Responding To The Challenges Of Pain Management With Former United States Secretary Of Veterans Affairs David Shulkin, MD

Welcome back to the Healing Pain Podcast with David Shulkin, MD

I had the honor to interview the ninth United States Secretary of Veteran Affairs. Secretary and Dr. David Shulkin was born on an Army base in Illinois, where his father served as a military psychiatrist. Upon his father’s discharge, the family moved to Philadelphia, where his mother, a social worker, was from and where Dr. Shulkin grew up.

His career spans several decades working in private medical centers but took a turn in 2015 when President Barack Obama appointed him as the United States Secretary of Veteran Affairs for health. In 2017, Dr. David Shulkin became Secretary Shulkin and served as the ninth United States Secretary of Veteran Affairs under President Donald Trump. Secretary Shulkin is known for tackling tough problems in our healthcare system and for his ability to turn around alien hospitals and medical centers.

I spoke with Secretary Shulkin about his experience working in private medical centers, as well as his time in the Veterans Administration Health System, ways we can improve our nation’s mental and physical wellbeing, healthcare technology and innovation. He shares some of his recommendations for better serving those living with chronic pain. Without further ado, let’s begin and meet Secretary and Dr. David Shulkin.

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Responding To The Challenges Of Pain Management With Former United States Secretary Of Veterans Affairs David Shulkin, MD

Secretary Shulkin, thanks for joining us on the show. It’s an honor to have you here.

I’m glad to be here.

I’m excited to talk to you about some of your personal and professional history in health and medicine, some of your work in the private, as well as the public sector and later on talking about chronic pain and some ways we can start to address that more effectively as we move forward. When I look back at your history, people know you in circles as someone who rehabilitated hospitals going into major medical centers.

A lot of them are in the New York tri-state area but other parts of the country as well. In 2014, you transitioned to government-based healthcare. President Obama appointed you and brought you in. I’m wondering if you can tell us at that time where you were working in the private sector and how did you prepare for that transition from private to more government-based healthcare?

First of all, it’s great to be with you. You got a good summary of my career correct, which is I’m not the person to come in and run an organization that’s working smoothly. I’m not the guy who keeps the operations going. I like challenges. I’m attracted to very mission-driven work that needs to be fixed. Fortunately, in healthcare, there’s no shortage of problems and ways that we can make our healthcare system work better for the average person. That’s ultimately what I’m about.

In 2014, I was the CEO of Morristown Medical Center, which is in Northern New Jersey. It’s about a $1.3 billion organization that had a large tertiary acute hospital, children’s hospital, a rehabilitation hospital and several large integrated structures like accountable care organizations and physician groups. I was working towards transitioning that health system into a value-based health system, trying to better integrate risk-based contracting. Not because I thought it was the most productive business model but because I believed that an integrated approach towards healthcare delivery would improve the care of the populations we served in Northern New Jersey.

At that point, I got a call from the White House, which corresponded to what was happening. I was watching on the television and reading in the newspapers about what was called the wait time crisis, where hundreds of thousands of veterans were not able to get the appointments they needed in the VA. At the time, we were seeing pretty severely injured soldiers returning from overseas after horrific combat experiences, both the physical and emotional wounds of war.

President Obama at the time asked me whether I would help him come into the VA healthcare system and fix that problem. I simply was not something that I was prepared to do but knowing the experience that I had in healthcare and taking on difficult challenges because I think I’m good at it, I said, “I’ll help you, Mr. President.” That started a process towards becoming a political appointee to lead the Veterans Health Administration.

You’re coming into the largest healthcare system in the United States of America, which is no small feat for someone who’s been in the private sector. How did you start to prepare and say, “I might be entering into a different game than I’m used to?”

No doubt that I did not understand government. That was a deliberate choice of the president. He did not want to replicate the current system and thinking that existed in government because there were plenty of talented people with 400,000 employees in the department of Veteran Affairs affiliated with every major academic medical center in the country. There were plenty of people who understood the VA system.

He was looking for somebody who understood the private sector, who would think about the problems that led towards the wait time crisis in a different way and come challenge the system. I was somewhat naive. I had not worked in Veterans Affairs since I was a resident in my medical training. I thought, “How difficult could this be? I know private sector healthcare. I’ve run a lot of organizations and people are people. This is going to be pretty easy. I’m going to show the government how efficiently the private sector runs things. I’m going to bring all the tools, tricks and experience I have to the VA and fix it.”

When I got there, it was exactly the opposite, which is the tools and techniques of the private sector do not translate easily into the government setting. It’s a whole different environment, culture and set of rules. If I wanted to be successful, I would need to understand how the system worked and how I could be helpful. One of the ways I did that was by putting on my white coat, stethoscope, and getting right into the clinics practicing first in Manhattan, in New York City at the VA, taking care of veterans.

HPP 263 | Challenges Of Pain Management
We should be trying to move towards better integration risk-based contracting not because that was the most productive business model, but because an integrated approach towards healthcare delivery would improve the care of the populations that we serve.

 

I wanted to see how the systems worked, how the patients felt about the system and how the healthcare professionals felt the system was allowing them to do what they knew how to do best. I learned a lot. At the same time, I deliberately kept my outsider hat on. I did not want to accept the ways that things were. I wanted to be a change agent because we were having a national crisis going on. I was determined to fix that.

You did publish research after that, where the primary aim with this wait time is the overall wait time of primary care dermatology and cardiology significantly reduced through your efforts at the VA. That is an important point because some of those, especially primary care and cardiology, are important services for many veterans.

I focused on both primary care and mental health. The crisis in the VA at the time was both in physical illness and people not getting timely care and also in behavioral health issues. These are what we call the invisible war where people were coming back and may have looked fine from the outside, but inside there were issues. The way we saw that was when I got to the VA, there were 22 veterans a day taking their life by suicide. That was a national crisis of its own. I made it the single top priority of the VA.

The first thing I did was, I said, “The goal is not to continue the system of trying to give veterans appointments within 30 days,” which is what the VA had in place. I said, “We’re going to move towards same-day appointments.” If somebody has an urgent physical or emotional problem, they need to be seen that day. People thought I was crazy, but this is part of the strategy that I had, which is you don’t look for incremental improvement when you have big problems. You go for essentially what I call a moonshot or a big, significant improvement.

For me, the only way I could assure the country and the president that veterans weren’t waiting for care unnecessarily was to say, “We’re going to see him that same day, Mr. President.” Before President Obama left office in December of 2016, I went to the White House and said, “Mr. President, I want to tell you that every VA medical center in the country has same-day appointments for both physical and mental health.” That was the way I assured that we had fixed that problem.

A lot of that work that you did relied on integrating behavioral health into the primary care setting, which allowed people to access that in a way that was faster.

One of the things that I learned when I said that I was in some ways pretty naive thinking, “I’m going to teach the VA a lot of the lessons from the private sector,” it turned out to be exactly the opposite. I learned so many things from the VA that the private sector should be doing frankly. It was reverse. One of those things was the VA is free from a third-party reimbursement system. In other words, as a private hospital CEO, when I ran the hospitals like Beth Israel, New York, or Morristown in New Jersey, I had to make sure that not only were we doing the right thing, but we were going to be paid for it. I wouldn’t be in business very long.

At the VA, I would go to the congress and say, “I need a certain amount of money at the beginning of the year to take care of nine and a half million veterans who got care in the VA system.” They would pass a budget and I would get that money. I was allowed to spend the money in a way that I thought was responsible for taking care of the country’s veterans. I did not have to worry about submitting bills to commercial insurance companies. That allowed us to do things like integrating behavioral health and primary care.

When you’re a veteran and see your primary care doctor, you’re seeing them in a team of professionals. It’s not a referral to go to another building and see your psychiatrist or psychologist. It’s all delivered as part of a cohesive team. That helps improve access and coordination of care. It’s very beneficial. I was also able to do several other things to address the wait time crisis. The first is I pressed very hard on telehealth. We’re used to being in COVID, so everyone understands telehealth.

Back then, I had the wait time problem. I had to deliver care to veterans that lived hours away from the closest VA facility. I knew I needed to use technology. When I talked about putting on my stethoscope, I soon added seeing patients in person in Manhattan and taking care of patients myself in Oregon from my office in Washington using telehealth.

I got to see firsthand how powerful this is. I ended up bringing my telehealth equipment to the west wing of the White House, demonstrating it to the president with my patients in Oregon. I got his support for expanding telehealth. We rapidly expanded telehealth back in 2017 before the pandemic to hundreds of thousands of veterans.

I also gave advanced independent practice authority to many non-physician licensed professionals. I felt that if we were going to do the right thing for our veterans’ sure access, I had to give nurses and independent practice authority pharmacists, physical therapists, occupational therapists, to be able to practice at the top of their license.

HPP 263 | Challenges Of Pain Management
Every VA medical center in the country now has same day appointments for both physical health and mental health.

 

It’s not a competition over reimbursement that you see in the private sector, but what’s the right thing to do for our patients and how do you practice as a team of healthcare professionals that would allow our pharmacists to prescribe medications, which they do a terrific job of it? They ran their clinics and our nurses to be out there with their primary care panels. That was part of our strategy as well.

That’s going to resonate with this audience as far as supporting licensed health professionals across the board to encourage and enable them to practice at the top of their scope of practice, whether that be their personal or professional scope of practice. There are turf wars and scope of practice battles when you move into the private sector. There’s a place where we have to make sure that licensed health professionals have the skills. There’s also a part where it keeps us stuck in a system that can’t serve people the way we know we can on some level.

It was the single most controversial decision I made. I made lots of controversial decisions when I was in government, but I got 450,000 letters, emails and phone calls from people when I was going to decide on giving this additional practice authority to non-physicians. I will tell you that 50% of the calls I got were for it and 50% were against it. I did not even realize that time because I was somewhat new to politics that there were doctors’ caucuses in congress who wanted to assure I wouldn’t do it and there were nurses’ caucuses in congress who wanted to assure that I would give practice authority.

I did what felt natural to me. I made the decision not on who thought this was the right or wrong thing to do but based on the principle. The principle was I was trying to solve veteran’s wait time issues. I wanted to do it in a responsible, quality way, but I’ve always practiced with nurses, pharmacists, physical therapists, and psychologists throughout my career. I felt very comfortable as a primary care doctor that I needed their help and they often had more experience than I did in their areas of expertise. I felt comfortable making that decision. It was not received well by everybody, but I am confident it was the right thing to do for our veterans and the country.

It’s interesting because you and I have been practicing long enough that we can remember the rise of nurse practitioners. At one point, there were no nurse practitioners. Over time, NPS has come in and they’ve taken somewhat of a primary care role in lots of different places and functions and provide quality care. The physical therapy profession has gone through something similar where every university is a doctoral degree, the licensed healthcare providers.

Multiple studies show that early physical therapy access can positively impact things like opioid use disorder and use rates. How do we help my profession specifically? This applies to a lot of other professions besides PT. How do we encourage our set PTs on the right path to help them work as primary healthcare providers in the VA and outside the VA, where they start serving in critical roles where there are missing pieces to people’s health care?

It’s very important to continue to talk about the research that demonstrates exactly the types of outcomes you’re talking about. It’s very important to be working in settings that support people who can contribute in the way that you’re talking about, who want to practice in collaborative environments, who essentially want to be a valued member of the team. We are in a unique time where there are staffing shortages of people who are not feeling valued where they work have the ability to move.

We’re at a time where there’s a lot of potential disruption, whether it’s using technology or different business models to change how healthcare is delivered so that people have more choice in how they access care. We’re seeing this in physical therapy with the dramatic boom and the ability to bring physical therapy-based solutions directly to people in their homes using telephysical therapy using remote patient monitoring and value-based reimbursement models. People understand the importance of prevention the way that you’re talking about it. It is the right time to be able to make some significant advances in this area.

When I look back into your history, you started a startup in the basement of your home that focused on values-based care years ago before values-based care was even a blip on anyone’s radar. How did you come about that idea and where did that go? It seemed like it was a little bit before its time. Although it’s ripe for that type of approach in many health care models.

There’s a warning in there for all your readers who are thinking about doing a startup. It’s great to be on the early side to innovate and be disruptive, but it’s important to be successful to get the timing right. Sometimes, it’s not good to be as early as it was. When I was leading health systems, I was very focused on quality and patient safety, particularly in the initial part of my career. I saw that those hospitals and healthcare practitioners who focused on quality and safety were doing good, but they were not rewarded for it.

There was a punitive measure in that. If you focus on anything but volume, you end up making less money. You were rewarded negatively. Therefore, I felt that where the system needed to go was to be able to have a differential payment system to pay those that were providing a higher quality of care more and those that were providing a lower quality of care less.

The only way to do that would be to be able to measure that and differentiate between high-quality practices and lower-quality practices. That was my initial startup, using publicly available data and patient-reported data to differentiate high-quality doctors, hospitals, and healthcare professionals from lower-quality ones. We were quite successful at that, but the market has taken about twenty years to catch up where we were back then.

HPP 263 | Challenges Of Pain Management
It’s very important to be working in settings that support people who have the ability to contribute in the way that you’re talking about, who want to practice in collaborative environments, who essentially want to be a valued member of the team.

 

There’s a lot of values-based talk in the health and the physical therapy industry specifically. A lot of it was around chronic lower back pain because that’s one area that we spend a lot of money on. We should start to award people who are delivering high-value care that is changing people’s quality of life versus lower value of passive treatments, which did not have good study outcomes.

You also are doing a lot of work in the digital health space. You could start it when you’re in the VA with telehealth before any of us in the private sector were using telehealth. Where do you see digital health is going? We can look at this from the perspective of non-communicable diseases and overall health, mental health, and chronic pain, which is your focus. Where do you see that heading?

I don’t think that you can generalize where it’s heading. You have to take it specifically. The area that will have the easiest time demonstrating the value and the improved outcomes with digital health will be in the behavioral health care space. There is a preference for some or many patients to be able to have the interactions in a way they feel more confidential, secure, which ensures privacy and digital does that. Take many of the physical conditions and digital works against that, where you’re saying in the physical illness world. There may be good effectiveness data on digital therapeutics but low engagement levels. Less than 10% of people will follow through with a digital health plan.

In behavioral, you’re saying better follow through and better engagement. I don’t think we should make generalizations, but the technology revolution that we’re seeing, including digital health, is here to stay. It was not limited to a pandemic-type environment. It’s part of this whole transition from facility-based care or hospital brick and mortar to an environment that is much more healthcare without any specific address, whether it’s your home, work or when you’re traveling. That type of convenience and access is something that consumers and patients like you and I are not going to want to see go away.

As we begin to see the ability to have real use cases for artificial intelligence and predictive analytics to make us smarter about our decision points and have a learning system type environment, the more value we’re going to place on that. We’re not willing to let that go either. Going to your doctor and hoping that they read last month’s journal or remember something from years ago that they might’ve learned is probably not the best way to do something.

It would be like going on the airplane and saying you don’t need radar because you’ve flown to Atlanta before to the pilot. That’s true, but it doesn’t mean that they’re going to get there with the precision of radar. Digital health is going to continue to evolve, improve, and be how we’re going to deliver care for the future.

You mentioned the distinction between physical health and the behavioral health space. That makes sense that behavioral health may have an easier time having a positive impact. Chronic pain is interesting because it straddles both. There’s that psychological, behavioral health element and there’s a physical element to it as well. Do you see that as an area where we need to do more research around and see how it goes and develops or do you see it fitting more into a behavioral health approach for someone’s care?

I see it more on the behavioral health side. Chronic pain is a particularly important area to focus on. One is because right before the pandemic started, we had our own essentially public health crisis with chronic pain. It was the opioid crisis. That was very similar to the pandemic. Overnight, people stopped writing prescriptions for opioids. When I trained in medicine, we were trained in that if you’re in pain, there is no need to worry about addiction. The worst thing to do would be to let somebody stay in pain. People were encouraged to write for these types of medications.

When the opioid crisis came to light, that light bulb turned off and people stopped writing them. What I worried about was how you can take people on narcotics or opioids and overnight say to them, “Your pain is not real and you should learn how to do yoga and mindfulness. You’ll be okay.” That simply didn’t work. What it did is it turned people to illicit drugs and into significant behavioral health issues, including suicide.

An immediate crisis forced a different way of doing things, but as opposed to the effort that we put into developing a vaccine, doing large-scale testing and developing antivirals and antibodies that are coming out for COVID. That didn’t happen as much in pain. I was part of the White House opioid initiative where we were trying to develop non-narcotic pain alternatives, but the money and the mind chair weren’t put into it the way we saw in COVID. We still have this problem in what we do with chronic pain. I know it’s something that you spend a lot of time on.

I am attracted to big problems and problems that need solutions. That’s why I am very engaged. I spend a huge amount of time on the chronic pain issue because I believe it’s one of the top issues we need to address in this country. It affects up to 100 million Americans. People’s lives are ruined by this. People are not getting help. Our system is fragmented, siloed and filled with dramatic variation in the quality of offerings being given and lots of snake oil salesmen in this area. I am very committed to making progress in this.

Digital telehealth, brain science, physical therapy, motion and retraining one’s brain circuit or what we call neuro-plasticity are things that have some evidence there already and are things that we can build upon and need to implement. Some of the challenges have to do with the reimbursement system that we talked about.

HPP 263 | Challenges Of Pain Management
We should not make generalizations, but the technology revolution that we’re seeing, including digital health, it’s clearly here to stay, it is not limited to a pandemic type environment.

 

Some of it is regulatory, not letting physical therapists practice to the fullest extent they can. This problem of chronic pain is very much all about what we’ve been talking about and very much in the wheelhouse of what I’ve worked on in the Department of Veteran Affairs. It includes some pieces of what I’ve learned in the Department of Veteran Affairs that we haven’t talked about, like peer support and self-care tools, which are an important part of this component in the chronic pain area.

When you spoke on that White House Opioid Summit, you did a nice job of distilling. You like complicated problems and you distilled it down into this one acronym, which is STOP PAIN. The acronym speaks to all of us. We all want to stop the pain, but you took that acronym. You said, “Here’s an acronym that helps you understand what’s happening with the chronic pain epidemic and it’s something you can use, whether you’re an individual working in practice or you’re a big health system.” Can you go through that acronym for us and explain it?

The basic idea behind an acronym is to define the components of what you’re trying to address and solve. The issue with the opioid crisis, in particular, is this needs to be addressed at both a policy level, medical level, bio-psychosocial level and economic level. This is essentially the integration of a different type of model that’s usually applied to medical problems.

The STOP PAIN has to do first with the S for Step care approach, which is not starting with narcotics but starting at the lowest level of intervention that will be effective and beginning in a methodical way to work up towards getting adequate pain relief. The T is for Treatment alternatives. It’s the things like getting people to move more and better with physical therapy, looking at alternatives to medications, even things like emotional support dogs and addressing some of the bio-psychosocial issues that we talked about, like peer support.

The O for STOP PAIN is the Ongoing monitoring and usage of a treatment plan, whether it’s with medications or not. It’s not like starting a patient and seeing how they do. You have to have an effect of ongoing monitoring usage. This is where digital therapeutics and tools help and ensure both adherence compliance as well as the effectiveness and the treatment. The P for STOP is Practice guidelines. The Department of Defense and VA have some excellent pain management guidelines, but many other organizations do. That’s important.

The P for PAIN is Prescription monitoring. It’s important that when you are a physician about to prescribe that you’ve checked to make sure that other physicians haven’t already prescribed. You’re not contributing to the oversupply of medications out there and you address side effects. The A is Academic detailing. That’s education, making sure that our healthcare professionals are knowledgeable. You do a tremendous service by educating your colleagues about chronic pain and pain science, which is important.

The I is Informed consent. This is about the self-care and the involvement the patient needs to have accountability for their healthcare journey. They need to be involved in informed consent whenever a treatment is involved, including taking the medication. The patient has the responsibility not to overuse the medication. Finally, N is Naloxone, which is a life-saving way when people overdose. Unfortunately, we’re seeing many overdoses continuing not only with opioids but with fentanyl and even research that was out on the side effects and morbidity associated with other pain medications like Tramadol.

You had done work to raise people to the highest scope of their practice. You also mentioned peer support. As licensed healthcare professors, all of us have a tremendous amount of education and knowledge. That peer support sounds like a conduit that all of us can start to use to help people with chronic diseases.

Peer support is something even in addition to that. It allows people to talk to other people in a way that they have a shared experience and understand what somebody has gone through. Maybe it makes sense to people who are reading to understand why that’s so powerful for veterans because veterans tend to think that other people don’t understand that they’ve not gone through their experiences, but when they hear it from their brothers and sisters who have gone through that, it has an impact and it gets through in a way that that doesn’t happen in other ways.

You take somebody with chronic pain who has experienced chronic pain says, “I understand what you’re going through. I know how hard this is, but here are some ways that I have found that have been helpful.” That’s extremely powerful. In the VA, it’s what I call the superpower of the VA of this ability to have people supporting one another who have these shared experiences.

Secretary Shulkin, it’s been an honor speaking with you. Thank you for all the information you shared. Everyone can find all the information at the Integrative Pain Science Institute. Where can people learn more about you and the things you’re up to?

First of all, I encourage people to follow me on Twitter @DavidShulkin. Find me on LinkedIn. I have a website, Shulkin Solutions. I love interacting with people, so feel free to reach out.

At the end of every episode, I ask you to share this with your friends and family on social media, where everyone’s talking about how to treat chronic pain safely and effectively. I want to thank Secretary Shulkin for joining us.

Thank you.

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About David Shulkin

HPP 263 | Challenges Of Pain ManagementThe Honorable Dr. David J. Shulkin is the Ninth Secretary of the US Department of Veterans Affairs having been appointed by President Trump. Secretary Shulkin previously served as Under Secretary for Health, having been appointed by President Obama and confirmed twice unanimously by the US Senate.

As Secretary, Dr. Shulkin represented the 21 million American veterans and was responsible for the nation’s largest integrated health care system with over 1,200 sites of care, serving over 9 million Veterans.

Prior to coming to VA, Secretary 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, Secretary Shulkin founded and served as the Chairman and CEO of DoctorQuality and has served on boards of managed care companies, technology companies, and health care organizations.

Since leaving government, Secretary Shulkin has been the University of Pennsylvania Leonard Davis Institute Distinguished Health Policy Fellow and Professor at the Jefferson University College of Population Health. He is a board-certified internist and received advanced training in outcomes research and economics as a Robert Wood Johnson Foundation Clinical Scholar at the University of Pennsylvania. Over his career Secretary Shulkin has been named, “One Hundred Most Influential People in American Healthcare” by Modern Healthcare.

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