Dr. David Shulkin, Chief Executive of the Veterans Health Administration

Dr David Shulkin (EARLIER INTERVIEW)

Mark Masselli: This is Conversation on Healthcare, I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Well, Margaret, as the Obama president is winding down, the
President is taking on another public health issue, one that leads to more than
38,000 deaths per year in the country, traffic accidents.

Margaret Flinter: Well you know the number of drunk driving crashes are down
over the past several decades, but traffic fatalities increased last year by 7%,
despite the strong seatbelt laws and good compliance with them, despite drunk
driving laws, despite distracted driving laws or prohibit texting or using your
phone while driving. So I know it’s not very scientific Mark, but based on what I
see every day when I am driving, I would say there is something of a distracted
driving epidemic.

Mark Masselli: But the President has pretty ambitious goal. He is aiming to end
traffic fatalities within 30 years. The Department of Transportation is going to
deploy more robust initiat ives to bolster seatbelt laws, expand the use of rumble
strips on the roadside and raising awareness about drunk and distracted driving.

Margaret Flinter: Well 94% of all traffic accidents are the result of human error
and so the President is looking ahe ad to the future growth of self - driving car
technology, to help support his agenda. One bright spot, the advent of ride -
hailing services like Uber and Lyft have led to a sharp decline in drunk driving
and that is very good news on the driving front.

Mark Masselli: That really is and speaking of advancing a big agenda, our guest
today is tasked with helping to overhaul the veteran’s health administration.

Margaret Flinter: Dr. David Shulkin is the Under Secretary for the Health at the
VA. He has got a big job ahead of him at the VA, which is the largest integrated
health system in the entire country and serves the complex health needs of some
9 million veterans. We are looking forward to that conversation.

Mark Masselli: We are indeed and Lori Robert son stops by, the Managing Editor
of FactCheck.org, but no matter what the topic you can hear all of our shows, by
going to www.chcradio.com and as always, if you have comments, you can email
us at [email protected] or find us on Facebook or Twitter. We love
hearing from you.

Margaret Flinter: We will get to our interview with Dr. David Shulkin in just a
moment.

Mark Masselli: But first, here is our producer Marian ne O’Hare with this week’s
Headline News.

Dr David Shulkin (EARLIER INTERVIEW)

Marianne O’Hare: I am Marianne O’Hare with these Healthcare Headlines.
Theranos is official out of the lab testing business, their rising diagnostic startup
led by Elizabeth Holmes. And once valued at $9 billio n has been banned from
the diagnostic business for 2 years after multiple problems were found. The
company was founded on the promise that a comprehensive lab testing could be
done with the finger prick and simple drop of blood, instead of the vial typica lly
taken out of the arm. Theranos announced it would lay off 340 people just under
half its workforce and get out of the business of administrating blood test all
together, Holmes herself will stay on at the restructured company.

Hurricane Matthew left quite a bit of devastation in it’s wake and public health
officials are worried about a number of potential threats, the rise of cholera in
Haiti which is an ongoing problem in that country, which has already sickened
more than 28,000 people this year. Th ey are also concerns about a resurgence
of Zika in the Caribbean Islands, that were hit as well as in Florida and the
Bahamas. The Haiti’s mosquito that carries the virus needs, just a tiny amount of
water for breeding.

Well the recent tale of the Flint, Michigan water crisis still lingers, there is actually
some good news on the lead levels in kid’s front. A numbers of kids between 1
and 5 with elevated lead levels dropped from 26% in 1988 to around 2% last
year. However racial disparities persist, bla ck children were twice as likely to
have elevated blood levels than whites, linked largely to a poverty issue, even a
tiny amount can have lasting effects on a child’s development over a lifetime.

And call it a very thin silver lining, the soaring number of deaths due to overdose
has had an impact on one challenging reality, the shortage of organs for people
waiting on organ donor list. There were 48,000 overdose deaths in 2014, far
surpassing automobile accidents as the primary source for donated organs,
transplants surgeons are now screening organs from addicts determining that
even with the presence of something like hepatitis C now are treatable condition,
it still makes more organs available, dozens of organs have been donated in New
England from pati ents who had OD in the past few years still there are 120,000
people on organ donor waitlist, nationwide. I am Marianne O’Hare with these
Healthcare Headlines.

Mark Masselli: We are speaking today with the honorable Dr. David Shulkin,
Under Secretary of Health at the U.S. Department of Veteran’s Affairs as Chief
Executive Officer of Veteran’s Health Administration. Dr. Shulkin leads the
nation’s largest integrated healthcare system serving the health needs of almost
9 million U.S. veterans. Dr. Shulkin is the former President and CEO of Beth
Israel Medical Center in New York City and served as Chief Medical Officer at
the University of Pennsylvania Health System and the Medical College of
Pennsylvania Hospital. A board certified internist Dr. Shulkin i s a fellow of the
American College of Physicians and has been named one of the 50, most

Dr David Shulkin (EARLIER INTERVIEW)

influential physician executives in healthcare by Modern Healthcare. He received
his medical degree from the Medical College of Pennsylvania, completed his
internship at Yale University School of Medicine and his residency at the
University of Pittsburgh. Dr. Shulkin, welcome to conversations on healthcare.

Dr. David Shulkin: Thank you, glad to be here.

Mark Masselli: Congratulations on the work that you are doing at the Veteran’s
Administration, you came in from the private sector to help the VA tackle some
very serious administrative problems. But the VA also serves admirably 9 million
American veterans at 1700 care sites. I wonder if you could share with our
li steners the sort of scope and complexity of the challenges you face.

Dr. David Shulkin: Well, I don’t think most people realize, this is the largest
healthcare system in the country, so we are the largest employer of doctors,
nurses, largest number of ho spitals in the country, but just to give you a size, we
are the only healthcare system that is responsible for delivering care in every
nook and cranny of this country wherever a veteran lives, even if we don’t have
VA facilities there. So we work closely with community providers and do what it
takes to be able to provide the veterans to this country, the healthcare that they
deserve.

Margaret Flinter: Dr. Shulkin, I know a whistleblower called attention to the
problem of the long wait lines in 2014 and there is an independent audit showing
the problem was pretty pervasive. And the VA really responded strongly to this
long wait time issue, with the program called Veteran’s Choice. But that program
had a whole new set of administrative issues and challen ges, help us understand
the intent of veteran’s choice and the challenges you encountered and how is
that fairing now.

Dr. David Shulkin: Well, first of all, I do have to say that what we now call the
wait - time crisis was a significant challenge to the V A healthcare system. I, of
course came at the president’s request after the crisis to bring my private sector
experience to the VA. So this has been my number one priority. Congress
actually gave us the Choice program as an additional tool, but you have to
remember that the VA has for years and years provided about 20% of its care in
the community already, to supplement the VA healthcare system and the Choice
program was supplemental funding provided by Congress to be able to do this.

The Choice program was filled with administrative complexity and the VA
healthcare system had 90 days from the passage of the Choice program to
implement a nationwide new program. And I think that we all know now in
retrospect that to do a program of this size and scope th at it probably needed to
take longer than 90 days, but we have worked through many of those problems
as we have increased our authorizations of care in the community over fourfold in
the past year. But it’s still is a program that’s far too complex and to o

Dr David Shulkin (EARLIER INTERVIEW)

burdensome. So we have asked Congress to make major changes in the
programs so it works better for veterans and that legislation is pending for
congressional vote we hope.

Mark Masselli: You know speaking of complexities, veteran’s face a whole host
o f medical issues that are unique to their service, perhaps one of the most
pervasive is posttraumatic stress disorder. And I think an estimated 20% of
veteran’s face lingering effects of PTSD and other mental health issues. And it’s
estimated that 20 vet erans are committing suicide every day and wonder if you
could talk to us a little bit about the VA’s targeted effort in addressing the crisis
and also how does President Obama’s campaign to improve mental health
access for vets and their family coming to play here.

Dr. David Shulkin: It’s just a horrific number, unacceptable and really one of our
areas of top focus to address this. When you look into that number and there
were 20 veterans a day taking their life, only 6 of them are getting care within t he
VA healthcare system that means there were 14 a day who were out there,
potentially disconnected from the best resources that can help them and address
their care. So one of the things that we are doing very diligently is reaching out
to as many commun ity organizations as we can, churches and other groups and
friends and family of veterans and making sure that they know that if they see a
veteran that is potentially in crisis to make sure that they are utilizing the
resources that are available in the V A particularly our Veterans Crisis Line, which
is open 24 hours a day, 365 days a year.

We have over 300 suicide prevention coordinators who do nothing everyday but
work to address this issue. We are implementing a research tool that actually
uses our da ta to analytically predict those at highest risk for suicide and
proactively reaching out to those veterans and making sure that we can offer
them help and assistance. And it is such a critical issue not only for veterans but
really for all Americans wher e the crisis and suicide really has reached what I
would call epidemic levels.

Margaret Flinter: But let me ask you first, you have related to mental health but
also an independent risk factor is the problem of homelessness among our
veteran population a nd I think the stat on this is in 2014 which is a couple of
years ago now, there were an estimated 50,000 homeless veterans across the
country. And yet just in the past year even I have heard some reports of
significant progress in some states including o ur own about particularly targeting
homeless vets, tell us about the program that VA and states across the country
have, to try and mitigate this problem.

Dr. David Shulkin: One of the unique things about the VA healthcare system is
that it not only focu ses on the physical health issues of our veterans but it
actually focuses on the social issues, the psychological issues and the economic
issues. And as a physician you can’t really address a person’s health and

Dr David Shulkin (EARLIER INTERVIEW)

wellbeing if they don’t have a home. And s o VA has really focused on this and
over the last 4 years we have reduced veteran homelessness across the country
by 46%. And that means that we have housed hundreds of thousands of
veterans and their families. But as you know the issue of homelessness i s a
chronic problem. In fact we were just with the group of veterans recently in the
south that were homeless. And all of them actually had jobs but at minimum
wage they weren’t able to afford housing. We are working with the housing and
urban developme nt federal officials are working with local builders and real -
estate landlords to try to find affordable housing for those that needed and
certainly our goal is to end veteran homelessness, states like Connecticut that
you are mentioning have really done a terrific job in pulling together state, local
and federal resources to be able to actually end homelessness among veterans.

Mark Masselli: We are speaking today with the honorable Dr. David Shulkin,
Under Secretary of Health at the U.S. Veteran’s Affair Department and the Chief
Executive of the Veteran’s Health Administration, Dr. Shulkin leads the nation’s
largest integrated healthcare system serving the 9 million U.S. veterans. Dr.
Shulkin you have a national reputation in transforming healthcare and yet you
took a 90% pay cut to join the VA, so it was really obviously about service but I
would love to hear from you of what motivated you to take on the challenges.
And what are the building blocks for success as you think about moving a very
large ship in a different direction?

Dr. David Shulkin: I like to think that I am no different than any other American
as I was watching now over two and a half years ago, the wait - time issues play
out over national TV and newspapers. I was as outraged as most Am ericans,
what I didn’t realize is that, in few weeks I would be getting a phone call from the
White House asking whether I would be willing to step up and be part of the
solution and help fix it. How can you say no? So I left my position and here I am
an d I hope that all of my experience that I have brought to the table is helpful in
transforming the VA in the way that you described.

Margaret Flinter: But Dr. Shulkin you have also spent time in your career
teaching. And I am not sure that many people o utside of healthcare know that
the VA is actually the largest organization training health profession students, talk
with us little bit about the scope of health professions training in the VA?

Dr. David Shulkin: Yeah one of the questions I hear quite fr equently is, you know
why do we need the VA system, why not just give out a voucher system. And
people may not realize the other things that the VA healthcare system does for
the country. We train over a 120,000 health professionals every year in the VA
system. We are the largest trainers as you said of doctors, nurses, physical
therapists, pharmacists, social workers, if it was not for the VA healthcare system
there would not be the supply of healthcare professionals for the rest of America.
70% of U.S . physician medical students go through the VA during part of their
training. I know in my training, I went through 3 VA medical centers. As you

Dr David Shulkin (EARLIER INTERVIEW)

mentioned I do still practice internal medicine, I practice in the VA system now, I
think it’s really importa nt that I stay close to what’s happening and I interact with
these trainees and these students when I practice.

Interestingly I practiced both in - person but I also practice in Grants Pass, Oregon
from my office here in Washington DC overlooking the White House using
telemedicine. And what people don’t recognize is VA is very technologically
advanced, the largest user of telemedicine in the country by far. And this is
another thing that we expose our trainees to, so they come out of the VA system
knowing how to use electronic medical records, knowing how to use telehealth,
knowing how to use these advanced technologies and they bring that skill to the
rest of American medicine.

Mark Masselli: Well I would like to pull the thread a little on that, because you
were just talking about engaging in new delivery systems. The President has a
new Precision Medicine Initiative that’s out there, where do you see the role of
precision medicine, genomics and the like being rolled out in the veterans
administration?

Dr. David Shulkin: Well I think under the President’s leadership we have really
embraced this type of medicine as the future of where healthcare is going, how
we can do a better job to treat veterans and all Americans, VA has played a
central role not on ly in precision medicine but in the moon shot efforts which the
Vice President leads in order to help find an events are caring curing of patients
who have cancer. One of these other things that makes VA unique is our
research. We provide over $1.6 billi on of research every year dedicated
specifically to advancing the health of veterans. And we are the world’s largest
database of genomic material doing sequencing on the materials of over 1 million
veterans and today have the largest database in the world of this type of genomic
data.

So we are doing studies to advance cancer care and care for PTSD and
traumatic brain injury and mental health, all in a way that no other organization in
the country is able to do it at this point. And so our commitment to precision
medicine, our leadership in precision medicine, we believe is yet another
example of why VA is so critical for not only veterans but all of American
healthcare.

Margaret Flinter: But Dr. Shulkin I think we all in healthcare have benefitted from
that and also you are work in healthcare delivery system redesign, your patient
care align teams, so many areas that I think have really been a benefit to
everybody in healthcare, so thank you for that. Just one more innovation we
would like to check in with you, on the Blue Button Initiative, the online electronic
health portal for veterans, what’s your research and utilization and delivery
systems study showing you in that arena?

Dr David Shulkin (EARLIER INTERVIEW)

Dr. David Shulkin: One of the very early innovators of electronic medica l records
was VA and 30 years of history now of using this. And so what we have been
working on is interoperability of sharing of information. So VA is participating in
hundreds of these health information exchanges around the country because our
veteran s are getting care both within the system and outside this system. And
we have been trying to innovate in this area, the Blue Button of course was one
of those innovations but we have a whole team called the U.S. Digital Team that
was actually one of the President’s initiatives to bring people from Silicon Valley
and helping us design many of these innovations in a similar way. We are just
launching a website called Vets.gov which will be a single source of information.
Now you have to go to multiple web sites and you have to know the right numbers
to call but Vets.gov will be the single source where people can access all of the
information on veteran services so we continue to try to innovate in this area.

Mark Masselli: We have been speaking today with the honorable Dr. David
Shulkin, Under Secretary of Heath at the U.S. Department of Veteran’s Affairs,
the nation’s largest integrated healthcare system serving the health needs of
almost 9 million U.S. veterans. You can learn more about their work by go ing to
VA.gov or you can follow them on Twitter at Veteran’s Health. Dr. Shulkin, thank
you so much for joining us on conversations in healthcare.

Dr. David Shulkin: Sure, thank you.

Mark Masselli: At conversations on healthcare we want our audience t o be truly
in the know when it comes to the facts about healthcare reform and policy, Lori
Robertson is an award - winning journalist and Managing Editor of FactCheck.org,
a non - partisan, nonprofit consumer advocate for voters that aim to reduce the
level of deception in U.S. politics. Lori, what have you got for us this week.

Lori Robertson: In the vice presidential debates, Republican Mike Pence implied
that Hillary Clinton was wrong when she sighted the fatal shooting of an African
American man by an Af rican American cop as a case of implicit or unconscious
bias. But scientific research shows African Americans are not immune to this
form of bias against members of their own racial group.

In his criticism of Clinton, Pence was referring to the shooting of Keith Lamont
th
Scott by Officer Brentley Vinson on September 20 in Charlotte, North Carolina,
both men were African American. Pence asked, why would Hillary Clinton
accuse that African American police officer of implicit bias? To be clear Clinton
didn ’t directly accuse Vinson of implicit bias, but regardless Pence was wrong in
implying that African Americans can be subject to implicit bias of other African
Americans. According to the Stanford Encyclopedia of Philosophy, implicit bias
refers to relativ ely unconscious and relatively automatic features of prejudice,
judgment and social behavior. Implicit bias is opposed to explicit bias or
judgment the person consciously hold.

Dr David Shulkin (EARLIER INTERVIEW)

In other words, it’s possible for a person to explicitly believe that white a nd black
American should be treated equally, but implicitly judge situations counter to that
explicit belief. The group has looked at a variety of biases including those
concerning racial issues and found even numbers of black respondents showing
a pro - wh ite bias and show a pro - black bias and that’s my FactCheck for this
week, I am Lori Robertson, Managing Editor of FactChecks.org.

Margaret Flinter: FactChecks.org is committed to factual accuracy from the
country’s major political players and is a projec t of the Annenberg Public Policy
Center at the University of Pennsylvania. If you have a fact that you would like
checked, email us at www.chcradio.com we will have FactCheck.org, Lori
Robertson, check it out for yo u, here on Conversations on Healthcare.
Margaret Flinter: Each week conversations highlights a bright idea about how to make wellness a part of our communities and to everyday lives. Cathryn Couch is a self - taught chef with a love of organic foods and p assion for helping people
in need. After launching her own Meal Delivery Service in Northern California, she often encountered a particular kind of client someone battling a serious illness who is just too tired or too sick to prepare nutritious food just when they
needed it most.
Cathryn Couch: What happens when people get diagnosed with a serious health problem is their life becomes very stressful. And especially for cancer patients you also don’t feel like eating. And so food at the moment when it n eeds to be really, really important for many people drops to the bottom of their priority list for a whole host of reasons. And on the other side we are raising a generation of young people that don’t know how to prepare food and don’t understand the powe r that food has in their own life but also for the life of the community and for the environment.
Margaret Flinter: Couch is driven by the idea that food is medicine, especially for
somebody who is suffering the toxic side effects of chemotherapy. When a friend asked her, she would employee her teenage daughter in her kitchen for summer, she stumbled on a way to grow her enterprise, higher teenage workers use professional chefs to train them to cook healthy meals with organic ingredients and place the po wer of healing with food into their hands. She launched the series project named after the goddess of agriculture and fertility. She expanded
her kitchen facilities and started hiring dozens of local teenagers many of whom had never cooked or held a job. And she says that transformation in these kids
is just amazing.
Cathryn Couch: They walk into a situation where people are being the best of who they can be. They are invited into that. They are given an opportunity to be an owner and to make a real difference in someone’s life. We have this rich resourced in our community of teenagers who are actually longing to be given real opportunities to contribute. So it’s a win - win in all those levels and at the

Dr David Shulkin (EARLIER INTERVIEW)

same time they are all learning how to cook ea t healthy food and they
understand that you know when they buy organic carrots instead of eating
processed chips that they are actually making the environment better.

Margaret Flinter: Couch has since grown her enterprise from her home - based in
Sonoma Co unty to Marine County in Northern California. And she has been
contacted by interested organizations around the country that seek to replicate
the program. The series project earned Couch a CNN Heroes Award, but the
real reward she says, she experiences in everyday encounters, in the hundreds
of teens that she has trained and in the thousands of clients that they have
served healthy meals to during a time of need.

Cathryn Couch: We do a block where clients come in everyday and talk about
what it was lik e to be diagnosed as they have been sick and the difference that
the food has made for them. And it include sometimes people who know they
are terminal, it include sometimes partners who have lost their partner who come
in and talk about the difference th at the kids made for their partner at the end
stage of life. And there is a lot of tears that happenin that room and it’s very
profound.

Margaret Flinter: A program that trains young people in the art of healthy
cooking, using those skills to feed those suffering from serious illness who might
otherwise face malnutrition, empowering empathy in the kids, helping others to
fight illness in the process, these are all bright ideas.

Margaret Flinter: This is Conversations on Healthcare, I am Margaret Flinte r.

Mark Masselli: And I am Mark Masselli, peace and health.

Conversations on Healthcare broadcast from the campus of WESU at Wesleyan
University streaming live at wesufm.org and brought to you by the community
health center.