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Wait times worsening at the VA


By Quil Lawrence, Eric Whitney and Michael Tomsic (all connected with NPR)

Via Kaiser Health News

Veterans are still waiting to see a doctor. Two years ago, vets were waiting a long time for care at Veterans Affairs clinics. At one facility in Phoenix, for example, veterans waited on average 115 days for an appointment. Adding insult to injury, some VA schedulers were told to falsify data to make it looks like the waits weren’t that bad. The whole scandal ended up forcing the resignation of the VA secretary at the time, Eric Shinseki.

Congress and the VA came up with a fix: Veterans Choice, a $10 billion program. Veterans received a card that was supposed to allow them to see a non-VA doctor if they were either more than 40 miles away from a VA facility or they were going to have to wait longer than 30 days for a VA provider to see them.

The problem was, Congress gave them only 90 days to set up the system. Facing that deadline, the VA turned to two private companies to administer the program — helping veterans get an appointment with a doctor and then working with the VA to pay that doctor.

It sounds like a simple idea but it’s not working. Wait times have gotten worse. There are 70,000 more vets waiting at least a month for an appointment than there were at this time last year.

The VA claims there has been a massive increase in demand for care, but the problem has more to do with the way Veterans Choice was set up. It is confusing and complicated. Vets don’t understand it, doctors don’t understand it and even VA administrators admit they can’t always figure it out.

Veterans Face Delays And Worry

This is playing out in a big way in Montana. That state has more veterans per capita than any state besides Alaska. This winter Montana Sen. Jon Tester sent his staff to meet with veterans across the state. Bobby Wilson showed up to a meeting in Superior. He’s a Navy vet who served in Vietnam and is trying to get his hearing aids fixed. Wilson is mired in bureaucracy.

“The VA can’t do it in seven months, eight months? Something’s wrong,” he said. “Three hours on the phone,” trying to make an appointment. “Not waiting,” he said, “talking for three hours trying to get this thing set up for my new hearing aids.”

Tony Lapinski, a former aircraft mechanic, has also spent his time on the phone, with Health Net, one of the two contractors the VA selected to help Veterans Choice patients.

“You guys all know the Health Net piano?” he said. “They haven’t changed the damn elevator music in over a year!” That elicits knowing chuckles from the audience. Later during an interview, he said when he gets through to a person, “They are the nicest boiler room telemarketers you have ever spoken to. But that doesn’t get your medical procedure taken care of.”

Lapinski has an undiagnosed spinal growth and he’s worried. “Some days I wake up and go, ‘Am I wasting time, when I could be on chemotherapy or getting a surgery?’ ” he said. “Or six months from now when I still haven’t gotten it looked at and I start having weird symptoms and they say, ‘Boy, that’s cancer! If you had come in here six months ago, we probably could have done something for ya, but it’s too late now!’ ”

Lapinski finally got to a neurosurgeon, but he didn’t exactly feel like his Choice card was carte blanche. Doctors, it turns out, are waiting, too — for payment, he said.

“You get your procedure done, and you find out that two months later the people haven’t been paid. They have got $10 billion that they have to spend, and they are stiffing doctors for 90 days, 180 days, maybe a year!” said Lapinski. “No wonder I can’t get anyone to take me seriously on this program.”

He said he gets it. He used to do part-time work fixing cars, and he would still take jobs from people who had taken more than 90 days to pay him or bounced a check. But he did so reluctantly.

“I had a list of slow-pay customers,” he said. “I might work for them again, but everybody else came before them. So why would it be any different with these health care professionals?”

Hospitals, clinics and doctors across the country have complained about not getting paid, or only paid very slowly. Some have just stopped taking Veterans Choice patients altogether, and Montana’s largest healthcare network, Billings Clinic, doesn’t accept any VA Choice patients.

Not cool, said Montana Sen. Jon Tester, of Health Net and other contractors.

“The payment to the providers is just laziness,” Tester said. “I’m telling you, it’s just flat laziness. These folks turn in their bills, and if they’re not paid in a timely manner, that’s a business model that’ll cause you to go broke pretty quick.”

The VA now admits the rushed timeframe led to decisions that resulted in a nightmare for some patients. Health Net declined to be interviewed for this story. But in a statement, the company said that VA has recently made some beneficial changes that are helping streamline Veterans Choice. For example, the VA no longer demands a patient’s medical records be returned to VA before they pay.

Meanwhile, though, veterans continue to wait. “If I knew half of what I knew now back then when I was just a kid, I would’ve never went in the military,” said Bobby Wilson. “I see how they treat their veterans when they come home.”

Scheduling Lags Also Irk Doctors’ Offices and VA

And there’s another whole side to the coin. Doctors are frustrated in dealing with another government healthcare bureaucracy.

In Gastonia, N.C., Kelly Coward dials yet another veteran with bad news.

“I’m just calling to let you know that I still have not received your authorization for Health Net federal. As soon as I get it, I will give you a call and let you know that we have it and we can go over some surgery dates,” she told a veteran.

Coward works at Carolina Orthopaedic & Sports Medicine Center, a practice that sees about 200 veterans. Dealing with Health Net has become a consuming part of her job.

“I have to fax and re-fax, and call and re-call. And they tell us that they don’t receive the notes. And that’s just every day. And I’m not the only one here that deals with it,” she said.

Carolina Orthopaedic’s business operations manager, Toscha Willis, is used to administrative headaches — that’s part of the deal with health care — but she’s never seen something like this.

She said it takes, “multiple phone calls, multiple re-faxing of documentation, being on hold one to two hours at a time to be told we don’t have anything on file. But the last time we called about it they had it, but it was in review. You know, that’s the frustration.”

It can take three to four months just to line up an office visit.

The delays have become a frustration within the VA, too. Tymalyn James is a nurse care manager at the VA clinic in Wilmington, N.C.  She said that Choice has made the original problem worse. When she and her colleagues are swamped and refer someone outside the VA, it’s supposed to help the veteran get care more quickly. But James said the opposite is happening.

“The fact is that people are waiting months and months, and it’s like a, we call it the black hole,” she said. “As long as the Choice program has gone on, we’ve had progressively longer and longer wait times for Choice to provide the service, and we’ve had progressively less and less follow through on the Choice end with what was supposed to be their managing of the steps.”

The follow-through is lacking in two ways. The first is the lengthy delay in approving care. And after that’s finally resolved, there’s a long delay in getting paid for the care.

At least 30 doctors’ offices across North Carolina are dealing with payment problems, some that have lasted more than a year.

Carolina Orthopaedic’s CEO Chad Ghorley said his practice is getting paid after it provides the care. It’s the lengthy delay on the front end that burdens his staff and, he worries, puts veterans at risk. He’s a veteran himself.

“The federal government has put the Band-Aid on it when there’s such a public outcry to how the veterans are taking care of, all right?” he said. “Well, they’ve got the Band-Aid on it to get the national media off their backs. But the wound is still open, the wound is still there.”

Those experiences for both veterans and providers are typical. Congress is now working on a solution to the original solution, a bill is expected to clear Congress by the end of the month.

This story is part of a partnership that includes Montana Public Radio, WFAE, NPR’s Back at Base project and Kaiser Health News.

Centene completes Health Net purchase


Centene has completed its  $6 billlion acquisition of Health Net, creating the largest Medicaid managed-care organization.  California regulators’ approval of the deal paved the way for the transaction to close.

The acquisition expands Centene’s government products to include Medicare Advantage and contracts with Department of Defense and the Veterans Administration,  as well as expanding its role in the health-insurance marketplaces. The integrated company will be insuring more than 10 million members.

The Department of Justice and some state insurance departments are still reviewing Aetna’s acquisition of Humana as well as  Anthem’s  purchase of Cigna.

Even in Calif., still seeking mental-health parity


By JENNY GOLD, for Kaiser Health News


After the State of California fined her employer $4 million in 2013 for violating the legal rights of mental-health patients, Oakland psychologist Melinda Ginne expected her job — and her patients’ lives — to get better.

Instead, she said, things got worse.

Within months, Ginne, a whistleblower in the 2013 case, was back to writing her supervisors at Kaiser Permanente about what she considered unconscionable delays in care. Patients who were debilitated or dying from physical diseases for which they were receiving regular medical treatment had to wait months for psychological help, she said. Some patients, she said, might not live long enough to make the next available appointment.

“I can’t tell a family whose elderly mother is declining that I can’t provide treatment until 2014,” she wrote to her managers at the Kaiser Medical Center in Oakland in September 2013. In February, two years after assessing the second largest fine in its history, the California Department of Managed Health Care stepped in again, finding that Kaiser Foundation Health Plan had improved somewhat but still was short-changing patientson mental health care. The state is considering another fine against the health maintenance organization, which is not affiliated with Kaiser Health News.

“Every time the DMHC has an edict, Kaiser Permanente has a way around it,” said Ginne, who retired in September 2014.

California has taken perhaps the most proactive stance in the nation in enforcing laws to ensure people with mental illnesses have fair and timely access to care. But even in this state, it’s proving difficult to ensure mental patients truly have equal access to treatment. Parity laws, including a sweeping measure passed by the federal government in 2008 and an older California law, require insurers to provide mental health and substance abuse benefits on par with the coverage they offer for other medical care. And a separate state law requires insurers to provide patients with access to mental treatment within a specific timeframe – 48 hours for an urgent visit and 10 business days for a non-urgent one.

After the 2013 fine, Kaiser patients continued to face not just ongoing delays – they faced arbitrary limits on treatment in direct violation of the state’s parity statute, officials found. The law was intended to prevent such things as annual caps on patient visits that would not typically be faced, for instance, by patient with another chronic illness such as diabetes or heart disease. Yet, according to the 2015 report, some Kaiser staffers told mental health patients that they were not entitled to long-term individual therapy — ever.

“No one ever sees a therapist once a week in the Kaiser Health Plan,” according to a 2014 email a Kaiser psychologist sent to a patient, which was cited in the state’s most recent report. “Not a covered benefit for the past 20-something years and will not be a benefit in the future.”

Dr. Mason Turner, Kaiser Permanente’s associate director of regional mental health for Northern California, said that the organization has fixed the problems identified by the state. “Between the time the DMHC made their [initial] findings and now, we’ve made substantial improvements, hired many more staff, and really put into place a lot of mechanisms to address the initial concerns that were brought up,” Turner said in April.

The access problems, he said, were caused by an increase in demand, which rose in part because of the influx of new enrollees under the Affordable Care Act. In response, he said, Kaiser increased the ranks of therapists by 25 percent and arranged to contract with outside therapists when necessary.

The actions against Kaiser highlight both how far California has come in ensuring equal treatment for mental health patients and how far it has yet to go. On one hand, after many years of “abysmal” enforcement, “now we have regulators who seem to be enthusiastic,” said Randall Hagar, director of government relations for the California Psychiatric Association. Hagar gives credit to managed-healthcare department director Shelley Rouillard, who spent 20 years in consumer advocacy before joining the department in 2011 and becoming director in 2013.

On the other hand, critics say, Rouillard and her staff are making slow progress at best.

“This is one of the ‘pace car’ states, and it’s still slow going,” said Carol McDaid, who runs the Parity Implementation Coalition, an advocacy group made up of addiction and mental health consumer and provider organizations.

Holding Insurers Accountable

In challenging Kaiser Permanente in 2013, the state’s managed-care department took on one of the largest not-for-profit health plans in the country. It is a huge player in the California market, with almost 7.5 million members in the state and a net income nationally of $3.1 billion last year.

But officials soon realized the problems with unequal coverage of mental health were much broader.

For years, California, like most states and the federal government, relied on consumers to bring complaints alleging that their rights had been violated under parity laws. State regulators grew concerned that the approach was too passive — few consumers were complaining, perhaps because of the stigma attached to mental illness. So as a first step, the department last year began requiring insurers under its watch to show — at least on paper – that they were complying with federal parity law.

The results were not encouraging: Of 26 managed-care insurers, from Aetna to Western Health Advantage, zero were able to prove that they were fully in compliance. Most filed incomplete or flawed documents, state officials said.

“It is rather shocking,” Rouillard said.

Part of the problem, Rouillard said, is that the federal government did not release the final regulations dictating how its parity law should be enforced until November 2013 – five years after the law was passed.

In their review of documents, her department’s analysts found it hard to even compare mental and general healthcare because of simple errors in the way insurers documented them, such as putting data in the wrong fields, Rouillard said. But she said they also found insurers trying to control costs in ways that could be discriminatory — for example, by limiting the number of days a patient could receive inpatient care for a mental health condition.

“Mental-health services are still sort of a second class benefit as far as the health plans are concerned,” Rouillard said.

At this point, Rouillard says the managed-care plans she regulates are in varying stages of compliance with the federal parity law. Just one plan, Health Net, has so far been able to prove on paper that its benefits fully comply. Rouillard says she expects the other plans to follow suit by the end of the year, and in 2016, the department plans a more intensive review.

Charles Bacchi, President and CEO of the California Association of Health Plans, disputed that insurers see mental health as a second-tier benefit. “We’re committed to providing this coverage for our enrollees. It’s very important, and it’s something that we’re working hard to do,” he said.

But the law poses a huge challenge for health plans, he said, in part because the science underpinning diagnosis and treatment of mental illness is constantly evolving. In addition, health plans are trying to adapt not just to parity law but to the implementation of the Affordable Care Act, which has transformed the national insurance landscape.

Even so, he said, “I think by the end of this year, all the plans will have filed the right documents and will have approval from the department, and this will be something that’s in the rearview mirror.”

‘Your Hands Are Tied’

In her psychiatry department, Ginne felt she was in a good position to compare patients’ access to mental-health treatment with other care. Many of them suffer from neurological or terminal diseases with psychological components – Alzheimer’s, for instance, or Parkinson’s.

“I could see from their medical charts that they were receiving all the medical care that they needed,” Ginne said. “We couldn’t do that in psychiatry because we were so severely under-staffed.”

Finding that her situation did not improve even after the first investigation and fine, Ginne made a request of her managers — copied to Rouillard – in December 2013. She asked that six of her sickest patients be transferred to other providers who could see them more frequently. One of them, an elderly man with dementia and depression, was hallucinating “fully-formed humans,” Ginne said in an interview.

One day, he wandered down the block at 5 am in his pajamas, panicked, and flagged down a truck driver who called the police.

“He was a danger to himself,” Ginne said.

According to Ginne, the backup in appointments meant she could see him for individual therapy only once every few months. The man had been assigned to regular group therapy, she said.

But because Kaiser did not have a session for dementia patients, he was in a depression group, which Ginne felt was inappropriate for his condition.

When her supervisors did not transfer the man to another individual therapy provider, Ginne reported the case to Adult Protective Services, because she said she believed him to be imminent danger.

It was “such a bad solution,” she said, shaking her head. Ultimately, he and his wife decided to quit therapy entirely.

“It does something to your spirit to realize your hands are tied, that you are completely unable to do the work you’re dedicated and trained to do,” Ginne said.

The follow-up report released by the DMHC in February 2015 found Kaiser had improved its tracking of mental health patients but still had serious problems in the area of access to care. In one case, a sexual assault victim diagnosed with post-traumatic stress disorder and major depression tried to schedule both individual and group therapy visits, but her psychiatrist told her to seek private therapy in the community at her own expense.

According to the doctor, “weekly individual therapy was not available in the Plan, and Plan group therapy did not address sexual assault.” The patient was eventually able to schedule an appointment with a Kaiser therapist — five months after her initial visit, the report said.

In another case cited by the report, a child with aggressive and sexualized behaviors at both home and school was brought in by her family in crisis. After an initial intake visit, the child was not seen for therapy until seven weeks later, though the medical chart indicated that the family had pleaded for treatment.

Rouillard said that many insurers have a long way to go to ensure fair and equal access to mental health care for Californians. But she also said there’s only so much her department can do. Access to care at companies such as Kaiser is also an issue of capacity – and that’s not within the department’s purview, she said.

“There just aren’t enough therapists to see everyone who needs help,” she said. “It isn’t just a plan problem; it’s a societal problem. And that is really the crux of the matter. We’re trying to address a problem that is beyond our ability to fix, and that is a challenge.”

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