For the second time in two years, the state of California has faulted HMO giant Kaiser Permanente for failing to provide patients with appropriate access to mental health care.

Some Kaiser patients still have to wait weeks or even months to see a therapist or psychiatrist, which violates state laws intended to ensure timely access to mental health treatment, the state Department of Managed Health Care said in a report released Tuesday. (Kaiser Health News is not affiliated with Kaiser Permanente.)

In addition, the department, which regulates California’s managed health care companies, found that Kaiser’s informational materials — as well as some providers themselves — improperly indicated to customers that long-term individual therapy was not available to enrollees, even though coverage of treatment for severe mental illness is required under state and federal mental health parity laws.

Tuesday’s report is a follow-up to an inspection released in March 2013, which identified four major deficiencies in the health plan’s delivery of mental health services. Kaiser agreed to pay a $4 million fine — one of the largest ever by an insurer in the state. At the time, the managed health care department said it would follow up on the plan’s progress a few months later. The results were not released until now.

In this follow-up report, the department found that Kaiser had solved two of the four problems by improving the way it collects and analyzes data about access to appropriate mental health care.

“Kaiser has made progress in being able to identify when and where the problems around access are occurring, but they are still not able to address the problems when they arrive,” said department director Shelley Rouillard. “They still have a lot of work to do.”

Kaiser officials say they have made significant strides in bolstering their provider network, including increasing their therapist staff. In addition, Kaiser is working with a separate company called ValueOptions to provide additional mental health care when necessary.

“We are proud of the progress we have made to improve access to mental health care,” Kaiser Permanente officials said in a statement. “We are committed to continuing to improve. We acknowledge there are still some areas where we need to continue making progress and do better for our patients,” including improving access to appointments at some locations.

In Kaiser’s Northern Region, the managed health care department found 22 percent of patients did not have timely access to either an initial or follow-up appointment. In one case, a sexual assault victim diagnosed with post-traumatic stress disorder and major depression was prescribed an antidepressant in an initial visit, but no follow-up appointment was scheduled.

The patient tried to schedule both individual and group therapy visits, but her psychiatrist responded by “offering psychotherapy in the community at the patient’s expense and suggested that the patient investigate appropriate group therapy in the community because weekly individual therapy was not available in the Plan, and Plan group therapy did not address sexual assault,” according to the report.

The patient was eventually able to schedule an appointment with a Kaiser therapist — five months after her initial visit, the report said.

According to another case cited by the department, a psychiatrist wrote an email to a patient saying that, “No one ever sees a therapist once a week in the Kaiser Health Plan. Not a covered benefit for the past 20-something years and will not be a benefit in the future.”

Based on Tuesday’s report, the managed health care department’s Office of Enforcement will consider whether Kaiser Permanente should face further disciplinary action, which could include another fine.

Kaiser Permanente is one of the largest not-for-profit health plans in the country, with an operating revenue of $56.4 billion and almost 7.5 million members in California.

The company has been in a protracted labor dispute with the National Union of Healthcare Workers, which represents the plan’s therapists. Union leaders have accused the health plan of a “chronic failure to provide … quality mental health care.” In its written statement, Kaiser blamed the union for continued problems in providing timely access to mental health care.

“We need union leadership to work constructively together with us to remove obstacles and solve problems more quickly …” the statement said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The sleek hospital tower that Johns Hopkins Medicine built in 2012 has the frills of a luxury hotel, including a meditation garden, 500 works of art, free wi-fi and a library of books, games and audio.

As Dr. Zishan Siddiqui watched patients and some fellow physicians in Baltimore move from their decades-old building into the Sheikh Zayed Tower, the internist saw a rare opportunity to test a widespread assumption in the hospital industry: that patients rate their care more highly when it is given in a nicer place.

For decades, hospital executives across the country have justified expensive renovation and expansion projects by saying they will lead to better patient reviews and recommendations. One study estimated $200 billion might have been spent over a decade on new building. Hopkins’ construction of the tower and a new children’s hospital cost $1.1 billion. Patient judgments have become even more important to hospitals since Medicare started publishing ratings and basing some of its pay on surveys patients fill out after they have left the hospital.

Siddiqui’s study, published this month by the Journal of Hospital Medicine, contradicts the presumption that better facilities translate into better patient reviews. Siddiqui examined how patient satisfaction scores changed when doctors started practicing in the new tower, which has 355 beds and units for neurology, cardiology, radiology, labor and delivery and other specialties.

Siddiqui discovered that for the most part, patients’ assessments of the quality of the clinical care they received did not improve any more than they did for patients treated in the older Hopkins building, which had remained open. Units there were constructed as early as 1913 and as late as 1980, Hopkins officials said. They functioned as the control group in the study, since a hospital’s satisfaction scores often change over time even when a hospital’s physical environment remains constant.

The study used the responses both to Medicare-mandated surveys and private ones from Press Ganey, a consulting company that administers surveys. In the study, Hopkins patient ratings about the cleanliness and quiet in new tower’s rooms — elements Medicare uses in setting pay — soared, as did views on the pleasantness of the décor and comfort of the accommodations. But patient opinions about their actual care — such as the communication skills of doctors, nurses and staff — did not rise any higher than they did in the older building.

“Despite the widespread belief among health care leadership that facility renovation or expansion is a vital strategy for improving patient satisfaction, our study shows that this may not be a dominant factor,” Siddiqui and his fellow authors wrote.

The study’s results were startling because previous studies have found that patients in older hospital buildings give lower scores on the quality of their care. Hospital executives have noticed it anecdotally as well; for instance, when NYU Langone Medical Center relocated its cardiology unit to a renovated floor, its patient experience scores rose.

Newer buildings allow for some medical benefits, such as better organized nursing stations and private rooms that protect against the spread of infectious bacteria and diseases. But the Hopkins researchers said “hospitals should not use outdated facilities as an excuse for achievement of suboptimal satisfaction scores.”

A nationwide survey from 2012 conducted by the consultants J.D. Power and Associates reached similar conclusions to the Hopkins paper about the influence of the physical environment on satisfaction scores. That survey found that communication by doctors, nurses and other staff was most important, while the facility accounted for a fifth of patient satisfaction.

After reading the Hopkins study, Dr. Bradley Flansbaum, a physician at Lenox Hill Hospital in Manhattan wrote on the blog of the Society of Hospital Medicine that “it just might be that what doctors do and say matters, and a first-class meal and green gardens cannot paper over, or in the converse, sully our evaluations.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Since 2010, 9.4 million people with Medicare have saved over $15 billion on prescription drugs.

VISALIA, Calif. — In the farming town of Exeter, deep in California’s Central Valley, Anne Roberson walks a quarter mile down the road each day to her mailbox. Her walk and housekeeping chores are the 68-year-old’s only exercise, and her weight has remained stubbornly over 200 pounds for some time now.

“You get to a certain point in your life and you say, ‘What’s the use?’”

For older adults, being mildly overweight causes little harm, physicians say. But too much weight is especially hazardous for an aging body: Obesity increases inflammation, exacerbates bone and muscle loss and significantly raises the risk of heart disease, stroke, and diabetes.

To help the 13 million obese seniors in the U.S., the Affordable Care Act included a new Medicare benefit offering face-to-face weight-loss counseling in primary care doctors’ offices. Doctors are paid to provide the service, which is free to obese patients , with no co-pay. But only 50,000 seniors participated in 2013, the latest year for which data is available.

“We think it’s the perfect storm of several factors,” says Dr. Scott Kahan, an obesity medicine specialist at George Washington University. Kahan says obese patients and doctors aren’t aware of the benefit, and doctors who want to intervene are often reluctant to do so. It’s a touchy subject to bring up, and some hold outmoded beliefs about weight problems and the elderly.

“It used to be thought that older patients don’t respond to treatment for obesity as well as younger patients,” Kahan says. “People assume that they couldn’t exercise as much or for whatever reason they couldn’t stick to diets as well. But we’ve disproven that.”

Indeed, one study found two out of three older patients lost 5 percent or more of their initial weight and kept it off for two years.

Weight loss specialists place the blame for poor awareness of the new benefit on the federal government’s decision to limit counseling to primary care offices.

“The problem with using only primary care providers,” says Bonnie Modugno, a registered dietician in Santa Monica, California, “is that they completely ruled out direct reimbursement for the population of providers who are uniquely qualified and experienced working with weight management. I think that was a big mistake.” She was referring to registered dieticians like herself, as well as specialists such as endocrinologists, who might be managing a person’s diabetes, and cardiologists, who monitor patients with heart disease. Both conditions can be caused by or made worse by excess weight.

The drafters of the health law deliberately wrote the benefit narrowly out of concerns about widespread fraud, if charlatans were able to bill Medicare for obesity counseling. Modugno says she is sympathetic to that concern, but it is too restrictive as enacted.

“Unless we change the nature of how…the counseling occurs, I don’t see it being available to people in a meaningful way,” said Modugno.

As for Anne Roberson, she says the extra weight she has long carried on her petite frame has begun taking a toll on her joints, her sleep and her mood. On a recent morning, Roberson listened politely to her longtime physician, Dr. Mylene Middleton Rucker, during her first Medicare weight-loss counseling session. Rucker suggested she eat more vegetables and less meat and encouraged her to join an exercise class.

Rucker, who is obese herself, says she doesn’t expect her older patients to lose a lot of weight. “I think you’ll see weight loss of 10 to 20 pounds, but whether you’re going to see people lose 50 to 100 pounds as they’re older, I doubt it.”. Still, Rucker says, even with small amounts of weight loss in her older patients, she expects to see a decrease in the complications of chronic medical diseases, including diabetes-related leg amputations.

Roberson says she has tried to lose weight before, but “you hit a couple of rough weeks and you kinda slough off.” This time, Roberson says firmly, she will have to come back and answer to Rucker.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The Obama administration has blocked health plans without hospital benefits that many large employers argued fulfilled their obligations under the Affordable Care Act.

Companies with millions of workers, mainly in lower-wage industries such as staffing, retailing, restaurants and hotels that had not offered health coverage previously, had been flocking toward such insurance for 2015.

Plans lacking substantial coverage of hospital and physician services do not qualify as “minimum value” coverage under the law and so do not shield employers from fines of $3,000 or more per worker, the Department of Health and Human Services said late Friday.

The move closes what many saw as a surprising loophole, first reported by Kaiser Health News in September, that let companies bypass the health law’s strictest standard for large-employer coverage while at the same time stranding workers in sub-par insurance. Employees offered such plans would have been ineligible for tax credits to buy more comprehensive coverage in the law’s online marketplaces.

The agency did decide to allow such plans for this year only if employers had signed contracts by Nov. 4.

However, it also granted relief to workers offered such coverage, saying they may receive tax credits according to their income to buy more comprehensive insurance in the online exchanges. Ordinarily, employees offered coverage qualifying as minimum value aren’t eligible for the subsidies.

Despite what Washington and Lee University law professor Timothy Jost called “a lot of pushback” from employers, HHS has now followed through on earlier guidance that it intended to disallow such coverage.

A plan without hospital benefits “is not a health plan in any meaningful sense,” the agency said in a large batch of regulations issued Friday. Scoring such a plan as minimum value “would adversely affect employees (particularly those with significant health risks) who understandably would find this coverage unacceptable. …”

The ruling ends a debate that erupted last summer over HHS’ official, online calculator for determining minimum value in a large-employer plan.

The Affordable Care Act does not specify “essential health benefits” in large-employer plans, such as hospitalization and drugs, as it does for individual and small-business insurance. Instead, the minimum-value test requires large companies to cover at least 60 percent of expected medical costs.

One way to certify a plan as minimum value is to plug its components — benefits, deductibles and so forth — into the official calculator. Many were shocked to learn that the calculator gave passing scores to plans with no inpatient hospital coverage.

Now HHS is saying: Ignore the calculator. Large-employer plans must pay for substantial amounts of hospital care no matter what.

“What remains a mystery is whether the calculator was at fault,” Alden Bianchi, a lawyer who advises many companies that were considering such plans for 2015, said via email. “The regulators don’t say. Rather, they take the [position] (not unreasonable or nutty, in my view at least) that a plan with these services is not real health insurance.”

Even with its allowance for companies that had signed contracts by Nov. 4, HHS stopped short of employer pleas for more flexibility. Industry groups wanted a green light to temporarily offer plans without hospital benefits if companies had made substantial preparations to do so but hadn’t signed a deal.

It’s unclear how many firms will offer such coverage for 2015. Nearly half of the 1,600 employer members of the American Staffing Association, which employ 3 million temporary employees on any given day, had committed to offer or were considering the plans last fall before KHN reported that regulators were moving against them.

While some members followed through and adopted such coverage, most did not, said Edward Lenz, senior counsel for the association, a trade group of temp and recruiting firms.

Calculator-approved plans lacking hospital benefits are comparatively rich in outpatient services such as doctor visits. Consultants selling the coverage had argued it was a good first step for lower-wage, high-turnover employers that had never offered major-medical insurance.

“I’ve had a couple discussions in the last several days with clients who were interested but disappointed they were too late to install them for 2015,” said Edward Fensholt, a benefits lawyer with brokers Lockton Companies. Other companies “leapt on them,” he said.

For employers that planned to offer such coverage but hadn’t pulled the trigger by Nov. 4, “this is very disruptive news,” Bianchi said. “Best I can recall, I have about a half dozen clients that are in this position.”

Anne Lennan is president of the Society of Professional Benefits Administrators, whose members process claims for self-insured employers.

“A very small number of non-hospital plans were implemented by my members — as a percentage of all the plans they administer,” she said via email.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Republican efforts to replace the federal health law have been given new urgency by the Supreme Court.

As soon as this spring, the court could invalidate health insurance subsidies available to millions of Americans if it rules for the challengers in a case called King v. Burwell.

Republicans who hate the Affordable Care Act are rooting for the court to do what they have been unable to accomplish – dismantle a key part of the law. But as the party that controls Congress, some Republicans also fear the potential for a backlash if they don’t have a plan to help those who would effectively be stripped of coverage, many of whom are voters in Republican-led states.

There’s another reason to agree soon on a replacement for the law, instead of continuing their long campaign to repeal it. If Republicans present a reasonable alternative, it could help swing a justice or two who might otherwise worry about the possible ramifications of cutting off the subsidies. Or so the reasoning goes.

“The Republicans would love to give the justices some comfort that if they rule against the Obama administration, there will be something there to deal with the fallout,” says Dean Clancy, a Republican strategist and former aide to House Majority Leader Dick Armey.

Those pushing the case argue that language in the law limits help to pay for insurance to residents of states that have established their own health insurance exchanges. So far only 13 states have – the rest use the federal healthcare.gov exchange.  The administration contends that Congress clearly intended that the subsidy — tax credits based on income — be available in all states, and has declined to discuss any possible contingency plans.

If the court rules against the administration, the impact will fall heavily on Republican-led states, such as Florida and Texas, that didn’t create their own exchanges, increasing pressure on Congress to act.

“I really do believe that this situation has concentrated the minds of many people on [Capitol] Hill,” says Avik Roy, a senior fellow at the Manhattan Institute and a former health advisor to GOP presidential candidate Mitt Romney. If the Supreme Court rules that subsidies cannot be provided through the federal health exchange, he says, Republicans in the House and Senate “realize if they don’t do something, they will be held accountable for that. Because they are running Congress now, so they can’t blame it on the Democrats.”

Still, putting something on the front burner does not guarantee it will get done. Republicans have been vowing to “repeal and replace” the Affordable Care Act almost since it became law in 2010. So far, the GOP-controlled House has held more than 50 separate votes to repeal or otherwise cancel parts of the law. Replacing, however, has been another story.

“Republicans are united around repeal. And they’re united around replace. But obviously they’re not united around ‘replace with what,’” says Dean Rosen, a health policy consultant who was a top aide to former GOP Senate Majority Leader Bill Frist and to the House Ways and Means Committee.

Republican health strategist Terry Holt, a former aide to the GOP House leadership, agrees. He says Republicans “are serious about a replacement” for the Affordable Care Act, “but it’s the law, and it’s harder to change law than to make it.”

There are several efforts underway to come up with a consensus Republican alternative to the health law. The repeal bill the House approved Feb. 3 includes language requiring the four main committees that handle health legislation in that chamber to approve a replacement, but no time limit is specified.  Separately, three of those committee chairmen were tasked by House Majority Leader Kevin McCarthy in January to come up with a health bill, again with no specific deadline.

Across the Capitol, two GOP senators with deep backgrounds in health — Finance Committee Chairman Orrin Hatch, R-Utah, and Richard Burr, R-N.C. — along with House Energy and Commerce Committee Chairman Fred Upton, R-Mich. have unveiled the outlines of a plan that was first floated last year.

And House Ways and Means Committee Chairman Paul Ryan, R-Wis., has said Republicans in the House are working on a short-term “bridge” for those who could get stripped of their insurance subsidies, although again, no specifics have been offered.

Even with new incentives, getting to specifics won’t be easy, says Clancy, for much the same reasons that have kept Republicans from being able to agree on a health overhaul for the past five years.

“There are pro-business Republicans and pro-market Republicans, and you see the divide on lots of issues, including health care,” he says.

For example, the more pro-market, libertarian types “would say let’s get the federal government out of the health insurance business altogether if possible, or at least create a much more voucher-like system with as little centralized control as possible,” he says. But the more traditional pro-business Republicans “are not going to be keen on blowing up the employer-based system.” Currently a majority of Americans still get their insurance through their or a family member’s job.

Another complication, says Rosen, is the impending presidential campaign, and the possibility that several sitting members of the Senate may run. “And you can see that the people who are posturing to be candidates … don’t just want to do Obamacare light,” he said.

Still, the prospect of millions of people in states run by Republican governors and Republican legislatures losing their insurance could be the deciding factor, says Holt. “These are people who have been promised something and are expecting it to continue, and it’s hard to see how you cut people off,” he says.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

The Obama administration said Friday it will allow a special health law enrollment period from March 15 to April 30 for consumers who realize while filling out their taxes that they owe a fee for not signing up for coverage last year.

The special enrollment period applies to people in the 37 states covered by the federal marketplace, though some state-run exchanges are also expected to follow suit.

People will have to attest that they first became aware of the tax penalty for lack of coverage when they filled out their taxes. They will still have to pay the fine, which for last year was $95 or 1 percent of their income, whichever was greater. By signing up during the special enrollment period for 2015 they can avoid paying most of the tax penalty for this year.

The Affordable Care Act requires most Americans to have health insurance or pay a financial penalty. But some people may not realize they face a penalty for not having coverage until they file their tax returns ahead of the April 15 tax deadline.

The administration also said Friday it sent out the wrong information to 800,000 people to help them calculate whether they received too much of a subsidy for health coverage last year or too little. Those affected are being notified today by email or telephone – and are being asked to wait to file their taxes until after new 1095-A forms are sent in early March.

For the 5 percent of those affected who have already filed returns for 2014, more instructions are to come from the Treasury Department, officials said.  The 800,000 represents about 20 percent of the total number of people who were sent 1095-A tax forms.  Officials declined to say how the mistake occurred.

The administration would not estimate how many people it expects to take advantage of the new enrollment period. Millions of Americans who did not enroll in a plan are exempt from the requirement to buy coverage because their income is too little or they qualify for other exemptions. Officials said this special enrollment would be just for this year to account for people who did not hear or heed messages about the individual insurance mandate that was included in the health law approved by Congress in 2010.

So far, 11.4 million Americans have enrolled in private health insurance through Obamacare during the open enrollment period that ended on Sunday.

Separately, administration officials have said they will allow people who had trouble completing their enrollment by Feb. 15 to finish by Sunday Feb. 22. Officials estimated it would help fewer than 150,000 people.

Julie Appleby contributed to this story.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

A “teachable moment” is one way to describe the  consternation that many uninsured people may feel when they file their taxes this spring and realize they owe a penalty for not having health insurance.

According to a new survey, the number of people who may need to be schooled is substantial: Forty-four percent of uninsured people who may be subject to the penalty say they know nothing or only a little about the penalty they may face.

The Urban Institute analysis was based on its December 2014 Health Reform Monitoring Survey of uninsured adults with incomes above the poverty level, a group that might be expected to owe a penalty for not having coverage.

For 2014, the penalty is the greater of $95 or 1 percent of annual income. In 2015, the penalty increases to 2 percent or $325, whichever is greater.

People who don’t become aware of the penalty until they file their 2014 taxes in March or April could end up owing penalties for both years. The open enrollment period to sign up for 2015 health insurance ended Feb. 15.

Consumer advocates have been strongly encouraging the Obama administration to create a special enrollment period for uninsured people who only realize the financial hit they’re facing after open enrollment has ended. While they probably can’t avoid a penalty for being uninsured last year, they could avoid getting dinged again in 2015 if they enrolled this spring.

“These results suggest that a special enrollment period could help a significant percentage of the uninsured get coverage,” says Stephen Zuckerman, co-director of the Urban Institute’s Health Policy Center and a co-author of the analysis.

In addition to being generally unaware of the penalties for not having insurance, 30 percent of those surveyed said they had not heard of the state health insurance marketplaces, while 29 percent said they knew about the marketplaces but didn’t know about the Feb. 15 enrollment deadline.

“There’s a general gap in knowledge,” Zuckerman says. “Looking across the years, there’s a surprising persistence of people who are not aware of the various provisions of the health law.”

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.