PhD/PsyD Veterans choice and VA services

[erg923]

This is likely and unpopular opinion/perspective, but I really am curious about this. So here goes.

With all the controversy and griping going on about the veteran's choice program, this got me thinking: Why should the VA pay a private doctor to treat non-service related medical conditions? The VA was set up to care for those who bore the battle, right? I get it. If a person puts in 2 or 3 years of honorable service there should be benefits. And there are. Training, education and a GI Bill when out of the military. But, if you are in good health when leaving the military, why should a healthcare system instituted to care for combat wounded and wartime disabled men and women take responsibility for anything occurring after military service? If you insist on using the VA then your insurance should pay the VA. If you have no insurance that is a different story. But what logical or moral argument can be made that a veteran who breaks his leg 2 years after discharge with no service connected conditions can ask the VA to pay for his medical care at a civilian provider location?

I think I am just becoming increasingly at odds with the VAs metamorphosis from a healthcare service to a welfare service.

Thoughts?

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[deleted106747]

The VA pays for it? Don't the same rules apply, just the veteran sees someone in the community?

 

[erg923]

The VA pays for it?

But thats the question. Why? If you insist on using the VA for non-service incured conditons, then your insurance should pay the VA. At least in my mind.

 

[deleted106747]

But thats the question. Why? If you insist on using the VA for non-service incured conditons, then your insurance should pay the VA. At least in my mind.

I work in the VA but am continually confused by these things, so I could be wrong, but I was under the impression that insurance does have to pay for non service connected conditions.

 

[erg923]

I work in the VA but am continually confused by these things, so I could be wrong, but I was under the impression that insurance does have to pay for non service connected conditions.

Yes, exactly! So if its not military related/incurred, then why are we obligated pay (ourselves, not the insurance company) for outside care? See my broken leg example in first post. I can see our obligation to help arrange it if we cant meet reasonable service times, but pay for it? Why?

 

[deleted106747]

Yes, exactly! So if its not military related/incurred, then why are we obligated pay (ourselves, not the insurance company) for outside care? See my broken leg example in first post. I can see our obligation to help arrange it if we cant meet reasonable service times, but pay for it? Why?

and what I'm saying is I thought that is what's happening - VA is arranging for non service connection conditions but not paying for them. No?

 

[erg923]

and what I'm saying is I thought that is what's happening - VA is arranging for non service connection conditions but not paying for them. No?

Ugh, now you got me confused. lol

I assumed when vet uses the choice program, the VA pays the chosen civilian provider out of pocket no matter what is being treated.

 

[WisNeuro]

The Veteran's Choice program is designed for those who either have to wait a certain period of time for an appointment, or they live a certain distance from a facility that can provide that care. It's not a free-for-all for patients to do whatever they want.

There is a lot of misinformation about the program, I would suggest reading up on it via the link and also checking into some of the recent changes.

 

[erg923]

Ok. So, am I understanding that if they meet one of the two criteria but the problem/condition isn't service connected, then we arrange for them to see an outisde provider, but dont actually pay for it? Then whats the purpose/benefit, just having us do the footwork of arranging the appt?

 

[WisNeuro]

I believe it's a similar process as when we fee base out services, so these networks are already in place. So yes, if we promised that we could provide certain services, but cannot adequately do so, we arrange for it to be done.

 

[CheetahGirl]

...And I heard in staff meetings, that this service is temporary (i.e., an initial psychiatric exam may be in the community) until they can get back into the VA for continuation of services. No one at our VA likes this option (which is in response to long-wait periods for the next available appointments), and in fact, they are moving appointments and schedules around to accommodate seeing some patients earlier rather than sending the Veteran out in the community for initial care. However, when the Veteran is initially displeased with the wait-times, they are offering this service and Veterans are either declining or insisting (per medical need) that they be seen sooner here. Luckily, everyone's been making it work since the plan was first implemented...at least in at my VA in the mental health departments. I don't know about primary care, etc.

 

[erg923]

...And I heard in staff meetings, that this service is temporary (i.e., an initial psychiatric exam may be in the community) until they can get back into the VA for continuation of services. No one at our VA likes this option (which is in response to long-wait periods for the next available appointments), and in fact, they are moving appointments and schedules around to accommodate seeing some patients earlier rather than sending the Veteran out in the community for initial care. However, when the Veteran is initially displeased with the wait-times, they are offering this service and Veterans are either declining or insisting (per medical need) that they be seen sooner here. Luckily, everyone's been making it work since the plan was first implemented...at least in at my VA in the mental health departments. I don't know about primary care, etc.

I am extemely out of the loop with this because I work for and in primary care, not the mental health service, and I do not have to "clear consults' because many times consults are never made to me. The doc just walks em to my office or messages me. When a consult is made, it's "cleared" by health techs when the do they phone screening for me/on my behalf. After my intial appt, which I can almost alway offer within two weeks, we settle on a freqencey for the 6 sessions if they chose to enage with me in the primary care mental health integration program. And half the initials I end up triaging to another MH service or the MHC. So, this issue has never preented itself to me.

 

[AcronymAllergy]

I am extemely out of the loop with this because I work for and in Primary care, not the mental health service and I do not have to "clear consults' because many times consults are never made to me. The doc just walks em to my office or messages me. When a consult is made, it "cleared" by health techs when the do they phone screening.

My specialty initially had a rather lengthy wait time when I arrived at my location, but we've knocked it down quite a bit since bringing on a couple neuropsychologists (myself included). In general, I haven't heard of the program being used much here; when it does come up, I want to say it's mostly with some of the specialty clinics that may only have one or two providers available to see patients.

 

[WisNeuro]

I'm only scheduled out a couple weeks for my visits in the main hospital. I see some CBOC evals that are scheduled farther out, maybe a month and a half. Good luck getting it quicker in the community though. When I used to work at a private hospital, they were scheduling out npsych evals 6 months in advance.

 

[AcronymAllergy]

I'm only scheduled out a couple weeks for my visits in the main hospital. I see some CBOC evals that are scheduled farther out, maybe a month and a half. Good luck getting it quicker in the community though. When I used to work at a private hospital, they were scheduling out npsych evals 6 months in advance.

I'm down to being a few weeks out as well, which is great. I've even been able to work some patients in within a week of their referral after cancellations.

And yeah, I don't imagine it's a whole lot different in the community, depending on how much you're willing to pay. I remember way back when in our university clinic, we also were almost always booked out at least 3-4 months, and at times up to 6-7 months.

 

[CheetahGirl]

I am extemely out of the loop with this because I work for and in Primary care, not the mental health service and I do not have to "clear consults' because many times consults are never made to me. The doc just walks em to my office or messages me. When a consult is made, it "cleared" by health techs when the do they phone screening.

So it seems that unless you cannot accommodate the Veteran within a responsible time (and this is where it is vague: within 2 weeks, because 2-6 weeks is "too long" per my understanding), then the Veteran can choose to go elsewhere in the community or just wait. Also, this has mainly been affecting psychiatry appointments...with all our staff psychologists, social workers, and interns in both disciplines, it is really only the MDs who are impacted by the super-long wait-times.

I agree with AA...this is mostly specialty clinics here too. We've had a lot of recent hires and they've been blocking days to account for the massive influx of patients lately so that wait-times are reduced.

 

[PsyDr]

I got some letter in the mail, asking me to sign up for this or something like it. The end demanded that I respond in one week. I threw it away. There was a follow up that demanded to know why i didn't respond. I thought it was pretty self explanatory.

 

[WisNeuro]

I got some letter in the mail, asking me to sign up for this or something like it. The end demanded that I respond in one week. I threw it away. There was a follow up that demanded to know why i didn't respond. I thought it was pretty self explanatory.

Sign up as a provider? Was it through HealthNet?

 

[Therapist4Chnge]

1. We go through cycles (unknown to us, but it seems to be at least once a year) where we get 25+ referrals all at once for neuropsych evals from one or more VA hospitals in the state/neighboring states. The challenge is I'm not contracted with them, and the process is a hassle. They make the process as clear as mud and respond about as quickly as you'd expect from the VA system.

2. Interspersed throughout the year are requests to do neuropsych evals for TriCare, but the restrictions are plenty (limited hours for testing & report writing) and the reimbursements are poor. I prefer to donate my time than accept such poor terms. It is the same dance every 6-8 months.

 

[Ollie123]

I think a lot of those things (i.e. "equine therapy") have some parallels to the EMDR thread. Conflation of apparent cause with actual cause where the mechanism is often something very basic that is no different from things we've been doing for years but has more bells and whistles (or collars...).

I'm not in the VA system right now and haven't been following it closely enough to comment on how the program works. I do think if a service should be provided but can't be within a reasonable time frame, its perfectly reasonable to expect the VA system to pay for it elsewhere. How exactly the multitude of "grey" in that gets handled I think is very much up for debate. I think the defense budget as a whole is out of control and is actually the first place we should be looking to trim the fat in all these budget debates as opposed to something seen as untouchable, but I definitely don't think the VA system should be where that starts. I did see incredibly profound entitlement within the VA system when I was on practicum and its one of the things that would make me very hesitant to pursue employment there. I'd like to say the good folks would make up for the bad, but I'm not convinced that is true (for me personally).

 

[eremitestar]

I like the idea in theory (it makes sense to do what we can to get people help in a timely manner), but it causes a lot of problems in practice. For one, waits don't tend to be any shorter in the community. For another, we often have appointments open up due to cancellations. This means we have people who could have been seen within 30 days if they hadn't opted for a community provider. At my VA, it winds up primarily being a major hassle for our clerks. Almost nobody opts for community providers, but the clerks have to make all the phone calls offering it anyway. And it's my understanding that the VA only pays for tx of service-connected conditions, just as they do with services at the VA.

 

[Fan_of_Meehl]

I think a lot of those things (i.e. "equine therapy") have some parallels to the EMDR thread. Conflation of apparent cause with actual cause where the mechanism is often something very basic that is no different from things we've been doing for years but has more bells and whistles (or collars...).

I'm not in the VA system right now and haven't been following it closely enough to comment on how the program works. I do think if a service should be provided but can't be within a reasonable time frame, its perfectly reasonable to expect the VA system to pay for it elsewhere. How exactly the multitude of "grey" in that gets handled I think is very much up for debate. I think the defense budget as a whole is out of control and is actually the first place we should be looking to trim the fat in all these budget debates as opposed to something seen as untouchable, but I definitely don't think the VA system should be where that starts. I did see incredibly profound entitlement within the VA system when I was on practicum and its one of the things that would make me very hesitant to pursue employment there. I'd like to say the good folks would make up for the bad, but I'm not convinced that is true (for me personally).

As a VA provider (who is scheduled for 7 to 8 hourly individual psychotherapy appointments every day) what really burns my hide lately is all the bean-count circle-jerking and barking about 'productivity' (generally taking an accusatory tone against providers and implying that we are not being productive enough) from the bureaucratic/administrative class when, for every one provider (who is actually providing services and has a full schedule) you see, I dunno, 7-10 non-provider 'support' personnel (we even have a full time 'signage' guy at our facility) who do about 20-60 min of real work per day and no one is looking at their 'productivity' at all. It's like a 200 lb. tick on a 100 lb. dog.

 

[Ollie123]

I still technically am a "practicum" student at the VA. I tried 25 times to get HR reps to call me back to process me out of the system and turn in my badge (really...I documented this and sent it to my supervisor). The only time they actually returned my call was to tell me they were going on vacation for 2 weeks. I gave up at that point and resigned myself to having permanent practicum student status there.

 

[cara susanna]

I still technically am a "practicum" student at the VA. I tried 25 times to get HR reps to call me back to process me out of the system and turn in my badge (really...I documented this and sent it to my supervisor). The only time they actually returned my call was to tell me they were going on vacation for 2 weeks. I gave up at that point and resigned myself to having permanent practicum student status there.

After less than one year of internship at a VA, I have way worse HR stories

 

[Therapist4Chnge]

I got lost in their computer system...twice. The first time I had to register twice (to access CPRS). The lady who was responsible for ALL of the interns, med students, etc....I swear she worked 3-4hr a day, max. The irony...after my internship I couldn't get OUT of the system. I kept receiving mail about my fed insurance benefits (for 1.5yr after)...very annoying to keep having to call to get it changed.

 

[Fan_of_Meehl]

We have the following (essentially clerical) annual 'peer review' procedures in place at our facility for doctoral level psychologist practitioners: 10 progress notes are reviewed and four items are rated yes/no: (1) was sucidality/homicidality documented/addressed? (it is part of our template); (2) were any abbreviations used; (3) was the note professional in tone; (4) was there an Axis I diagnosis? We are really swingin' for the fences in terms of setting the bar for professional practice pretty high, eh?

We just as easily could be focusing on real quality in terms of clinical services by, I dunno, maybe instituting a meaningful 'peer review' process (randomly selected cases reviewed by your true peers) that is non-hostile and that you can't 'fail' as long as you take the consensus feedback gracefully and demonstrate good faith efforts over time to expand you knowledge/competence in areas that are directly relevant to your clientele and your work is anchored in empirically-supported principles of behavior change.

We are required to write/complete a separate 'patient education' note (using a template that was designed for a general medical encounter) because, apparently, there was a survey that concluded that physicians/nurses were not providing patient education. So, psychologists have to do a patient education note when I still have not had anyone explain to me how the {*fluckystars*} it is even possible for a psychologist to conduct a psychotherapy session (using pretty much any therapeutic approach) and NOT provide some form of explicit or implicit 'patient education'--it is inherent to the activity itself even if you are doing breathing retraining or behavioral activation. Of course, the physicians/nurses rarely if ever do the patient education notes anymore (the original reason for this 'one size fits all' policy in the first place).

 

[PsyDr]

They wanted me as a provider. I don't remember the title of the program. It had the dod and va seals on it. The signature was from someone with a lot of government titles. I didnt care for their demands, or that they sent it to my residence.

Now that everyone is mentioning it, I was theorectically on va staff until 2013 (u.e., I quit around 2007, but they didn't do anything). I wonder if that has anything to do with it.