VA Psychologist: Would you rather work in PCMHI or BHIP?

[IWillSurvive]

I am considering a change in clinic and am wanting to hear about experiences within PCMHI and BHIP. Which do you prefer? What are some of the challenges? Which do you think is the better position for psychologists within the VA? I know preferences will vary by individual but I am hoping to hear a range of perspectives!

Part B: Have you found any unique positives and/or challenges with PCMHI via telehealth? Thank you!

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[JustNoticing]

I don't know if there's a right answer here, I think a lot is going to depend on which model of care is a better fit for your work style or clinical approach. PCHMHI - doing lots of 20-25 minute appointments each day, with mostly psycho-ed or very brief behavioral interventions with limited follow up care is not my jam. I know plenty who love the fast paced environment, working in a more medicalized setting, and getting to consult on behavioral med issues, and being a bit more in the "expert consultant" role. I like my 45 minute sessions and doing traditional psychotherapy, though BHIPs seem to be run quite differently at different facilities. Big drawback in a lot of places seems to be huge caseloads and therefore not being able to do regular individual therapy appointments.

 

[cara susanna]

So PCMHI is nice because you don't really have a panel, per se, and you have open access so you don't have as many scheduled appts. You don't really discharge people and don't have to worry about them being "yours" forever. However, because of open access you could theoretically see warm handoffs the entire time, and even at the end of the day. It's very unpredictable, which is why I ended up going full time OPMH when I had the chance. I did love the 30 min appts, though!

OPMH of course, you have to worry about panel size, access, and being slammed with appts. And productivity including RVUs--RVUs are less of an issue in PCMHI because of the open access.

 

[IWillSurvive]

Is there room to do cognitive assessment or atleast screening for dementia in primary care? I did alot of that type of assessment before taking my current job so I would like to have more of that back in my clinical work if possible...

 

[psych.meout]

Is there room to do cognitive assessment or atleast screening for dementia in primary care? I did alot of that type of assessment before taking my current job so I would like to have more of that back in my clinical work if possible...

Basically just MMSE or MOCA. Just enough to know whether you need to refer to MHC or neuropsych.

As far as PCMHI vs BHIP, it really depends on what you orientation is. If you're more interested in traditional mental health, then BHIP is probably going to be a better fit. If you're more of a health psych person, PCMHI is probably better.

 

[cara susanna]

Our PCMI psychologist does capacity evaluations.

 

[deleted106747]

Our PCMI psychologist does capacity evaluations.

I think this is pretty common for PCMHI psychologists. I used to do a lot of capacity evaluations.

 

[thebalmofhurtminds]

Basically just MMSE or MOCA. Just enough to know whether you need to refer to MHC or neuropsych.

As far as PCMHI vs BHIP, it really depends on what you orientation is. If you're more interested in traditional mental health, then BHIP is probably going to be a better fit. If you're more of a health psych person, PCMHI is probably better.

I would disagree with this as a blanket rule. I'm a health psych person and I did not enjoy PCMHI much. The format certainly has its uses, but makes it very difficult to address common health psych problems (e.g. chronic pain, health behavior change).

 

[erg923]

I would disagree with this as a blanket rule. I'm a health psych person and I did not enjoy PCMHI much. The format certainly has its uses, but makes it very difficult to address common health psych problems (e.g. chronic pain, health behavior change).

I think its a commonly mistaken belief that PCMHI is a health psych thing. Its not. You can do it there, and you will certainly do it there more often there than in a general MH clinic, but it is often just a "diet MH clinic." At least that is primarily how it was used as recently as 3 years ago when I was there

 

[IWillSurvive]

How do they measure productivity in PCMHI? I've heard it's less rvu-based.

 

[Mercury in Taurus]

Is there room to do cognitive assessment or atleast screening for dementia in primary care? I did alot of that type of assessment before taking my current job so I would like to have more of that back in my clinical work if possible...

In PCMHI, I have done brief screeners, such as SLUMS, MoCA, Y-BOCS, ASRS...
We refer them to a specialty care team, neuropsych, or psychiatry if further testing needed.

 

[beginner2011]

How do they measure productivity in PCMHI? I've heard it's less rvu-based.

Based on my experience rotating through PCMHI as an intern: If I recall correctly I believe it's more clinic-wide performance evaluation, and it's a combination of percentage of same-day appointments and something else. I believe the metric has a name like "The PCMHI-5" where 5 indicates it's the fifth version of the metric. Hopefully others with more knowledge will comment.

 

[cara susanna]

Based on my experience rotating through PCMHI as an intern: If I recall correctly I believe it's more clinic-wide performance evaluation, and it's a combination of percentage of same-day appointments and something else. I believe the metric has a name like "The PCMHI-5" where 5 indicates it's the fifth version of the metric. Hopefully others with more knowledge will comment.

Yes, the metrics are more things like penetration rate (what percentage of PACT patients are being seen by PCMHI), same day access/warm handoffs, and I think they're also tracking what percentage of your appts are 30 min or less.

 

[erg923]

Yes, the metrics are more things like penetration rate

Gigitty....

 

[erg923]

So....the more primary care patients you see....the better? How does that work to anyone's benefit? I would bet that in half those patients, your consultation makes no real difference.

Seems a strange metric. How does that measure or attest to the effectiveness/prevention and cost saving element of embeddeding doctoral-level providers with in a primary care setting?

How bout percentage of patients asking for or recommended for "psychiatric consolation" instead?

 

[erg923]

Yes, the metrics are more things like penetration rate (what percentage of PACT patients are being seen by PCMHI), same day access/warm handoffs, and I think they're also tracking what percentage of your appts are 30 min or less.

I would think that the VAs greatest victory would actually be having a somewhat low-level of treatable mental aberrance within their primary care clinic visits?

This would help to justify the billions spent by DoD every year to this effect.....and attest to the effiecney of getting veterans treated by the VA system vs other systems. I mean, even as a civilian, there is nothing worse than having to go to your PCP to then just get referred for "specialty care."

 

[cara susanna]

So....the more primary care patients you see....the better? How does that work to anyone's benefit? I would bet that in half those patients, your consultation makes no real difference.

Seems a strange metric. How does that measure or attest to the effectiveness/prevention and cost saving element of embeddeding doctoral-level providers with in a primary care setting?

How bout percentage of patients asking for or recommended for "psychiatric consolation" instead?

I mean, I agree with you, but we all know the VA has to put numbers to *something*

 

[WisNeuro]

I mean, I agree with you, but we all know the VA has to put numbers to *something*

Hey now, we need jobs for random middle management types who only know how to make meaningless spreadsheets.

 

[cara susanna]

IMO another annoying thing is that the warm handoffs metric only counts same day appts. When I was in PCMHI, we had a lot of people who didn't want to stick around to talk to PCMHI the same day, and so we scheduled future appts with them. Because of that, we didn't do as well on that metric.

 

[WisNeuro]

IMO another annoying thing is that the warm handoffs metric only counts same day appts. When I was in PCMHI, we had a lot of people who didn't want to stick around to talk to PCMHI the same day, and so we scheduled future appts with them. Because of that, we didn't do as well on that metric.

Metrics don't work much better on the outside. My spouse has a potential quarterly bonus that is partially calculated by how many of her patients are smokers, among other patient characteristics. As you can imagine, these metrics vary quite a by what city you practice in, punishing providers who want to work in low SES areas with underserved populations.

 

[AcronymAllergy]

Metrics don't work much better on the outside. My spouse has a potential quarterly bonus that is partially calculated by how many of her patients are smokers, among other patient characteristics. As you can imagine, these metrics vary quite a by what city you practice in, punishing providers who want to work in low SES areas with underserved populations.

"But, like, you're a doctor, can't you just make them stop smoking? There's gotta be a pill for that."

 

[Sanman]

Metrics don't work much better on the outside. My spouse has a potential quarterly bonus that is partially calculated by how many of her patients are smokers, among other patient characteristics. As you can imagine, these metrics vary quite a by what city you practice in, punishing providers who want to work in low SES areas with underserved populations.

Sounds like they are just taking MIPS requirements and rolling them downhill.

 

[beginner2011]

Metrics don't work much better on the outside. My spouse has a potential quarterly bonus that is partially calculated by how many of her patients are smokers, among other patient characteristics. As you can imagine, these metrics vary quite a by what city you practice in, punishing providers who want to work in low SES areas with underserved populations.

How stupid of the system administrators. What a wasted opportunity to incentivize working with lower SES areas with high rates of risk factors. It'd be great to see the opportunities for the biggest bonuses going to the folks with the most complex/challenging/costly patients. Basic economic math tells you that the system benefits most from having the most effective providers working in those settings, no?

 

[Sanman]

How stupid of the system administrators. What a wasted opportunity to incentivize working with lower SES areas with high rates of risk factors. It'd be great to see the opportunities for the biggest bonuses going to the folks with the most complex/challenging/costly patients. Basic economic math tells you that the system benefits most from having the most effective providers working in those settings, no?

It has little to do with system administrators and more to do with payors. Medicare and private insurers will cut your pay if you don't meet certain quality measures that they want. Screening for tobacco and offering a cessation program is a common one. Welcome to the new age of healthcare.

https://qpp.cms.gov/docs/QPP_qualit...ures/2019_Measure_226_MedicarePartBClaims.pdf

 

[beginner2011]

It has little to do with system administrators and more to do with payors. Medicare and private insurers will cut your pay if you don't meet certain quality measures that they want. Screening for tobacco and offering a cessation program is a common one. Welcome to the new age of healthcare.

https://qpp.cms.gov/docs/QPP_qualit...ures/2019_Measure_226_MedicarePartBClaims.pdf

Theoretically, couldn't leadership structure compensation in such a way that redistributes the payor funds, based on incentivizing providers to work with high-risk pops (and ultimately increase their payor funding as a system) though? I guess that's assuming the system includes both patient populations the include both low and high tobacco use risk, which is unlikely.

 

[WisNeuro]

How stupid of the system administrators. What a wasted opportunity to incentivize working with lower SES areas with high rates of risk factors. It'd be great to see the opportunities for the biggest bonuses going to the folks with the most complex/challenging/costly patients. Basic economic math tells you that the system benefits most from having the most effective providers working in those settings, no?

As @Sanman noted, it's partially to do with payors. The company has some control over other aspects, oh which it is doing a poor job as well. That place, my former employer has a greater than average amount of churn in it's employees compared to other systems. One of the reasons my spouse is passively keeping an eye out for other jobs that meet certain parameters.

 

[WisNeuro]

Theoretically, couldn't leadership structure compensation in such a way that redistributes the payor funds, based on incentivizing providers to work with high-risk pops (and ultimately increase their payor funding as a system) though? I guess that's assuming the system includes both patient populations the include both low and high tobacco use risk, which is unlikely.

Medicare/Medicaid do not pay well, compared to many private insurers. As a matter of fact, we just closed the one hospital in our system with the highest proportion of Medicare/Medicaid clientele. This was not a coincidence.

 

[Sanman]

Theoretically, couldn't leadership structure compensation in such a way that redistributes the payor funds, based on incentivizing providers to work with high-risk pops (and ultimately increase their payor funding as a system) though? I guess that's assuming the system includes both patient populations the include both low and high tobacco use risk, which is unlikely.

Sure, but why? Higher SES folks are healthier, have better paying insurance, and come with fewer headaches. It is a better business. There is no reason a hospital system wants to deal with lower SES folks other than it has to do so to stay in business. Not to mention, leadership has no interest in trying to create a complicated system of realigning incentives for providers. They just want to get paid. If payors give them a hoop, they will give the providers the same hoop so they get their money. The nicer systems will make these hoops easy to jump through for their providers.