As the largest public insurance program in the US, Medicare has an outsize influence in how many people in the US access and receive health care. Recently appointed Director of Center for Medicare Meena Seshamani, MD, PhD, joins JAMA Associate Editor Karen Joynt Maddox, MD, for a discussion of equitable, patient-centered approaches to health care delivery, and how her own experiences as a physician have illuminated how she leads the program.
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Karen Joynt Maddox: Hi, my name is Karen Joynt Maddox. I'm a Cardiologist and Co-Director of the Center for Health Economics and Policy at Washington University in St. Louis. I'm also an Associate Editor at JAMA and, in that capacity today, I have the honor of speaking with Dr. Meena Seshamani today. She is the current Director of the Center for Medicare within the Centers for Medicare and Medicaid Services. Dr. Seshamani is also an Otolaryngologist by training and we are delighted to have her with us today to talk a little bit about medicine, Medicare, and about being a leader in these unprecedented times. Welcome Dr. Seshamani, thank you for being with us.
Meena Seshamani: Thank you so much for having me.
Karen Joynt Maddox: I'd like to start just by having you introduce yourself. Tell us just a little bit about your experiences.
Meena Seshamani: Well, thank you, Karen. So as you mentioned, I am an otolaryngologist by training. And until recently I was practicing at Georgetown as part of the MedStar Health, health system. And before that, I practiced as a head neck surgeon at Kaiser Permanente in California as well. In addition to being an otolaryngologist, I'm also trained as a health economist. I have a PhD in Health Economics, and I have worked in policy. In the Obama administration, I served as the Director of the Office of Health Reform, leading implementation of the Affordable Care Act.
Meena Seshamani: And I brought these experiences to bear at my role at MedStar Health, where in addition to practicing medicine, I led care transformation efforts for the health system. So thinking about how we can provide care more holistically, leading service lines like community health, geriatrics, palliative care. And I bring all of this now with me to my current role where I am the Director for the Center for Medicare and the Center for Medicare serves as the focal point for all policies and operations for the Medicare program, serving 63 million Americans, those age 65 and older, those with end-stage renal disease, and those with disabilities.
Karen Joynt Maddox: Great. So how does your experience as a physician being in the system that you're now sort of helping to shape, how does that shape your vision for where Medicare can take us?
Meena Seshamani: Well, as a physician, I have definitely seen firsthand the impact on patients, their families, and their communities when the system doesn't work for them. And I've also seen the tremendous and lasting benefit when the system does work. So just a few examples that are near to me as I approach my work now leading the Medicare program. So as I mentioned, when I was at MedStar Health, one of the programs that I led was Community Health.
Meena Seshamani: And just to share one example of the power of care transformation to profoundly impact the health of people we serve. So at MedStar Health, we had a woman with chronic obstructive pulmonary disease who kept getting readmitted to the hospital with breathing difficulties. So we paired a community health worker with her, who went to her house and discovered that her power kept getting shut off, preventing her from using her nebulizer. This community health worker was then able to resolve her lack of electricity and she stayed healthy and was not readmitted to the hospital, so that's just one example.
Meena Seshamani: And then speaking more personally, as a practicing physician, I speak Spanish fluently and I had a mother bring in her daughter, Spanish speaking family, bring in her daughter to my clinic because she had been having, 9-year-old girl, she had been having this nasal discharge. Mom had gone to the primary care doctor, repeatedly was told that her daughter had allergies, was trying all these allergy medications, pretty foul smelling discharge. Her daughter is now getting made fun of in school. And her mom is telling me like, "There's just something not right here." And so I started speaking to her and spoke to her in Spanish and asked about what was going on, about the impact that it's having on her daughter's life. And I said, "By any chance, did your daughter ever stick anything in her nose?" And mom said, "Well, actually, when she was five years old, she put a bean in her nose," but nobody asked about anything like that and it was so long ago...Nobody... I mean, nobody asked about anything like that and it was so long ago. Well, took my endoscopes. And what did I find in the girl's nose, but a four-year-old bean husk.
Meena Seshamani: And removing that bean husk, mom started crying, thanked me for listening to her, for speaking with her in her language. Daughter's problem was fixed. We were able to take out that bean husk and these examples stay with me as I think about what we can do for Medicare. So I think we'll talk more about this, just the incredible influence that the Medicare program can yield on the health system. And so when I think about being able to provide culturally and linguistically appropriate services and accessible services for people, I think of that Spanish speaking family that I helped. Or when we think about how we can provide care, that really takes care of people and communities and keeps people healthy, I think of that community health worker example, and I really bring these to bear in the role that I have now leading the Medicare program.
Karen Joynt Maddox: Yeah. I love those stories because it really connects the personal to the sort of organizational or systemic. And I think medicine is so much about people and I love that you have the experience to bring those to your now your day job. Can you tell us a little bit about what we should be looking for in Medicare for the next year? What are your priorities, your vision for where we go and I'm suspecting that might intersect with some of the things that you just touched on.
Meena Seshamani: Yes, absolutely. So in fact, I published a piece in Health Affairs on the vision for the Medicare program, along with Liz Fowler, who's the director for the Innovation Center and the CMS administrator, Chiquita Brooks-LaSure. And I think the key piece here is the Medicare program pays for one in five healthcare dollars in our country. We partner with more than 1 million clinicians, 6,000 hospitals. And so when you make a change in Medicare, it really can wield an enormous influence on the health system, writ large. And that's an opportunity and a responsibility that I take seriously. And I feel, especially now, as we have been going through the pandemic, we are at a pivotal time in our nation's health and it truly is an honor to lead the Medicare program during this time. And so in this vision piece, I talk about the pillars of what we are going to be focusing and to really help move the needle on advancing health in our country.
Meena Seshamani: And the first pillar is on advancing health equity. So for Medicare and for CMS more broadly, what does health equity mean? It means the attainment of the highest level of health for all people, where everyone has a fair and just opportunity to attain their optimal health, regardless of race, ethnicity, disability, sexual orientation, gender identity, socioeconomic status, preferred language, or other factors that can affect access to care and health outcomes. And so for this reason, in this pillar of health equity, we must look at everything we do through the lens of health equity. Because again, as I was discussing with you, Karen, when the system doesn't work, it's those individuals with complex health and social needs who fall through the cracks. And so again, bringing that experience to bear working as a clinician, improving operations is key to our advancing health equity.
Meena Seshamani: Making sure that care is reliable. It's easy to navigate. It's high quality. It's comprehensive. And making sure that we in the Medicare program are engaging partners. Providers, payers, people with Medicare and especially people whose voices may not have always been heard, as we try to improve care. And so some examples of what I'm talking about. We are prioritizing increasing enrollment in something called the Medicare Savings Program. This is a program that's available for people with Medicare of lower income who have difficulty affording their care. What we found is that only half of eligible people are enrolled in this program. So this is a perfect opportunity for us to increase outreach, increase education, and make sure that people are taking advantage of those supports that are available to them. So during the last Medicare open enrollment, I did a bunch of virtual media tours and really emphasized the benefits of this program and how people can find out if they're eligible and enroll.
Meena Seshamani: So this is some work that we want to continue doing, again, where we are looking at our operations, where we have opportunities to reach out to people where they, and really make sure that they're making the most of what we have. Another example is being able to improve the capacity of organizations, like provider organizations to address healthcare disparities and advance equity. And so as some of you may have seen, we are now expanding funding for medical residency positions. It's the largest increase in about a decade and we are doing so prioritizing rural and underserved areas. Because again, where people train, that's where you learn about the needs of the local community. And providers tend to then practice in areas in which they've trained. And so those communities can benefit for years to come.
Meena Seshamani: So again, thinking about all of our operations and what we do with that lens of equity, and then being able to focus some policies to improve care for vulnerable populations. So for example, we have made permanent payment for tele behavioral health and for audio only. So if people don't have access to a video, they will be able to still have access to those services. Another example is that we are providing an enhanced payment for an easy to use home dialysis technology. Again, we know that people with Medicare in historically underserved and under-resourced communities have higher rates of end-stage renal disease. And so we want to make sure that care is meeting them where they are at. So I think that equity bucket is to your question an area that you'll see a lot of work coming forward and an area that we want to partner.
Meena Seshamani: And another area is around driving high quality person-centered care. One thing that always struck me when I was in my medical training, taking care of patients during a surgery, during their hospitalization during a clinic visit, is that's what we're doing. We're taking care of someone who's coming in with a specific diagnosis or specific procedural code during a specific episode. And I think we have all been striving towards moving towards taking care of a person across all aspects of their lives that impact their health. And there is a lot that we can do in the Medicare program to support that. So one key way is to drive these holistic care models. We have a goal of having 100% of people with original Medicare in a care relationship that has accountability for quality and total cost of care by 2030. Some ways to do this are through accountable care organizations. Where providers come together, in these accountable care organizations, to have more accountability on cost and quality and to have more flexibility in terms of how to care for their populations. We have definitely seen successes with these programs.
Meena Seshamani: Particularly in the pandemic, the investments made in care managers and community health workers, that was able to be leveraged to really address the needs of communities that were struggling to stay healthy during the pandemic. Being able to leverage technologies, like telehealth, to continue to provide access to care. We want to build on all of that by, number one, aligning a lot of these models that are out there. Because again, as a provider, I know that when there are multiple ways to do things, it can be confusing for providers, for the people that you're caring for.
Meena Seshamani: Where can we align the models that are within the Medicare program, Medicare Advantage, these ACOs? Thinking about the commercial market, thinking about Medicaid so that we can really enable providers to focus on what's most important to drive meaningful change in the system. We also want to be able to grow these programs, particularly in rural and underserved areas where having that holistic approach to care can really make a difference in enabling providers to do what they want to do, what they went into medicine to do and to help people in those communities to be able to get and stay healthy.
Meena Seshamani: I think the last aspect of the work that we're doing in this innovation in value-based care is around equity. Where when you can have these more holistic models, that's what's going to enable that community health worker to discover that there is an electricity issue that's leading to a woman coming back to the hospital multiple times. Where can we forge those partnerships between healthcare and social services and community-based care so that we can really keep people healthy and drive that meaningful change in the system?
Meena Seshamani: Those are just two of the buckets that we have. We also want to be able to expand access to care, to have sustainability of our program, and to really engage in partnership with everyone who's in the healthcare system, from the people we care for to the people who are caring for them so that we can make sure that we're all working together towards these common goals.
Karen Joynt Maddox: I love the focus on partnership there. Getting everyone rowing in the same direction to really be around a patient, feels like a goal that, as clinicians and as patients and as all the people involved in that care, I'm sure a lot of people will be excited to get behind. What are some of the challenges that you think about? We're sort of, hopefully, coming out of a global pandemic. We've learned some things. You mentioned some takeaways that will hopefully spur improvements in team-based care and flexibility in the future, but what are some of the big challenges that you see going forward?
Meena Seshamani: Well, it's interesting because I think the challenge is the flip side of the coin of what we've been talking about. In order to really drive this meaningful change, it really does require partnership. It requires people maybe leaving their comfort zone and working with other types of providers that they haven't worked with before.
Meena Seshamani: Just to take the example of the community-based organizations and the healthcare organizations, the number of times I hear that people are speaking different languages and how can we bridge that? How can they bridge that both through the data so that there's that common platform for people to understand what is happening with the people they're caring for, and how do we bridge that just in terms of the language and the communication and the working together, the collaborating together? I think that is a challenge and an opportunity. And, if we want to do everything for the people we serve, we have to keep people at the center of what we do.
Meena Seshamani: That means that people need to understand what we're doing. Healthcare is very complex and it's very personal. How do we explain what we're doing? How do we explain our vision in a way that can get people involved so we can hear, at the outset, what they want healthcare to be for them? We incorporate that into the work we do that when we are rolling out a policy, when we're trying to implement a program, we explain what it is we're trying to do so that people can give us real-time feedback. Then they can engage.
Meena Seshamani: Again, to come back to the example of that Medicare Savings Program. Wonderful program, half of the people who are eligible were enrolled. There are such opportunities for us to bridge those gaps so that we really can have true partnerships so that we are operating in an optimal way, and we are able to engage so that people can take the most benefit from what we do as well.
Karen Joynt Maddox: One of the groups that you've mentioned as a partner, and you just touched on a little bit, is beneficiaries. I think some people get a little confused when they hear about traditional Medicare and Medicare Advantage and Medigap and all these various things that come in. When you think about how Medicare sort of looks to beneficiaries, are there ways that you see changes coming in terms of how a beneficiary should think about its sort of relationship with Medicare?
Meena Seshamani: Absolutely. Just as a foundation, Medicare really is composed of several different pieces. There is original Medicare, also known as fee-for-service Medicare, where we partner with a million clinicians, 6,000 hospitals to be able to provide care to beneficiaries. That includes both the hospital and institutional side of care, as well as the outpatient side of care. We also have the Medigap that you mentioned, which is supplemental onto that program. Then there's Medicare Advantage, where the Medicare program partners with private health plans to provide that care that I was describing, the institution care, the outpatient care. You have Medicare Advantage. Then you have prescription drug. It's A and B. A is institutional, B is ambulatory, C is Medicare Advantage, D is prescription drug.
Meena Seshamani: I really view all of those as pieces of the puzzle, that there are options for people with Medicare to choose from. I mean, we have 63 million people in the program. There is not going to be a one-size-fits-all. It's important to be able to have options, and it's important for people to be able to understand what those options are and to be able to navigate those options. Absolutely, we are thinking about continuing improvements that we can make to Medicare.gov and Plan Finder so that we can make sure that people understand how different options compare.
Meena Seshamani: We also are doing work, for example, in one of the recent regulations that we put out for the private plans, Medicare Advantage, where we are proposing to regulate more on the third-party marketing that occurs to make sure that marketing is not misleading and is not predatory on some of our more frail members of our society. Doing work on language access, as I've mentioned before, this is something that's very, very important to me and to the administration. We are proposing to require multi language inserts, translation services. So really thinking about how we can make the system more accessible and navigable for people with Medicare and for providers caring for them. Because I know that you all get questions as well, on what does this mean? And what does a provider network mean? And what does a drug formulary mean? And I have been there working with a woman who was on Medicare and I had to put her on second, third line antibiotics for a recalcitrant ear infection. Looking up with her about what drug would be on her formulary. And what would that mean for an out of pocket cost? I think it's important that we engage with the provider community as well on this, because you all play a very key role in helping the people that you care for to be able to navigate, to find what works best for them too.
Karen Joynt Maddox: Yeah. Certainly having everyone in the same partnership is super important and so complicated when you think about just how big the program is. One thing you've touched on a few times that I'd be curious to get your thoughts on is data. We think a lot about all of the various ways that the system fits together and our data sits in a bunch of different buckets from Medicare Advantage, to the hospitals, to clinicians, to patients themselves. Are there things we should be looking for coming down the line in terms of how Medicare's thinking about harmonizing data or bringing people together around data?
Meena Seshamani: Absolutely. So I like to say that data is the common language. It can provide that platform to really bridge across what we've been talking about. The different providers who are caring for someone. From a healthcare organization, being able to coordinate with a community based organization. One of the things that I worked on in my last role in a health system was bringing a social need screening into our electronic medical record and enabling closed loop referrals to a community based organization. I think there's a lot of power in that and also in transparency and being able to get data so that we can understand what innovations are occurring in our healthcare system. What are things that are working that should be scaled? What are things that maybe aren't working and should be adjusted? And so really thinking about data from both of those angles.
Meena Seshamani: We're certainly working with our Office of the National Coordinator, who's doing a lot of work around continued improvements and interoperability. And really thinking about it with an eye towards extending beyond interoperability, just in the traditional healthcare space. But also thinking about, again, the community based organizations and social services and where we can engage there.
Meena Seshamani: We're also thinking about data in terms of things like remote patient monitoring and how can we move outside of the four walls of an episode of a hospitalization or a clinic visit to really get a more holistic view of a person and their health. And then on the transparency side, again, working with our private public partnership where we're proposing, for example, with Medicare Advantage to have plans report on the dollars that they're spending on what's called supplemental benefits. So when they're spending money on dental benefits or hearing or transportation, meals assistance, housing assistance, we want to be able to get some data and information on that because that can help inform all of us as we are all working together to try to improve care and to think about care in a different and more holistic way moving forward.
Karen Joynt Maddox: That's great. Is there anything else you'd like us to know as the listener thinks about what to look for in Medicare going ahead? Things you're particularly excited about that you'd like to leave us with today?
Meena Seshamani: Well, on a very tactical note, I will say that we have our applications open for these GME slots that I mentioned earlier. And again, with an eye towards really trying to advance equity and improve the capacity of healthcare organizations. And those applications are open now. So people definitely should look into that. And more generally I will say, the pandemic has definitely taught us a lot, has put us through a lot. I think it's really forged new partnerships. And I think it's been really tough on everyone. And I say thank you to everything that all the frontline workers have done and continue to do. I say that as someone who until recently was helping to lead the COVID-19 response for our area.
Meena Seshamani: And I want you to know, when I came into my role, one of the first things I did when I met with all of the staff on my first day, meet the staff, I thanked them for everything that they had done through the pandemic to that point. Because I know from helping to lead the COVID response, all of the waivers that were put into place, all of that partnership, all of that agility was very important. And that is something that we need to think about moving forward. So when we have our vision to really advance health equity, to drive innovation in this high quality person centered care, to promote affordability and sustainability in the Medicare program, that is the lens with which we want to partner and to work all of the innovations that have happened during the pandemic. All of the challenges that have arisen, all of the inequities that have been laid bare. We really want to partner to be able to address these issues to learn from of the pandemic and to be able to change things moving forward.
Karen Joynt Maddox: Great. Well I think that's a great note to end on, leaving us with a message of hope going forward, coming out of a pandemic and working together to really improve the health of people across the country. Thank you so much for being with us at JAMA today. We really appreciate your time and we look forward to seeing what the year and the rest of your tenure holds.
Meena Seshamani: Thank you again Karen, and to the JAMA team for having me.
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