What's going on with the VA?

[Sanman]

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Maybe we can continue this conversation in another thread:

Conversation on social justice and the role of psychologists



How do you see MFA hurting psychology? I could see it reducing demand for psychologists and increasing demand for masters level providers, but I don't believe that necessarily hurts psychologists. All the psychologists doing independent practice in metro areas that I know are denying/referring upwards of 10+ people per week. I see MFA as a having at most a marginal cost for some psychologists in some areas, and for the vast majority a net-neutral effect. Aware of my practical ignorance here.

Do you know any metro area psychologists accepting Medicare? In major metros most don't because the economic don't work. In major metros it is often cash only. I will be brief because I brought this up in the U.S. healthcare thread:

In the last 5 years Medicare has done 3 things:

1. Increased audits of practices for fraud and installed private companies to help manage costs, aka poorly done utilization review based on billing

2. Increased overhead costs across the board by requiring EHR and reducing reimbursement for not doing extra paperwork in the form of quality measures. This hit medical practices first in 2019 and caused many physicians to close and take hospital jobs or employment. We get hit in 2021.

3. Cut mental health reimbursement 8% for 2021 to pay physicians more for E/M codes.

Additionally, medicare has a clause that if you take Medicare in one context (day job), you can't refuse it anywhere (side private practice).

Currently, many practitioners manage these problems by limiting or refusing medicare patients. Is that feasible under MFA? If not, it will kill a lot the PP work in psychology. Sure, there will be a minority of metro folks that are cash only, but anyone accepting insurance will take a hit and there will be more people opting to use their insurance benefits and not pay cash. How is that good for us?

 

[cara susanna]

Soo most of what I would have said has been mentioned already (Fan of Meehl, do we work at the same clinic? lol). Basically, it's that the VA's decision making is politically, and not clinically, driven. You are at the whims of politicians and administrators who aren't in the "front lines" deciding things based on pretty sounding concepts. There's also an obsession with access at the expense of actual clinical care. You know that Simpsons meme where Homer looks good in the front but then it shows his fat is all clipped up behind him so you can't see it? That's the VA's approach to access in a nutshell. Lately too our administration has become really focused on RVUs. As someone who specializes in treating PTSD, which is generally associated with high no show and cancellation rates, that's been stressful.

Also, yeah, the constant issue with benefits and patients that just aren't motivated for psychotherapy yet still entitled to access it. Infantalization and fragilization of our population goes along with that.

 

[Sanman]

Soo most of what I would have said has been mentioned already (Fan of Meehl, do we work at the same clinic? lol). Basically, it's that the VA's decision making is politically, and not clinically, driven. You are at the whims of politicians and administrators who aren't in the "front lines" deciding things based on pretty sounding concepts. There's also an obsession with access at the expense of actual clinical care. You know that Simpsons meme where Homer looks good in the front but then it shows his fat is all clipped up behind him so you can't see it? That's the VA's approach to access in a nutshell. Lately too our administration has become really focused on RVUs. As someone who specializes in treating PTSD, which is generally associated with high no show and cancellation rates, that's been stressful.

Also, yeah, the constant issue with benefits and patients that just aren't motivated for psychotherapy yet still entitled to access it. Infantalization and fragilization of our population goes along with that.

The RVU thing is stupid ,IMO. You have patients incentivized to be sick that dont want to do real work. Add in therapists pressured for RVUs and you get a social club for "supportive therapy" chit chat that costs a lot of money.

 

[cara susanna]

The RVU thing is stupid ,IMO. You have patients incentivized to be sick that dont want to do real work. Add in therapists pressured for RVUs and you get a social club for "supportive therapy" chit chat that costs a lot of money.

Yup! We're actually being pressured to do more groups because more RVUs. And treatment groups here are not well attended so guess what kind of groups we would need...

Also, should I be punished for efficiency and brevity during my sessions? One thing I miss about PCMHI.

 

[thebalmofhurtminds]

Yup! We're actually being pressured to do more groups because more RVUs. And treatment groups here are not well attended so guess what kind of groups we would need...

Also, should I be punished for efficiency and brevity during my sessions? One thing I miss about PCMHI.

Don't get too nostalgic. We're now getting criticized when we don't have enough same day access. As if that's something we can control.

 

[cara susanna]

Don't get too nostalgic. We're now getting criticized when we don't have enough same day access. As if that's something we can control.

We have a provider dedicated to just same day access for that purpose. Before that we were also criticized.

 

[WisNeuro]

Have I mentioned lately that I don't miss the VA 😉

 

[erg923]

We have a provider dedicated to just same day access for that purpose. Before that we were also criticized.

Thought that was what PCMHI was partly for?

 

[thebalmofhurtminds]

I meant specifically that we weren't getting enough Veterans for same day access. We had providers dedicated to it.

 

[cara susanna]

Thought that was what PCMHI was partly for?

Our PCMHI is in another building so that provides some obstacles. Plus they follow the national model pretty strictly, so they won't see patients if they aren't referred from PACT or aren't established with our CBOC's Primary Care (and not all of our patients are).

I meant specifically that we weren't getting enough Veterans for same day access. We had providers dedicated to it.

Lol, they really need to decide if they want access or full utilization. We can't have both.

 

[erg923]

Our PCMHI is in another building so that provides some obstacles. Plus they follow the national model pretty strictly, so they won't see patients if they aren't referred from PACT or aren't established with our CBOC's Primary Care (and not all of our patients are).

Lol, what? The whole idea of primary care mental health is open access, no "referrals" should be needed, etc. Why would a provider care if they were "established" with primary care or not. Has PCMHI changed in the past 3 years?

 

[thebalmofhurtminds]

Lol, what? The whole idea of primary care mental health is open access, no "referrals" should be needed, etc. Why would a provider care if they were "established" with primary care or not. Has PCMHI changed in the past 3 years?

Well, the first part of PCMHI is Primary Care to be fair...

 

[erg923]

Well, the first part of PCMHI is Primary Care to be fair...

Not really. It suppose to be an integration of the 2. Why does the order of establishing services matter? Just get them connected with primary care as part of your appt? There is no logical reason a PCMHI clinician cant see a walk-in just because they dont have an already assigned PC doc. That's just silliness.

 

[thebalmofhurtminds]

Not really. It suppose to be an integration of the 2. Why does the order of establishing services matter? Just get them connected with primary care as part of your appt? There is no logical reason a PCMHI clinician cant see a walk-in just because they dont have an already assigned PC doc. That's just silliness.

I mean, I agree with you. Just thinking with VA logic.

 

[cara susanna]

Lol, what? The whole idea of primary care mental health is open access, no "referrals" should be needed, etc. Why would a provider care if they were "established" with primary care or not. Has PCMHI changed in the past 3 years?

It must have. Back when I did PCMHI I attended a regional training and it was emphasized that referrals come from Primary Care only. We didn't take referrals from OPMH.

 

[erg923]

It must have. Back when I did PCMHI I attended a regional training and it was emphasized that referrals come from Primary Care only. We didn't take referrals from OPMH.

1. We did, cause the OPMH providers were usually booked solid, so we filled in the walk-in gap. Just stabilization/triage/problem solving, not ongoing treatment or more than one session usually.

2. There were no referrals (in CPRS, if thats what you meant) for PCMHI when I was there. It was all hand-offs and such when I was there. The idea that you can't access brief MH services (especially in a pseudo crisis situation) because you don't already have a established primary care doctor seems bizarre and the antitheses to Primary Care Mental Health Integration. If they don't have a primary care provider when they come to the clinic, I'll would just get them one. Its not that hard and doesn't take that long, really.

 

[Sanman]

Not really. It suppose to be an integration of the 2. Why does the order of establishing services matter? Just get them connected with primary care as part of your appt? There is no logical reason a PCMHI clinician cant see a walk-in just because they dont have an already assigned PC doc. That's just silliness.

It's a protecting your time thing that is part of an ongoing departmental turf war, imo. Especially when case loads are bursting at the seams. HBPC follows the PCMHI model as well. MH is pushing for all of us to take on additional work to stem the tide in the Mental Health Clinic. PCMHI and HBPC/GEC management are attempting to protect clinician time to ensure open and timely access to the clinics under their purview. I was the object of a bit of this wrestling match when I first started. As HBPC is not subject to traditional productivity metrics, I was on the side that meant less work and stress for me.

 

[erg923]

It's a protecting your time thing that is part of an ongoing departmental turf war, imo. Especially when case loads are bursting at the seams. HBPC follows the PCMHI model as well. MH is pushing for all of us to take on additional work to stem the tide in the Mental Health Clinic. PCMHI and HBPC/GEC management are attempting to protect clinician time to ensure open and timely access to the clinics under their purview. I was the object of a bit of this wrestling match when I first started. As HBPC is not subject to traditional productivity metrics, I was on the side that meant less work and stress for me.

Ok, yes. But when I did PCMHI, I was twiddling my thumbs for a couple hours many days (2-4 30 minute open access slots). There is no reason to have such a ridiculous policy of someone cant see a dedicated MH provider because said provider happens to work in the primary care clinic(s) and the patient doesn't have a primary care provider. That's silly. Figure that **** out later or after the encounter. Again, it suppose to be integration....not "one has to be done before the other."

I think focus and/or policy may have changed in the past 3 years? I think you came on right when I was leaving?

 

[Fan_of_Meehl]

Just found out today that they're not going to fill/renew the psychologist (clinical) position at my facility that has just been vacated by a psychologist moving on to a Workplace Violence Coordinator position (non-clinical position). So, we're down another full-time outpatient provider position. It's like watching the slow motion ******ed suicide of the organization.

 

[erg923]

Just found out today that they're not going to fill/renew the psychologist (clinical) position at my facility that has just been vacated by a psychologist moving on to a Workplace Violence Coordinator position (non-clinical position). So, we're down another full-time outpatient provider position. It's like watching the slow motion ******ed suicide of the organization.

What, lol? Get alot of "violence" there? Call da cops...and maybe look at policy and root cause stuff. You need a dedicated "psychologist" for that? Wonder how many "Workplace Violence Coordinator" positions that have at our local ERs and university hospitals. Only in the VA. Goodness.

 

[Fan_of_Meehl]

What, lol? Get alot of "violence" there? Call da cops!

Right. I have been here 8 years and haven't even heard of an incident of physical violence ever occurring (once) between employees here but, apparently we need a full time clinical psychologist to work on 'preventing' an occurrence that...never...even...occurs and abandoning a FTE clinical position/caseload.

But I'm sure they will use a 'broad' definition of 'violence' to include off color remarks/jokes, 'manspreading,' and/or using non-preferred pronouns or, I dunno, forgetting the secretary's birthday or something.

 

[cara susanna]

1. We did, cause the OPMH providers were usually booked solid, so we filled in the walk-in gap. Just stabilization/triage/problem solving, not ongoing treatment or more than one session usually.

2. There were no referrals (in CPRS, if thats what you meant) for PCMHI when I was there. It was all hand-offs and such when I was there. The idea that you can't access brief MH services (especially in a pseudo crisis situation) because you don't already have a established primary care doctor seems bizarre and the antitheses to Primary Care Mental Health Integration. If they don't have a primary care provider when they come to the clinic, I'll would just get them one. Its not that hard and doesn't take that long, really.

That's a bit complicated here because we have other nearby CBOCs where they may be established with Primary Care. Some of our patients travel a long ways to come here for MH.

 

[Sanman]

Ok, yes. But when I did PCMHI, I was twiddling my thumbs for a couple hours many days (2-4 30 minute open access slots). There is no reason to have such a ridiculous policy of someone cant see a dedicated MH provider because said provider happens to work in the primary care clinic(s) and the patient doesn't have a primary care provider. That's silly. Figure that **** out later or after the encounter. Again, it suppose to be integration....not "one has to be done before the other."

I think focus and/or policy may have changed in the past 3 years? I think you came on right when I was leaving?

Not sure how it is elsewhere, but a lot our PCMHI folks are otherwise full and referring to community care. The new solution to improving utilization seems to be telehealth (got a free hour or a no show; call them and do it via tele-health, woohoo). Besides, you need thumb-twiddling time to spend 3 hours in the middle of the day on the departmental and committee meetings that they insist are an integral part of my job. Also, how else would I find time to post on SDN?

 

[erg923]

Not sure how it is elsewhere, but a lot our PCMHI folks are otherwise full and referring to community care. The new solution to improving utilization seems to be telehealth (got a free hour or a no show; call them and do it via tele-health, woohoo). Besides, you need thumb-twiddling time to spend 3 hours in the middle of the day on the departmental and committee meetings that they insist are an integral part of my job. Also, how else would I find time to post on SDN?

Population health based utilization review metrics. Not a novel concept in the rest of the world. 🙂 If you can fund a "Workplace Violence Coordinator" ...I mean come on?

And after a year in the VA, I went to 2 meeting per month (the staff psychologist meeting and the PCMHI meeting). When I was confident other BS meetings didn't reflect on my performance review, I stopped going. Someone has to make the sausage....

 

[Sanman]

Population health based utilization review metrics. Not a novel concept in the rest of the world. 🙂 If you can fund a "Workplace Violence Coordinator" ...I mean come on?

And after a year in the VA, I went to 2 meeting per month (the staff psychologist meeting and the PCMHI meeting). When I was confident other BS meetings didn't reflect on my performance review, I stopped going. Someone has to make the sausage....

Sorry the VA only does Politically driven lobby based utilization review metrics. They also manage to get themselves in trouble with being both over (No access ready and waiting) and under (Lazy government employees) utilization all at the same time. God bless bureaucracy, the great job creator.

 

[AcronymAllergy]

Ok, yes. But when I did PCMHI, I was twiddling my thumbs for a couple hours many days (2-4 30 minute open access slots). There is no reason to have such a ridiculous policy of someone cant see a dedicated MH provider because said provider happens to work in the primary care clinic(s) and the patient doesn't have a primary care provider. That's silly. Figure that **** out later or after the encounter. Again, it suppose to be integration....not "one has to be done before the other."

I think focus and/or policy may have changed in the past 3 years? I think you came on right when I was leaving?

MH is now required to see walk-ins, so that might also have something to do with it. Almost all of the providers in MH at my clinic, for example, have open access slots built in to their clinics.

 

[Aleaz]

Ok. I'm an Army surgeon wounded in Iraq and forced retirement due to injuries. I get MY care at the VA mostly so have both sides to see.
CONS:
1. UNDERpaid=poor quality docs or foreign docs who cannot get a job anyplace else.
2. SOME docs are there because they love tx. Veterans and are great docs. They have a TERRIBLE time because they end up towing the rope for the lazy-*ss docs who could care less--and then those lazy *ss docs complain about them--and they get into hot water with Admin!!! I have gone to bat for several caught this way. If the new 'system' gets rid of those good docs it will go into the garbage.
PROS:
1. For training? It is stellar for psychology/psychiatry due to the extremely high PTSD and mental health issues of returning vets from all our wars--not just Iraq/Afghanistan. Huge patient load, lots of getting your hands dirty. You can find a job ANYWHERe after the experience at the VA.

As a aside--if you think working there is a drain, a pain, etc--PLEASE LEAVE. We vets gets enough bull. I actually had a female doc TELL me, "You could not have been wounded in Iraq because women are not in combat." (by 2014 over 200 women had died) For the first and only time in my life, I told a doc to FU and walked out and never went back to the Woman Clinic. THAT is how many of us are treated daily there. So if you are contributing to the unhappy, whiney crowd, for our sakes--leave and work elsewhere. But if you really want to learn, see ful blown PTSD and try and help? STAY and learn.

 

[WisNeuro]

Many of has seen plenty of full blown PTSD, some of it at the VA. Many of us have also seen malingered PTSD, much of it at the VA.

The VA in general has better MH providers than most other systems, in general. Not sure how long it'll stay that way, though.

 

[cara susanna]

Most of us like our patients and working with them, at least for the most part. It's the administrative stuff that burns us out.

Also, it would be nice if I got to set more limits with my patients. You know how PT is allowed to discharge if patients aren't doing their exercises at home? I envy that.

 

[PikminOC]

A response to my direct inquiry about 'what would be (even in theory) considered (by admin, my supervisors) an upper limit to panel size or caseload numbers' I was told...wait for it...

"It is every clinician's responsibility to manage their caseload."

Arithmetic doesn't matter. Numbers don't matter; logic doesn't matter.

Rate of patient flow in compared with time needed to process them 'out' (even with an idealized '12 weeks to cure') framework...doesn't matter.

No VA functionary (supervisor, admin, or day-to-day bureaucrat) is able or willing to have a meaningful conversation about arithmetic (yet they babble on about 'metrics' all the time to the point of a numbers fetish). They can't even handle conversations such as 'I spend an entire day doing other duties in a different clinic, so only, 4 out of five (or 80 percent of days) are available for me to see patients in this particular clinic. Therefore, my 'productivity' estimates need to be adjusted to 80 percent of 100 percent for that reason.' The probability that they can conceptualize or follow along with a discussion of a dynamic system where numbers are constantly in flux (patient inflow vs. outflow) is nil.

They are not even willing to commit to, 'sure, more than 5000 people in your caseload would be too many for you to properly treat/handle.'

Welcome to the VA.

M4A sounds like it will be great too