“If Kaiser is making it effectively impossible to get a particular, important mental health treatment, that could definitely be a violation of our parity law,” said state Sen. Scott Wiener (D-San Francisco), the bill’s author.
KP officials responded by saying they always follow the law. They also say its integrated structure — as both the health insurer and the health provider — makes it different from traditional insurers. At KP, a patient’s doctor determines whether a medication is appropriate, not the health plan, and the criteria doctors use are recommendations, not requirements or prerequisites that patients need to “exhaust,” said Dr. Maria Koshy, KP’s chair of psychiatry for Northern California.
“At the end of the day, this is an individual clinical decision by both the provider — the physician — and the patient,” she said.
But inside KP, the workplace culture is such that doctors are expected to follow these recommendations, according to former KP clinicians who spoke on background — as well as legislative experts familiar with KP’s model. They say that when KP doctors deviate from the recommendations, they can get questioned or face other consequences.
“These physicians know that if they start routinely ignoring these bad recommendations, that that could have impacts on them professionally,” said Wiener, who has worked on several bills aimed at regulating KP and other insurers in California. “Whether it’s couched as a recommendation or a requirement is almost irrelevant. It has the same effect.”
To McDonald, her physician seemed to follow the recommended criteria as if they were requirements when she declined to prescribe brexanolone. Another patient, Yesenia Muñoz, got a similar response when she sought brexanolone treatment. KP’s grievance department sent her a letter denying the request because she had not failed enough medications.
“When I talked to the caseworker at Kaiser that had denied the medication, he said that Zulresso was very expensive,” said Muñoz, referring to brexanolone’s brand name.
In addition to the $34,000 cost for brexanolone, the three-day hospital stay can tack on another $30,000 to a patient’s bill. Another complicating factor is the FDA requirement that health centers obtain special certification to infuse brexanolone, because of the risks of excessive sedation or fainting from the drug. KP doesn’t have the certifications yet to administer the treatment at its own hospitals, so it must pay outside hospitals to provide it for its patients. KP officials say they have plans to eventually open three of their own certified centers in Northern California.
Muñoz, 35, was devastated by the denial. She was overwhelmed by postpartum depression and anxiety shortly after her daughter was born in August 2020. But none of the medications or therapies KP offered her worked. Four months after giving birth, she still felt suicidal.
“I could get out the door sometimes and take the stroller and go walk, and my mind kept on saying, ‘If you just step in front of the car, it’s all going to go away,” she remembered.