Marilyn Tavenner Discusses Healthcare Reform and the Role of CMS

Marilyn B. Tavenner

The American Journal of Managed Care recently sat with , administrator of the Centers for Medicare & Medicaid Services (CMS), as she discussed CMS’s role in the new, evolving healthcare landscape. This special AJMCtv interview highlights just some of the initiatives CMS has implemented, as well as some of the challenges that remain for the organization.

Ms Tavenner says that CMS is ensuring successful implementation of the exchanges through several methods including the website HealthCare.gov, 24/7 call centers, and various forms of in-person assistance such as the navigator program. In fact, CMS recently awarded $67 million nationally to help people understand what health insurance is available for purchase, and how to sign up for coverage. There are also volunteers called counselors, both hospital based and located at other federally qualified health centers, who are helping individuals sign up for coverage. Ms Tavenner adds that CMS has even partnered with retail clinics like those at Walgreens and CVS to help the uninsured learn about the marketplace.

Ms Tavenner further explained CMS’s role in enrolling Americans with navigator programs, suggesting that they are available in all states. Some states, if they’re state-based exchanges, are running their own programs. Nationally, CMS is running about 34 programs for those states that utilize federal exchanges. In order to participate, entities applied and were awarded grants to train individuals (ie, “navigators”) to assist Americans in enrolling in health plans on the health insurance marketplace.

“These individuals will offer in-person assistance so that if you’re having trouble understanding what’s necessary to put together an application, if you need assistance in completing forms—they’ll also be able to do it different languages,” said Ms Tavenner. She noted that “It’s an additional way to help individuals.”

In discussing states’ expansion of Medicaid programs, Ms Tavenner says CMS is pleased with the number of states that chose to do so. She says that they plan to make a case with those states that have yet to expand their programs, arguing that Medicaid expansion under the Affordable Care Act (ACA) is 100% federally funded for 3 years, and the lowest it ever drops to is to 90% federally funded.

“We will continue to work with states,” said Ms Tavenner. “For those states that don’t expand, we will help those individuals rely on some of the more traditional historical resources such as free clinics.”

CMS continues to regulate Medicaid and Medicare spending by approaching everything with the “three-legged stool” of quality, access, and cost. Through the ACA and other mechanisms over the last 3 years, CMS has not only implemented ways to lower costs, but they’ve seen some of the best cost trends in the last 50 years.

“A lot of the way we are doing that is through some of the pilots we have in the innovation center, where we are tying payment directly to quality as opposed to tying payment to the number of procedures done, or number of hospitalizations,” said Ms. Tavenner. “We’re now focused on quality and tying payment and quality more closely together.”

Ms Tavenner adds this is a new “era” for CMS, as models like the accountable care organization (ACO) and bundled payment initiatives drive quality and cost-effectiveness.

ACOs remain important for CMS, especially after 9 of the pioneer ACOs dropped out of the program in its first year. Ms. Tavenner said they learned the importance of data and are now working to improve data usage. She adds that many of those former pioneer organizations have chosen to join the traditional shared savings program and are continuing to work on modifying the ACO model in a different way.

Other new models and innovations will be important for CMS as the organization moves away from the fee-for-service payment system. For instance, CMS says it has tied payment to quality as it relates to re-hospitalizations. “We’ll continue to look at other areas where we believe you can pay someone for an episode of care versus for a procedure, and you’ll be able to improve quality and actually lower cost,” she said.

Ms Tavenner says the United States will still face major challenges through 2014, in everything from infant mortality to longevity, but CMS will continue to work on those areas.

“I think the goals of CMS will stay as an outline. We’ll be focused on access, we’ll be focused on continuing to lower our costs—particularly costs per beneficiary. We know that the Medicare program’s going to continue to expand rapidly—there’s a large number of baby boomers—so how do we actually look at cost per beneficiary?” she said. “Then we will stay focused on quality.”