And Who Should Bear the Cost?
Jill Squyres, PhD
As a teenager growing up in the post Viet Nam era, I have to admit my opinion of veterans was less than flattering. When I was offered a research job at a prestigious VA Hospital when I was 22, I was excited by the research opportunity but chagrined that I would be working at a VA Hospital. However, I was favorably impressed by my experience. I grew to have a deep respect for what veterans had done for my freedom and the way of life I valued. I went on to do my clinical psychology internship at another VA hospital several years later and discovered I really enjoyed working with vets. In 1991, I was hired as a staff psychologist at the VA Hospital in San Antonio Texas. I resigned in frustration in 2002 and I am now in private practice. I take many different insurance plans in my practice, but I am proud to continue serving veterans and their families as a Tricare provider. I was shocked and dismayed to receive a letter two weeks ago informing me that my Tricare reimbursement rate, already one of the lowest among all managed care plans, was being reduced. How could they be offering to pay me less to treat veterans and their families when the need for psychological services was going up? It didn’t make sense.
I have been watching the recent news about veteran’s services with interest and frustration. When I started out at the VAMC in San Antonio, I was proud of the excellent care we provided to our patients. We were appropriately staffed with caring employees and well-credentialed professionals. Then the budget cuts began. The number of veterans needing services increased. Our documentation requirements were raised. Standards of care became more rigorous. In most settings, the logical response would have been to hire more staff to meet increased demand. Instead, my job was put on a list to be RIF-ed. The RIF (Reduction in Force) list was based solely on longevity as a civil service employee. I was explicitly told that the quality of my work, my credentials, and my expertise in my job were irrelevant. Eventually the RIF list was quietly withdrawn. The budget was balanced by instituting a hiring freeze accompanied by natural employee attrition. Unfortunately, this increased the pressure to do more with less and spread fear among us that one of our coworkers might choose to retire and leave us with twice as much work to do with 100% less help.
General dissatisfaction and complaints escalated. Wait times increased dramatically. Staff members quit and were not replaced. Some patients started hiring their own caregivers to stay with them at the hospital because the nursing staff was overworked and did not respond to their calls. The Spinal Cord Injury unit where I worked allowed family members to spend more and more time with their loved ones, otherwise paralyzed patients might not have anyone to help them eat or provide basic personal care.
We were strongly encouraged to reduce visit length and raise the number of patients seen each week. While enhanced efficiency is both responsible and desirable, increasing “numbers” at the expense of effectiveness is not. We were required to do our work with little to no administrative support. I would type my own forms and run any copies I needed, while still being expected to see more patients every day. There was no one to delegate administrative tasks to since much of that staff had already been downsized. I became very proficient at fixing the copy machine, an absurd task for a psychologist but a necessary one when I had a psychotherapy group waiting for handouts and no copies to give them.
My salary and benefits were good. I was doing meaningful work for patients who deserved the best medical care available. I was part of a great team of caring professionals. However, all the fat in the system was trimmed and we were well into the lean muscle. Without appropriate funding, even the most caring and capable professionals cannot provide quality services. Administrators can’t allocate money they don’t have in their budgets. Is it prudent for those in charge to dissemble when the truth is discouraged? My decision to resign was difficult but also prudent.
Private practice is not easy. Managed care can be frustrating. I can no longer treat patients without concern for their ability to pay. I miss that flexibility but it is a business reality. We can blame whomever we want for the troubles at Walter Reed and the VA but we, the public, need to hold up a mirror and reconsider our priorities. We cannot afford peace at any price. Our veterans should not continue to bear the cost of our freedom with frustration and substandard care. If we can find money for bombs, why can’t we find money to care for our vets after they come home? The cost of a war includes bearing the cost of care to veterans and their families. In 1865, Abraham Lincoln promised that our country would “care for him who shall have borne the battle and his widow and his orphan”. It is my fervent hope that we decide this still holds true