Amid a worsening pandemic, the San Diego VA is making access to mental health care harder for local veterans, outraging therapists who say the agency’s actions are dangerous and irresponsible.
“I don't understand how this is ethical nor taking care of our veterans. People who have served should never have to fight for this,” said Devin Price, a psychotherapist with a practice in Mission Valley that treats around 40 veterans under a VA contract.
“This mentality, that a person who's been sexually traumatized, or has been in combat, or any of the other things that the veterans have endured, should ever have to be denied care — that needs to stop,” she said. Price is one of five clinicians who told inewsource that without much warning or explanation the San Diego VA recently started making it more difficult for veterans to get authorization to go outside the system for mental health care. inewsource also spoke with veterans affected by the changes. In some cases, treatments stopped before eventually getting approval. In others, veterans and therapists told inewsource they've been waiting weeks or months for authorizations. Several therapists said they're continuing to treat patients with no guarantee of payment by the VA because they can't bring themselves to stop helping the vets. The therapists said the VA’s actions could leave thousands of depressed, suicidal or traumatized veterans with nowhere to turn in the middle of coronavirus-related lockdowns.
“I'm concerned that this is like the perfect storm,” said Wendy Belding, a La Jolla-based therapist. “It’s frankly frightening what’s going to happen to veterans.”
Those interviewed for this story told inewsource at least three veterans have taken their lives over these developments. One was Price’s patient. “In December, she was denied further sessions,” Price said, adding that the veteran stopped coming as often for treatments because of the out-of-pocket expense. The vet took her life in April.
Price said she wrote up a report and sent it to the San Diego VA. It detailed what happened, the years of treatment she provided and the role the VA’s actions played in her patient’s death.
She said the VA never responded.
Suicide prevention help
If you are having thoughts of suicide, you can call the National Suicide Prevention Lifeline at (800) 273-8255 or the San Diego Access and Crisis Line at (888) 724-7240. Other resources are available here.
inewsource sent the San Diego VA a list of questions about the mental health care cuts: What’s happening and why? What are the agency’s protocols when it learns of a veteran’s suicide? What measures are being taken to ensure a continuity of care for mental health patients? In response, a VA spokesperson didn’t answer any of the questions but asked for the names of the veterans and therapists interviewed for this investigation. “No patients are encountering clinically significant delays,” said spokesperson Christopher Menzie, adding that although the agency is aware of issues related to administrative transitions, the VA has “always maintained our role in making sure Veterans got timely access to services in as expedient a manner as possible.” Menzie did not respond to follow-up questions.
A ‘free-for-all’
The San Diego VA doesn’t have the resources to treat the 86,000 veterans it provides healthcare to in San Diego and Imperial counties, so the agency contracts with community providers.
The arrangement is required under the 2018 MISSION Act, a federal law meant to expand veteran access to healthcare across the country.
Under the law, vets suffering from PTSD, depression, sexual trauma, suicidal impulses and other mental illnesses are often connected with and cared for by outside clinicians.
Some, like Navy veteran April Koeberle, have finally found stability with these non-VA clinicians after years of being bounced from one psychiatrist to another within the VA system.
“It does lead to suffering in the care because you can't provide consistency,” Koeberle said, “and with mental health care, that's really important.” The 37-year-old joined the Navy just weeks after graduating from high school in West Chester, Pa., served for seven years and then moved to California. She said she stayed with the VA for mental health care because she thought its doctors would know more about military trauma than those in the private sector.
She thought they would know how to help her work through the PTSD and suicidal thoughts that stem from her time serving on the John F. Kennedy aircraft carrier in the Persian Gulf. But the turnover rate among VA psychiatrists at the Long Beach and San Diego VA locations where she went was frustrating, Koeberle said, and having to retell — and therefore relive — her trauma every few months with a new doctor was “really damaging.” Eventually she found Alexandra Laifer, a clinical psychologist from a military family who treats veterans as an outside provider with the San Diego VA. For the past three years, the two have worked through Koeberle’s trauma.
Having that consistency with the same person was invaluable, Koeberle said. The VA reimburses Laifer for the cost of Koeberle’s sessions but must first “authorize,” or sign off on, treatments beforehand.
Until recently, TriWest Healthcare Alliance handled much of the rest — getting authorizations from the VA to the providers, coordinating patient care, scheduling appointments for veterans and serving as their primary customer service contact.
TriWest was awarded a contract last year — with a value of up to $26 billion — to manage the VA’s community care network among 13 western states, including California.
Yet now the majority of the work TriWest did coordinating care and interfacing with community providers in San Diego has shifted back to VA staff, and the therapists don’t know why.
“All the people who we used to contact at TriWest were suddenly let go,” Laifer said. The VA never gave outside providers a “big packet of information” about what to expect after TriWest exited nor were clinicians told how to navigate the new system, she said.
A spokesperson for TriWest told inewsource that the changes reduced the need for its staff and prompted the company to move “its physical footprint in San Diego to a virtual environment.”
As a result, she and dozens of other providers are in a "weird free-for-all,” Laifer said. “We have no idea what to do.” No one’s available to answer questions at the VA, she said, and her colleagues have been on hold with the agency for 45 minutes only to be disconnected, or they receive different answers depending on who they’re able to reach.
“And at the end of the day, the people who are suffering are the veterans who we treat,” Laifer said. “Because nobody really knows how to maneuver the system.” Meanwhile, her patient, Koeberle, is stuck in limbo waiting to hear whether Laifer will receive VA authorization to continue treatments. The veteran has tried advocating for her own care by making calls and sending emails to no avail. She described the work as “almost a full-time job.” “I keep having to push to get what they promised, and it’s exhausting,” Koeberle said. “I know why a lot of people give up.”
Warning signs
Though suicide rates among military personnel reached an all-time high last year, recent reports suggest COVID-19 may be making things worse: Army officials reported a 30% increase in suicides among active-duty soldiers during the first six months of the pandemic. “This is not a good time for the system to wobble,” said Nancy Lin, another San Diego psychologist with roughly a dozen veterans as patients whose authorizations for mental health care have recently expired.
“There is already a pandemic causing social isolation, increased depression, increased substance use, canceled medical appointments and fewer outlets for healthy coping,” Lin said.
She described the recent changes at the San Diego VA as a “veritable comedy of errors” and said some of her colleagues are opting to see fewer veterans rather than deal with the hurdles involved.
Belding, the therapist in La Jolla, said the same. “You have to have so much tenacity, and you have to just put your head down and fight,” Belding said. Combined with the pandemic, the situation for mental health patients couldn’t be worse, she said. “That's why I'm just horrified that people might have their care cut off right now,” she said. Belding described hours spent on hold with the San Diego VA trying to clear up the authorization problems and listening to the agency’s pre-recorded music and messages about how concerned it is with veteran suicides.
“I actually caught myself humming the song the other day,” Belding said.
One of her patients, Army veteran Taylor Taylor, ran a successful acupuncture practice in San Diego but recently lost his business and his clients due to COVID-19, he said. “When this year kicked off, it was just one too many things I couldn’t juggle,” Taylor said. [PHOTO 4] The 48-year-old described a tough life — bouncing around states and foster families as a child, where he said he suffered physical, psychological and sexual abuse. He joined the military as an escape and “found a sense of self-worth,” eventually becoming a combat medic. After his service, he worked at the Fresno VA and eventually set up an acupuncture practice in San Diego.
Many of his clients were veterans, he said, who’d share with him their problems accessing mental health care through the San Diego VA. “There seems to be a huge cutback in psych-related care, especially through the community, and everybody’s getting denied left and right,” Taylor said.
One of those clients was denied community care and recently took his life, Taylor explained while choking up.
“The last time I saw him he looked and sounded unbreakable,” he said. The Army veteran doesn’t hold back about his disdain for how the VA treats veterans, having experienced it firsthand. “The majority of the experience at the VA makes me hopeless, helpless, and that much more depressed,” he said. “If I didn’t have faith, and if I didn’t have a very strong will and determination, I would have just called it quits a long time ago.” Koeberle, the Navy veteran, feels the same frustration. “You don’t send a generation to war and be like, ‘Well, I’m done,’” she said, while mimicking washing her hands. “No, that’s not OK.”
History repeating itself
inewsource previously reported about a local Navy and Marine veteran who took her life after learning the San Diego VA was cutting her off from seeing her outside provider, Dr. David Feifel.
Feifel administers ketamine to help curb suicidal impulses and depression at the Kadima Neuropsychiatry Institute in La Jolla. For several years, the San Diego VA referred dozens of high-risk veterans to the doctor to great success. Then, without warning, the agency stopped authorizing vets for sessions with Feifel despite having no alternative treatment plan in place. In some cases, vets were told less than 24 hours before a scheduled appointment that the treatment they’d relied on for years would no longer be an option.
Feifel sent emails and made phone calls pleading with the VA to consider the consequences. He asked the agency to work with his staff to come up with a solution for easing the veterans off a drug they’d come to see as a lifeline.
The agency ignored those warnings and the veteran, Jodi Maroney, took her life.
The doctor shared with inewsource an email he sent the VA after Maroney’s death, in which he again petitioned the agency to consider its actions. The subject line read, “WILL IT REQUIRE ANOTHER VETERAN TO COMMIT SUICIDE?”
In the email, Feifel attached more than 30 pages of documents showing how unresponsive the VA had been to his requests and wrote that it exemplified the agency’s “ludicrously broken system.” “I find it remarkable that I have written an email as blunt and openly angry as this one,” Feifel wrote to VA leadership.
“Me and my team have acted with great restraint in our dealings with the VA even after Jodi’s suicide, which upset us very much especially because it was clearly preventable. But we are finding it increasingly difficult to be patient with the non-responsiveness and incompetence which we feel is utterly inexcusable.” As with Price’s patient who died in April, the VA never followed up with Feifel about Maroney’s suicide. Instead, it continues to deny authorizations to his clinic.
