The response to COVID-19
Among hospitals and other providers, the leadership response to the coronavirus pandemic has been “incredible,” Shulkin said. He cited early steps such as delaying elective surgeries to accommodate COVID-19 patients, creating unprecedented surge-capacity plans and seeking out innovative supply chain solutions. “We’re seeing the best of what American healthcare can do.”
Yet significant issues hampered the response, Shulkin said in late March. The lack of equipment was a big concern, even as manufacturers stepped up to try to address that need.
Staffing was a potentially more insurmountable obstacle. Based on past studies, he said, 35% to 50% of staff are unavailable or unwilling to work when a pandemic reaches its peak. “This is where we’re going to see the limitations of what our healthcare system can do in response to a pandemic.”
Preparation for future public-health emergencies
After the COVID-19 outbreak subsides, Shulkin anticipates a more widespread acceptance of the role of government in ensuring the safety and health of citizens. People are seeing that in a public health crisis, “It really is government that they rely upon not only to set the rules and the policies, but to answer the need for large populations,” he said.
The change in outlook also will entail a greater focus on establishing an integrated healthcare system and ensuring equitable access, Shulkin said. “You recognize that viruses like this do not discriminate based on socioeconomic status. I think it’s going to reframe the way that people view healthcare, public health and government.”
Emergency preparedness will become more of a focus. “In the VA, it was one of our missions to train and prepare for emergencies,” he said. “I think that’s going to become a core competency of healthcare leadership in the future.”
Other changes likely will involve telehealth, which has the potential to significantly improve care access and the patient experience if utilized well, Shulkin said. In response to the pandemic, CMS issued Section 1135 waivers that alleviated regulatory barriers to effective telehealth.
“It’s going to be hard to step back to regulations and reimbursement policies that frankly never really made a lot of sense if your goal was to take better care of patients,” Shulkin said.
At the VA, which provides care for veterans starting when they leave service and continuing for the rest of their lives, “The lifelong approach to population health is very different than what many people see in the private sector,” Shulkin said in an earlier interview.
The healthcare industry long has struggled to guarantee adequate access to care. Shulkin said the concern is not merely about convenience, but more about ensuring that patients with urgent clinical issues can get care immediately — and not just at the nearest emergency department.
Shulkin joined the VA as undersecretary for health in 2015, when the agency was coming under fire for lengthy delays in the availability of appointments. He addressed the problem by making sure those with urgent clinical concerns were given top priority, eventually implementing same-day access to both physical and mental healthcare for those cases.
Another step was to publish wait times for appointments, a key aspect of being accountable to patients.
“To my knowledge, the VA is still the only health system in the country that publicly publishes its wait times,” Shulkin said. Data indicate that the VA’s wait times improved significantly from 2016 to 2018, he noted, while those in the private sector stayed flat.
A drawback of the VA model is the ability to treat only the veteran rather than the family unit. “So much of care happens in the family,” Shulkin said. “The more that we can look at how the healthcare system interacts with not only the patient but the whole unit of support around them — family, friends, community — the stronger our outcomes will be.”
A fundamental step toward improving care coordination and population health management is establishing a better payment system, Shulkin said.
Many industry observers can recite a litany of issues with fee for service, but Shulkin noted that past experiences with pure capitation — or with any system that assigns risk to only one party — have been problematic as well.
“We need to create a new model for reimbursement …. a hybrid system,” Shulkin said. His ideal model:
- Rewards productivity and innovation
- Incorporates components that truly impact outcomes
- Engages patients
The long-standing conflict of interest between payers and providers needs to be resolved, Shulkin added, whether through new contracting strategies or possibly formal joint-venture arrangements. “We can’t just be using language that sounds good. There has to be a true alignment of the clinical and economic goals and objectives for those types of partnerships to work. That’s going to be necessary to achieve the type of healthcare system that we want.”