“I think we’re agreeing, but in a way that sounds like we disagree."
In what was deemed a “fireside chat,” two former CMS administrators sat before a packed, standing-room only group at HIMSS 2017 and parsed the political climate as it related to the healthcare industry, creating something of a microcosm of the current healthcare debate, albeit markedly more open and civil.
Mark McLellan, who headed the Centers for Medicare & Medicaid Services from 2004 to 2006, and before that the U.S. Food and Drug Administration from 2002 to 2004 under the Bush administration, and Andy Slavitt, who had been the acting Administrator of CMS from January of 2015 until last month under Obama, traded insights on stage for nearly an hour. The occasion was moderated by John Kansky, President and CEO of the Indiana Health Information Exchange, who strove for some preemptive levity before the two dove into details: “Who thinks Beyonce got snubbed at the Grammies?” he quipped, calling that the “big question.”
Both men were deliberate about the desire to separate the contentiousness of politics from the imperative to improve patient outcomes and curb costs. The conversation did, however, still carry binary undercurrents of the political division: frustration and optimism.
McClellan was conciliatory, but spoke generally. He called for increased patient engagement and transparency, believing that a lot of the trends that have applied well for providers, like shared savings, need to make their way to the consumers. He noted that the political tensions have a way of leaving people feeling frozen, but that it was important to step back recognize the positives: “Don’t get too caught up in the politics of the moment…these fundamental trends are still there.” There will be administrative action related to Medicaid “that will be of considerable interest and support from Governors of both parties.” To McClellan, the debate itself seemed to be distracting from ongoing progress.
Both wanted to see an increased effort on behalf of the private sector. “I would like to emphasize for the IT industry that it’s not just about meeting CMS requirements and filling in the gaps, but really being drivers for reform,” the former CMS and FDA head McClellan suggested.
Slavitt delivered another jab for the health IT industry: “Instead of spending $2 million for a booth at HIMSS, why not wait until we have a bunch of thrilled customers and then do that?” The line was the only moment that drew applause from the crowd.
The more recent Administrator was not short on quotable lines, cracking that the two probably had to think differently about the role of the IT industry during their terms at the CMS because “Mark’s was a little more paleo.” Having spoken to thousands of physicians across the US, he said, he was concerned that some became locked in to older technologies, and weren’t able to constantly update to the best and newest. That trend caused some headache: “Ask most primary care providers about the technology they use and a lot of them hate it because it isn’t speeding up their lives at all,” believing that things could be faster and more efficient but that a human element was limiting that. He acknowledged CMS’s own culpability in that problem, saying they had created “regulatory hurdles that companies spent their time trying to get over them when they should have been spending time with providers and patients.”
The Affordable Care Act, as expected, was a major hinge in the conversation.
“When you repeal the ACA, you repeal the money,” Slavitt said, referring to Medicaid expansion and cautioning about the number of lives and jobs that are currently built around that aspect. He had barbs for Republicans regarding the uncertainty about a potential ACA replacement: “At a certain point you have to wake up and realize that you won,” but he as well called for collaboration: “I would rather take half a loaf that both parties own than a full loaf that only one or the other does.”
McClellan detailed the Republican concerns with healthcare costs: the CMS is a trillion-dollar organization, and America is an outlier in the developed world when it comes to health expenditures as compared to social services and even defense spending. “Other priorities that could do more for population health are being squeezed down,” by those cost commitments, he said.
Speaking to Healthcare Analytics News following the forum, the men laid their philosophies on the matter out.
“The current issue is, there’s really no plan,” said Slavitt, “Wherever we end up, whatever changes we end up making, history tells us we’re going to live with for the next 10 to 15 years…If we do any kind of do-over and we start from scratch, it would be an incredibly long cycle for people to figure out how to get around that. We need to do more incremental thinking.”
Asked about any regrets regarding his time in the CMS, he first championed the ACA’s achievements before turning to failings.
“If you look at the substance of what ACA did…all those things are substantive improvements. What we didn’t do very well was help the average American family understand what the ACA meant to them and how much it changed their lives. Half the people who were employed used to have lifetime caps in their policies, they don’t have that anymore and they don’t know it’s from the ACA. We could have done a better job helping the American people understand what the benefits are.”
McClellan stayed consistent with much of the conversation coming from leaders in the new administration.
“The full resolution on ACA repeal and replace is going to take a while, even if there is some repeal legislation soon. A lot of the pieces and specific details on how to replace and implement are going to take some time to unfold,” he said, “I think what’s not getting attention and should is the extent of administrative changes that will be taking place not only in the ACA exchanges, but especially in Medicaid and Medicare administration and the implementation of MACRA. So those are programs that affect more than half of the US population and have a fundamental impact on the direction for healthcare.”
McClellan continued that he sees flexibility and choice for patients and providers as the primary focus in the coming years. “That at its core is a very Republican idea…more opportunities for patients to take control, around transparency and sharing in the savings if they are able to choose a provider and take steps to lower costs. That was a big part of Part D, and I think it’s going to be a big part of the next administration’s initiatives too.”
At one point earlier in the conversation, response to a question about whether providers should slow investment in a climate of uncertainty drew a small chuckle: Slavitt said they should if there’s an ACA repeal, and McClellan said it depended on what the repeal entailed, following with, “I think we’re agreeing, but in a way that sounds like we disagree.”