Virtual Care’s Evolution with Dr. David Shulkin and Mike Brandofino

Welcome to Digital Health Frontiers, where we explore the cutting edge of healthcare technology, policy, and innovation, hosted by Mike Brandofino, President and COO of Caregility. Today we’re honored to have a distinguished guest, Dr. David Shulkin, whose career has been at the forefront of healthcare transformation. Dr. Shulkin has served in several key leadership roles, most notably as the ninth Secretary of the US Department of Veterans Affairs, and prior to that as the undersecretary of health for the VA. During his tenure, Dr. Shulkin made significant strides in expanding access to care for our nation’s Veterans. Through the innovative use of telehealth services as a board-certified Internist and a widely respected authority in the field of healthcare management, Dr. Shulkin’s insights into the evolution of virtual care are both invaluable and timely. Please join us in welcoming Dr. David Shulkin to Digital Health Frontiers.

Mike Brandofino:

Hi, Dr. Shulkin. Thank you for joining our podcast. It’s great to have you. You have so much experience. I look forward to the conversation.

David Shulkin, MD:

Mike, I am glad to be with you today.

Brandofino:

So Dr. Shulkin, based on your extensive experience, especially with the Veterans Administration, how do you see the evolution of virtual care impacting patients across the US, particularly in underserved areas?

Shulkin:

Well, there’s no doubt that this is a technology that’s been around a long time. It was dramatically unutilized until the pandemic and then, out of necessity, became essentially a mainstay of much of the way that we delivered healthcare. And, unfortunately, now it’s sort of coming backwards and people are returning to the old ways. I think that what we saw in the pandemic and what we now know is that healthcare can be delivered either in person or virtually, but the virtual option, when it’s most appropriate, really does provide access to care to many populations that have struggled to get access to care not only in rural settings, but those who have disabilities, those who have cost issues with transportation, and those who quite frankly wouldn’t be receiving care like in tele-behavioral health if it weren’t for the anonymity and the convenience of being able to get care when and where they want it.

Brandofino:

We definitely saw that during COVID; the extensive use of virtual care across many modalities, not just the Teladoc in your home version with the extensions due to expire. What are your thoughts on whether there’ll be an action taken this year or a concern for the future of virtual care?

Shulkin:

Well, you’re right, Mike, the regulatory relief that was given to telehealth has been extended only to December of 2024. That’s important because it gets us past the election in November, and then I think that there clearly is an expectation that there’s bipartisan interest in extending, if not expanding this regulatory relief in telehealth. And there are many bills that have been introduced in terms of the Telehealth Improvement Act. Most of them have strong bipartisan support, but I think, as most people see, it’s a challenge to get almost any piece of regulation or law through Congress at this point just because of the political nature and the divisiveness over so many of the key issues that frankly Americans just wish that Congress could work together on to get done. But I do have confidence that these regulations will not expire and go away, but that they will be extended and in fact enhanced and improved to allow telehealth to operate in the way that frankly, it contributes positively to American healthcare.

Brandofino:

Yeah, I think especially with the shortage of care providers, it really helped to allow cross-border use and people to really work across multiple hospitals at the same time. So, we hope that it gets extended as well. During your time at the VA, I’m sure you’ve learned some key lessons that could probably be applied to the commercial space. Do you have any thoughts on how what you learned and experienced at the VA can be applied to improve virtual care and patient outcomes?

Shulkin:

Yeah, I entered the VA largely because of VA’s inability to provide adequate access to Veterans. Veterans were waiting too long for care, many of them not able to frankly get the care that they had earned because of their service and their sacrifices. And so, in order to solve that — dealing with all of the issues that you mentioned, particularly workforce shortages and the fact that many Veterans live in rural settings out of choice where you don’t have many healthcare professionals at all — we relied heavily upon virtual care in order to improve wait times to improve access. And I think part of what I learned, again out of necessity, was that even though I was the head of the agency having the ability to utilize federal supremacy, which means the ability of the federal government to go above state law, I still struggled with this cross-licensure, cross-state issue because when I tried to implement federal supremacy laws, the states challenged it.

I ultimately needed to ask the President to personally intervene, which I did, and the President did intervene, and we were able to get federal supremacy so that VA was able to operate across all 50 states. And I saw the impact that that allowed us to make, where we had healthcare professional expertise to where Veterans needed it throughout the country. And the playbook that we used in terms of this regulatory relief and being able to use telehealth in the way that I just described was actually the playbook that CMS used in the pandemic. When they acted very quickly and decisively to initiate this regulatory relief, they were able to follow the playbook that we did in the VA. And so, I felt very comfortable that that was going to be very positive for the country. We had watched that, several years earlier, make such a big difference among our Veteran population.

Brandofino:

Well, like you, I hope calmer heads prevail on the regulatory front, basically assuming that something does happen. How do you envision the future role of virtual care and what should healthcare providers do now to prepare to take more advantage of virtual care?

Shulkin:

Well, there’s no doubt in my mind that virtual care is going to be a permanent and important part of the way that we deliver healthcare still. Unfortunately, access to care is a big issue, and telehealth not only provides easier access to care and frankly, in many cases, more efficient access, but some of the models that I think are going to develop are that it will allow an easier way to provide interdisciplinary or team-based care, which I think for many chronic illnesses is really an essential component that’s missing from the healthcare model as we know it today. So, imagine a primary care provider taking care of their patient using a telehealth model. They need to bring in a behavioral healthcare provider, bring in a specialist into the discussion, bring in ancillary healthcare professionals, maybe addressing social determinants issues, and you can actually bring all those people together in a model much like you see happening in a Teams meeting or in a Zoom setting, and even think about bringing the caregiver into the model, family members and peer support.

So I think the future of telehealth is not only going to be to address access, but to really advance the model of care. And of course, I believe that you can also personalize healthcare much easier using a virtual model, matching what the patient needs to the provider’s competence, but also the type of provider — whether it’s to match gender, culture, educational backgrounds — so that patients get the type of experience that they feel that they do best with and that frankly that they deserve to have. So, I think that we’re just in the early phases of integrating technology into the patient care model. Of course, think about the implications of AI running in the background of telehealth visits and bringing in information that both the provider and the patient should be aware of and new findings and new diagnostic and therapeutic opportunities that present themselves because of the artificial intelligence and the natural language processing that can go on at the same time.

So I think we are in the early innings, but that’s not to say that virtual care is going to replace traditional care. I think that we’re really looking at a hybrid model. I think that there are absolutely times that patients need to be physically examined where touch is important, where face-to-face interactions are going to be needed, where procedures are going to have to be done, lab tests and others that will need to be done in person. So, I think the healthcare providers and the payers who think about integrated hybrid systems of care are probably the ones that I think are headed in the right direction.

Brandofino:

Absolutely. You mentioned social determinants is definitely being a factor. The digital divide is also a challenge and I guess the lack of trust in some communities of healthcare systems and healthcare providers. What do you think virtual care can do in improving the accessibility and the equitable distribution of healthcare for those?

Shulkin:

Well, look, I think that sometimes the stereotypes of different people and their use of technology is probably beyond what the reality is. I hear people say that older people are technophobic and aren’t using smartphones and internet, and frankly, that’s just not true. I think that people are quickly adapting to the new world of technology, and those that haven’t, it’s because they’re not offered the opportunity to learn or to provide access. But there are many government programs providing significantly discounted access to internet or actually free. There are other health plans that are helping people connect in a technical way. And quite frankly, and I don’t mean this in a humorous way, but when I am in many cities and you see the significant issue with homelessness around the country, and of course there are 45,000 homeless Veterans, even many homeless people you can see have their smartphones with them, and it’s in fact their only way that they can stay connected and frankly to reach them and for them to reach back into the medical system. So, I think that technology, it may not be the answer for everybody, and I think that a good healthcare system has to have numerous ways of communicating and interacting with their patients, but I think technology really is increasingly the important foundation on which to build future models of care based upon integrating technology.

Brandofino:

Sure. It’s interesting. We’ve had a number of our customers implement virtual nursing programs, and what we’re seeing, and it’s a little bit surprising, is a huge uptick in patient satisfaction when they’re in a hybrid care model. And we dug into that a little bit, and it really seems to be because the virtual care giver has more time to spend in a face-to-face, albeit through a video call with the patient, and the patients feel like they’re getting more attention. So, what are your thoughts on that whole idea of improving quality of care in this hybrid model and what technology do you think will even enhance that more?

Shulkin:

Well, it doesn’t surprise me that you’re finding that there is an increased satisfaction with the customer experience. But look, when people, particularly in hospital settings, need assistance, they want quick access to care, right? If you’re in discomfort, if you need help with something, you don’t want to be waiting as that call button goes off and five, ten minutes go by because nurses or other people are busy with other patients that may need their help. So, if the system provides you with more immediate access that can address your issue, frankly, that is what people are going to describe as a better experience. And I do think that this hybrid model is really the way to do it. If you can get quick access to somebody to speak to them who can sort out whether you need somebody in your room at that time or whether the issue can be addressed virtually, I think then that really is the way to design the optimal type of patient experience.

Brandofino:

So we talked a little bit about policymakers. If you had the opportunity to talk to lawmakers, what would your recommendations be? And hopefully you do have access to lawmakers and you’re whispering in their ears. What types of things would you like to see happen that would really help us grow virtual care?

Shulkin:

Yeah, I tend to be, particularly when it comes to policy and large-scale government programs, I tend to be one who thinks about when you’re going to legislatively change something, when you’re going to put taxpayer resources into something, you should be looking for big significant change, not incremental change. All of these bills that add a little tiny piece of improvement may be important, but I don’t think that’s the way, at least when I approach government and legislation. So, when it comes to telehealth, I’m actually in favor of starting with the patient. What does the patient need? How do you provide them the right type of medical care and access? And that would mean, quite frankly, the way that I put it together, that all of these state regulatory requirements, separate licensing requirements, separate state restrictions, frankly don’t serve the patient very well, and in fact represent barriers to the delivery of care.

So I would go for a design of a system that actually says, let’s put first what the patient needs, and let’s put second the protection of the current business models and the protection of state rights. Now, look, I’m not a constitutional scholar, but I understand the architects of the constitution inherently wanted there to be state federal tension so that there wasn’t a centralization and a power among the federal government. And I understand that. But healthcare, I think one can argue should be somewhat different. And if somebody is not able to get access to care, whether it’s behavioral care or specialized medical care, because there aren’t professionals, I hate to see state regulatory requirements in place that frankly, I view as mostly protectionism of current business models. So, I’m more in favor of radical change. But one thing you learn when you spend time in Washington, you can’t always get your way.

And compromise, which is a dirty word in Washington, in my mind, is still the only way to govern. You never get your way completely. So, you do look for those opportunities to support the bills that will get you the most bang for the buck, which means make the most difference for patients. And it probably won’t be a wholesale elimination of state’s rights. I think that’s probably unrealistic. But what I like that I’m seeing are the pacts, the consortiums of state licensing. You see the psych pact happening, psychologists, you see the nursing pacts that are happening. There are some medical licensing pacts. Although they are very complicated, burdensome, difficult to use, I think they can be improved. And I think that telehealth, frankly, can be an exception to many of the regulations that we’ve had. And CMSs has implemented a number of them, but I think there are others that are important for us to look at as well.

Brandofino:

Sure. Well, that’s great. And David, thank you so much for joining us today. This has really, hopefully been insightful for folks who are going to watch the podcast. This is such an important topic. We’ve been helping customers, and our philosophy is to get care to wherever the patient is. And it sounds like that’s what you propose as far as the lawmakers are concerned. And I hope they listen to that, and I hope we get some movement this year. So, thank you very much for joining the podcast. I appreciate it.

Shulkin:

No, listen. Thank you. I think your comments right there are exactly right. This has never really been a technologic issue, and certainly with what you described, I’m confident that the technology is there. This is really something that is more us challenging ourselves. Can we do better for patients? And do we have the courage to take the steps necessary to do that? But this is very possible to do in the near future, and I appreciate all the work that you and Caregility are doing to advance the model of care.

Brandofino:

Thank you very much.