This week four years ago, I was working for the Centers for Medicare and Medicaid Services, helping lead the national Medicaid program. The Affordable Care Act was hitting its stride. The number of uninsured people was at a historic low. The rate of people being readmitted to hospitals soon after being discharged was coming down.
But costs were unsustainably rising, health care providers were burning out, and the opioid crisis was spiraling out of control.
We were ready to tackle these issues under President Hillary Clinton, but President Donald Trump surprised us.
During the Trump administration, Seema Verma, who headed CMS, pushed for ineffective Medicaid work requirements, defunded ACA health insurance exchanges, and sidelined senior staff whose expertise conflicted with her ideology.
Under President Joe Biden, I am confident that the next CMS administrator will not have disdain for the department she or he runs. Here’s what I would advise the next administrator to do during her or his first 100 days — based on what I learned while working at CMS and investing in health care since then — to begin undoing unscientific policies, instituting new ones based on evidence, and building a more resilient organization.
Reaffirm the vision of the Quadruple Aim
As an investor, I spend most of my time serving on boards and advising companies and nonprofits, which range from early startups to Fortune 500 firms. CMS is a bigger ship with a smaller rudder than most of my portfolio companies, but the same change management best practices apply.
Business management guru Jim Collins says the foundation of organizational strategy is having a clear vision, sticking to what the organization is uniquely capable of doing, and focusing on the sustainability engine, the financing model that keeps the organization afloat.
The vision for CMS is inculcated in the much-amended Social Security Act of 1935, constraining each administrator’s scope for setting their vision, hence the tiny tiller. Given the organization’s legislative underpinnings, the visions expressed in the strategy slide decks of politically divergent Andy Slavitt, the administrator of CMS under President Obama from March 2015 to January 2017, and Seema Verma had more similarities than differences.
In recognition of current failures in the health care market, growing gaps in health equity, and unprecedented threats to the solvency of Medicare and Medicaid, I believe that the vision for CMS should be a version of the Quadruple Aim:
- Equitably improve population health
- Flatten the total-cost-of-care growth curve
- Improve the health care experience for beneficiaries
- Improve the well-being of care teams
Even if a Republican-controlled Senate does not confirm the CMS administrator that Biden appoints through another Berwickian block, senior career staff are sufficiently familiar with the Quadruple Aim to steer CMS back towards its true north.
Control Covid-19 and remedy the market failures that drive disparities
With a clear vision in place, the next administrator should base CMS’s strategy on its unique capability to remedy health care market failures and reduce health inequities. Before the Covid-19 pandemic, there were several dramatic disparities. Behavioral health issues were a growing problem, and deaths of despair were on the rise. The number of people who had no health insurance or too little of it was growing. Women’s health was severely compromised with growing maternal mortality rates among women of color and an erosion of reproductive rights.
Covid-19 worsened inequities and created devastating new ones. Nursing home deaths reached catastrophic levels, with significantly higher rates among Black and Hispanic residents. Access to prevention and treatment services plummeted, especially for behavioral health services for marginalized communities. Children’s health was severely compromised with children of color and socioeconomically disadvantaged children carrying the highest burden of Covid-19 infection as well as housing insecurity, food insecurity, and learning loss.
The next administrator’s policy imperative for the first 100 days should be to build upon the recommendations of Biden’s Covid-19 task force and develop a coordinated CMS plan to address the pandemic. This plan would include a broad, evidence-informed approach to virtual care and an emphasis on the whole-person including upstream drivers of poor health, not just health care.
He or she should also use the response to Covid-19 as a catalyst to accelerate the shift from institutional to community-based care.
In addition to implementing a sound Covid-19 strategy, I would counsel the next administrator to revamp how regulations are reviewed and developed to ensure they don’t cause CMS to row in the wrong direction, like the cynical SUNSET rule, under which almost all regulations — including those covering Medicare, Medicaid, and the Children’s Health Insurance Program — that aren’t reviewed by the Department of Health and Human Services within certain periods of time would automatically expire.
New regulations and, where possible, previous ones, would need to be:
- Evidence-based;
- If evidence is lacking, create a rigorous but not overly burdensome evaluation framework to accompany the policy to measure whether the hypothesized benefit was fulfilled;
- Informed by a service blueprint to ensure an in-depth understanding of the full constellation of stakeholders that might be affected by the policy;
- Co-created with key stakeholders through an iterative process before making formal notice of the proposed rule;
- Reviewed by beneficiaries with lived experience relevant to the proposed policy.
Develop financial resilience
Moving toward science-driven policies that focus on the end user, whether it’s the beneficiary, provider, state, health plan, or other entity, is necessary for achieving the Quadruple Aim, but it isn’t sufficient. The Medicare trust fund will be depleted by 2026. And state Medicaid programs are experiencing unprecedented budget deficits secondary to the recession induced by Covid-19.
For the Medicare and Medicaid motor to sustainably run, the next CMS administrator will need to use the response to Covid-19 to springboard out of the fee-for-service model of health care provision and toward Category 4 alternative payment models. These reimbursement methodologies fully align providers’ financial rewards with the outcomes they deliver to patients. I suggest tacking toward tying 70% of payments to Medicare and Medicaid providers to Category 4 models by 2024. Anything less than that would keep providers paralyzed, with one foot in the fee-for-service boat and one in the value-based payment boat. The shift toward value-based payments should apply not only to medical care but also to drugs and devices.
Reinvest in making CMS a learning organization
To address market failures and reduce disparities in a financially sustainable way, CMS must remove the disconnect between end-user needs and the policies that CMS designs for them. Under the Trump administration, CMS was overly reliant on the crude instrument of deregulation to reduce its administrative burden. But administrative burden is not necessarily correlated with the number of policies. It is instead due to the kind of poor policymaking processes captured in the cartoon below.
Continuous training of CMS staff in process improvement and innovation are necessary to prevent the smoldering coals of paternalistic policy-making habits from reigniting. Under Obama, CMS administrators Donald Berwick, Marilyn Tavenner, and Andy Slavitt made significant investments in training CMS staff in human-centered design, quality improvement, and agile and lean skill sets. During the Trump administration, divestment from these capacity-building initiatives and the emergence of unethical policies induced cognitive dissonance in the staff, leading to a brain drain at CMS, especially among tech-savvy staffers and medical officers, myself included.
To avoid poor policy design, the next CMS administrator should reinvest in enterprise-wide training in change management. She or he should also reinvest in the United States Digital Service, the General Services Administration’s 18F program, and the Presidential Innovation Fellows program. Doing so would pair CMS policy experts with internal digital transformation experts and clinicians.
Given the waves of work it must do, CMS appropriately relies heavily on contractors. Verma’s efforts to curtail CMS’s spending on contractor sprawl fell short and raised ethical red flags. The next CMS administrator should reinvigorate the innovative agile procurement practices pioneered in the Obama administration, which started to align contractor payment and performance. Value-based partnering with innovative and nimble firms, like those in the Digital Services Coalition, would improve CMS’s data-driven policy making and improvement activities.
By pursuing the Quadruple Aim, controlling Covid-19, erasing equity gaps, vaulting into value-based payments, and leaning into being a learning organization, the next administrator will be able to make CMS more buoyant and better able to meet the needs of the Americans it serves.
Andrey Ostrovsky is a pediatrician, managing partner at Social Innovation Ventures, and the former chief medical officer for the Center for Medicaid and CHIP Services.
