Shulkin Out as VA Secretary

[cara susanna]

Wanted to see if any of my fellow VA employees wanted to process this. I know that we had a thread the last time there was a administrative shake-up at the VA, so it seemed appropriate.

Trump ousts Veterans Affairs chief Shulkin, nominates personal physician to replace him

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[NeuroLady]

Is this a move towards privatization? What does that mean for the VA?

 

[MCParent]

Is this a move towards privatization? What does that mean for the VA?

A fun game of musical chairs of six different chiefs in the next two years, each more unqualified than the last?

 

[cara susanna]

Is this a move towards privatization? What does that mean for the VA?

Most likely. Shulkin revealed that he was likely being targeted because he wasn't in favor of extreme privatization. I mean, the travel stuff didn't help either.

 

[NeuroLady]

Most likely. Shulkin revealed that he was likely being targeted because he wasn't in favor of extreme privatization. I mean, the travel stuff didn't help either.

Does anyone think the VA will actually be privatized?

 

[deleted106747]

Does anyone think the VA will actually be privatized?

I think they are certainly going to try. But the system is huge. It's hard to fathom.

This administration is exhausting.

 

[erg923]

Does it really matter who the VA secretary is folks?

Peak...most people didnt even know who he was. Shinseki, there when I started as staff, was career military and the system was obviously on autopilot under his reign. McDonald came in with all his corporate experience and knowledge to clean up the joint and really overall the culture. Literally nothing changed. Shulkin, a physician with prior experience running a large healthcare system was brought in. Literally nothing changed.

 

[deleted106747]

Does it really matter who the VA secretary is folks?

Peak...most people didnt even know who he was. Shinseki, there when I started as staff, was career military and the system was obviously on autopilot under his reign. McDonald came in with all his corporate experience and knowledge to clean up the joint and really overall the culture. Literally nothing changed. Shulkin, a physician with prior experience running a large healthcare system was brought in. Literally nothing changed.

You really don't think anything changed in the VA? Choice program, wait list/access stuff, new scheduling, money for loan repayment, increased suicide prevention, walk-in rules, shift in hiring practices, at-will employment?

 

[erg923]

You really don't think anything changed in the VA?

No, I dont.

 

[PsyDr]

Wanted to see if any of my fellow VA employees wanted to process this. I know that we had a thread the last time there was a administrative shake-up at the VA, so it seemed appropriate.

Trump ousts Veterans Affairs chief Shulkin, nominates personal physician to replace him

Please not Andrew Wakefield, please not Andrew wakefield.... whew

 

[WisNeuro]

No, I dont.

At its core, things have changed considerably in the VA in the last 5 years. The changes will just move faster and have more impact on the ground level clinicians now. They've changed the pension before, expect them to further erode it, and I wouldn't expect people to be grandfathered into old rates anymore, they'll make it universal.

 

[enduroevo]

Any idea how privatization would affect hiring of psychologists / retention of current psychologists? Similarly, how the Veterans Choice program affects psychologists at the VA?

Also, as a side note: I would be curious to hear thoughts on how the VA mental health expansion bill, which is supposed to pass soon, might affect jobs at the VA? I thought (perhaps wrongly) that if there were suddenly a lot more people in the system, there would need to be more clinicians hired to account for all these new service members who weren't eligible for services before? I thought this might especially be the case as a lot of the people who received dishonorable discharges, etc, likely had higher rates of SUDs and psychopathology relative to those that received honorable discharges?

 

[Rivi]

I wouldn't worry about it.

If you want something to worry about, focus your energy on:

Financially:
-Paying off student loans as quickly as possible
-Growing savings account/having a nice emergency fund as quickly as possible
-Investing (Index funds, ETF's, bonds, real estate, whatever fits your financial goals) as quickly as possible

Clinically:
-Diversifying your skill set
-Networking, and knowing lots of people within the field

I'm sure there are plenty of doom and gloomers on the list servs. Whatever.

If all of those things are in place, even if you are laid off, it won't take long at all to get back up and running at 100%.

 

[Justanothergrad]

I think they are certainly going to try. But the system is huge. It's hard to fathom.

This administration is exhausting.

Well, and even when they give the choice program a go it's hard to make it work because many of the reimbursement rates are pathetically low. They pay 80 for a comp & Penn as I recall. The only way that is a viable earning strategy is if you fraudulently assign poorly fitted diagnoses without much of a meeting with the vet.... which I've seen as the norm for those. And even that, thats still a crap rate.

Then imagine an outpatient putting up with the no show rates for psych appointments that we see in the VA.

 

[deleted106747]

Well, and even when they give the choice program a go it's hard to make it work because many of the reimbursement rates are pathetically low. They pay 80 for a comp & Penn as I recall. The only way that is a viable earning strategy is if you fraudulently assign poorly fitted diagnoses without much of a meeting with the vet.... which I've seen as the norm for those

Yikes, $80.

I don't think it will be a quick process, that's for sure. I think primary care and mental health care will stay within the system, for at least awhile.
When/if it does happen, I think we'd all be fired and then rehired. The question would be whether it would be at a comparable salary/benefits.

 

[cara susanna]

Well, and even when they give the choice program a go it's hard to make it work because many of the reimbursement rates are pathetically low. They pay 80 for a comp & Penn as I recall. The only way that is a viable earning strategy is if you fraudulently assign poorly fitted diagnoses without much of a meeting with the vet.... which I've seen as the norm for those

Then imagine an outpatient putting up with the no show rates for psych appointments that we see in the VA.

Choice programs also often have long waits or less availability than the VA clinics.

 

[psych.meout]

Based on Jackson's history, the biggest change to VA will be adding 2 inches to every patient's height and subtracting several dozen lbs from their weight.

 

[msgeorgeeliot]

Based on Jackson's history, the biggest change to VA will be adding 2 inches to every patient's height and subtracting several dozen lbs from their weight.

MOVE! ...or not

 

[PsyDr]

They pay 80 for a comp & Penn as I recall.

 

[futureapppsy2]

Based on Jackson's history, the biggest change to VA will be adding 2 inches to every patient's height and subtracting several dozen lbs from their weight.

 

[Sanman]

Yeah, I don't think privatization is happening any time soon. CHOICE is chronically backed up and in danger of running out of money. Beyond that, I am really curious as to what is going to happen with veteran groups crying foul when no one gives damn about veteran problems in the private sector and they are simply in the back of the line. Is anyone in the private sector willing to take on the comprehensive care of severe PTSD, dual diagnosis, etc veterans? The problem you have is that there is little profit motive in many of the things that we treat at the VA. Hell, my job doesn't exist in the private sector, because no one makes money on home visits at a market insurance (non fee-for-service) rate. Personally, I'm not too worried. However, if they start eroding benefits then I will be job hunting sooner than anticipated as the cost/benefit analysis may no longer make the hassles worth it.

 

[smalltownpsych]

I predict that the VA will talk about improving healthcare and especially mental health for the vets while cutting programs, decreasing clinicians compensation. and increasing hiring of midlevels then adding more layers of bureaucracy and executive compensation. Or maybe I’m just a cynic.

 

[MAClinician]

Op-ed piece by the guy just fired:

Opinion | David J. Shulkin: Privatizing the V.A. Will Hurt Veterans

 

[AcronymAllergy]

I agree that I don't think privatization is the way to go; there are other/better ways to try and improve access and efficiency. I imagine that if they make significant efforts to privatize, once many/most folks get some experience in the private sector, they'll want to head back to the VA. But perhaps giving more of an option in this regard, and increasing the sense of agency and choice in patients, will lead to increased engagement in their healthcare.

 

[MCParent]

I predict that the VA will talk about improving healthcare and especially mental health for the vets while cutting programs, decreasing clinicians compensation. and increasing hiring of midlevels then adding more layers of bureaucracy and executive compensation. Or maybe I’m just a cynic.

As short a time ago as February, the Ministry of Plenty had issued a promise (a "categorical pledge" were the official words) that there would be no reduction of the chocolate ration during 1984. Actually, as Winston was aware, the chocolate ration was to be reduced from thirty grams to twenty at the end of the present week.

 

[WisNeuro]

I agree that I don't think privatization is the way to go; there are other/better ways to try and improve access and efficiency. I imagine that if they make significant efforts to privatize, once many/most folks get some experience in the private sector, they'll want to head back to the VA. But perhaps giving more of an option in this regard, and increasing the sense of agency and choice in patients, will lead to increased engagement in their healthcare.

Yeah, some of the VA patients would be in for a rude awakening as we on the outside don't have to reschedule multiple times after no-shows, and I can freely refuse to see any patient and call security if they threaten my office staff. There is no 8-strike rule in the real world, I saw way too much leniency with hostile and threatening behavior in some clinics while at the VA. I agree, privatization would lead to poorer healthcare for those in the system who actually need the care, but once they start down that slope, I have a hard time seeing them pump the brakes.

 

[smalltownpsych]

Sometimes I think the only thing worse than a government agency is a private agency with a government contract.

 

[WisNeuro]

Sometimes I think the only thing worse than a government agency is a private agency with a government contract.

I've got my problems with the system, mostly as a provider, but, my neuro patients (the ones that actually needed care anyway), received better and more timely care in the VA than anywhere else I have worked on the outside. People like to **** on it, but they aren't making honest comparisons to how things actually work elsewhere in the healthcare world. If it were a better system for providers, I would have never left.

 

[Justanothergrad]

Yeah, some of the VA patients would be in for a rude awakening as we on the outside don't have to reschedule multiple times after no-shows, and I can freely refuse to see any patient and call security if they threaten my office staff. There is no 8-strike rule in the real world, I saw way too much leniency with hostile and threatening behavior in some clinics while at the VA. I agree, privatization would lead to poorer healthcare for those in the system who actually need the care, but once they start down that slope, I have a hard time seeing them pump the brakes.

Wait...

The VA strikes people out after 8 no-shows? I thought OP was "Swing til you don't want us to pitch anymore"

 

[smalltownpsych]

I've got my problems with the system, mostly as a provider, but, my neuro patients (the ones that actually needed care anyway), received better and more timely care in the VA than anywhere else I have worked on the outside. People like to **** on it, but they aren't making honest comparisons to how things actually work elsewhere in the healthcare world. If it were a better system for providers, I would have never left.

I agree and actually I include the rest of the healthcare industry as private with a government contract because the government money and policies really do run things other than in a relatively small exclusively private pay environment.

 

[erg923]

At its core, things have changed considerably in the VA in the last 5 years. The changes will just move faster and have more impact on the ground level clinicians now. They've changed the pension before, expect them to further erode it, and I wouldn't expect people to be grandfathered into old rates anymore, they'll make it universal.

Correct.

You really don't think anything changed in the VA? Choice program, wait list/access stuff, new scheduling, money for loan repayment, increased suicide prevention, walk-in rules, shift in hiring practices, at-will employment?

What I really meant was larger changes that would really solve problems--both patient and provider.

As its currently run, Choice hasn't solved any problems, lets not have any delusions about that. More suicide prevention, great! Scheduling process changes, eh, maybe? Not consistent from what I saw, and it didn't really have a large-scale impact from what I saw. Walk-ins didn't really end up happening at my CBOC when I was there (physician and nurse resistance, I think)...and for MH I think that can be problematic anyway. Loan repayment? Yep, I got for my 5 years. What did it really do for veterans though? I didn't notice any differences in hiring practices...maybe you can inform me how this helped veterans/patients?

"Mental Health Suite" is a disaster, as is the MHTC thing. Both create time and labor for providers with zero ROI for anyone involved. The push toward LEAN is a joke given bureaucratic red-tape and VHA Central Office dictation of clinical/practice documentation. Telehealth is way behind due to bureaucratic nonsense and rigid rules about "tour of duty." PCMHI leaders/advocates stress that we can treat almost everything in primary care (including suboxone and a miraculous 3 session PE protocol), yet at the same time stresses it is NOT a MH service and sends consults to MH like 70% of the time. Infantilizing of the patient population is problematic clinically, and is a pain for providers. On the flip side, I saw patients escorted out of the clinic due to being upset and assertive about their needs because the PCP didn't want to deal with it. C&P creates problems for the recovery model of mental healthcare. I don't think VHA Central Office talks to its budget office...if it has one. They don't pay for your license or CEUs (my current employer does).

I saw vets for almost 10 years consecutively in different roles, sans one year (psychometrist, graduate school training, and then as a staff psychologist). Same complaints, different year. I never once had a veteran say something to the effect of, "Hey, this new program, or this new Secretary (Peak, Shinseki, McDondald, Shulkin) is really turning things around here!"

Frankly, I think having 4-5 different CEOs within 10 years is problematic for a large organization, but what do I know?

And, don't get the wrong idea by this, but what do these people do? There are literally dozens of OD and I/O staff psychologists working for the VA. I never a heard word from this group (or in the press) in 9-10 years about anything.
National Center for Organization Development Home

After working for VA, I started to have doubts about whether having a segregated health system for military veterans is the right thing or not? The quality, due to its size, is variable. And I often wonder if it perpetuates a divide between "us and them" that doesn't really need to be there.

 

[deleted343839]

After working for VA, I started to have doubts about whether having a segregated health system for military veterans is the right thing or not? The quality, due to its size, is variable. And I often wonder if it perpetuates a divide between "us and them" that doesn't really need to be there.

I have often wondered this myself. I don't support privatization of the VA, but there are alternatives to the current model. For instance, what might be the fallout of reducing the scope of VA services while enrolling every VA-eligible veteran in Medicare? There are already a large number of VA/Medicare dual users to begin with.

 

[erg923]

I have often wondered this myself. I don't support privatization of the VA, but there are alternatives to the current model. For instance, what might be the fallout of reducing the scope of VA services while enrolling every VA-eligible veteran in Medicare? There are already a large number of VA/Medicare dual users to begin with.

Government polices of "separate but equal" do not have a historically good track record. I do realize the VA is as good or better about some aspects of care as the non-VA world, but I really don't understand the need for such segregation at this point. I think its actually damaging on some levels.

The VAs lead in EBP for MH care is admirable, but not without flaws and (significant) gaps. The argument that "signature war-wound" services such TBI, PTSD and general psychological maladjustment cannot be treated competently outside the VA is pretty ridiculous if you think about it. In total, active duty and veterans are essentially 10% of the American populous. Are we really saying 90% of Americas are not able to get care for these relatively prevalent psychological and neuropsychiatic conditions?!

I think sticking to cemetery admin and monetary benefits is probably where the VA of the future (15-30 years) should be.

 

[deleted106747]

Correct.


What I really meant was larger changes that would really solve problems--both patient and provider.

As its currently run, Choice hasn't solved any problems, lets not have any delusions about that. More suicide prevention, great! Scheduling process changes, eh, maybe? Not consistent from what I saw, and it didn't really have a large-scale impact from what I saw. Walk-ins didn't really end up happening at my CBOC when I was there (physician and nurse resistance, I think)...and for MH I think that can be problematic anyway. Loan repayment? Yep, I got for my 5 years. What did it really do for veterans though? I didn't notice any differences in hiring practices...maybe you can inform me how this helped veterans/patients?

It's black and white to say Choice hasn't solved any problems. You spent 10 years in a VA, it looks like. Was it one VA? then you've seen one VA. I have seen a lot of benefits from Choice. I've gotten people into MH tx closer to their homes, into sleep studies within a few weeks, and have seen people engaging in ongoing services, for example PT, in their communities without having to travel to the VA. Walk-ins happen at my VA regularly. As for loan repayment, there are several providers in my clinic who likely would have left had they not gotten loan repayment. Continuity of care, consistency etc. helps Veterans.

"Mental Health Suite" is a disaster, as is the MHTC thing. Both create time and labor for providers with zero ROI for anyone involved. The push toward LEAN is a joke given bureaucratic red-tape and VHA Central Office dictation of clinical/practice documentation. Telehealth is way behind due to bureaucratic nonsense and rigid rules about "tour of duty." PCMHI leaders/advocates stress that we can treat almost everything in primary care (including suboxone and a miraculous 3 session PE protocol), yet at the same time stresses it is NOT a MH service and sends consults to MH like 70% of the time. Infantilizing of the patient population is problematic clinically, and is a pain for providers. On the flip side, I saw patients escorted out of the clinic due to being upset and assertive about their needs because the PCP didn't want to deal with it. C&P creates problems for the recovery model of mental healthcare. I don't think VHA Central Office talks to its budget office...if it has one. They don't pay for your license or CEUs (my current employer does).

You'll get no argument from me as to Mental Health Suite. MHTC depends. It can work quite well if it's done correctly - e.g. a provider who can actually meet with a Veteran and discuss MH treatment as opposed to the quickest and easiest person to get on the chart to meet the measure. Telehealth is a pain in the butt. No one in my PCMHI leadership has ever pushed that we treat everything in PCMHI. I've drawn firm guidelines, and been supported in drawing those guidelines, around which patients are appropriate and which are not.

We are agreed on the infantalizing. I have not seen patients escorted out for being assertive, but I have seen them escorted about appropriately for being aggressive.

I saw vets for almost 10 years consecutively in different roles, sans one year (psychometrist, graduate school training, and then as a staff psychologist). Same complaints, different year. I never once had a veteran say something to the effect of, "Hey, this new program, or this new Secretary (Peak, Shinseki, McDondald, Shulkin) is really turning things around here!"

I have gotten consistent positive feedback from Veterans as to their care in our VA.

Frankly, I think having 4-5 different CEOs within 10 years is problematic for a large organization, but what do I know?

And, don't get the wrong idea by this, but what do these people do? There are literally dozens of OD and I/O staff psychologists working for the VA. I never a heard word from this group (or in the press) in 9-10 years about anything.
National Center for Organization Development Home

After working for VA, I started to have doubts about whether having a segregated health system for military veterans is the right thing or not? The quality, due to its size, is variable. And I often wonder if it perpetuates a divide between "us and them" that doesn't really need to be there.

I am not completely against a VA/public sector merger in some ways. But I do not think the core should be destroyed. I saw, for example a rural prosthetics van waiting outside the medical center the other day. Some of these services are pretty amazing. You don't need to rip down the whole house to make improvements. I am not a Veteran, but I don't think giving them a Medicaid card for everything is the answer. Part of what they signed up for is the services of the VA.

 

[Justanothergrad]

If we give them Medicaid as a solution, you will have months long waitlists for any services where there are providers- at least in rural counties. It just doesn't pay well. That's part of why choice is limited in its utility. Payrates are set by Medicaid rates. Testing is a joke for payment. You can't charge no shows either, so that would be a major hit given no show rates.

Then there is the whole 6 session yearly limit for adult MH without authorization. Let's assume that CPT/PE are first wave treatments for PTSD, that's 8-12 needed as a base guideline.

That solution is only a solution if the system gets fixed and you have the same chance of doing all that as passing a single payer system imho.

 

[deleted106747]

If we give them Medicaid as a solution, you will have months long waitlists for any services where there are providers- at least in rural counties. It just doesn't pay well. That's part of why choice is limited in its utility. Payrates are set by Medicaid rates. Testing is a joke for payment. You can't charge no shows either, so that would be a major hit given no show rates.

Then there is the whole 6 session yearly limit for adult MH without authorization. Let's assume that CPT/PE are first wave treatments for PTSD, that's 8-12 needed as a base guideline.

That solution is only a solution if the system gets fixed and you have the same chance of doing all that as passing a single payer system imho.

Good point. In my area, it's next to impossible to find a psychologist who takes Medicaid. Typically one or two patients are the limit for those that do, and they do that as a service.

 

[Sanman]

Good point. In my area, it's next to impossible to find a psychologist who takes Medicaid. Typically one or two patients are the limit for those that do, and they do that as a service.

There are MH providers in my area that accept choice. However, it is not often that it is a psychologist. Rather, another MH provider that is supervised by a psychologist. I can't imagine that many are trained in EBPs for PTSD and other complex mental health etiologies. Training costs money that private entities don't want to commit to as it loses money and takes time from billable hours. It will be largely supportive therapies with master's level providers, IMO. I certainly would not opt to take in these patients when there are many short-term and less complex patients that are willing to pay more. Personally, I have seen several medical providers that have lost licenses for improper prescribing practice with the veterans I see as they were the only local option. At the moment, proper pain management in the private sector is hard to find. However, docs prescribing medical marijuana are everywhere. Wonder how long before marijuana is a leading treatment for PTSD if the VA pushes for privatization.

 

[deleted343839]

If we give them Medicaid as a solution, you will have months long waitlists for any services where there are providers- at least in rural counties. It just doesn't pay well.

Indeed. Medicare would be a preferable solution though still not without its challenges.

 

[Therapist4Chnge]

Indeed. Medicare would be a preferable solution though still not without its challenges.

Agreed.

Medicare would be the absolute minimum of what most psychologists would tolerate. I still have doubts that testing rates woukd be competitive, but at least there would be more therapy options.

As for Medicaid....the red tape + reimbursement rates make it COST providers money. I’d rather do pro-bono work than attempt to take Medicaid. For testing, their rates are insulting. Then there is the paperwork....

 

[erg923]

@Psycycle

Just to be clear:

1. I realize that there are local variations in adherence to new programs, procedures, etc. This is to be expected in such a large system. Which, I think, is part of the problem. Too big to manage. The VA has expanded WAY beyond what it was originally set out to do/accomplish, yet we seem to think we can/should keep making it even bigger and more comprehensive? Not sure that's the answer anymore. We can keep trying, but I think this is a risk, both finacially and in terms of QA and general patient care.

2. I had many compliments toward the VA as well. I also had many complaints, many bogus but many quite legitimate. The basic themes of the legitimate complaints never changed over 10 years I was there. I was struck by the number of pissed off people who continued to use the VA despite their hatred of it, or feeling like it was poor quality. This was bizarre to me (that people would continue to patronize a system they felt sucked and didn't care about them). Alot of this is on them (misperceptions, unrealistic expectations... or simply not making other means for themselves in life), but some of it is on the VA too.

3. Loan repayment is great but "golden handcuffs" are just that. I think retention after the period is up is probably a better metric to look at. For psychologists is might be pretty good though, because the salaries and benefits are hard to match in certain parts of the country. But for other services/professions, I might wonder.

 

[deleted106747]

@Psycycle

Just to be clear:

1. I realize that there are local variations in adherence to new programs, procedures, etc. This is to be expected in such a large system. Which, I think, is part of the problem. Too big to manage. The VA has expanded WAY beyond what it was originally set out to do/accomplish, yet we seem to think we can should keep making it bigger? Not sure that's the answer anymore. We can keep trying, but I think this is a risk, both monetarily and in terms of QA and general patient care.

2. I had many compliments toward the VA as well. I also had many complaints, many bogus but many legitimate. The basic themes of the legitimate complaints never changed over 10 years. I was struck by the number of pissed off people who continued to use the VA despite their hatred of it, or feeling like it was poor quality. This was bizarre to me (that people would continue to patronize a system they felt sucked and didn't care about them). Alot of this is on them (misperceptions, unrealistic expectations... or simply not making other means for themselves in life), but some of it is on the VA too.

3. Loan repayment is great but "golden handcuffs" are just that. I think retention after the period is up is probably a better metric to look at. For psychologists is might be pretty good though, because the salaries and benefits are hard to match in certain parts of the country. But for other services/professions, I might wonder.

I think there can still be a centralized governance, but perhaps there can be more locality nuance. I really can't see the private sector absorbing the VA population. Research doesn't necessarily show that military service is the primary factor that makes Veterans different from the general population, but rather the SES factors that led people to join in the first place. That, coupled with the fact that those we serve (further out from discharge) are still low SES. You get a somewhat unique mix of MH and PH factors from that blend.

There's a more vulgar way I say this in my real life, but eating the VA's bread while kicking it in the gut is pretty much everyone's MO. I've done my share of complaining, but the VA has been good to me.

As for the loan repayment, yeah, people may bolt after five years, but what job these days is a lifer? I don't necessarily see myself spending my whole career in the VA, not because it's been a bad experience, but because I want to challenge myself with new experiences in my career. Five years in is better than bolting after six months.

 

[deleted106747]

There are MH providers in my area that accept choice. However, it is not often that it is a psychologist. Rather, another MH provider that is supervised by a psychologist. I can't imagine that many are trained in EBPs for PTSD and other complex mental health etiologies. Training costs money that private entities don't want to commit to as it loses money and takes time from billable hours. It will be largely supportive therapies with master's level providers, IMO. I certainly would not opt to take in these patients when there are many short-term and less complex patients that are willing to pay more. Personally, I have seen several medical providers that have lost licenses for improper prescribing practice with the veterans I see as they were the only local option. At the moment, proper pain management in the private sector is hard to find. However, docs prescribing medical marijuana are everywhere. Wonder how long before marijuana is a leading treatment for PTSD if the VA pushes for privatization.

Agreed on the supportive therapies with MA level providers. I can't fathom people willingly taking the Veterans the VA serves with their liability, low SES, and other unique factors. Unless they had some VA insurance that paid more than Medicaid.

 

[erg923]

I really can't see the private sector absorbing the VA population.

Why? And what exactly do you mean by that?

Low SES factors are a challenge in MH, no doubt. But medicare and medicaid (especially) deal with this type of population too. And at a rate, prevalence, and severity infinitely higher than the veteran population I would say. And there are actually a plethora of Community-Based Psychiatric/Supportive services offered by Medicaid...I oversee these services in several states actually. There are literally a dozen CPT codes for these varied services.

Most veterans don't use the VA for medical or MH services, and many "double-dip" as it is (medicare, medicaid, Tricare, commercial plans). The "absorption" is really just a couple million across the entire US. You would have to have more strict policies about no shows of course, but the geographic dispersion and availability of services would be greater than current dispersion of VAMCs and their associated CBOCs.

 

[deleted106747]

Why? And what exactly do you mean by that?

Low SES factors are a challenge in MH, no doubt. But medicare and medicaid (especially) deal with this type of population too. And at a rate, prevalence, and severity infinitely higher than the veteran population I would say. And there are actually a plethora of Community-Based Psychiatric/Supportive services offered by Medicaid...I oversee these services in several states actually. There are literally a dozen CPT codes for these varied services.

Most veterans don't use the VA for medical or MH services, and many "double-dip" as it is (medicare, medicaid, Tricare, commercial plans). The "absorption" rate is really just a couple million across the entire US. You would have to have more strict policies about no shows of course, but the geographic dispersion and availability of services would be greater than current dispersion of VAMCs and their associated CBOCs.

It's the combination of low SES, childhood factors, and military experience. I have found the population to be unique.
In my area, there simply isn't good access to good mental health care for the low SES population. Community mental health is overrun, and providers are burned out.

 

[Justanothergrad]

Why? And what exactly do you mean by that?

Low SES factors are a challenge in MH, no doubt. But medicare and medicaid (especially) deal with this type of population too. And at a rate, prevalence, and severity infinitely higher than the veteran population I would say. And there are actually a plethora of Community-Based Psychiatric/Supportive services offered by Medicaid...I oversee these services in several states actually. There are literally a dozen CPT codes for these varied services.

Most veterans don't use the VA for medical or MH services, and many "double-dip" as it is (medicare, medicaid, Tricare, commercial plans). The "absorption" is really just a couple million across the entire US. You would have to have more strict policies about no shows of course, but the geographic dispersion and availability of services would be greater than current dispersion of VAMCs and their associated CBOCs.

There just isn't a system in place to provide the same quantity of services. The payrates suck for services using the choice program (to such a point that it reduces them from unlikely to impossible in the case of many- especially testing services), the time limits on treatments differ, and the willingness to treat many of the MH clients at the level and manner in which they are accustomed is not there for clinicians.

Advocating to address those changes is too big of an issue to say it's simply a matter of privatizing services.

 

[WisNeuro]

Why? And what exactly do you mean by that?

Specialty services would be the biggest challenge. In the neuro world, many private practice people wouldn't take medicare/medicaid/tricare rates, and many are just purely cash only anyway. Most of the hospital or clinic based people in my metro area are already sitting at 6 month+ waitlists. I used to work at the VA in this metro area, we couldn't absorb the number of evals they were churning out without pushing those wait lists to at least 9 months. And that's not even taking into account the SC/CGS/etc type evals. Those would get farmed out to those gullible/poorly trained schmucks who will do those evals for chump change.

 

[corticalatrophy]

It is complicated but I do think the criticisms of the VA are really overblown when you look at the actual facts. Lost in all this constant hue and cry about VA care is the comparative research that despite the generally poorer and sicker patient base at the VA the actual care provided is equal or better in terms of outcomes compared to the private sector and ahead in cancer and diabetes screening, heart attack readmission, mortality rates, surgical complications, and so on. Even the bathrooms are rated "cleaner" than private sector hospitals. It also has probably the highest accountability agency of any healthcare system in the world and I can't imagine what would be found if any other major hospital system fell under so much scrutiny. We've all experienced medical care in our profit private payer system...any stories about unnecessary treatments, procedures, malpractice, or poor access in the private sector? Clearly when you do surgery for profit, you do more surgery--maybe surgery that is not needed and will not help.

I think there are also important societal values at work here too. Could the private sector absorb the veterans and do an adequate job...I don't know. One of the questions is that the "right" thing to do. Most veterans prefer the VA and "choice" means that they can choose private care or the VA, not be forced into private care. The VA also plays a chief educative role for all types of healthcare professionals, medical research, and is the largest employer of psychologists in the US. In that regard it serves much more than just our veteran population.

 

[NeuroLady]

Would anyone mind posting citations on the topic (comparing VA care to private hospitals)? I was able to locate a 2016 review pretty easily but would appreciate more.

 

[WisNeuro]

Would anyone mind posting citations on the topic (comparing VA care to private hospitals)? I was able to locate a 2016 review pretty easily but would appreciate more.

Phillip Longman has a bunch of references in his book, but they are slightly dated at this point. Outsode of that, RAND just had a newish one out.

 

[corticalatrophy]

Would anyone mind posting citations on the topic (comparing VA care to private hospitals)? I was able to locate a 2016 review pretty easily but would appreciate more.

Apparently I haven't posted enough on this forum to be able to post links. There are so many of these, really. google "HERC comparing VA to non-VA costs" and Comparison of Quality of Care in VA and Non-VA Settings: A Systematic Review

I am not familiar with all the arguments for privatization but if quality care is the issue I'm not certain there is evidence to support that vets get better care in the private sector. If cost is the issue there are also a number of cost comparisons of VA care vs. non-VA care which suggest it is less expensive for the tax payer than private care.

So if it works, delivers on the investment and according to a VFW survey veterans prefer it, why privatize?