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Each week, Health Affairs' Rob Lott brings you in-depth conversations with leading researchers and influencers shaping the big ideas in health policy and the health care industry.
A Health Podyssey goes beyond the pages of the health policy journal Health Affairs to tell stories behind the research and share policy implications. Learn how academics and economists frame their research questions and journey to the intersection of health, health care, and policy. Health policy nerds rejoice! This podcast is for you.
Hello, and welcome to A Health Podicy. I'm your host, Rob Lott. As most listeners know, most episodes of A Health Podicy feature the authors of recent health affairs journal articles. But every once in a while, we break from that tradition and host a very special guest to speak more broadly about some of the most timely issues in health and health care and to contemplate their experiences in the policy making trenches. Well, I can't think of a better person to do exactly that than the one and only Doctor.
Rob Lott:Mina Seshamani, who we're thrilled to have on the podocy today. Most recently, doctor Seshamani led the Medicare program as deputy administrator for the Centers for Medicare and Medicaid Services. She left that role this January at the end of the Biden administration, and after a much deserved break, will be taking on a brand new gig. She was appointed by Maryland governor Wes Moore to serve as the new secretary of Maryland's Department of Health, taking office next week. How lucky are we to catch doctor Sastramani in this brief window between such critical jobs?
Rob Lott:And so with our conversation today, I'm hoping we can do a little looking back, a little looking forward, and some meaningful reflection all along the way. Doctor. Seshamani, welcome to A Health Odyssey.
Meena Seshamani:Thank you so much for having me, Rob.
Rob Lott:Well, let's dive right into it. You took the role of Director of the Center for Medicare in July of twenty twenty one. Can you take us back to that moment? It seems like a lifetime ago. What was the state of the program at that time?
Rob Lott:And what did you see as perhaps the biggest, most urgent challenge facing you and the program at that time?
Meena Seshamani:Yeah, that's a great question. So I did start in July 2021. And if we look back, that was still in the throes of the pandemic where I had to introduce myself to nearly 1,000 career staff on a Zoom webinar because everybody was still remote. And, you know, we can talk more about leadership and, you know, getting to know your team and gaining trust and being able to have forward momentum when what you see our little, you know, zoom rectangles on your screen. I think in the near term, given the pandemic, you know, CMS, Medicare in particular had more than 100 pandemic related waivers, because as we know, and as I knew, because I was leading response for MedStar Health, you know, before taking the role in Medicare, those waivers were essential for us to be able to adapt and respond to the ever changing pandemic.
Meena Seshamani:And that also creates, an important inflection point where as we were moving forward and eventually moving past the pandemic, how do you determine lessons learned? What are those waivers that were worth keeping? What were technologies and innovations that really could advance us in care delivery? So both for the near term to be able to, you know, address issues of the pandemic, evaluate these waivers, but then also what that means for the longer term in terms of harnessing an incredibly disruptive time for healthcare, but harnessing it towards those lessons learned so that we can continue to innovate in healthcare because I think those of us in healthcare knew that the healthcare system was not necessarily working in an optimal way.
Rob Lott:Okay, great. So now walk us through the next three years if you can and, you know, in as little time as we have, what did you learn during that period, those three years leading Medicare? Were there any surprises when you look back on that initial assessment compared to what you experienced day to day in doing the work that was maybe perhaps most challenging or exciting for you in that job?
Meena Seshamani:Yeah, I mean, I think having come from practicing, I was seeing patients as an otolaryngologist, you know, ear, nose, and throat surgeon at Georgetown. You know, again, helping to lead the COVID response, you know, leading care transformation for a health system. So community health and case management and all of our disease pathways. Having that on the ground experience really enabled me to see where there are opportunities for us to make sure that the healthcare system is actually taking care of people and is not just treating a diagnostic code, you know, with a billing code. And, you know, I think to come back, Rob, to what we were talking about, you know, I knew how incredible the Medicare team was when I met with them in that Zoom webinar.
Meena Seshamani:One of the first things I did was thank them because I was the recipient of much of their hard work around these waivers and to be agile with us and to be good partners so that we could address the pandemic. And I think during the course of my three and a half years, the Medicare team is really truly an incredible group of people. They are mission driven, they're incredibly smart. They know more about the Medicare program in their pinky nail than, you know, one could ever hope to know in a lifetime. And I think what I appreciated was their willingness to bring ideas forward, to incorporate, listen to stakeholders, and bring ideas forward for what we could do to really improve care.
Meena Seshamani:And I think one of the biggest surprises for me was just how broad of a reach the Medicare program has. I knew that Medicare had a huge reach, right? Everybody looks at the Medicare program to see what it's doing, from payment rates to how we're encouraging care delivery through various models. But it's things like, as we were evaluating lessons learned from the pandemic, and we realized that we didn't have good preparedness around domestic production of PPE, for example. Lo and behold, Medicare has a lever that can be utilized where we created a policy, creating differential reimbursements for domestically produced N95 masks to try to encourage domestic production to give us that domestic resiliency in the case of another pandemic.
Meena Seshamani:Like there are things that I would have never even thought about that Medicare really touches. And again, I think it speaks to just the incredible responsibility and opportunity in running the Medicare program and the incredible importance of having a really strong team that can help identify those areas where Medicare can really put its shoulder to the wheel alongside and in partnership with all the people in the healthcare ecosystem to drive meaningful change.
Rob Lott:Okay, let's talk about some of the broad scope of that program. One of the most pronounced trends over the last three and a half, four years has been the continued growth of Medicare Advantage. And I'd love to hear from you what that looked like from the inside. Was the program's growth a surprise to you? And what's your take?
Rob Lott:Is that a good thing for Medicare overall, for beneficiaries, for taxpayers?
Meena Seshamani:So I think Medicare Advantage is a very important part of the Medicare program. You know, when I was leading community health at MedStar, I used to say, what's the first word in community health? Community. You know, there is no one size fits all for healthcare. There needs to be options for people.
Meena Seshamani:And those options need to be navigable and they need to make sure that the market is competing on what matters to consumers. So quality and access. And, you know, I'm a health economist as well as a physician. Did my PhD in health economics. I don't want to say how many years ago because that will date me.
Meena Seshamani:But one of the first things you learn in health economics one hundred one is that healthcare markets are imperfect. You have asymmetry of information, you have supply induced demand, you have moral hazard, you have an inability for organizations to smoothly enter and exit the market. And, you know, a role of regulation is to be able to address some of these market imperfections. And so a lot of what we did in the Medicare Advantage Program was trying to assess by asking everybody, any stakeholder who is interested in Medicare Advantage, what are the things that are working? Where are the areas for improvement?
Meena Seshamani:And being able to make common sense data driven improvements accordingly. For example, streamlining prior authorization, which is something that we heard of from every stakeholder group as an issue that needed to be addressed. Clamping down on misleading marketing practices so that choice really matters for people. And making adjustments to the payment model so that you are paying accurately by using the most up to date data, the most up to date diagnostic nomenclature, etcetera. So, you know, again, I think Medicare Advantage is a very important part of the program and they're just like every part of Medicare, there were opportunities for improvement.
Rob Lott:Speaking of which, you were leading the Center for Medicare during the first round of drug price negotiation under the IRA. And there have been plenty of analyses of the negotiations and their outcomes in plenty of publications, including health affairs, folks looking at the various factors that were used in the negotiation or perhaps should have been used. So instead, I'm thinking maybe you and I can take a step back and ask a more philosophical question, which is that at the heart of the program's sort of very existence is this tension between accessibility in the form of making drugs more affordable, a goal the government's trying to achieve, and innovation in the form of financial incentives to invest in novel drug development, something drug developers want to protect. And, you know, some say that most innovative drugs in the world are worthless if no one can afford them. The counterargument is that when negotiation reduces profitability, it reduces developers' ability to pursue that innovation.
Rob Lott:And so my question, I guess, is how did you and the folks behind the curtain at the negotiation table think about this tension? And do you feel like the law was designed and implemented in a way to achieve the right balance of those factors?
Meena Seshamani:Yeah, I mean, that's a great question. And one of the first things that we did was meet with everybody who was interested in how we were going to be implementing drug negotiation from patient groups to clinicians, to drug manufacturers, pharma and biotech, health plans. And, you know, to this point that you made about innovation and access, there actually is a common goal and a common win win that you want people to have access to the innovative cures and therapies that they need. And, you know, being able to drive innovations that result in significant improvements in people's lives and being able to lay a foundation for the negotiation program on real world evidence so that you're really looking at what the value of a drug brings to someone in their natural environment with a caregiver in their communities. You know, that is a huge step forward in the ongoing conversation about what innovation means for people.
Meena Seshamani:And to your point, that innovation is only so good as people can actually get access to the drugs, which is why, you know, you have the drug negotiation aspects of the inflation reduction act paired with some of the most significant changes to the prescription drug benefit in decades, including the $2,000 out of pocket cap. You know, when I was practicing, medicine, I had one Medicare patient, I had to get on GoodRx with her to try to find a prescription that I could prescribe for her that she could afford. And if she didn't have that barrier, like there could have been other medications that I could have given her. And so she didn't have access to those innovations. So, you know, I think it was very important for us to work with all of the various stakeholders to really understand what is important to them in innovation.
Meena Seshamani:What is important to them in access? And again, it comes back to how do we enable the market to work as effectively as possible so that competition is on what matters to the people who rely on these cures and therapies.
Rob Lott:Great. Do you feel like that first round of negotiation hit that mark? And if not, sort of where do you think the next round and the round after that should focus on in terms of improvements or refining the process?
Meena Seshamani:Yeah, I mean, I absolutely think that, you know, our first round of negotiations were successful. You know, as you know, we estimated that had those negotiated prices been in place in 2023, there would have been a net savings of $6,000,000,000 to the Medicare program, including $1,500,000,000 out of pocket for, you know, people with Medicare prescription drug coverage. And importantly, you know, there was stability with this. You know, when you look at the stock market, there were no major swings because again, we underwent, you know, comment with our guidances, we incorporated feedback. You know, I will say that one of the biggest compliments that I got in my job as I was ending my tenure was a stakeholder telling me, you know, we didn't always agree with everything that you did, but we understood why you did it and your team was always so professional and so responsive.
Meena Seshamani:Because ultimately, whenever you're tackling tough complex issues, there's no silver bullet. Right? There's no panacea and it really is a matter of engaging in thoughtful dialogue and trying something, evaluating it and moving forward from there. And that's why with the negotiation process, we did guidances only year by year because we wanted to have that opportunity to be able to learn along the way to see how the market reacts because markets are dynamic, to be able to incorporate changes. And to give you one example, we realized in the first round of negotiation that we really wanted to make sure we were doing as much as possible to incorporate the patient voice, the caregiver voice.
Meena Seshamani:And that was a specific area that we asked for feedback in the second round of guidance and made significant changes to the negotiation process to better incorporate feedback, you know, lived experience from people taking the selected drugs.
Rob Lott:Great. Well, speaking of tough and complicated issues, I wanna ask you about your, new job coming up, which we'll do after this break. And we're back. I'm here with Doctor. Mina Seshamani, the former director of Medicare and the soon to be secretary of the Maryland Department of Health.
Rob Lott:Doctor. Seshamani, to the extent that you're comfortable sharing the conversation between you and Governor Wes Moore, did he ask you that classic job interview question, why do you think you'd be a good fit for this job? And what was your answer?
Meena Seshamani:Well, you know, it was truly an honor to be considered for this role by the governor. And one of the things that we talked about was, you know, what excites me about the role. And I think, you know, to piggyback Rob on some of what we talked about before the break in what I learned leading the Medicare program, There is a tremendous opportunity to harness the strength in a state of all the people who are invested in the health and well-being of that state's residents. And to be on the ground really working across the various communities to drive improvements and to have that, to be able to feel that tangible impact. And I think through my experiences leading the Medicare program, you know, I have a clinical background that I can bring to bear.
Meena Seshamani:I have an economics background that I can bring to bear. I am also a flesh and blood human being. I really want to understand what people's hopes are, what they're happy about, where they wanna see improvements, and really be able to roll up our sleeves and work together on that. And I think that's how you really drive innovation and states are a great laboratory for innovation. So I think that both answers the question of why I am a good fit and, you know, what the governor and I spent quite a bit of time talking about in terms of how, you know, I would envision this role.
Rob Lott:Great. So following up on that, obviously, the scope of this new role is much broader than your role at Medicare, which of course was incredibly broad. And it includes responsibilities for things as diverse as public health and disease surveillance, behavioral health. I was looking at the list of various boards that the Department of Health oversees, and it's quite long and there's some boards I had no idea even existed. And so I'd love to hear from you how you're sort of preparing your own headspace to kind of grapple with the sheer breadth of what you've got ahead of you.
Meena Seshamani:Yeah. Well, you know, what's interesting is I think one of the reasons that when I was in the Medicare role, one of the reasons that we were able to drive such significant improvements. You know, I did an interview with Modern Healthcare where they said like, you guys drove some of the most significant improvements in Medicare in three years than had been done in prior decades. And I actually think a lot of it was because I didn't just think of it quote unquote as a payment program. CMS is a large public health agency where the policies we make around quality, around payments, around care delivery models, they enable us to connect between a traditional healthcare setting and where people actually spend the majority of their time and have their experiences impact their health.
Meena Seshamani:So in the Medicare program, being able to create payments for community health services, support family caregivers, integrate behavioral health with primary care. You know, I think that ability to connect the dots was critical for the many changes that we made with Medicare. And I think that is exactly what I am hoping to bring to, you know, the role in Maryland where you can see tremendous opportunities for integration between care for people with disabilities, the Medicaid program, behavioral health, you know, our public health service and how data that we have on the ground can help inform how we are keeping people healthy both in and out of healthcare settings. So I think it is that, you know, ability to just roll up your sleeves, talk to people on the ground, and be able to see in particular where there are those common threads that you can pull to really drive significant improvements.
Rob Lott:So as a federal employee, as director of Medicare, you had to work a fair bit with state policymakers. Now as a state official, you'll have to work pretty closely with the feds. The difference this time, obviously, is that there's a very different administration at the federal level. And there's sort of inherent in that relationship between the feds and the states, especially when it comes to health and health policy, a bit of a tension. And so I'm curious how you're thinking about how you're going to approach that relationship.
Meena Seshamani:Yeah. I think ultimately, people who go into health care want to improve health at the end of the day, whether you are a, you know, an advocate, a clinician, someone working in a health plan, someone working for a pharmaceutical company, whatever side of the aisle you're on. And I think it's important that we always tap into what are our common goals and have that guide us with conversations. Again, there is no gold standard. There is no silver bullet.
Meena Seshamani:This is all very much continuous learning and being able to harness data to be able to have thoughtful conversations where we are weighing pros and cons, I think is the fundamentals regardless of which administration is present. And I think that is how we approached when I was there, all of the care transformation work we did to innovate in partnership with CMMI, the work we did as you and I discussed to, you know, make improvements to Medicare Advantage and the work we did to implement the Inflation Reduction Act. I think that's a common theme and a common foundation that that can and should be utilized not just by policymakers, but honestly, anybody in an organization that, you know, you're looking at tapping into what it what is driving people to do the work they do? What are their common goals? And, you know, can we find that commonality to be able to collectively problem solve?
Rob Lott:Earlier, you mentioned coming into Medicare in the throes of the COVID-nineteen pandemic. And I think one of the big realizations to come out of the pandemic was the relative inadequacy of state and local health departments. And this is not to undervalue the incredible work that these departments do and the lives that they saved during the pandemic in the face of really nearly impossible conditions. But I think the responsibility for some of the shortcomings of that system writ large comes back to the failure to invest and prepare among national stakeholders and state leaders. And since then, we've seen numerous proposals to quote, reimagine public health and really bridge the gap between health care and public health.
Rob Lott:And I'd love to hear how you're thinking about that problem and where you plan to start in that work when you take office.
Meena Seshamani:Yes. Well, and I will come back to my work in Medicare because having been in a healthcare organization, working with public health to combat the pandemic, I think I saw firsthand how important services that fall outside of a traditional healthcare paradigm are to keeping people healthy, not just for addressing a pandemic, but even more broadly to keeping people healthy. And one of the things that I sought to do when I was leading the Medicare program was again, how do we make the market work better? How do we have the market reward and encourage those kinds of services that are really fundamental to improving the health of population? So as I mentioned, paying for community health workers, you know, enabling value based payment arrangements where doing the right thing actually leads to a financial reward.
Meena Seshamani:And I think that is something that I want to continue now on the state side where there are opportunities to have, you know, more regular routinized funding flows for public health services that are tied to healthcare services. And for example, again, being able to utilize, you know, Medicare funding streams, Medicaid funding streams, particularly because investing upstream in someone's health can avoid the hospitalization, the ED utilization so that financially this makes sense because you're spending money in a smarter way. And for some for outcomes, it makes sense because you're keeping people healthy. So I certainly think that is something that I wanna continue doing now from the state side and the public health side.
Rob Lott:Great. Well, that's about all of our time for today. Doctor. Seshramani, thank you so much for taking the time during this brief window and between your jobs to talk to us and the listeners of Health Odyssey. Thank you for being here.
Meena Seshamani:Well, thank you so much for having me.
Rob Lott:And to our listeners, thank you for tuning in. If you enjoyed, please recommend it to a friend. Smash that subscribe button and tune in next week. Thanks for listening. If you enjoyed today's episode, I hope you'll tell a friend about a health policy.