Kaiser has begun substituting them with live or even pre-recorded webinars. While these webinars may be educational, they completely lack the therapeutic value of a clinician-led session and should not be considered replacements for genuine therapy in any way.

Despite mental health parity laws, Kaiser operates a two-tiered system. Mental health services are underfunded and understaffed, compared to the medical department. At Kaiser in Southern California, where I work, behavioral health employees are compensated between 25% to 50% less than comparable medical surgical employees.

And that's when comparing workers with similar level of skill, education, licensure requirements, and patient care responsibilities. Additionally, there's a disparity within Kaiser's own behavioral health system. Northern California mental health workers receive more staffing resources, more patient care time, higher pay, and pensions. Southern California clinicians feel undervalued and overburdened.

After six months of striking, NUHW has just reached a tentative agreement with Kaiser, but we still haven't received a fair contract or true equity with our colleagues. It's a bitter pill, that we returned to work this week feeling that Southern California patients matter less to Kaiser, and even worse, that Kaiser is allowed to get away with this.

It's important to note that during our six-month strike, Kaiser repeatedly told the media, regulators, elected officials, and their own Plan Members that everything was fine and that they were in full compliance with the law. But it was not true. We are advocating for systemic changes that prioritize ethical and effective mental health care across California.

NUHW has proposed solutions, including mandating timely access to care, ensuring clinicians have adequate time for treatment and documentation, addressing chronic understaffing, improving working conditions to help retention, and challenging Kaiser to invest in a robust behavioral health system, instead of paying fines after the fact. Mental health is health.

The current state of care at Kaiser would be unacceptable in any other medical department and our Southern California patients deserve better, and so do the mental health professionals committed to their care. Thank you so much for your time and for listening.

Thank you. Please go ahead.

Madam Chair, Members of the Committee, I'm Sophia Mendoza. I'm the President of the National Union of Healthcare Workers. I do have a prepared testimony, but first and foremost, I would like to echo the disappointment that Madam Chair expressed about Kaiser not being here.

We believe that it's going to take all of us to address the needs of the mental—of California's mental health needs, and it merits all of our engagement, and unfortunately, this sort of behavior is something that we are used to with Kaiser, right, where there's just a lack of engagement, especially with the folks who actually provide the care and see their patients day in and day out.

So, last year, I was honored to succeed NUHW President, Emeritus Sal Rosselli, who led our Union since its founding in 2009 and led our predecessor Union since 1988.

When I look at everything that we've heard here today, I conclude, and I hope that you do too, that the root of the problem is the ongoing systemic undervaluation of behavioral health care by Kaiser Permanente. Kaiser simply does not give behavioral health the same priority that it gives medical surgical care.

All around the state, we've heard the same refrain from Kaiser Plan Members. If you break your arm, if you have diabetes, you'll get great care, but if you have depression or anxiety, don't count on getting any help. We must be clear; there should be no difference in the priority given behavioral health care and medical surgical care.

There should just be health care. That's the whole principle of behavioral health parity, which is required by law. Our state's health plans and medical groups must be held accountable to ensure that their patients thrive, not only in body, but also in mind.

In the 1990s, a series of strikes led Kaiser's CEO to approach the leaders of Kaiser unions, including Sal, and proposed building a constructive relationship, one where workers had a real voice in determining staffing levels, shaping how care was delivered, and striving for the best patient outcomes.

Over many years, that constructive relationship allowed us to make Kaiser our state's best place to receive and to give medical and surgical care, earning it the reputation that it enjoys today. Unfortunately, Kaiser's 5,000 behavioral health providers in Northern and Southern California never received equal priority.

In 2010, these workers helped form NUHW, but the constructive relationship they sought was never extended to them. In fact, Kaiser's treatment of its behavioral health employees since then has been punitive. In Southern California especially, Kaiser's punishments have been harsh. In 2015, Kaiser Southern California eliminated the Defined Benefit Pension for new behavioral health employees.

On the other hand, that benefit continues to be enjoyed by nearly every other Kaiser employee statewide, to this day. From 2011 to 2024, Kaiser Southern California behavioral health employees received a 0% cost of living increase in seven different years. On the other hand, Kaiser's medical surgical employees received raises of at least 2.75% every year.

Why has Kaiser treated its behavioral health providers this way? Because Kaiser does not value behavioral health care like it values medical surgical care. And when the state's largest health plan doesn't value the behavioral health of its members, it's like pouring gasoline on a fire in a state that is being consumed by, by a behavioral health crisis.

When Kaiser officials are asked about how they're responding to this crisis, they often say they have difficulty recruiting and retaining staff. We must ask, what kind of employer would address labor market challenges by stripping pensions and freezing wages?

The fact is, if this were any medical field other than behavioral health, Kaiser would respond to the workforce shortage it bemoans with recruitment bonuses, retention bonuses, enhanced cost of living increases, and more. But Kaiser doesn't value behavioral health care like it does medical surgical care. That is the root of the problem.

And NUHW Members aren't the only ones who know it. DMHC has cited and fined Kaiser for behavioral health violations far more frequently and seriously than any other health plan, imposing sanctions in 2005, 2009, 2013, 2015, 2017, 2021, 2023, and twice, so far, in 2025.

In 2023, DMHC levied a $50 million fine against Kaiser, as part of $200 million in settlement penalties, the largest ever in California. I do want to note, though, that of their $115 billion in total revenue, this $40 million is nothing.

And I also want to note that, in terms of the corrective action plan, it does not even mention anything about increasing staffing provisions, which is what we really believe will solve this crisis. You know, but it doesn't have to be this way, right? Kaiser has $66 billion in reserves.

In 2024, Kaiser committed to investing $9.3 billion in two newly acquired out-of-state hospital systems, in Pennsylvania and North Carolina. Also in 2024, Kaiser increased rates by 13% for the CalPERS basic plan.

There's no reason for Californians to be paying Kaiser record high premiums while still being denied behavioral health care that meets the minimum requirements of the law. For a mere fraction of its billions of premium dollars, Kaiser could fix its badly broken behavioral health system.

This weekend, we reached a tentative agreement to end our most recent of many strikes to make Kaiser change its misplaced priorities. That strike, which has lasted more than six months, is the longest behavioral health strike in our nation's history, and NUHW Members are voting on the tentative agreement as we speak.

The agreement is a compromise that provides more time for behavioral health Clinicians to provide follow up care for patients, and while annual cost of living increases have been restored over the life of the contract, behavioral health employee wages will fall further behind those of comparable medical surgical employees.

And in another example of punitive treatment, Kaiser would not allow NUHW Members to return to work Monday morning. If they had wanted to return to work last week, before the tentative agreement had been reached, they would have been welcomed with open arms.

Unfortunately, the tentative collective bargaining agreement does not give Southern California caregivers as much patient care time, outside appointments, as their Northern California counterparts receive, and it doesn't yet achieve the full parity of compensation that behavioral health clinicians deserve and that is required to recruit and retain the number of clinicians Kaiser needs.

In order to take the next steps to ensure Kaiser Members receive the behavioral health care they need and have paid for, and to ensure that behavioral health caregivers are valued, we must chart a new course, both at the Capitol and in the workplace.

At the Capitol, NUHW is sponsoring AB 1429, which will provide Kaiser Plan Members who need behavioral health services with relief by streamlining their access to out-of-network care. We're also sponsoring SB 747, which will gather data needed to address the compensation disparities highlighted by NUHW Clinician, Cassandra.

Legislators and Administration Officials must also consider how DMHC can be strengthened so it can address behavioral health care failures in real time. We believe the state must impose corrective actions that go beyond systems and process fixes, to include outcomes validated by the independent examination of medical records.

In the workplace, despite the long history of violations, despite the strikes and despite the takeaways, NUHW caregivers remain ready to chart a new course with Kaiser that restores caregivers' rightful voice in staffing and patient care. Kaiser has 9.4 million Plan Members in California.

If we are successful in helping Kaiser embrace and implement true behavioral health parity, by valuing behavioral health care as much as it values medical surgical care, and by investing in it accordingly, it will be a game changer, not only for these Plan Members, but for our state's entire health care system.

I thank the Chair and Committee who have shown that you recognize the importance of behavioral healthcare by holding this hearing. I thank you for the opportunity to speak with you today, and I believe that together we can make this change.

Thank you so much for that testimony. I will bring it back to the Committee for any questions or comments and thank you. Assemblymember Carrillo.

Thank you, Madam Chair, and thank you for the presentation. As a representative of Southern California, it's concerning to hear that employees are treated differently in Southern California versus Northern California, and that translates into patient care. You don't have to tell us why, maybe you cannot, but in your personal opinion, why is that?

Why is there a preferential treatment between Southern California and Northern California?

I mean, in general, we believe that, that Kaiser does not invest enough in its behavioral health care, north and South, right? I, I don't know. You would have to ask Kaiser, to be honest, right, like, why the difference in treatment? Yeah.

Thank you for that. That's basically all I wanted to say—that it's troubling hearing that Southern California patients, because again, it translates into patients. Yes, the employees are the ones suffering—the different treatment. But again, it just translates to the patient care.

Because obviously if they're not treated the same and they're just not being able to get equal treatment across the way, across the organization, it's the patients that are suffering the consequences.

I agree with you, and what I will offer is when we have asked that, asked Kaiser directly, right, they, they wouldn't dignify the question most of the time, and then we did get an answer, and they said there are different geographic regions, and a lot of our members feel discriminated against. And, are you talking about different demographics?

Right? Geographic regions is the answer we were given. And so, our Southern California employees feel discriminated against, that, you know, we earn less, that we're given less, we still don't have a pension, and that 100% trickles down to our patients.

Yeah. That goes even beyond to the deep concern because, you know, communities that are not fairly represented, too. But anyway, thank you for allowing me to make the comment.

Thank you.

Thank you, Assemblymember Carrillo. Assemblymember Schiavo.

Thank you so much for being here today. Thank you for sharing your story. And there's so many concerns raised by this panel, really, and ones that I share, as a Kaiser patient myself, and family members in Kaiser who have had some of the struggles that were described today.

And, you know, one of the things I wanted to ask about a little bit more is that we know that Kaiser has a Corrective Action Work Plan, and that the 2023 Settlement Agreement between Kaiser and DMHC cited Kaiser for violating the Mental Health Parity Act.

And specifically, the Settlement found that Kaiser prohibits patients with mental health conditions from scheduling more than one appointment at a time.

And so, even though that allows for, you know, patients with medical conditions to schedule multiple appointments at a time for, you know, other medical conditions, it seems that in this space, it's just specifically restricted to mental health settings and that, you know, that Settlement Agreement with Kaiser instructs them to fix the violation.

However, the Corrective Action Work Plan, from what I understand, backtracks on these findings and says that simply, Kaiser will conduct a feasibility study to determine whether or not they will, or will not, make this change, which, you know, seems to go right in opposition of the agreement that was made with DMHC.

Are you, Ms. Gutierrez Thompson, are you able to explain why one appointment is a concern, the rule around that, and if you think it's a problem that they're being permitted to investigate themselves and determine whether or not they're going to put this rule in place or not?

Yeah, thank you for asking. I mean, the first thing I'd like to reiterate is that Kaiser's one appointment at a time rule is a clear violation of the Mental Health Parity Law. Health plans are prohibited from setting limitations on behavioral health, right, that are more restrictive than what they place on physical care.

And so, this rule is a violation because the same one at a time limitation does not apply to medical surgery, surgical appointments. And so, on the behavioral health side, a patient can only have one appointment on the books scheduled at a time, and they can't schedule their next appointment until they attend their current one, right?

And the implications of this is that by the time a patient sees me, my calendar is most likely full the next week. And especially if they're, you know, they need to see at 7:00, right, because they, they work and they, they don't have a job where they can have, you know, the luxury of leaving in the middle of the day. And so, clinically, per their treatment plan, a patient may need to be seen weekly.

But with this only being able to schedule an appointment, you know, one at a time rule, it makes it almost impossible for our providers to offer weekly sessions and in any way that provides a continuity of care and to accommodate scheduling for our patients. So, the violations compound, right? First, there's definitely a more restrictive limitation.

And second, the clinical guidelines for ethical and quality treatment that are supposed to be followed are completely ignored. And, you know, to answer your last part, it's a violation, so allowing them to investigate a feasibility study is allowing them to continue violating the law. And as an advocate for my patients, this is harmful and it's frankly unacceptable.

Thank you.

Thank you for that. You know, I really—I hope that DMHC will look into this because it really concerns me that they're backtracking in this way. And, you know, it doesn't even seem like an appropriate comparison to talk about other medical appointments because a lot of times, you know, my kid, for their wellness, they just need one wellness check a year.

But when you're going for mental health treatment, especially if you, you know, are in a serious condition, you need regular appointments, you need that reliability, and, and it's normal to have to go multiple times, for a while.

And so, to have that kind of restriction and barrier when it's so, I mean, everyone knows what a pain it is to set up appointments and match it up with your schedule.

Like if you can just do every Thursday at 4:00 PM, or whatever it is that you can just have reliably on your calendar and know that you can also depend on that to be there.

Because, you know, I've, I've only personally gone to Kaiser one time for mental health and they basically told me that because I was not suicidal, they couldn't see me.

And, and that was, and then they, you know, suggested a group and that was the end of me trying to get my own mental health, you know, services at Kaiser, even though I've been a Member there for, I don't know, 20 years probably. So, and with family members it's been much, much more serious and much, much more difficult.

And even in those serious moments, it's hard to get a once a month appointment with a Kaiser physician or a Kaiser therapist, and then you're, you know, they've often been referred out to outside services, and they are almost all virtual, which, you know, for some folks that doesn't really work for them.

They don't want to be on a screen trying to talk to someone and you know, trying to find someone in their area that you can have a physical appointment with is nearly impossible. The driving, the, you know, I think they were finding appointments that were an hour away and you know, so, this has been a long fight.

I mean, I, you know, many years ago was on the picket line with Kaiser, or with NUHW Members at Kaiser, you know, well before the Pandemic. I mean, this has been a many-year struggle, to really try to make sure that Kaiser is providing the care that they should.

And when you talk about having a $66 billion Reserve, there's no way they can argue that they can't afford it. They can afford to give the care that people need and deserve after paying, you know, in many of our situations for decades into Kaiser, as Members, and really deserve to make sure that that is there for them.

And then, you know, the other struggle that I have with this is that this is, I feel like this sets up a situation. And Mr. Brown, you're welcome as a, you know, professional in this area too to also jump in with Cassandra.

But I feel like this sets up a situation where it's just, you're kind of like—the patients are kind of treading water. You know, you're not ever really getting to the point where you are truly helping them cross that line of getting healthy.

You know, it's just kind of "low-grade depression is okay," that's what it feels like. It's like, well, we're maintaining you and maybe you're not suicidal anymore, so we're going to call that a win and just keep maintaining this low-grade depression, anxiety, whatever the, you know, whatever the diagnosis is.

And it never, there's never time to really, for Clinicians to really focus and figure out what is the treatment that's needed, or to be able to give that—the treatment that is needed to be able to help patients truly heal, you know, in, in the best way that they can. And so, that's what's so frustrating.

It's like you're just stringing people along and wasting a lot of people's time by not truly solving the situation, not really being able to tackle the issues that need to be tackled.

Like you said, the more complicated, you know, diagnoses or, or things like that, that, that need to be addressed, and it's just address depression and anxiety and you know, and ignore the rest of it that might be impacting people's lives.

So, I don't—I'll leave that up to you to comment on, but just, it feels like that's what's happening for a lot of people.

Yeah, I appreciate your understanding of therapy, right. And that therapy happens in the confines of a relationship. And how can you have a relationship with your therapist if you are seeing them every 3-4 weeks or shuffled around and you know, are you going to stay or your therapist leaves?

We have a—we have such high turnover because it's a really hard place to work, right? And so, you know, 100% like what you just said, right? There needs to be continuity of care. And I do so many intakes in my current role—inappropriate intakes, right? Folks that are, should not be sent to my Program.

But and all of these, a lot of these folks will say, well, I tried, I tried therapy at Kaiser and didn't work. And I'll ask them, well, what did that look like? And they're like, well I, I went twice, but it was like once a month. And I just didn't really feel connection.

And they frankly probably had a burned-out therapist or either retelling their story, right? And in my model, you know, you cannot do good clinical work in 20 or 25 minutes. And it's just, it's completely unethical, I think, right? And you're right. I think often, you know, you using the word treading water is accurate.

But what that means is we are delaying healing and patients are suffering. Kaiser is prolonging suffering with these shortcuts. And so, you know, there's, there's so many times where—and again, this idea that all Kaiser therapists should just be lifespan therapists and you should just be able to treat anyone is ridiculous.

What other field would you expect someone, a professional, to be able to treat anyone, right? We need to be able to send people—you've trauma, you need to see a trauma therapist and benefit from EMDR, right? You have a gambling addiction, you should see someone who's qualified and has advanced treatment in this, right?

Like our addiction medicine programs. And so, Kaiser kind of expects us to treat everyone and we do the best that we can because we care. But again, that is only prolonging the suffering of our patients and it's bandaging, right?

And so, 100%, and I think, you know, the adapt this model was created because they can see twice the amount of patients, right? We were launched September 2022, I'm sure you know, very much so in line with the DMHC investigation.

And sure it's—we can crank out a ton of appointments, but what is actually happening in those appointments and a lot of those patients would be better served in a different modality, right? Getting the help that they really need.

And as Clinicians we try to advocate to, to work with certain patients longer, but we get pressure from management. You need to graduate these patients. There's a lot of punitive consequences if you advocate and push back.

And so, at every, you know, at every place it is, it is really challenging and it's, it comes down to how much do you care and how much are you going to go to bat to try to fight for, for your patients?

And you know, if you've seen 14 to 16 patients at the end of the day and you still have to write a bunch of notes, it gets to a point where you just don't have the energy or stamina to do that anymore.

And a patient's care shouldn't be dependent on how much a—someone advocates for them or how much they advocate for themselves or how many times they call a helpline. We're talking about folks who are pervasively, you know, mental illness.

Maybe all the—maybe all the bandwidth they have that day was to get out of bed and shower, and to put the onus on them to call and advocate to get the care that they pay for and that they deserve, is completely unacceptable. And it's heartbreaking, frankly.

So, thank you very much for understanding that the work that we do can only be done in a relationship with continuity of care, with regular appointments, and with enough time, right? So, thank you. I don't know if you want to add anything.

I think the issues of inadequate quantity and delays are really, really obvious. Less obvious is what I believe are pervasive inadequacies in the quality, the content, specifically evidence-based treatments. So, I've asked quite a few of my Clinic clients to describe the details of the services they got. Sometimes I look at their treatment records with them.

And when I was participating in the intensive Outpatient Program, I met other parents, and I asked a lot of very specific questions. And it is common that Kaiser Members barely get evidence-based approaches to care. They are watered down, and they don't meet the standards that I learned in graduate school.

And they—Kaiser doesn't have a reliable process even for having the targets, the written targets in the treatment plan. It's not even mentioned what they're striving for. It's just whatever they can fit into the 30 minutes or an hour, flying by the, by the seat of their pants.

So, they're not targeting high quality treatments by building off of research recommendations. And quite often for many disorders, the research-supported approaches are twice as effective than generic therapy approaches. So, that's, to me, that's an equally big gap as the insufficient quantity.

Thank you. I think Assemblymember Rodriguez had a question.

Yes, thank you. I think—I just want to start by thanking the Chair for coordinating and facilitating this discussion today. I'm also disappointed that Kaiser is not here to speak for themselves, but I also think their absence speaks volumes.

I'm a SoCal Kaiser patient myself, so the challenges you mentioned have a real impact on families like mine and communities like mine in the Northeast San Fernando Valley.

I wanted to follow up on a question that Assemblymember Carrillo had raised, and I don't know if this data is available, but it was about the difference between NorCal and SoCal. Are there demographic differences, that you're aware of, between the behavioral health employees in Northern California and Southern California?

Yeah, I mean, I don't want to speak without having we have some data, but we don't have all of the data. So I, you know, I can't answer your question at the moment.

Okay, thank you. My next question was in regards to some of the comments. Ms. Mendoza, you mentioned strengthening DMHC and Ms. Fink, you mentioned that oversight and enforcement of behavioral health parity requires a lot of technical paperwork, heavy work.

So in your opinion, how should DMHC balance the need for greater attention to this work with the need for more extensive, rigorous investigation of consumer complaints and experiences?

Yeah, great question. And I think the conversation we were just having really gets at this too, where we've got two pretty substantial, pretty important nation leading laws implemented in California. So we have our mental health and substance use disorder parity law, but really what it is is a mental health and substance use disorder access law.

It goes almost beyond what we would think of just simple comparisons between medical, surgical and allows for and mandates medically necessary care for all mental health and addiction. And that's really important because I think a lot of the stories we're hearing today would get at some of these examples of that not necessarily being the case.

And some of the beauty of the federal parity rules that have recently come out are a renewed focus on outcomes data.

And I think what we're hearing a lot of is that outcomes are not what we need them to be or not what we're sort of dreaming of in statute and what we're hearing everyone here saying today about what we need for Californians to have medically necessary mental health care.

So I would say a focus on outcomes data is super important. That's something that the department can absolutely do. That's something that this Legislature can request.

And I think working with the Department on enhanced regulatory enforcement actions and making sure that as we go through these detailed corrective action work plans that they are aligned with the state's and the Federal Government's parity laws, which are really, really protective of mental health and substance use disorder care throughout the whole continuum of care.

So I think those are really important and those are questions that this Legislature can ask as part of its budget process or as part of its ongoing work with the Department. I think making sure that those questions are getting implemented in the corrective action work plans are really important.

Thank you. And lastly, I just want to thank you, Mr. Brown, for coming and sharing today. It's incredibly helpful for us to hear. And we're so sorry for what you've experienced.

Assembly Member Gonzalez.

Hi, good afternoon. I apologize for not being here earlier, but I was watching from, from my office and I want to thank the chair for putting this together, my colleagues and the staff for, for having this important conversation. And thank you, Ms. Rodriguez, for confirming that Kaiser's not here today to be at the table.

I've been at many picket lines with NUHW. I know all too well that that the logo itself is supposed to be, is a sunburst, which is a symbol that, that's reflective of health, healing and, and addressing those unique challenges. That's what literally the K stands for.

The K is supposed to be that human figure which focuses on patient care and well being. Part of that is mental care, mental healthcare services. My very good friend, actually Jessica Duran, who I've known since seventh grade, has been on those picket lines 196 days and counting.

And so seeing her stories, knowing what she's been meant for this business since day one, especially in my personal story, I mean, Jessica has been there through my trials and tribulations. When one of my brothers passed away. Being LGBT early 2000 was not a thing.

And so it helps to have somebody who's probably dealt with someone like me in that world. But I think it's important the work that you guys do because you're saving lives and your work, the work that you guys do and the folks that you do in behavioral health are literally the lifeline.

And for those who have insurance, let's be clear about that too. But we've had many discussions here about other sort of arenas where it comes to medications, when it comes to access with clinics or hospitals and so forth.

And so one of the many things that we've discussed, and I just have to praise the chair for addressing so many of these unique challenges that we as a Committee have to face and the conversations that we have to have.

But learning since I'm from La, there are other parts of the state that exist, especially in our rural areas. We have rural economic disadvantaged areas, economically disadvantaged areas in my area. But I also represent a high AAPI communities, Little Tokyo, Chinatown, Koreatown. But I also represent Boyle Heights and PICO Union, heavy Spanish speaking community.

So I just wanted to know what are the unique challenges that exist for non English speaking or rural and disadvantaged communities in trying to access behavioral health, behavioral health care, specifically at Kaiser and especially given the fact that culturally I'll speak for myself, getting mental health care is not typically a norm because you don't talk about your feelings.

And so if you can address the piece on accessibility.

Sure, I can speak to that. And Jessica is an amazing colleague and clinician, proud to stand on the strike line with her. You bring up really great questions. And, you know, frankly, first of all, you know, Kaiser just does not staff enough clinicians. Let's be clear about that. Right.

They hire one therapist for every 3,000 patients in Southern California, which is deplorable. So there's that Kaiser cannot meet the demand internally right of their patients. And so, you know, we are utilizing a robust external network, which is not all bad. I think that could be a great partnership.

But some of the challenges you brought up, you know, we have, like Riverside is a huge encachment area, right? We have large encachment areas. And most of these external providers do not have in person services. They can only offer virtual care. So we have members in these areas who want to be seen in person.

And, you know, family therapy, couples therapy, pediatrics, kids, you know, children's therapy. And a lot of our geriatric populations are not great with technology and want and actually socialization be part of their treatment plan.

So a lot of these external networks that Kaiser's relying on, Rula being one large partner, cannot do in person appointments and definitely cannot meet the demand. Right. Of our patients. So that's, that's one issue also.

I get a lot of folks coming back saying, I was referred out and I don't like it and I want to come back, you know, a. They're making me, you know, you have to put a credit card in Rula. A lot of our patients are uncomfortable with that.

You cannot be in their system without putting your credit card. They're charged 99 cancellation fee if you cancel your appointment. And so if finances are challenging, you know, having to pay 99 cancellation fee because something came up is, is a huge barrier.

We also have folks who have just, they've just told me horror stories because, you know, there's no follow through, right? There's no. Kaiser's not following up on these providers. Their notes are not in the system, right?

So for an integrative care model, and if you have a complex case where maybe your Doctor needs to see, you know, some of your mental health notes, it's not there. So a lot of our patients who have been referred out for, for some of them it might work, right? And for some of them it isn't.

And they're asking to come back for all of these reasons. And so, you know, you bring up a good point of, you know, I don't know how these external providers are able to provide a variety of, you know, Clinicians that speak the same language. Right. As our patients need.

Obviously, I think it's really difficult for them to provide in person access. There's additional fees, right. Could be additional co-pays based on your plan, definitely cancellation fees. And it's just, again, it's outside of the system.

And the other part that I find very concerning as a clinician is all of these patients are not tethered to, to a home clinic. Right. We do the referral and then they're just kind of out there and there's not follow up.

They're not eligible for any other type of treatment at the clinic, like a caseworker or, you know, a group. And if they were, if they had an issue, they would have to come back and start over. Right. And you know, an external provider can all of a sudden say, I'm no longer available and can just terminate. Right.

There isn't the same kind of relationship if that person's within Kaiser where a provider would leave, then Kaiser will have to figure that out and get another therapist, hopefully within a certain amount of time. So there's just a lot of lack of accountability with these external networks. Right.

And so again, I don't think it's 100% bad solution, but the over reliance on it is problematic and not a great solution for a lot of our populations.

Thank you. And. And they may not physically be here, but we know they're watching. So thank you.

Thank you. I just. Sorry. Madly jotting down. You guys are talking faster than I can keep up with at this point, which is sad. Okay, so I just have a couple questions. One I wanted to just ask President Mendoza if you could give us a sense of whether you believe.

I'm sure you are thoroughly familiar with the Corrective Action Work Plan. Do you. How would you characterize the Corrective Action Work Plan in terms of being able to articulate an impact on service delivery?

Yeah, I mean, I think your question at the beginning for DMHC about the Corrective Action Plan containing smart goals. I would say that there are absolutely no smart goals. The Corrective Action Plan that was supposed to be number one according to the settlement agreement. Out for a series for some time. Right.

Wasn't out for a really, really long time. What we had expected and what we were looking for. Right. Were specifics, metrics that are measurable benchmarks. Because what we wanted to do is we wanted to educate our Members to be able to hold Kaiser accountable to these various, very, very concrete, specific things.

But when the Corrective Action plan came out. I would say that it is Kaiser PR. And I am, you know, and, and I don't, I don't mean to, you know, I don't mean to.

Well, I'm just going to say what, what, I mean, it's frustrating, right, to deal with the dmhc and you know, we've been filing all these complaints, right, and there just doesn't seem to, there just doesn't seem anything that's done about it. Right.

You know, one thing that they mentioned earlier was, zero, you know, we got certain number of complaints in Southern California and most of it was about their Kaiser therapist being on strike and not coming back and them not wanting to, them not wanting to return, them not wanting to go to a different therapist.

The way that they spoke, right, like they talked about continuity of care. They know this, right? The folks in the DMHC who are supposed to be overseeing Kaiser know that it is incredibly important for continuity of care.

And so what we, you know, so when we got the settlement agreement, right, and you know, you know, I could go on, but like, it's also surprising for them to say that they did not anticipate this, the seven month strike when we had informed them 10 months before the strike that there was a strike looming, right?

So what I really want them to be able to do in terms of strengthening their ability to hold Kaiser accountable specifically is if you understand that continuity of care is important, then maybe there were things that should have been done before the strike happened that prevented this strike. Let's not talk about the length of the strike.

Let's talk about preventing the strike. Because if you understand how behavioral healthcare works, that that is detrimental, right? That is detrimental. That break is detrimental to the patients. And the reasons why our Members have decided to do it is because what they are experiencing in Kaiser is not sustainable. Right.

You know, Kaiser itself, right, in the settlement agreement said that they needed to overhaul, an extreme overhaul, you know, of their behavioral health services. Everything in the settlement agreement covers, you know, from, from the moment that people get, people get appointments to the grievance process and everything in between, right?

And so, you know, so it's just, it is absolutely surprising to me and Assemblymember Schiavo mentioned this, right, that there seems to be like some backtracking from what the settlement agreement, which is very strong, right, Very detailed about what, you know, what the, what the problems were to the corrective action plan that took them so long to come up with.

And again, the way that it reads is it's Kaiser PR and it's essentially allowing Kaiser to, you know, to be its own oversight. You know, how could we let that continue to happen when, you know, when I was listing the number of years that Kaiser has been cited, how can we let that happen?

So I don't know if that answers your question.

Well, thank you, President Mendoza, for speaking to that. I think I've had an opportunity in this role to be able to work closely with DMHC on a host of different issues. And I believe that the team, when they say that they meet weekly to try to help support the situation.

And I know that as individuals they are incredibly passionate about ensuring that we have a strong behavioral health infrastructure. And so I'm sure that they heard your comments today and our Assembly Members kind of speaking to that as well. And in the spirit of constant improvement, we'll take that under advisement as well.

I wanted to just ask a couple questions of Ms. Finke because you actually provided some very concrete opportunities for difference in legislative oversight and approaches to that. And you actually listed out a lot of different things. I want to just give you an opportunity to speak, speak to anything related to transparency benchmarks.

I think one of the challenges that we've had throughout this process, throughout the many, many years that President Mendoza spoke about is that it's essentially kind of a closed loop process, right? There are complaints that are happening. They go to an agency, that agency understands and that they, that there needs to be change.

There's and focuses on supporting that change through corrective action. We get on paper settlement agreements and a corrective action work plan. And there isn't a lot of opportunity really for there to be conversation and looping back in the Legislature into this, into this oversight process.

So I just wanted you to be able to speak a little bit more to some of the things in the spirit of improvement that the Legislature can focus on related to transparency and setting up a methodology to be able to create stronger feedback and oversight.

Sure. Thank you for that question, Chair. And I think a lot of what you just mentioned has sort of been the experience of many of the advocates as well. And we can only advocate the best of our ability if we're understanding how we're. How things are, you know, meeting benchmark standards.

And so I think there's, there's, you know, standardized compliance metrics. There's also implementation reporting. So, you know, reporting back to the Legislature, detailed status reports on any number of investigations.

So the behavioral health investigations that DMHC mentioned are one and then really, you know, giving continual updates about the status of how those things are being amended and you know, violations that have been found have been rectified.

I think one of the things that we often see, which is part of the way that the structures of the department are set up too, is that you have an open investigation and lots of things cannot be shared or disclosed during open investigations. And then that investigation closes and then these summary reports come out.

But they are often pretty high level summary reports. And I think that the transparency around the benchmarks and the standards isn't always up to par with what we would consider good data standards for understanding whether, as folks have said earlier, whether there's real compliance happening.

And so what you end up seeing is a long list of many years of non compliance, which begs some questions about is it really compliance in the years that we don't mention or is it just that we haven't found that yet?

So I think really having transparent benchmarks around standardized compliance metrics that all plans have to use, federal parity rules have very specific data reporting that the state can request, and this Legislature can also request enforcement activities and very specific updates about what those look like. And then I think there's General data reporting.

We talked about the IMR process. The help centers were mentioned. You know, I think there's a lot we don't know about those processes. The IMR resolution process, for example, we don't even know if what the denial rates between mental health and substance use disorder are as advocates we know them combined.

But as we know a lot of times addiction care has much higher disparities across the board. And so things like that, that really can, we can bring light to.

And then, you know, in the help center processes, I guess I would also just say that that's relying on people who have the wherewithal and all the energy really to be able to bring those complaint forward, complaints forward.

And if you are going through the mental health or addiction crisis yourself, or you're dealing with a family member who is. It's exhausting. It takes up all of your emotional energy. And I think having those, you know, the other regular processes in place for oversight makes it even more important.

And so I would hope that a lot of these transparency metrics that, that were being discussed, we really could see through them and actually have reports on those so that we don't just have really high level summaries, but we kind of know what we're working with so that we as an advocacy community know how to bring these things forward to the Legislature and that the Legislature itself has that information to move forward and, you know, do what it needs to do to shore up some of the gaps that exist.

I want to thank you for that. And I think seeing no other questions or comments from the panel, from my colleagues here, I would love just to just conclude this panel with some observations and new things that we should be considering.

And we have these discussions and these informational hearings to be able to bring to light that which we haven't had an opportunity to really fully be able to discuss. And they're incredibly rich discussions. They are courageous conversations often.

And we certainly invite the public and our actors in our behavioral health system and in our overall health system to be able to come to the table, to be able to make sure that we can do better and do better and do right by Californians.

And that, as you shared, speaks to making sure that we're all fully engaged in the process. I think President Mendoza, you also commented on that. I know that DMHC was fully engaged in this process. I know that my legislative colleagues are fully engaged in this process.

I know that the public and advocates are fully engaged in this process. I know that NUHW is fully engaged in this process. Again, this is a hearing entitled Kaiser Permanente's Behavioral Health Care System.

Our informational hearings are incredibly powerful tools for us to be able to engage in conversations about areas of policy where we need to improve in our practice. Collectively, it is certainly the case that California is facing behavioral health and mental health crisis.

We have dozens, if not hundreds of bills that come through this Legislature that deal with substance abuse, behavioral health, mental health, integrated health opportunities. We know that we are striving to be able to do that.

And I want to have a tie back to that aspiration of being transformational in the way that we're providing services and supports to Californians. I think one of the observations that I had that came through, and it's not necessarily in the settlement agreement, it's not articulated fully in the corrective action work plan.

But there are areas for additional data gathering where it might be helpful for us to fully understand with a more robust picture how we can improve on the system that we have.

I just want to highlight that I heard focusing on the specific treatment modalities that are offered as an area of concern, making sure that we're actually, particularly in a closed system like Kaiser, that we are promoting integrative care and, and where we are not doing that as it relates to tying in behavioral health care.

We certainly heard loud and clear the under investment in behavioral health care and our behavioral health care workers, which impacts directly patient care, which I want us to hold. And I really appreciated Assemblymember Chiavo's comment about what we're striving for.

Like are we striving for people to just be a little less in pain as the standard of care? I know I'm not as a mother, I know she's not as a mother, I know I'm not as a Legislator.

So I think we have a lot of work to do and I think that there are ways that we can look at some of these dynamics. And if we have to do it through legislation, then we shall use that tool.

And I'm very thankful to the panelists, both this panel and the prior, for being able to engage fully in that conversation. I also just want to note that we had, as I've mentioned a couple of times, 36 different personal stories shared.

We intentionally removed any information that we thought would be too sensitive that's personally identifying to those individuals. But they have been provided to the Committee Members here.

And we're incredibly heart wrenching stories of people suffering and in pain and where our system right now is falling short, certainly of the aspiration of transformative care and in fact is costing lives. So I know that we need to do better.

I don't think any of the panelists that were a part of either of our panels would say any difference. And I'm thankful that we are working together to try to make a stronger system. And we won't be sharing those individual stories because of their personal nature.

But I did want to make sure that the people who wrote them knew that we read them and we felt them and we heard them and we seek to respond to them with this. Now I want to thank the panel for being here for your advocacy, your testimony.

And we'll close out this panel and move on now to public comment. And I invite everyone in the room who would like to provide public comments to come up to the microphone. You'll each have one minute to provide testimony.

And I just again want to thank my colleagues and the Legislature and the speaker of the Assembly for allowing us to be able to have this hearing and to our amazing staff on the Health Committee for pulling this together. And to all of the panelists who came forward to be able to help us build a stronger system.

Thank you.

Beth Capell with Health Access California. We're the consumer statewide consumer advocacy coalition. We have heard for years the complaints about Kaiser and Behavioral Health.

I would just ask this Committee, as you read those 36 stories and as you think about the stories you've heard today to say to yourself, would Kaiser treat a patient with heart disease or cancer the way they treat people with mental health needs? The answer is no. They did. They cleaned up their act.

That was in the 90s. We have faith that they can serve the needs of their enrollees who have significant behavioral health needs. But that's what they need to do. Just as they do for people with other serious conditions. Thank you.

Madam Chair and Members of the Committee. I'm Tara Draper with the National Union of Healthcare Workers. I'm here to inform you about recent issues we're facing at Kaiser Permanente in Northern California that compromise patient care. Instead of hiring sufficient staff to meet appointment access requirements, Kaiser is penny pinching.

Taking dangerous shortcuts that remove important decision making authority from licensed therapists. Patient calls are now being answered by unlicensed clerical staff who use a scripted set of screening questions and an algorithm to book patients into appointments.

Our Members report that this system has led to patients being booked into inappropriate treatment programs and in some cases, delaying care to patients who. Who are at risk of suicide.

In a cynical attempt to give the impression that it's meeting state timely access laws, Kaiser has recently begun scheduling patients for a first appointment into treatment programs that do not fit their diagnosis, causing delay in care and is contrary to best practices. These are dangerous shortcuts that Kaiser would never implement in its medical services.

Our contract for 2400 licensed therapists expires on September 30th of this year. And these access to care and other important care issues will be forefront and prominent in our negotiations. Thank you.

Good afternoon. There we go. Good afternoon. My name is Shaunsi Ezrin. I am with the California Association of Marriage and Family Therapists. We represent over 38,000 marriage family therapists across the state, including Members who work at Kaiser facilities. Thank you first and foremost for organizing this very important hearing.

Wanted to share that we've worked very closely with NUHW over the last many years, over a decade, advocating for timely access to care for patients and also for fair treatment for our providers.

We greatly appreciate the work of the Department of Managed Healthcare and of Kaiser in the corrective action work planning to make significant changes to improve the delivery of behavioral healthcare services. The ongoing areas of concern that we want to continue to highlight here is included in Kaiser's revised corrective action work plan.

So they include ensuring timely access to mental health care services, network adequacy and continuity of care that meets the requirements both of state law and of our regulations. Want to just close out by saying that we look forward to the implementation of those actions in the areas of that I've mentioned in the upcoming quarterly reports. Thank you.

Good afternoon Madam Chair and Members. Tyler Rinde on behalf of the California Psychological Association. First, we're grateful to the community for holding this hearing on Kaiser's behavioral health system.

We have serious ongoing concerns about and we have sent letters regarding this over the last decade on Kaiser's chronic understaffing, their long wait times and limited ability for Clinicians to provide the care that matches patients needs leading to individuals needing to have their conditions worsen before they're able to receive the care that they desperately need.

Our hope was renewed by the DMHC settlement agreement with Kaiser back in 2023. Although ensuring that there's compliance with the transformational change that is needed is remains a concern, we respectfully request that DMHC be as transparent and as detailed as possible on the oversight and enforcement of Kaiser to ensure that they are achieving that transformational need.

Thank you.

Good evening Chair and Members. Omar Altamimi with the California Pan Ethnic Health Network. Thank you for the robust discussion. We're gravely concerned about the shortages and systemic barriers patients face in accessing behavioral healthcare through Kaiser. And we look forward to seeing these kernels addressed and thank the efforts by the Legislature, GMHC and others in addressing them.

CPAN would like to see and urges DMHC to hold Kaiser accountable for providing culturally and linguistically appropriate behavioral healthcare. Communities of color often struggle to find in network providers who meet their cultural and language needs. This leads to delays in care, dropped.

Treatment, inappropriate services or families being forced to choose between paying out of pocket for care or covering other basic necessities. The the Corrective Action plan must include standards and enforcement to ensure Kaiser delivers culturally and linguistically appropriate behavioral health services. Thank you.

Good afternoon. Linda Way with Western Center on Law and Poverty. We appreciate you hosting this hearing as legal aid advocates report behavioral health care access issues across health patents, but particularly with Kaiser Members.

Over 18 months after the latest settlement agreement, there's still no publicly approved reimbursement process for out of pocket behavioral health service costs, which means some consumers are making decisions about paying for needed health care services or rent and food.

We urge timely progress toward the Corrective Action work plan completion and that one of the strategies include access to culturally and linguistically appropriate behavioral health options. We also support groups greater transparency and accountability as outlined by the Kennedy Forum. Thank you.

Good afternoon, Madam Chair Committee Members. Karen Vicari on behalf of mental health America of California, a statewide. Peer led mental health advocacy organization. We want to thank you for holding this hearing today on such an important issue. As a statewide advocacy organization, we frequently.

Hear stories of people who are unable to access appropriate mental health care through private insurance. But also I'm a person with lived. Experience and I'm the parent of a child with a mental health diagnosis. There was a time when my daughter. Needed mental health care. Through Kaiser we received an appointment with.

For a consultation with the child psychologist. And after about 15 minutes he told us that not only were her problems. Common and didn't deserve treatment, but that her problems were my fault. And at that time I feared self harm. I was very scared for her.

So we just left, we went straight home and we found her a private pay practitioner. The point I want to make is that there are so many access issues that are not reflected in IMRs grievances. Reviews from DMHC so again, thank you so much for holding this hearing and.

We really hope that you will continue to closely monitor parity access through private insurance. Thank you.

Good afternoon Chaired Members Jorge Cruz on behalf of the California Behavioral Health Association. Access to care is a shared goal, but delayed in behavioral health care remains too common. CBOs across the state are already working on closing these gaps. And that's why we need stronger, more. Transparent partnerships with managed care plans that.

Recognize the unique strengths that that community. Based of community based care. And as we navigate the workforce shortage. We encourage MCPs to be proactive partners in supporting the people who make the system run. When providers feel undervalued or unheard, the ripple effect lands on the patient and.

As as the 115 waiver nears expiration, we ask this body to ensure that continuity of community support services. These programs are essential for prevention, early intervention and stabilization and helping people long before they reach a crisis. And lastly, sustained reimbursement is key.

If MCPs rely on CBOs to provide care, we need to make sure that those providers can sustain their workforce and meet rising demands. Thank you so much.

That concludes public comment and this hearing. I again want to thank my colleagues for participating in this very robust informational hearing and to the panelists again for fully participating in building out a stronger behavioral health care system. With that, we are adjourned.