Venture Partner Perspectives: Dr. David Shulkin (Ninth Secretary, U.S. Department of Veterans Affairs)

Welcome to FundRx Venture Partner Perspectives, where a FundRx team member conducts a brief interview with a FundRx Venture Partner, with the aim being to share the knowledge and opinions of a diverse array of healthcare clinical and industry experts. Subsequently, we hope these interviews spur further thought and potential innovation and action in the areas discussed.

This interview features David Shulkin, MD. Dr. Shulkin served as the Ninth Secretary of the US Department of Veterans Affairs, having been appointed by President Trump. Dr. Shulkin previously served as Under Secretary for Health, having been appointed by President Obama and confirmed twice unanimously by the US Senate.

Prior to coming to VA, Dr. Shulkin was a widely respected healthcare executive having served as chief executive of leading hospitals and health systems including Beth Israel in New York City and Morristown Medical Center in Northern NJ.

As an entrepreneur, Dr. Shulkin founded and served as the Chairman and CEO of DoctorQuality (acq. by Quantros) and has served on boards of managed care companies, technology companies, and health care organizations. Over his career, Dr. Shulkin has been named, “One Hundred Most Influential People in American Healthcare” by Modern Healthcare. Currently, he is President of Shulkin Solutions (www.ShulkinSolutions.com). Follow him on Twitter @DavidShulkin.

*This interview has been edited and condensed for clarity.**

Dr. Chris Duff: What does your current day to day look like, and what’s most exciting to you and your team right now?

Dr. Shulkin: This is really a very different time for me. Once I left government, I’ve gotten a chance to sit back and reflect upon so much of what I’ve seen happen in health care over the last 30 years.

My focus now is really to spend my time on things that are going to make a difference, and that really involves thinking through where the most transformation is going to happen in health care over the next decade. I’ve taken a deliberate approach to identifying areas and opportunities that are going to be making the most difference in health care, and that’s where I’m spending my time — areas that I think are mostly innovative.

I’ve also dedicated time to both teaching and academic writing, so that I’m able to continue to contribute back to others the lessons that I’m learning, which is always an important part of my professional life. I think it’s really important to invest in those that are going to continue to come up the ranks and be the ones who will be the leaders and transformers of health care.

Chris: Can you describe your experience going from a physician executive in the private sector, to public, and then back to private? What are some of the unique opportunities and challenges associated with each sector, and how did you adapt your mindset accordingly?

Dr. Shulkin: I spent almost all of my career prior to government in the private sector, and I deliberately, upon entering government, didn’t want to give up those management skills and the way I approached things in the private sector. I wanted to bring that private sector approach to government.

I think that I entered the Department of Veteran Affairs (DVA) at a unique time, when there was clearly a crisis in wait times and it appeared to me that the traditional way of dealing with that in government wasn’t working. I took a very private sector approach towards trying to solve the problems that I thought were most important.

Much of what I learned in the private sector was transferrable to the public sector. The big difference I found was that in the private sector, almost everything that worked required you to really think through the alignment of clinical interests and financial interests.

In government, it’s not as strong about the alignment of the financial interests. In other words, at VA we were essentially given a lump-sum budget each year by Congress, and we were then told to fulfill our mission, which was to do the right thing and help promote the well-being of veterans.

In many ways, it was an easier focus, because there was a clear path towards doing the right thing and making sure that the resources that we were given were being utilized, without the constraints of so many of the third-party requirements.

In other words, we didn’t have to worry as much about what we billed for and what we collected. Rather, the goal was to make sure that we were using our resources most effectively.

There are differences in operating in the private and public sectors, and it takes a while to get used to that. Certainly, the political component of having 435 members of Congress and the executive branch interested in what you’re doing requires a different approach, and a different set of skills.

But the overall management strategy of identifying priorities, setting achievable milestones, measuring the outcomes, sticking to timelines and holding people accountable are all pretty transferable between the private sector and the public sector.

Chris: During your tenure at the VA, would you be able to describe one or two examples of successful product or service deployments within that particular department and/or within the hospital system for the VA?

Dr. Shulkin: When I first entered VA under the Obama administration, the mandate was pretty clear: improve the wait-time issues. The first approach that we needed to accomplish was to quantify the problem. We really didn’t have metrics that allowed us to identify which patients needed to be seen at what time.

In other words, we didn’t have an assessment regarding the urgency of the clinical problems. But once we were able to identify which patients needed to be seen first, we were able to put solutions in place that ultimately eliminated the wait list for urgent care, and we established same-day services in every VA medical center in the country by December 2016.

Part of our solution for eliminating wait times was the dramatic expansion of the use of telehealth, and that required some regulatory changes, as well. We were able to use our federal supremacy to be able to cross state lines and deliver health care via telehealth from anywhere in the country to anywhere else in the country. That was a very effective deployment of technology resources to help address the wait time issue.

A second implementation that I think was very important and still will continue to be important as our 21 million veterans continue to age, is addressing the issues of the largest population of patients who are the Vietnam War veteran group — with an average age of nearly 70 years old. As these veterans continue to age, we’re going to have to do a better job at long-term care, and addressing well-being in senior populations. I set forth a mandate to be able to provide broader and more comprehensive care in the home care setting.

Again, this was a very comprehensive implementation where we not only used technology like remote monitoring, but also used service offerings, like home care visits from primary care and specialty physicians. We worked to implement a comprehensive program for caregivers at home, supplying pharmaceuticals, durable medical equipment at home, and providing a comprehensive set of services to give veterans an alternative to having to leave their homes and go into institutional settings. This was a second broad implementation across the country.

Thirdly, I would just mention a specific example, addressing hepatitis C. With the introduction of new drugs to the market that had very effective cure rates — at the 95 percent cure rate level and above — we targeted an approach to eliminate hepatitis C in the veteran population.

Using our data analytics, were able to identify veterans that were serologically Hepatitis C positive. We then used a team-based approach to care with pharmacists leading our clinics, and were able to proactively contact veterans and bring them in for treatment. As a result, we treated over 100,000 veterans who had known Hepatitis C over the course of approximately 18 months.

These three challenges serve as examples of: getting the system aligned around goals; setting timelines; creating the budgets and the accountabilities; and really being able to measure the impact of broad implementation of programs and systems to be able to improve the health and well-being of the veteran population.

Additionally, as Secretary, I would put on a lab coat, and I would go and practice medicine. I felt there was no better way than that to see the technology/clinical implementations firsthand in order to understand the impact of some of the policy decisions and how they were being implemented.

I would practice in New York City and take care of veterans in person at the Manhattan VA. I would also practice from my office in Washington, DC that overlooked the White House. Using telehealth, I could reach veterans in Grants Pass, Oregon, which is a very rural site that had lost its primary care physician. I was able to step in using telehealth.

Telehealth really allowed me to be able to see how care was being delivered and to use the electronic medical record (EMR). Again, I later made the decision to replace that existing EMR with a commercial system, but I felt like if I hadn’t used it and understood what its strengths and weaknesses were, I wouldn’t have been as effective in being able to make decisions like that.

Chris: All things considered, from a private and public perspective, what are the some of the biggest gaps in healthcare that are most in need of energy and innovation, in your mind? Any companies/technology developments that have promise to address those gaps?

Dr. Shulkin: As I’ve looked around and done my environmental scan of what’s happening in health care and cross-matched that with the areas that I personally am passionate about and see the biggest gaps in, I think that there are general areas that I’ve identified.

The first is behavioral health. I think from both my private and my public sector experience, there’s nothing more broken in our system than the behavioral health care system. Whether it’s access to care, the effectiveness of care, or the outcomes of care, I think that we have the most opportunity to narrow the gap by finding effective solutions in behavioral health.

The second would be social determinants of health (SDoH), and this is really the superpower of VA. Not being limited by our current private sector reimbursement system, VA has been able to focus on many of the SDoH.

If a veteran is homeless, there are programs to help identify both temporary and permanent housing. This is key since there’s nothing more difficult than improving the health of a person who doesn’t have a place to pick up medications or a safe place to live at night. I think that the work that’s now being done and being energized within the private sector on social determinants is going to be very important.

The third area is personalized medicine. I’m pretty convinced that if we’re really going to make substantial improvements in the cost and outcomes of care, we’re going to have to do much better at diagnosing the right conditions earlier, and then targeting the right treatments to those conditions.

I still think we have tremendous variation in the way that medicine is practiced across this country. We have a lot of care that’s being delivered ineffectively — not deliberately — but because people just don’t know the proper diagnosis or the proper treatment strategies. I think personalized medicine is going to be an important part of that.

A fourth area is predictive analytics. Some of the work that I was doing and continue to do at the DVA uses big data to identify which patients can be intervened upon at an earlier point of their disease progression.

At VA, my single top priority was to reduce veteran suicide, since 20 veterans a day are taking their own lives. We had developed a predictive database, REACH VET, where we were able to identify veterans at 80X the baseline risk over the next 12 months for suicide. We began to contact those veterans to try to see whether there were proactive interventions to implement before a veteran reached the point of wanting to take his or her own life.

I think that predictive analytics have a lot of potential opportunity and will be important in the future. I’ve also mentioned my interest in remote monitoring technologies which are getting better. They’re not only allowing a more efficient transfer of information back to providers, but they’re also allowing patients themselves to take more control of their health care and get more involved in their own health planning and understanding of their conditions. This will improve compliance and that could begin to start impacting outcomes.

The field of genomics, which is related to personalized medicine, is witnessing the introduction of 70 new genomic tests coming onto the market every day. I think that the science and the practice of medicine are going to have to start coming together, and as providers learn more about how to integrate genetic information into their practices, it will have an impact.

Lastly, I think the consumer engagement tools and the ability of consumers to take more control of their health care on both the financial and the clinical sides will be important drivers in the continued evolution of the way that we see health care play out over the next decade.

These are the areas that I’m following closely and am working with in order to have the biggest impact on health care delivery.

Chris: In order to stay up to date in those areas and just health care, in general, what are some of your go-to resources — news, readings, speaking with particular individuals, your own clinical experience — to really stay up to date with the latest happenings and developments within the industry?

Dr. Shulkin: I’m generally pretty old school about this and there’s so much information overload out there right now. I think that it’s pretty easy to fall into the path of just following the crowd in health care, seeing what people are talking about and jumping onto it. When I say I’m sort of old school, I prefer the general strategy of continuing to have conversations with people whose opinions I respect and who have a unique perspective.

I reach out to colleagues, do the traditional get together for breakfasts and lunches and really talk to people about what their experiences are — — what they’re seeing and their take on things. I’m very much learning from my own social network, as opposed to learning from the mass social networks that are out there.

For example, when I attend an industry conference, I tend to spend more time outside the general sessions talking to people and colleagues that I bump into — rather than sitting in the audience listening to the presentations. I tend to learn better by having personalized or individual discussions with people rather than through formal presentations.

Chris: Obviously you’ve had an extraordinarily successful career within the healthcare industry. What is the most rewarding aspect of your current role, and what advice might you give young people interested in science or healthcare, to gain a leg up and contribute in a meaningful way?

Dr. Shulkin: I think there’s no doubt, when I look back upon my career, and I look back upon other people’s successes, is that having help along the way is critical. As others find their way in their own careers, I am having an impact by mentoring some of them, and many of the people that I’ve had a chance to mentor, either through formal programs or fellowship programs, have gone on to do great things.

It’s really a multiplier effect. If you can have an effect on another person and influence their career and their ability to realize their own potential — and you can do that many times during your career — those people are going to go out and do great things. That really begins to have an impact.

We all started our careers at the beginning and know how important it was to have had mentors and people that we’ve looked up to, people who have given us advice. To me, that’s the most rewarding thing. Keeping in touch with the people who I’ve had the chance to work with and see them go on and develop their careers. I think this is the most professionally and personally satisfying aspect of my career.

The advice that I would give people is this: if you’re going to envision yourself as a leader in healthcare or a person who transforms or disrupts healthcare, you just can’t be satisfied with the status quo. You have to be willing to challenge the conventional thinking, be willing to take risks, and be willing to fail.

The important thing is to stick with it and continue to push the system to get better and better serve patients. Ultimately, this is really what the healthcare field is all about. I think that sort of constant dissatisfaction with the way things are and by challenging conventional thinking are what really prompts people to make an impact.

Chris: To wrap up, where can people find out more about what you’re up to and potentially connect if there’s some potential value?

Dr. Shulkin: I do have a website: www.shulkinsolutions.com, and I am on Twitter, @DavidShulkin, and I’m working on a few things to be able to share my experiences and lessons that I’ve learned. I’ll be working on these over the summer and will share them with people as they’re ready to come out.

As we talked about initially, one of my goals is to be able to have an impact on what people are doing, to be able to help those that are in the position to be transformative. I’d like to share my experience and to focus on those things that I am passionate about. Part of that is just making sure that people know what I’m doing, so more to come on that.

Chris: That’s a great teaser and I am sure they are going to be exciting projects. Any additional parting thoughts for the audience that you didn’t get to touch on before? Anything else you wanted to mention?

Dr. Shulkin: Knowing that there are so many entrepreneurial people out there and people trying to create things, I just have a tremendous admiration and respect for how hard the work is and how tough it is every day to wake up and to be fighting the inertia and the sort of slowness to change that makes up so much of healthcare.

The thing that gives me the most hope about where we are headed is knowing how many people are out there — trying to change the model and trying to improve the way we do things. But, I recognize it’s never easy.

When you see somebody who’s successful, it’s very hard to remember all the small failures that they had along the way. Nobody ever has a straight path towards success, and I just really want to provide my encouragement to those that are continuing to face the daily struggles to build something that’s sustainable and impactful. I thank them for all their efforts.