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A Trauma Doctor Raises Questions over VA Outsourcing

Updated: May 25, 2021

Edward Machtinger, MD, is a VHPI Advisory Board Member and Professor at UCSF. He recently spoke at VHPI's Zoom forum on the AIR Commission, which you can view here.

I'm an internal medicine primary care doctor and I run a research program at UCSF called the Center to Advance Trauma-Informed Health Care. We have a clinic that is basically a learning laboratory about how to care for patients with high rates of trauma.

As a practicing physician who works on the frontlines of the delivery of primary care and who has tried to encourage primary care practitioners to deal more effectively with trauma, I want to debunk the idea that a person who needs primary care and who has any significant mental illness, substance abuse, behavioral, social needs, or other complex problem or issue, can receive adequate primary care in the non-VA sector. I also want debunk the idea that if a veteran gets access to a top-tier medical institution like mine, UCSF, that that veteran will have access to adequate primary care services.

The primary care system outside of the VA is not only not designed to take care of somebody who is a veteran (or anyone else) who may have a number of trauma-related health conditions. For financial reasons, the primary care system outside the VA is deliberately designed not to see the veteran – or any other patient --who has a number of trauma-related health conditions or complex healthcare needs.

Primary care clinics outside the VA don't want lower paying, complex primary care patients. There are, in fact, many examples of how the system is designed to exclude them. Let me use my institution, UCSF, which is not unique in this regard, as an example.

UCSF is a fabulous institution. If you're a veteran and have a brain tumor, you should come to UCSF right away. We'll take out your brain tumor with incredible skill.

But if you're a veteran who has PTSD, if you have depression, if you have substance use, and you come to our UCSF primary care clinic, you will encounter many obstacles. That’s because, there is only one, lone medical social worker assigned to the twenty-eight thousand patients in our clinic.

What are the ramifications of having only one social worker for 28,000 patients? UCSF is essentially hanging out a sign saying, “We can't take care of you and we do not want you to come here.” I mean this quite literally. This is deliberate. We have only one medical social worker to serve 28,000 primary care patients because we don’t want patients with complex health, social, and economic needs.

Let me briefly explore the real world implications of this reality. If you are a patient with depression and you were being seen in a primary care clinic that has one medical social worker, you are given a list of therapists who are hypothetically available to see you for depression. One of these hospitals may, for example, be UCSF's Langley Porter, which doesn’t take Medical and would not accept the payment rate that offered under the VA MISSION Act. So, that hospital would not be available to VA patients.

The depressed individual who receives this list, moreover, will have to call each person on it, then be asked to leave a message, which will probably not get a response. Why is this? Because most mental health professionals outside the VA do not want to take on patients with complex health and social needs.

They do not want to see a suicidal patient. They do not want see someone with complex PTSD. They do not want to see somebody who has had a lot of trauma. They don't have the capacity to handle that in the private sector. So, if you're a veteran who has complex health and social needs, you are out of luck.

Even more critically, a patient who has serious mental health problems and acts out in any way in a primary care practice outside the VA will not be helped by a social worker. Because there isn’t one available. Who will be called to deal with that disruptive patient? A team of clinicians or staff educated in how to deescalate conflicts and handle a patient who likely has PTSD or another trauma-related reaction or illness? Hardly. The service that will handle this problem is hospital security – i.e. the police.

We see this happen all the time with our patients. Many of our patients have, like veterans, suffered enormous trauma and have complex PTSD. Trauma and complex PTSD make people very reactive. So, if one of our patients wants to be seen and encounters an obstacle, they are likely to become angry and upset. Rather than seeing this reaction as a symptom of trauma and calling a trained social worker to deal with the patient, a stressed out and untrained medical assistant will perceive this reaction as hostile and dangerous.

These well-meaning but untrained staff won't know how to de-escalate. Their training and resources won’t allow them to have compassion for the patient or try to understand them. What they do know how to do is call the police or security. That happens all the time. The physicians in these clinics also don't understand many other issues that are important to know for the medical care of veterans. They have never been trained in screening for exposures to toxins or in how to screen for and treat PTSD. They don't have a trauma lens like the VA has.

Even the embedded mental health providers in clinics, which really don't exist in most clinics, don't understand complex PTSD. They understand simple depression. They understand anxiety.

So, here is my take home message. As someone who has worked in and trained in the VA and now works in a premier medical institution that has a large primary care practice, I am here to tell you: do not think for a second that a veteran with any complex health and social needs can get adequate primary care outside the VA with any dependability or predictability. Sure, there are examples of where they can. But please, disabuse yourself of the idea that because an institution claims to be number one or is highly rated that that institution is capable of – or even has the will to – care for veterans with trauma or other complex medical and mental health conditions. We have to understand the reality of American healthcare today. Not only do most private sector health institutions fail to provide adequate care that is based on an integrated, coordinated primary care model, they are actually systematically structured to make sure that it is impossible for most individuals with trauma or other complex conditions to access care in their institutions at all, or to receive good care once they do.

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