Former VA Secretary David Shulkin, MD, talks about his accomplishments since leaving government work, his vision of the VA as a care coordinator, and where he thinks the US health system is headed.
David Shulkin, MD, served the US Department of Veterans Affairs from 2015 to 2018. First as Under Secretary under President Obama, and later Secretary under President Trump. He is currently chief innovation officer at Sanford Health, a Sioux Falls, SD health system with a presence in 26 states and 9 countries. Dr Shulkin works in academia and provides strategic direction and advice on national health care issues. Prior to joining the VA, he held key executive positions at several hospitals and health systems. Dr Shulkin is a board-certified internist who maintains a keen interest in generating positive outcomes at the point of care. First Report Managed Care recently sat down with him to catch up.
Dr Shulkin, what have you been up to since leaving the VA in 2018?
After leaving government, I took some time to reflect on how I wanted to continue my work and have an impact on things that matter to me. Besides my family, I want to continue to advocate on behalf of this country’s veterans, and I want to be involved in the continued evolution of health care, searching for ways to improve outcomes and improve efficiency. Rather than focus on just one activity, I’ve been able to get involved with a number of organizations and companies that are committed to making a real difference in people’s lives. I also have time to write and publish, and to work clinically in a federally qualified healthcare center in New York City.
One of the organizations you now serve is Sanford Health, a Sioux Falls, SD health system with a presence in 26 states and 9 countries.
As chief innovation officer, I focus on helping Sanford innovate new ways to deliver health care and advance technology. I am an advocate of bringing precision medicine to the bedside.
You specialize in health care management. What drew you to that area of work?
I’ve always defined myself first as a physician. I still look at things first from a clinical perspective—what I can do to help patients have healthier and more productive lives. But I have also been a person with a big curiosity about how complex things work and I like to solve problems. That led me to focusing more of my time on the management of systems. My first area of management focus was on quality and safety and that led me to dig deeper into ways that we could make our system work better for patients and providers.
You have a particular affinity for patient-centered care, which is not surprising given your ‘physician first’ approach. Can you address the importance of making sure issues related to healthcare management don’t get caught up in the esoteric or theoretical?
The reason I still practice medicine—which I also did as Secretary of the VA—is to make sure that I remain grounded in what is important. In the end, the patient and the provider experience determines the success of an executive’s initiatives.
What have you found are the keys to making a real difference at the point of care?
To me it’s about providing timely and appropriate access, making the right clinical decisions in both diagnosis and treatment, involving the patient and family in decision making, and being transparent about results and outcomes.
Prior to joining the VA, you spent quite a number of years in the private sector at hospitals and group practices. And you served as president of the Morristown Medical Center, as well as president of the Atlantic Health System accountable care organization (ACO). What did that experience teach you about the importance of outcomes?
I’ve always believed that to make real progress there needs to be an alignment of the clinical and financial incentives. The ACO model is a move in that direction, where improving outcomes
and lowering costs can both be achieved. Gaining management attention and provider focus is required to be successful and the ACO model has shown some real success in accomplishing this.
Do you think the current focus on quality measures by ACOs and others is helping improve outcomes?
If you look at where we are with quality measures in ACOs at this time, I think we are moving in the right direction. The ACO should be viewed as a transitional model of care. It moves us from fee for service to a more managed model, but it is only a partial solution to achieving optimal outcomes.
So, what should come next?
As the ability to use data improves to do predictive analytics and to create better decision support systems, we will also see the model of care change. That’s when you’ll start to see big improvements.
What do you think makes the VA special?
The VA represents an important delivery system for the country for several reasons. First, it is essential for us to deliver on our commitment to caring for those that have served and put their lives on the line for all of us. It provides a unique delivery system that meets the specific needs of those injured in the line of duty. Second, it provides an essential part of our medical education system in training so many of our country’s physicians, nurses, pharmacists, psychologists and other professionals. Third, the research that is done in the VA not only improves the lives of veterans, but it also has changed the way we deliver care to all Americans.
The VA system has repeatedly shown better outcomes of care than what we see in the private sector. While that may be a surprise to many, it does not surprise me. The VA offers a comprehensive approach to health that integrates the physical, psychological, spiritual, and economic parts of a veteran’s life. It is this
holistic approach—which some today call the social determinants of health—that is the superpower of the VA, and has shown the
ability to improve outcomes of care.
You favor a model at the VA that moves toward privatization, but with the VA firmly in charge. Can you explain why you think that is the best approach?
I am a proponent of a hybrid model that include a strong VA system that is focused on those services that it can do best, supplemented with care from the private-sector that concentrates on what it can perform best.
Can you tell us more about that approach?
Sure, it calls for evolving the current system by expanding private partnerships. It’s not “one size fits all.” Rather, it is a different mix of services depending on the unique needs of local markets. The one commonality would be an integrated seamless experience for veterans going from within the VA to the private-sector and back.
You’ve written extensively on this topic, including in a perspective that ran in The New England Journal of Medicine, “Becoming a High-Performance Network” in 2016.
In this type of system there would be private-sector delivery systems that make it through a highly competitive process involving measurement of access standards, service levels, and clinical outcomes, as well as additional community providers who would be subjected to specific quality care requirements. They would treat veterans who cannot receive clinically appropriate care at a VA-available care. It is an outcomes-based that system allows veterans to access the best care anywhere that is available.
Of course the VA is not without its challenges, as evidenced by a recent VA Inspector General report citing unusually long wait times and inaccurate wait time reporting in the VA scheduling system. What do you say to those who advocate for faster or full privatization of the VA?
This model of care, i have just described must be implemented carefully so it does not result in the complete privatization of VA, but rather creates a world class system of care for veterans.
The VA needs to transition from being a pure provider of care to a network coordinator of care, and at the same time focus its efforts on modernizing facilities and systems in areas that veterans rely upon most. In order to accomplish this, the VA must have a strong focus on primary care delivery and mental health delivery. This, in conjunction with selected specialty services, would allow the VA to be the network coordinator of care.
What are some of the health policy issues you are working on today?
My interest today is in furthering our work in public health issues that impact veterans, as well as all Americans. At the top of my list is suicide prevention. To address this problem, we must look at the underlying issues with our behavioral health care system and address issues such as social isolation and loneliness.
We must also look at tough problems like pain and substance abuse. I am also interested in population health approaches to issues that we can have an impact on such as hepatitis and chronic care management.
Given the political climate and divisiveness in Washington, where do you see our health system heading in the near future?
Political predictions are not my strong suit, and much of what occurs must be viewed at in the political context. But I do believe that whatever political solution we choose to follow as a country, we must ensure that access to affordable health care is a priority. We also have to be able to use technology to help reduce the cost of care and improve the accuracy of diagnosis and treatment if we are use our resources better in the future.
What advice would you give managed care stakeholders as they navigate an uncertain and divided climate?
Health care one of the few industries that has not seen a major disruption to their business model. I believe that two things will impact the system in a major way in the next 10 years. First, we will see a big move to the model of direct to consumer health care. This will be enabled much like people are used to getting information from the internet in other areas of their life, making choices based upon readily available information, and controlling their own data. Second, is the use of technology with personalized medicine and artificial intelligence. This will allow for more targeted approaches to care and overall improvements in quality and value. Stakeholders will need to adapt to those changes