April 1, 2025 • 27 mins
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Health Affairs' Senior Deputy Editor Rob Lott interviews Dr. Meena Seshamani, the incoming Maryland Secretary of Health, to discuss her time as the director of Medicare at the Centers of Medicare & Medicaid Services and what the future holds in her new role.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Rob Lott (00:31):
Hello, and welcome to A Health Podicy. I'm your host,
Rob Lott. As most listenersknow, most episodes of A Health
Podicy feature the authors ofrecent health affairs journal
articles. But every once in awhile, we break from that
(00:52):
tradition and host a veryspecial guest to speak more
broadly about some of the mosttimely issues in health and
health care and to contemplatetheir experiences in the policy
making trenches. Well, I can'tthink of a better person to do
exactly that than the one andonly Doctor.
Mina Seshamani, who we'rethrilled to have on the podocy
(01:15):
today. Most recently, doctorSeshamani led the Medicare
program as deputy administratorfor the Centers for Medicare and
Medicaid Services. She left thatrole this January at the end of
the Biden administration, andafter a much deserved break,
will be taking on a brand newgig. She was appointed by
(01:37):
Maryland governor Wes Moore toserve as the new secretary of
Maryland's Department of Health,taking office next week. How
lucky are we to catch doctorSastramani in this brief window
between such critical jobs?
And so with our conversationtoday, I'm hoping we can do a
little looking back, a littlelooking forward, and some
(01:59):
meaningful reflection all alongthe way. Doctor. Seshamani,
welcome to A Health Odyssey.
Meena Seshamani (02:06):
Thank you so much for having me, Rob.
Rob Lott (02:09):
Well, let's dive right into it. You took the role of
Director of the Center forMedicare in July of twenty
twenty one. Can you take us backto that moment? It seems like a
lifetime ago. What was the stateof the program at that time?
And what did you see as perhapsthe biggest, most urgent
(02:32):
challenge facing you and theprogram at that time?
Meena Seshamani (02:36):
Yeah, that's a great question. So I did start
in July 2021. And if we lookback, that was still in the
throes of the pandemic where Ihad to introduce myself to
nearly 1,000 career staff on aZoom webinar because everybody
(02:57):
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 tohave forward momentum when what
you see our little, you know,zoom rectangles on your screen.
I think in the near term, giventhe pandemic, you know, CMS,
(03:23):
Medicare in particular had morethan 100 pandemic related
waivers, because as we know, andas I knew, because I was leading
response for MedStar Health, youknow, before taking the role in
Medicare, those waivers wereessential for us to be able to
adapt and respond to the everchanging pandemic.
(03:47):
And that also creates, animportant inflection point where
as we were moving forward andeventually moving past the
pandemic, how do you determinelessons learned? What are those
waivers that were worth keeping?What were technologies and
innovations that really couldadvance us in care delivery? So
(04:10):
both for the near term to beable to, you know, address
issues of the pandemic, evaluatethese waivers, but then also
what that means for the longerterm in terms of harnessing an
incredibly disruptive time forhealthcare, but harnessing it
towards those lessons learned sothat we can continue to innovate
in healthcare because I thinkthose of us in healthcare knew
(04:33):
that the healthcare system wasnot necessarily working in an
optimal way.
Rob Lott (04:38):
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 thatperiod, those three years
leading Medicare? Were there anysurprises when you look back on
that initial assessment comparedto what you experienced day to
(04:59):
day in doing the work that wasmaybe perhaps most challenging
or exciting for you in that job?
Meena Seshamani (05:06):
Yeah, I mean, I think having come from
practicing, I was seeingpatients as an otolaryngologist,
you know, ear, nose, and throatsurgeon at Georgetown. You know,
again, helping to lead the COVIDresponse, you know, leading care
transformation for a healthsystem. So community health and
case management and all of ourdisease pathways. Having that on
(05:31):
the ground experience reallyenabled me to see where there
are opportunities for us to makesure that the healthcare system
is actually taking care ofpeople 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,
(05:51):
you know, I knew how incrediblethe Medicare team was when I met
with them in that Zoom webinar.
One of the first things I didwas thank them because I was the
recipient of much of their hardwork around these waivers and to
be agile with us and to be goodpartners so that we could
address the pandemic. And Ithink during the course of my
(06:11):
three and a half years, theMedicare team is really truly an
incredible group of people. Theyare mission driven, they're
incredibly smart. They know moreabout the Medicare program in
their pinky nail than, you know,one could ever hope to know in a
lifetime. And I think what Iappreciated was their
(06:32):
willingness to bring ideasforward, to incorporate, listen
to stakeholders, and bring ideasforward for what we could do to
really improve care.
And I think one of the biggestsurprises for me was just how
broad of a reach the Medicareprogram has. I knew that
Medicare had a huge reach,right? Everybody looks at the
(06:53):
Medicare program to see whatit's doing, from payment rates
to how we're encouraging caredelivery through various models.
But it's things like, as we wereevaluating lessons learned from
the pandemic, and we realizedthat we didn't have good
preparedness around domesticproduction of PPE, for example.
(07:16):
Lo and behold, Medicare has alever that can be utilized where
we created a policy, creatingdifferential reimbursements for
domestically produced N95 masksto try to encourage domestic
production to give us thatdomestic resiliency in the case
of another pandemic.
Like there are things that Iwould have never even thought
(07:36):
about that Medicare reallytouches. And again, I think it
speaks to just the incredibleresponsibility and opportunity
in running the Medicare programand the incredible importance of
having a really strong team thatcan help identify those areas
where Medicare can really putits shoulder to the wheel
(07:58):
alongside and in partnershipwith all the people in the
healthcare ecosystem to drivemeaningful change.
Rob Lott (08:05):
Okay, let's talk about some of the broad scope of that
program. One of the mostpronounced trends over the last
three and a half, four years hasbeen the continued growth of
Medicare Advantage. And I'd loveto hear from you what that
looked like from the inside. Wasthe program's growth a surprise
(08:26):
to you? And what's your take?
Is that a good thing forMedicare overall, for
beneficiaries, for taxpayers?
Meena Seshamani (08:36):
So I think Medicare Advantage is a very
important part of the Medicareprogram. You know, when I was
leading community health atMedStar, I used to say, what's
the first word in communityhealth? Community. You know,
there is no one size fits allfor healthcare. There needs to
be options for people.
And those options need to benavigable and they need to make
(09:00):
sure that the market iscompeting on what matters to
consumers. So quality andaccess. And, you know, I'm a
health economist as well as aphysician. Did my PhD in health
economics. I don't want to sayhow many years ago because that
will date me.
But one of the first things youlearn in health economics one
hundred one is that healthcaremarkets are imperfect. You have
(09:24):
asymmetry of information, youhave supply induced demand, you
have moral hazard, you have aninability for organizations to
smoothly enter and exit themarket. And, you know, a role of
regulation is to be able toaddress some of these market
imperfections. And so a lot ofwhat we did in the Medicare
(09:44):
Advantage Program was trying toassess by asking everybody, any
stakeholder who is interested inMedicare Advantage, what are the
things that are working? Whereare the areas for improvement?
And being able to make commonsense data driven improvements
accordingly. For example,streamlining prior
(10:04):
authorization, which issomething that we heard of from
every stakeholder group as anissue that needed to be
addressed. Clamping down onmisleading marketing practices
so that choice really mattersfor people. And making
adjustments to the payment modelso that you are paying
accurately by using the most upto date data, the most up to
date diagnostic nomenclature,etcetera. So, you know, again, I
(10:27):
think Medicare Advantage is avery important part of the
program and they're just likeevery part of Medicare, there
were opportunities forimprovement.
Rob Lott (10:36):
Speaking of which, you were leading the Center for
Medicare during the first roundof drug price negotiation under
the IRA. And there have beenplenty of analyses of the
negotiations and their outcomesin plenty of publications,
including health affairs, folkslooking at the various factors
(10:59):
that were used in thenegotiation or perhaps should
have been used. So instead, I'mthinking maybe you and I can
take a step back and ask a morephilosophical question, which is
that at the heart of theprogram's sort of very existence
is this tension betweenaccessibility in the form of
making drugs more affordable, agoal the government's trying to
(11:23):
achieve, and innovation in theform of financial incentives to
invest in novel drugdevelopment, something drug
developers want to protect. And,you know, some say that most
innovative drugs in the worldare worthless if no one can
afford them. The counterargumentis that when negotiation reduces
(11:43):
profitability, it reducesdevelopers' ability to pursue
that innovation.
And so my question, I guess, ishow did you and the folks behind
the curtain at the negotiationtable think about this tension?
And do you feel like the law wasdesigned and implemented in a
(12:03):
way to achieve the right balanceof those factors?
Meena Seshamani (12:08):
Yeah, I mean, that's a great question. And one
of the first things that we didwas meet with everybody who was
interested in how we were goingto be implementing drug
negotiation from patient groupsto clinicians, to drug
manufacturers, pharma andbiotech, health plans. And, you
(12:29):
know, to this point that youmade about innovation and
access, there actually is acommon goal and a common win win
that you want people to haveaccess to the innovative cures
and therapies that they need.And, you know, being able to
drive innovations that result insignificant improvements in
(12:54):
people's lives and being able tolay a foundation for the
negotiation program on realworld evidence so that you're
really looking at what the valueof a drug brings to someone in
their natural environment with acaregiver in their communities.
You know, that is a huge stepforward in the ongoing
(13:15):
conversation about whatinnovation means for people.
And to your point, thatinnovation is only so good as
people can actually get accessto the drugs, which is why, you
know, you have the drugnegotiation aspects of the
inflation reduction act pairedwith some of the most
(13:35):
significant changes to theprescription drug benefit in
decades, including the $2,000out of pocket cap. You know,
when I was practicing, medicine,I had one Medicare patient, I
had to get on GoodRx with her totry to find a prescription that
I could prescribe for her thatshe could afford. And if she
(13:56):
didn't have that barrier, likethere could have been other
medications that I could havegiven her. And so she didn't
have access to thoseinnovations. So, you know, I
think it was very important forus to work with all of the
various stakeholders to reallyunderstand what is important to
them in innovation.
What is important to them inaccess? And again, it comes back
(14:19):
to how do we enable the marketto work as effectively as
possible so that competition ison what matters to the people
who rely on these cures andtherapies.
Rob Lott (14:30):
Great. Do you feel like that first round of
negotiation hit that mark? Andif not, sort of where do you
think the next round and theround after that should focus on
in terms of improvements orrefining the process?
Meena Seshamani (14:46):
Yeah, I mean, I absolutely think that, you know,
our first round of negotiationswere successful. You know, as
you know, we estimated that hadthose negotiated prices been in
place in 2023, there would havebeen a net savings of
$6,000,000,000 to the Medicareprogram, including
$1,500,000,000 out of pocketfor, you know, people with
(15:09):
Medicare prescription drugcoverage. And importantly, you
know, there was stability withthis. You know, when you look at
the stock market, there were nomajor swings because again, we
underwent, you know, commentwith our guidances, we
incorporated feedback. You know,I will say that one of the
(15:29):
biggest compliments that I gotin my job as I was ending my
tenure was a stakeholder tellingme, you know, we didn't always
agree with everything that youdid, but we understood why you
did it and your team was alwaysso professional and so
responsive.
Because ultimately, wheneveryou're tackling tough complex
(15:52):
issues, there's no silverbullet. Right? There's no
panacea and it really is amatter of engaging in thoughtful
dialogue and trying something,evaluating it and moving forward
from there. And that's why withthe negotiation process, we did
guidances only year by yearbecause we wanted to have that
(16:13):
opportunity to be able to learnalong the way to see how the
market reacts because marketsare dynamic, to be able to
incorporate changes. And to giveyou one example, we realized in
the first round of negotiationthat we really wanted to make
sure we were doing as much aspossible to incorporate the
patient voice, the caregivervoice.
(16:35):
And that was a specific areathat we asked for feedback in
the second round of guidance andmade significant changes to the
negotiation process to betterincorporate feedback, you know,
lived experience from peopletaking the selected drugs.
Rob Lott (16:51):
Great. Well, speaking of tough and complicated issues,
I wanna ask you about your, newjob coming up, which we'll do
after this break. And we'reback. I'm here with Doctor. Mina
(17:24):
Seshamani, the former directorof Medicare and the soon to be
secretary of the MarylandDepartment of Health.
Doctor. Seshamani, to the extentthat you're comfortable sharing
the conversation between you andGovernor Wes Moore, did he ask
you that classic job interviewquestion, why do you think you'd
(17:47):
be a good fit for this job? Andwhat was your answer?
Meena Seshamani (17:52):
Well, you know, it was truly an honor to be
considered for this role by thegovernor. And one of the things
that we talked about was, youknow, what excites me about the
role. And I think, you know, topiggyback Rob on some of what we
talked about before the break inwhat I learned leading the
(18:13):
Medicare program, There is atremendous opportunity to
harness the strength in a stateof all the people who are
invested in the health andwell-being of that state's
residents. And to be on theground really working across the
(18:34):
various communities to driveimprovements and to have that,
to be able to feel that tangibleimpact. And I think through my
experiences leading the Medicareprogram, you know, I have a
clinical background that I canbring to bear.
I have an economics backgroundthat I can bring to bear. I am
also a flesh and blood humanbeing. I really want to
(18:57):
understand what people's hopesare, what they're happy about,
where they wanna seeimprovements, and really be able
to roll up our sleeves and worktogether on that. And I think
that's how you really driveinnovation and states are a
great laboratory for innovation.So I think that both answers the
question of why I am a good fitand, you know, what the governor
(19:19):
and I spent quite a bit of timetalking about in terms of how,
you know, I would envision thisrole.
Rob Lott (19:25):
Great. So following up on that, obviously, the scope of
this new role is much broaderthan your role at Medicare,
which of course was incrediblybroad. And it includes
responsibilities for things asdiverse as public health and
disease surveillance, behavioralhealth. I was looking at the
list of various boards that theDepartment of Health oversees,
(19:46):
and it's quite long and there'ssome boards I had no idea even
existed. And so I'd love to hearfrom you how you're sort of
preparing your own headspace tokind of grapple with the sheer
breadth of what you've got aheadof you.
Meena Seshamani (20:09):
Yeah. Well, you know, what's interesting is I
think one of the reasons thatwhen I was in the Medicare role,
one of the reasons that we wereable to drive such significant
improvements. You know, I did aninterview with Modern Healthcare
where they said like, you guysdrove some of the most
significant improvements inMedicare in three years than had
(20:31):
been done in prior decades. AndI actually think a lot of it was
because I didn't just think ofit quote unquote as a payment
program. CMS is a large publichealth agency where the policies
we make around quality, aroundpayments, around care delivery
models, they enable us toconnect between a traditional
(20:52):
healthcare setting and wherepeople actually spend the
majority of their time and havetheir experiences impact their
health.
So in the Medicare program,being able to create payments
for community health services,support family caregivers,
integrate behavioral health withprimary care. You know, I think
that ability to connect the dotswas critical for the many
(21:14):
changes that we made withMedicare. And I think that is
exactly what I am hoping tobring to, you know, the role in
Maryland where you can seetremendous opportunities for
integration between care forpeople with disabilities, the
Medicaid program, behavioralhealth, you know, our public
(21:35):
health service and how data thatwe have on the ground can help
inform how we are keeping peoplehealthy both in and out of
healthcare settings. So I thinkit is that, you know, ability to
just roll up your sleeves, talkto people on the ground, and be
able to see in particular wherethere are those common threads
(21:56):
that you can pull to reallydrive significant improvements.
Rob Lott (22:02):
So as a federal employee, as director of
Medicare, you had to work a fairbit with state policymakers. Now
as a state official, you'll haveto work pretty closely with the
feds. The difference this time,obviously, is that there's a
very different administration atthe federal level. And there's
(22:25):
sort of inherent in thatrelationship between the feds
and the states, especially whenit comes to health and health
policy, a bit of a tension. Andso I'm curious how you're
thinking about how you're goingto approach that relationship.
Meena Seshamani (22:43):
Yeah. I think ultimately, people who go into
health care want to improvehealth at the end of the day,
whether you are a, you know, anadvocate, a clinician, someone
working in a health plan,someone working for a
pharmaceutical company, whateverside of the aisle you're on. And
(23:05):
I think it's important that wealways tap into what are our
common goals and have that guideus with conversations. Again,
there is no gold standard. Thereis no silver bullet.
This is all very much continuouslearning and being able to
harness data to be able to havethoughtful conversations where
(23:27):
we are weighing pros and cons, Ithink is the fundamentals
regardless of whichadministration is present. And I
think that is how we approachedwhen I was there, all of the
care transformation work we didto innovate in partnership with
(23:47):
CMMI, the work we did as you andI discussed to, you know, make
improvements to MedicareAdvantage and the work we did to
implement the InflationReduction Act. I think that's a
common theme and a commonfoundation that that can and
should be utilized not just bypolicymakers, but honestly,
anybody in an organization that,you know, you're looking at
(24:11):
tapping into what it what isdriving people to do the work
they do? What are their commongoals? And, you know, can we
find that commonality to be ableto collectively problem solve?
Rob Lott (24:21):
Earlier, you mentioned coming into Medicare in the
throes of the COVID-nineteenpandemic. And I think one of the
big realizations to come out ofthe pandemic was the relative
inadequacy of state and localhealth departments. And this is
not to undervalue the incrediblework that these departments do
(24:42):
and the lives that they savedduring the pandemic in the face
of really nearly impossibleconditions. But I think the
responsibility for some of theshortcomings of that system writ
large comes back to the failureto invest and prepare among
national stakeholders and stateleaders. And since then, we've
(25:06):
seen numerous proposals toquote, reimagine public health
and really bridge the gapbetween health care and public
health.
And I'd love to hear how you'rethinking about that problem and
where you plan to start in thatwork when you take office.
Meena Seshamani (25:23):
Yes. Well, and I will come back to my work in
Medicare because having been ina healthcare organization,
working with public health tocombat the pandemic, I think I
saw firsthand how importantservices that fall outside of a
traditional healthcare paradigmare to keeping people healthy,
(25:47):
not just for addressing apandemic, but even more broadly
to keeping people healthy. Andone of the things that I sought
to do when I was leading theMedicare program was again, how
do we make the market workbetter? How do we have the
market reward and encouragethose kinds of services that are
(26:07):
really fundamental to improvingthe health of population? So as
I mentioned, paying forcommunity health workers, you
know, enabling value basedpayment arrangements where doing
the right thing actually leadsto a financial reward.
And I think that is somethingthat I want to continue now on
the state side where there areopportunities to have, you know,
(26:30):
more regular routinized fundingflows for public health services
that are tied to healthcareservices. And for example,
again, being able to utilize,you know, Medicare funding
streams, Medicaid fundingstreams, particularly because
investing upstream in someone'shealth can avoid the
(26:51):
hospitalization, the EDutilization so that financially
this makes sense because you'respending money in a smarter way.
And for some for outcomes, itmakes sense because you're
keeping people healthy. So Icertainly think that is
something that I wanna continuedoing now from the state side
and the public health side.
Rob Lott (27:10):
Great. Well, that's about all of our time for today.
Doctor. Seshramani, thank you somuch for taking the time during
this brief window and betweenyour jobs to talk to us and the
listeners of Health Odyssey.Thank you for being here.
Meena Seshamani (27:26):
Well, thank you so much for having me.
Rob Lott (27:29):
And to our listeners, thank you for tuning in. If you
enjoyed, please recommend it toa friend. Smash that subscribe
button and tune in next week.Thanks for listening. If you
enjoyed today's episode, I hopeyou'll tell a friend about a
health policy.
Hello, and welcome to A Health Podicy. I'm your host,
Rob Lott. As most listenersknow, most episodes of A Health
Podicy feature the authors ofrecent health affairs journal
articles. But every once in awhile, we break from that
(00:52):
tradition and host a veryspecial guest to speak more
broadly about some of the mosttimely issues in health and
health care and to contemplatetheir experiences in the policy
making trenches. Well, I can'tthink of a better person to do
exactly that than the one andonly Doctor.
Mina Seshamani, who we'rethrilled to have on the podocy
(01:15):
today. Most recently, doctorSeshamani led the Medicare
program as deputy administratorfor the Centers for Medicare and
Medicaid Services. She left thatrole this January at the end of
the Biden administration, andafter a much deserved break,
will be taking on a brand newgig. She was appointed by
(01:37):
Maryland governor Wes Moore toserve as the new secretary of
Maryland's Department of Health,taking office next week. How
lucky are we to catch doctorSastramani in this brief window
between such critical jobs?
And so with our conversationtoday, I'm hoping we can do a
little looking back, a littlelooking forward, and some
(01:59):
meaningful reflection all alongthe way. Doctor. Seshamani,
welcome to A Health Odyssey.
Meena Seshamani (02:06):
Thank you so much for having me, Rob.
Rob Lott (02:09):
Well, let's dive right into it. You took the role of
Director of the Center forMedicare in July of twenty
twenty one. Can you take us backto that moment? It seems like a
lifetime ago. What was the stateof the program at that time?
And what did you see as perhapsthe biggest, most urgent
(02:32):
challenge facing you and theprogram at that time?
Meena Seshamani (02:36):
Yeah, that's a great question. So I did start
in July 2021. And if we lookback, that was still in the
throes of the pandemic where Ihad to introduce myself to
nearly 1,000 career staff on aZoom webinar because everybody
(02:57):
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 tohave forward momentum when what
you see our little, you know,zoom rectangles on your screen.
I think in the near term, giventhe pandemic, you know, CMS,
(03:23):
Medicare in particular had morethan 100 pandemic related
waivers, because as we know, andas I knew, because I was leading
response for MedStar Health, youknow, before taking the role in
Medicare, those waivers wereessential for us to be able to
adapt and respond to the everchanging pandemic.
(03:47):
And that also creates, animportant inflection point where
as we were moving forward andeventually moving past the
pandemic, how do you determinelessons learned? What are those
waivers that were worth keeping?What were technologies and
innovations that really couldadvance us in care delivery? So
(04:10):
both for the near term to beable to, you know, address
issues of the pandemic, evaluatethese waivers, but then also
what that means for the longerterm in terms of harnessing an
incredibly disruptive time forhealthcare, but harnessing it
towards those lessons learned sothat we can continue to innovate
in healthcare because I thinkthose of us in healthcare knew
(04:33):
that the healthcare system wasnot necessarily working in an
optimal way.
Rob Lott (04:38):
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 thatperiod, those three years
leading Medicare? Were there anysurprises when you look back on
that initial assessment comparedto what you experienced day to
(04:59):
day in doing the work that wasmaybe perhaps most challenging
or exciting for you in that job?
Meena Seshamani (05:06):
Yeah, I mean, I think having come from
practicing, I was seeingpatients as an otolaryngologist,
you know, ear, nose, and throatsurgeon at Georgetown. You know,
again, helping to lead the COVIDresponse, you know, leading care
transformation for a healthsystem. So community health and
case management and all of ourdisease pathways. Having that on
(05:31):
the ground experience reallyenabled me to see where there
are opportunities for us to makesure that the healthcare system
is actually taking care ofpeople 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,
(05:51):
you know, I knew how incrediblethe Medicare team was when I met
with them in that Zoom webinar.
One of the first things I didwas thank them because I was the
recipient of much of their hardwork around these waivers and to
be agile with us and to be goodpartners so that we could
address the pandemic. And Ithink during the course of my
(06:11):
three and a half years, theMedicare team is really truly an
incredible group of people. Theyare mission driven, they're
incredibly smart. They know moreabout the Medicare program in
their pinky nail than, you know,one could ever hope to know in a
lifetime. And I think what Iappreciated was their
(06:32):
willingness to bring ideasforward, to incorporate, listen
to stakeholders, and bring ideasforward for what we could do to
really improve care.
And I think one of the biggestsurprises for me was just how
broad of a reach the Medicareprogram has. I knew that
Medicare had a huge reach,right? Everybody looks at the
(06:53):
Medicare program to see whatit's doing, from payment rates
to how we're encouraging caredelivery through various models.
But it's things like, as we wereevaluating lessons learned from
the pandemic, and we realizedthat we didn't have good
preparedness around domesticproduction of PPE, for example.
(07:16):
Lo and behold, Medicare has alever that can be utilized where
we created a policy, creatingdifferential reimbursements for
domestically produced N95 masksto try to encourage domestic
production to give us thatdomestic resiliency in the case
of another pandemic.
Like there are things that Iwould have never even thought
(07:36):
about that Medicare reallytouches. And again, I think it
speaks to just the incredibleresponsibility and opportunity
in running the Medicare programand the incredible importance of
having a really strong team thatcan help identify those areas
where Medicare can really putits shoulder to the wheel
(07:58):
alongside and in partnershipwith all the people in the
healthcare ecosystem to drivemeaningful change.
Rob Lott (08:05):
Okay, let's talk about some of the broad scope of that
program. One of the mostpronounced trends over the last
three and a half, four years hasbeen the continued growth of
Medicare Advantage. And I'd loveto hear from you what that
looked like from the inside. Wasthe program's growth a surprise
(08:26):
to you? And what's your take?
Is that a good thing forMedicare overall, for
beneficiaries, for taxpayers?
Meena Seshamani (08:36):
So I think Medicare Advantage is a very
important part of the Medicareprogram. You know, when I was
leading community health atMedStar, I used to say, what's
the first word in communityhealth? Community. You know,
there is no one size fits allfor healthcare. There needs to
be options for people.
And those options need to benavigable and they need to make
(09:00):
sure that the market iscompeting on what matters to
consumers. So quality andaccess. And, you know, I'm a
health economist as well as aphysician. Did my PhD in health
economics. I don't want to sayhow many years ago because that
will date me.
But one of the first things youlearn in health economics one
hundred one is that healthcaremarkets are imperfect. You have
(09:24):
asymmetry of information, youhave supply induced demand, you
have moral hazard, you have aninability for organizations to
smoothly enter and exit themarket. And, you know, a role of
regulation is to be able toaddress some of these market
imperfections. And so a lot ofwhat we did in the Medicare
(09:44):
Advantage Program was trying toassess by asking everybody, any
stakeholder who is interested inMedicare Advantage, what are the
things that are working? Whereare the areas for improvement?
And being able to make commonsense data driven improvements
accordingly. For example,streamlining prior
(10:04):
authorization, which issomething that we heard of from
every stakeholder group as anissue that needed to be
addressed. Clamping down onmisleading marketing practices
so that choice really mattersfor people. And making
adjustments to the payment modelso that you are paying
accurately by using the most upto date data, the most up to
date diagnostic nomenclature,etcetera. So, you know, again, I
(10:27):
think Medicare Advantage is avery important part of the
program and they're just likeevery part of Medicare, there
were opportunities forimprovement.
Rob Lott (10:36):
Speaking of which, you were leading the Center for
Medicare during the first roundof drug price negotiation under
the IRA. And there have beenplenty of analyses of the
negotiations and their outcomesin plenty of publications,
including health affairs, folkslooking at the various factors
(10:59):
that were used in thenegotiation or perhaps should
have been used. So instead, I'mthinking maybe you and I can
take a step back and ask a morephilosophical question, which is
that at the heart of theprogram's sort of very existence
is this tension betweenaccessibility in the form of
making drugs more affordable, agoal the government's trying to
(11:23):
achieve, and innovation in theform of financial incentives to
invest in novel drugdevelopment, something drug
developers want to protect. And,you know, some say that most
innovative drugs in the worldare worthless if no one can
afford them. The counterargumentis that when negotiation reduces
(11:43):
profitability, it reducesdevelopers' ability to pursue
that innovation.
And so my question, I guess, ishow did you and the folks behind
the curtain at the negotiationtable think about this tension?
And do you feel like the law wasdesigned and implemented in a
(12:03):
way to achieve the right balanceof those factors?
Meena Seshamani (12:08):
Yeah, I mean, that's a great question. And one
of the first things that we didwas meet with everybody who was
interested in how we were goingto be implementing drug
negotiation from patient groupsto clinicians, to drug
manufacturers, pharma andbiotech, health plans. And, you
(12:29):
know, to this point that youmade about innovation and
access, there actually is acommon goal and a common win win
that you want people to haveaccess to the innovative cures
and therapies that they need.And, you know, being able to
drive innovations that result insignificant improvements in
(12:54):
people's lives and being able tolay a foundation for the
negotiation program on realworld evidence so that you're
really looking at what the valueof a drug brings to someone in
their natural environment with acaregiver in their communities.
You know, that is a huge stepforward in the ongoing
(13:15):
conversation about whatinnovation means for people.
And to your point, thatinnovation is only so good as
people can actually get accessto the drugs, which is why, you
know, you have the drugnegotiation aspects of the
inflation reduction act pairedwith some of the most
(13:35):
significant changes to theprescription drug benefit in
decades, including the $2,000out of pocket cap. You know,
when I was practicing, medicine,I had one Medicare patient, I
had to get on GoodRx with her totry to find a prescription that
I could prescribe for her thatshe could afford. And if she
(13:56):
didn't have that barrier, likethere could have been other
medications that I could havegiven her. And so she didn't
have access to thoseinnovations. So, you know, I
think it was very important forus to work with all of the
various stakeholders to reallyunderstand what is important to
them in innovation.
What is important to them inaccess? And again, it comes back
(14:19):
to how do we enable the marketto work as effectively as
possible so that competition ison what matters to the people
who rely on these cures andtherapies.
Rob Lott (14:30):
Great. Do you feel like that first round of
negotiation hit that mark? Andif not, sort of where do you
think the next round and theround after that should focus on
in terms of improvements orrefining the process?
Meena Seshamani (14:46):
Yeah, I mean, I absolutely think that, you know,
our first round of negotiationswere successful. You know, as
you know, we estimated that hadthose negotiated prices been in
place in 2023, there would havebeen a net savings of
$6,000,000,000 to the Medicareprogram, including
$1,500,000,000 out of pocketfor, you know, people with
(15:09):
Medicare prescription drugcoverage. And importantly, you
know, there was stability withthis. You know, when you look at
the stock market, there were nomajor swings because again, we
underwent, you know, commentwith our guidances, we
incorporated feedback. You know,I will say that one of the
(15:29):
biggest compliments that I gotin my job as I was ending my
tenure was a stakeholder tellingme, you know, we didn't always
agree with everything that youdid, but we understood why you
did it and your team was alwaysso professional and so
responsive.
Because ultimately, wheneveryou're tackling tough complex
(15:52):
issues, there's no silverbullet. Right? There's no
panacea and it really is amatter of engaging in thoughtful
dialogue and trying something,evaluating it and moving forward
from there. And that's why withthe negotiation process, we did
guidances only year by yearbecause we wanted to have that
(16:13):
opportunity to be able to learnalong the way to see how the
market reacts because marketsare dynamic, to be able to
incorporate changes. And to giveyou one example, we realized in
the first round of negotiationthat we really wanted to make
sure we were doing as much aspossible to incorporate the
patient voice, the caregivervoice.
(16:35):
And that was a specific areathat we asked for feedback in
the second round of guidance andmade significant changes to the
negotiation process to betterincorporate feedback, you know,
lived experience from peopletaking the selected drugs.
Rob Lott (16:51):
Great. Well, speaking of tough and complicated issues,
I wanna ask you about your, newjob coming up, which we'll do
after this break. And we'reback. I'm here with Doctor. Mina
(17:24):
Seshamani, the former directorof Medicare and the soon to be
secretary of the MarylandDepartment of Health.
Doctor. Seshamani, to the extentthat you're comfortable sharing
the conversation between you andGovernor Wes Moore, did he ask
you that classic job interviewquestion, why do you think you'd
(17:47):
be a good fit for this job? Andwhat was your answer?
Meena Seshamani (17:52):
Well, you know, it was truly an honor to be
considered for this role by thegovernor. And one of the things
that we talked about was, youknow, what excites me about the
role. And I think, you know, topiggyback Rob on some of what we
talked about before the break inwhat I learned leading the
(18:13):
Medicare program, There is atremendous opportunity to
harness the strength in a stateof all the people who are
invested in the health andwell-being of that state's
residents. And to be on theground really working across the
(18:34):
various communities to driveimprovements and to have that,
to be able to feel that tangibleimpact. And I think through my
experiences leading the Medicareprogram, you know, I have a
clinical background that I canbring to bear.
I have an economics backgroundthat I can bring to bear. I am
also a flesh and blood humanbeing. I really want to
(18:57):
understand what people's hopesare, what they're happy about,
where they wanna seeimprovements, and really be able
to roll up our sleeves and worktogether on that. And I think
that's how you really driveinnovation and states are a
great laboratory for innovation.So I think that both answers the
question of why I am a good fitand, you know, what the governor
(19:19):
and I spent quite a bit of timetalking about in terms of how,
you know, I would envision thisrole.
Rob Lott (19:25):
Great. So following up on that, obviously, the scope of
this new role is much broaderthan your role at Medicare,
which of course was incrediblybroad. And it includes
responsibilities for things asdiverse as public health and
disease surveillance, behavioralhealth. I was looking at the
list of various boards that theDepartment of Health oversees,
(19:46):
and it's quite long and there'ssome boards I had no idea even
existed. And so I'd love to hearfrom you how you're sort of
preparing your own headspace tokind of grapple with the sheer
breadth of what you've got aheadof you.
Meena Seshamani (20:09):
Yeah. Well, you know, what's interesting is I
think one of the reasons thatwhen I was in the Medicare role,
one of the reasons that we wereable to drive such significant
improvements. You know, I did aninterview with Modern Healthcare
where they said like, you guysdrove some of the most
significant improvements inMedicare in three years than had
(20:31):
been done in prior decades. AndI actually think a lot of it was
because I didn't just think ofit quote unquote as a payment
program. CMS is a large publichealth agency where the policies
we make around quality, aroundpayments, around care delivery
models, they enable us toconnect between a traditional
(20:52):
healthcare setting and wherepeople actually spend the
majority of their time and havetheir experiences impact their
health.
So in the Medicare program,being able to create payments
for community health services,support family caregivers,
integrate behavioral health withprimary care. You know, I think
that ability to connect the dotswas critical for the many
(21:14):
changes that we made withMedicare. And I think that is
exactly what I am hoping tobring to, you know, the role in
Maryland where you can seetremendous opportunities for
integration between care forpeople with disabilities, the
Medicaid program, behavioralhealth, you know, our public
(21:35):
health service and how data thatwe have on the ground can help
inform how we are keeping peoplehealthy both in and out of
healthcare settings. So I thinkit is that, you know, ability to
just roll up your sleeves, talkto people on the ground, and be
able to see in particular wherethere are those common threads
(21:56):
that you can pull to reallydrive significant improvements.
Rob Lott (22:02):
So as a federal employee, as director of
Medicare, you had to work a fairbit with state policymakers. Now
as a state official, you'll haveto work pretty closely with the
feds. The difference this time,obviously, is that there's a
very different administration atthe federal level. And there's
(22:25):
sort of inherent in thatrelationship between the feds
and the states, especially whenit comes to health and health
policy, a bit of a tension. Andso I'm curious how you're
thinking about how you're goingto approach that relationship.
Meena Seshamani (22:43):
Yeah. I think ultimately, people who go into
health care want to improvehealth at the end of the day,
whether you are a, you know, anadvocate, a clinician, someone
working in a health plan,someone working for a
pharmaceutical company, whateverside of the aisle you're on. And
(23:05):
I think it's important that wealways tap into what are our
common goals and have that guideus with conversations. Again,
there is no gold standard. Thereis no silver bullet.
This is all very much continuouslearning and being able to
harness data to be able to havethoughtful conversations where
(23:27):
we are weighing pros and cons, Ithink is the fundamentals
regardless of whichadministration is present. And I
think that is how we approachedwhen I was there, all of the
care transformation work we didto innovate in partnership with
(23:47):
CMMI, the work we did as you andI discussed to, you know, make
improvements to MedicareAdvantage and the work we did to
implement the InflationReduction Act. I think that's a
common theme and a commonfoundation that that can and
should be utilized not just bypolicymakers, but honestly,
anybody in an organization that,you know, you're looking at
(24:11):
tapping into what it what isdriving people to do the work
they do? What are their commongoals? And, you know, can we
find that commonality to be ableto collectively problem solve?
Rob Lott (24:21):
Earlier, you mentioned coming into Medicare in the
throes of the COVID-nineteenpandemic. And I think one of the
big realizations to come out ofthe pandemic was the relative
inadequacy of state and localhealth departments. And this is
not to undervalue the incrediblework that these departments do
(24:42):
and the lives that they savedduring the pandemic in the face
of really nearly impossibleconditions. But I think the
responsibility for some of theshortcomings of that system writ
large comes back to the failureto invest and prepare among
national stakeholders and stateleaders. And since then, we've
(25:06):
seen numerous proposals toquote, reimagine public health
and really bridge the gapbetween health care and public
health.
And I'd love to hear how you'rethinking about that problem and
where you plan to start in thatwork when you take office.
Meena Seshamani (25:23):
Yes. Well, and I will come back to my work in
Medicare because having been ina healthcare organization,
working with public health tocombat the pandemic, I think I
saw firsthand how importantservices that fall outside of a
traditional healthcare paradigmare to keeping people healthy,
(25:47):
not just for addressing apandemic, but even more broadly
to keeping people healthy. Andone of the things that I sought
to do when I was leading theMedicare program was again, how
do we make the market workbetter? How do we have the
market reward and encouragethose kinds of services that are
(26:07):
really fundamental to improvingthe health of population? So as
I mentioned, paying forcommunity health workers, you
know, enabling value basedpayment arrangements where doing
the right thing actually leadsto a financial reward.
And I think that is somethingthat I want to continue now on
the state side where there areopportunities to have, you know,
(26:30):
more regular routinized fundingflows for public health services
that are tied to healthcareservices. And for example,
again, being able to utilize,you know, Medicare funding
streams, Medicaid fundingstreams, particularly because
investing upstream in someone'shealth can avoid the
(26:51):
hospitalization, the EDutilization so that financially
this makes sense because you'respending money in a smarter way.
And for some for outcomes, itmakes sense because you're
keeping people healthy. So Icertainly think that is
something that I wanna continuedoing now from the state side
and the public health side.
Rob Lott (27:10):
Great. Well, that's about all of our time for today.
Doctor. Seshramani, thank you somuch for taking the time during
this brief window and betweenyour jobs to talk to us and the
listeners of Health Odyssey.Thank you for being here.
Meena Seshamani (27:26):
Well, thank you so much for having me.
Rob Lott (27:29):
And to our listeners, thank you for tuning in. If you
enjoyed, please recommend it toa friend. Smash that subscribe
button and tune in next week.Thanks for listening. If you
enjoyed today's episode, I hopeyou'll tell a friend about a
health policy.
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