As Barbara Ragan stood atop a Kaiser Permanente parking garage in Northern California this summer, traces of Xanax, Prozac and a generic antidepressant were in her blood.
Yet the 83-year-old longtime Kaiser patient was distraught: The drugs had proved ineffective for her depression, and her next psychiatric appointment was weeks away, a wait she told her family felt interminable.
When she stepped off the roof and fell to her death, her suicide stunned onlookers — but was really directed, her husband believes, at her healthcare provider.
"She could have jumped anywhere, but she went right to Kaiser," said Ragan's husband, Denny. "It's like sending a message right to them: 'You couldn't take care of me, so here I am.'"
The Oakland-based health maintenance organization has battled accusations for more than two years that its mental health services put patients at risk.
Now Ragan's suicide has increased scrutiny of the giant healthcare provider, which last year paid a $4-million fine to resolve allegations by the state Department of Managed Health Care that it inadequately treated mental health patients, including some who waited weeks to see therapists. A follow-up report by the agency in February found that some patients were still waiting too long.
Kaiser spokesman John Nelson said the HMO should not be faulted for Ragan's suicide. He noted that she received frequent psychiatric counseling and had spoken to a psychiatrist by telephone in the days before her death. An earlier in-person appointment, he said, was available if she had asked.
"Any time somebody is receiving care from us and they take their life, it's a terrible tragedy," Nelson said. "In this case, access was not an issue. She had received regular access to mental health professionals."
He acknowledged, however, that it has been a challenge to improve Kaiser's mental health services even as the HMO has increased staffing from 1,097 therapists in January 2011 to 1,508 this June. Kaiser even departed from its traditional business model — in which patients generally see only doctors who are members of its Permanente Medical Groups — to contract with an outside group of providers called ValueOptions.
"We're not perfect. We said that all along," Nelson said. "We had locations, and we said this two years ago, that were struggling to deliver timely access. We've been addressing that in hiring and bringing in outside providers."
Some experts say the shortage has been exacerbated by more newly insured patients under the federal Affordable Care Act, while others say Kaiser's size has made it an easy target for activists. The HMO also claims that a union contract dispute has fanned the flames.
William Arroyo, regional medical director for the Los Angeles County Department of Mental Health, said his agency has struggled to hire enough psychiatrists to meet demand.
"In California, we clearly have shortages," he said. "Kaiser is a gorilla health plan, so the impact for them may be greater as a result."
But such explanations carry little weight for Kaiser critics, who cite federal law that requires insurers to provide the same level of treatment for mental illness as they do for physical illness.
They also note Kaiser has been sued by families of two other patients who committed suicide. The families claim that their loved ones were often shuttled into group therapy, instead of giving them more costly — and effective — individual counseling. An Alameda County judge recently rejected Kaiser's request to dismiss the lawsuit.
Yet another lawsuit contends Kaiser pressured some of its most seriously ill mental health patients to cancel their plans and accept government assistance for long-term hospitalizations.
Sonoma County Supervisor Shirlee Zane was outraged to learn of Ragan's death, which touched a personal nerve for her. Zane's husband committed suicide in 2011 while under Kaiser's care.
"They have been saying, very arrogantly, that they have fixed the situation and are providing access," Zane said. "This woman obviously didn't get adequately treated, or she wouldn't have killed herself."
Ragan, a retired Kaiser clerical worker who lived in Santa Rosa with her husband, had battled depression for many years, but her condition worsened this year.
Her psychiatrist told her to stop taking Prozac and instead prescribed depression drug Zoloft and anti-anxiety medication Xanax, her husband said, but she continued to struggle.
In June, she began trembling while grocery shopping and asked her husband to take her to the emergency room at Kaiser Permanente Santa Rosa Medical Center. There she was sent to another psychiatrist and this time received prescriptions for anxiety medication Ativan and Lexapro, an antidepressant.
A few weeks later, Kaiser sent her a notice by mail that she had an appointment with a psychiatrist on Aug. 25. "She said, 'Two months, Denny? I can't wait that long,'" he said.
The breaking point came July 3, her husband said. After speaking to clinical staff, she went to Kaiser to pick up a new prescription that she hoped would improve things. Waiting for her was a bottle of Prozac, the drug her psychiatrist had stopped a few months earlier.
"Then she got really down. She said, 'What am I going to do? They told me Prozac wasn't working,'" Denny Ragan recounted.
Two days later, Ragan, dressed in pajamas and slippers, slipped out of the couple's home without saying goodbye, drove to the Kaiser facility in Santa Rosa and jumped from the three-story parking structure to the concrete below. Preliminary autopsy results found the Xanax, Prozac and citalopram in her blood. Her suicide was first reported by the Santa Rosa Press-Democrat.
Ragan's son, Michael, said his mother could have benefited from more individual counseling.
"All they do is distribute drugs," he said. "She was upfront with them and gave them every opportunity to help her out, but it was just, 'This is all we're going to do for you and we hope it works.'"
In its most recent report, the state Department of Managed Health Care said it reviewed medical records of nearly 300 Kaiser patients and found a continuing problem with long waits for treatment. In Northern California, patients didn't get timely appointments in 22% of cases. In Southern California, Kaiser failed to meet the standard in 9% of cases.
Regulators cited several cases in an effort to illustrate the problem, including a sexual assault victim who was told to seek therapy from an outside clinician at the patient's expense and another who was told by a Kaiser psychiatrist, "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."
Rodger Butler, a spokesman for the state agency, said an investigation into Kaiser's services is continuing.
Walter Bubnow, a 35-year-old Bell Gardens resident, said Ragan's suicide was a painful reminder of his experience with Kaiser. He said the HMO declined to provide him with regular individual therapy after his diagnosis with panic disorder in 2008.
"I know exactly what she was going through," he said. "When I was at rock bottom, couldn't leave my house, they did nothing to help me. I deteriorated so bad between appointments it made things worse. They said you have to be a threat to yourself or other people in order for them to provide you weekly care."
Instead, Bubnow said, he was given medication. "You go in there, the doctor asks you how you're feeling and he bumps up the medication."
When he told Kaiser staff that medication alone wasn't helping, Bubnow said, they referred him to group therapy.
"It didn't work," he said. "They were all different mental illnesses: bipolar, depression, schizophrenia. When I'd go to therapy, they'd all talk about their pills. It was a medication class, that's all it was.... How can you treat nine different disorders in 45 minutes? It's simple: You can't."
Bubnow said he left his job with the Los Angeles County Public Works Department last year because of his disorder. Now unemployed, he receives treatment through Medi-Cal at Los Angeles County-USC Medical Center.
He said he has the illness under control, thanks to therapy he's received. "It's like night and day," he said. "I get hands-on care at USC, a county hospital, that I never got at Kaiser."
Kaiser spokesman Nelson declined to specifically comment on the details of Bubnow's case, citing medical privacy laws. (Ragan's family signed a waiver permitting Kaiser to discuss her case.) But he said individual therapy is available.
"It is absolutely not the case that somebody suffering from anxiety would not have access to individual therapy," he said.
Ragan's family has been working with a Kaiser ombudsman and has not yet decided whether to pursue legal action. Her husband said he's still searching for answers about why his wife killed herself, and what Kaiser could have done differently.
Before her death, Ragan wrote a one-page goodbye note to her family and left it inside her desk. Denny Ragan didn't find it until two days after she died.
Her final words: "I couldn't stand the pain."