Tom Sullivan | October 21, 2019
Former Veterans Affairs Secretary David Shulkin was famously fired – on Twitter, no less – by President Trump in 2018. Now, he’s out with a new book: It Shouldn’t be This Hard to Serve Your Country.
Health Evolution Editor-in-Chief Tom Sullivan spoke with Shulkin ahead of the book’s release. Shulkin also shared insights drawn from his experience at the VA working on population health, value-based care and holistic practices.
Q: Let’s start with the book. What was the inspiration for writing it?
A: I wrote the book for two reasons. One is that when I left the private sector to go into government, I did that because I believe Veterans need the system to work better for them. If any group in this country deserves the best health care it’s our veterans. I came in at a time of crisis, the wait time crisis, and we needed to fix that.
I believe we found the formula and were making great progress. I had spent 3 years learning what worked and what didn’t – then President Trump abruptly ended that when he fired me. I had all this knowledge and felt an obligation to put it down on paper so hopefully we can keep the improvements in motion.
The second reason was that, just like I left the private sector to go into public service to help, I want to encourage other people to do that. But our environment today is becoming so toxic and hard to work in that I’m really concerned about the future of public service. So I wanted to share my story and what I experienced for future leaders.
Q: Having worked as a private sector CEO and Secretary, what are your takeaways from time spent at the VA?
A: There are many takeaways from my experience at the VA and government. One is that going in I naively thought I was bringing all this private sector experience but I did not anticipate I would learn so much at the VA that the private sector needs to learn. It’s what I call the superpower of the VA.
A: We had better population health than commercial systems and were able to focus on physical, spiritual, mental, economic – what people call social determinants of health. What VA does is, it gets a budget allocation from Congress, a sum of money to go take care of its population of veterans. That means the VA doesn’t have to worry about third-party reimbursement – so it’s able to allocate resources where they’ll have the biggest impact, such as housing, medication, transportation, a very heavily-resourced system for behavioral health, economic benefits such as disability. It’s a much more holistic approach toward health and wellness than the private sector because commercial organizations are so limited by how they are reimbursed. To me, that’s the biggest lesson from the VA.
Q: Based on your description of the VA getting a lump sum from Congress to manage care for veterans, in addition to the population health lessons, what are the insights relative to value-based care for private sector CEOs?
A: One of the examples in value-based care is I took a look across our health care system of Veterans and asked how many have Hepatitis C? We looked in our database at bloodwork and found 163,000 people who were positive for it. The reason I asked that question is that a medication had just come on the market for it and curing this disease would be good for veterans and also save taxpayers money down the road. I went to Congress and said I wanted to eliminate Hepatitis C and I needed $1.5 billon to do it and they allocated it. Using a systemwide outreach approach and using professionals to run clinics in a short period of time we’ve been able to almost eliminate Hepatitis C from our veteran population. The VA has now treated more than 100,000 of those and within this year should have completed the rest.
That’s the way health care systems that are value-based are going to have to start thinking, and being more proactive.
Q: Getting back to your book, what did you learn from the VA’s wait time crisis and what lessons are there for private sector CEOs?
A: When I came to VA, I was given the gift of knowing the problem and what my initial priorities should be. So I did three things. One, I made it clear to more than 350,000 employees that our number 1 focus was going to be fixing the wait time issues and in order to do that we needed to understand the problem better. The issue wasn’t how long Veterans waited, it was whether Veterans waiting for care were harmed by that.
If you had a 5-6 week wait for an annual eye exam, that wasn’t a problem. But if you were short of breath or had cancer, that was a problem. I had to redefine the way we measure the wait times. Once we did that I was able to prioritize so we took care of the most urgent needs first, and we were able to reduce that time.
Second, I never wanted us to be in the situation again where we might be causing harm for veterans, so I created a mandate for same day services in every VA in the country. That took about 15 months but in December 2016 I was able to tell President Obama we had achieved it.
The third thing was to post all our wait times across the country. VA became the first system to publicly post its wait times so we had accountability but also so veterans could have the choice to go to different facilities.
Q: As a final question, are there other messages or themes in the book that we did not discuss?
A: The reason I’d like my colleagues to read this is to understand how they can help. The VA needs to remain a strong sustainable system that focuses on things the private sector doesn’t do as well: prosthetics, PTSD, traumatic brain injury, environmental hazards of war. Veterans need a strong government-led system but the VA cannot be everything and it cannot provide the same quality in all areas so the private sector needs to contribute. When I came to VA, 19 percent of veterans were getting care in the private sector. When I left it was 36 percent and I think it’s important that our colleagues in the private sector understand how they can participate in serving veterans the best way.