The leading health care official at the Veterans Affairs Department says the agency needs better integration with private-sector medical providers in order to “re-engineer” the way veterans access treatment.

Dr. David Shulkin, the undersecretary for health at VA, told the Federal Drive with Tom Temin that the VA has taken an all-hands-on-deck approach to the “crisis of access” that came to light in April 2014. Ensuring quality of care, he said, doesn’t make a difference to veterans if they can’t schedule an appointment.

“The way that I look at the health system is that you can’t separate out the administrative functions and the clinical functions,” he said. “That when you look at it from a veteran’s perspective, it’s actually both that make a difference. So if you can’t schedule an appointment in an efficient way, you don’t ever get to benefit from the health care services that the health system has.”

The problem of long wait times for veterans to see doctors at VA medical centers had been building over time until it hit a  crisis point, Shulkin said, and became a simple matter of demand outpacing supply.

“The intensity of the injuries coming out of the recent wars, as well as the number of conditions and the intensity of the conditions as people live longer and utilize more services within VA are the real reasons why the demand for services has just increased so much,” he said.

In order to reduce the backlog of patients waiting to receive care, Shulkin said the VA has to reinvent itself as an organization that funds treatment at private medical facilities for veterans, in addition to offering services at their own centers.

The Veterans Access, Choice and Accountability Act,  passed by Congress in 2014, gives VA broad enough powers to make those structural changes, he said.

“The Choice Act actually gave us expanded authority and expanded resources to be able to do that. Now our new veterans choice plan comes out and says that a future health care system for the veterans must include both care within the VA health care system and care in the community. And the VA must transition to an organization that can ensure the very best quality for veterans, whether they get care within the VA or outside of the VA,” Shulkin said.

Data analytics and care management

In order to innovate its way out of the problem, Shulkin said the VA needs to focus on better data analytics — being able to track veterans’ medical histories regardless of where they get their treatments.

That means VA will need to build more health information exchanges, VA computer systems that can interact and communicate seamlessly with systems from outside providers.

Shulkin touted VA as the first large adopter of electronic health records in the United States, and said that the VA has more than 20 years of electronic health records on the veteran population.

“Now that the private sector is rapidly adopting electronic medical records, we have to have the ability for these two systems to talk to each other,” he said.

Aside from better data, Shulkin said VA health care providers need to help veterans better navigate the health care system to ensure a “continuity of care,” where veterans don’t have to start back at square one if they move or seek treatment at a different facility.

“Where I think that the health care environment is going to is giving the patient, or in this case the veteran, more control over their personal health information. We have a portal called ‘My HealtheVet‘ that we have millions of users of, so that veterans are now becoming owners of their own information,” Shulkin said.

Reducing backlogs through ‘stand downs’

By the end of 2016, Shulkin said the Veterans Health Administration will have moved closer to its goal of veterans receiving same-day access for primary care. Shulkin said more than 20 percent of VA centers are already doing this.

“We have to learn even from within our own system. We have to teach each other. What we’re doing is we’re taking the 20 percent of medical centers that are already doing this and having them teach other medical centers how to do it,” Shulkin said. “This is actually about implementing best practices across the VA health care system, and beginning to act as one integrated health system rather than individual medical centers.”

In order to cut through the backlog, the VA has been organizing national “stand down” days, when veterans in need of urgent care who had been waiting 30 days or longer receive on-the-spot treatment.

“Every single medical center across the country, without exception, was open, seeing patients who had these urgent appointments, trying either to resolve them on the spot, or if not, try to move them up so that veterans were waiting shorter periods of time,” Shulkin said.

Of the 80,000 veterans nationwide who came forward during the latest stand down in February, Shulkin said 93 percent received medical attention the same day. VA hosted its first stand down in November 2015.

“Not everybody needs to be seen on the same day. Some people just need to have a phone call to resolve their issue, to get their prescriptions refilled, let’s say. But we certainly want to make it that if you really need to be seen by your primary care doctor, you will be able to be seen that day by the end of 2016,” Shulkin said.

Shoring up management

When it comes to hiring and retaining medical talent, Shulkin said the VA offers competitive salaries for doctors, nurses, surgeons and pharmacists. But when it comes to management pay, he said that’s another matter.

“Those, we are dramatically below market rates, and that’s one of the reasons why we have so many openings for medical center directors throughout the country,” Shulkin said.

The majority of medical center leadership roles are largely Senior Executive Service positions. Shulkin is asking Congress that those position be converted to Title 38.

“Title 38 does provide us the flexibility to be to more competitive with what health care professionals are receiving in the private sector,” he said.

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