How quickly can I get an appointment with a psychiatrist?

Waiting times for psychiatric care are unacceptably long, patients and doctors say

After years of complaints from health care providers and patients about the extremely long wait to see a psychotherapist at the Permanente Clinic, a San Francisco Board of Supervisors committee today heard from stakeholders, including clinic management.

Supervisory board members Dean Preston, Raphael Mandelman and Connie Chan interviewed representatives of the health care giant about their standards for access to mental health care - and generally concluded that the insurance company and health care provider were not doing a good job.

"As someone on the front lines of this worsening problem, let me testify that patients in San Francisco are getting worse and very upset at best," said Ilana Marcucci-Morris, an admissions physician at the Permanente clinic.

Marcucci-Morris said that months-long delays are typical for patients seeking psychiatric care in non-emergency cases.

When she checked the clinic's system today, she said, the closest available appointment she could offer a patient was not until Jan. 27 -- more than three months away. According to Marcucci-Morris, who serves the Northern California region at the call center in San Leandro, San Francisco is "by a wide margin" the hardest place to find therapy appointments.

California state law requires that mental health patients be seen within 10 days of admission, and that emergency mental health patients be seen within 48 hours. According to Leanne Jones, director of behavioral health quality at the medical facility, the clinic is generally more than 95 percent compliant with these requirements.

But when it comes to follow-up care - the ongoing therapy that many people need after their initial appointment - both patients and doctors say that the process of treating non-urgent cases is so long that it can be dangerous.

"Trying to navigate the clinic's behavioral health system has greatly exacerbated my already severe symptoms of depression and suicidality," reads a statement read on behalf of one of the clinic's patients during public comment.

The demand for mental health services has increased in recent years, and the pandemic has only exacerbated those needs. A 2020 CDC study found that one in four U.S. survey respondents had seriously considered suicide in the past 30 days.

According to San Francisco Health System data presented at the hearing, 42 percent of those surveyed reported a decline in mental health during the pandemic, and 57 percent reported an increase in anxiety levels.

Along with the growing demand for services, the clinic says, the workforce is shrinking.

"There is a huge gap between supply and demand," said Dr. Maria Kosci, chair of the clinic's Department of Psychiatry, adding that this is a national problem not specific to the clinic. "Hiring staff is a big part of our strategy. But it won't be enough, because without expanding the talent pool, we won't have enough people to hire."

The company said it has hired more than 600 new psychiatrists in California since 2016 and said it will double the number in San Francisco over the past three years. The clinic is also investing $30 million to further increase their numbers.

The San Francisco government is a major purchaser of clinic services: According to the San Francisco Health System's 2021 Demographic Report, as of January, about 70,000 city employees and retirees were covered by clinic services.

Union organizers hope this bid means the city can push the clinic to make some needed changes. But, they say, the issues raised at today's hearing have been around for a long time, without much change.

Former inspector John Avalos, now assistant director of political and community organizing for the National Union of Healthcare Workers, pointed to several cases in which the clinic had already been accused of "fudging the numbers. San Diego recently sued the clinic for misrepresenting staffing numbers, and in 2013 the clinic was fined $4 million for poor tracking of mental health services.

"For almost all of our [union's] 10 years, we've been fighting with the clinic to provide better access and timely mental health care," Avalos said.

He disagreed with the clinic's excuse that understaffing was to blame, saying the company simply "doesn't value psychiatric care at the same level as physical care." Mental health care, Avalos said, requires ongoing treatment and can be expensive.

In November 2020, 65 San Francisco psychiatrists signed a letter to company management warning that patients were waiting months to start therapy and six to 12 weeks between appointments.

"Clinician burnout and turnover rates are high," the letter says. "We are unable to provide services that meet the standards of care accepted by our profession. This practice violates the legal requirements of parity."

Jeffrey Chen-Harding, another physician at the clinic who was involved in triage and providing therapy to patients, was one of 65 people who signed the letter.

"I was so demoralized by having to constantly tell people, 'Yes, you have to get help next week, and I can't give it to you,'" Chen-Harding says.

During today's meeting of the Government Audit and Oversight Committee, Supervisor Dean Preston seemed unhappy that even inside the clinic there is no data on the average or estimated follow-up time after admission.

Despite Preston's repeated questions, Dr. Maria Kosci of the clinic insisted that wait times are not necessarily an indicator of adequate psychiatric care.

"Nowhere else in other areas do we talk about frequency of care as a major indicator of quality of care," Cauchy said.

Chen-Harding rejected this idea as simply untrue.

"If you want to look in psychiatric and psychology journals, you'll find a lot of evidence-based studies that provide individual therapy weekly or more often," Chen-Harding said at the hearing. "That's the recommended standard of care. So let's call things by their proper names."

Cauchy and other clinic officials acknowledged that the company is restructuring its care to prepare for July 2022, when the new health care law requiring timely mental health services goes into effect. Under SB-221, health care providers will be required to provide follow-up care to mental health patients within 10 business days of their initial appointment.

Avalos hopes that today's hearing will address the inadequate data that clinics are self-reporting. "Perhaps the Health System will be able to require a whole different level of reporting and compliance," Avalos said. The hearing has been rescheduled to an undetermined later date.

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