They will be joined this week by anoth­er 700 Kaiser work­ers who report sim­i­lar issues at almost three dozen strike loca­tions where pick­et­ing will be tak­ing place. Kaiser is the largest HMO in Cal­i­for­nia and the state’s largest pri­vate provider of men­tal health care.

Around 2,600 ther­a­pists, psy­chol­o­gists, and social work­ers rep­re­sent­ed by the Nation­al Union of Health­care Work­ers in Cal­i­for­nia (NUHW) began a week­long strike this Mon­day to protest inad­e­quate care for their patients due to what they say is under­staffing at Kaiser Per­ma­nente med­ical cen­ters through­out the state.

The pick­et lines are the lat­est esca­la­tion by work­ers in a con­flict that has seen an uptick in activ­i­ty since 2011 when NUHW began efforts to push the Cal­i­for­nia Depart­ment of Man­aged Health Care (DMHC), the state’s health care reg­u­la­tors, to fine Kaiser for their vio­la­tion of ​“time­ly access” state laws. The $4 mil­lion penal­ty was hand­ed out in 2013 and was the sec­ond high­est fine ever imposed by the agency. The laws require HMOs to pro­vide care with­in 10 busi­ness days for both ini­tial and fol­low-up treat­ment appoint­ments. Accord­ing to the reg­u­la­tors, as many as 60 per­cent of appoint­ments at var­i­ous Kaiser clin­ics observed dur­ing its peri­od of assess­ment were out­side of what is con­sid­ered ade­quate wait time.

But Clement Papaz­ian, an Oak­land-based Kaiser employ­ee in psy­chi­atric emer­gency care who acts as the union’s men­tal health clin­i­cians North­ern Cal­i­for­nia dis­trict pres­i­dent, says that DMHC’s report only focused on ini­tial diag­nos­tic appoint­ments at Kaiser clin­ics. ​“Rather than increase staffing, [Kaiser] actu­al­ly shift­ed resources so now it’s eas­i­er for patients to get a diag­nos­tic appoint­ment, but they end up hav­ing to wait weeks and even months for treat­ment appoint­ments,” he says. ​“It cre­ates an unsus­tain­able care sys­tem for patients and providers.”

Papaz­ian says lengthy peri­ods of wait­ing occur because ​“Kaiser doesn’t staff the psy­chi­a­try depart­ments with enough psy­chol­o­gists, ther­a­pists and social work­ers to han­dle the case­load. There aren’t enough of us to pro­vide the time­ly and ade­quate care that patients seek when they come to see us.”

Despite Kaiser’s claims of a 25 per­cent increase in staff between 2011 and 2014, NUHW claims that data from Kaiser reports sug­gest that the num­ber is actu­al­ly clos­er to 10 per­cent. The men­tal health work­ers at NUHW argue this increase is not enough, espe­cial­ly when con­sid­er­ing what they say is Kaiser’s large-scale fail­ure to pre­pare for a sig­nif­i­cant influx in mem­ber­ship growth due to the Afford­able Care Act. In just the first nine months of 2014, Kaiser added over 420,000 peo­ple to its mem­ber­ship .

Tom Meier, the trea­sur­er and senior vice pres­i­dent at Kaiser, told the San Fran­cis­co Busi­ness Times last year that sign-ups through Cov­ered Cal­i­for­nia, the state’s ACA health care mar­ket­place, account­ed for three-quar­ters of mem­ber­ship growth through­out the year. This growth far exceed­ed the approx­i­mate­ly 100,000 peo­ple it bud­get­ed for.

“The real­i­ty is that Kaiser has not been able to treat all of the men­tal health patients it was already respon­si­ble to care for,” explains Papaz­ian. ​“Our issues with them pre­date the Afford­able Care Act, and we knew that ACA would be a gold­mine for Kaiser, [enabling them] to enroll thou­sands of more mem­bers,” he says.

2014’s prof­its were a report­ed $3.1 bil­lion, accord­ing to Kaiser offi­cials — a 40 per­cent increase from the pre­vi­ous record-break­ing year and anoth­er incre­men­tal fig­ure to con­tribute to the total $14 bil­lion that Kaiser has made since 2009.

John Nel­son, Vice Pres­i­dent of Gov­ern­ment Rela­tions at Kaiser Per­ma­nente addressed the union’s claims of under­staffing by say­ing, “[Kaiser] con­tin­u­al­ly analyze[s] [its] staffing lev­els in all care deliv­ery. Increased demand for men­tal health ser­vices is being expe­ri­enced in the behav­ioral health com­mu­ni­ty at large as well as at Kaiser Per­ma­nente. In response, Kaiser Per­ma­nente has been and con­tin­ues to hire addi­tion­al men­tal health providers to meet our mem­bers’ needs.”

Regard­ing aver­age wait time for appoint­ments, Nel­son says, ​“Each patient’s sit­u­a­tion is eval­u­at­ed and treat­ed indi­vid­u­al­ly. Just as it is with oth­er types of health care, depend­ing on the case, a patient may need to be seen again indi­vid­u­al­ly the same day, the next day, in a week, in two weeks, or in a month or longer — there real­ly is no such thing as an ​“aver­age” time for addi­tion­al vis­its or an aver­age range of addi­tion­al visits.”

The DMCH report that led to Kaiser’s 2013 fine cites that regard­less of any cal­cu­la­tion of aver­age wait time, “[Kaiser]’s method­ol­o­gy for mon­i­tor­ing appoint­ment wait times relies on aver­ag­ing all report­ed wait times for a giv­en month. Although cal­cu­lat­ing the Aver­age Days Wait may pro­vide some insight into the over­all month­ly trend, the Plan’s method­ol­o­gy does not account for each enrollee’s wait time indi­vid­u­al­ly, and may mit­i­gate or hide exces­sive wait times by aver­ag­ing them with short­er wait times,” lead­ing the agency to con­clude that the HMO was there­fore vio­lat­ing reg­u­la­to­ry standards.

Kaiser’s alleged com­bi­na­tion of under­staffing and unplanned-for patient growth has led NUHW to bring legal action against the HMO in order to block any fur­ther par­tic­i­pa­tion in Cov­ered Cal­i­for­nia. In 2013, NUHW filed motions against Cov­ered Cal­i­for­nia in order to force it to fol­low laws requir­ing HMOs to be in good stand­ing before being able to enroll new mem­bers through the state’s health exchange. Papaz­ian says the law­suit is still active and ongoing.

Jim Clif­ford, a psy­chi­a­trist-ther­a­pist from San Diego and NUHW mem­ber, remarks that while there is a chance that many pre­vi­ous­ly unin­sured indi­vid­u­als will be off of Kaiser’s rolls in the near future because of the pend­ing legal action, strik­ing work­ers have an oblig­a­tion, as men­tal health pro­fes­sion­als, to be advo­cates for their patients so they receive high-qual­i­ty care.

“ACA was the largest sin­gle increase in cov­er­age, as far as we know, in his­to­ry. While we’re glad obvi­ous­ly to see more peo­ple get cov­er­age, we expect Kaiser to not only increase staff but also make invest­ments in psy­chi­atric facil­i­ties,” says Clifford.

Although Kaiser spokes­peo­ple sug­gest that there is a ​“short­age” of qual­i­fied clin­i­cians to hire, Clif­ford rea­sons that any per­ceived short­age ​“has to do with the dis­crim­i­na­tion, as we see it, against psy­chi­atric patients” they will poten­tial­ly be treat­ing. He added that find­ing appli­cants is dif­fi­cult ​“when they know [the clin­ic is] going to be over­loaded with patients and that Kaiser will be attack­ing their wages and benefits.”

Union lead­ers have pro­posed ​“clin­i­cian-man­age­ment com­mit­tees” at each facil­i­ty to ensure that union mem­bers have a say in hir­ing prac­tices, but mem­bers say these sug­ges­tions have not fared well at the bar­gain­ing table. Kaiser would not respond to the spe­cif­ic pro­pos­al, with Nel­son com­ment­ing, ​“Out of respect for the bar­gain­ing process, we don’t dis­cuss pub­licly what occurs at the bar­gain­ing table.” This past week­end, as nego­ti­a­tions appeared to be going nowhere, the union focused on strike confirmation.

As soon as the strike was announced Nel­son remarked in a press release pub­lished on Kaiser’s offi­cial web­site that ​“since its cre­ation in 2009, [NUHW] has nev­er nego­ti­at­ed a con­tract with Kaiser Per­ma­nente. In fact, NUHW stands alone as the only union that has been unwill­ing or unable to reach a fair agree­ment con­cern­ing a con­tract cov­er­ing our employ­ees dur­ing that time.”

When asked about Nelson’s com­ments, Clif­ford replied, ​“We believe that by reject­ing their pro­pos­al, we are reject­ing a broad strat­e­gy that they have made very clear to us while across the bar­gain­ing table: … that they want to elim­i­nate ben­e­fits for all employ­ees at Kaiser. And they are start­ing with us.

“We agree with Kaiser in that we are the only union at this point that has been unwill­ing to accept their con­tract offer. And we are proud of that.”

Accord­ing to Clif­ford, Kaiser has been seek­ing dai­ly meet­ings with union lead­er­ship since the start of the strike — a marked change from the month­ly meet­ings that Clif­ford says Kaiser man­age­ment did ​“not take very seriously”.

In addi­tion to this week’s strike, which will end on Jan­u­ary 19, Kaiser’s headaches could be com­pound­ed when more than 18,000 Kaiser nurs­es rep­re­sent­ed by Cal­i­for­nia Nurs­es Association/​National Nurs­es Unit­ed par­tic­i­pate in a two-day strike on Jan­u­ary 21 – 22, a walk­out that will affect all 86 of Kaiser’s hos­pi­tals in the state over staff and eco­nom­ic issues sim­i­lar to the ones faced by NUHW.

The HMO will also be receiv­ing anoth­er report from DMHC at the end of Jan­u­ary, which may result in a fine for Kaiser even larg­er than 2013’s $4 mil­lion penal­ty. Papaz­ian says that this ​“one-two punch” will leave Kaiser with an unprece­dent­ed amount of pres­sure to change.

“Kaiser could antic­i­pate these find­ings to begin the process of mak­ing change and includ­ing the mar­riage-fam­i­ly ther­a­pists, social work­ers and psy­chol­o­gists into the staffing deci­sions that need to be made,” he says.