Latest / CareTalk: Healthcare. Unfiltered. / Transforming Veteran Healthcare with David Shulkin, MD

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Transforming Veteran Healthcare with David Shulkin, MD · CareTalk: Healthcare. Unfiltered.

• 0:00
  President Obama appointed Dr.
• 0:02
  David Shulkin to the VA, and then President Trump promoted him to a cabinet level role and eventually fired him.
• 0:09
  Now in the private sector, Dr.
• 0:10
  Shulkin is a dogged advocate for veterans and involved in everything from drug pricing to living to 100 plus.
• 0:24
  Welcome to CareTalk, America's home for incisive debate about healthcare business and policy.
• 0:28
  I'm David Williams, president of Health Business Group.
• 0:31
  And I'm John Driscoll, the President of Walgreens Health.
• 0:34
  Have you checked out the CareTalk Newsletter lately?
• 0:36
  It's the source for trending healthcare industry news, links to the latest podcast episodes and highlights, and original blog posts that dive deeper into our podcast topics.
• 0:46
  Subscribe today at caretalkpodcast.
• 0:48
  com slash newsletter.
• 0:50
  Welcome David, and thank you for your service.
• 0:54
  Hey, thanks, John.
• 0:54
  It's great to be with you both today.
• 0:56
  So how did you come to decide to go to D.
• 1:00
  C.
• 1:01
  in the first place with President Obama?
• 1:04
  Well, you know, John, uh, as I always say, this is, this is where you have to be careful about accepting a free lunch.
• 1:12
  I was, um, I had lunch with somebody in Washington that I didn't know who asked to have lunch.
• 1:18
  I always enjoy meeting people like you do.
• 1:21
  And the conversation came around to If I had any regrets in my career and I said, you know, maybe one in that I'm reading right now in the newspaper, all the headlines about the veterans who weren't able to get access to care coming back from Iraq and Afghanistan needing help.
• 1:40
  And yet the wait times were so long in the VA.
• 1:44
  And I said, I really wish I could do something about that because our veterans deserve better.
• 1:50
  And I've never had a chance to serve my country by going into the military.
• 1:55
  I was in medical school in training in most of my twenties.
• 1:59
  And the person just said, you know, I understand that.
• 2:03
  And, um, the next thing I know, I get a call from the white house and they asked me whether I would consider coming to take over the VA at this time of crisis.
• 2:14
  And I remember talking to president Obama and saying, look, you know, why, why me?
• 2:19
  I was running a health system at the time.
• 2:23
  I'd spent my time in the private sector, but I said, you know, you have so many people who've worked in the VA who understand it, who know the culture, who know how it works.
• 2:33
  And he said, that's exactly why we want you because you don't, you know, how private sector works.
• 2:38
  And we need somebody with fresh eyes to come in and take a look at it.
• 2:42
  And of course, you know, when your country asks you for help, particularly for our veterans, I knew that.
• 2:49
  I needed to do that.
• 2:51
  And I think most of us would probably feel the same way.
• 2:54
  How, how did you start to crack the code on something at the time when you walked in, it was seen as an impossible job.
• 3:02
  That's probably why they could only bring someone in who was an outsider.
• 3:07
  Uh, it was a, just a, people forget how dire the news was and, and how few people on Capitol Hill wanted to do anything other than investigate as opposed to help.
• 3:19
  That's right.
• 3:20
  And you know, first of all, I should say, I came in with no political loyalty to anybody.
• 3:28
  I came in with no desire to gain political office.
• 3:32
  It's probably the reason why I'm the last member of the cabinet ever to get a hundred to zero confirmation because I don't do politics.
• 3:40
  So I was there to fix the problem.
• 3:43
  And when I walked in, I was given a gift and that gift was, it was a burning platform.
• 3:48
  This was, this was frankly, a major issue.
• 3:53
  For the president to fix.
• 3:55
  This was a major issue for the public to fix.
• 3:58
  And of course, for the veteran community.
• 4:00
  So when you have a burning platform, you have an imperative to get something done.
• 4:05
  I knew I didn't have a lot of time.
• 4:08
  And I also assessed that unfortunately, when I came to VA, they did not have a solution and I entered the VA.
• 4:15
  about a year after the wait time crisis had started because Senate confirmation took that long.
• 4:23
  And so I went in with a very specific plan, very aggressive.
• 4:27
  I called what was called a stand down, which is a military term where you stop what you're doing.
• 4:32
  You focus on the problem and you get the job done.
• 4:36
  And that's what, that's what we did.
• 4:38
  We had a wait list of over several hundred thousand veterans.
• 4:42
  I established that we were going to go Not the 30 day wait times as the VA had, but to same day appointments.
• 4:51
  If a veteran needed to be seen, I wanted them seen the same day, whether it was physical health or mental health.
• 4:58
  And by the time that president Obama was leaving office, I remember in December of 2016, a month before he was leaving office, I was able to say, Mr.
• 5:08
  President, I can tell you that every VA in this country now has same day appointments.
• 5:14
  And that was the only way I could assure him that the wait time crisis had been addressed.
• 5:18
  So that's, that's amazing.
• 5:20
  And when he left office, though, you didn't.
• 5:21
  And in fact, I read a, a, an account of your interview with then president elect Donald Trump.
• 5:26
  And I, I actually had a hard time, even after reading about it, understanding what the hell had happened.
• 5:30
  What, what happened in that interview?
• 5:31
  Oh, me too.
• 5:32
  I, I, I didn't understand.
• 5:33
  When I, when I left his, his office, he had asked to meet with me, frankly.
• 5:39
  I had my boxes packed.
• 5:41
  I was leaving like every other Obama appointee.
• 5:44
  Uh, and this was a week before his inauguration.
• 5:47
  I was leaving the following week to, to, you know, return to private sector.
• 5:53
  And, um, he asked to meet with me.
• 5:55
  I thought it was an exit interview.
• 5:57
  And frankly, I was glad because I wanted to see the successes that we were having.
• 6:02
  Continue, and I was glad the president elect was interested in that, so I went to his office and, you know, all I can describe it as a Saturday night live scene.
• 6:12
  It was, it was the most sort of wild, uh, hour and a half I had with the present people running in and.
• 6:22
  I love the fact that he starts by saying he's pretty good looking.
• 6:27
  Yeah, yeah, yeah, I, I did not know what to say to that.
• 6:31
  But, but, uh, but anyway, when I left, uh, you know, first call was to my wife who was.
• 6:37
  You know, waiting to hear what happened in this meeting, and I, I, I said, I have no idea what happened in that meeting, but I can tell you, it was pretty fun and interesting, but I had, I had no idea what had happened.
• 6:54
  So, you know, I, so the last time I, I saw you, we were, we were at a conference together and, and you were trying to coerce another group to tell you how to live to be a hundred.
• 7:04
  And, uh, you weren't having that much success, if I may say so.
• 7:07
  You, you got down, you got same day appointments at the VA, but you couldn't get these experts to tell you their real advice.
• 7:14
  Yeah, it was a pretty frustrating panel for me because, you know, this issue of longevity, um, is obviously one that most of us care about a little bit more each day and, you know, in the absence of good scientific information, people are making all sorts of...
• 7:35
  Judgments about that, you know, you take a look at how much people are spending on supplements and various types of treatments and, you know, different strategies and, you know, I think this is where science can come and help sort of dispel the things that aren't working and point people towards things that even if it doesn't necessarily extend your life in terms of the number of days or years that you might live.
• 8:01
  Might extend the quality of the life that you have while you're here.
• 8:04
  And so, so I think it's an important topic and I think this issue of data, uh, large, large language models and generative AI and, you know, all the data we have out there should be helpful in guiding us towards that path.
• 8:19
  And that was the purpose of the panel.
• 8:21
  I'm not sure I took away a lot of answers from it either, but I do think there's a lot of interesting work going on.
• 8:29
  And it's something that frankly, I think is part of the solution of helping us drive.
• 8:35
  Healthcare costs down, improving the quality of life, improving productivity.
• 8:40
  And so hopefully there will be more time and effort spent in that area.
• 8:45
  How much of that is the problem?
• 8:47
  Because we don't look at aging as a disease.
• 8:49
  We look at it as a natural.
• 8:52
  A natural part of the human condition, even though I guess the beginning of the 20th century, I think the average lifespan was closer to 49 than than where it is right now, closer to 80 in the US.
• 9:03
  So we've made enormous progress on lifespan and in some cases health span, but we don't seem to be willing to really.
• 9:11
  It's interesting.
• 9:12
  It's almost more private sector funded than, to your point, research funded.
• 9:16
  What's driving that?
• 9:19
  Well, look, I think there's a lot buried in this issue, but, you know, only, John, because I've recently had to prepare for this panel, did I do the research.
• 9:29
  Surprisingly, we're nowhere near 80.
• 9:32
  Um, Lifespan in this country, longevity, has actually gone down since 2021.
• 9:39
  So, we're seeing a decrease for the first time since 1921 in American lifespan.
• 9:46
  And that gap is increasing actually between men and women.
• 9:51
  It's, um, but every age group, every disparate, I mean, every racial group, every, uh, group of socioeconomic status has experienced a decline in longevity since 21.
• 10:05
  Uh, I do think that, that this idea of approaching it more as a physiologic disease state, rather than, uh, You know, the way that it often is approached right now is an important issue because, you know, this is so tied into the whole sustainability.
• 10:25
  Of our healthcare system with 60, 000 people turning 65 every day, entering the Medicare system, the birth rate in the U S going down, the ratio between workers and those that are going to be on retirement and public systems going up.
• 10:41
  We do need to find some type of sustainable solution that is going to keep people healthier longer and keep people productive longer, quite frankly, if we're going to make the whole system sort of work out.
• 10:54
  And so I do think it is now time to approach this now.
• 10:58
  There's lots of interesting things, you know, with new pharmaceutical compounds coming on the market, the GLP ones actually may end up being, um, you know, a longevity drug in some ways, you know, now I know lots of concern about how they're being used, but, you know, we're seeing also look can be come onto the market again, having, there are lots of adverse event problems, but to treat Alzheimer's disease, Uh, and to have an impact on that.
• 11:25
  I think this is, this is the right type of direction.
• 11:29
  You know, I, I didn't see this panel, but I think it might've been more successful.
• 11:32
  Another one that you moderated, which was about rural health care and obviously an important topic and a big intersection with the veterans community, uh, as well.
• 11:41
  How, how did that go?
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  And what's.
• 11:42
  What's your view of rural health care these days?
• 11:45
  Yeah, absolutely.
• 11:46
  I think, I think rural health care, you know, one of the reasons I got interested in it, 45 percent of veterans live in rural communities and the VA has responsibility for delivering care no matter where a veteran lives.
• 12:00
  Uh, and so we had, uh, work to figure out how do you do that in places that you don't even have facilities.
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  And so that was a reliance on technology.
• 12:09
  It was a reliance on home based care.
• 12:12
  Uh, and frankly, the models of reimbursing and paying for rural health care with the increasing shortage of professionals available in those areas.
• 12:23
  Uh, is, is a key issue for the country at the national health policy level.
• 12:28
  And now you're seeing a new entrance in the market like Main Street Health having just raised 315 million two weeks ago with new models of risk based care for rural communities.
• 12:41
  You're seeing new proposals to reinvent the critical access hospital.
• 12:46
  You're seeing health systems, uh, with increased interest in it.
• 12:49
  And I was with a number of those CEOs this week at this summit.
• 12:54
  Uh, I think it's just an area where there is a lot of innovation and frankly, technology, I think, is going to be part of the solution on how we close the disparities of care because going back to our prior discussion, unfortunately, you have a much higher incidence of dying from heart disease, lung disease, suicide.
• 13:14
  other types of chronic conditions if you live in a rural area than if you live in an urban area today.
• 13:22
  What's the, what do you think the status, if you look back right now at the VA, as opposed to where you, where it should be, what kind of grade would you give the VA and what can you recommend the current administration to improve the care of veterans?
• 13:37
  I mean, obviously You made enormous progress, David.
• 13:39
  And, uh, and again, I know some of the people who turned down the top job, not because they didn't want to serve, but they didn't see a path to success.
• 13:49
  There are plenty of resources, but there's, I don't know, I forget the number of committees of jurisdiction, but it's too many and, and, and yet you clearly made progress, um, what, what's your outsiders, insider, outsider view now.
• 14:04
  Of what the VA should be doing right now, not just in rural care, but in general to improve the care of veterans.
• 14:10
  Some of many of whom are still broken from sort of the forever war we've been fighting, uh, in the war against terrorism.
• 14:17
  Absolutely.
• 14:18
  And, and, and John, because, because I think that we have this commitment to people who serve the country, it's the reason why I continue to stay involved in this today.
• 14:30
  And, you know, I think as Vincent said, President Trump may have fired me, but that didn't stop.
• 14:36
  My willingness and desire to continue to give back to our, our veterans.
• 14:42
  And frankly, I'll stay involved in that as long as I live, quite frankly, or as long as I'm capable of contributing.
• 14:48
  Uh, so I think a lot about this.
• 14:50
  I think the first part of your question is I think the VA is in a much better place.
• 14:54
  Then when I entered the VA back in the original wait time crisis now, eight or nine years ago, and, uh, I think that we've stabilized a lot of things.
• 15:03
  I think now VA has a plan and a formula for continuing to build on its successes in the past.
• 15:11
  And, and I think secretary McDonough, who's now leading the VA is doing an excellent job, and I have a lot of faith in the undersecretary.
• 15:20
  Dr.
• 15:20
  Elnahal, um, he was my fellow when I was the undersecretary, uh, at VA.
• 15:26
  And I think, I think they're both doing a great job.
• 15:29
  That doesn't mean that the VA doesn't continue to have problems, that the VA doesn't continue to let down some of our veterans.
• 15:36
  I can tell you, I hear from hundreds of them each month.
• 15:40
  that believe that we should be doing better.
• 15:42
  And, and of course I agree with them.
• 15:44
  So I think the key areas for improvement for VA, and I think this is more, uh, really continuing.
• 15:53
  To focus on this, that the current administration is, is focusing, but we need to make more progress is modernizing the system.
• 16:01
  We still have, uh, facilities that are largely built in the 1940s and fifties.
• 16:07
  And we need veterans to have modern care.
• 16:10
  The rule in private sector is I would build a new hospital or a hospital wing every 10 years.
• 16:16
  VA.
• 16:17
  hasn't been doing that.
• 16:19
  So they need to catch up and I think they need to do that through public private partnerships.
• 16:23
  I think VA needs to continue to invest in, in, in its technology, its, uh, information technology systems.
• 16:31
  Uh, for, for a large part of based on old technology, the Vista EMR is still mumps technology.
• 16:39
  Um, you know, we need more viable, sustainable, interoperable systems.
• 16:47
  And that's one of the reasons why I felt that VA needed to move towards a commercial system such as Cerner.
• 16:53
  So.
• 16:54
  Uh, I hope that that continues.
• 16:56
  I think that VA needs to continue to be very transparent.
• 17:01
  And I think, you know, I was, I was very, uh, outward in publishing our wait times and publishing our opioid rates and publishing all of our quality data.
• 17:12
  I think VA has stepped off a little bit from that.
• 17:14
  And I think that's a mistake because if you want to keep the trust of the people that you serve and the trust of the American public, um, I think that.
• 17:24
  You need to be transparent with that.
• 17:26
  So, so that's nary.
• 17:28
  I think that drove performance, David.
• 17:29
  I thought that was courageous.
• 17:30
  And also it created a competitive dynamic that was quite powerful.
• 17:35
  And, and John, you're exactly right.
• 17:37
  I published an article in the new England journal saying that competition is the way to improve the VA.
• 17:43
  Don't be afraid of it.
• 17:44
  Competition, while it is scary, makes us all better.
• 17:48
  It makes us up our game.
• 17:50
  And I had the utmost confidence that VA could provide.
• 17:53
  That level of competitive care in an environment that understood who veterans are and understood the veteran experience to make it extraordinarily competitive.
• 18:04
  I believed in the VA, but I believe hiding behind a monopolistic theory of management never works.
• 18:10
  So, so, so there are a number, there are a number of things that, uh, that I think are important, but frankly, you know, continuing to invest in the centers of excellence for War related illnesses for areas that VA does extraordinarily well like.
• 18:27
  prosthetics, orthotics, uh, rehabilitation, but also behavioral health.
• 18:34
  TBIs and behavioral?
• 18:35
  Absolutely.
• 18:36
  And integrating physical and behavioral health care models, interdisciplinary care, home based care, caregiver support, peer support, adaptive sports, you know, these are all things that I think VA does extraordinarily well and needs to continue to build upon.
• 18:53
  Well, that's it for another episode of Care Talk.
• 18:56
  Dr.
• 18:56
  David Shulkin had been a guest at Trump Tower before, but this is his very first time as a guest on Care Talk.
• 19:02
  I wonder which will be more memorable or more understandable.
• 19:05
  I'm David Williams, President of Health Business Group.
• 19:09
  And I'm John Driscoll, President of Walgreens Health.
• 19:11
  If you liked what you heard or you didn't, please subscribe on your favorite service.
• 19:15
  Thank you, David, and thanks again for your great service.