VA Mental Health Provider Venting / Problem-solving / Peer Support Thread

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texanpsychdoc said:
I'm also a firm believer in, when it's feasible, we should be advocating for people using SC benefits to grow and get better as to not need SC benefits going forward. I realize this may not be feasible for everybody, but I'd imagine a statistical majority are able to improve functioning as to be more independent and less reliant on disability benefits.
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Indeed. I also wonder if a mindset change is needed even earlier. I've certainly heard some (obviously not all or even most) active duty folks essentially say that SC is their retirement plan.
 
The dirty secret is that most people don't lose their benefits if they do get better. The VA PTSD community talks about this often and no one's been able to identify a single person they know who lost their SC after doing treatment. And if they're permanent and total, they will only get reevaluated if they apply for a new condition or an increase.

I'm having a LOT of new patients lately showing up for PTSD EBP who are actively in the SC application (initial or an increase) process. It's really frustrating. I give them the talk about how these are opposing concepts and doing treatment could hurt their chances, and they still agree to do treatment, because what else are they supposed to say?
 
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Good discussion!

If we really wanted to be treatment focused, one model might be eliminating any new service connected payments for mental health disorders and directing that money into treatment and non-cash support resources.

So essentially, people are still rated for mental health either as they are leaving the service or afterwards, but that rating will be to ensure free health care, as well as eligiblity for non direct cash services like housing vouchers via Hudvash.

A even more drastic push would be to guarantee unlimited free mental health care for all former service members (including dishonorably discharged) but with zero possibility of direct VA financial benefit from the perspective of the patient.
The recent Compact Act that pays for all acute care related to suicide operates on a similar premise.

Also, during the past year or so, caregiver support programs have supposedly been reevaluating enrollees who qualified for a MH reason versus physical disability.

I don't know how many people are actually being kicked out given pushback to this announcement but I seem to see almost 100% denials of new CSP applications where mental health is the driving concern and on the whole, that seems like a good thing IMO.
 
summerbabe said:
Good discussion!

If we really wanted to be treatment focused, one model might be eliminating any new service connected payments for mental health disorders and directing that money into treatment and non-cash support resources.

So essentially, people are still rated for mental health either as they are leaving the service or afterwards, but that rating will be to ensure free health care, as well as eligiblity for non direct cash services like housing vouchers via Hudvash.

A even more drastic push would be to guarantee unlimited free mental health care for all former service members (including dishonorably discharged) but with zero possibility of direct VA financial benefit from the perspective of the patient.
The recent Compact Act that pays for all acute care related to suicide operates on a similar premise.

Also, during the past year or so, caregiver support programs have supposedly been reevaluating enrollees who qualified for a MH reason versus physical disability.

I don't know how many people are actually being kicked out given pushback to this announcement but I seem to see almost 100% denials of new CSP applications where mental health is the driving concern and on the whole, that seems like a good thing IMO.
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Yeah...there is no (nor has there EVER been) any rationale (let alone evidence) for a full-time paid 'caregiver' to treat or manage PTSD, anxiety, or depression.

This was 100% political from the get-go and the year that they implemented this I said they would have to be clawing that nonsense back someday. It took many years and many $$$ though.

The way these things play out in the consulting room is almost a script (like you could make a Pocket Card for it for interns) or something:

Veteran: "I need you to write that I need my wife as caregiver for my PTSD"

Me: "Why would you need that?"

Veteran: "She's the only one who can keep me from f*($()& people up 'cause of my PTSD, I don't got no patience with nobody...she is the only one who can calm me down"

Me: "Are you saying that without your wife around you're unable to keep from inflicting physical violence on others?"

Veteran: {does not compute}

Me: "Because, you know, being able to not engage in random unpredictable serious acts of physical violence is kind of a precondition of being able to live in society, otherwise you'd need to be in an institution like a hospital, prison, or nursing home or something."

That usually does it.
 
summerbabe said:
Good discussion!

If we really wanted to be treatment focused, one model might be eliminating any new service connected payments for mental health disorders and directing that money into treatment and non-cash support resources.

So essentially, people are still rated for mental health either as they are leaving the service or afterwards, but that rating will be to ensure free health care, as well as eligiblity for non direct cash services like housing vouchers via Hudvash.

A even more drastic push would be to guarantee unlimited free mental health care for all former service members (including dishonorably discharged) but with zero possibility of direct VA financial benefit from the perspective of the patient.
The recent Compact Act that pays for all acute care related to suicide operates on a similar premise.

Also, during the past year or so, caregiver support programs have supposedly been reevaluating enrollees who qualified for a MH reason versus physical disability.

I don't know how many people are actually being kicked out given pushback to this announcement but I seem to see almost 100% denials of new CSP applications where mental health is the driving concern and on the whole, that seems like a good thing IMO.
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They were previously very liberal with csp funds such as PCAFC was only eligible to post 9/11 veterans. After expanding the program in 2020 to veterans of all eras, they made the criteria more stringent.
 
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AcronymAllergy said:
Indeed. I also wonder if a mindset change is needed even earlier. I've certainly heard some (obviously not all or even most) active duty folks essentially say that SC is their retirement plan.
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I hear this routinely. Much of the time in my clinic I have people who sign up to do therapy but erroneously think they can use my evaluation and notes to support their future application for SC benefits. Once I have a conversation about how that is not the case with them....they flake out and/or they half ass their way through therapy and waste my time and VA resources...because even 0% SC means they have a $0 co-pay...so why not come over for 45 minutes once a week to shoot the ****. With current VA policies essentially rivaling Burger King's, it's a safe haven for this kind of behavior since it is reinforced and "validated" by so many.
 
cara susanna said:
I'm having a LOT of new patients lately showing up for PTSD EBP who are actively in the SC application (initial or an increase) process. It's really frustrating. I give them the talk about how these are opposing concepts and doing treatment could hurt their chances, and they still agree to do treatment, because what else are they supposed to say?
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Do they tend to differ in treatment engagement versus other vets who aren't seeking (more) SC?
 
summerbabe said:
So essentially, people are still rated for mental health either as they are leaving the service or afterwards, but that rating will be to ensure free health care, as well as eligiblity for non direct cash services like housing vouchers via Hudvash.

A even more drastic push would be to guarantee unlimited free mental health care for all former service members (including dishonorably discharged) but with zero possibility of direct VA financial benefit from the perspective of the patient.
The recent Compact Act that pays for all acute care related to suicide operates on a similar premise.
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An issue I can see with this is that we still can't effectively treat all mental illnesses--PTSD, yes, we can treat well and a lot of depression and anxiety (though none of those are treatable in *all* cases, ether), but things like psychosis/schizophrenia have a much, much dimmer outlook on every metric. and patients can engage in good treatment and still have lots of functional impairment
 
cara susanna said:
Not that I've seen.
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Agreed. I work in a (supposedly) 'specialty' clinic (a PCT)...basically a PTSD specialty clinic which is supposed to prioritize receipt and tx of patients who are ready to engage in EBP protocols.

These days--I crap you not--about 80% of my patients are either totally non-engaged or what I would characterize as pseudo-engaged in the psychotherapy enterprise. This means that my time, energy, attention, intervention, and documentation during 80% of my time with my patients is focused on identifying and attempting to address barriers to engagement with the psychotherapy process rather than the implementation of psychotherapy itself (in terms of 'active' interventions and protocols with an actually 'engaged' patient).

This is a hard core reality that no one in admin will ever acknowledge as the truth.
 
Fan_of_Meehl said:
Agreed. I work in a (supposedly) 'specialty' clinic (a PCT)...basically a PTSD specialty clinic which is supposed to prioritize receipt and tx of patients who are ready to engage in EBP protocols.

These days--I crap you not--about 80% of my patients are either totally non-engaged or what I would characterize as pseudo-engaged in the psychotherapy enterprise. This means that my time, energy, attention, intervention, and documentation during 80% of my time with my patients is focused on identifying and attempting to address barriers to engagement with the psychotherapy process rather than the implementation of psychotherapy itself (in terms of 'active' interventions and protocols with an actually 'engaged' patient).

This is a hard core reality that no one in admin will ever acknowledge as the truth.
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This is my experience as well - having worked in a PTSD-SUD residential clinic in the past and my current role in a SUD IOP clinic....much of my work is addressing things other than SUD stuff. That's if they actually show up and/or don't flake out early on. I had to have a very stern conversation with a vet yesterday who insisted for the 10th time in the past 2 months they be admitted to our residential program and I would tell them no and why and reinforce why. They decided to weaponize the the whole suicide thing to be admitted to our ER yesterday. Of course I loop my director in (as I always do in situations like this) and they had my back and also agreed with my decision and even told me this vet is on our "no fly list" as they have frequently used/abused our residential resources. The ER social work team had reached out to me, my director and a SW I worked with on pertaining to this vet and we had unified front in terms of what we advised the SR social work team and they reinforced our position with that vet. yesterday when they appeared to the ER. So much for trying to go over our heads right?

I can't wait to be gone from here in 4 weeks.
 
cara susanna said:
I'm a remote PCT member and I pretty much do at least 80% PTSD EBPs (the rest of the team is another story, lol).
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As a member of a PACT team, the idea of actually doing the short-term focused EBP work is laughable when GMC is a 3-6 month wait and referrals are a waste of time. I enjoy the EBP work, but 20% proper EBP is optimistic. I am doing 80%+ case management.
 
Sanman said:
As a member of a PACT team, the idea of actually doing the short-term focused EBP work is laughable when GMC is a 3-6 month wait and referrals are a waste of time. I enjoy the EBP work, but 20% proper EBP is optimistic. I am doing 80%+ case management.
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If it helps, I'm also 50% GMHC and I feel this. We keep our EBP slots separate from IND slots.
 
cara susanna said:
Anyone else feel like OPMH referrals have been really weak lately? Like a lot of patients who don't need or decline MH when they get to the intake?
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How long is your wait time? I feel like a lot of folks "in need of services" simply improve or address their acute concern before ever getting off the waitlist and then lose interest. Maybe that is just the terrible local PCP referrals I happen to look at.
 
Yeah, it's about 2 months I would say. I've seen people improve during the wait time and then decline services, but lately it seems like they shouldn't have been referred in the first place
 
cara susanna said:
Anyone else feel like OPMH referrals have been really weak lately? Like a lot of patients who don't need or decline MH when they get to the intake?
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Very frustrating. I usually do a good job of steering people to the right place, but it does feel like a waste of time sometimes. I try to reframe it as helping them better understand the different levels of care offered. Usually they’re fine with a drop in coping skills group. Some people just want to know there’s somebody there who knows their name that they can reach out to in the future. Lately I’ve gotten a lot of referrals who departing colleagues successfully terminated with d/t improvement. Suddenly it’s “I feel abandoned I need more therapy”.

Shiori said:
I'm in a cycle of chronically depressed clients who have tried therapy after therapy with no significant changes. Meds aren't helping either. It's been pretty demoralizing.
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I feel this, but with personality disorders. I’ve had several folks on my caseload who came to me with those diagnoses and it was apparent in 1 session that it is 100% accurate (sometimes I see “PD features” noted just because the person is abrasive). Being roped into the cycle of: getting angry at constructive feedback > drop out of care > come back > repeat, is wearing on me. These folks have narcissistic/histrionic/dependent so I already feel out of my depths with what to even offer them that would be effective. Consulted with DBT program and they said full model is contraindicated for those folks.

EDIT: typos
 
ccpsych16 said:
Very frustrating. I usually do a good job of steering people to the right place, but it does feel like a waste of time sometimes. I try to reframe it as helping them better understand the different levels of care offered. Usually they’re fine with a drop in coping skills group. Some people just want to know there’s somebody there who knows their name that they can reach out to in the future. Lately I’ve gotten a lot of referrals who departing colleagues successfully terminated with d/t improvement. Suddenly it’s “I feel abandoned I need more therapy”.


I feel this, but with personality disorders. I’ve had several folks on my caseload who came to me with those diagnoses and it was apparent in 1 session that it is 100% accurate (sometimes I see “PD features” noted just because the person is abrasive). Being roped into the cycle of: getting angry at constructive feedback > drop out of care > come back > repeat, is wearing on me. These folks have narcissistic/histrionic/dependent so I already feel out of my depths with what to even offer them that would be effective. Consulted with DBT program and they said full model is contraindicated for those folks.

EDIT: typos
Click to expand...
I know exactly the cycle you're talking about.

me 'what goals would you have for therapy?

client: "I need HELP!!! You gotta help me get my anger under control. I'll do ANYTHING!!!!!"

Me: "Here's this awesome cog-behavioral structured workbook to teach self-monitoring and anger management skills, step by step..."

2 sessions later when client repeatedly and steadfastly refuses to fill out anger monitoring form...

client: "I don't have time for this (5 mins in 2 weeks) to fill out no damn forms!!!! and all these questions about my anger are pissing me off, you need to back off!"

me: so what do you want to do?

client: "I don't know! Why you askin ME? You the damn DOCTOR!!!"

I'll spare you the compete rinse/repeat
 
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Fan_of_Meehl said:
I know ecactly the cycle you're talking about.

me 'what goals would you have for therapy?

client: "I need HELP!!! You gotta help me get my anger under control. I'll do ANYTHING!!!!!"

Me: "Here's this awesome cog-behavioral structured workbook to teach self-monitoring and anger manahement skills, step by step..."

2 sessions later when client repeatedly and steadfastly refuses to fill out anger monitoring form...

client: "I don't have time for this (5 mins in 2 weeks) to fill out no damn forms!!!! and all these questions about my anger are pissing me off, you need to back off!"

me: so what do you want to do?

client: "I don't know! Why you askin ME? You the damn DOCTOR!!!"

I'll spare you the compete rinse/repeat
Click to expand...
Oh I just LOVE when anger management clients say “I can’t do the anger management class, other people’s opinions make me mad!!” Well, sounds like that’s the exact place you need to be…
 
Fan_of_Meehl said:
client: "I need HELP!!! You gotta help me get my anger under control. I'll do ANYTHING!!!!!"

Me: "Here's this awesome cog-behavioral structured workbook to teach self-monitoring and anger manahement skills, step by step..."
Click to expand...
This but with chronic pain or migraines. Had a CBT-HA person who refused to fill out the migraine log or relaxation log. Then told me that therapy wasn't working. Ok then.
 
Fan_of_Meehl said:
I know exactly the cycle you're talking about.

me 'what goals would you have for therapy?

client: "I need HELP!!! You gotta help me get my anger under control. I'll do ANYTHING!!!!!"

Me: "Here's this awesome cog-behavioral structured workbook to teach self-monitoring and anger management skills, step by step..."

2 sessions later when client repeatedly and steadfastly refuses to fill out anger monitoring form...

client: "I don't have time for this (5 mins in 2 weeks) to fill out no damn forms!!!! and all these questions about my anger are pissing me off, you need to back off!"

me: so what do you want to do?

client: "I don't know! Why you askin ME? You the damn DOCTOR!!!"

I'll spare you the compete rinse/repeat
Click to expand...

I usually tell them to give me a call when they are ready and I show them the door.
 
psycho1391 said:
This but with chronic pain or migraines. Had a CBT-HA person who refused to fill out the migraine log or relaxation log. Then told me that therapy wasn't working. Ok then.
Click to expand...

Do they also skip the gym, eat a donut, and complain they can't lose 10 lbs?
 
Officially licensed now, but it was very anticlimactic. Just an emailed wallet card. Nothing in the mail or a fancy certificate like some of my colleagues have. I was hoping HR would process my grade increase before this shutdown nonsense, but that was wishful thinking… It should have shown up on yesterday’s paycheck with my backpay.

EDIT: To those who went from GS-11 to 12, did you get an NPI through the VA’s credentialing pross? Or did you do it yourself? Of course, all my emails asking about how to start that process have been ignored.
 
I already had an NPI assigned from a prior (state) government job when I joined VA, so I'm not sure. Someone on the board will know.

Regarding HR (or payroll) following up on anything...I think there is now an online 'ticket' system to request they address an issue (HR Smart?). I'd look into that and create a ticket.
 
Shiori said:
Yaaay! Congratulations. You just get an NPI number yourself. It's pretty easy. You go to the NPI website and fill out a form. They emailed me within an hour with my number. I passed it on to the credentialing staff when they asked for it.
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Thanks!
Fan_of_Meehl said:
I already had an NPI assigned from a prior (state) government job when I joined VA, so I'm not sure. Someone on the board will know.

Regarding HR (or payroll) following up on anything...I think there is now an online 'ticket' system to request they address an issue (HR Smart?). I'd look into that and create a ticket.
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Yep, I’ve used HR Smart (over a year later my first ticket is still open and unresolved 😡). I looked at the ticket category that credentialing falls under, and the disclaimer says it’s only to be used for onboarding new hires. I debated whether to just submit it anyway and let them kick it back if that’s not the appropriate place for current staff.
 
ccpsych16 said:
Officially licensed now, but it was very anticlimactic. Just an emailed wallet card. Nothing in the mail or a fancy certificate like some of my colleagues have. I was hoping HR would process my grade increase before this shutdown nonsense, but that was wishful thinking… It should have shown up on yesterday’s paycheck with my backpay.

EDIT: To those who went from GS-11 to 12, did you get an NPI through the VA’s credentialing pross? Or did you do it yourself? Of course, all my emails asking about how to start that process have been ignored.
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Congrats!
I DIYed the NPI.
 
PsychPhDone said:
Congrats!
I DIYed the NPI.
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Thank you! I’m surprised none of my colleagues mentioned it. We have a few who went from 11 to 12 here. I submitted my app today after reading up on a couple old APA articles about choosing a specialty. Not so relevant for us I guess but it may be down the line should I leave VA.
 
ccpsych16 said:
Thank you! I’m surprised none of my colleagues mentioned it. We have a few who went from 11 to 12 here. I submitted my app today after reading up on a couple old APA articles about choosing a specialty. Not so relevant for us I guess but it may be down the line should I leave VA.
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If you're billing independently, VA or not, you still need an NPI.
 
WisNeuro said:
If you're billing independently, VA or not, you still need an NPI.
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Yes. I was referring to choosing your taxonomy, and how depending which one(s) you choose, reimbursement could be affected. Billing works differently in some ways for us in the VA vs other places, which is why I said that.
 
God I love these consults where you intake a patient with depression and then they say:

1. I don't want a referral to a psychiatrist or any psychotropic medication
2. I'll try "talking to someone" (with their pissed off wife sitting next to them) but have no real interest in changing my behavior

Ok, hang on, let me just go find my magic wand...I think it is in a box with my grad school diplomas
 
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Sanman said:
God I love these consults where you intake a patient with depression and then they say:

1. I don't want a referral to a psychiatrist or any psychotropic medication
2. I'll try "talking to someone" (with their pissed off wife sitting next to them) but have no real interest in changing my behavior

Ok, hang on, let me just go find my magic wand...I think it is in a box with grad school diplomas
Click to expand...
These days, after and initial session or two, I've gotten pretty militant about the fact that therapy is YOU doing YOU and either making goals to change:

(a) your patterns of thinking/beliefs
or
(b) your patterns of behavior

'My goal is to be less anxious'

Okay, let's break that down into changes you can make in your thinking or your behavior. Nothing else is an appropriate 'goal' for psychotherapy.

And no continuous recitation of symptoms, either. That's not you participating in therapy.

"You gotta help me stop these nightmares/flashbacks."

Your nightmares/flashbacks are symptoms of your (service-connected) diagnosis of PTSD, right?

"Yes"

Okay, let's go back to what the literature / expert consensus guidelines say about treating PTSD (and its associated symptoms such as nightmares/flashbacks). Oh, lookeee here! It says we need to do some CPT/PE/EMDR. You know, work on YOU changing YOUR patterns of thinking/beliefs and/or behavior.

What's that? Can't make weekly sessions? Don't want to discuss your trauma? Aren't interested in a professional service that involves YOU changing your actions/ beliefs? That's okay, we don't have to reschedule. I wouldn't want to go to the Audi dealership if all I wanted was a unicycle, either. It's important to be 'in the market' for the service being offered.
 
Fan_of_Meehl said:
These days, after and initial session or two, I've gotten pretty militant about the fact that therapy is YOU doing YOU and either making goals to change:

(a) your patterns of thinking/beliefs
or
(b) your patterns of behavior

'My goal is to be less anxious'

Okay, let's break that down into changes you can make in your thinking or your behavior. Nothing else is an appropriate 'goal' for psychotherapy.

And no continuous recitation of symptoms, either. That's not you participating in therapy.

"You gotta help me stop these nightmares/flashbacks."

Your nightmares/flashbacks are symptoms of your (service-connected) diagnosis of PTSD, right?

"Yes"

Okay, let's go back to what the literature / expert consensus guidelines say about treating PTSD (and its associated symptoms such as nightmares/flashbacks). Oh, lookeee here! It says we need to do some CPT/PE/EMDR. You know, work on YOU changing YOUR patterns of thinking/beliefs and/or behavior.

What's that? Can't make weekly sessions? Don't want to discuss your trauma? Aren't interested in a professional service that involves YOU changing your actions/ beliefs? That's okay, we don't have to reschedule. I wouldn't want to go to the Audi dealership if all I wanted was a unicycle, either. It's important to be 'in the market' for the service being offered.
Click to expand...

Most of them barely make two sessions before dropping out. Usually when the wife or family member forcing them to show up gets busy or fed up.
 
Sanman said:
Most of them barely make two sessions before dropping out. Usually when the wife or family member forcing them to show up gets busy or fed up.
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Yup. Frustrating but...hey, if the VA wants to pay me to play the professional therapy equivalent of 'pick up sticks' all day long then so be it.

I'm here because my husband needs help.
- Does he want help?

I'm here because I want my PTSD symptoms to go away.
- Are you willing to make systematic changes, no matter how incrementally, to your patterns of thinking and/or behavior and complete self-monitoring and practice forms?

I'm here to buy a unicycle.
- Sir, this is an Audi dealership.
 
Shiori said:
I'm in a cycle of chronically depressed clients who have tried therapy after therapy with no significant changes. Meds aren't helping either. It's been pretty demoralizing.
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That is frustrating. Is it possible some may have been misdiagnosed? I wonder sometimes if a lot of treatment-resistant depression may actually be bipolar 2, BPD, etc.
 
cara susanna said:
Yeah, it's about 2 months I would say. I've seen people improve during the wait time and then decline services, but lately it seems like they shouldn't have been referred in the first place
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I think some this may be some non-MH providers not wanting to have to deal with any emotional things from patients, so they just refer to mental health. Or the "all veterans always have PTSD" stereotype.
 
Sanman said:
God I love these consults where you intake a patient with depression and then they say:

1. I don't want a referral to a psychiatrist or any psychotropic medication
2. I'll try "talking to someone" (with their pissed off wife sitting next to them) but have no real interest in changing my behavior

Ok, hang on, let me just go find my magic wand...I think it is in a box with grad school diplomas
Click to expand...

Haha, yeah, I love when referrals are like "I don't know what to do with this person" like you're gonna know what to do with them or you have some magical solution.
 
cara susanna said:
Haha, yeah, I love when referrals are like "I don't know what to do with this person" like you're gonna know what to do with them or you have some magical solution.
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For my folks, it is often a lack of reading the chart.

"He is yelling at his wife"

Based on his medical chart, he has been arguing with his wife for 40 years and they have been divorced and remarried twice.

If I could fix that (in one session), why would I be working here and not charging $10,000/hr?
 
cara susanna said:
Yeah, I get PCPs are busy but could you take maybe like FIVE seconds to read the chart before referring someone for therapy who's already being seen for appts weekly in the community?
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There is not a chart note in the notes tab, the treatment does not exist.

For the referral I had, this the third referral for the same symptoms. Last one was was 10 years ago. The only things that have seemed to have changed in that time is a complete turnover of the staff. I often think back to a couples therapy case I had as an intern. Being the therapist I am today, my first question would have been "I am the fourth therapist you are seeing for the same problem, what exactly is it that you are hoping to accomplish here?". Then again, that does not help get your required check boxes.
 
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Sanman said:
God I love these consults where you intake a patient with depression and then they say:

1. I don't want a referral to a psychiatrist or any psychotropic medication
2. I'll try "talking to someone" (with their pissed off wife sitting next to them) but have no real interest in changing my behavior

Ok, hang on, let me just go find my magic wand...I think it is in a box with grad school diplomas
Click to expand...

I had this happens multiple times and my response to them usually is "well...that's why you are here to see me, to talk to someone. What else did you think this was, the DMV?"
 
futureapppsy2 said:
That is frustrating. Is it possible some may have been misdiagnosed? I wonder sometimes if a lot of treatment-resistant depression may actually be bipolar 2, BPD, etc.
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Oh certainly. I'm quite careful in how I assess and describe symptoms, and relatively often I get to say "your antidepressants aren't helping because you don't have depression" and then, after treating what the patient actually has, they magically get better.
 
Shiori said:
My newest consult has a no-show rate that requires scrolling. They want me to do PTSD treatment.
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Fine.

I can play 'pick up sticks' all day long if they want to pay 'full price' for a psychologist to do that.

It's just sad/demoralizing to see all the 'waste' in the system due to 'leadership's' failures to actually make any decisions that could possibly, in some universe, under ideal circumstances, possibly...piss off a veteran, family member, or congressperson.

A sliding-scale $5 - $25 copay would simultaneously SOLVE so many problems (including so-called 'access issues') it's unreal.
 
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