TRANSCRIPT Depresh Mode Ep. 181: Mysterious Cancellations Block Veterans’ Mental Health Care

[00:00:00]

John Moe: A note to our listeners, this episode contains references to suicide.

The war in Afghanistan lasted 20 years, the longest in American history. It overlapped with the war in Iraq, which lasted nearly 9 years. Before that, there was another much shorter war in Iraq. But that’s not all. While there aren’t a lot of World War II veterans around, there are Korean War vets with us, and a lot of veterans from the Vietnam War—the second longest war in US history.

And the thing about war is that, certainly from a mental health perspective, it’s hell. So, you have a whole lot of veterans in rough shape—with psychic wounds, with lasting damage from the things that they’ve experienced. And you have a government that put them there and has the responsibility of taking care of these veterans. That’s why the Veterans Administration is there, and the VA Medical Centers, and telehealth conducted by the VA. It’s a big system. A whole ton of appointments. All these scheduled appointments.

And there’s a problem. Because many of these appointments are being cancelled. And it’s hard to tell why. The upshot is that veterans aren’t getting the care they need. So, what’s going on?

It’s Depresh Mode. I’m John Moe. I’m glad you’re here.

Transition: Spirited acoustic guitar.

John Moe: The website Military.com, with the assistance of the Pulitzer Center, recently conducted an investigation into reports of a rash of cancelled appointments for veterans seeking mental health treatment, especially through telehealth. Military.com ran a recent article about this. It was headlined, “Canceled Appointments, Unexplained Mix Ups, Veterans Facing Challenges Getting VA Mental Health Care”. Reporter Patricia Kime explained that some veterans, unable to get the care they need to which they are entitled, are now going to platforms like BetterHelp and paying out of pocket. Others are simply going without. Which is bad.

Transition: Spirited acoustic guitar.

John Moe: Patricia Kime, welcome to Depresh Mode.

Patricia Kime: Well, thank you for having me. I’m excited to be here.

John Moe: It’s a fascinating story and a kind of upsetting story that you’ve written about this situation with the VA. What’s a typical situation that veterans are finding themselves in that you found when looking for help with mental health?

Patricia Kime: Well, I hear it quite a bit. The story is largely about, in the past several years—beginning with the pandemic, obviously a lot of appointments were canceled. But repeatedly veterans that we spoke to were finding that appointments—their appointments for mental healthcare were just randomly cancelled by facilities or their providers. Often with no explanation or—you know, even so badly—not beforehand. You know, the lead gentleman in my story, you know, several times would go do a telehealth appointment, and just nobody would be there.

I think we’ve all been there where we’re wondering is it our equipment? You know, is something wrong? Is there a problem on the other end? But in this case, and several cases of his and then other veterans I spoke to—you know, they would get a message like halfway through, like a text message or a pop-up message that would say, “Oh, your appointment’s been canceled.”

So, for veterans who have, you know, taken the steps to try to get some mental health support, it’s a terrible situation.

John Moe: And was this unique to mental health patients? Was this happening to physical therapy appointments too?

Patricia Kime: You know, we concentrated on mental health, because that was sort of our focus for the story, but I have received a lot of mail since the story ran of appointments being canceled for physical appointments and, you know, just all sorts of things—needed cardiology appointments or definitely PT. In that case, a lot of times it’s likely provider shortage. It could be that—one of the interesting things I learned through this process was that a lot of VAs just have the amount of staff that they can handle, and they don’t have any extras. So, the backup—if somebody goes on vacation or they get sick, you know, there’s not a lot of backup. There’s no coverage. There’s no teamwork of like, “Hey, I’ve got to be out; can you take my patients?” kind of situation.

[00:05:00]

John Moe: Right, right. Well, how—? I mean, the stories that you tell of people waiting for an appointment—which is not easy for a lot of people to schedule an appointment, not easy to keep an appointment, and then not easy to hang in there and then only to have it canceled. I mean, that could be really discouraging, to the point where people aren’t going to end up getting any treatment that they desperately need.

The stories are heartbreaking. How widespread is it? I imagine this isn’t just a collection of anecdotes, but this is a real, systemic problem.

Patricia Kime: Well, we did—you know, we took a look at the data. It’s hard to really pin down, you know, the reason behind the data. But we found—you know, obviously early in the pandemic, according to the VA—you know, I forget what percentage. It was in 2020, if you factor in all the early cancellations for COVID, the pandemic, the cancellation rate by facility was 12%. That’s down to, according to the VA, a little over 8% as of this year, this fiscal year. So, it’s declined, but there is some data out there. I wrote that the Americans for Prosperity Foundation had done a FOIA looking for this kind of data, and they filed a lawsuit over it.

And they looked at 14 sample facilities and found that, on average, the cancellation rate by facility was like almost 21%. Which is, you know, 1 in—almost 1 in 4. So, that’s for mental health appointments. That’s not good.

John Moe: Was there—? And I saw that you had gathered information from other groups as well as doing your own research. And is there a—ugh, I hate to ask it, and I hate to—I’m not sure how to phrase it. But is there a political motivation behind some of these groups to find more flaws happening within the Biden administration?

Patricia Kime: Yeah, I mean, to be honest, that is one of the theories as to why that VA might not want this data out there. They might want to cover it up. I mean, it’s obvious. I think people realize that the Americans for Prosperity Foundation—which is also affiliated with Concerned Veterans for America, which is a proponent of more access to private care for veterans—that is definitely a conservative leaning—

John Moe: So, they’re opposing the VA itself to some extent.

Patricia Kime: Yes. I mean, they say they don’t. I mean, you know, I know the folks over there pretty well. You know, their pitch and what they say is they want the best care for veterans wherever. Like, if it’s at VA, they should be able to get it at VA without waiting. If it’s in private care, they should be able to get it in private care. So, that is their pitch. It is a conservative talking point. So, yes, there are political motivations to everything. I mean, there’s political motivations in Washington and everything, right?

John Moe: I suppose so. (Chuckles.) Yeah, it’s not getting any less political. That’s for sure.

Well, I want to get into possible reasons why these cancellations and why, more importantly, this frustration and this lack of care are happening. But what becomes of these vets when an appointment is canceled? Like, does something get rescheduled right away? Are they booted out to a private care provider? Or do they just need to start over from square one?

Patricia Kime: Oftentimes the vets I spoke with said that, you know, some of their appointments were rescheduled. But then those got canceled. So, most of the ones—I mean, I talked to at least three or four different vets who literally had a cancellation, got it rescheduled, had a cancellation. And I’ve seen the data, the documents, like four times in a row. So, just kicking the can down the road kind of thing.

And some of them just, you know, give up. They’ll either—they’ll pursue health care somewhere else. Or in one case, their psychiatrist at the VA was pretty good about making sure they got their medication. So, they just continued with the medication they had, but had no access to talk therapy or mental health support.

[00:10:00]

You know, they just stay on their meds and hope for the best is really what one guy told me.

John Moe: Yeah. Boy, which, you know, can put them in a good position to be treated, but it isn’t really a substitute for talk therapy, substitute for—

Patricia Kime: Especially if that’s what you want. I mean, these are people who actually want that. You know, some people are just like, “I just want, you know, to be on my meds, and I just want to be (inaudible) my life and in my house, and I’m fine.” You know, other people really would like the opportunity to talk things out or connect or work things, you know, through a therapist. And these folks didn’t have that kind of access.

John Moe: You mentioned that a lot of these—that there are a lot of cancellations and a lot of missed appointments at the beginning of the pandemic. Was that because online therapy wasn’t as available, that telehealth wasn’t as much ready to go?

Patricia Kime: Well, you know, they did—VA really did work to step up the telehealth almost—very quickly. But you know, there were several months in there where literally everything was shut down, right? So, VA hospitals were shut down. They were concentrating on treating VA patients with COVID, veterans with COVID. But they also have a government federal mission to treat people in the community in a national emergency.

So, the VA Health—Veterans Health Administration was addressing all of that. And you know, there was quite a bit of shutdowns then. You know, at some point in time, they got a lot of people up to speed on telehealth. You know, most of the vets I spoke to were young people who were able to transition to telehealth pretty easily and didn’t have a problem with technology, right?

You know, I guess one of the concerns in writing that story is it does make me wonder about the older vets, who may not be as familiar with the technology. One of the things that VA offers quite a bit is group therapy. The younger vets I spoke to, once they decided they wanted mental health treatment, behavioral health, they wanted to have a therapist. They wanted to talk to a psychologist or somebody one-on-one. They don’t want to share their stories. Older vets seem to; many of them have been in group therapy at VA for a really long time. So, I feel like that was addressed, but I think older vets who may have problems with technology, who aren’t already in group therapy at VA—you know, I’m not sure what happened to them.

Transition: Spirited acoustic guitar.

John Moe: More with Patricia Kime from Military.com after the break.

Transition: Gentle acoustic guitar.

John Moe: Back with Patricia Kime, reporter for Military.com. I asked her why, as far as she could tell, all these cancellations were happening.

If someone—you know, you meet someone on the street; you tell them about this article that you wrote. Somebody says, “Well, why is all this happening? Why are all these schedules—appointments being canceled?” What do you tell them?

Patricia Kime: Well, you know, I basically say—you know, one theory is a provider shortage. You know, there’s a national provider shortage of psychologists and therapists. And you know, it’s just—it’s a nationwide—there’s a nationwide problem with mental health treatment in America. Right?

(John agrees.)

You know, we have—I can look around where I live near Washington, D.C., and there are, you know, hundreds of therapists. But number one, it’s really hard to get an appointment. Number two, they’re in such high demand, the really good ones are cash only. So, like that’s—you know, so, there’s a provider shortage. What’s causing the provider shortage? Well, you know, I think you really have to want to work with veterans to go work for the VA. Because if you’re really good, you know, you could go hang a shingle and make cash only payments and, you know, make a lot of money.

So, that’s hard. The VA is competing with the rest of the world in trying to get quality providers, right? So, there’s that problem. The other problem is—and you touched on this earlier a little bit. You know, there’s a theory out there that they, the VA, wants to make sure that it keeps veterans in-house, because their budget for community care has grown significantly.

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And while it’s two separate pots of money in DC, you know, there is a thought that the more we pay for community care—which is basically veterans going out into the community, and that care is paid for by the VA—that that money takes away from the brick-and-mortar VA hospitals. And you know, there’s concern about that. So, this desire to make sure that the VA keeps its patients in the VA.

John Moe: In the physical building?

Patricia Kime: In the physical building. Or you know, in the clinic or whatever. Yeah. That they maintain their patients, and that they don’t lose them to community care.

John Moe: Okay. Okay. So, is that then by design that these appointments are getting dropped? To encourage people to go into the physical buildings? Or is it more of a kind of neglect that just leads to that?

Patricia Kime: You know, I wish I could—

John Moe: (Empathetically.) Wish you knew.

Patricia Kime: That’s a $100 question. You know, depending on who you talk to, people do think that, you know, it’s by design. But you know, other people think it’s just simply mismanagement. You know, I talked to a medical center director who told me that, you know, the VA has sort of had a—they had a hiring spree last year. They have reduced that because of the cost. They insist that this does not affect hiring of mental health professionals, but yet medical center directors are being told, “You’ve got to watch your budget. And you really—you know, the hiring, you got to really think before you hire. And then you really have to think before you refer veterans to community care.” So, it’s an issue.

John Moe: So, is it a situation where—? I’m just trying to—(chuckles) I’m like a project manager. I’m trying to identify the bottleneck. You know? Is it a matter of the funding is there to get people in place, but there aren’t enough people to fill the positions? Or is there a drag, is there a slowdown that is preventing people who want the jobs from getting in there and getting access to the patients?

Patricia Kime: Well, there’s definitely a drag. But the VA has been working really hard on that. A lot—the VA, there’s a lead time between the time that the VA says, “We want to give you a job,” and then the time you get actually in a seat. And VA has been working to shorten that for quite a while. But it is a distractor, because of all of the bureaucracy you have to go through to actually be a government employee, it scares people off. You know, they get the job, and they wait six months, and then they still aren’t working. So, they move on, you know.

So, that’s a concern. You know, other concerns are just—are the budget. Secretary McDonough just had to go back to Congress and ask for $12,000,000,000 for next year extra before the budget’s even passed. So—and that’s for the Veterans Health Administration. So, that’s to cover the growing costs of care, both within the VA and community care.

John Moe: This is Denis McDonough, the Secretary of the Department of Veteran Affairs.

Patricia Kime: Yes, he was on the Hill a couple of—well, just at the end of September, because they needed additional money for claims this year, because of the PACT Act. Which is the law that broadened benefits for overseas for combat vets exposed to burn pits and other toxic exposures. So, they’ve been really increasing the disability claims. So, they needed like $3,000,000,000 this year for that. And they need $12,000,000,000 for medical care for next year.

John Moe: A couple other factors that came up in your article that certainly raised my eyebrows: There’s an issue about wait time metrics that people thought might be contributing to this cancellation problem that’s been going on. Can you explain what wait time metrics are and how they might factor into this?

Patricia Kime: So, I don’t know how familiar you are. But in 2014? I’m thinking—I’m trying to get the year right; don’t hold me on it. But there was a scandal at the Phoenix Veterans Affairs Medical Center where they were keeping off the book appointment calendars.

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Because the VA has to meet certain metrics where, you know, you’re supposed to get a primary care appointment by—you know, I believe it’s 20 days—and a mental health appointment by 20 days, and specialty care by this much. If you don’t get that within the VA, you’re supposed to be able to be referred to community care. Other ways to be referred to community care are you live too far away from a VA, and you should get referred.

So, the wait time metrics are something that, because it’s a measure for referrals to community care, there is some conjecture that in order to make your—not have to refer to community care, if you show that your average wait time—you’re still meeting your wait time metrics, then you save having to refer people to community care. So, that’s a theory behind that. And the math is interesting, the way the VA does it. You know, conservative think tanks don’t feel like the VA complies with the way they feel like the law was written. You know, the VA also—if the VA Medical Center cancels the appointment—if they can get the veteran to cancel the appointment—(stammering) I don’t know; it’s very complex. I don’t even want to go there.

But anyway, the long story short is it’s tied to referrals to community care, which is why there are some people who believe that perhaps the VA, you know, plays with the wait care metrics to make sure that they keep people in-house.

John Moe: So that their numbers look good?

Patricia Kime: Yes.

Transition: Spirited acoustic guitar.

John Moe: Coming up, what is the VA doing about all this?

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Transition: Gentle acoustic guitar.

John Moe: Back with reporter Patricia Kime.

So, when we talk about the investigation that you’ve done and these stories of people getting their appointments canceled, are we mostly talking about people not walking in the doors of the VA? Is this not a problem for people who show up at the facility itself?

Patricia Kime: It’s a problem. You can, if you go to an ER—if you are in a mental health crisis, and you go to a VA emergency room, you are supposed to get seen. There are rare occasions, and it’s not that many, where you would be turned away. So, there’s always that. Now, a lot of times people go to the ER, and they will be treated for whatever emergency they have then. And then they say—you know, the ER says, “You need to make an appointment at this facility to get your mental health care.” You know, whether they follow through with that, whether they get the appointment—there’s some, you know, issues there. But.

John Moe: But they’re sent home. They—

Patricia Kime: Well, unless they are really—you know, then they’ll be admitted. You know, they can be admitted. They can be basically admitted directly to inpatient care. There’s no really emergency outpatient care. One of the examples in my story, the Veteran was in a crisis.

[00:25:00]

Her parents didn’t realize how severe the crisis was. She actually, from when I talked to her dad, she was told that she should probably go to the big medical center. Like, go to San Francisco or one of the local like bigger medical centers. I think her mother misinterpreted that and just heard “Come on in.” And so, they went to the local clinic. And the local clinic could not accommodate them that day. They gave her an appointment. They gave her some prescriptions. They gave her a prescription, which she wanted, but she was in a severe crisis. And you know, that was an example.

But it’s my understanding that initially she—they had said go to the big VA. You know, the outcome might have been better if she had been there, but definitely that clinic in Chico, California could not accommodate her. And when she went home, she was in a crisis, and she unfortunately had a gun. And she shot her mother and actually shot her father and tried to beat him to death before they called 911. Somebody managed to call 911. And he’s alive. She’s still alive. But her mom is deceased.

John Moe: In many cases, the veterans themselves are being blamed for cancellations that, the way you describe it anyway, there’s some questions about whether these are their fault that they’re being blamed for.

Patricia Kime: Right. You know, I’ve seen—people gave me screenshots of discussions, of the VA reaching out and saying, “Hey, you know, how come you didn’t show up for this appointment?”

And the veteran was like, “I didn’t have an appointment.”

There’s no—one of the veterans said out that there’s no set way for each VA to actually tell a veteran that they have an appointment. You know, normally you’re there; you go to the doctor; you go to the desk afterwards; they tell you when your next appointment is; you stick it in your calendar. A lot of veterans have said that, you know, they maybe—you know, the appointment book’s not open for that far in advance or something, and they’ll get a letter.

You know, veterans said sometimes they’ll get a letter, sometimes they’ll get a text, sometimes they’ll get just a message on the My Healthy Vet if they have an appointment. But sometimes they would just randomly see that they had an appointment that they hadn’t scheduled. So, I don’t know what’s going on there. I wasn’t able to get to the bottom of that. But it’s frustrating for the veteran. And you know, it does make you wonder like what is the purpose of those sort of, you know, ghost appointments?

John Moe: Well, I mean, so often—even in the non-veteran medical field, in the mental health field itself—the people who are in the worst way, in the worst crisis, are the least equipped for that high level of executive functioning of handling all that hassle that goes into getting seen. So, it’s kind of a perfect storm in many ways.

Patricia Kime: Well, I think one of the things that just struck us when we started receiving these stories of veterans—yeah, I mean, you said it. People are already having issues with their daily lives. And they are trying to balance their medical care and trying to get things right. And they’ll write things down, and then they’re told that, you know, no, they don’t have an appointment, or they do have an appointment, or it’s been canceled.

You know, (hesitating) gaslighting is now an overused phrase, but it is a form. I mean, they feel like that’s what’s happening. You know, “What is going on here?” So, you know, and then—and you put that on top of having a mental health diagnosis. Like, that’s just, you know, bad.

John Moe: Yeah. I mean, speaking of bad, is there any link to some of these—this wave of cancelled appointments and people dying by suicide?

Patricia Kime: You know, we definitely took a look at that. I have spoken to a couple family members. I mean, I definitely spoke to Marty Larsen, the father of the young lady who is now in a California state mental hospital. He said that his daughter’s appointments were cancelled. Actually ProPublica did a big exposé on Chico, on that clinic.

[00:30:00]

And it turns out they were exceedingly short staffed. So, you know, she tried to get medical care, tried to get mental health care there. And it was so short staffed that so many of her appointments were cancelled. Now, she obviously committed a homicide and is still with us, but I’ve talked to some other—I talked to some family members and an attorney for one of the families who said that he has records that show that, you know, the VA kept saying, “Oh, well, this person canceled their appointment, and this person, he canceled. He kept canceling his appointments.”

And he has records that say—and they’re now court documents—that it was not the veteran that canceled the appointments, that it was the facility themselves. So—and he died by suicide. So, you know. And how big of an influence it is, I don’t know. But there are connections for some.

John Moe: Yeah. Yeah. There’s some data there. Well, what does the VA say about what they’re doing about this whole issue?

Patricia Kime: Well, they—you know, they have obviously made vast inroads in hiring. They’re definitely very focused on providing mental health services. At least, you know, central office. You know, how that’s trickling down to the individual medical centers is a challenge. You know, you’ve probably heard this phrase a zillion times, but if you’ve seen one VA, you’ve seen one VA.

John Moe: One VA, yes.

Patricia Kime: It’s not standardized. There are some that are outstanding and seem to be doing quite well and some facilities that struggle. So, the VA is embarking on hiring. Still. They’re still hiring. They are working to diminish the cancellation rates. I mean, they have fallen since 2020. So—according to their data. And I’ll point out that the Americans for Prosperity Foundation data was old and hasn’t been updated. So, you know, VA—you know, have they recognized that they had a problem, and they need to address it?

It looks like it’s being addressed somewhat. Although, I’ll caveat that by saying that I heard from veterans who are like, “This happened to me this year,” you know, in 2020. So—and you know, they’re expanding. They’re building new clinics. They’re opening new clinics. They’re making some inroads and hiring, trying to get partnerships with—in places, rural communities, where it’s hard to get healthcare. So, they are trying to tackle the issue of providing care to veterans in remote areas and underserved areas.

John Moe: It just seems—like, at first blush, I’m like, “Well, get your system together, you guys. Get your—you know, get this worked out.” But then I also think on a bigger scale of like, okay, here we are—a country that was at war for decades; you know, lots of people going through the military, lots of people coming out with damage from the military. And then trying to manage something as often challenging and complex and frustrating as mental healthcare, and do all that within the parameters of a government agency. I mean, sometimes when I think about it, it’s like is this too big of a system to succeed ?To get all that needs to be done within this system? It seems very daunting to me.

Patricia Kime: Well, it’s interesting that—after the Vietnam War, you know, there was many—there were mental health issues. Obviously, a lot of issues. And one of the things that VA did back then was create these little sort of satellites places called Vet Centers, which provide non-medical therapy. They provide counseling and marital counseling. And they’re part of the VA, but they’re sort of their own little thing in that literally their medical records and things don’t really go into the official VA medical record, unless there’s a threat to self or—you know, the reporting requirements. You know, threat to self or others.

[00:35:00]

But anyway. You know, here in the 1970s, they came up with this really interesting concept. And throughout the Iraq and Afghanistan wars, these Vet Centers became in more demand as Veterans realized that, you know, they were still around, and they serve more than just—not just Vietnam Veterans. So, I think there was a lot of creativity there after Vietnam with a really much smaller VA.

It’ll be interesting to see what they can do. Is throwing so much money at it, at the current system, the right thing to do? I don’t know. Like, it might need, you know, some creative thought. Like the Vet Centers were created to really tackle this vast number. And it’s huge numbers that are coming into the system. I mean, America has 18.1 million veterans. And while they are going to decline in population over the next few years, they are going to age, and they’re going to have continued—you know, all these people are going to have health issues compounded by combat as they age.

John Moe: You mentioned you had heard from veterans since your story came out. What have they been saying?

Patricia Kime: I have. You know, the common thread through the emails that I’ve received has been, “Oh, I thought it was just me. You know, thank you for covering this issue. I just thought that, you know, I couldn’t track my own appointments. I didn’t know what was going wrong. I thought it was just my VA.” And that kind of thing. That’s really the common thread. As far as any feedback from the VA, um… they’ve been pretty quiet. (Laughs.) But I also haven’t seen the secretary recently. So, I’m sure the next time I see him, he might say something. (Laughs.)

John Moe: Okay. Well, I mean, the term buttoned-up probably originated in the military. So, he’s not going to be real loose-tongued about that, I suppose.

Patricia Kime: I don’t know. He’s pretty—he says things. He does not seem to mince words when—probably to the frustration, I would say, probably to the frustration of his public affairs staff. I’ve seen him say some things, and they’ve been like, “Oh, great.” (Laughs.)

John Moe: Yeah. Right. Okay. Well, we’ll follow up if we hear more from him. The article is “Cancelled Appointments, Unexplained Mix Ups, Veterans Facing Challenges Getting VA Mental Health Care”. It appears in Military.com. And Patricia Kime, thank you so much for your time.

Patricia Kime: Oh my goodness, thank you so much for having me. It’s been great.

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Hi, credits listeners. I can’t stop listening to the song “Quarry” by the band Wednesday. Maybe you’ll enjoy it as much as I do, but maybe you’ll have as much of an earworm with it and be stuck with it in your head for the rest of your life. Like I am.

Depresh Mode is made possible by your contributions. Our production team includes Raghu Manavalan, Kevin Ferguson, and me. We get booking help from Mara Davis. Rhett Miller wrote and performed our theme song, Building Wings.

Depresh Mode is a production of Maximum Fun and Poputchik.

[00:40:00]

I’m John Moe. Bye now.

Music: “Building Wings” by Rhett Miller.

I’m always falling off of cliffs, now

Building wings on the way down

I am figuring things out

Building wings, building wings, building wings

 

No one knows the reason

Maybe there’s no reason

I just keep believing

No one knows the answer

Maybe there’s no answer

I just keep on dancing

 

I’m always falling off of cliffs now

Building wings on the way down

I am figuring things out

(Music fades out.)

Transition: Cheerful ukulele chord.

Speaker 1: Maximum Fun.

Speaker 2: A worker-owned network.

Speaker 3: Of artist owned shows.

Speaker 4: Supported—

Speaker 5: —directly—

Speaker 6: —by you!

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