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

[cara susanna]

I wonder how the Supreme Court will rule.

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[WisNeuro]

I wonder how the Supreme Court will rule.

Depends, are either of the parties in litigation individuals who have bought any of the Justices an RV, or taken them on lavish vacations recently?

 

[cara susanna]

I'm reading the case materials. Granted, I'm not a lawyer, but I find this bananas. In what world do we give more weight to the treating clinician (who is biased) than the independent evaluator?

 

[WisNeuro]

I'm reading the case materials. Granted, I'm not a lawyer, but I find this bananas. In what world do we give more weight to the treating clinician (who is biased) than the independent evaluator?

Actually, this is a common tactic in personal injury/WC/disability cases.

 

[Sanman]

Actually, this is a common tactic in personal injury/WC/disability cases.

Just from my time in the VA, the amount of time treating clinician's justify things as "because it would be helpful to the patient/veteran" is astounding. Of course free money is helpful. A new boat would be helpful to my personal mental health. I don't expect the government to buy me one and I have worked for the government longer than most veterans.

 

[cara susanna]

Actually, this is a common tactic in personal injury/WC/disability cases.

Tell me more, please.

 

[WisNeuro]

Tell me more, please.

Plaintiff attorney is always going to make the case that the treating notes are the definitive opinion as they "know the claimant better," and they are always going to try to paint the independent expert as biased or a "hired gun." This is why my reports are essentially mini-theses, as I have to show all of their deviations from best practices and how their conclusions are not supported by the science.

 

[Fan_of_Meehl]

Actual differential diagnostic workups to rule in/out PTSD in the VA system are unbelievably variable in terms of their detail, validity/reliability and their quality. Basic stuff like doing a military/trauma history, verifying at least one Criterion A stressor, doing a detailed clinical interview around ostensible trauma- and stressor-related disorder sxs (and their connection to traumatic events vs. other causes and comorbidities), establishing functional impairment, onset of symptoms, etc, is almost NEVER done/documented at VA.

Usually it's people slinging PCL-5s (if that) and using 'begging the question' and 'arguments from authority': "I'm a provider and Mr. X CLEARLY has PTSD." Not even kidding.

The fundamental organizational pathology/issue is, of course the reward/punishment (incentive) structure. There is every incentive in the world to either ignore the issue or be a PTSD diagnosis "rubber stamper" while there is every disincentive to conduct a thorough, accurate, multi-modal differential diagnostic eval process that may result in actually ruling out PTSD and upsetting a veteran. The iron-clad but almost never-spoken-aloud 'rule' that you NEVER question a PTSD dx (no matter how flimsily supported) if the veteran has been service-connected for PTSD results in PTSD specialty clinics being 'haunted' for decades by treatment resistant/immune cases of "PTSD" whose sx self-reports are only worsened by trials of PE/CPT/EMDR/meds/residential stays, etc. At least until that 90% total s/c becomes a 100% P&T or TDIU with some caregiver support or aid and attendance on the side. And now, most of the PCT intakes are recently retired veterans in their late 60s and early 70s who are presenting with requests to be evaluated for PTSD right after retirement from a stellar career at the sheriff's office or fire department. I'd wager that half the local sheriff's departments are 70%+ s/c for disability, most of that being due to PTSD/MH.

I am convinced that the sickness runs too deep in the organization to ever change, short of complete collapse and privatization. I am not advocating privatization, but VA isn't going to change. 'Leaders' will watch the system collapse before they will exhibit the courage to call for accurate PTSD assessments or condone saying 'no' on occasion to a veteran. Disability compensation is going to get so out of control (there is no governor on the system right now) and 'leadership' will keep cannibalizing full time provider positions (idiotically) to help their cronies out (hooking their buddies up with those sweet, sweet GS13/14 non-clinical non-caseload-having expertologist and excellentologist positions) until access becomes so problematic and the remaining providers retire/quit that the system will grind to a halt. What happens then is anyone's guess.

 

[cara susanna]

You know that "is this...?" meme format?

I feel that way about community care and DBT. They have no idea what DBT is. I refer someone for full model and they get skills training only, or some private practice person who says they do DBT but is not full model.

 

[Sanman]

Actual differential diagnostic workups to rule in/out PTSD in the VA system are unbelievably variable in terms of their detail, validity/reliability and their quality. Basic stuff like doing a military/trauma history, verifying at least one Criterion A stressor, doing a detailed clinical interview around ostensible trauma- and stressor-related disorder sxs (and their connection to traumatic events vs. other causes and comorbidities), establishing functional impairment, onset of symptoms, etc, is almost NEVER done/documented at VA.

Usually it's people slinging PCL-5s (if that) and using 'begging the question' and 'arguments from authority': "I'm a provider and Mr. X CLEARLY has PTSD." Not even kidding.

The fundamental organizational pathology/issue is, of course the reward/punishment (incentive) structure. There is every incentive in the world to either ignore the issue or be a PTSD diagnosis "rubber stamper" while there is every disincentive to conduct a thorough, accurate, multi-modal differential diagnostic eval process that may result in actually ruling out PTSD and upsetting a veteran. The iron-clad but almost never-spoken-aloud 'rule' that you NEVER question a PTSD dx (no matter how flimsily supported) if the veteran has been service-connected for PTSD results in PTSD specialty clinics being 'haunted' for decades by treatment resistant/immune cases of "PTSD" whose sx self-reports are only worsened by trials of PE/CPT/EMDR/meds/residential stays, etc. At least until that 90% total s/c becomes a 100% P&T or TDIU with some caregiver support or aid and attendance on the side. And now, most of the PCT intakes are recently retired veterans in their late 60s and early 70s who are presenting with requests to be evaluated for PTSD right after retirement from a stellar career at the sheriff's office or fire department. I'd wager that half the local sheriff's departments are 70%+ s/c for disability, most of that being due to PTSD/MH.

I am convinced that the sickness runs too deep in the organization to ever change, short of complete collapse and privatization. I am not advocating privatization, but VA isn't going to change. 'Leaders' will watch the system collapse before they will exhibit the courage to call for accurate PTSD assessments or condone saying 'no' on occasion to a veteran. Disability compensation is going to get so out of control (there is no governor on the system right now) and 'leadership' will keep cannibalizing full time provider positions (idiotically) to help their cronies out (hooking their buddies up with those sweet, sweet GS13/14 non-clinical non-caseload-having expertologist and excellentologist positions) until access becomes so problematic and the remaining providers retire/quit that the system will grind to a halt. What happens then is anyone's guess.

I agree. However, a proper differential for PTSD is not within the scope of my job or many others in the VA and the truth is that we are not staffed appropriately for most people to receive a proper diagnostic interview. This is really the job of C&P, which the government has offloaded to the cheapest contractors they can find or the Trauma services (which usually does not have the time or staff). So, I will continue to the fastest PCL-5 slinger in the east.

 

[cara susanna]

I swear, the consult toolbox is getting to be as bad as Mental Health Suite in terms of things that are well intended but only make our lives more difficult

 

[psycho1391]

I swear, the consult toolbox is getting to be as bad as Mental Health Suite in terms of things that are well intended but only make our lives more difficult

Do you use consult tracking manager? I prefer to use that app rather than messing with consults in CPRS.

 

[Shiori]

Is there a way to stop receiving CPRS notifications for patients who are no longer on my caseload? I get so many.

 

[Sanman]

Is there a way to stop receiving CPRS notifications for patients who are no longer on my caseload? I get so many.

Are you listed as their MHTC?

 

[Shiori]

Are you listed as their MHTC?

Nope. From what I can gather, I will see notifications for them if I closed the psychotherapy consult regardless of whether or not I took them on as a client.

 

[cara susanna]

There is buzzing around my facility that our budget deficit is so high, they will likely have to cut positions in the future. Eep. Our CBOC is super busy, so hopefully it wouldn't be here.

 

[WisNeuro]

Starting to look like the VA isn't the safe haven of guaranteed predictable, easy work and a pension anymore.

 

[summerbabe]

There is buzzing around my facility that our budget deficit is so high, they will likely have to cut positions in the future. Eep. Our CBOC is super busy, so hopefully it wouldn't be here.

Our facility (which includes many CBOCs) is supposedly under a directive to cut about 100 more positions overall.

We’ve already paused/cancelled new or backfill positions that were deemed non-essential/priority.

But there’s obviously a pretty big difference in salary for an MD and an MSA so I don’t know how that is being factored into the supposed 100 FTEs that we need to eliminate.

And there are tons of non-patient care related positions like in fiscal.

If I had to guess, some of these back of the house things will be first on the chopping block so good luck ever getting a hold of somebody responsible for things like EDRP in the future if it goes in that direction.

 

[Sanman]

There is buzzing around my facility that our budget deficit is so high, they will likely have to cut positions in the future. Eep. Our CBOC is super busy, so hopefully it wouldn't be here.

Our facility (which includes many CBOCs) is supposedly under a directive to cut about 100 more positions overall.

We’ve already paused/cancelled new or backfill positions that were deemed non-essential/priority.

But there’s obviously a pretty big difference in salary for an MD and an MSA so I don’t know how that is being factored into the supposed 100 FTEs that we need to eliminate.

And there are tons of non-patient care related positions like in fiscal.

If I had to guess, some of these back of the house things will be first on the chopping block so good luck ever getting a hold of somebody responsible for things like EDRP in the future if it goes in that direction.

Yeah, the push seems to be to get rid of non-clinical folks and I am sure @Fan_of_Meehl will be happy to see some of those non-clinical folks be given clinical workloads in the future as well. I am sure some labor mapping and time studies will be conducted to see how busy folks are. That said, if you make it a terrible enough of an environment, clinicians will leave too. I have little to no concern of being fired. They can't find enough MH folks in my area to hire. That said, we are being asked to help out in areas as people are leaving or backfills are denied. If you make me miserable enough, I will go.

 

[Sanman]

Starting to look like the VA isn't the safe haven of guaranteed predictable, easy work and a pension anymore.

I'm not sure it has been easy for a long time. WWII and Korean War folks were a different breed and often easier to manage. Vietnam and gulf era veterans seem to be lower SES and larger headaches overall as far as patient management. More folks trying to live off that disability income as the economy changes. I personally found the work easier outside of the VA, but the productivity expectations were higher. That said, always look out for yourself first and save your pennies for a rainy day. This is why I have changed my thinking regarding the older model of solo private practice being better.

 

[AcronymAllergy]

I'm not sure it has been easy for a long time. WWII and Korean War folks were a different breed and often easier to manage. Vietnam and gulf era veterans seem to be lower SES and larger headaches overall as far as patient management. More folks trying to live off that disability income as the economy changes. I personally found the work easier outside of the VA, but the productivity expectations were higher. That said, always look out for yourself first and save your pennies for a rainy day.

I think Wis would agree that the typical VA patient isn't easy. I'm guessing it may be more in relation to workload expectations relative to other settings. Which I would say can of be a mix of pretty light (e.g., explicit wRVU quotas) vs. neverending (e.g., implicit pressure to always see more people and attend more meetings).

In neuropsych, for example, my expectation was 4 outpatient evals/week (no testing support) + associated feedback appointments. That was pretty much it. Not sure there are many other hospital systems that'd give a similar workload.

 

[WisNeuro]

To clarify, AA is correct, I was referencing the workload expectations. At least at the several VAs I was at, expectations were about half or less of what would be expected in an outside job. It was comical how easy it was to hit my targets.

 

[Sanman]

I think Wis would agree that the typical VA patient isn't easy. I'm guessing it may be more in relation to workload expectations relative to other settings. Which I would say can of be a mix of pretty light (e.g., explicit wRVU quotas) vs. neverending (e.g., implicit pressure to always see more people and attend more meetings).

In neuropsych, for example, my expectation was 4 outpatient evals/week (no testing support) + associated feedback appointments. That was pretty much it. Not sure there are many other hospital systems that'd give a similar workload.

You will get no argument for me regarding the productivity expectations being lower. That said, I think that is somewhat offset by the customer service demands of the VA folks. I find myself more involved with the social work issues with them that would not be my problem in private practice (ordering them VA ipads, navigating caregiver issues, transportation, referrals to community care or other programs, etc.).

IME, some of the older folks were higher SES and generally had greater resources. A lot of the Vietnam and younger folks fall into the medicaid population outside the VA.

 

[Sanman]

To clarify, AA is correct, I was referencing the workload expectations. At least at the several VAs I was at, expectations were about half or less of what would be expected in an outside job. It was comical how easy it was to hit my targets.

As AA mentioned, I really think that it depends on the job you have and the general staffing of your hospital, clinic, etc. The push towards using telehealth and the recent incentive pay increases have kept me at the VA longer than expected. If we trend back down the usual path of freezes and problems, I imagine it may be time to move on. I have a feeling the likelihood is that those of us that negotiated better terms during the pandemic will keep them for a while. Folks that want to come in now though may have a tough time of it. This is a cycle the VA has gone through a few times before. There was a freeze post 2008 and in 2017 as well. Lets see how many of those pension years I can rack up.

 

[cara susanna]

My supervisor said that they aren't going to cut existing and filled positions, after all (unfilled or open, yeah, those are gone). Apparently the deficit is so bad that even cutting hundreds of positions would barely make a dent, so it's pointless.

I'm pretty relieved. I'm not worried about getting another job, either, but I like a lot of things about my job that I don't think I could get elsewhere without moving to a new city (which is not gonna happen).

 

[Behaviorismiscool]

VA Improperly Awarded $10.8 Million in Incentives to Central Office Senior Executives

In September 2023, VA announced it had erroneously awarded millions of dollars in critical skill incentive (CSI) payments to senior executives at its central office. VA cancelled the payments, notified Congress, and requested the Office of Inspector General (OIG) review the matter.

www.vaoig.gov

 

[Sanman]

VA Improperly Awarded $10.8 Million in Incentives to Central Office Senior Executives

In September 2023, VA announced it had erroneously awarded millions of dollars in critical skill incentive (CSI) payments to senior executives at its central office. VA cancelled the payments, notified Congress, and requested the Office of Inspector General (OIG) review the matter.

www.vaoig.gov

Not really surprising. Though, it does amuse me that even the government admits it is not hard to recruit central office managers.

 

[AcronymAllergy]

Not really surprising. Though, it does amuse me that even the government admits it is not hard to recruit central office managers.

Agreed, not at all surprised. It's nice that they caught it, though. This time at least. Now if only they'd actually terminate problematic leadership as opposed to just perpetually shuffling them around between different VAs.

Edit: to be fair, I should also mention that I had many excellent supervisors/senior leaders at VA. There were also just some really, really bad ones.

 

[Sanman]

Agreed, not at all surprised. It's nice that they caught it, though. This time at least. Now if only they'd actually terminate problematic leadership as opposed to just perpetually shuffling them around between different VAs.

Edit: to be fair, I should also mention that I had many excellent supervisors/senior leaders at VA. There were also just some really, really bad ones.

At the end of the day, I am sure this was an attempt to justify additional pay and do an end run around the GS pay cap that just got bumped up to keep them competitive and it will probably cause some of the good ones to leave for greener pastures. However, most of these folks do not have specialty skills like healthcare professionals do. It is certainly harder to keep a specialty psychologist, physician, etc. employed at the VA than anyone at the business office and that is not really reflected in pay or prestige.

 

[Sanman]

My supervisor said that they aren't going to cut existing and filled positions, after all (unfilled or open, yeah, those are gone). Apparently the deficit is so bad that even cutting hundreds of positions would barely make a dent, so it's pointless.

I'm pretty relieved. I'm not worried about getting another job, either, but I like a lot of things about my job that I don't think I could get elsewhere without moving to a new city (which is not gonna happen).

Outside of general mental health clinic, I find most VA jobs are difficult to replace for like outside of the system.

 

[cara susanna]

I just heard that our Primary Care is losing staff and not able to hire replacements, and not allowed to close new referrals because of the Sprint initiative. They even took away their team meeting time because they're so swamped.

Classic Congress, make the VA take on a bunch of new patients and then underfund them

 

[Behaviorismiscool]

I just heard that our Primary Care is losing staff and not able to hire replacements, and not allowed to close new referrals because of the Sprint initiative. They even took away their team meeting time because they're so swamped.

Classic Congress, make the VA take on a bunch of new patients and then underfund them

Losing psychology staff or other positions, like nursing?

 

[cara susanna]

Losing psychology staff or other positions, like nursing?

PACT providers, so like PCPs

 

[Sanman]

I just heard that our Primary Care is losing staff and not able to hire replacements, and not allowed to close new referrals because of the Sprint initiative. They even took away their team meeting time because they're so swamped.

Classic Congress, make the VA take on a bunch of new patients and then underfund them

Par for the course and when the rest of them get sick and tired of the extra work, they will leave too. This is how the government works. Make big promises and push unfunded mandates onto others.

 

[AcronymAllergy]

Par for the course and when the rest of them get sick and tired of the extra work, they will leave too. This is how the government works. Make big promises and push unfunded mandates onto others.

Followed by VA then being forced to refer patients out into the community after enough people complain about wait times, not getting whatever meds they want, etc. So Congress yells at VA, says VA is incompetent and can't do its job, says vets deserve the best care, etc., and says, "we're going to make that happen by approving a(nother) program that gets vets into the private sector where everything is better anyway." Then patients go into the private sector, hate it (because wait times are just as bad or worse, care provided isn't better, they can be fired as patients, etc.), and want to return to VA. Quietly, in the background, Congress funds more VA positions because they knew that was going to happen, and they can then come in afterward and talk about how they fixed everything.

 

[Sanman]

Followed by VA then being forced to refer patients out into the community after enough people complain about wait times, not getting whatever meds they want, etc. So Congress yells at VA, says VA is incompetent and can't do its job, says vets deserve the best care, etc., and says, "we're going to make that happen by approving a(nother) program that gets vets into the private sector where everything is better anyway." Then patients go into the private sector, hate it (because wait times are just as bad or worse, care provided isn't better, they can be fired as patients, etc.), and want to return to VA. Quietly, in the background, Congress funds more VA positions because they knew that was going to happen, and they can then come in afterward and talk about how they fixed everything.

Except we are going to require tons of confusing paperwork for providers, reimburse poorly, and provide this poor reimbursement very slowly. What could go wrong with community care?

 

[WisNeuro]

Except we are going to require tons of confusing paperwork for providers, reimburse poorly, and provide this poor reimbursement very slowly. What could go wrong with community care?

Yeah, there is literally no reason for most of us to sign up for this in the non-VA world. Clinically, I only take a few insurances, one's that are easy to deal with and reimburse decently, and I still have a long clinical waitlist. What incentive would I have to accept a lower paying source that comes with added, non-billable, admin time??

 

[Fan_of_Meehl]

Except we are going to require tons of confusing paperwork for providers, reimburse poorly, and provide this poor reimbursement very slowly. What could go wrong with community care?

I've always wondered...do the community care providers get to bill their customary fees for, say, no-shows and last-minute cancellations? If not, then given the high rates of these by veteran outpatients, there's NO WAY it would be feasible to see a lot of veterans. If so, then that would just be added expenses for providing these services in the community vs. at VA hospitals.

 

[WisNeuro]

I've always wondered...do the community care providers get to bill their customary fees for, say, no-shows and last-minute cancellations? If not, then given the high rates of these by veteran outpatients, there's NO WAY it would be feasible to see a lot of veterans. If so, then that would just be added expenses for providing these services in the community vs. at VA hospitals.

Depends, we can't get no-show/cancellation fees from some sources (e.g., Medicare). But, due to several factors, long waitlists being one of them, my no-show/late cancel rate is extremely small for clinical patients. And, one of those patients died the week before, and another was hospitalized for organ failure the night before. SO, hasn't really been a problem in private practice. When I was in the VA, that rate was about 30%.

 

[Sanman]

I've always wondered...do the community care providers get to bill their customary fees for, say, no-shows and last-minute cancellations? If not, then given the high rates of these by veteran outpatients, there's NO WAY it would be feasible to see a lot of veterans. If so, then that would just be added expenses for providing these services in the community vs. at VA hospitals.

They can't bill customary fees to most insurance providers for cancellations or no-show. However, they can opt to not reschedule the patient unlike us. Therefore, single time occurrence. That said, many VA folks have to wait so long for a community appt , they don't miss it. Our system encourages the behavior.

 

[WisNeuro]

They can't bill customary fees to most insurance providers for cancellations or no-show. However, they can opt to not reschedule the patient unlike us. Therefore, single time occurrence. That said, many VA folks have to wait so long for a community appt , they don't miss it. Our system encourages the behavior.

My patients wait 2-3 months, many have MCI/mild dementia and still show up to their appointments, and on time.

 

[Sanman]

My patients wait 2-3 months, many have MCI/mild dementia and still show up to their appointments, and on time.

Right now, for community care mental health in some areas, the wait was 6+ mths and if you miss initial, it is bottom of the waiting list for you. Neurology in some of the more rural non-va areas is around 4 months. With my gero folks, a lot is SES and psychosocial problems. Most of those folks struggle with transportation or a reliable caregiver. I have folks that miss VA appts on the regular that don;t mess around with community care because they know the consequences are different. They miss VA VVC appts with docs because they could not bother to get out of bed and just have their PCP send a new consult. They don't need to do anything.

 

[psy.d. 2021]

OK, I think I know the answer to this...

I work in a BHIP setting, general mental health clinic at a VA. How do we effectively manage chronic no showers that keep asking to get back on our panel? More or less I was told we have to deal with it. Is this something I can effectively use in my informed consents going forward or would it be largely non-enforceable because of larger VA policy that allows for Veterans to do this without any consequences?

 

[Sanman]

OK, I think I know the answer to this...

I work in a BHIP setting, general mental health clinic at a VA. How do we effectively manage chronic no showers that keep asking to get back on our panel? More or less I was told we have to deal with it. Is this something I can effectively use in my informed consents going forward or would it be largely non-enforceable because of larger VA policy that allows for Veterans to do this without any consequences?

VA policy is that you have to take them back. That said, nothing stops you from addressing this in session and making it a goal of treatment. Usually this makes you so annoying that they prefer to be someone else's problem.

 

[psy.d. 2021]

VA policy is that you have to take them back. That said, nothing stops you from addressing this in session and making it a goal of treatment. Usually this makes you so annoying that they prefer to be someone else's problem.

I generally don't like being annoying (who does?). But you're right, I need to make it a focal point until either they a) start coming and we can do actual work on a treatment plan or b) they go away because they don't want to deal with it

 

[cara susanna]

OK, I think I know the answer to this...

I work in a BHIP setting, general mental health clinic at a VA. How do we effectively manage chronic no showers that keep asking to get back on our panel? More or less I was told we have to deal with it. Is this something I can effectively use in my informed consents going forward or would it be largely non-enforceable because of larger VA policy that allows for Veterans to do this without any consequences?

It depends on clinic local policy. We have a policy that, with two consecutive NS or cx, future appts will be cancelled and not r/s until the patient is able to demonstrate regular attendance (through Whole Health, peer support, groups, etc). They are informed of this at intake or their first appt.

Overall, there is nothing in VA national that prevents clinics from having this, it just depends on if your administration will be supportive when you get pushback or complaints.

 

[Sanman]

It depends on clinic local policy. We have a policy that, with two consecutive NS or cx, future appts will be cancelled and not r/s until the patient is able to demonstrate regular attendance (through Whole Health, peer support, groups, etc). They are informed of this at intake or their first appt.

Overall, there is nothing in VA national that prevents clinics from having this, it just depends on if your administration will be supportive when you get pushback or complaints.

Curious how they would demonstrate regular attendance if not rescheduled? Unless they are kicked to a group or something.

 

[cara susanna]

Curious how they would demonstrate regular attendance if not rescheduled? Unless they are kicked to a group or something.

Whole Health, peer support, or group.

 

[Sanman]

Whole Health, peer support, or group.

That is really the loophole that some services can use depending on what else is available. I know that in our BHIP, there are no groups and you are responsible to take them back if they return within a year or so.

 

[cara susanna]

That is really the loophole that some services can use depending on what else is available. I know that in our BHIP, there are no groups and you are responsible to take them back if they return within a year or so.

I would really encourage the clinic to revisit this policy. We are required to offer them options, sure, but they don't have to be therapy if the patient has demonstrated they can't engage. It just takes up valuable appt slots and burns out therapists. We're a CBOC with just us, no specialty mental health clinics (unless you count my 50% PCT role), and we still manage to set boundaries.

The latest policy about rescheduling efforts helps with this, too.