Trump Pick for CMS Would Ease Up on Physicians

February 17, 2017

Seema Verma, MPH, President Donald Trump's choice to head the Centers for     Medicare & Medicaid Services (CMS), has mixed feelings about electronic     health record (EHR) systems.

It's just one example of how she's on the same page with many physicians     regarding healthcare.

"My doctor…is staring at her computer instead of looking at me," the     healthcare policy consultant told the US Senate Committee on Finance during     her confirmation hearing yesterday.

Verma's comment came in response to a question about the future of the CMS     incentive program for meaningful use of EHRs, much criticized by physicians     for turning them into data entry clerks. She also recounted seeing signs in     physician waiting rooms that apologized for schedule delays due to EHR     implementation. Yet another tech challenge she cited was the lack of EHR     interoperability, which prevents different programs from freely exchanging     data.

"We need to make sure [EHR technology] is fulfilling its promise and not     being more burdensome," said Verma.

                                                               

Seema Verma, CMS administrator nominee for President Trump, smiles during a Senate Finance Committee confirmation hearing in Washington, DC,  on Thursday, February 16, 2017. Source: Pete Marovich/Bloomberg/Getty Images

                       

If confirmed, Verma would play a major role in Republican efforts to repeal     and replace the Affordable Care Act (ACA) as a lieutenant of US Department     of Health & Human Services Secretary Tom Price, MD. Like Dr Price, she     wants the federal government to ease up on physicians in a number of ways     as it enacts a Republican version of healthcare reform:

Regulations:     "Patients and their physicians should be making decisions about their     healthcare, not the federal government," Verma said. "We want to identify     regulations that might motivate providers not to participate [in Medicare     and Medicaid]."

Mandatory Medicare pilot projects:     Congressional Republicans and medical societies have complained about     Medicare experiments in healthcare delivery and payment that make physician     participation required instead of voluntary. Verma said she was on their     side. Innovation is important but "we need to make sure we're not mandating     individuals to participate."

Medicare financial risk:     The new reimbursement system established by the Medicare Access and CHIP     Reauthorization Act holds the most rewards for physicians who assume     significant financial risk — that is, the possibility of a revenue cut —     for not meeting quality and cost targets in so-called advanced alternative     payment models. It's all a part of moving Medicare from fee-for-service to     pay-for-performance. However, some medical societies argue that the     government's financial-risk requirements are unrealistically high for some     medical practices. Verma agrees.

"I don't know that rural providers and small [practice] providers would     want to take on risk at all," Verma told lawmakers. "They don't have the     large financial reserves that big systems have."

        State Medicaid Programs Need More Leeway to Innovate, Says Verma    

Many of the questions that lawmakers posed to Verma yesterday centered on     Medicaid, which stands to change dramatically as the ACA is repealed and     replaced. Besides undoing Medicaid expansion in 31 states and Washington,     DC, the Trump administration and Congressional Republicans want to give     states more leeway in designing their own programs. As a consultant to     states on Medicaid policy, Verma fits right in.

She is the architect, for example, of a "consumer-directed" Medicaid     program called Healthy Indiana Plan (HIP), which gives beneficiaries there     something akin to a health savings account — a Personal Wellness and     Responsibility (POWER) account — to apply toward a $2500 deductible. Verma     also helped create HIP 2.0, which expanded Medicaid coverage in the state     under the ACA with the help of federal dollars.

Launched in 2015 when Vice President Mike Pence was Indiana's governor, HIP     2.0 requires beneficiaries to contribute 2% of their income to their POWER     account each month. That skin-in-the-game entitles them to extra benefits     such as dental and vision coverage.

Verma told the Senate Finance Committee that sicker individuals in HIP 2.0     were more likely to contribute to their POWER accounts, obtain preventive     care, take their medicines, and experience better outcomes. "What we found     is that when we gave [beneficiaries] choices, they made good choices,"     Verma said.

It took Indiana 5 years to receive a waiver from CMS to expand Medicaid     through HIP 2.0, Verma said. An "inflexible system" stands in the way of     other states making similar reforms.

Congressional Republicans believe they can loosen things up by converting     now open-ended federal contributions to state Medicaid programs into either     a giant block grant, or a "per capita cap," a fixed amount for each     beneficiary. Either way, states would have more say-so on how to spend the     money. Democrats counter that states will end up with less money to spend     on Medicaid, forcing them to either kick people off the rolls, reduce     benefits, or reduce provider reimbursement.

When Sen. Maria Cantwell (D-WA) asked Verma if she supported Medicaid block     grants, Verma suggested that it could be an option in the pursuit of better     health outcomes.

"What I support is the program working better, whether that's a block grant     or a per capita cap — there are many ways to get there," she said. "The     status quo is not acceptable. This is the United States of America. We can     do better for these vulnerable populations."

Under the status quo, she said, one state now may spend almost four times     as much per Medicaid beneficiary as another, "but can we show the outcomes     are better? Can we show that the individual is receiving accessible, high     quality care? One third of doctors aren't taking Medicaid patients."

Pinning Down the Nominee

Senate Democrats expressed consternation at times that they couldn't pin     down Verma on policy matters like Medicaid block grants.

When Sen. Debbie Stabenow (D-MI) asked if Medicare should be allowed to     negotiate drug prices with manufacturers, Verma said, "We need to do     everything we can to make drugs more affordable for seniors." Marketplace     competition, she explained, was the key to lowering prices. Stabenow then     asked if Verma favored preserving the ACA provision that eliminated the     out-of-pocket expense called the "doughnut hole" in the Medicare Part D     drug program.

"I support seniors having access to affordable medicines," Verma said.

Sen. Robert Menendez (D-NJ) fumed. "I can't vote for someone to be [CMS]     administrator…if I can't glean from you in an open session under oath what     your answers are to these questions."

Verma was more forthcoming on another drug issue — government outlays for     Mylan's EpiPen for emergency allergy treatment. Mylan's classification of     EpiPen in the Medicaid program as a generic as opposed to a branded product     translated into significantly smaller rebates that the manufacturer paid to     the federal program. Verma called that "disturbing" and said she would like     to review the classification process to ensure that the government received     the drug rebates it was entitled to.

While Senate Democrats appeared vexed at times with Verma, Republicans, who     control the Finance Committee, praised her. "We have an outstanding nominee     in front of us," said Sen. Michael Enzi (R-WY). "You haven't just studied     Medicaid and Medicare; you've done things."

"You have acquitted yourself very well," added Sen. Orrin Hatch (R-UT), the     committee chair.

The next step in the confirmation process is for the committee to send     Verma's nomination to the full Senate for a final vote.

Follow Robert Lowes on Twitter        @LowesRobert    

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