The Future of Healthcare with Dr. David Shulkin, former Secretary of the United States Department of Veterans Affairs Part 1

When I got to the VA and I got to meet the people and the families that were serving our country, and many times I was meeting the parents of children that had been killed in Afghanistan or taken their lives in suicide after they had returned home from overseas. And I began to understand the commitment and the dedication of these families, that it wasn't just one child serving in these families. It was often three or four children and nephews and cousins and uncles, that there were, you know, entire communities where service was the way that they define themselves.

And then there are other parts of the country where you couldn't find anybody in the family that served. And it really began to bring home this point that we all need to get to know each other and we need to share this responsibility among all of us and not put all the burden on a smaller community. Hello, hello, and welcome to Pharma Sessions, a place for pharmaceutical leaders to come and learn from each other. I'm your host, Jonathan Kaskey.

Technology and market trends are bringing change at an ever-accelerating rate, and no person, team, or company can afford to be left behind. Here, we dive into the strategies and tactics that our guests use to tackle these challenges and create new opportunities and how you can do the same in your own organization. This episode of Pharma Sessions is sponsored by Exont, makers of the X1 reporting platform. So on today's episode of Pharma Sessions, I'm thrilled to welcome Dr.

David Shulkin, physician, healthcare executive, and ninth secretary of the United States Department of Veteran Affairs. Dr. Shulkin is the only person to have led the VA healthcare system under two different presidential administrations, overseeing the nation's largest integrated health system serving more than 9 million veterans. With a career-spanning academic medicine, hospital leadership, entrepreneurship, and public service, David brings a uniquely informed perspective on the challenges and opportunities facing public health in the U.

S. today. So on this episode, we'll explore the current state of public health, the intersection of policy and care delivery, the role of innovation and technology, and really what must change to better serve patients. So with that, David, welcome to the show.

Glad to be here. All right. Was I accurate in my introduction? Is that a fair summation of uh kind of a wide and varied career to date?

I think you did a good job. Okay, good. Checkbox one. Where are you calling in from today?

Philadelphia. Oh, nice. I lived in Mount Erie for about 10 years and I'm now just down the road in Rehoveth Beach, Delaware. So come by and we'll get some crabs sometime.

Sure. But um all right. Well, so that was a quick intro, but maybe if you'd like, can you share a bit of your background and kind of what led you from the path of practicing medicine or as a physician into public service? I don't have a really good story.

I was minding my own business, uh running health systems, and thought I would do that forever because it was really a job that I love doing. Uh, I'm a physician. I define myself largely as a physician and having the opportunity to be able to oversee these institutions that deliver care to their communities, largely not-for-profit institutions. I've always had a commitment to the underserved.

And uh one day my phone rang and I was asked to help come during a time that the VA was struggling with a large wait time crisis. This is when many men and women were returning from Iraq and Afghanistan and really needed a lot of help. But it was also at the same time that our Vietnam veterans were turning on average, age 75, and their medical needs were really becoming to be in high demand as well. And the VA was overwhelmed, and they needed somebody to come in and to help take a look at the system, the way that we were delivering care.

And when the president calls you to ask you to do that, your life changes. And so, of course, I said of I'd be honored to come in to help. And I left my job and moved to Washington. And what year was this?

2014. Interesting. So, just on a personal note, my dad was actually working for the VA around that time. He's a psychiatrist, and so he was probably treating a number of both of those generations of people, right?

The Vietnam and then the recent wars in the in the Middle East until he joined and started sharing his stories. I didn't really have a concept of the scope of the VA, but it is a humongous organization, right? Like one of the largest organizations in our country, as far as second, probably to the military, right? For a number of people.

Yeah, it's actually the largest integrated health system in the country. In terms of government agencies, it is the second largest. The Department of War is the largest and then the VA, but it has a very large scope. It employs the most doctors in the country, the most nurses, physical therapists, social workers.

It trains the most number of physicians and nurses and other ancillary professionals anywhere in the country. A lot of people just don't think about it, but it's very important for the overall healthcare ecosystem in the country as well as our national security system. One of the other things just related to your dad, I had really no idea myself until I got into the VA, but it is largely a very, very strong behavioral health care system. As you know, the behavioral health care system for many Americans just simply doesn't work very well.

Behavioral health care was carved out of our insurance system from physical health care, which makes no sense how you can separate the brain from the rest of the body, but our insurance executives found a way to do that. It essentially would I believe dumbed down the behavioral health care system. So it made it harder for people to get that type of help. But in the VA, it is a strong, deep system.

And of course, behavioral health care issues, particularly the issue of suicide among veterans, is still a very critical and serious issue. That's the argument that he's always had with people that aren't in the mental health aspect is like, no, these are diseases that have an actual mortality rate, even more so in the VA, unfortunately. But was it interesting? This is a little bit of a digression, but I was actually impressed with some of the programming that they were able to do that was kind of very outside the box.

So a lot of stuff that he was dealing with was around like addiction rehabilitation, basically, and then PTSD, of course, right? And but one of the things for people that were on the maybe that were the outpatients, right? That were not in an inpatient facility, they had a program that he was saying that's absolutely loved, where it was actually like they go and they'd have their sessions and then they would do go-kart races of all things, right? And he's like, these are very competitive group of people, and them just getting to do the hard work and then have this fun, right?

Together and feel that camaraderie. I thought it was kind of amazing that when you think of what you were just talking about with the scale of the organization, they're still able to do kind of interesting and innovative, innovative things where you could imagine something like that getting hung up in red tape a million different ways. Yeah. I'm I mean, Jonathan, it sounds like um we should be doing a different podcast than talking about pharmaceuticals.

This is an area I'm passionate about. My dad also was a psychiatrist, an army psychiatrist. I was born on an army base when he was serving in the army. But this issue of the fact that as secretary, I would get the money from Congress, that means the taxpayers, and then they would allow me to figure out the best way to spend it.

I didn't have to follow the third-party insurance rules the way that most other executives do. And so we could do things exactly like what you're talking about. The VA invested very heavily in things like peer support, in adaptive sports. Go-karts might be an example of that, but we would take people skiing down mountains who had lost their legs or who were paralyzed.

We get them engaged in wheelchair games like the Olympics, in wheelchairs, golfing, whatever we could do to get people re-engaged in their social life, to prevent isolation, to create peer support. And you just can't do that when you work in a health system where you're evaluated by how much you bill and how much you collect from insurance companies. And it's one of the powers that the VA can provide. Yeah, that's fascinating.

And I think that bringing it back around to what you had first started was essentially coming on to lead this massive, massive organization. And I think that the initial challenge that you had were were trying to adjust was wait times, right? So I'm curious how you even begin tackling something like that across an organization at that scale and what what your approach was and what the results were. Well, I think in many ways I had a couple advantages.

One is I was an outsider, so I was able to come in with a fresh set of eyes, but I didn't have a bias about doing it a certain way. Second thing is I had a very strong burning platform. This wait time issue with veterans not being able to be seen, allegations of veterans dying because of wait times in Phoenix, Arizona, uh, the fact that it was in the national spotlight, not only in the press, but in the Congress, but also directly from the president who had asked for the resignation of the previous secretary over this.

I knew that this was important, so I was able to focus on it. And the first thing I did was I established the new standard, and that was veterans who had very urgent health care issues, whether they were physical care or mental health care, would be seen the same day. And that gave a very clear sense to the organization about what success looked like. And then we went about implementing it.

And it took a number of different programs and initiatives to get us to implement that, including the dramatic expansion of telehealth across the country, giving advanced practice nurses full license authority to be able to see veterans, being able to redesign our workflow, publishing publicly our wait times. The end result was by the end of the Obama administration in December of 2016, I was able to tell President Obama that we had solved the wait time crisis. And the way that we knew that is that every VA in the country had implemented same-day appointment scheduling.

We were able to measure that and demonstrate that there weren't veterans waiting who had urgent medical and psychiatric problems. That type of burning platform to fix it is a very powerful one, particularly when you're doing it for such a deserving population. So you ended up implementing between joining in 2014 and the end of the Obama administration in 2016, you ended up implementing the same day appointments. What was the wait time before?

Just curious. There were well over 500,000 veterans that were waiting for urgent medical care more than 30 days. More than 30 days. So more than 30 days to the same day.

Wow, that's really incredible. I will say, and it's interesting. I'm like going into this conversation, I was struggling with like how to have the conversation, honestly, given the current political environment, like how much demonization there is of many people on the government side of giving health care by our own government, right? And I think the results you're describing are amazing, but the intent that you're describing doesn't surprise me at all.

Have been fortunate enough to spend a lot of time with people in the FDA. And like the first word that comes to mind is just professionalism. Like these people are professionals to the point where, you know, we're at conferences or something, and everybody's going out to dinner and drinks, and it's like they won't come to that, right? Because they don't even want the appearance of the impropriety that it would be to have have a drink with somebody from industry, basically.

And so I think that it's just really good to hear these stories of you know people trying really hard. And as you said earlier, there is no profit motive. I mean, I'm sure you know the numbers better than I do, but everything that I've seen shows that when you actually look at how much of healthcare spending goes to actually providing healthcare versus other things, the public sector actually does it much better than the private sector. Just how do you feel having worked so closely in this organization and doing the things that you're doing now with the state of the discourse and how things are portrayed?

First of all, it's it's nice to hear your reflection on this. Most people I talk to feel a very similar way. And in the past, veterans issues, uh, military issues, many public service issues were not partisan issues, but we've seen this over the past couple of administrations, not just this last one, that many of these topics had become politicized. And we take a look at what's happening currently in the CDC and other areas, and you can see that politics has crept in and it's hurt the overall reputation of the agency and the trust of information coming from government that the public, you know, has to now interpret under a different lens.

And so I've worked very hard to try to keep at least the Department of Veteran Affairs, and I think the secretaries that have followed me have had a similar desire to try to keep this out of the political realm. And of course, I was confirmed 100 to zero twice. And to me, that's not so much about me as it is about the fact that the Congress really wants to be able to have the trust in organizations that care for people like our veteran. And yet there are many people that are trying to force their politics into these situations.

In my term, particularly in the first Trump administration, dealt with what I call the political appointees that I think put their own political ideology above the needs of the veterans and tried to politicize the environment. I ended up writing a book about this called It Shouldn't Be This Hard to Serve Your Country about what it's like to try to enter public service like I did, not for personal gain. I left being a CEO of a large health system where I can tell you I had a lot greater salary than I did as a cabinet member.

But I did it because I thought it was the right thing to do, and people should give back to their country. And I came up against political ideologues that clearly had other ideas in mind, and it made the job much, much more difficult. So Washington is a tough place. Those who say if you want a friend, get a dog.

I now understand that very, very well. There's not a lot of people in Washington that are trying to manage from the center. They're trying to manage more from the political spectrums. And I think it makes running public agencies more difficult.

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That's XS-U-N-T.com. All right, let's jump back into the episode. So, what do you see as a path forward or a potential solution, right?

Because it to me, again, I'm an outsider to this, but it seems unrealistic to say we're going to be able to get politics out of the VA, for example. What is the path forward to still focus on patient outcomes and improving quality of care while navigating these waters? Well, I think what's encouraging is precisely what you said. When you go into these organizations, you find people that are truly professionals, that are mission-oriented, that understand that administrations come and go, but their job is to continue to do what they're there for, and that is to provide the right types of services without politics in mind.

So I uh I don't wake up worried about these institutions. I wake up more worried about our leaders. And I hope that there are leaders that in the future that rise to the top that do represent the majority of Americans, which are in the center. They're not pure political ideologues on either the left or right, but want to see the country run well, doing the right things, taking care of those that need help.

That's the role of government. The other role of government, of course, is national security to make sure that our country remains independent, strong country. And I think you can manage most of these issues from the center. And that means without having to point fingers or or villainize people who don't have the same exact beliefs as you.

And one of the things that always makes me proud of being an American is the fact that in America we have the ability to respect people's personal beliefs, religious beliefs, and get along. And right now I'm spending time like many people watching the Olympics, and it just makes me proud that we have so many different types of people representing our country, and we're all cheering for them to do the best that they can. We're recording this the day after I'm blanking on her name, but we have have an American who won the gold for the women's figure skating for the first time in quite some time.

So very cool to see. What do you think? So you really do have a view into the scope of America through the VA. What do you think about the the way the the veteran population receives treatment that reveals any gaps in access, equity, continuity of care across the U.

S.? Well, the VA is really a system that operates within the U.S. healthcare system.

So many of the problems and inequities that we see throughout America do exist in the VA. But in terms of being able to deliver care regardless of the ability to pay, regardless of where people live, that is rural America or urban America, regardless of the demographic of the population, everybody who has served this country and been discharged honorably from the military gets treated the same. I think that it is very powerful to see that when people serve together, whether they're black, white, whether they're Christian, Jewish, Muslim, if they serve together, they have each other's backs, they view themselves as brothers and sisters, and those bonds exist often for a lifetime.

And so to me, watching this sort of melting pot of the U.S. military and the way that they serve together and then we treat them afterwards is the way that I think the rest of our society should be modeled. And it's one of the reasons why I believe that the current situation that we're in, where people just seem to live in their own bubbles and hear ideas and beliefs from people who think like them but don't get exposed to others, is really only polarizing society more.

I've come to believe that one. Of the answer should be implementing a year of public service after high school. And a year of mandatory service after public high school, after public after high school may not sound very popular. I think it is essential for the country to come together, for young people to have a shared mission, but for young people to be exposed to people that aren't necessarily like them, who don't come from their communities, but who work together under common purpose.

And it wouldn't necessarily have to be a year where they serve in the military. They could serve in any type of social good project, whether it's to help the homeless in our cities throughout the country, whether it's to teach across America, whether it is to be involved in environmental projects, to serve overseas, like in the Peace Corps. There are so many ways that that could happen. But I think the imprinting, the foundational experience of working with other people and having to share an experience with people who aren't like you is so important for the future of this country that we really do need to begin to think like that.

That's fascinating. And did you have any similar types of experience in your own life that you're drawing that from? Or what's the inspiration for this concept? I wish that I had had that experience.

One of the reasons why I really was very willing to leave my private sector job and go into the VA when I was asked by the president is because I did not serve in the military. I did not give back to the country in some way. I was in medical school during my twenties, and other people chose to do other things with their lives during that time. But the ability for me to be in public service gave me that experience.

For me, I had grown up very much in a bubble in my community's social circles, even though my father and had served in the military. But when I grew up and I grew older, I didn't know many people who served in the military or many military families. And as you probably know, less than 1% of Americans actually serve in the U.S.

military. So many people don't know these families. But when I got to the VA and I got to meet the people and the families that were serving our country, and many times I was meeting the parents of children that had been killed in Afghanistan or had taken their lives in suicide after they had returned home from overseas. And I began to understand the commitment and the dedication of these families that it wasn't just one child serving in these families.

It was often three or four children and nephews and cousins and uncles, that there were, you know, entire communities where service was the way that they define themselves. And then there are other parts of the country where you couldn't find anybody in the family that served. And it really began to bring home this point that we all need to get to know each other and we need to share this responsibility among all of us and not put all the burden on a smaller community. Yeah, it's really interesting.

I mean, just from my personal experience, which has not been as intense as either what you're describing or taking a full year, but just for example, right now I work with this local group, kind of for a teen mentorship perspective. A lot of these kids are trying to be maybe the first one in their family to go to college, for example. Whether it's that, whether it's habitat for humanity, right? Anytime I spend time volunteering, I leave feeling so optimistic and like so fulfilled, basically, because it is very much, I mean, the commonality is not hard to find amongst people.

Everybody kind of wants the same thing, right? They want to feel safe, secure, happy, they want to feel like there's a future, right? And there's certainly, I mean, it's obviously there's a lot that people across the political spectrum don't have in common, but there's a lot more that they probably do, right? And it also, when we talk about like pride of being an American, right?

You feel a connection to the place where you live. If you can drive down and you can tell your kids, like, hey, I helped build that house, right? Like that you've been, you're a part of the community in a different way. So if we could end on an optimistic note, let me ask one final question here, which is looking back on your career in healthcare leadership, in public service, what gives you optimism right now about the future of public health in America?

As I'm looking right now, I am seeing a complete new openness to thinking about the future of our healthcare system. And that's really happening from two points of view. The most obvious one that I think people think about is what's happening on the technology front. And with the new applications of artificial intelligence, we have the ability to really not only reimagine the way that healthcare can be delivered, but delivered in a way that really tracks towards the evidence and the science of what works, and the ability to identify and explore new ways of doing things much quicker, much more efficiently than we've ever done before, whether that's using artificial intelligence for new drug development, or whether it's using artificial intelligence in large databases to look at where things are working and where they're not working, but then the ability to be able to actually take those lessons and the evidence and apply it to actual practice ethics.

So on the technology side, I think it's a whole new world. On the payment side and the model of healthcare, I also think this is a time that we're seeing new policy ideas and new models of delivering care in a much more vigorous way than we've seen in decades. And the idea that we're going to have to do something different than traditional fee-for-service medicine. We're going to have to move towards more population health approaches and more value-based care approaches.

I think we're seeing these ideas now coming out of our leaders in Washington and more support, even in the private sector, for doing this more aggressively, largely because a recognition that the way that we're doing it isn't working, that healthcare costs are continuing to go up, that we're seeing probably more Americans being uninsured and having problems with access to care. And a recognition that continuing to do things the same way is not going to get better. It's going to get worse.

So we have this sort of combination of the business model and the technology, both driving towards new ways of doing things. And that gives me a very optimistic outlook on the future. Love that. All right.

Well, Dr. David Shulkin, thank you so much for joining. It was an absolute pleasure. This episode of Pharma Sessions is sponsored by Xunt, makers of the X1 reporting platform.

And that's a wrap on today's episode of Pharma Sessions with me, Jonathan Kaske. If you enjoyed today's conversation, don't forget to hit follow or subscribe and share it with someone else in the pharma world who might need to hear it. For more on pharma trends, career growth, and business strategies, connect with me, Jonathan Kaske, on LinkedIn. Until next time, thanks for listening.