Telehealth, a long-overdue technology is the need of the hour today. Historic legislation is passed and billions of dollars are committed by the Government to prepare healthcare practitioners to deliver virtual care. But, is the healthcare ecosystem ready for a change? And if so, can it be scaled up in a sustainable manner? Let’s find out.
Dr. David Shulkin is an experienced healthcare professional who has served the United States as the Secretary of Veteran Affairs. In 2017, he was unanimously confirmed to lead the Department of Veteran Affairs after serving as an Under Secretary during President Obama’s tenure. He has a lot of hands-on experience in implementing Telehealth across VA’s own healthcare system of over 1200 hospitals and clinics across the country. Dr. Shulkin has a medical degree from the Medical College of Pennsylvania and has helped leadership roles with multiple hospitals and healthcare systems. He has also authored the book “It shouldn’t be this hard to sell the country”.
CAN YOU GIVE US A BIT OF A FLAVOR OF YOUR BACKGROUND AND HOW, ACCORDING TO YOU, IS THE HEALTHCARE SYSTEM DIFFERENT FROM A CORPORATE SIDE OF THE WORLD TO THE POLITICAL SIDE OF THE WORLD?
Well, I’ve been in health care for quite a while. Primarily, though I’m a physician and I look at the world through the eyes of how a physician cares for a patient and in all of my various roles, including being Secretary of the Department of Veteran Affairs, I never took off my white coat or my stethoscope. I always made sure I made time to take care of patients because that helps me in understanding the job that I’m trying to do in leading an organization. It also keeps me grounded.
Why do I do the work that I do? I’ve had the privilege of working in academic health systems, in community hospitals, doing startups, being the Dean of medical school, working in government, working with men care organizations. I’ve seen healthcare across different spectrums. Right now, even with the various challenges that we face, like the Coronavirus, I’ve never been more excited about the opportunity to make advances in health care with looking at the various types of technologies that we have coming on board, looking at new ways and approaches to managing populations of patients. I think it’s a very exciting time where there’s gonna be considerable change going on. And I would just add back in about the current crisis that we face with Coronavirus. Times of crisis are often times that things move quicker out of necessity, and people put aside traditional ways of looking at things and understand that the world will never necessarily be the same. We’re looking as we come out of this crisis and a dramatically rapid changing period that can end up making health care only better for all of us.
WHY HAS TELEHEALTH BEEN SO SLOW TO BE ADOPTED IN THE HEALTHCARE SECTOR? DOES IT HAVE ANYTHING TO DO WITH THE READINESS OF THE TECHNOLOGY?
I don’t think there has ever been a technology issue. We’ve had telehealth one way or another for over 40 years. There has been solely a reimbursement issue and a regulatory issue. When you ask healthcare leaders or physicians to do things that are against their economic best interests, they’re simply not going to do it. Since telehealth has not been paid for in a way that has parody to physical visits, it should be no surprise that this is a slowly adopted technology. When you have regulatory barriers that prevent you from being able to perform normal patient functions, such as being able to care for a patient on an initial visit or being able to prescribe certain medications using telehealth, it is no surprise that this has been so slow to be adopted. I return to my comments about the crisis. Now that this crisis of Coronavirus has been built almost precisely for the use of telehealth. We see that CMS was very quick to issue 1135 waivers where they’ve created both parody reimbursement and have removed many of the nonsensical regulatory barriers so that telehealth can be used because it’s necessary to be used. And it’s gonna be very hard to put the genie back in the bottle and these are permanent changes for the health care system.
LET’S TAKE THAT AS OUR NEXT QUESTION. IS IT GOING TO BE TEMPORARY JUST TO DEAL WITH THE CRISIS OR THEY WILL SUSTAIN?
I don’t think it’s gonna be easy to put this back as the way it was before. Frankly, it’s not fair to the health care system or the patients. You can’t say, we’re gonna show you how well and easy this technology works and how convenient it’s been, that it saved a lot of lives by keeping people out of waiting rooms, but we’re just kidding about that. Now we want to go back to the old ways of being bureaucratic and regulatory, and pay us for that. If the provider in the public can tolerate that type of behavior, then we have to remind people that people in government work for the people, not for bureaucracies. I certainly hope that it does not go back to the way it was.
WHAT DO YOU HAVE TO SAY ABOUT THE READINESS OF THE HEALTHCARE ECOSYSTEM ITSELF, LIKE READINESS OF THE HOSPITALS TO UNDERSTAND HOW TECHNOLOGY PLAYS A ROLE?
Every hospital and health system in the country is using this time that they are waiting to see which way this infection goes in their community to rethink their strategies. Most hospitals and health systems in this country, including physician practices and ambulatory centers, are experiencing significant declines in revenue and not only in operating revenue but non-operating revenue that kept many organizations going. They’re going to have to do complete financial re-forecasts. They’re gonna have to do new capital plans. They’re gonna have to rethink their strategy. And frankly, not all these organizations are gonna have an easy time finding their way out of this crisis. Those organizations that are most capable will rethink what they’ve seen. Try to understand how this pandemic has changed behavior and will adopt a different strategy. And that is going to mean that they’re going to have to think much more about investing in areas that they have not and not investing in areas that they have. They’re gonna have to do it in partnership with the government, because the government pays more than half of the health care bill right now and the payers that they work with. What is so complex about making a change in health care is that you can’t change alone, because if you change your service offering, but the payers don’t change with you, it doesn’t work very well. If you change without the regulators working with you, it doesn’t work very well. I think it takes a pandemic of this size and scope for everybody to stop doing what they’re doing to sit back and think, how can we make this system work better? If there’s ever a time to do that, it’s gonna be once we come out on the other side of this crisis.
WHAT BASIC TECHNOLOGY AND INFRASTRUCTURE ARE NEEDED FOR THE HEALTHCARE SYSTEM TO BE IN PLACE TO EVOLVE FROM THIS AND THINK ABOUT TELEHEALTH AS A STRATEGY?
First of all, having my last position run the largest health care system in the country, I thought a lot about this, that if we weren’t gonna lead in this area, how would you ever see change? So three years ago, I made the changes that we are now all talking about in telehealth. I went to President Trump, I got his support. As I’ve been a practicing doctor, I was seeing telehealth patients myself from my office in Washington D.C. that overlooked the White House to Grants Pass Oregon, which is a very rural part of Oregon where I was the doctor in the VA clinic there taking care of veterans using telehealth. I brought my telehealth equipment to the West Wing and showed President Trump how I cared for patients. I introduced him to my staff and my patients, and asked him for his help because I had all those same regulatory barriers that the rest of the healthcare faced. We couldn’t deliver telehealth outside of a VA facility. We couldn’t deliver it in the home because of regulatory issues. We had problems crossing state lines. I got all that resolved three years ago and saw the impact that it had on veterans. Last year, we delivered 900,000 veterans care through TeleHealth, which is pretty amazing. It’s just continuing to expand more and more all the time. But what is going to be needed besides some of these regulatory and reimbursement changes that I’ve already talked about, is we’re gonna have to finally tackle the issue of interoperability of healthcare data. Another example where I do not believe that the barriers are not technology related. It is not technically difficult to get one data source to communicate with another data source. What we have here is a business model problem where there are companies that believe that they have found a way to monetize and get paid for the transfer of data or the ability to block data and have to build interfaces that they charge for. That has limited so much of the ability of technology to be effective in health care. What we need is, we need the patient to be the owner of the data who controls everything related to them and not the technology vendors and the electronic medical record companies. That’s the next major change we’re beginning to see. The Office of the National Coordinator in the Centre for Medicare and Medicaid Service is taking a lead on this, writing some regulations, but it’s going to take a real commitment from providers and payers to force this change to happen.
WHAT COULD THE HEALTHCARE SYSTEM BE AWARE OF AND NOT MAKE BIG MISTAKES?
While most innovation happens out of necessity and I had a big problem leading the VA where we had an access problem. We had veterans waiting too long for their health care and many were being harmed because of that wait. So for me to most efficiently deliver care to parts of the country that didn’t have health care professionals like many rural parts of the country who didn’t have specialists, I needed to find a way to deliver the expertise that I had in the V A, which usually resided in metropolitan areas like New York, Philadelphia, Pittsburgh, Boston Chicago and use them to be able to help people in other parts of the country. Telehealth again was designed perfectly to be able to do that and the help I just needed to get rid of the regulatory barriers. In the Department of Veteran Affairs, the reimbursement issues weren’t a big deal because we get our money from Congress. Congress then says, “Here’s your budget. Go do what’s in the best interest of veterans.” In the private sector, you have to deal with reimbursement alignment issues as well. But it was the necessity that allowed us to make as much progress as we did in the area of Telehealth.
WHERE DO YOU SEE TELEHEALTH IS APPLICABLE BASED ON WHAT WE CURRENTLY HAVE FROM TECHNOLOGY PERSPECTIVE AND WHERE IT WILL HAVE THE MOST IMPACT?
I don’t particularly like the model that this facility is based on. We have to design this system around what the patients want, what the patients need. In this current crisis that we’re seeing with COVID-19, you can see that it’s really important to be able to deliver care in the patient’s home and where they need to be. And that’s the model that I believe is going to be most effective. People are gonna want to get their care from their phones where they get everything else, even work at home. We need to design a system that meets the lifestyle of the needs of our customers. The model of care is direct to consumer model, one that doesn’t require ancillary healthcare staff to deliver the examination. Now there are increasing devices that have allowed patients to do their examinations, using video and using insular devices incorporated into a handheld machine. We’re going to see more point of care testing in the patient’s home. We’re going to see more advanced illness management in the patient’s home, and that’s going to be the model that is going to be the most effective. There still will be abilities to have facility-based telehealth and some specific disease management components of telehealth models. But the primary model it’s gonna have to be a mobile model that creates an environment in the home for care management.
HOW DO YOU THINK THE FINANCIAL ASSISTANCE TO TELECOMMUNICATION INDUSTRY TO ENABLE HEALTHCARE PROVIDERS TO SUPPORT TELEHEALTH WILL HELP OVERALL IN BUILDING THE INFRASTRUCTURE THAT IS NEEDED?
It’s a good first step because for some the infrastructure investments are going to be challenging particularly in implementing telehealth where there aren’t good 4G or 5G networks available. That’s always been the limitation, particularly in parts of the country where we need it the most like in rural areas. What the government will have the biggest wrongdoing is to continue to maintain these relaxations of the regulatory burdens and in trying to assure that there will be a reimbursement parody. And then consumer demand and the market will take care of the rest of the problem.
DO YOU SEE 5G WILL PLAY A ROLE IN SETTING THE RIGHT INFRASTRUCTURE TO PROVIDE CONNECTIVITY THROUGHOUT THE COUNTRY?
Yeah, it’s gonna be critical. Without the bandwidth to be able to use some of the data flow tools and the necessity to do more extensive types of care over the Internet, we’re gonna need to have that infrastructure in place. I think it’s going to make a big difference.
Without high-quality connectivity across the country, telehealth cannot succeed. The alignment gap between the regulators, repairs, and the health care system must be filled to make virtual care accessible to everyone in the country. Your efforts to make health care available to our veterans is commendable. You have proven the technology is ready and we hope the industry adopts it soon. And yes, let’s not put the genie back in the bottle.