Seema Verma

Scott Tittle

I want to welcome to our program Seema Verma, to our Versed VIUM Capital podcast. Seema, welcome.

Seema Verma

Thanks for having me, Scott.

Scott

Great. Yeah. Hey, we've been friends for a long time and worked together in certain roles, worked around each other in certain roles, and I've really have been so honored to follow your career over the years, and really just blessed to have you on our podcast. I'm excited for our listeners to get to know more about you, what you did before your roll at CMS, what you did during CMS, and what you've been up to now. So, looking forward to our conversation today. I kind of wanna dive right into something that we worked on together a long time ago, when we both worked for Indiana Governor, Mitch Daniels. You really led the charge on a very innovative Medicaid finance program at the state level called the Healthy Indiana Plan. Why don't you tell our listeners a little bit about HIP, why that was so innovative from a Medicaid policy and financing standpoint at the time and really why it still is pretty innovative?

Seema

Sure. You know, Scott, I don't think I appreciated at the time what we were actually getting done. You know, at the surface level, HIP is a consumer directed health savings account model for Medicaid beneficiaries. I think what that program was really about was, that was probably the first time that there was something that was that innovative in the Medicaid program. And once CMS approved that waiver, a lot of states kind of looked at that as the model. The thinking around that was a little bit different as well, because I think we've always looked at Medicaid as a program for very vulnerable, age, blind, disabled kids, and pregnant moms. And we were saying, well, we're gonna use Medicaid to now cover the low income adults. That population, we felt, were probably more able and, and better suited to be more exposed to some of the typical private market insurance things, copays, making small premium payments.

So we incorporated a lot of that I would say private market construct into the Medicaid program. If the programs endured, I think a lot of folks would like to see a more traditional model in Medicaid, where Medicaid's just the bill payer. That HIP really sought to improve outcomes and also implement and try to reinforce principles around personal responsibility. We felt like when people were making a contribution towards their healthcare, they're gonna get better outcomes. And there's been study after study of that program, and the results have been strong and the program endures. I think moreover, it really became an example of what states could do around Medicaid. A lot of states have borrowed pieces of that program.

Scott

What I remember from those days back then was the governor really got a lot of pushback then, right? For trying to create a very innovative Medicaid financing program to really help move the needle on healthcare. But I think what you were able to show is when you give consumers the power of choices in healthcare, great things can happen not only on the provider side, but also certainly for outcomes for the individual as well.

Seema

Right. I think it was also a strong statement about states’ rights and states’ innovation. Unfortunately, we've seen that not get better, but actually erode, and there seems like there's a push to have the federal government make all the decisions about Medicaid and how that program works. But as you know, and I know, that healthcare is very local. The other strong point about that program was that it was done in a bipartisan way. I know you had a lot to do with that piece of it in particular. But, that was probably a great example of Republicans and Democrats coming together around a program, and it has endured. So we haven't seen that in a long time as well.

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Scott

Yeah, certainly was a great example of how you reach across the party lines, really to do the right thing in healthcare and yeah. So the reason why I wanna bring that up, is I wanted to then pivot toward your, your role at, at CMS as the administrator for the Centers for Medicare Medicaid Services, because you really brought a unique perspective to that role. One of the very first administrators to ever have significant Medicaid experience. Maybe say a little bit about those early years running CMS and what that was like.

Seema

Yeah, I think from my perspective, that was my first introduction to the agency, was Medicaid and helping states negotiate waivers. And wow, it kind of came across as extremely bureaucratic, hard to deal with, it was like it's a black box. We never really knew what was going on with CMS. So I really sought out to kind of change that framework. I wanted the agency to be more open, to be listening to stakeholders, understanding their perspectives, and trying to really work with people out in the community and stakeholders, patients, providers to try to build better policy. I think the thing that was most surprising about CMS was I really appreciated the strong team that they had there, and that those individuals were extremely knowledgeable, very capable, and, and absolutely willing to move the ball forward.

I think with the right leadership, they were able to achieve that, and I had a great time. The only thing I would say is that in terms of surprising is how long it takes to get things done. You know, the agency can actually be pretty, I would say nimble and able to come up with new ideas. But what happens in the federal government has to go through all these layers of approval through HHS, OMB, and the White House. And so it may only take us a couple of months to put something together, but it'll literally take nine months sometimes, almost a year to get it through the entire process. So that explains a lot of the bureaucracy, but I can report that I don't think it was the CMS team, they were very nimble and adapt at moving good policy out the door.

Scott

Well, and one of the things I remember about your early tenure Seema, is that you really challenged your team to get out of the building in Baltimore and get out into the field to really understand healthcare from the front lines. I think specifically for our listeners in the long term care industry, I remember you toured a number of long term care facilities around the country. It wasn't just in the Baltimore Maryland area, and I know that was incredibly well received from the brighter community to see that the highest leaders at CMS were really trying to understand the business model, what was happening on the front lines, so I remember those days well.

Seema

Right. Well, we had a big initiative, patients over paperwork, and it was about reducing regulatory burden. We started out with a nationwide tour, and you're hearing from people on the front lines, they still remember visiting a sniff, and they came out with two big binders, five, six inches thick, and they said, these are all the regulations and they're trying to serve patients. They're trying to do what's best for the patient. Having to sit in the back room and go through all these regulations and are the regulations really helping us with improving quality and safety and quality of life for patients? And it kind of struck me that the people in Baltimore, while very well intended, many of them have been there for so many years, 20, 30 years, that they're not necessarily in touch with what's going on on the front lines.

My edict to the team was, if you are writing regulations for hospitals, for hospice, for nursing homes, you've gotta go out there. You've gotta understand what their day to day is and the markets change. Technology, staff, there's just so many things that are changing in the market that I thought it was really important for them to get out there. And the best part about it was they loved it. They were so grateful for that opportunity to go out there and really seeing what's going on on the front lines.

Scott

Yeah, I think there are a lot of great leadership lessons in there and really challenging your team to really understand the client, understand the consumer, understand the impact you're making when, when making some significant changes in regulations. I do remember those early days and how impressed the whole provider community was with those efforts. So thanks for that Seema, certainly. Let's kind of dive into the topic at hand, which is covid. I mean, no one certainly saw that coming. When you took over the ranks at CMS, I mean, to think that that was around the corner, I mean what a significant change in your work there, that's understated to say the least. But what were those early moments like, when you first realized, Wow, this is gonna be a significant impact to our economy, to healthcare, and maybe say a little about long term care in particular?

Seema

Yeah, I think it was a slow start in terms of CMS’ role. And initially you might recall that CMS was left off at the task force, and they put the vice president in charge. They just made those announcements, and I think I got home. It was a Saturday, I remember I got home from the gym, flipped on the tv, and they're reporting about the facility in Seattle. I immediately kind of got into action, spent the whole weekend trying to coordinate what our response was gonna be. I really wanted us to go into that facility so we could understand what had transpired and really try to take lessons from that experience. That required a lot of, as you can imagine, logistics and planning and coordination. But I called the vice president and I said, Hey, CMS regulates nursing homes, and he immediately got it and said, You should absolutely be on the task force. So that week, there were a lot of different meetings that we were attending. I think by the end of the week we went to Seattle and actually visited the community and the public health leaders met with the governor, and I came back to the office and I told my chief of staff. I said, this is a game changer, everything's different. This, what we are doing today it has changed.

We literally got out all of the project management worksheets. Here's all the things that we're working on, and just went through. It was kind of painful, quite frankly, and kind of okay, we've gotta stop because I need the entire agency focused on a response here, so it was pretty early on. I think that probably was the end of February and it was before the shutdown, before the NDA. We were kind of springing into action pretty early on. But it did end up being totally different for the agency. We almost had to stop what we were doing to be able to respond.

Scott

Well, Seema, I think for those of us in long term care, it's one of those moments in our careers where we all remember where we were when. I certainly remember where I was, certainly like you did too, when we heard about Kirkland Washington. It was certainly a sense that somebody was gonna be different. I don't think anyone knew exactly what just yet. But, tell you Seema, you got and deserve a lot of credit for the outreach you undertook after that week to all providers and all associations to really understand kind of, what was needed, what was essential, what resources must be employed immediately. Then maybe as importantly, understand back to our discussion on the regulations, what flexibility was needed to make sure that residents were gonna be safe and that that staff was gonna be safe.

You really went on a listening tour, a virtual listening tour with all of the healthcare providers, and constituencies to really understand what regs could be waived, could be amended, what public health directives needed to be modified. Again, you got and deserved a lot of credit for that. I have no doubt that despite the fact that Covid was incredibly devastating for long-term care in particular, the sector would've been much worse off without your leadership. Thank you very much for that. You know last week, President Biden, much to everyone's surprise, including many of his closest advisors on 60 Minutes announced the pandemic was over. I think that obviously caused a lot of confusion, a lot of frustration, a lot of important questions to be asking. We're still losing several hundred people a day to covid, tens of thousands of people are being hospitalized. Certain markets are getting impacted harder than others. For long term care, Census is still down, costs are still through the roof. There's a workforce crisis. I mean, I guess this may be a philosophical question, but is there a point at which we can really, truly say the pandemic is over?

Seema

Well, I think we've gotten to the point where because of, whether it's immunizations or by this time, I mean, I know few people at this point that have not gotten covid. I think that most people when experienced it, they got through it. Some people it was fewer symptoms, some people had some more severe symptoms. So people have gotten through it. I think the vaccines have largely been effective. So I think it's more of we're learning to live with it, right? It's not, it's never gonna go away. It's like the flu. It's gonna be there every year. Hopefully the vaccines will protect us from having the most severe responses. It looks like it's gonna mutate and they'll be different variants. But that being said, I don't think that all of the impacts are necessarily alleviated.

So if we think about the mental health impact, I think we've all seen that in terms of our kids. That's sort of a, it's not a short term, you can say the pandemic is over, or not over. Covid’s still here, and the impact that it's had we're all dealing with. Especially in the healthcare system, I think that the nursing shortages in particular and what's going on in the nursing homes has a downstream impact to the whole system. It's not like nursing homes are in isolation, and if they don't have beds open, then that creates kind of a backlog in the hospital. They can't discharge patients. Their stays are longer. What we're seeing from hospitals across the board, the financial results are coming out and they're having issues as well, but a lot of them are reporting losses. Some of that is the nursing shortages, they're paying more. Some of it may be can't discharge patients. So there's a lot of different reasons that kind of had their root in covid.

Scott

Well, certainly for all healthcare providers, the continuation of the public health emergency is incredibly essential. It's set to expire here in October 15th or 17th of this year. Certainly without announcement that they're gonna discontinue it, it's gonna continue into early 2023. So there's at least some good news there. But boy, the advocacy efforts to continue the PHE through 2023 to make sure that all those stimulus dollars, Medicaid funding the regulations for waivers, serve regulations continue. That'll be an ultimate for the sector, so I think how Washington sees the pandemic and where it is in stage of either recovering or not, that'll say a lot for next year as well. So I guess maybe turning to the Biden administration, kinda a general question, what are your thoughts on President Biden's healthcare agenda generally?

Seema

Well, I think that they have largely been focused on covid, right? I mean, that was something that he ran on, and they've been focused on that. I think the other area that we've heard a lot about is health equity, which I think is certainly an important issue for the country. It's a long time coming that there's this type of focus. Beyond that, it's not clear to me exactly where else they're trying to go. A lot of it, I think, has to sort of do with what's going on in the landscape. For most administrations, they have a big piece of legislation to implement. We did not have that, which gave us the opportunity to really focus across the market on so many different issues. They have not until recently, they now have a big piece of legislation that's focused on drug pricing. I think that their focus on covid health equity, and now it's going to be the drug pricing piece and putting out those regulations and those, that's gonna be a huge undertaking. So it seems like that's their focus, whereas I think we had kind of a broader look at it in absence of a piece of legislation.

Scott

Yeah. Well, two pinpoint proposals that I wanna maybe get your thoughts on that the Biden administration has put forth respect to long-term care. One is President Biden in his State of the Union address actually mentioned long-term care providers and announced an initiative to create a national minimum staffing ratio for all skilled nursing providers. That obviously has gained a lot of concern among the provider community, not only from the significant cost and potential operational impact, but also just from the current workforce crisis that many sectors are going through.

Seema

Yeah.

Scott

What are your thoughts on that and where that could go?

Seema

Yeah, I didn't say it initially because I feel like they've talked about it, but what they're proposing isn't gonna necessarily move the needle. So I think we're all concerned about quality and safety in long term care facilities. That's a long term issue and something that has consistently been something that most administrations have focused on. My concern is that are we implementing the policies that are really gonna get us there and something around staffing ratios? I just don't, I think it's irrelevant. Even yesterday they announced they finally got a database of, here's the ownership of nursing homes. And at the end of the day, very bluntly, I would say, Who cares? Who cares who owns what? I think what patients want and what their families want is high quality care, and there should be transparency around what's going on in the nursing homes so that families and patients can make better decisions that work for them.

We need to be focusing our time on, how do we improve quality inside the nursing home? I think it's safe to say that the survey certification process that we've had isn't working, right? We have the same issues over and over and over again. How do we move the ball forward on infection control? And having a database of ownership and having staffing requirements isn't going to move the needle on those issues that are impacting patients today. So I've been a little bit, I appreciate their focus, but I've been disappointed on the strategies that they are taking. I don't think they're gonna move the needle forward. And I think it's important for the country at this point to really think outside the box on survey and certification. We have an antiquated process that isn't yielding better results. It's not changing things, and it's cumbersome.

If you think about it, you send a survey out there once a year. Well, there's a lot that's going on the other 364 days in the year. We've gotta figure out a better way of understanding what's going on in nursing homes, supporting the nursing homes, if there are problems, how do we help them? We can't just say, here's a citation and a fine, and good luck to you. That has not been effective. We've gotta figure out how to get in there and make improvements and support them in that process. I think a rethinking of that would be a whole lot better than a database of ownership. At the end of the day, you may see some differences in for profit or profit, but that's not improving the life of a person living inside a sniff. So hopefully we'll have a different focus going forward.

Scott

Yeah, thanks for your thoughts and on direction all that, Seema. That's really helpful. I'm now thinking back before covid hit, you were doing a lot of work internally, especially among the CMS regional offices on helping improve the survey and certification process. I know a lot of us would've liked to have seen where that conversation could have gone outside of covid. So thanks for your hard work on all of that and couldn't agree with you more. Seema, we've got our time kind of drawing a little bit to a close. I kinda want our listeners to get a sense of what you're up to now. I know you're on the board of several really impressive companies, Lameris and Monogram Health. Maybe say a little bit about those two companies in particular, what they're doing to help move the needle in healthcare and kind of what drew you to an opportunity to work for each of them.

Seema

Right. Well, what I appreciate about Lumeris, which is a company that's an MA plan, but they're also focused on direct contracting, and their sole focus is value based care and working with health systems to implement value based care. I'm a big believer in that, in terms of how we change the system to deliver better results and lower costs. The same thing with Monogram. They're focused on their sort of value-based care for kidney care patients. As you know, kidney care is one of the highest cost centers for Medicare. We spend a lot of money and most of the patients are getting dialysis and having to go to facilities two or three times a week. Monogram’s really trying to change the whole paradigm around kidney care and in-home dialysis, but actually preventing the progression of kidney disease. They're doing it in value based arrangements. They're bringing the best of breed solutions, they're doing home visiting, and they're making a real difference. So I'm excited to be a part of those companies. Right now, I tell people all the time, it's like, what are you doing? I feel like I'm in the dating phase. I'm looking around, meeting, talking to a lot of people, and we'll see what comes next. Not ready to get married yet.

Scott

Well, Seema, again, we've been friends for a long time and I've had the opportunity to be blessed to be a colleague of yours as well. You've had an incredible career, both in public and private sector and consulting. I'm personally really excited to see what you do next and hope we have you back on the podcast to sit, kind of talk about that in the future. That'd be really a great experience for us.

Hey, before I let you go, I ask all of my guests one question, which is, what's on your nightstand? Is there a book that you're reading right now that you'd like to recommend? Or is there a past reading that you hand to people and say, This is something you must read, whether it's something professional or a personal read you really like, I mean, is there anything you recommend?

Seema

Right. Well the funny thing is Scott there's so many of my colleagues from the White White House days and Trump administration days are writing books. So my book, my nightstand is stacked with everybody's books. Scott Gottlieb, Kellyanne Conway, Jared Kushner, Deborah Berke, Scott Atlas, I've got all of their books. Some of it is, gosh, do I really wanna relive that again? But they've all done a great job with their books, and I'm working my way through all of them.

Scott

Well, thanks. I think there are a lot of great titles there and reads for people to pick up and follow. So again, Seema, I can't thank you enough for your time. Thanks for all you've done throughout your career and specifically, thanks for what you did during covid to help the long-term care providers get through it. I really can't thank you enough.

For our listeners, thank you for tuning in to another episode of Versed, a VIUM Capital podcast. This is Versed.