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Dr. David Shulkin: Government's role in health technology and infrastructure

Dr. David Shulkin: Government's role in health technology and infrastructure
Cadence Team

Cadence Team

09
June 2022

In a new episode of Cadence Conversations, Founder and CEO of Cadence Chris Altchek sat down with Dr. David Shulkin, 9th Secretary, U.S. Department of Veteran Affairs to discuss the future of remote patient monitoring (RPM) and what it will take for new technologies like RPM to take hold and get adopted across the U.S. healthcare system.

The wide-ranging conversation centered around the opportunities and challenges in reforming health systems, as well as the role that technology can play in addressing rural health disparities. It was recorded as a part of Cadence's new podcast Cadence Conversations, featuring healthcare and technology leaders discussing how new technology is transforming healthcare. 

Prior episodes of Cadence Conversations include CEO of Rubicon Founders Adam Boehler discussing how to build an impactful healthcare business, advanced heart failure specialist and cardiologist at the Duke University Medical Center Dr. Marat Fudim discussing how RPM can transform a cardiology practice, and President & CEO of Rush University Medical Center Dr. Omar Lateef discussing how new technologies can improve health outcomes for patients.

In addition, Shulkin also recently participated in a roundtable conversation held in Nashville about the future of remote patient monitoring, which featured a panel of experts including Dr. Toby Cosgrove, David Dill, Dr. David Shulkin, and Dr. Lynn Simon.

Shulkin, who has served in both the private sector as well as in government over the course of his career, began by sharing some of his many lessons learned from public service. Having previously held leadership roles at the Department of Veterans Affairs during the Obama and Trump administrations, Shulkin discussed how and when change actually happens in the U.S. healthcare system. 

"When things happen in healthcare, it's because of the fact that it's both clinically the right thing to do, but also financially the right thing to do, for either a payer or for a provider, or for the patient themselves, for a company that's providing the payment services. That's when you really see the changes happen in healthcare, when that alignment works the best."

COVID-19 has ushered in a rise in new technologies in healthcare, including the transition of care from traditional hospital settings in the home using technologies like RPM. Shulkin shared some of his lessons learned from the COVID-19 pandemic, and what types of innovations we are likely to see in the future.

"We've learned there are better ways now of delivering, or at least alternative ways that are successful, in delivering care, whether it's virtual care, whether it's the use of data collection out in the field, delivering more care where people reside, either at work or at home," he said.

For new technologies to take hold in the healthcare system, according to Shulkin, they cannot just be a new gadget or new workflow. Instead, he believes that companies must demonstrate real value for patients and ultimately enable better, more immediate, and more timely access to care.

"I do think that we're going to see technology that allows improved access, improved information sharing among the various stakeholders in the healthcare system, and improved data flow. These are the things that I think are most likely to make the difference, and not all technology's going to achieve those objectives," Shulkin said.

Shulkin concluded by sharing his views on the future of remote patient monitoring and why he is bullish that companies like Cadence can help play a role in reducing rural health disparities across the country.

"We still have a system that every year is more expensive, we still have a system where there are huge disparities in care. The biggest predictor of outcome turns out to be the zip code that you live in," said Shulkin. "And so we do need to be thinking about new ways of adopting changes in our practice, and technology needs to play an important part of that."



Listen above to the entire conversation and be sure to subscribe to Cadence Conversations wherever you get your podcasts in order to listen to future episodes. 

Read the full transcript of the conversation below:

Table of Contents:

Introduction: Welcome to Cadence Conversations, where we're talking with prominent physicians, healthcare leaders, and tech entrepreneurs about their experiences driving innovation and progress. This week, Chris Altchek, founder and CEO of Cadence, had a chance to follow up with Dr. David Shulkin, ninth Secretary, U.S. Department of Veteran Affairs. 

After his appearance on our panel in Nashville, the two chat about the opportunities and challenges in reforming health systems, the role technology can play in those health systems, particularly in driving health equity in rural communities, and how to overcome some of the skepticism around adopting those technologies. Dr. Shulkin could also offer some advice for physicians looking to transition into administrative and leadership roles. So let's get to this week's Cadence Conversation.

A Career in Management of Healthcare

Chris Altchek (CA): We're excited to speak with you today, Dr. Shulkin, and welcome to the podcast. Take us back. Can you give our listeners brief background on your work as a physician, and how that led to your serving in senior positions in government during the past two administrations?

Dr. David Shulkin (DS): Sure, Chris. It's a pleasure to be with you. I am an internist, I've always maintained an active practice, but I've spent most of my career focused on the management of healthcare. I trained specifically in both health services research, but also in the science of how to change physician and organizational behavior to move towards better quality, better safety, better value in healthcare. And that's been a really incredible journey where I've got to have the chance to lead many organizations, work with many different physician groups throughout the whole ecosystem of healthcare, and then ultimately, back in 2014, during a time of crisis for the Department of Veteran Affairs, that was known as the wait time crisis, where veterans were returning from Iraq and Afghanistan with great needs, but not able to get appointments to get the help that they needed, that resulted in the White House reaching out to me and asking whether I'd be willing to come to try to help that situation.

And of course, that wasn't necessarily a plan of mine, but I didn't feel like I could say no, that if I felt like I had the ability to help, I wanted to help. And so I left my job running hospitals and health systems to go to Washington to help fix the VA system, first for President Obama, and then later on for President Trump.

Transitioning into a Healthcare Leadership Role

CA: And I'm sure you've mentored many physician leaders over the years. What advice do you have for physicians who want to transition into administrative and leadership roles?

DS: So what I tell people is, first of all, you have to pursue what you really enjoy doing. So many people come to me and say, "Well, should I go get an MBA or should I go back to school?" And I say, "Only if you enjoy going back to school," that ultimately the experience that you get in those types of academic environments once you're a physician, can be valuable. Usually the most valuable thing is the people that you're going to school with, that you work with on the day-to-day basis that you maintain relationships with. But if you really enjoy that type of learning, you should absolutely do it. But if it's painful, then you should find a different way to achieve your goals. And that means working your way up through various organizations, working on real-life projects that improve the quality of your practice, or the quality of your environment for patients. So there are many different ways to achieve your goals, but most important is to find a path that you enjoy and feel passionate about.

Clinical and Financial Alignment in Health Systems

CA: And that's a great transition. As a leader in the private sector and in government, you've seen both the opportunities and the major challenges in reforming how health systems operate in the United States. What have you seen as some of the biggest opportunities and challenges, repeatedly across your career?

DS: Well, I think that whenever I look for change, you always need to look for two things. You need to make sure that what you're working on is the right thing, clinically. And that's what differentiates physician leaders. That they have the knowledge and the ability to determine whether something is actually going to be good for patients, improve outcomes, improve safety, improve the wellbeing of a patient and those around them. And that clinical approach though, is often not enough. It has to be aligned with a financial incentive as well. When things happen in healthcare, it's because of the fact that it's both clinically the right thing to do, but also financially the right thing to do, for either a payer or for a provider, or for the patient themselves, for a company that's providing the payment services.

So that's when you really see the changes happen in healthcare, when that alignment works the best. And I always try to see whether you can achieve that clinical and financial alignment in order to make the type of changes that I think people are hoping for in our healthcare system. Because when that happens, then you improve access to care, then you improve satisfaction with care, you improve outcomes, you improve efficiency. And those are the things that frankly, our system still struggles with to this day.

The Future of Healthcare Technology Infrastructure

CA: Let's talk about the future of technology in healthcare. What are the biggest gaps you see around healthcare infrastructure today? And where do you think technology companies like Cadence can play a role in addressing these gaps?

DS: Technology is not going to advance in healthcare just because it's a new way of doing something, or it's a new gadget. It's got to address a real problem in healthcare. And the problems that still exist are the ones of being able to get good, immediate and timely access to healthcare. Being able to make sure that the information that's available, that one provider has, is available to other providers, closing the gaps in care that prevent us from doing chronic management, the way that frankly, we know that we can do. And so I do think that we're going to see technology that allows improved access, improved information sharing among the various stakeholders in the healthcare system, and improved data flow. These are the things that I think are most likely to make the difference, and not all technology's going to achieve those objectives.

Interlude: At Cadence, we have a world-class Care Delivery Team who serve as an extension of our hospital system partners and help manage patients' care on a daily basis. In Care Delivery Stories, we'll hear from one of our team members about the impact Cadence is having on their patients.

April Clarin: Hi my name is April Clairin and I am a Nurse Coordinator at Cadence.

We have a patient who took a 20 minute walk for the first time this morning, and they felt great and better than they have for quite some time. Just the day before, the patient had reported to me feeling hesitant to walk even to the mailbox and back.  

We agreed to set an exercise goal of 10 minutes, 3 times per week and increase this as tolerated. The patient absolutely crushed their goal on their first attempt! 

I think this is a really exciting example of how our Care Delivery Team, along with our remote patient monitoring technology, can help to keep patients healthy and allow them to reach their own health goals and improve their lives.

How Skeptical Physicians Can Move Toward Embracing Change


CA: As a physician, you're well aware of the skepticism that many physicians have around new technologies. How did you personally come to embrace the constant pace of change in technology in healthcare, and what have you coached the physicians you've worked with along the way, to figure out how to adopt technology most effectively for them and their patients?

DS: I think that understanding when technology's going to be valuable and when it really is in advance over the current practice is one thing. Understanding the timing of when those changes are really going to be accepted and adopted is something else. And I have to say, I personally still often get the timing in healthcare wrong because there is a big push to keep the status quo in healthcare. And it's not because there's anybody who has bad intentions, it's just that this is a very complex system that requires a lot of different people to all have to agree that this change is good for it to happen quickly. And that's why, frankly, sometimes you need to wait for government to take the leadership to say, "This is the way that we're going to do things." An example would be interoperability of data that the government has put into certain regulations, that has had to really been the motivator to get the entire industry to start moving in a common direction.

We still have a system that every year is more expensive, we still have a system where there are huge disparities in care. The biggest predictor of outcome turns out to be the zip code that you live in. That the socioeconomic determinants of health are probably as powerful as any clinical aspect of healthcare. And so we do need to be thinking about new ways of adopting changes in our practice, and technology needs to play an important part of that. And so we're likely to see early adopters of technology, who then are going to either prove that it works or it doesn't, and others will learn from that. And over time, we will see a rapid adoption. I don't know if it'll be rapid, we will see adoption. When you do see rapid adoption, it's usually because there's some type of external stimulus. We just saw this with COVID and the public health emergencies, that there was a rapid adoption of virtual technology because of the necessity imposed by the public health emergency. We've also seen rapid adoptions when government comes in and adds a mandate or a regulation, or a financial incentive.

Government’s Role in Telehealth Adoption

CA: And the government played a huge role in the growth of telehealth and virtual care during COVID, making it possible. What would you like to see from policymakers in this post-COVID world going forward, to enable continued transformation, continued innovation, but in a responsible way?

DS: Well, I think the first thing is, having gone through what all of us have gone through these past couple of years with COVID, we have to resist the temptation to say, "Well, the pandemic is easing. It may be ending in terms of a declaration or a public health emergency, but we can't go backwards." I think that we've learned there are better ways now of delivering or at least alternative ways that are successful in delivering care, whether it's virtual care, whether it's the use of data collection out in the field, delivering more care where people reside, either at work or at home. We also understand that the importance of breaking down some of the silos in healthcare between physical health, behavioral health, pharmaceutical use, device use, these were all silos that prevented us from achieving optimal outcomes. And now I think we have a chance to be able to look at this differently.

CA: And you recently wrote on your blog about digital health apps and their effectiveness, especially given the explosion of the last two years. How do you think about proving clinical effectiveness of new technology? What do you want to see from innovative companies and what do you want to see from the government to promote truly effective uses of technology?

DS: Well, I think that it's a good thing that we're innovating and trying things, and looking at what works and what doesn't work. I do think that it's a mistake to treat all technology the way that we would treat a pharmaceutical, in that I don't believe that many of the digital apps, and much of the innovation that's happening in the digital world, needs to undergo the type of expense of long-lasting clinical trials, that frankly, FDA is putting a lot of these companies through, because I think it's actually slowing down our adoption. I think that it is important to understand what works, but I think you can do this in real-world evidence. And I think that you can begin to start learning and reporting with transparency and accuracy, and there can be authentication, there can be audits to make sure that these are real data being reported. But I don't think that we want to replicate the expense and time of bringing a new drug to market.

Patient-reported outcomes, patient use, patient engagement rates, patient compliance, these are all things that I think are important when we start thinking about evaluating and determining the appropriateness of digital tools.

The Case for Public-Private Partnerships in Healthcare Governance

CA: Is there a regulatory body that you think should be taking a leadership role here, in figuring out these self-reported standards? And Cadence, just a good example where we just submitted a data set to a journal for an initial abstract around heart failure. It's just interesting to know which government bodies should be getting a copy of our data and being able to review it.

DS: I think that it's not clear that we have this figured out. Right now, the FDA takes the lead on this. And look, the FDA is the natural existing body that would be taking a look at a device and ensuring the safety for patients. But the FDA, clearly, especially during the pandemic has been overwhelmed. And that has put these types of technologies and these types of evaluations a little bit further down on the priority list. So my feeling is that we should probably be looking for a new type of agency. These types of specific technologies that are not only here now, but will come in the future. My hope would be that this is not a pure government agency, so it doesn't become purely another bureaucratic organization. But that we have looked at, and we've learned about models of public-private partnerships that do allow for industry to be part of the solution, and part of implementing practices that frankly, are based in the real world.

Driving Health Equity in Rural Communities through Remote Care

CA: The Biden administration recently announced new initiatives to drive health equity in rural communities. What would you like to see from the government, and what would you like to see from technology companies, to ensure equitable outcomes and help address the massive gaps in care and health delivery today?

DS: Well, I think the administration has highlighted something that is now becoming really clear to many people in healthcare, and I think that we've seen this over the decades, but there really hasn't been the public policy focus on working to eliminate these types of disparities. So I think it's a very laudable goal. It is important to remember, whenever you put up one objective above the other, something is going to be focused on and something's not going to be focused on. So we also have to worry about the unintended consequences of what we're not focusing on. And so we have to keep in mind that we're trying to achieve a number of things. We're trying to achieve access to care, and that needs to be addressed from where you live and your socioeconomic status, so that this does not become one of those inequities, based upon what standing you have in our society.

But we also need to continue our focus on quality of care, we need to focus on the affordability of care, we need to focus on what is most effective in terms of driving improvement in outcomes and wellbeing. And we need to break down, as I mentioned before, some of these silos between behavioral health, physical health, pharmaceutical health, device health, data interoperability. So there are many, many components of what is important to focus on when you're doing public policy. And it's great to see that we are highlighting several of these areas, but we have to remember, we don't want to highlight areas that then defocus us on other parts of healthcare, that are going to be really important to achieving the type of healthcare system I think we all want.

CA: Well, Dr. Shulkin, with that, we will wrap. It's been an honor speaking with you. We really appreciate your time and perspective, and so do our listeners. So thank you very much.

Thanks again to Dr. Shulkin, for spending so much time with the Cadence team on these last two episodes. To make sure you get updates on our future conversations, please subscribe to Cadence Conversations wherever you listen to podcasts. And for more information about Cadence and how to get involved, visit cadence.care. At Cadence, we believe that everyone deserves to receive the best care possible, and we won't stop working until that vision becomes reality.

Author bio

Cadence Team
Cadence Team
Cadence is a pioneering health technology company helping the nation’s most patient-centric health systems deliver world-class care outside of the four walls of the hospital. Cadence’s Care in Sync™ platform couples powerful new technology with clinical excellence, providing its patients a precise and personal level of care through remote patient monitoring and virtual care.