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.
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.