David Shulkin Looks Back on His Tenure as Veterans Affairs Secretary
The most controversial change David Shulkin, MD, made during his time as U.S. Secretary of Veterans Affairs now enables VA advanced practice nurses (APRNs) to practice at the top of their license without physician supervision, even in states with laws that would otherwise prohibit them from doing so.
In 2017, Shulkin's Veterans Health Administration (VHA) Directive 1350 used the power of "federal supremacy" to amend VA medical regulations, granting full practice authority to more than 5,000 APRNs working in 170 VA Medical Centers and 1,063 VA outpatient sites across 50 states.
"I got 375,000 messages and phone calls and was very heavily lobbied for and against by Washington lobbyists and members of Congress," Shulkin said in a talk at the University of Pennsylvania's Leonard Davis Institute of Health Economics (LDI). "I made the decision after traveling to high-need areas, like facilities in rural communities where 45% of veterans live. What I found there were nurse practitioners who were not able to practice. I knew what I needed to do and I think it's really been quite effective in helping the VA address some of its access issues."
'Important, prudent policy'
Shulkin's national directive was an "important, prudent policy choice," said Matthew McHugh, Associate Director of Penn Nursing’s Center for Health Outcomes and Policy Research. "The VA system stands as an excellent example of safe care by APRNs and increased access without these restrictions."
That nurse experience was one of several the former VA Secretary discussed in an LDI Policy Seminar presentation entitled "Innovating in Health Care" that looked back at lessons learned while managing the country's largest integrated health system. The VA's Veterans Health Administration (VHA) provides care to more than nine million former soldiers, sailors and airmen, many of whom suffer physically and mentally debilitating war wounds.
Former Penn RWJF Clinical Scholar
The event in LDI's Colonial Penn Center auditorium was part of Shulkin's year as an LDI Distinguished Health Policy Fellow. It also marked his return, 30 years later, to the building where he once had an office as a Penn Robert Wood Johnson Foundation Clinical Scholar and worked as a medical resident at Philadelphia's VA Medical Center.
Prior to joining the federal government, Shulkin had a distinguished career in hospital administration as CEO of Beth Israel Medical Center in New York, Chief Medical Officer of the University of Pennsylvania, and Chairman of Medicine at Drexel University School of Medicine.
A central theme of his LDI talk was how dramatically different the VA medical health system is from the country's other health care systems.
'A lot of criticism'
"The VA justifiably takes a lot of criticism but in many ways, it is an extraordinary health care system that takes a population-based approach to things," Shulkin said. "What I observed was that everything that I did as Chief Medical Officer at Penn for a decade was playing to the rules of the reimbursement system but at the VA, we were free of that. The VA doesn't need to follow Medicare or commercial insurance plan rules. It just has to plan for a population and do what's best."
"As a primary care doctor seeing patients at (previous jobs), I used to say 'Look, what's your chief complaint?' and try to make sure I tried to help the patient with that physical issue and get them out of my office or refer them somewhere. The VA's definition is actually much broader than that and is about well being. The VA system builds in components like the use of peers to help veterans get through issues, crisis lines, care givers, and behavioral health services integrated with primary care."
"The VA uses a 'whole health' model of care that has three circles," Shulkin continued. "The first is the impact of peers helping patients to navigate the health care system; the VA is now creating a job category called 'peer counselor' to pair peers with veterans. The second circle is self-care. You train the veteran on how to care for themselves, how to establish goals of well being, how to create tools to help get through tough times, how to use integrated medicine techniques and other disease-specific strategies. The third circle is teaching a team of health care professionals how to practice in this type of environment to support peers and self-care. This type of model is not supported by the private sector's current reimbursement systems."
Disabled Veterans Sports
Shortly after he was brought into the VA by President Barack Obama in 2015, Shulkin went on his first trip to the VA Winter Sports Clinic in Aspen, Colorado. "This was where we took 400 veterans who were paralyzed or had spinal cord injuries, lost limbs and prostheses into the mountain to show them how to ski and introduce them to competitive sports," Shulkin said. "While I thought this would be interesting, I didn't realize how impactful it would be on me. I had never thought that as a physician, it would be my role to get patients involved in things like adaptive sports but there in the mountains, I saw the power of this as veterans would tell me their stories about being lost and suicidal and filled with medication and then suddenly able to regain their competitive spirit and have a reason to be excited again."
The VA routinely conducts programs that get wounded warriors involved in other sports like surfing and rock climbing. One of the therapies used for PTSD treatment is pairing veterans with horse or dogs.
"There is much the private sector can learn from the VA," Shulkin said. "There's a lot of focus on the negative parts of the VA but the innovative research work that has been done in the VA over the years has influenced all of us in American Medicine in many different ways. People don't realize that."
Most advanced prosthetic
"And the VA today continues to innovate on the research front," Shulkin continued as he showed a side of the incredibly life-like LUKE prosthetic limb that was developed in a collaborative effort by researchers and engineers at the VA and the Defense Advanced Research Projects Agency (DARPA). Unveiled and presented to its first two amputee veterans by Shulkin last year, the "Life Under Kinetic Evolution (LUKE)" arm is the world's most advanced prosthetic.
"Many of us as doctors in the VA still see people coming in with hooks," said Shulkin. "The new prosthetics like this arm took $90 million to develop. There is no commercial reason any private company would develop such an arm because the market's not large enough to justify the investment. That's why this is an area where you can see research by government dollars and VA scientists is really important to be able to help veterans because this just would not happen in the free market."
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Hoag Levins is the Editor of Digital Publications at the University of Pennsylvania's Leonard Davis Institute of Health Economics (LDI), and a former staff reporter and editor at newspapers and magazines in Philadelphia, New York and Washington, D.C.