In his visit to Miami, a Q&A with the secretary of the Veterans Administration

U.S. Veterans Affairs Secretary David Shulkin visited the Miami VA Healthcare System on Friday, less than a month after he was unanimously confirmed to lead the Veterans Affairs Department in February.

He is the only member of President Donald Trump’s Cabinet to have served in the Obama administration, having previously spent 18 months as undersecretary for health in charge of the sprawling VA medical system, which serves 9 million veterans a year.

The 57-year-old internist and longtime healthcare executive is the first non-veteran to serve as VA secretary. Shulkin was president and CEO of New York City-based Beth Israel Medical Center from 2005 to 2009 and he supports integrating the VA system with private-sector healthcare.

With a $75.2 billion annual budget, the VA manages veterans benefit programs and operates the largest integrated healthcare system in the nation, including nearly 1,300 VA medical centers. The Miami VA Healthcare System is among Florida’s busiest, serving about 58,000 patients a year, with an annual budget of $537 million and about 2,800 employees.

Among Shulkin’s first acts as secretary was to offer urgent mental-health care beginning this summer to thousands of veterans with less-than-honorable discharges, part of a broader effort to stem a high rate of suicide among former service members.

Following confirmation, Shulkin publicly outlined his priorities for the department. His goals include passing the new accountability legislation and extending the Choice Program that allows veterans to see doctors and hospitals outside of the federally run system.

Questions and Shulkin’s responses have been edited for context and length.

Q: You support the VA Accountability First Act of 2017, which would make it easier for you to fire employees for performance or misconduct. Why hasn’t there been more accountability in the past at the VA, and what will the bill do to bring that forward?

A: I think what’s happened in the past is that as we’ve worked through decisions, particularly as they relate to removal of employees, that when the secretary has made a decision to remove them that those decisions have too often been reversed by the appeals process. ...

What we’re seeking in the accountability legislation through the House right now is to make sure that the appeals process is balanced in the right way to assure a fair process for employees because I do believe in due process, but also so the decisions made by management are not so easily overturned when it’s inappropriate to overturn them.

Q: You recently told Congress that you would like to see the Choice program expanded. Has Choice helped to reduce veterans’ wait times for care, and if so, by how much?

A: The Choice program, as I’ve said repeatedly, started with a very slow start. We had to take a program from never having existed to a nationwide program in 90 days. I think most of us who have done this before would say that was very unrealistic.

Now, two years into the program it’s working much better. We have 7 million appointments that have been scheduled through the Choice program, and this year alone we had, in the past year, 5.5 million visits. So we can see it’s beginning to have the intended impact.

Q: Is the Choice program working better in Florida than in 2015 when Florida hospitals said the VA had not paid them for services? Why weren’t they getting paid?

A: We had early significant problems with paying our providers on time. I come from the private sector, being a provider, knowing what it’s like to deliver services and not get paid, and that was not acceptable. I instituted several changes. The main reason why we weren’t paying on time was because we were requiring all the clinical information to be returned before we would pay the bill. I suspended that rule. So we made 70 contract modifications to the Choice program.

Q: You recently stated that suicide is a significant problem among veterans. What has prevented the VA from doing more to prevent suicides among veterans? And what will the VA do to address that problem?

A: The single most disturbing fact that I’m aware of today is that 20 veterans are taking their life every day from suicide. This is really completely unacceptable. One suicide a day among veterans is not acceptable to us. This is a major problem in the VA system, but let’s also remember this is a significant public health problem across all of America. ... In the VA one of the realities of it is of those 20 veterans a day, 14 are not getting care in the VA system, so that they’re out there in the community not getting the care they need. Part of the recognition of solving the problem is to work much closer with community groups and community partnerships and family members because we need to reach those 14 that are not getting the care that they should be getting today.

Q: How has the Miami VA improved its drug addiction treatment center that was criticized by the agency’s Office of Inspector General after a veteran overdosed while enrolled in the program?

A: Anything that is impacting our veterans’ well-being is important to us, and unfortunately substance abuse is a very significant problem that still remains. When the VA sees a problem it’s often the beginning of what the rest of the country sees. So, now I think there’s an awareness that heroin use and other substance abuse across all Americans, particularly young Americans, is just skyrocketing.

The VA is a leader in these types of treatments, so we do want people to come in for help. We are providing programs that frankly you’re not seeing across the rest of America. We provide a lot of peer support, which is peer-to-peer counseling. We are providing residential programs that frankly the private sector just is not able to do anymore. We’re looking for new and better ways to provide treatment. There are new medications that are out there that the VA is aggressively implementing and working with. And we’re doing research in this area because more needs to be discovered about why this is continuing to be such a problem.

Q: Veterans have complained that VA doctors prescribed them opioids for pain, and after years of taking those medications these veterans now cannot get their prescriptions filled. Is there a new policy to wean vets off opioids?

A: No, there is no policy that would prevent a doctor from prescribing the right medication.

What there is is a comprehensive system that VA has put in place to make sure when pain medications are prescribed that they’re prescribed appropriately. We’re spending a great deal of time with education of our physicians about the use of alternatives, making sure that our physicians are educating our patients when they start them on pain medications about what their roles and responsibilities are. And looking at alternative treatments, and so the VA is a leader in complementary care, using non-medication treatments for pain management.

We’ve seen a 22 percent reduction in the use of opioids since 2013, and that’s providing an example for the rest of American medicine.

Q: You come from the private sector. Will there be privatization of VA services in the future?

A: I am not in favor of privatizing the VA. That is not a direction that we’ll be heading under as long as I’m secretary. What I am in favor of is doing what’s right for veterans and that means taking advantage of what’s best in the VA system and taking advantage of what’s best in the private sector and letting veterans have the best of those worlds.

Q: As more women serve in the armed forces, more of them will need VA services. Is the VA prepared?

A: Women in the VA is the fastest-growing segment of any veteran group, so it’s very important that we continue to expand our services for women veterans. Here in the Miami VA, we’re building a brand new center for women’s healthcare that’s going to be bigger and better and offer more services.

Q: How comfortable are you with this administration?

A: I’ve never been more confident and optimistic. I believe that we have everything in place from the president all the way down to be able to make the system work better, and we’re going to do just that.

This story was originally published March 10, 2017 at 5:54 PM with the headline "In his visit to Miami, a Q&A with the secretary of the Veterans Administration."