Kaiser used an algorithm — not clinicians — to triage mental health patients, a union alleges

A health worker union has accused Kaiser Permanente of screening patients and making care recommendations through “a digital, automated algorithm” without clinician oversight — a practice the union says violates state law. 

The complaint, filed with state regulators by the National Union of Healthcare Workers, targets the integrated healthcare provider’s e-visit screening tool, which evaluates patients who think they may be experiencing anxiety or depression. Patients answer a multiple choice questionnaire, and the tool “automatically and instantaneously generates care recommendations and referral pathways based on the responses provided,” the complaint states. 

That’s not necessarily an appointment with an in-person therapist: recommendations also include referrals to virtual therapy, health education classes and self care apps, according to the complaint. 

The union represents therapists and social workers among other health workers at Kaiser facilities. According to the Department of Managed Health Care, which oversees health plans, this is the first time a union has filed a complaint against a health plan related to its supposed use of algorithms and artificial intelligence in behavioral healthcare.

Union members say they’ve seen no evidence that licensed mental health clinicians review patients’ e-visit answers in real-time, or at all, before the tool issues recommendations for follow-up care. At a hearing held by the San Francisco Board of Supervisors on this issue last week, therapists and social workers said that digital automated screenings cannot replace a clinician’s assessment. 

“Artificial intelligence and algorithms don’t capture what trained humans can,” said Ilana Marcucci-Morris, a therapist and a member of the union’s bargaining committee. She notes that people with depression commonly minimize their symptoms — so an algorithm relying solely on a patient’s answers may miss signs of a more severe condition.

Kaiser skipped last week’s hearing. But in an emailed statement to CalMatters, Kaiser pushed back on the union’s characterization of its behavioral health processes.

The e-visit tool “does not use AI to diagnose patients, make clinical decisions, or determine medical necessity. Clinical decisions remain with licensed healthcare professionals,” said Lena Howland, a Kaiser spokesperson. She did not provide more details about the technology behind the tool.

Howland said patients can still reach a live person by calling a phone number displayed during the e-visit process. “The online screening tool “is an additional path to getting care—not the only path,” she said. 

In a blog post from last year, Kaiser describes the e-visit tool as increasingly popular, especially among younger members, and available for about 30 health concerns. In the post, Kaiser says patients’ answers “are reviewed by a health care professional” and that members “receive a response by secure message within 4 hours, and usually sooner.”

Union leaders counter that care recommendations typically come in almost immediately after completing the questionnaire. They argue no clinician can realistically be reviewing patients’ answers that quickly.

The union contends Kaiser’s screening practice violates state law, which requires that medical decisions come from a licensed healthcare professional and bars “artificial intelligence, algorithms, or other software tools” from supplanting that judgment. 

The Department of Managed Health Care said it has received the union’s complaint and is investigating. “Details of ongoing enforcement investigations are confidential in compliance with the law and to protect the integrity of the investigation,” the department said. 

A shift in mental health triage

The complaint lands in the middle of contract negotiations between the healthcare union and Kaiser Northern California, which have dragged on for more than a year without an agreement. 

Therapists and health workers who spoke at last week’s hearing said that a new triage system including the e-visit tool started in 2023. Before that, dedicated Kaiser triage teams made up of licensed clinicians — who could pick up on cues like tone of voice — took patients’ brief histories over the phone, screened for self-harm, and provided a preliminary diagnosis and next steps in care.

Now, the union says clerical staff or the tool do most mental health triaging. The healthcare union filed a separate complaint last year alleging Kaiser used telephone service representatives, instead of clinicians, to answer mental health calls.

Marcucci-Morris said she typically sees patients about two weeks after Kaiser’s new system triages them. “The acuity and critical nature of symptoms I am seeing has increased significantly because the app, AI, an algorithm, or an unlicensed telephone operator incorrectly determined that they could wait 10 days to see me,” she said.

San Francisco Supervisor Chyanne Chen said she called last week’s hearing because of concerns she’d been hearing from constituents — both Kaiser employees and patients — about the health giant’s mental health services. Kaiser serves about a third of San Francisco’s population. 

Chen called Kaiser’s absence from the hearing “unacceptable,” and said it left many of her questions unanswered.

“As a San Franciscan, I’m not against technology,” Chen said. “For me it’s making sure we’re not shortcutting our quality of care and safety.”

Kaiser’s troubled mental health record 

This isn’t the first time Kaiser has skipped a hearing on its mental health services. Last year, state legislators criticized the health plan after it declined to participate in an informational hearing about its behavioral health services. 

Kaiser’s mental healthcare problems are well documented. In 2023, Kaiser agreed to pay a $50 million fine and to invest $150 million to improve its programs in exchange for settling state findings that its behavioral health patients were experiencing serious delays in care. In 2021, California regulators had noted a jump in behavioral health-related complaints, which prompted regulators to conduct a survey that led to the settlement. Kaiser now operates under  a corrective action plan and must submit quarterly progress reports to the state.

In 2014, state regulators fined Kaiser $4 million for long wait times between therapy appointments. Kaiser has largely attributed its past problems to a shortage of care providers.

The health plan is also facing mounting criticism over its broader use of AI and digital tools in care.

Kaiser’s own mental health workers have objected to transcription tools that record patient appointments, saying  the company won’t disclose how it uses or shares the data. Separately, call center nurses have also raised concerns about Kaiser using AI and software to monitor their calls.

Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.