Is the VA Mental Health Scheduling System Gamed? Senators Seek Audit

by U.S. Medicine

January 10, 2012

WASHINGTON — Frustrated by the numerous reports of veterans unable to receive timely mental healthcare at VA facilities, legislators have called for the VA Office of the Inspector General to conduct a formal audit of wait times.

Sen. Patty Murray (D-WA)

In a letter to the VA IG, Sen. Patty Murray,  (D-WA) chairwoman of the Senate VA Committee and Sen. Richard Burr (R-NC), the committee’s ranking Republican, raised issues that have emerged in recent hearings.

Most notably, they are concerned about the contradiction between what VA staffers in the field are saying about their difficulties in getting expeditious care to veterans compared with the more optimistic tone VA officials have taken with Congress.

The senators specifically asked for an investigation of how accurately VA was tracking wait times.

“[Does] wait-time data VA collects represent an accurate depiction of veterans’ ability to access those services?” Murray and Burr wrote in their letter. “In addition, we ask that your office evaluate whether VA is accurately and completely reporting the data they collect.”

They have asked VA officials to fully cooperate with any forthcoming audit, and VA has agreed to do so.


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Long Wait Times, Short Staffing

The call for an investigation into VA wait times came after the latest Senate hearing on VA mental healthcare, in which VA provider testimony was in sharp contrast to that of VA leadership. The suggestion was that some VA schedulers were “gaming” the system to meet first-appointment requirements at the expense of quality of care for new and existing patients.

“Due to chronic short staffing at my facility and the inability to manage my patients’ appointments based on their individuals needs, I am frequently frustrated by my inability to provide care,” said Michelle Washington, PhD, coordinator of PTSD services and evidence-based psychotherapy at the Wilmington, DE, VA, who testified on behalf of the American Federation of Government Employees.

Several types of PTSD treatment are dependent not only on getting the patient into therapy as quickly as possible. but also making sure that the servicemember receives regular, usually weekly, treatment.

“But, too often I am told the patient will need to wait up to six weeks for an initial appointment,” Washington said. “Frequently the patient loses interest, or their PTSD worsens.”

Schedulers at the Wilmington VAMC are under huge pressure to make first appointments within the 14-day window set as a systemwide goal by VA headquarters. As a result, the treatment of current patients is sometimes sacrificed to meet that goal.

“They may take one of my regular PTSD patients’ appointments to fill this new patient’s appointment,” Washington said. “This hurts the effectiveness of my patient’s treatment.”

In addition, patients who have finished their courses of treatment sometimes stay on her roster for much longer than needed, due to the difficulty in making timely referrals to other VA physicians, Washington said. These patients take up slots that are desperately needed for new patients coming into the system.

One part of this problem, according to Washington, is the very low staffing of primary-care physicians assigned specifically to new veterans. Another is the lack of freedom that clinicians have in directing the course of care for each patient, either due to VA policy or to lack of resources, she said.

“As long as providers have little say in where and when to help patients, this will keep happening,” Washington told the committee.

That these staffing and scheduling issues could directly affect the efficacy of PTSD treatment was reinforced by Col. Charles Hoge (ret.), who directed the military’s research into PTSD from 2002 through 2009.

“Treatment is 70% to 80% effective for combat-related PTSD, if the veteran comes in for care and receives a sufficient number of sessions for treatment,” Hoge said. “And having coordination with primary care — having access to mental health as part of primary care — is really critical in the treatment of veterans.”

Is the VA Mental Health Scheduling System Gamed? Senators Seek Audit Cont.

Gaming The System

Legislators were particularly disturbed by one practice at the Wilmington VAMC, revealed by Washington. She said a veteran’s first appointment is frequently used only to gather background information and often involves little to no discussion about possible courses of treatment.

Richard Burr

“They may get in within that 14-day window, but it’s just for consultation and getting background information,” Washington said. “A first appointment can be a month to six weeks, easily.” 

When VA leaders testified later in the hearing, Murray asked them to respond to Washington’s testimony. “Do you think facilities are gaming the system and not fully reporting wait times?” Murray asked Mary Schohn, VA director of mental health operations.

“VHA does not condone gaming of any sort. I am not aware of particular facilities doing anything of the kind, and if I were I would react immediately,” Schohn said. “We are engaged in auditing to ensure that’s not happening.”

Having a background-gathering session count as a patient’s first appointment to fulfill VA regulations is not how the VA policy is written, Schohn added. “I don’t know about Wilmington, but that’s something I certainly want to follow up on. That’s not the expectation of how services are to be delivered.”

Despite that, the problem of long wait times and lack of physician resources is not limited to a few VAMCs. In July, Murray requested that VA survey their frontline mental-health professionals about whether they have sufficient resources to get veterans into treatment.

VA did so and found that nearly 40% of providers said they cannot schedule an appointment in their own clinic within that 14-day window, and 70% said they did not have adequate staff or space to meet the needs of veterans.

According to an IG report published earlier this year, only 16% of VA facilities visited by IG investigators met their staffing requirements for mental healthcare.

At a committee hearing in May, Antonette Zeiss, PhD, VA’s mental health chief, testified that VA had enough mental healthcare resources to serve its patient population. At this recent hearing, Murray asked Zeiss if she had a different answer.

“I believe we have unprecedented resources, and we’ve gotten them out to the field and we’ve hired and enormous number of staff,” Zeiss said. “And at the time, I believed they were adequate, if used in the most effective ways possible.”

VA is continuing to see an increase in mental-health patients, partially due to increased outreach by the agency, Zeiss said. The department will “aggressively follow all the data” to ensure they have effective predictions of how much funding and staffing is needed.

Legislators questioned whether policy at the top level will have a big enough impact on the needs of specific facilities.

“According to wait-time data provided by VA, veterans at the Spokane VA in my home state wait an average of 21 days for an appointment with a psychiatrist, with the maximum wait time being 87 days. I’ve been told that all of the psychiatrists in Spokane are booked solid for several months,” Murray told Schohn. “I’m very disturbed on the disconnect between providers and your testimony on the wait time issue.”

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