Andy Slavitt will leave his post as Acting Administrator of the Centers for Medicare & Medicaid Services (CMS) this month. On the last day of the 2016 CMS Quality Conference, Slavitt shared with Jean Moody-Williams, Deputy Director of CMS’ Center for Clinical Standards and Quality, what he has taken away from his experience at CMS, as well as what the audience should keep in mind under the new administration.
Here is their conversation with additional insights from Slavitt.
Jean Moody-Williams: What are your main reflections on your time at CMS?
Andy Slavitt: Right away, meeting the people at CMS who are so smart, so generous, so gracious and so talented, I realized that my job was to give them an opportunity to be creative, listen, interact and go outside the lines. Basically, to have a culture where the team could thrive. I knew that would always lead to better results.
JMW: You came from the private sector into this public sector machine. What observations did you make about us and did you think that we needed to change?
AS: My lens was not so much what needed to change, but how to help the organization adapt. I do think that in either sector, we tend to get siloed and rigid because as we get tasks on our plate, we focus on the most efficient way to do them. At CMS, what was so fascinating was that the talent was in so many different places – in the regions, the Quality Improvement Organizations, in Medicare, CMMI [Center for Medicare and Medicaid Innovation] – people didn’t have as many opportunities to interact with each other. They didn’t have a chance to get the best results. So a lot of my work was facilitating a very simple thing like teamwork, and the team itself drove to great results from there.
JMW: You have a passion to break down barriers so that physicians and clinicians can care for the patients they serve. That hasn’t been an easy job. What do you observe that we need to do to move that ball forward?
AS: First of all, all of us have our own experiences in the health care system. We tend to think of them personally and they tend to overwhelm us when they are going on in our lives. As an industry, we try to make the system better as a whole and sometimes it can feel very overwhelming. So the people that provide technical assistance to the community are vital. With the Quality Payment Program there is only so much that we, as an agency, can accomplish on our own.. What really needs to happen is all of the people in the community should have an opportunity to participate and succeed. It’s not going to be successful if everyone doesn’t have access to high quality care. I already know some Americans have access to great care, that’s not the problem. It’s reaching everyone.
JMW: What do you see as the vision going forward with health care technology?
AS: The promise of technology is to connect us, to make things simpler, to take something that takes 30 minutes and make it 15. But even though technology is part of our everyday lives, it is not yet in health care. That has to change. When a physician says, ‘I want to talk to you about technology,’ what do you expect: a good or bad conversation? As a country we’ve tethered ourselves to technology and providers are supposed to create their personal and work lives around it and they deeply resent it. So what can we do about it?
First, CMS worked hard to lighten the load of regulations and box checking. Second, the technology companies have to be able to compete to please physicians. They are going to be required to have open Application program interfaces (APIs). By providing developers with programmatic access to a proprietary software applications, the desktop lock physicians are experiencing today will go away. This takes me to the third thing, which is interoperability. Let me be clear: there is not a technology barrier to interoperability; there is a business model barrier. It’s not a privacy concern and it’s not an intellectual property concern. This is shameful. We’ve spent $30 billion to create data siloes, and physicians won’t be happy until we solve all these problems. I know we can. Will we?
JMW: We’ve talked about the Quality Payment Program (QPP) a lot at this conference. As one of the chief architects, is there anything we need to know?
AS: We have a very diverse health care community. A two-physician practice in Arkansas is a lot different than Massachusetts General Hospital, so we can’t shove a one-size-fits-all program down everyone’s throat. That’s why we established five priorities very early on in the program:
1. Focus on the patient: Patients tell us they want and expect us to pay for what works and for higher-quality outcomes. Clinicians tell us that they want to focus on delivering the care that is best for their patients, not on reporting or paperwork. For this reason, we have reduced the number of required measures and provided practices more flexibility to select the measures that they believe best represent their patients’ needs.
2. Start out gradually: The first couple of years are aimed at getting physicians gradually more experienced with the program and vendors more capable of supporting physicians.
3. Create more pathways to participate in Advanced Alternative Payment Models: Our goal over the next few years is to have more options that fit the diversity of practices and care across the nation, while maintaining robust models that actively encourage high-value care – the best care at the best price – for our Medicare beneficiaries.
4. Adapt for small and rural practices: We know that small practices deliver the same high-quality care as larger ones. Yet at every practice we visited or event we held, we heard from physicians in small and rural practices concerned about the impact of new requirements. We heard these concerns and are taking additional steps to aid small practices, including reducing the time and cost to participate and excluding more small practices to make sure the juice is worth the squeeze.
5. Simplified MIPS as much as possible: First, we simplified the requirements for the two quality components of the program – the quality measures and practice-specific improvement activities. Second, we are moving to align the measurement of certified EHR technology with the improvement activities. Finally, we rolled out the new QPP.cms.gov, which explains the new program and helps clinicians easily identify the measures and activities most meaningful to their practice or specialty.
We listened to physicians in order to design a program for physicians. They should be able to customize it to their needs and their practices. It should feel accessible and they should know where they stand. And we should do this with a great deal of listening and humility. If the program looks the same a year from now and hasn’t iterated and improved, we will have failed. We need insights from the field to adapt or we will get it wrong.
JMW: What are your thoughts on the coordination between Medicare and Medicaid?
AS: The thing I think is most important is health equity. A family member of mine was recently at a physician’s office and they saw a gold star on their file that said, ‘Related to CMS Administrator.’ Well, that shouldn’t happen. Every patient in this country deserves to be treated like they have a gold star. Think about it – we know how to deliver great care. That’s not the problem. If we can make sure that the people that don’t have access to the best care do, we’d be in really good shape. Getting serious about that means for us, in everything we do, we shouldn’t be asking what the average care is. We need to look at the worst care and the most challenging obstacles. Wrapping our head around that is going to be key.
JMW: How will you answer the question, ‘What was your legacy?’
AS: Transitions are akin to relay races. I hope I pass the baton in this relay race in a way that created some improvement and allows the next set of folks to make health care better. Don Berwick told me early on, ‘The leadership and the career staff at CMS are the most passionate, committed, focused and smart set of people in health care.” We have to be that good because healthcare is so dependent on CMS. I’ve found that to be so true. As a leader that comes into an organization like that, for me it was about focusing on the culture so that people felt like they could do their absolute best and others would want to work there as well. Hopefully, it will continue to get better and better, and I think it will.
JMW: On behalf of everyone, we thank you.
AS: Thank you.