When clinical psychiatrist Cher Morrow-Bradley and other health care providers call the Veterans Choice program, they are greeted with a recorded, 90-second "thank you" from Veterans Affairs Secretary Bob McDonald.
It's not having the intended effect.
"Why don't you make this easier? The process is so cumbersome, and I have to listen to you thanking me for spending all this time and then I get put on hold," says Morrow-Bradley, adding that she hasn't figured out how to skip the message.
She and many others say this is emblematic of the Veterans Choice program that was intended to quickly work through the backlog of vets waiting for medical care. Anyone more than 40 miles from a Veterans Affairs facility or waiting more than 30 days for an appointment could go get private care outside the VA system.
But nearly two years in, there are more vets waiting than before. Health care providers are frustrated with the program, which makes it hard to keep them in the network. Without enough providers to see them, vets end up waiting anyway.
Or, in Morrow-Bradley's case, the vets get the care and the doctors don't get paid in a timely fashion, if at all.
She moved to North Carolina to work with veterans, first at the VA and now in a small private practice. Previously she gave VA patients care as a private doctor through a program called PC3. When Veterans Choice started in 2014, she was happy to participate, because she knows VA mental health specialists are overwhelmed.
A Satisfied Patient
One Afghanistan vet, Jacob Hansel, gives Morrow-Bradley a rave review.
"I believe therapy is stronger than medicine," says the former Marine, who returned from deployment with serious anxiety and depression issues. When the local VA told him it would be a four-month wait for a therapist, he used the Choice program to see Morrow-Bradley.
"I have days when I almost have panic attacks. ... A lot of it is just realizing when the anxiety comes; she's helped me figure how to keep it under control," says Hansel.
Morrow-Bradley has treated Hansel since last year, along with others in the Choice program. She has submitted her bills to a company called Health Net, which administers Veterans Choice across most of the Eastern United States.
"I just assumed I was being paid. I found out six months later I had five, six [thousand dollars] outstanding to Veterans Choice," says Morrow-Bradley.
It took her most of a year to get paid. Health Net refused requests for an interview.
Dr. David Shulkin, the head of the Veterans Health Administration, acknowledges this problem has hindered the Choice program in getting providers big and small.
"One thing I know is that when you perform a service, when you see a patient, you want to be paid. And these hospital systems don't have the cash flow to be waiting around for months and months to get paid," he says.
Shulkin points to one rule that has been scrapped to speed up reimbursement — originally providers wouldn't get paid until they had returned an updated medical record to the VA.
Challenges In Getting Certified
Other providers say they want to join the Veterans Choice program but can't jump through the hoops to get certified.
Psychologist Diane Adams devotes a portion of her practice in Renton, Wash., to veterans, saying it's something she considers important.
She sees patients at her home office at the midpoint of a steep winding hill. Adams has provided counseling to veterans as part of the VA's community care programs for nearly a decade.
Last July, she got a letter inviting her to join the Choice program, from TriWest Healthcare Alliance, the company that administers Veterans Choice in most of the Western U.S.
Adams went online together to begin the credentialing process. It all seemed pretty straightforward.
"We checked that box and waited and waited," Adams said.
In December, after hearing nothing for five months, Adams finally gave TriWest a call.
"I spoke with somebody and yes, they had received my information and they thought, well maybe it's just taking a long time for the contractual process," Adams said.
Adams called back again in January and March. Each time a courteous TriWest representative took a message. No one called back.
Tri West's chief medical officer, Frank Maguire, acknowledges the Veterans Choice program isn't exactly nimble.
"Things have gotten much better but I'll tell you we still have persistent educational confusion issues. The program itself is not uncomplicated," Maguire said.
As a result, small mistakes can mean big problems. Turns out, way back, when Adams filled out the first form, she checked the wrong box. And that held everything up. Finally, in March, Adams was informed that she'd been credentialed since January and should have gotten a welcome letter. It never arrived.
Maguire says the program is still new and may need more time.
"We think we've done consistently a much better job as time has gone on," Maguire said. "At the same time there's not a lot of patience. People want it perfect right away and it's a new program. I think still needs more time to mature."
Now that she's in, Adams faces a new hurdle: Some of her regular veteran patients can't get Veterans Choice to approve visits to see her.
Vets are supposed to be able to call the number on the back of their Choice card and get an appointment. But so far it's been like climbing that steep winding hill to her office — more phone calls, more faxing, more forms.
"I guess what I'm worried about is what happens to the veterans who can't handle it and they just don't have the internal resources to put up with it and so they throw up their hands and they give up," Adams said.
A possible interruption in treatment is a particular problem for mental health care, where continuity is paramount.
It's no accident that both Adams and Morrow-Bradley are mental health care providers. That's one of the areas in shortest supply at the VA. Unfortunately the Choice program hasn't been well-suited to fixing that problem.
In North Carolina, Morrow-Bradley keeps seeing her Choice patients. Some come free. Others use secondary insurance that at least pays some of the bill. She says she can't just halt treatment.
"It's not like I'm a dentist. If I start working on your teeth then you could go [elsewhere to] be seen and the work would be completed," she said. "Post-traumatic stress disorder work is very sensitive. You need to have a relationship with the person; it's stressful for the therapist and the client."
And Healthnet won't authorize enough visits at a time, she says. For patients she needs to see twice a week it would take a new authorization almost every month.
"People have been not very interested in participating," said Chuck Ingoglia, with the National Council on Behavioral Health, a group of 2,800 mental health organizations nationwide.
He says the Choice program doesn't cover much beyond basic therapy. If you do anything additional you won't get reimbursed.
"Participating in the Vets Choice program would limit the kind of robust mental health and substance use treatment they have historically been able to provide to veterans."
For those reasons and others, at least two states, Maine and Montana, have taken the extraordinary step of excluding mental health care from their Choice program. They use other programs to pay for it and have sent harshly critical letters to the VA about the Choice program.