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In June 2015, David J. Shulkin, MD was sworn in as VA Under Secretary of Health—a position that had been empty for more than a year following the resignation of Robert Petzel, MD, in the wake of the Phoenix wait-time controversy. Carolyn M. Clancy, MD, had filled the position on an interim basis. Federal Practitioner recently sat down with Dr. Shulkin to discuss his plans for improving both health care quality and employee morale across the VA, which has been sapped by the recent scandals.
Building a New Health Care System
VA Under Secretary of Health David J. Shulkin, MD.I think there is an overlap between the design of a new health care system and having high levels of staff satisfaction. To me, it starts with being able to provide your employees, physicians, and staff with the types of tools and resources that they need to be able to take care of patients and a work environment that allows them to feel that they can practice to the best of their professional levels.
When I go around to visit VA facilities across the country, I see tremendous variation. I see some facilities that have invested in great programs, so their staff feels like they are practicing in world class facilities. And I see other places [where] it looks like they’re practicing 30 years ago.
The plan that we’ve put forth proposes that we invest our resources in a way that allows everyone who works in the VA to feel like they are working in a world class center. But that also means that we won’t be able to do everything for everybody. When you make investments, it means that you’re going to invest in one place and not everywhere. So there are some things that the VA may actually no longer do.
However, our plan allows us to develop the types of facilities where people will want to work and continue to want to work, by leveraging what already exists that’s being done well in the private community.
Applying Best Practices to the VA
Dr. Shulkin. Implementing best practices is not the same to me as standardizing everything. I think that all you have to do as a physician is reflect back upon medical school. Almost everything I learned in medical school is no longer relevant and none of the drugs. So there is a recognition that in order to be good at something, you need to be continually challenging the evidence that you have and the beliefs that you have and learning and improving and evolving and innovating. So implementing best practices, to me, is not stifling innovation or stifling experimentation. What it says is that if you have an organization as big as ours and somebody is doing something well, others should be learning from it and adopting it.
The example I point to is James A. Haley Veterans’ Hospital in Tampa, Florida. They’re doing same-day access primary care. They have no wait times. That’s our issue, wait times, and here’s a place that has no wait times. And the staff love it and the patients love it.
Why isn’t every VA doing that? I can’t think of a reason. It doesn’t mean they’re going to have to do it exactly the same way, and it doesn’t mean 5 years from now there won’t be a different way of having patients get appointments and access to care. But today, that’s the best practice that I can see, and I want every VA doing that.
Bringing an Outside Perspective
Dr. Shulkin. There were times when having an outside person come in to be Under Secretary would have been a challenge. But I think right now, given where the VA is, there is a recognition that having outside eyes is a good thing. Within the VA, there is a thirst for understanding how problems are solved in the private sector, and there is a real openness to new ideas. I think this comes from a recognition that it doesn’t feel good to be working as hard as I know most VA professionals are and continuing to see themselves bashed in the press
So people are open to new ideas, and they want to get beyond where we are. Having outside eyes on this is seen, today, as a good thing. But it needs to be done carefully and in a way that respects the things that have made the VA great, the good parts of the culture, and the hard work of the professionals who are caring for veterans every day. This can’t be a message of changing everything in the VA because, clearly, there are lots of things that are working really well. But there are areas where we can benefit from perspectives outside of the VA, and that’s what I’m trying to bring to the organization.
Increased Hiring Within the VA
Dr. Shulkin. A large part of the Veterans Choice Act funds that were authorized in 2014 were targeted toward new hires. The VA has hired a net increase of 14,000 employees. I think there were 1,600 net new physicians and 3,500 net new nurses. We’ve hired professionals in almost every part of the organization, including homeless coordinators, social workers, and pharmacists. You’ve seen hiring across the board. I think that you will continue to see that, but it will be more targeted toward areas we’ve identified that will impact access the most and where the shortages are the greatest.
Primary care doctors and psychiatrists will be 2 areas where there will be targeted hiring, and there are specialty areas that, depending on the geography, that will be targeted for hiring as well. Depending upon what our budget looks like, which we still don’t yet know for 2016, 2017, and 2018, we will see how much additional flexibility may be there for hiring.
Cost vs Quality of Care Debate: Lessons Learned From Hepatitis C Care
Dr. Shulkin. I think the challenge and the lessons that we’re trying to learn from the hepatitis C example was that when we put our 2015 budget together, we didn’t even know that new hepatitis C drug [cures] existed. We were looking at the older version—the interferons, which of course, weren’t curative in the same way. By the time that our budget actually hit, there was a new drug that offered new hope. Frankly, for the VA, that amounted to about a billion dollars in unfunded monies, because we didn’t know about the drug when we put that budget together. So that is a challenge for us.
Having said that, I’m very proud of the way that VA responded by moving money around to make sure that veterans got the right care. Nobody in this country has treated more veterans with hepatitis C than the VA. Nobody even comes close. More than 35,000 veterans received treatment for hepatitis C that’s curative in 2015. Nobody does it by addressing disparities in health care the way the VA does. We reach out to those that are in most need. Those with the mental health issues. Those that are essentially socially isolated. We’re calling them and bringing them in. No other health system does this. The VA has actually shown why it’s a great organization in responding this way. 2016 and beyond, we are committed to trying to find ways to do that. We will work with our ethics people, our hepatologists, our policy people, Congress, and drug makers to make sure that we can do the best we can for veterans.
Providing Long-term, Quality Care While Offering Options to Veterans
Dr. Shulkin.The VA is not a voucher program. This is not sending people out into the community to find their own care. VA health care is a well-integrated coordinated plan for people who we feel a responsibility for, for life. They are going to be VA patients as long as they want to be VA patients. But this is our responsibility, so that when they go out into the community, their care needs to be coordinated and tied back into VA health care. It can’t be seen as a separate health care system or a fragmented health care system.
That’s the problem that we’ve learned in health care, both in the VA and outside the VA. When you fragment care, when you separate care, that’s where you find quality problems and gaps in care that lead to people missing necessary testing or treatments that they need.
We deliberately designed Veterans’ Choice to address these issues, because these are our patients and our responsibility. When they go into the community, it doesn’t mean they leave VA. It means they’re getting care in the community as part of the VA health care system.
In June 2015, David J. Shulkin, MD was sworn in as VA Under Secretary of Health—a position that had been empty for more than a year following the resignation of Robert Petzel, MD, in the wake of the Phoenix wait-time controversy. Carolyn M. Clancy, MD, had filled the position on an interim basis. Federal Practitioner recently sat down with Dr. Shulkin to discuss his plans for improving both health care quality and employee morale across the VA, which has been sapped by the recent scandals.
Building a New Health Care System
VA Under Secretary of Health David J. Shulkin, MD.I think there is an overlap between the design of a new health care system and having high levels of staff satisfaction. To me, it starts with being able to provide your employees, physicians, and staff with the types of tools and resources that they need to be able to take care of patients and a work environment that allows them to feel that they can practice to the best of their professional levels.
When I go around to visit VA facilities across the country, I see tremendous variation. I see some facilities that have invested in great programs, so their staff feels like they are practicing in world class facilities. And I see other places [where] it looks like they’re practicing 30 years ago.
The plan that we’ve put forth proposes that we invest our resources in a way that allows everyone who works in the VA to feel like they are working in a world class center. But that also means that we won’t be able to do everything for everybody. When you make investments, it means that you’re going to invest in one place and not everywhere. So there are some things that the VA may actually no longer do.
However, our plan allows us to develop the types of facilities where people will want to work and continue to want to work, by leveraging what already exists that’s being done well in the private community.
Applying Best Practices to the VA
Dr. Shulkin. Implementing best practices is not the same to me as standardizing everything. I think that all you have to do as a physician is reflect back upon medical school. Almost everything I learned in medical school is no longer relevant and none of the drugs. So there is a recognition that in order to be good at something, you need to be continually challenging the evidence that you have and the beliefs that you have and learning and improving and evolving and innovating. So implementing best practices, to me, is not stifling innovation or stifling experimentation. What it says is that if you have an organization as big as ours and somebody is doing something well, others should be learning from it and adopting it.
The example I point to is James A. Haley Veterans’ Hospital in Tampa, Florida. They’re doing same-day access primary care. They have no wait times. That’s our issue, wait times, and here’s a place that has no wait times. And the staff love it and the patients love it.
Why isn’t every VA doing that? I can’t think of a reason. It doesn’t mean they’re going to have to do it exactly the same way, and it doesn’t mean 5 years from now there won’t be a different way of having patients get appointments and access to care. But today, that’s the best practice that I can see, and I want every VA doing that.
Bringing an Outside Perspective
Dr. Shulkin. There were times when having an outside person come in to be Under Secretary would have been a challenge. But I think right now, given where the VA is, there is a recognition that having outside eyes is a good thing. Within the VA, there is a thirst for understanding how problems are solved in the private sector, and there is a real openness to new ideas. I think this comes from a recognition that it doesn’t feel good to be working as hard as I know most VA professionals are and continuing to see themselves bashed in the press
So people are open to new ideas, and they want to get beyond where we are. Having outside eyes on this is seen, today, as a good thing. But it needs to be done carefully and in a way that respects the things that have made the VA great, the good parts of the culture, and the hard work of the professionals who are caring for veterans every day. This can’t be a message of changing everything in the VA because, clearly, there are lots of things that are working really well. But there are areas where we can benefit from perspectives outside of the VA, and that’s what I’m trying to bring to the organization.
Increased Hiring Within the VA
Dr. Shulkin. A large part of the Veterans Choice Act funds that were authorized in 2014 were targeted toward new hires. The VA has hired a net increase of 14,000 employees. I think there were 1,600 net new physicians and 3,500 net new nurses. We’ve hired professionals in almost every part of the organization, including homeless coordinators, social workers, and pharmacists. You’ve seen hiring across the board. I think that you will continue to see that, but it will be more targeted toward areas we’ve identified that will impact access the most and where the shortages are the greatest.
Primary care doctors and psychiatrists will be 2 areas where there will be targeted hiring, and there are specialty areas that, depending on the geography, that will be targeted for hiring as well. Depending upon what our budget looks like, which we still don’t yet know for 2016, 2017, and 2018, we will see how much additional flexibility may be there for hiring.
Cost vs Quality of Care Debate: Lessons Learned From Hepatitis C Care
Dr. Shulkin. I think the challenge and the lessons that we’re trying to learn from the hepatitis C example was that when we put our 2015 budget together, we didn’t even know that new hepatitis C drug [cures] existed. We were looking at the older version—the interferons, which of course, weren’t curative in the same way. By the time that our budget actually hit, there was a new drug that offered new hope. Frankly, for the VA, that amounted to about a billion dollars in unfunded monies, because we didn’t know about the drug when we put that budget together. So that is a challenge for us.
Having said that, I’m very proud of the way that VA responded by moving money around to make sure that veterans got the right care. Nobody in this country has treated more veterans with hepatitis C than the VA. Nobody even comes close. More than 35,000 veterans received treatment for hepatitis C that’s curative in 2015. Nobody does it by addressing disparities in health care the way the VA does. We reach out to those that are in most need. Those with the mental health issues. Those that are essentially socially isolated. We’re calling them and bringing them in. No other health system does this. The VA has actually shown why it’s a great organization in responding this way. 2016 and beyond, we are committed to trying to find ways to do that. We will work with our ethics people, our hepatologists, our policy people, Congress, and drug makers to make sure that we can do the best we can for veterans.
Providing Long-term, Quality Care While Offering Options to Veterans
Dr. Shulkin.The VA is not a voucher program. This is not sending people out into the community to find their own care. VA health care is a well-integrated coordinated plan for people who we feel a responsibility for, for life. They are going to be VA patients as long as they want to be VA patients. But this is our responsibility, so that when they go out into the community, their care needs to be coordinated and tied back into VA health care. It can’t be seen as a separate health care system or a fragmented health care system.
That’s the problem that we’ve learned in health care, both in the VA and outside the VA. When you fragment care, when you separate care, that’s where you find quality problems and gaps in care that lead to people missing necessary testing or treatments that they need.
We deliberately designed Veterans’ Choice to address these issues, because these are our patients and our responsibility. When they go into the community, it doesn’t mean they leave VA. It means they’re getting care in the community as part of the VA health care system.
In June 2015, David J. Shulkin, MD was sworn in as VA Under Secretary of Health—a position that had been empty for more than a year following the resignation of Robert Petzel, MD, in the wake of the Phoenix wait-time controversy. Carolyn M. Clancy, MD, had filled the position on an interim basis. Federal Practitioner recently sat down with Dr. Shulkin to discuss his plans for improving both health care quality and employee morale across the VA, which has been sapped by the recent scandals.
Building a New Health Care System
VA Under Secretary of Health David J. Shulkin, MD.I think there is an overlap between the design of a new health care system and having high levels of staff satisfaction. To me, it starts with being able to provide your employees, physicians, and staff with the types of tools and resources that they need to be able to take care of patients and a work environment that allows them to feel that they can practice to the best of their professional levels.
When I go around to visit VA facilities across the country, I see tremendous variation. I see some facilities that have invested in great programs, so their staff feels like they are practicing in world class facilities. And I see other places [where] it looks like they’re practicing 30 years ago.
The plan that we’ve put forth proposes that we invest our resources in a way that allows everyone who works in the VA to feel like they are working in a world class center. But that also means that we won’t be able to do everything for everybody. When you make investments, it means that you’re going to invest in one place and not everywhere. So there are some things that the VA may actually no longer do.
However, our plan allows us to develop the types of facilities where people will want to work and continue to want to work, by leveraging what already exists that’s being done well in the private community.
Applying Best Practices to the VA
Dr. Shulkin. Implementing best practices is not the same to me as standardizing everything. I think that all you have to do as a physician is reflect back upon medical school. Almost everything I learned in medical school is no longer relevant and none of the drugs. So there is a recognition that in order to be good at something, you need to be continually challenging the evidence that you have and the beliefs that you have and learning and improving and evolving and innovating. So implementing best practices, to me, is not stifling innovation or stifling experimentation. What it says is that if you have an organization as big as ours and somebody is doing something well, others should be learning from it and adopting it.
The example I point to is James A. Haley Veterans’ Hospital in Tampa, Florida. They’re doing same-day access primary care. They have no wait times. That’s our issue, wait times, and here’s a place that has no wait times. And the staff love it and the patients love it.
Why isn’t every VA doing that? I can’t think of a reason. It doesn’t mean they’re going to have to do it exactly the same way, and it doesn’t mean 5 years from now there won’t be a different way of having patients get appointments and access to care. But today, that’s the best practice that I can see, and I want every VA doing that.
Bringing an Outside Perspective
Dr. Shulkin. There were times when having an outside person come in to be Under Secretary would have been a challenge. But I think right now, given where the VA is, there is a recognition that having outside eyes is a good thing. Within the VA, there is a thirst for understanding how problems are solved in the private sector, and there is a real openness to new ideas. I think this comes from a recognition that it doesn’t feel good to be working as hard as I know most VA professionals are and continuing to see themselves bashed in the press
So people are open to new ideas, and they want to get beyond where we are. Having outside eyes on this is seen, today, as a good thing. But it needs to be done carefully and in a way that respects the things that have made the VA great, the good parts of the culture, and the hard work of the professionals who are caring for veterans every day. This can’t be a message of changing everything in the VA because, clearly, there are lots of things that are working really well. But there are areas where we can benefit from perspectives outside of the VA, and that’s what I’m trying to bring to the organization.
Increased Hiring Within the VA
Dr. Shulkin. A large part of the Veterans Choice Act funds that were authorized in 2014 were targeted toward new hires. The VA has hired a net increase of 14,000 employees. I think there were 1,600 net new physicians and 3,500 net new nurses. We’ve hired professionals in almost every part of the organization, including homeless coordinators, social workers, and pharmacists. You’ve seen hiring across the board. I think that you will continue to see that, but it will be more targeted toward areas we’ve identified that will impact access the most and where the shortages are the greatest.
Primary care doctors and psychiatrists will be 2 areas where there will be targeted hiring, and there are specialty areas that, depending on the geography, that will be targeted for hiring as well. Depending upon what our budget looks like, which we still don’t yet know for 2016, 2017, and 2018, we will see how much additional flexibility may be there for hiring.
Cost vs Quality of Care Debate: Lessons Learned From Hepatitis C Care
Dr. Shulkin. I think the challenge and the lessons that we’re trying to learn from the hepatitis C example was that when we put our 2015 budget together, we didn’t even know that new hepatitis C drug [cures] existed. We were looking at the older version—the interferons, which of course, weren’t curative in the same way. By the time that our budget actually hit, there was a new drug that offered new hope. Frankly, for the VA, that amounted to about a billion dollars in unfunded monies, because we didn’t know about the drug when we put that budget together. So that is a challenge for us.
Having said that, I’m very proud of the way that VA responded by moving money around to make sure that veterans got the right care. Nobody in this country has treated more veterans with hepatitis C than the VA. Nobody even comes close. More than 35,000 veterans received treatment for hepatitis C that’s curative in 2015. Nobody does it by addressing disparities in health care the way the VA does. We reach out to those that are in most need. Those with the mental health issues. Those that are essentially socially isolated. We’re calling them and bringing them in. No other health system does this. The VA has actually shown why it’s a great organization in responding this way. 2016 and beyond, we are committed to trying to find ways to do that. We will work with our ethics people, our hepatologists, our policy people, Congress, and drug makers to make sure that we can do the best we can for veterans.
Providing Long-term, Quality Care While Offering Options to Veterans
Dr. Shulkin.The VA is not a voucher program. This is not sending people out into the community to find their own care. VA health care is a well-integrated coordinated plan for people who we feel a responsibility for, for life. They are going to be VA patients as long as they want to be VA patients. But this is our responsibility, so that when they go out into the community, their care needs to be coordinated and tied back into VA health care. It can’t be seen as a separate health care system or a fragmented health care system.
That’s the problem that we’ve learned in health care, both in the VA and outside the VA. When you fragment care, when you separate care, that’s where you find quality problems and gaps in care that lead to people missing necessary testing or treatments that they need.
We deliberately designed Veterans’ Choice to address these issues, because these are our patients and our responsibility. When they go into the community, it doesn’t mean they leave VA. It means they’re getting care in the community as part of the VA health care system.
