When COVID-19 hit, Djuna Day said her mental health deteriorated. By the end of the pandemic’s first year, her crippling depression was making it hard to work.

She went on disability for six months in November 2020 to focus on getting better. Day has a history of depression and her therapists had recommended transcranial magnetic stimulation, a procedure in which magnetic fields are used to stimulate nerve cells in the brain. It’s typically used when other treatment options haven’t worked.

Day said it required going to a clinic multiple times a week for the half-hour sessions. Side effects can include headaches and lightheartedness, so she was hoping to be finished with the treatment before going back to work.

But when she contacted Kaiser’s behavioral health office she said she was told there was a backlog and she wouldn’t be able to see a doctor for three or four months. It then took an additional month to get a referral.

Her first session was finally scheduled for the first day she was scheduled to go back to work.

“There were a lot of moving parts that took a long time to move through and it would have been really nice if it was able to happen within that six-month period,” Day said. “Instead, it literally took six months to get it done.”

Day said that her struggles to obtain mental health services didn’t end after her transcranial magnetic stimulation, which she said unfortunately didn’t help her depression.

A trans woman, who transitioned six years ago, Day said she was struggling with gender dysphoria and has been trying for weeks to find an out-of-network therapist who specializes in the issue.

“I’m running into limitations on what can be done physically and my dysphoria is still, I think, a major factor in my depression,” Day said.

She said Kaiser gave her five names of therapists, but they either weren’t accepting new patients or didn’t accept her Kaiser Quest health insurance, a Medicaid plan. She obtained referrals and sought out about 15 other therapists who she found online, but said most weren’t accepting her health plan.

“I would be directed to call Kaiser or I would get names of people I had already called,” she said. Day said she’s still seeking out a therapist.

Kaiser said it couldn’t comment on Day’s case, citing patient privacy. But the company said it’s a leader in providing “equitable and compassionate medical care” for transgender and gender diverse people. Its Care Pathway Center in Hono­lulu specializes in transgender care.

Kaiser hasn’t denied it has a shortage of mental health specialists, but has stressed that those shortages exist nationwide and were exacerbated by the pandemic. A 2021 Kaiser Family Foundation study found that shortages were particularly bad in Hawaii, where just 14.6% of the statewide need for mental health professionals is met, compared with the national average of 27.2%.

The health maintenance organization, which operates as a health care provider and insurer, says it’s actively trying to improve.

“Kaiser Permanente is committed to helping our members stay mentally, physically and emotionally healthy,” Kaiser said in a statement. “This commitment includes ensuring members seeking mental health and addiction care can access appointments in a timely, clinically appropriate manner.”

Kaiser said that it is working to recruit more psychiatrists, therapists and other behavioral health staff. The company says it has created 11 new positions in 2022, and plans to add the same number of positions through 2025. If filled, the positions would nearly double the number of behavioral health therapists on staff.

But the National Union of Healthcare Workers, the union representing about 50 Kaiser mental health providers, says that Kaiser hasn’t done enough. The issue has become ensnared in union negotiations that have dragged on for more than three years. Kaiser’s mental health professionals unionized in 2018 and are still negotiating their first contract.

The union says Kaiser’s shortage of mental health professionals has led to overwhelming caseloads and poor access to care, and that Kaiser needs to improve salaries and benefits in order to attract more therapists.

In May, clinicians held a three-day strike. Now, the union is threatening to launch an open-ended strike starting Monday.

“We’ve done everything possible to make Kaiser stop violating the rights of our patients,” said Justin Maeda, a psychologist at the Waipio Clinic, in a media release announcing the planned strike. “The only option left is to strike for as long as it takes for Kaiser to invest in mental health care, so we can offer our patients the care they need to get better.”

Kaiser has decried the union’s strike tactics. “It is disappointing that the National Union of Healthcare Workers (NUHW) has again called on our dedicated and compassionate mental health professionals to walk away from their patients in Hawaii at a time when the need for mental health care is so critical,” Kaiser said in a statement.

Union complaints

The union says that Kaiser has been downplaying its problems with mental health access. Earlier this year the National Committee for Quality Assurance, an accreditation agency based in Washington, D.C., determined that Kaiser needed to improve its behavioral health services and put it under a “corrective action” plan for failing to meet national quality standards.

Kaiser has said that despite this, it actually scored 100% on a behavioral health access standard requirement and accused the union of using regulatory complaints as a bargaining tactic. The union had filed a complaint with the NCQA earlier this year, prompting the investigation into Kaiser’s behavioral health services in Hawaii.

In July, Kaiser did not respond to a request by the Honolulu Star-Advertiser for a copy of the results from NCQA’s review. But the union was able to obtain Kaiser’s corrective action plan during contract negotiations and provided the Star-Advertiser with a copy.

Kaiser had provided the union with a redacted version, but apparently didn’t do a good job of blacking out the portions it didn’t want the union to see. NUHW’s research director was able to reveal the text by removing the black overlay.

Among the portions that Kaiser had redacted was NCQA’s determination that Kaiser’s mental health provider shortage was a problem before the pandemic and dropped even further during the pandemic.

“While (behavioral health) access is a challenge in Hawaii in general, lack of access to behavioral health for Kaiser members poses a potential patient safety risk,” NCQA wrote, adding that Kaiser’s efforts to improve access to mental health services “have been largely ineffective.”

NCQA also concluded that Kaiser’s efforts to develop and fund a strategy to address the problems didn’t begin until well into 2021, and still had not been fully implemented.

NCQA said Kaiser needed to expand its out-of-network providers to address members’ immediate needs to access psychotherapy.

Kaiser didn’t respond to questions about the redactions.

A Star-Advertiser search for behavioral health providers on Kaiser’s search engine for finding doctors turned up 19 in-network behavioral health specialists statewide and zero out-of-network providers.

Kaiser has a directory for out-of-network physicians for its Kaiser Added Choice plan, but it’s not clear how many members benefit. Kaiser declined to answer questions about what percentage of Kaiser-affiliated doctors only accept Kaiser Added Choice, or how many members are on this plan, one of many offered by the insurer. Kaiser said the information was proprietary.