Thoughts on Current VA Issues

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bcliff

bcliff

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I've been following the current VA wait-list story (scandal..?) a little bit, and I wanted to see what impact this is having on psychologists working in the VA, or just what everyone's thoughts are on the story.
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responded to the wrong thread
 
My CBOC was visited by the OIG folks Monday, I believe. The is no fixing of the books going on here for sure. We do have vets wait longer than 2 weeks for PCC visits thoug, no doubt. Not comom place, but it does happen. Mostly a staffing issue. Just need more docs.
 
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erg923 said:
My CBOC was visited by the OIG folks Monday, I believe. The is no fixing of the books going on here for sure. We do have vets wait longer than 2 weeks for PCC visits thoug, no doubt. Not comom place, but it does happen. Mostly a staffing issue. Just need more docs.
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This has been my experience as well at a larger VA hospital. It's certainly unfortunate, although I don't know that these types of issues are limited or specific to the VA; I'd imagine most large hospitals or hospital systems have their own problems. The Phoenix issues and wait times specifically do seem pretty bad, though, at least based on the news stories I've read.
 
When I worked at the Long Beach VA, the mental health system was exemplary for providing access for patients. Can't speak to the rest of the hospital. It was my opinion that the psychologists at that hospital were instrumental in providing a high level of service through excellent practicum, internship, and post-docs as well as seeking additional funding through grants which led to more hiring of psychologists. Because of the great experience i had there and how I saw psychologists can really do a good job running a relatively large system, I have always thought of the VA as a potential career path and still may someday pursue it.
 
erg923 said:
We do have vets wait longer than 2 weeks for PCC visits thoug, no doubt. Not comom place, but it does happen. Mostly a staffing issue. Just need more docs.
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Agreed. My system seems to function pretty efficiently, but you can't manufacture appointment slots out of thin air, and there are practical limits on the number of patients a doctor can see in one day.

ETA: Also, I'm impressed by how quickly OIG is moving on this nationwide review of the scheduling protocol.
 
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Currently the VA seems to be actively recruiting in most areas, including psychologist. In comparison with Private or Public Hospitals, from discussions with colleagues with MD/DO, the VA may not offer as much flexibility of hours or rate of pay. Seems common that they may have private practice and Hospital privileges with a number of medical facilities. VA may need to adapt and allow Veterans to be seen by private practice or private hospitals, especially when a life threatening disease process may result in death.

Not that I have a large sample size, but rarely do I hear positive opinions about VA Hospitals from family, friends, or patients. However, psychologists seem happy working at the VA and normally continue until retirement age.

VA system seems similar to socialized medicine and there needs to be more options available to Veterans for medical treatment.

With all of the health insurance options from the Affordable Health Care ACT; Veterans would be one group who should have other options besides using their VA card and going to the VA Hospitals.

I wonder if the VA would have improved success if it was privatized or operated under private hospitals? Seems that a number of medical schools are associated with private hospitals and they are having good patient outcomes.


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OneNeuroDoctor said:
Not that I have a large sample size, but rarely do I hear positive opinions about VA Hospitals from family, friends, or patients. However, psychologists seem happy working at the VA and normally continue until retirement age.

VA system seems similar to socialized medicine and there needs to be more options available to Veterans for medical treatment.

With all of the health insurance options from the Affordable Health Care ACT; Veterans would be one group who should have other options besides using their VA card and going to the VA Hospitals.

I wonder if the VA would have improved success if it was privatized or operated under private hospitals? Seems that a number of medical schools are associated with private hospitals and they are having good patient outcomes.
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I'm just curious - have you worked in a VA setting?
 
psychRA said:
I'm just curious - have you worked in a VA setting?
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No work experience in the VA. My father and brother were veterans and I have worked in facilities that have employed many veterans. I am not claiming to be an expert on the VA.

If there is long wait list it would seem obvious to provide additional options for those patients. Pragmatically speaking for Veterans who have defended their country and risked their lives, they deserve the highest quality health care.


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OneNeuroDoctor said:
No work experience in the VA. My father and brother were veterans and I have worked in facilities that have employed many veterans. I am not claiming to be an expert on the VA.

If there is long wait list it would seem obvious to provide additional options for those patients. Pragmatically speaking for Veterans who have defended their country and risked their lives, they deserve the highest quality health care.
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In certain clinics with long wait lists, we fee-basis out all the time. Having worked in VA's and also AMC's and private hospitals, I can say that quality and continuity of care at the VA is pretty good (at least in the several that I've worked at). Especially in the mental health sector. Now if only we could do something about our high no-show rates and secondary gain culture it'd be awesome.
 
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In addition to the above, just to clarify, Veterans of course aren't required to go to the VA. However, to receive service-connected care, they do indeed need to present to a VA hospital/medical center. I'm probably stating the obvious, but just wanted to be clear.

I can say that at least in my experiences, providers take wait times very seriously, and frequently go above and beyond not just to schedule folks quickly, but to send out various reminders and aftercare/post no-show calls to try to prevent folks from "falling through the cracks." There are some things the VA could do better, and some things it (IMO) does pretty darn well.
 
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WisNeuro said:
In certain clinics with long wait lists, we fee-basis out all the time. Having worked in VA's and also AMC's and private hospitals, I can say that quality and continuity of care at the VA is pretty good (at least in the several that I've worked at). Especially in the mental health sector. Now if only we could do something about our high no-show rates and secondary gain culture it'd be awesome.
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Same here. I've worked in several VA's of varying sizes, and the facilities that couldn't offer a specific service (or offered it, but the patient couldn't/wouldn't use it at that site for some reason) were able to fee basis out. In terms of mental health, at least in the hospitals where I've worked, patients are able to get services almost indefinitely - I have never had to fill out a single insurance form to justify my treatment, and no one is breathing down my neck to terminate after 6 or 12 sessions.

For those who are reading this thread and haven't worked there, keep in mind that "the VA" is actually a HUGE system of over 1700 care sites, including tiny community clinics, larger hospitals, and big medical centers. They're all under the same big umbrella, and there are a lot of things that are consistent throughout the system, but there's also a lot of regional variation within and between systems. There is also the fact that service eligibility and wait times differ according to the patient's priority group. Some patients are eligible for more services, and entitled to be seen faster, than other patients: http://www.va.gov/healthbenefits/resources/priority_groups.asp
 
Has anybody wondered where the VA PR team is on this one? I have heard crickets. Whats this about?

1. The Veterans Health Administration provides mental health care to literally millions of people who would not and could not get care anywhere else, at least not without paying an arm and a leg. The MH care usually is indefinite if needed or wanted. Where else can someone get that?!

2. The quality of care in multiple arenas, in terms of outcomes, exceeds that offered in the private sector.

3. Care is portable to anywhere in the US.

4. The VA has endless amounts of programs to help veterans get housing, work, income, voc rehab, stay out of jail (veteran justice outreach program), AND pays for them to travel to appointments. Who else does this?!

5. VA ERs do not turn away anyone who needs emergency treatment, even if not enrolled/eligible. When I hear that people died on the waiting list, i have to wonder of these people made attempts to utilize ER services. There is no waiting list. Its an ER. We will treat you.
 
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erg923 said:
Has anybody wondered where the VA PR team is on this one? I have heard crickets. Whats this about?

1. The Veterans Health Administration provides mental health care to literally millions of people who would not and could not get care anywhere else, at least not without paying an arm and a leg. The MH care usually is indefinite if needed or wanted. Where else can someone get that?!

2. The quality of care in multiple arenas, in terms of outcomes, exceeds that offered in the private sector.

3. Care is portable to anywhere in the US.

4. The VA has endless amounts of programs to help veterans get housing, work, income, voc rehab, stay out of jail (veteran justice outreach program), AND pays for them to travel to appointments. Who else does this?!

5. VA ERs do not turn away anyone who needs emergency treatment, even if not enrolled/eligible. When I hear that people died on the waiting list, i have to wonder of these people made attempts to utilize ER services. There is no waiting list. Its an ER. We will treat you.
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There's always more to the story, and I agree, in general, the VA delivers great care, particularly for the massive size of the organization. Find another hospital system that includes 1000+ care delivery centers, and I guarantee you'll find problems similar in scope.

As for the PR folks, I wonder if perhaps they figure that trying to say anything other than, "we take these allegations seriously and are doing all we can to investigate and remedy them" at this point would just be met with a negative reaction.
 
erg923 said:
Has anybody wondered where the VA PR team is on this one? I have heard crickets. Whats this about?

1. The Veterans Health Administration provides mental health care to literally millions of people who would not and could not get care anywhere else, at least not without paying an arm and a leg. The MH care usually is indefinite if needed or wanted. Where else can someone get that?!

2. The quality of care in multiple arenas, in terms of outcomes, exceeds that offered in the private sector.

3. Care is portable to anywhere in the US.

4. The VA has endless amounts of programs to help veterans get housing, work, income, voc rehab, stay out of jail (veteran justice outreach program), AND pays for them to travel to appointments. Who else does this?!

5. VA ERs do not turn away anyone who needs emergency treatment, even if not enrolled/eligible. When I hear that people died on the waiting list, i have to wonder of these people made attempts to utilize ER services. There is no waiting list. Its an ER. We will treat you.
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I only read one specific story, but one person who died on the waiting list was waiting for a referral to a primary care doctor for diagnosis (which ended up being cancer). I do agree that the VA does a lot of things really well and people shouldn't throw out the baby with the bathwater.
 
Seems that the Whistleblower reports suggests systemic problems throughout VA Health and that one solution would be allowing Veterans and their families to acquire mental health services in nonprofit agencies. Face the Nation round table today indicated that mental health needs for Veterans are not being adequately met for Veterans and commonly Veterans choose no services. One of the panel members indicated that the VA has a severe shortage of Social Workers but they are currently trying to expedite hiring more Social Workers.

Apparently a report is being released in two weeks by Obama that will mandate required changes in the VA Health System. My guess is that there will be additional options for treatment in the public or private non profit mental health sector for Vererans.

I am reading about RxP for Psychologist and it sounds like there is some interest and Congress may expedite allowing Psychologist to prescribe in the VA.

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How much money do you think said "vouchers" would be worth? You (and others) are buying into that like its a equivalent trade or something. Knowing what you know about thr pay structure of Medicaid and Medicare, what do you think about that? Take your time....

PS: In case you couldn't figure it out, my conclusion would be along the lines of: "Um, yea. Good luck talking private providers into taking a loss for government man. Healthcare is a business folks, the only person willing to LOSE money on it is the Feds."
 
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OneNeuroDoctor said:
I am reading about RxP for Psychologist and it sounds like there is some interest and Congress may expedite allowing Psychologist to prescribe in the VA.
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I wouldn't object to this, but anyone who views this aspect as the problem, or even a significant part of problem ain't in the loop. 1.) We have emergency prescriibers and coverage for psychiatric crisises. 2. We have ERs. 3.) PCP will usually prescribe anything other than maintenance APs and mood stabilizers, so access to psychotropic medication in and of themselves should not usually be an issue.[/QUOTE][/QUOTE]
 
erg923 said:
I wouldn't object to this, but anyone who views this aspect as the problem, or even a significant part of problem ain't in the loop. 1.) We have emergency prescriibers and coverage for psychiatric crisises. 2. We have ERs. 3.) PCP will usually prescribe anything other than maintenance APs and mood stabilizers, so access to psychotropic medication in and of themselves should not usually be an issue.
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[/QUOTE][/QUOTE]
I am surprised that mental health services are being mentioned as the issue for the VA. My experience was that the VA is ahead of the curve when it comes to delivery of mental health services. I also don't think this is a good argument for RxP. Kids that have serious psychiatric illnesses that have to wait for 2 to 3 months is a better one.
 
erg923 said:
How much money do you think said "vouchers" would be worth? You (and others) are buying into that like its a equivalent trade or something. Knowing what you know about thr pay structure of Medicaid and Medicare, what do you think about that? Take your time....

PS: In case you couldn't figure it out, my conclusion would be along the lines of: "Um, yea. Good luck talking private providers into taking a loss for government man. Healthcare is a business folks, the only person willing to LOSE money on it is the Feds."
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If they're talking about private practice, I agree wholeheartedly - I can't see any incentive for a private practice therapist to accept very low reimbursements. I don't think a private practice therapist would be able to absorb the lost income from frequent cancellations and no-shows either, and would have to terminate with those patients, whereas VA clinics are able to offer a TON of leeway in that regard.

I don't know which "nonprofit agencies" they're suggesting as an alernative treatment option for VA patients, but if they're referring to community mental health centers, I'm incredibly skeptical that patients would be able to get the same level of care. Based on my experience in CMHC, those clinicians are already struggling with massive caseloads. In every VA where I've worked, patients were able to get regular weekly therapy at minimum, often with multiple group options and residential programs available.
 
Well, hope everyone is happy now. Im not condoning anything, but frankly, I wonder who would/could have done a better job?
 
WisNeuro said:
Unfortunately, with the political climate what it is, someone had to be the scapegoat.
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Yep. By saying that he served as a "distraction," Shinseiki was basically saying, "politicians, etc. aren't going to shut-up about firing me/wanting to make 'heads roll' and allow us to focus on actually fixing the problems until I'm gone, so I should probably resign."

Now the folks calling for his resignation can feel like they've actually done something productive, when in reality many of them were probably the same folks who've either previously spoken against increased VA funding, or who suggested requiring decreased wait times without following that up with increased funding (and thereby setting the VA up for failure).

Just my take, anyway.
 
My experience is that there is exteme naivete on the part of most MH professionals about this whole issue. The "so simple a cave man could do it" mentality of just hire more people....increase access, etc without any regard to funding for said positions or space for said positions.
 
erg923 said:
My experience is that there is exteme naivete on the part of most MH professionals about this whole issue. The "so simple a cave man could do it" mentality of just hire more people....increase access, etc without any regard to funding for said positions or space for said positions.
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Seriously. I would add that it's incredibly frustrating to see how many people (MH professionals included) feel qualified to make statements about how things are, and how things should be done, in a system that they know absolutely nothing about. It's a huge, complex, underfunded system (yes, their budget has increased in recent years - and the number of patients in the system has increased even faster) in a massive space crunch. I don't think you have to work in a VA to comment on the VA, as there's plenty of actual data out there about the system and the services it provides, but I wish people would do a bare minimum of information gathering before putting their opinions out there. The fact that you watched "Born on the Fourth of July" on netflix, or your have a cousin who used to get care at a VA, does not mean that you have an understanding of the issues.
 
psychRA said:
Seriously. I would add that it's incredibly frustrating to see how many people (MH professionals included) feel qualified to make statements about how things are, and how things should be done, in a system that they know absolutely nothing about. It's a huge, complex, underfunded system (yes, their budget has increased in recent years - and the number of patients in the system has increased even faster) in a massive space crunch. I don't think you have to work in a VA to comment on the VA, as there's plenty of actual data out there about the system and the services it provides, but I wish people would do a bare minimum of information gathering before putting their opinions out there. The fact that you watched "Born on the Fourth of July" on netflix, or your have a cousin who used to get care at a VA, does not mean that you have an understanding of the issues.
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I think the total number of vets who are technically "enrolled" in VHA went down during the past 10 years due to deaths 0f WWII and Korea vets, but they probably utilize less services than the OEF/OIF guys AND the certainly didnt utilize MH services at the same rate. Moreover, tens of thousands of Vietnam vets have started utilizing services since in the past decade. While certain areas/clinics are understaffed (my primary care clinic could easily benefit from 2 more PC docs and another MHC provider), we have gotten every cent we asked for lately. Its not used very efficiently in many cases though. Sure, doubling ands tripling eveything would fix alot of problems, but thats just not realistic, nor is it efficient.
 
erg923 said:
I think the total number of vets who are technically "enrolled" in VHA went down during the past 10 years due to deaths 0f WWII and Korea vets, but they probably utilize less services than the OEF/OIF guys AND the certainly didnt utilize MH services at the same rate. Moreover, tens of thousands of Vietnam vets have started utilizing services since in the past decade. While certain areas/clinics are understaffed (my primary care clinic could easily benefit from 2 more PC docs and another MHC provider), we have gotten every cent we asked for lately. Its not used very efficiently in many cases though. Sure, doubling ands tripling eveything would fix alot of problems, but thats just not realistic, nor is it efficient.
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Good points. I've been lucky to be in well-funded systems myself, and I'm certainly not an expert on service enrollment and utilization. There are some numbers available in this site: http://www.va.gov/vetdata/utilization.asp. The number of enrolled vets in Priority Group 1 tripled between 2000 and 2012 (from around 441,000 to 1,307,000), and Priority Groups 2 and 3 each added 200,00 enrolled patients. Total VA enrollment increased by 2 million patients, and the number of outpatient visits in the entire system nearly doubled.

I agree that throwing money at the system won't solve every problem, but I get frustrated by bloggers and journalists who ignore the increased demands on the system, but seem to think that because the VA budget has increased, the system should be working perfectly. Ditto to the people who've never set foot in a VA, but make sweeping generalizations about the staff being cold and uncaring, the facilities being decrepit, or the patient care being terrible.
 
Just wanted to share a positive experience (yes, just anecdotal). Friday morning I came in about an hour early and a Veteran (not a personal patient of mine) stopped me as I was coming through the front door and thanked me for my service to the Veterans, and how much he appreciated the VA in spite of the national media attention. I thanked him back for his own service and had an appreciably better day because of that interaction.

Unfortunately, most people will only hear the negatives about the system. No one really cares to report on the positives.
 
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One of the worst things about this for me is the adversarial climate between Veterans and providers this has created, the opposite of the recovery model. There was always some of this tension, but now it is at explosive levels.
 
Speaking of "VA crisis," did anyone else see this article? Apparently the Institute of Medicine is calling out the VA and DoD for failing to adequately track PTSD treatment outcomes. It was mentioned in the div 56 listserv.

http://www.medscape.com/viewarticle/827105

It confused me because I thought that the VA was actually pretty good at tracking treatment outcomes, particularly for PTSD. Thoughts?
 
The article is behind a paywall. They are for certain things, like their inpatient treatment programs and such. Tracking treatment outcomes for PTSD is dicey considering the secondary context that the system sets up. I imagine part of the lack of treatment gain tracking is political in nature. You either don't screen for malingering and have wonky data that doesn't correspond to what we know in the literature, or you do assess for it and run the risk of congressional action against you when you exclude an X% of people who trip your SVT's. It's a lose-lose situation to be honest.
 
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