Mental Health Care: Last Week Tonight with John Oliver (HBO) 7/31/2022

[AbnormalPsych]

EDIT: For some reason the video was taken down. Here is the link to the video on the last week tonight official youtube channel:

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[BuckeyeLove]

That chief clinical officer of anthem...wow. bottom lines are bottom lines apparently. what a garbage human.

 

[cara susanna]

Whoa, I love John Oliver so it's exciting to see him cover something in my wheelhouse. Will have to watch when I have time.

 

[Sanman]

I like John Oliver ( and really most of the alums of Jon Stewart's Daily Show) and I am happy that he highlighted the issues of poor pay, administrative gatekeeping by insurance companies, tech companies being silly, and lack of diversity (though he should look at midlevels as well to really get the picture of diversity). I disagree with his stance about single payer healthcare. If that were the solution, then geriatrics would be the most popular specialty and no one would ever leave a VA job. Just not the case. I do think that changing laws to allow better access to providers and things like Psypact will help. Lower costs and let us live where we want while providing care.

 

[deleted106747]

I like John Oliver ( and really most of the alums of Jon Stewart's Daily Show) and I am happy that he highlighted the issues of poor pay, administrative gatekeeping by insurance companies, tech companies being silly, and lack of diversity (though he should look at midlevels as well to really get the picture of diversity). I disagree with his stance about single payer healthcare. If that were the solution, then geriatrics would be the most popular specialty and no one would ever leave a VA job. Just not the case. I do think that changing laws to allow better access to providers and things like Psypact will help. Lower costs and let us live where we want while providing care.

The VA IMO shouldn’t be conflated with what single payer healthcare would look like, or how happy providers would be. And I don’t think the public funding of the VA is the reason some people leave, since job satisfaction/leaving varies quite a bit between VAs.

 

[Sanman]

The VA IMO shouldn’t be conflated with what single payer healthcare would look like, or how happy providers would be. And I don’t think the public funding of the VA is the reason some people leave, since job satisfaction/leaving varies quite a bit between VAs.

The VA is not 100% what single payer healthcare would look like. However, one element of the VA that is also true of Medicare For All is that it simply causes demand to further outstrip supply. One of the reasons that people seek out the VA for MH and geriatric care is that it is accessible and cheaper. That means costs and access need to be controlled in some way. This combination is what leads to high volumes, limited term manualized care, and generally burn out among the employees. We can't keep MH staff for more than a year or two in the general outpatient clinics because the demand is so high and they never get a break. Without fully addressing cost of care, administrative burden, employee satisfaction, and educational training costs implementing single payor means nothing. Every person in the country could have Medicare tomorrow. If the rate is $100 and I can command $200-300 in the open (cash) market and fill my schedule, guess what I am doing?

 

[cara susanna]

The VA has its issues, but I think it's actually a great model for mental healthcare. As I was watching this episode last night, I kept thinking about how so many of the problems they discussed don't happen here. We would just need a system where we can discharge or "unilaterally terminate" treatment with patients who aren't engaging or don't need it. I actually bet it would be easier if people wouldn't be able to play the veteran card. Doesn't mean we should throw out the baby with the bathwater, imo.

 

[WisNeuro]

The VA has its issues, but I think it's actually a great model for mental healthcare. As I was watching this episode last night, I kept thinking about how so many of the problems they discussed don't happen here. We would just need a system where we can discharge or "unilaterally terminate" treatment with patients who aren't engaging or don't need it. I actually bet it would be easier if people wouldn't be able to play the veteran card. Doesn't mean we should throw out the baby with the bathwater, imo.

I know I'm a broken record on this, and I have my own issues with the VA as a provider, but out of all the places I have worked in healthcare organizations, by far the best MH care that patients received was in the VA. I'm sure there are private pay places for wealthy people that can blow teh VA out of the water, but for the vast majority of people, the VA is hands down better for MH care, on average, than what they can reasonably access in the community. This is especially true for older adult care, in my experience.

 

[Sanman]

I know I'm a broken record on this, and I have my own issues with the VA as a provider, but out of all the places I have worked in healthcare organizations, by far the best MH care that patients received was in the VA. I'm sure there are private pay places for wealthy people that can blow teh VA out of the water, but for the vast majority of people, the VA is hands down better for MH care, on average, than what they can reasonably access in the community. This is especially true for older adult care, in my experience.

The VA has its issues, but I think it's actually a great model for mental healthcare. As I was watching this episode last night, I kept thinking about how so many of the problems they discussed don't happen here. We would just need a system where we can discharge or "unilaterally terminate" treatment with patients who aren't engaging or don't need it. I actually bet it would be easier if people wouldn't be able to play the veteran card. Doesn't mean we should throw out the baby with the bathwater, imo.

I can't disagree with this. However, I also think one needs to consider the fact that the care is so comprehensive because they are veterans. HBPC as a program makes no fiscal sense outside the VA and is part of the great older adult care. It is justified through a combination of flag waving (no veteran left behind) and the fact that the VA is fiscally responsible for these people in a way that we are not for other members of the population. That program and others would not exist in a single payor setting, so the same gaps in care will occur. Same with MH care. At some level, there is fear that if there is a veteran who ends up in the paper not receiving care it will look bad. Especially if he/she commits a crime. Other MH professionals will not receive the pay bumps or lower volume expectations of the VA. They also will not be exempt from Medicare paperwork or audits. From audits to Medicare Advantage, that system is also being run by private contractors. So, it does not solve the larger issues with misaligned incentives.

That said, @WisNeuro doesn't work for a healthcare system. There is a reason for this and you have mentioned it. If you aren't willing to work for those wages, why should anyone else be? Certainly, it would provide a floor for all providers in terms of wages. However, that is not an incentive to see these people.

 

[WisNeuro]

I can't disagree with this. However, I also think one needs to consider the fact that the care is so comprehensive because they are veterans. HBPC as a program makes no fiscal sense outside the VA and is part of the great older adult care. It is justified through a combination of flag waving (no veteran left behind) and the fact that the VA is fiscally responsible for these people in a way that we are not for other members of the population. That program and others would not exist in a single payor setting, so the same gaps in care will occur. Same with MH care. At some level, there is fear that if there is a veteran who ends up in the paper not receiving care it will look bad. Especially if he/she commits a crime. Other MH professionals will not receive the pay bumps or lower volume expectations of the VA. They also will not be exempt from Medicare paperwork or audits. From audits to Medicare Advantage, that system is also being run by private contractors. So, it does not solve the larger issues with misaligned incentives.

That said, @WisNeuro doesn't work for a healthcare system. There is a reason for this and you have mentioned it. If you aren't willing to work for those wages, why should anyone else be? Certainly, it would provide a floor for all providers in terms of wages. However, that is not an incentive to see these people.

If I was doing 100% clinical work, the compensation difference between PP and some system jobs would be pretty negligible, assuming an insurance based practice and a similar number of hours/week worked. The big bucks come from the legal work, but that's not for everyone.

 

[Sanman]

If I was doing 100% clinical work, the compensation difference between PP and some system jobs would be pretty negligible, assuming an insurance based practice and a similar number of hours/week worked. The big bucks come from the legal work, but that's not for everyone.

If in an insurance based practice and working similar hours sure. However, you can make a lot more with a cash based therapy practice or a high volume/ lower quality insurance based practice. There is no incentive to provide quality with single payor. The incentive is to do as little as possible to collect your billables. I saw it in LTC/ALF work all the time. I remember hearing stories of a previous contracting psychologist I replaced who used to come in on Saturdays and sit in patient rooms reading the paper while billing for therapy.

 

[WisNeuro]

If in an insurance based practice and working similar hours sure. However, you can make a lot more with a cash based therapy practice or a high volume/ lower quality insurance based practice. There is no incentive to provide quality with single payor. The incentive is to do as little as possible to collect your billables. I saw it in LTC/ALF work all the time.

It's the same incentive in PP for the clinical work. As for the cash based practice, much harder to do for assessment than for therapy in my experience. My only real incentive for the clinical side of things is just that I enjoy some of it. If anything, the only work I do that has an incentive to put out the best product, is the legal work, as it's very reputation-based. I just don't see how single payor would degrade care in any appreciable manner in my clinical area. Perhaps in some others, but the same pressures, or lack thereof, apply in either scenario.

 

[Sanman]

It's the same incentive in PP for the clinical work. As for the cash based practice, much harder to do for assessment than for therapy in my experience. My only real incentive for the clinical side of things is just that I enjoy some of it. If anything, the only work I do that has an incentive to put out the best product, is the legal work, as it's very reputation-based. I just don't see how single payor would degrade care in any appreciable manner in my clinical area. Perhaps in some others, but the same pressures, or lack thereof, apply in either scenario.

You are increasing demand on the low end and removing options for increased pay on the high end. There is no more picking the best paying insurance and seeing those patients and cash pay for a higher salary. There is only cash pay and everyone else. It certainly would negate any reasons for provide care for more complex cases. Cases that involve difficult diagnoses, caregivers ,etc will not be worth it. It would be all mild adjustment disorders and the worried well. That is not so different than now, but better paying insurance provides some incentive at least.

 

[WisNeuro]

You are increasing demand on the low end and removing options for increased pay on the high end. There is no more picking the best paying insurance and seeing those patients and cash pay for a higher salary. There is only cash pay and everyone else. It certainly would negate any reasons for provide care for more complex cases. Cases that involve difficult diagnoses, caregivers ,etc will not be worth it. It would be all mild adjustment disorders and the worried well. That is not so different than now, but better paying insurance provides some incentive at least.

There's no wide spread in reimbursement in my area for testing codes. In general, Medicare is middle of the pack, and because it's so easy to use and doesn't require PA, it's usually the best bet in terms of reimbursement per time spent. There is little incentive to pick the "best" insurances as is. As for difficulty, it's all time based, so I get paid the same if it's an easy vs. hard case, so I don't see any issues there. I'm sure there are other areas in healthcare that will be more affected, but for me, it'd pretty much be the same thing on the clinical side of things.

 

[WisNeuro]

To clarify my personal stance,I think single payor would be best for overall health in our country, but I personally favor a reasonable public option, and still having private insurers.

 

[Sanman]

To clarify my personal stance,I think single payor would be best for overall health in our country, but I personally favor a reasonable public option, and still having private insurers.

There's no wide spread in reimbursement in my area for testing codes. In general, Medicare is middle of the pack, and because it's so easy to use and doesn't require PA, it's usually the best bet in terms of reimbursement per time spent. There is little incentive to pick the "best" insurances as is. As for difficulty, it's all time based, so I get paid the same if it's an easy vs. hard case, so I don't see any issues there. I'm sure there are other areas in healthcare that will be more affected, but for me, it'd pretty much be the same thing on the clinical side of things.

I can't disagree with you on testing or ease of Medicare billing for low volume providers (I am sure you never hit the audit minimums). MIPS can be a pain though and a problem in higher volume practices. So can the audit systems used (it targets higher utilizers and those with increased acuity codes, so a lot geriatrics folks). I am also speaking more from a therapy perspective. Plenty of small therapy PPs opting for a combo of cash and getting credentialed with one or two higher paying insurances. I also agree that a public option for hospitalization and basic care with more comprehensive private plans would be most workable solution. I am for a public "Bronze plan" as part of Obamacare at a reasonable cost to allow access to healthcare for all people. Let the insurers then compete to provide a better plan.

 

[PsyDr]

Inflation goes up, Medicare pays 4% less.... every year.

 

[cara susanna]

I don't think insurance companies should have the right to deny medically necessary care.

 

[borne_before]

John Oliver is Joe Rogan for people who memorize Hamilton songs.

 

[WisNeuro]

John Oliver is Joe Rogan for people who memorize Hamilton songs.

I'd have to disagree here. John actually researches things vs. just spouting random **** or bringing in known conspiracy theorists on segments all the time.

 

[WisNeuro]

I don't think insurance companies should have the right to deny medically necessary care.

Technically they don't, as long as they get to define what is "medically necessary."

 

[cara susanna]

Technically they don't, as long as they get to define what is "medically necessary."

Haha, touche. But you get what I meant!

 

[PsyDr]

I don't think insurance companies should have the right to deny medically necessary care.

They don't deny care, they deny paying for it.

That's how they avoid accusations that they are practicing medicine.

 

[cara susanna]

They don't deny care, they deny paying for it.

That's how they avoid accusations that they are practicing medicine.

Okay, then let me rephase: insurance companies shouldn't get to deny paying for care that a provider deems medically necessary.

 

[WisNeuro]

Okay, then let me rephase: insurance companies shouldn't get to deny paying for care that a provider deems medically necessary.

On the flip side, from my days as a reviewer way back when, some providers are absolutely ridiculous in what they deem "medically necessary." Like 8 hours of neuropsych testing for ADHD in an adult with no neurological rule outs. Or a full Rorschach, MMPI, and TAT in another ADHD eval. Or one provider who wanted to bill for 12 hours of testing (not counting interview and report writing) for a run of the mill dementia case. Lots of examples like these. Insurance companies definitely the bigger villains here, but there are plenty of either unscrupulous or incompetent providers who are not good stewards of healthcare resources.

 

[Sanman]

Okay, then let me rephase: insurance companies shouldn't get to deny paying for care that a provider deems medically necessary.

They don't have to. It is one of many games they can play. They can agree to pay for it after you meet your $100k annual deductible for XXX care. It is a service contract, kind of like a car warranty. No ever reads the exclusions until it is too late.

 

[Sanman]

On the flip side, from my days as a reviewer way back when, some providers are absolutely ridiculous in what they deem "medically necessary." Like 8 hours of neuropsych testing for ADHD in an adult with no neurological rule outs. Or a full Rorschach, MMPI, and TAT in another ADHD eval. Or one provider who wanted to bill for 12 hours of testing (not counting interview and report writing) for a run of the mill dementia case. Lots of examples like these. Insurance companies definitely the bigger villains here, but there are plenty of either unscrupulous or incompetent providers who are not good stewards of healthcare resources.

The question is whether they are supposed to be. I mean if the client wants a full body scan and 12 hours of neuropsych annually, do you advocate for your patient to ensure nothing is wrong or tell them they are going overboard to conserve resources. It depends on you stance, which is often based on what is better for the bottom line.

 

[WisNeuro]

The question is whether they are supposed to be. I mean if the client wants a full body scan and 12 hours of neuropsych annually, do you advocate for your patient to ensure nothing is wrong or tell them they are going overboard to conserve resources. It depends on you stance, which is often based on what is better for the bottom line.

Well, in the hypothetical of providers being the ones to determine what is medically necessary, then yes they should be. I think there is a space for payer sources to put some bounds on care, which they do. And, in certain extenuating circumstances, you can justify needing services above and beyond those limits, of which mechanisms exist.

 

[Sanman]

Well, in the hypothetical of providers being the ones to determine what is medically necessary, then yes they should be. I think there is a space for payer sources to put some bounds on care, which they do. And, in certain extenuating circumstances, you can justify needing services above and beyond those limits, of which mechanisms exist.

I personally don't disagree with you. Though, there are those that would see themselves as a patient's advocate rather than a steward of healthcare resources. Certainly, plenty of psychotherapy folks can justify keeping clients in for longer and the clients want to continue as well. Is it strictly necessary or just easier for everyone involved?

 

[WisNeuro]

I personally don't disagree with you. Though, there are those that would see themselves as a patient's advocate rather than a steward of healthcare resources. Certainly, plenty of psychotherapy folks can justify keeping clients in for longer and the clients want to continue as well. Is it strictly necessary or just easier for everyone involved?

Yes, but even as a patient's advocate, I provide care according to best practices and empirically derived assessment and intervention. I do not provide them with whatever they ask for, and I don't do things which have no basis in reality. And, while anyone paying out of their own pocket can generally have whatever they want, I don't think we should be forcing payers to cover things that have zero known benefit. Otherwise, our tax dollars would be paying for treatments like the snakeoil Amen clinic and similar shysters.

 

[erg923]

Okay, then let me rephase: insurance companies shouldn't get to deny paying for care that a provider deems medically necessary.

Sorry @cara susanna. No!!!

It is not fiscally responsible practice for a large company to just blindly take someone's word for it/pay for whatever services without looking into things a bit. That would be grossly negligent (fiscally and ethically). There have to be "checks and balances" in a third-party payor system.

Providers of all kinds request many services that are either clearly not working, not evidence-based, can be addressed at a lower-level of care, or are too high in length/intensity/frequency all the time. This is partly a side of effect of the fee-for-service model CPT codes. It also a result of the wildly variable quality of training in the mental health profession in the past several decades.

As was alluded to by prior posters, most "providers" are trained to advocate for patient wishes (the whole patient centered-care=patient dictated care thing), and are incentivized by payment for said services. Most don't think about "necessity".... or the larger use of scarce resources/time. Much less who is actually paying the tab, right? What you said above is simply not responsible fiscal policy for a third-party payor.

 

[erg923]

The question is whether they are supposed to be. I mean if the client wants a full body scan and 12 hours of neuropsych annually, do you advocate for your patient to ensure nothing is wrong or tell them they are going overboard to conserve resources. It depends on you stance, which is often based on what is better for the bottom line.

There are times where that is needed. There are times where it is not and would be wasteful of money and time. If someone else is going to pay for it, they have every right to look into a bit and use the available clinical evidence for that patient, and evidence-based practice guidelines, to guide that decision.

 

[AbnormalPsych]

Yes, I agree with that. But then if there is that view, then I think there also needs to be some checks and balances of the checkers and balancers, then. I am guessing insurance companies are also at times using this as a barrier and channel to improve their bottom line in a capitalistic system.

 

[erg923]

Yes, I agree with that. But then if there is that view, then I think there also needs to be some checks and balances of the checkers and balancers, then. I am guessing insurance companies are also at times using this as a barrier and channel to improve their bottom line in a capitalistic system.

There are multiple "checks and balances" embedded in managing payment denials issued by insurance companies. These include Peer-to-Peer telephonic reconsideration requests, written appeals, external appeal (if applicable), and talking/working/complaining to the state insurance commission.

I DO think there are some explicitly bad examples of policies and barriers that have been unreasonably applied and not supported by evidence based practice, yes. Such as internal UBH/OPTUM policies several years ago. This was in the news. But mostly... no. The goal of utilization management (UM) is to ensure proper use of resources AND that enrolled members are receiving/being approved to receive best practice/evidenced-based care and services.

 

[Shiori]

Yes, I agree with that. But then if there is that view, then I think there also needs to be some checks and balances of the checkers and balancers, then. I am guessing insurance companies are also at times using this as a barrier and channel to improve their bottom line in a capitalistic system.

This reminds me of the backlash to Aetna's prior authorization requirement for all cataract surgeries. I've seen more research into the pros and cons of specific checks and balances, and I'll be curious to see the results.

 

[cara susanna]

Sorry @cara susanna. No!!!

It is not fiscally responsible practice for a large company to just blindly take someone's word for it/pay for whatever services without looking into things a bit. That would be grossly negligent (fiscally and ethically). There have to be "checks and balances" in a third-party payor system.

Providers of all kinds request many services that are either clearly not working, not evidence-based, can be addressed at a lower-level of care, or are too high in length/intensity/frequency all the time. This is partly a side of effect of the fee-for-service model CPT codes. It also a result of the wildly variable quality of training in the mental health profession in the past several decades.

As was alluded to by prior posters, most "providers" are trained to advocate for patient wishes (the whole patient centered-care=patient dictated care thing), and are incentivized by payment for said services. Most don't think about "necessity".... or the larger use of scarce resources/time. Much less who is actually paying the tab, right? What you said above is simply not responsible fiscal policy for a third-party payor.

I mean, sure, there has to be some check in place. But the current setup isn't working, clearly.

 

[erg923]

I mean, sure, there has to be some check in place. But the current setup isn't working, clearly.

What set-up is that?

 

[WisNeuro]

What set-up is that?

I assume the current healthcare setup (non-VA) that most people have to use. If that's the case, I agree with @cara susanna . We continue to pay more, get less, and get sicker as the years go on. Medical debt is the most common delinquent collected debt and medical bankruptcy rates continue to climb. It's unsustainable and it's literally making us sicker on the whole as a society.

 

[smalltownpsych]

This is a good discussion about how to structure the financial aspects of healthcare in our country. I‘m probably on the side of - it’s broken and whatever we do to try to fix it will probably make it worse. How’s that for cynical? In the meantime, I’ll stick to my cash practice. All cash is obviously not a solution for all, but at least for my patients they determine what they will pay for and what they won’t. I hate insurance companies and government bureaucrats determining what is medically necessary, but the reality is that whoever pays has to determine what they will pay for and weigh the cost/benefits.

The whole concept of medical necessity is an odd one, and I think especially so as applied to mental health. With my patients I recommend a course of action and maybe a couple of options and then they determine what they are willing to do based on their resources, time, and money. I do think if we were to improve the current system, it would take an entire paradigm shift that we are unlikely to make. One aspect of this is that a lot of what we call healthcare is really trying to ameliorate the effects of unhealthy life choices that our society promotes.

Completely agree that our society is getting sicker, but I don’t think that’s necessarily because of actual medical care. In fact, our view that medical care can fix us despite unhealthy life choices is an odd one. Also, isnt it kind of odd that when I was young, people were drinking and smoking all over the place, including us kids in high school and now that we have aggressively targeted those behaviors, we aren’t getting better outcomes.

 

[Fan_of_Meehl]

The VA has its issues, but I think it's actually a great model for mental healthcare. As I was watching this episode last night, I kept thinking about how so many of the problems they discussed don't happen here. We would just need a system where we can discharge or "unilaterally terminate" treatment with patients who aren't engaging or don't need it. I actually bet it would be easier if people wouldn't be able to play the veteran card. Doesn't mean we should throw out the baby with the bathwater, imo.

"We would just need a system where we can discharge or "unilaterally terminate" treatment with patients who aren't engaging or don't need it."

I wholeheartedly agree with this assessment. It just seems that it would be devilishly difficult to implement. It would also require that there are sufficient motivations for 'leaders' to actually 'lead' (i.e., make decisions on controversial/contentious issues) so that they are not talking out of both sides of their mouths all the time (essentially, being politicians and PR propaganda clowns, not 'leaders'). The patients would need a system where they would be motivated to not unduly waste clinician/clinic time when they are not truly ready to focus on self-change (the heart of any actual psychotherapy). The only way that seems to make sense would be if they actually had any 'skin-in-the-game' such as at least a modest co-pay for sessions ($25?) and a fee for cancelling or no-showing at the last minute. Like ALL OF PRIVATE PRACTICE DOES (gee, I wonder why). If the rest of the mental health world operated like VA, can you imagine the demand for 'therapy?' It already greatly outstrips supply. That's part of what is so difficult about this problem. I think that nearly everyone could benefit from therapy. Where do you draw the line? Of course, we can use the DSM, but--hell--last I checked something like half the population (more?) technically qualify for at least one mental health diagnosis (say, if you were to SCID-5 everybody). What is really sad is that in systems like the VA or (I would predict) a universal/ single-payer system, the motivations and incentives are all screwed up and you end up with a situation in which the person who is MOST QUALIFIED and best situated to make determinations about, say, allocating clinician time/resources to patients is the person (the clinician) with the least power/authority and the most responsibility. I think this will happen every single time as a function of human nature and as a function of how these approaches are structured ('forget about cost, we're just going to 'do the right thing' (according to whom?) and provide 'free' care like air and water since it exists in such natural abundance for all'). The bureaucrats are motivated to be politicians and promise everyone everything (in public) while blaming/shaming providers for the fact that reality gets in the way of their ridiculous utopian visions of 'free potent heathcare for all that eliminates suicide/disease/suffering from the human condition,' the patients get entitled and have completely unrealistic expectations for what the system can (or should) 'do' for them, and the providers get sandwiched between both parties desperately trying to explain reality to very emotional and irrational parties on both sides.

 

[Fan_of_Meehl]

If in an insurance based practice and working similar hours sure. However, you can make a lot more with a cash based therapy practice or a high volume/ lower quality insurance based practice. There is no incentive to provide quality with single payor. The incentive is to do as little as possible to collect your billables. I saw it in LTC/ALF work all the time. I remember hearing stories of a previous contracting psychologist I replaced who used to come in on Saturdays and sit in patient rooms reading the paper while billing for therapy.

"There is no incentive to provide quality with single payor.'

Agreed. Because the actual CLIENT isn't actually 'the client' under such systems. I mean, they're not paying. 'The State' (and, by extension your state-appointed 'administrator/supervisor') is 'the client.' It is only human nature to be responsive to the person who is paying you...it's an exchange. I'm not arguing Ayn Rand stuff over here but this strikes me as rather obvious. Equally obvious, when the 'private' corporations get big enough (e.g., major international company-level size), they also appear to lose their respect for and responsiveness to the needs/concerns of INDIVIDUAL CUSTOMERS. There are no perfect solutions either way.

 

[Fan_of_Meehl]

On the flip side, from my days as a reviewer way back when, some providers are absolutely ridiculous in what they deem "medically necessary." Like 8 hours of neuropsych testing for ADHD in an adult with no neurological rule outs. Or a full Rorschach, MMPI, and TAT in another ADHD eval. Or one provider who wanted to bill for 12 hours of testing (not counting interview and report writing) for a run of the mill dementia case. Lots of examples like these. Insurance companies definitely the bigger villains here, but there are plenty of either unscrupulous or incompetent providers who are not good stewards of healthcare resources.

Agreed, all stakeholders should be 'represented' in some way in the process (meaning, their needs should be taken into account or represented).

One of the most disgusting aspects of the VA Compensation & Pension process (I did that full-time for a year) was that there was absolutely no one representing the reasonable needs of the taxpayers to not have everyone get 'service-connected' at the highest level possible, in perpetuity, even though they are, in many cases, drawing other pensions while working full-time in extremely demanding (police? firefighter?) high stress positions while being, ostensibly, '100% disabled' by their mental health conditions. And, yes, I know the niceties of the technicalities of the system (e.g., they are not '100% P&T,' just merely '100% schedular') but it just looks (and is) awful to the average taxpayer that someone is '100% disabled' for a mental health condition yet still successfully working full-time in a highly stressful position. But the only person even slightly representing taxpayer interests (those who 'pay' for all of this) is the clinician trying to 'do the right thing' and not just be a 'rubber stamper' for all claims. However, it appears that only the 'stampers' are able to keep doing that job and not burn out. There are NO meaningful incentives for them to scrutinize claims. In doing so, they are only inviting criticism from EVERYONE--the veterans, the patient advocates, their supervisors, their co-workers. It is a completely lopsided system and will only correct itself WAY downstream (decades from now) when we finally realize that we have people who are 'service-connected/disabled' for 'anxiety' who have been since they were in their early 30s and will be until their dying day...all the while, receiving 'evidence-based' treatment for said condition, never 'getting better' (only, in fact, INCREASING their SC percentage over time) while getting regular promotions up to police or fire chief of their local departments.

The more layers of separation between the money and the person(s) providing the money to the provider of services, the more corruption, waste, fraud, and inefficiency you'll have. If the average taxpayer knew, in detail, 'how the sausage was made' in terms of the VA disability/SC system and if they had any sense whatsoever, they'd be furious.

Sometimes, I fear, that psychology (and medicine/ mental health) tends to attract those who are so empathic/idealistic compared to the average citizen that we (myself included) can forget that, in the vast majority of human interactions (especially at the scale of a society), 'Money talks and bullcrap walks.'

 

[BuckeyeLove]

even though they are, in many cases, drawing other pensions while working full-time in extremely demanding (police? firefighter?) high stress positions while being, ostensibly, '100% disabled' by their mental health conditions.

Wait this really happens? Am i reading this right? So a veteran with 100% disability through the VA can go and work full time in another position, potentially high stress such as law enforcement? While receiving disability through the VA for a mental health condition? Howwwww is that possible.

 

[WisNeuro]

Wait this really happens? Am i reading this right? So a veteran with 100% disability through the VA can go and work full time in another position, potentially high stress such as law enforcement? While receiving disability through the VA for a mental health condition? Howwwww is that possible.

Yes, I had MANY vets as patients who were 100%SC and working FT jobs in various industries.

 

[Fan_of_Meehl]

Wait this really happens? Am i reading this right? So a veteran with 100% disability through the VA can go and work full time in another position, potentially high stress such as law enforcement? While receiving disability through the VA for a mental health condition? Howwwww is that possible.

Yes.

Edit: Yes, AND...

Because in the VA system, absolutely NO ONE is incentivized to represent the interests of the people (every taxpaying US citizen and business) footing the bill in the least. Or even the interests of objective reality. Try doing honest assessments (I did) and all you get is pain, blame, misery, resentment and punishment from a 360 degree circle of assailants claiming to be morally superior to you and driven by bravery, righteous anger, and angelic intent (puke). Sling PCL-5s, do a 10 min psychosocial history and call it a day as a C&P examiner, and you get praise for being so 'efficient' (with your 20 min from start to finish C&P 'evaluations') and timeliness of work products and extra time to 'help out' the boss with his/her job duties.

 

[smalltownpsych]

Every vet I run into these days is 100% disabled it seems. They all seem pretty young, happy, and healthy. I actually hired a couple of vets recently and I was hiring them because they appeared very capable. So I don’t get too frustrated with it, I just think of it as one heck of a reward for serving our country overseas. Its probably a good thing that they are still able to work and collect the check, especially since they can work. Engaging in productive activities promotes mental health as I recall.

 

[AcronymAllergy]

Yes.

Edit: Yes, AND...

Because in the VA system, absolutely NO ONE is incentivized to represent the interests of the people (every taxpaying US citizen and business) footing the bill in the least. Or even the interests of objective reality. Try doing honest assessments (I did) and all you get is pain, blame, misery, resentment and punishment from a 360 degree circle of assailants claiming to be morally superior to you and driven by bravery, righteous anger, and angelic intent (puke). Sling PCL-5s, do a 10 min psychosocial history and call it a day as a C&P examiner, and you get praise for being so 'efficient' (with your 20 min from start to finish C&P 'evaluations') and timeliness of work products and extra time to 'help out' the boss with his/her job duties.

The process definitely seems stacked against the C&P examiners (although I'm sure there are also extremes on the examiner end, with clinicians who basically vote "no" on case). At the same time, I also think the general public has little to no idea the service connection system exists, let alone the intricacies of it and the possibility that there are folks gaming it.

 

[Sanman]

Yes.

Edit: Yes, AND...

Because in the VA system, absolutely NO ONE is incentivized to represent the interests of the people (every taxpaying US citizen and business) footing the bill in the least. Or even the interests of objective reality. Try doing honest assessments (I did) and all you get is pain, blame, misery, resentment and punishment from a 360 degree circle of assailants claiming to be morally superior to you and driven by bravery, righteous anger, and angelic intent (puke). Sling PCL-5s, do a 10 min psychosocial history and call it a day as a C&P examiner, and you get praise for being so 'efficient' (with your 20 min from start to finish C&P 'evaluations') and timeliness of work products and extra time to 'help out' the boss with his/her job duties.

Let's add to that orgs like the VFW have folks that help vets fill out paperwork and coach them on what to do/say.

 

[bluecolourskies]

This is a good discussion about how to structure the financial aspects of healthcare in our country. I‘m probably on the side of - it’s broken and whatever we do to try to fix it will probably make it worse. How’s that for cynical? In the meantime, I’ll stick to my cash practice. All cash is obviously not a solution for all, but at least for my patients they determine what they will pay for and what they won’t. I hate insurance companies and government bureaucrats determining what is medically necessary, but the reality is that whoever pays has to determine what they will pay for and weigh the cost/benefits.

The whole concept of medical necessity is an odd one, and I think especially so as applied to mental health. With my patients I recommend a course of action and maybe a couple of options and then they determine what they are willing to do based on their resources, time, and money. I do think if we were to improve the current system, it would take an entire paradigm shift that we are unlikely to make. One aspect of this is that a lot of what we call healthcare is really trying to ameliorate the effects of unhealthy life choices that our society promotes.

Completely agree that our society is getting sicker, but I don’t think that’s necessarily because of actual medical care. In fact, our view that medical care can fix us despite unhealthy life choices is an odd one. Also, isnt it kind of odd that when I was young, people were drinking and smoking all over the place, including us kids in high school and now that we have aggressively targeted those behaviors, we aren’t getting better outcomes.

I did read in an article (I apologize can’t remember where) that compared to teens of the past, todays teens are getting pregnant less, smoking and drinking less (which I’m not sure I entirely believe because the vaping among kids is crazy), driving drunk less BUT mental health is worse. Which could be attributed to a variety of factors, like rise in social media and constant access to doom and gloom news, feeling more disconnected from people, etc.

 

[borne_before]

I did read in an article (I apologize can’t remember where) that compared to teens of the past, todays teens are getting pregnant less, smoking and drinking less (which I’m not sure I entirely believe because the vaping among kids is crazy), driving drunk less BUT mental health is worse. Which could be attributed to a variety of factors, like rise in social media and constant access to doom and gloom news, feeling more disconnected from people, etc.

Fomo, trigger warnings, and getting clout for having a mental illness.