Therapy Wait List Guilt

[thebalmofhurtminds]

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I'm generally not someone who is very prone to guilt, especially regarding larger systems decisions that I have no power in. However, since leaving the VA and having my own care line at an AMC, I'm definitely getting a lot of distressed patients regarding my wait list. I'm essentially the only provider in the system who offers these therapies. It doesn't help that there's also a wait to get in to the evaluation even before the therapy wait list.

Anyone else have this experience? Tips for ways to discuss this with patients? I'm not sure what the professional way to say "lol as if anyone asks me about hiring more psychologists" is.

 

[ClinicalABA]

This is a tough issue, and I feel you. My next opening (assessment only practice for very young children) is in September. I have the extra guilt factor in that most children in see are referred by their early intervention (state birth-three program providers) case coordinators, who not only assist these families with the referral process, but also attend the assessment and assist with follow-up services. Children age out of early intervention at three, so basically if they call today and are much older than two, they'll lose this key support before I see them. These kiddos tend to "disappear" without that level of support.

Other issue is because I'm diagnosing autism, main recommendation is ABA therapy. This therapy comes through a different source for kiddos under three (relatively short wait times with many provider options; state contracts with minimal ability to reject a referral) than for children over three (insurance funded; long wait lists; potentially less providers; providers have more leeway in not accepting clients). We also know that outcomes are better the younger we start. Working with a two year old for full year before they start preschool is so much better than starting with kiddo already in preschool.

It's so frustrating, and I struggle with what to tell parents (other than "sorry"). We actually have been trying (at least pre-COVID) hire additional psychologists, with very little luck (and it's a good paying, stable gig, that i think is a lot of fun).

 

[CheetahGirl]

I'm just chiming in here for validation of the frustration and words of encouragement. Just as I left a child psych rotation (during training), they lost funding from the AMC and closed the clinic housed in both the Departments of Pediatrics and Psychiatry. This clinic also worked closely with the District Attorney's office for forensic cases of child abuse. I was deeply saddened by the waitlist that just went *poof* when they closed the clinic. I'm sure that they referred the waitlist cases out, but they were all waiting for some type of therapy for 3-18 yo. I still think of that lost opportunity and damned the system that didn't allocated funds to that intercity clinic.

Hang in there. Ask for what you need. I hope someone has tactful advice on how to do so.

 

[Sanman]

I'm generally not someone who is very prone to guilt, especially regarding larger systems decisions that I have no power in. However, since leaving the VA and having my own care line at an AMC, I'm definitely getting a lot of distressed patients regarding my wait list. I'm essentially the only provider in the system who offers these therapies. It doesn't help that there's also a wait to get in to the evaluation even before the therapy wait list.

Anyone else have this experience? Tips for ways to discuss this with patients? I'm not sure what the professional way to say "lol as if anyone asks me about hiring more psychologists" is.

You have pretty much explained most of my career with that statement. Depending on the the reason, I discuss the issue with patients. It is often an issue of low pay and fewer providers in geriatrics and in rural areas, so I let them know to write letters to their congresspersons requesting better pay and access to services. If you can't blame it on the government, then who can you blame it on?

 

[PsyDr]

1) Are you the only provider of that service in the area? Or are you the only provider of that service in the area that is covered by insurance?
2) Start conceptualizing ALL of the patient's assets. How much is that car worth? How about that vacation or house?
3) Compare the cost of private pay treatment to #2.
4) Most people could pay for private services, they just don't want to.
5) In the case of insurance, people freely entered into that contract. Any problem with that is between the patient and their insurer.

 

[Sanman]

1) Are you the only provider of that service in the area? Or are you the only provider of that service in the area that is covered by insurance?
2) Start conceptualizing ALL of the patient's assets. How much is that car worth? How about that vacation or house?
3) Compare the cost of private pay treatment to #2.
4) Most people could pay for private services, they just don't want to.
5) In the case of insurance, people freely entered into that contract. Any problem with that is between the patient and their insurer.

As a young therapist, I still remember the parent of a child I was seeing with behavioral concerns spending several minutes arguing with me about how to pay my (comparatively very low) bill and arguing about a tiny credit card fee the practice charged. She then walked into my office and complained that her daughter had gotten angry with her and damaged the seats of the brand new $50,000 luxury SUV she had just leased. I was driving a 10 year old Toyota Camry at the time. That was the last time I felt guilty about asking a patient for payment. I also realized that you get what you pay for in this country.

 

[WisNeuro]

I did my time working for lower pay, and I volunteer my free time for other endeavors that help the underserved. I left behind any guilt in my clinical practice and billing of such a few years back. I am not solely responsible for fixing the broken parts of our healthcare system, and I am not going to sacrifice my well-being to chip away at it.

 

[AcronymAllergy]

My knee-jerk response: You can only do what you can do. If you can find ways to increase the efficiency of your clinic (that don't involve inordinate and unfair amounts of work for you), great. Otherwise, I would say it's not your job or responsibility to fix the unfortunate reality that sometimes (or often times when it comes to mental health), there just aren't enough good providers. And if you burn yourself out, there will be one less such provider.

You could see if there are any providers in the community offering similar treatments and provide their information to patients. But maintaining appropriate professional boundaries (e.g., not over-extending yourself by trying to squeeze in every extra patient possible) is probably one of the most important things you can do for the best interests of your patients and yourself.

 

[cara susanna]

My knee-jerk response: You can only do what you can do.

This has been my mantra ever since I started working in full time clinical practice (and in a system where I often have poor access).

 

[thebalmofhurtminds]

1) Are you the only provider of that service in the area? Or are you the only provider of that service in the area that is covered by insurance?
2) Start conceptualizing ALL of the patient's assets. How much is that car worth? How about that vacation or house?
3) Compare the cost of private pay treatment to #2.
4) Most people could pay for private services, they just don't want to.
5) In the case of insurance, people freely entered into that contract. Any problem with that is between the patient and their insurer.

Pretty sure I'm the only provider in the area for one of the two overall. There are graduate student trainees as an option for the other. I'm also in my first year here, so trying to figure out the lay of the land. The options are genuinely very limited from what I can see.

Really makes private practice sound tempting.

 

[thebalmofhurtminds]

RE all of the "you can only do what you can do": absolutely agree. I will say that I'm pretty good about any feelings/thoughts NOT leading to overbooking or anything like that. I've held pretty firm on the amount of patients I see, etc., and don't see that changing. I'm a stickler for working during work hours and not undervaluing myself by doing free overtime.

I've certainly had less frustrations since leaving the VA, but still somewhat bummed that our healthcare system is so terrible. It's easier to stake those boundaries without feeling to the department/hospital, but adapting the language to explain to my patients who have been struggling for years is more difficult for me.

 

[summerbabe]

It's easier to stake those boundaries without feeling to the department/hospital, but adapting the language to explain to my patients who have been struggling for years is more difficult for me.

This reminds me a bit of meeting with veterans who start with "It's taken me ___years to get seen by mental health and nobody returns my phone calls and the VA doesn't care about veterans".

I try to really briefly validate their frustrations and/or the delay in starting (if they didn't voice anything) and then quickly transition to how I'm glad they finally made it to me and that I'm excited to start our work together. It's certainly not easy when you know the wait is 100% on the healthcare system but hopefully that allows you and the patient to both focus on actually getting started.

 

[Sanman]

RE all of the "you can only do what you can do": absolutely agree. I will say that I'm pretty good about any feelings/thoughts NOT leading to overbooking or anything like that. I've held pretty firm on the amount of patients I see, etc., and don't see that changing. I'm a stickler for working during work hours and not undervaluing myself by doing free overtime.

I've certainly had less frustrations since leaving the VA, but still somewhat bummed that our healthcare system is so terrible. It's easier to stake those boundaries without feeling to the department/hospital, but adapting the language to explain to my patients who have been struggling for years is more difficult for me.

I recently had a talk with an angry patient about such an issue. I sympathized with them and agreed that the system should allow for better access to care, but I pointed out that they need not throw stones and criticize the only people willing to help (because all the other options are unwilling or too expensive).

Remember that from a rational economic perspective, the only reason that you have a long waitlist is that you are undercharging for your skills. If you were in any other industry and had a product with a months long waiting list, you would raise prices.

 

[AbnormalPsych]

As a young therapist, I still remember the parent of a child I was seeing with behavioral concerns spending several minutes arguing with me about how to pay my (comparatively very low) bill and arguing about a tiny credit card fee the practice charged. She then walked into my office and complained that her daughter had gotten angry with her and damaged the seats of the brand new $50,000 luxury SUV she had just leased. I was driving a 10 year old Toyota Camry at the time. That was the last time I felt guilty about asking a patient for payment. I also realized that you get what you pay for in this country.

When I heard how much money my dumb college friends are making after getting 2.5 GPAs in undergrad and the amount of hours they work per week, I lost all care for this kind of stuff. Pay me.

 

[AcronymAllergy]

As a young therapist, I still remember the parent of a child I was seeing with behavioral concerns spending several minutes arguing with me about how to pay my (comparatively very low) bill and arguing about a tiny credit card fee the practice charged. She then walked into my office and complained that her daughter had gotten angry with her and damaged the seats of the brand new $50,000 luxury SUV she had just leased. I was driving a 10 year old Toyota Camry at the time. That was the last time I felt guilty about asking a patient for payment. I also realized that you get what you pay for in this country.

Considering it's hard to find a base-model full-size pickup truck for much <$40-50k nowadays, you must be older than I thought....

....I kid, I kid. But the point is sound, don't be afraid to charge what you're worth (which the market will often bear out).

I do agree that discussing this information with patients can be difficult. My wait list is multiple months long and I feel the same stress at times, but I'm just honest with the patients as to when I can see them, and I try to brainstorm alternatives with them if needed/requested. And I never take any questions or statements about who else they could see personally.

I had to learn the hard way early on that in most healthcare systems, doing extra work as a temporary means of reducing backlog is typically thankless, unsustainable, and may result in the assumption or expectation that you'll just continue to do said extra work indefinitely.

 

[Sanman]

Considering it's hard to find a base-model full-size pickup truck for much <$40-50k nowadays, you must be older than I thought....

....I kid, I kid. But the point is sound, don't be afraid to charge what you're worth (which the market will often bear out).

I do agree that discussing this information with patients can be difficult. My wait list is multiple months long and I feel the same stress at times, but I'm just honest with the patients as to when I can see them, and I try to brainstorm alternatives with them if needed/requested. And I never take any questions or statements about who else they could see personally.

I had to learn the hard way early on that in most healthcare systems, doing extra work as a temporary means of reducing backlog is typically thankless, unsustainable, and may result in the assumption or expectation that you'll just continue to do said extra work indefinitely.

Considering that TV Shows like Macguyver, Magnum PI, and Beverly Hills 90210 have gotten TV reboots and I hear Nirvana and Pearl Jam on the classic rock station, I might be older than I thought too...

 

[R. Matey]

I appreciate this question and the responses. It helps clarify career goals for me though it's discouraging to hear that seemingly most clinical systems aren't that great for either patient or provider. I agree that we all should be paid, of course, but it's a cold comfort to patients who have to either wait for inordinate amounts of time for quality treatment or have better access to a substandard option.

My access right now as a postdoc is actually pretty good, but it's mainly because I don't take Medicare. If I were to work here as a clinician, it would be months to get an initial appointment with me.

 

[Fan_of_Meehl]

This reminds me a bit of meeting with veterans who start with "It's taken me ___years to get seen by mental health and nobody returns my phone calls and the VA doesn't care about veterans".

I try to really briefly validate their frustrations and/or the delay in starting (if they didn't voice anything) and then quickly transition to how I'm glad they finally made it to me and that I'm excited to start our work together. It's certainly not easy when you know the wait is 100% on the healthcare system but hopefully that allows you and the patient to both focus on actually getting started.

Exactly right...there's no need to get bogged down on that topic (while the clock is ticking away) beyond basic genuine validation of their frustration and offering to do specific things to begin helping them today. To the extent that the patient (after that prompt to move on and offer of help from you to do so) refuses and continues to try to attack you for half the session (or even longer), this serves as a pretty clear diagnostic sign pointing to a few interesting possibilities. It's like...okay, so you're spitting mad and resentful that it took you six months to 'get help' from a psychologist...I'm a psychologist offering you 90 mins of my time today...and you're (behaviorally) choosing to vent at me for an hour before engaging in the 'getting help' process which you have been so desperately needing and trying to engage in for the past six months. Always interesting. But, yeah, vast majority of people appreciate the genuine validation of their frustration and will quickly move to the therapeutic work with you.

 

[singasongofjoy]

We run into this a lot, and similarly long wait lists.... we don’t even tell people we have a wait list for therapy right now, just an “interest list” for adolescents and adults (autism clinic, only one around that takes Medicaid and offers some specialty approaches/groups).

We send a list of resources and, like others, I keep telling myself I can only do what I can do and I’m not responsible for holding the full weight of a large, broken system. Our staff have worked to create some more efficiencies which allows us to see a few more quickly snd triage those in urgent situations, which is enough to remind me we are all doing the best we can do while taking care of ourselves too and I feel just as strongly about protecting my staff from burnout.

This is likely an issue you’ll have to wrestle with for your entire career, unfortunately.

 

[thebalmofhurtminds]

We run into this a lot, and similarly long wait lists.... we don’t even tell people we have a wait list for therapy right now, just an “interest list” for adolescents and adults (autism clinic, only one around that takes Medicaid and offers some specialty approaches/groups).

We send a list of resources and, like others, I keep telling myself I can only do what I can do and I’m not responsible for holding the full weight of a large, broken system. Our staff have worked to create some more efficiencies which allows us to see a few more quickly snd triage those in urgent situations, which is enough to remind me we are all doing the best we can do while taking care of ourselves too and I feel just as strongly about protecting my staff from burnout.

This is likely an issue you’ll have to wrestle with for your entire career, unfortunately.

Yeah, in the VAs I trained at, we weren't allowed to call it a wait list and all that. Now that I'm out, I've wanted to be transparent, but maybe I should amend that a bit.

 

[ClinicalABA]

... it's discouraging to hear that seemingly most clinical systems aren't that great for either patient or provider...

In my case, it really isn't an issue with the system. Referral, scheduling, and authorization processes are pretty effective, and reimbursement rates, clinician access to resources, and clinician salaries and benefits are all pretty good. It's purely and issue of lack of appropriately trained and interested providers in the area.

 

[90833]

A long waitlist means that the market is telling you that you are in high demand, and your prices are too low. Time for a raise.

 

[ClinicalABA]

A long waitlist means that the market is telling you that you are in high demand, and your prices are too low. Time for a raise.

I get it, and maybe raising salaries would increase the number of clinicians who could/would do this work, but most of us aren't working in a free market system. As to prices being too low, we don't set our rates- CMS has done that for us. If we raise our prices beyond what what insurance will cover, we price ourselves out of business (as well as fail to meet our agency mission of delivering effective services in a manner that allows access to all).

 

[iliketohelppeople]

Yeah, in the VAs I trained at, we weren't allowed to call it a wait list and all that. Now that I'm out, I've wanted to be transparent, but maybe I should amend that a bit.

At one point, we were told by admins that we could not keep a 'list' of any kind in tracking patients. We asked, well, how can we keep track of folks to call for groups or follow up? There was no answer, so we kept 'interest lists.' I mean, I get it from a PR perspective, but, are you so removed from reality that you expect us to not keep a list of any kind? How would that even work? And, I am sure if something happens, and they find that crappy access database, then it would be blamed on the provider. Times when I am so glad I am not in the VA anymore.

 

[Sanman]

I get it, and maybe raising salaries would increase the number of clinicians who could/would do this work, but most of us aren't working in a free market system. As to prices being too low, we don't set our rates- CMS has done that for us. If we raise our prices beyond what what insurance will cover, we price ourselves out of business (as well as fail to meet our agency mission of delivering effective services in a manner that allows access to all).

That is really the problem. It is hard to estimate the number of people that will pay cash for something vs the number that are just there attempting to use insurance and only willing to fork over a co-pay. The problem with CMS rates is that it really is only worth accepting payment if you are providing very basic standardized services. Otherwise you are losing money. With the volume required even prep time can be difficult.

 

[Sanman]

At one point, we were told by admins that we could not keep a 'list' of any kind in tracking patients. We asked, well, how can we keep track of folks to call for groups or follow up? There was no answer, so we kept 'interest lists.' I mean, I get it from a PR perspective, but, are you so removed from reality that you expect us to not keep a list of any kind? How would that even work? And, I am sure if something happens, and they find that crappy access database, then it would be blamed on the provider. Times when I am so glad I am not in the VA anymore.

Some colleagues started a group for those that were interested in individual therapy and were not able to be scheduled in yet. Participants get selected for individual therapy out of that group. Hardly anyone shows up to the group. Great way to weed out the motivated from the unmotivated I thought.

 

[iliketohelppeople]

Some colleagues started a group for those that were interested in individual therapy and were not able to be scheduled in yet. Participants get selected for individual therapy out of that group. Hardly anyone shows up to the group. Great way to weed out the motivated from the unmotivated I thought.

At my other VA clinic, which was one of the best run I have ever seen (specialty outpatient clinic), they do a group (with info about the clinic/treatment) with a brief intake after for folks who may come to the clinic. Folks come and decide they aren't interested in the intensity of services. Really recommend.

 

[cara susanna]

At my other VA clinic, which was one of the best run I have ever seen (specialty outpatient clinic), they do a group (with info about the clinic/treatment) with a brief intake after for folks who may come to the clinic. Folks come and decide they aren't interested in the intensity of services. Really recommend.

I was in a clinic that did this and I really liked it.

Also, yes, the waitlist thing in the VA is soooo frustrating. There was actually a VA that got in trouble for having a waitlist for groups, even though people were in individual therapy (I think it was Denver?) I call it "interest notation." Haha.

 

[Sanman]

I was in a clinic that did this and I really liked it.

Also, yes, the waitlist thing in the VA is soooo frustrating. There was actually a VA that got in trouble for having a waitlist for groups, even though people were in individual therapy (I think it was Denver?) I call it "interest notation." Haha.

Can we institute this for congress? If a constituent is interested in speaking with their congressional representatives, they cannot be scheduled more than two weeks out and reps have to meet with all constituents...no waitlist.

 

[Fan_of_Meehl]

A long waitlist means that the market is telling you that you are in high demand, and your prices are too low. Time for a raise.

Another thing that greatly influences the market analysis is the 'cost' of appointment attendance. In the VA system, most folks pay nothing for the appointment time itself, nothing for no-shows/cancellations, and many utilize the time to audition for more benefits. This warps the entire market paradigm compared to the private sector, or other contexts of treatment.

 

[Fan_of_Meehl]

At my other VA clinic, which was one of the best run I have ever seen (specialty outpatient clinic), they do a group (with info about the clinic/treatment) with a brief intake after for folks who may come to the clinic. Folks come and decide they aren't interested in the intensity of services. Really recommend.

I wonder how many who don't opt in for the intense specialty services end up in the other open-access outpatient MH clinics, bogging them down.

 

[cara susanna]

I wonder how many who don't opt in for the intense specialty services end up in the other open-access outpatient MH clinics, bogging them down.

This is true - specialty clinics have the advantage of being able to discharge more easily.

Another thing that greatly influences the market analysis is the 'cost' of appointment attendance. In the VA system, most folks pay nothing for the appointment time itself, nothing for no-shows/cancellations, and many utilize the time to audition for more benefits. This warps the entire market paradigm compared to the private sector, or other contexts of treatment.

Don't forget travel pay.

 

[iliketohelppeople]

I wonder how many who don't opt in for the intense specialty services end up in the other open-access outpatient MH clinics, bogging them down.

True. It is the flip side of the coin. For what it is worth, I think our folks did a pretty good job of getting people who didn't quite fit our specialty criteria to situations that fitted them, which were, in many cases outside of the VA system.

Been in PCMHI where we had to do bridge care - our general mental health service was backed up months - so we had to maintain care until they were seen - there were Veterans that I saw 8 - 12 times in PCHMI as an intern. My supervisor would alternate between telling me I had to discharge them (so I could have more slots to see all of the other Veterans who needed care) or I had to keep them until they could establish care with a more appropriate provider/setting. I bet they were getting that pressure from above. Was not enviable at all. Lots of issues with the VA, but we got another thread for that.

 

[thebalmofhurtminds]

That is really the problem. It is hard to estimate the number of people that will pay cash for something vs the number that are just there attempting to use insurance and only willing to fork over a co-pay. The problem with CMS rates is that it really is only worth accepting payment if you are providing very basic standardized services. Otherwise you are losing money. With the volume required even prep time can be difficult.

Yeah, this is the frustrating aspect (other than the fact that I'm in my first year here, so my leveraging power is low already). Despite my long wait list for both evaluation and therapy, it's not as if I'm bringing in close to the same amount as the neuropsychologist next door. Like half of my patients are Medicare.