Gregg Masters 00:09 You’re listening to PopHealth Week on HealthcareNOW Radio. I’m Gregg Masters, Managing Director of health innovation media, the publisher of ACOwatch.com, and your PopHealth Week cohost with my partner, co-founder Fred Goldstein, President of Accountable Health, LLC, a Jacksonville, Florida based consulting firm. Today, we are indeed privileged to again speak with Secretary Shulkin. David Jonathan Shulkin, is an American physician and former government official. In 2017 Shulkin became the ninth United States Secretary of Veterans Affairs and served under President Donald Trump before assuming the top spot at the VA Shulkin served as the undersecretary of Veterans Affairs for health from 2015 until 2017, appointed by President Barack Obama on March 28 2018, President Trump in his usual style, dismissed Shulkin from his position by tweet. Since leaving office and returning to his life in the private sector, Secretary Shulkin has authored a book chronicling his time at the VA, it shouldn’t be this hard to serve your country, our broken government and the plight of veterans. So Fred, over to you help us get to know Secretary Shulkin. And what he’s chronicled in this just released book.
Fred Goldstein 01:33 Thanks so much, Greg, and Secretary Shulkin. It’s pleasure to have you back on PopHealth Week.
Secretary David Shulkin 01:36 Great to be back Fred.
Fred Goldstein 01:37 Yeah, it’s a it’s really a pleasure we had you on back in October, right after the release of your book, It Shouldn’t be this Hard to Serve Your Country, Our Broken Government and the Plight of Veterans. So what’s been the response so far, say from the industry, the administration, those within the VA, and perhaps most importantly, the veterans
Secretary David Shulkin 01:53 Fred, as you know, you write a book, which is often much more difficult task than you think when you start the project. And the whole goal is to have as many people read it as possible. And I’ve been really delighted to hear from so many people who have read it, I think the group that is most impactful for me are veterans themselves, ones that have really struggled to get the type of care and services that they need, who just felt that talking about the subject, talking about the system of care that they rely upon, is really important. And so I’ve been delighted with that reaction. I’ve also heard from a lot of employees at VA. And that, of course, was something that I wanted to make sure that I highlighted how incredible so many of these employees are and people who feel trapped in a system that’s not working for them and care a lot and want to do better and don’t want to leave. And one of the effects has been that they had no idea from the media coverage of these types of things were going on. And they were shocked to hear the story that I told, and I didn’t write it for its shock value. I wrote it, because I thought it was important that people understand that this is the way that government is functioning. And people who frankly, just are sorry to see the government in the state that it’s at, and want to see us return to some type of normality.
Fred Goldstein 03:12 Yeah, it really was. You know, a surprise when I read it, particularly many of the issues you discuss. And you talked about individuals within the VA and their responses, I can tell you a few weeks back, I was actually at American College of Healthcare eExecutives meeting on quality improvement and things like that. And one of the panelists was from the VA here locally did an excellent job and talked about their efforts, which sounded very similar to what you were trying to do. And instill in the VA of improving processes and really getting services out to veterans. So it was it was really a confirmation of much of your, your talk. When you or your book, as you’ve heard from these are you hearing any willingness or interest, ability to make some of the changes you talked about?
Secretary David Shulkin 03:55 I’m not unfortunately, I think what happens is, in a system, as big as the federal systems are, people feel that they are just one little piece of a much larger bureaucracy and so so it’s a very unempowered feeling. And so what you have is a lot of people who are trying to survive or suffer through a system that’s not working for them without any real place for them to go. And I think when they do reach out to me, they’re they’re really asking, Are there places to go for these types of reform efforts? And it’s one of the things that, I think without having the ability to have an honest dialogue about what the current situation is like, it’s very, very hard to see policy change. And so people wait a long time and get frustrated. And unfortunately, I think we’re seeing more often in government today, the brain drain the people that frankly, you don’t want to see leaving the government because they’re dissatisfied because they know that they can do better and they get so frustrated. They just leave for the private sector, and I think that makes the system actually perform less effectively than if they had a had an outlet in which to get their issues addressed effectively.
Fred Goldstein 05:11 And you came from the private side, went into the government to serve. And and are now back out on the private side within this whole amalgam of VA public-private, where does it go? Where do you think that fits? You talked about some in your book? Could you elaborate on that some more, and how much privatization we should see or would be appropriate?
Secretary David Shulkin 05:31 I think, you know, when I entered from the private sector, I had a very open mind on this issue. All that I knew was what I had been hearing about in the media was was how broken the system was, and and how veterans were suffering. And when I actually got into government and saw the way the system worked, I saw a very complicated picture, I saw incredible work being done and, and care being delivered with compassion. And, and with competency, that, frankly, I think, surpassed in many cases, the private sector. On the other hand, you couldn’t really do anything but conclude that the issues of the veterans were bigger than what the VA could do alone. And so I came to the conclusion that the best fix if you looked at it from the veterans perspective, which is really what I hope that anybody who’s leadership is looking at it from their perspective, the best solution was going to be a hybrid system where it was a strong functioning, sustainable VA working with a strong, vibrant private sector, where the veterans needs get put as the top priority, and they get to essentially utilize what’s best in both the private sector and the VA. And, of course, what I described in my book is how challenging it is to have a position today, where you are in the middle, where you have a compromise where you actually don’t sort of, you know, put your objectives at one end of the political spectrum. And I believe that the answer here was actually a middle ground, one that work both with the private sector and the VA. And and that didn’t make a lot of friends in Washington.
Fred Goldstein 07:15 And, and that’s interesting for, as you talk about, you’re trying, you’re talking about a middle ground from a health care service delivery model. And obviously, it appears in the political realm today, there’s no middle ground in the political spectrum, is that sort of lined up, and that creates the inability to, to create a product that sits in the middle.
Secretary David Shulkin 07:35 Well, I think the disappointing thing is, is that when it cut when it came to veterans, and maybe I’ll even extend that to the military, there has been a long history of bipartisanship, where where there was middle ground where, where people put veterans and the needs of the country above the politics. And unfortunately, I saw that begin to change under the Trump administration where the country became polarized, and I’m not necessarily pointing blame at either the left or the right, I think it takes both sides to have created this type of environment that we see today. But I did see and I continue to see veterans issues creeping into that political environment. And the bipartisanship that had really been there for decades, no longer is nearly as strong. I think that works to the detriment of our nation’s responsibility to our veterans,
Fred Goldstein 08:27 as you think about privatization. And they’re always talking about going to privatization in the in the commercial market sector. We’ve got this huge push now recognizing the inefficiencies in the system and the overutilization and pricing issues. And all the rest of it was the VA looking at some of those where it was appropriate to privatizes maybe looking more towards a value-based care model? Or were they still saying, well, the system out there is fee for service? We’re just going to pay for it that way? Was there any of that going on?
Secretary David Shulkin 08:55 Unfortunately, there wasn’t a lot of it. And the reason is, is because legislatively, VA was restricted to a fee for service system that was not able to adjust the fees that was fixed on the Medicare fee schedule. And of course, if you think about describing a fee for service system, that essentially has a fixed fee schedule, that really sounds very, very much like healthcare was back in the 70s and 80s. And all the payment reform that has happened then, the understanding of the impact of quality to payment and value-based payments and accountable care and, you know, risk-based payment systems. All of that has not been allowed to develop at VA because of the legislative requirements to pay on a fee schedule. And one of the things that I was able to get into what is now known as the Mission Act is a organization in VA that will be allowed to innovate and experiment on the payment side. So it’s much like the Center for Medicare and Medicaid Innovation Center that has had so much impact on the rest of the country with payment reform pilots and bundling of health care and accountable care. So that has now been established where there is a Center for Innovation in payment in VA, with the idea that we should be doing these exact things that we’ve learned in the private sector that have been effective, bringing that to VA and introducing new payment models, I think that I’ve not yet seen that center become active. And so there needs to be champions within VA, who have both the experience and the vision to be able to bring what has been working in the private sector to the Veterans Administration. And then there needs to be the support in Congress to be able to allow that innovation center to be able to test and demonstrate what it believes will be effective. And so Congress has oversight over that center. And so it is going to require a partnership between VA and Congress, for us to see these types of changes implemented,
Fred Goldstein 11:14 given what you discussed in your book about, you know, these groups of outsiders sort of overseeing the VA and putting pressure on it in a number of areas, do you think that center will go anywhere, or it would just be left?
Secretary David Shulkin 11:29 I worry more about the internal competency in VA, to understand how to bring these ideas to VA than I do worry about the political influence. You know, I think, I think that there’s always going to be political influence when you’re talking about government. And the antidote to political influence is just having the right values and having the competency. So I think that if ideas are put on the table, that make sense that are demonstrated to have had value in the private sector, that those should be brought and introduced into the VA system. And I believe that they will get support if they’re properly presented to Congress with clear objectives and deliverables that make sense that improve the health well being and the efficiency of the VA system. And and so, you know, my concern is, is that I haven’t yet seen that be taken advantage of when we worked very, very hard to begin to introduce these concepts and and this new center to allow VA to do this. So it’s going to take the right leadership now to to bring this to fruition.
Fred Goldstein 12:43 And you talked about the Center for Medicare and Medicaid Innovation somehow this is similar to that, in a sense, is they’re given it the VA may need some expertise in internally or to bring in from outside to help figure this some of this out, are there any ongoing relationships or discussions with CMMI, to try to learn from what they have or have done?
Secretary David Shulkin 13:05 I think that one of the disappointments that I had in VA, in and in government in general was that there wasn’t more cross-fertilization and closer working relationships between the agencies. Because clearly, I think the Center for Medicaid and Medicare innovation has been doing this for a while and has been quite effective in my, in my view, so that I have not seen a lot of that happening. But one of the ways that that can be accomplished is you can potentially detail some government employees from a center like CMMI, over to VA, to help jumpstart the process. And that would be something that is common in government to do and something that that I think would be quite helpful to take that experience. And to bring it over to VA, but it is not going to happen on its own. It’s going to take a deliberate effort and a focused attention to wanting to do payment reform. And my private sector experience has taught me that without payment reform, the types of changes to a big system, like we’re talking about are going to be much slower than if payment reform is an integral part of the change management approach.
Fred Goldstein 14:25 And if you were looking at some of the various ideas that CMMI and Medicare and CMS are putting out there from Medicare Advantage plans to ACOs or risk-bearing IDNs, bundled payments. Where do you see Do you see some of those more likely to play better in a VA hybrid system or, and others less likely?
Secretary David Shulkin 14:46 I think the two easiest places from my perspective are to start with bundles and you know you can do the 30, 60, 90-day bundles of care because I do believe that there is is a big opportunity to both improve quality and improve efficiency between the handoffs that happen in a patient’s journey between acute care and long term care and skilled care and ambulatory care. And then secondly, I believe that with the amount of business that the VA does, with the private sector, now, somewhere around $13 billion a year and growing with the mission act, that just tapping into those organized systems of care, that already exists in the private sector, and are used to value-based payments or risk-based payments, that if VA was able to pay and use the contracts similar to the way that commercial payers use those contracts that they could take advantage of the exact type of quality improvement systems that are being put in place by the private sector. So I think those are two relatively safe and easy approaches that if VA had the legislative approval to be able to do that, that’s where I would start.
Fred Goldstein 16:04 And you talk some about care coordination between, you know, the VA sector and the private sector. There’s also obviously a lot of care coordination, I would assume within the VA, which is sort of one of the centerpieces of population health very effectively within the VA or approaches like that.
Secretary David Shulkin 16:22 Yeah, I do believe that care coordination in the VA system, while certainly not perfect, and there are opportunities to improve it does work fairly well, that the 30-year history of having an integrated medical record of having, you know, most people geographically based in medical centers, and with a singular focus on a mission for improving the well being of veterans has allowed a communication system and a coordination system that, frankly, I think, create some of the improved outcomes that we see in the VA system, when you compare it to the private sector, the private sector tends to be more fragmented, there’s, you know, more patients that are getting care from various from different sites where in the VA system, that information tends to be held in a singular database. So the area that I think concerns me the most is, is now that we’re seeing more veterans getting care, sometimes in the VA, and then going out to the private sector, and there not being a care coordination system in place. That’s where we’re seeing concerns about quality really increasing. And there was an article that I wrote an editorial on in JAMA earlier this year, that talked about that medication complications were three times greater in veterans who were being sent out into the private sector than the control group that remained in the VA. And I think that all has to do with care coordination.
Fred Goldstein 17:57 You mentioned the VA, learning from the private sector, some of the new payment models, etc. What are some of the things you think the private sector can learn from the VA that you experienced?
Secretary David Shulkin 18:07 Overall, my insights after working government were that there was much more the private sector could learn from VA, then maybe even VA learning from the private sector. And the unique superpower of the VA, I believe, is that VA is in many ways freed from having to worry about the third-party insurance payments and having to focus and prioritize its activities where revenue is greatest, because the VA receives essentially its budget from Congress and is told your job now is to do what’s right to take care of veterans. And so VA is allowed to focus on things that frankly, the private sector doesn’t have the freedom to because the private sector wouldn’t get paid for them. So I’m talking about things like focusing a lot of attention on the social determinants of health. And, you know, VA can focus on things like transportation, and housing and food and different types of social support systems that frankly, the private sector just doesn’t have the ability to focus on. In addition, VA can look at integrating behavioral health care and physical healthcare into a singular unit of care where that often has been challenging in the private sector to get reimbursement for that type of service. So when you look at so many of the activities that VA has had success in in population health and and in behavioral health that would have been challenging to accomplish in in traditional fee for service payment systems, but as we start moving towards more risk-based systems and population health approaches in the private sector, I think many of the approaches that VA has been doing now for decades, begin to make a lot more sense for the private sector and they should be looking at what can be learned from the VA is experience?
Fred Goldstein 20:04 Yeah, I think, Secretary, you, you brought up something that Greg and I and other guests have discussed over the years now on this show, and that you mentioned global budgets, which is really a form of capitation. And so if you have a globally capitated population, then you’re free to make these decisions and maybe spend for as you said the transportation, integrate the mental health, because it’s not in or out of the benefit or have a limited benefit. But ultimately, you’re looking at the best interests of the patient. So that’s sort of how you view that and perhaps where the commercial market should move?
Secretary David Shulkin 20:33 I do think so I think that, you know, the more that I’ve had a chance to experience healthcare, both as a healthcare executive and a patient, I’m pretty convinced there’s no perfect system, you know, and I don’t think that I certainly wouldn’t want anybody to believe that I was arguing for a total government-run system or monopolistic payer system. But I do believe that there are some true advantages to getting away from what is a complete fee for service system and integrating the approaches that you’ve talked about with a with a global cap. But I also believe that there has to be a way to retain the ability to reward for those that are working harder reward for quality, reward for value. And there has to be a way to make sure that innovation and experimentation in terms of the scientific advances that we’ve seen, are allowed to continue and allow what has made the American healthcare system so good, to continue to be able to be sustainable. So I think, you know, interestingly, how we started by talking about that there needs to be the ability to compromise from political ideologies, to really looking at the evidence about what works and what doesn’t work, I believe you’re going to end up with a system that has somewhat of a hybrid component between the capitation system and the fee for service system.
Fred Goldstein 22:06 And you mentioned innovation. Are there any things you see out there in the innovation front that excite you now,
Secretary David Shulkin 22:12 I see incredible innovation and an opportunity. I think that the one thing that I again, you know, always I’m really learning is that things often take longer and healthcare than you initially would, would think that they would. So I don’t want to, I don’t want to oversell or hype, some of these innovations. But I certainly think the whole promise of personalized medicine, whether it’s genomics or proteomics, or you know, the ability to personalize a person’s health prescriptions, and not just on the medication side, I think it’s fundamentally a change in the way that we diagnose and treat patients. I do believe that the overused term of artificial intelligence will continue to have a big impact on improving the way that we deliver care, I believe our use of remote monitoring is going to have a big impact on the way that that we deliver care. And, and I believe that some of the technology that is both miniaturizing and changing the way that we are able to collect diagnostic information on patients will continue to innovate the way that we practice and innovate in a way that’s better. I think the role of the physician clearly is changing and needs to change as these innovations occur in technology groups.
Fred Goldstein 23:39 We started the show, actually, Greg about four years ago, and over four years ago, and David Nash was our first guest. He’s been on a lot. I know, we’re gonna see you at the population health colloquium coming up in March 30. through April 1, I believe you’ll be presenting there. Yeah. Any thoughts about population health at its 20th anniversary of his conference or the field in general?
Secretary David Shulkin 24:01 Well, you know, I’ve known David since we’re both trainees at the University of Pennsylvania, we were both Robert Wood Johnson Foundation, clinical scholars, and David’s always being way out ahead of where other people are. So I think that he saw some of these things that we’re talking about and saw these trends before many people did. And what I said about that they often takes a lot longer for these types of things to happen in healthcare than people realize is that it’s probably been a very frustrating period of time in that early on, I think these population health approaches made sense to a small number of people, but without the major payment reforms that we’re just still seeing, really eating at the periphery of the way that we spend our healthcare dollars. It is a slow road. And so until we see more of these payment reforms, population health, I think is going to continue to build in momentum but probably not have the major type of impact on the American healthcare system without some type of major payment reform.
Fred Goldstein 25:12 Well, I want to thank you so much for coming on again and discussing what’s going on in population health, the VA, congratulations again on your book, and we really look forward to seeing you coming up at the population health colloquium.
Secretary David Shulkin 25:25 Thank you so much. Appreciate it.
Fred Goldstein 25:27 Back to you, Greg,
Gregg Masters 25:28 and thank you for that is the last word on today’s broadcast. I want to thank Secretary Shulkin for his lifetime commitment to public service and the healing arts in particular, including his passion to serve the men and women of the United States military through the National Treasure of the Veterans Administration. For more information or to order Secretary Shulkin’s exceptionally informative and timely piece. It shouldn’t be this hard to serve your country our broken government and the plight of veterans See the link in our program description at PopHealth Week or go to PopHealth Week.com for PopHealth Week, my colleague Fred Goldstein, the Honorable Secretary Shulkin and HealthcareNOW Radio. This is Gregg Masters saying bye now.