[Senate Hearing 115-233]
[From the U.S. Government Publishing Office]
S. Hrg. 115-233
NOMINATION OF SEEMA VERMA
=======================================================================
HEARING
BEFORE THE
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
ON THE
NOMINATION OF
SEEMA VERMA, TO BE ADMINISTRATOR, CENTERS FOR MEDICARE AND MEDICAID
SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES
__________
FEBRUARY 16, 2017
__________
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COMMITTEE ON FINANCE
ORRIN G. HATCH, Utah, Chairman
CHUCK GRASSLEY, Iowa RON WYDEN, Oregon
MIKE CRAPO, Idaho DEBBIE STABENOW, Michigan
PAT ROBERTS, Kansas MARIA CANTWELL, Washington
MICHAEL B. ENZI, Wyoming BILL NELSON, Florida
JOHN CORNYN, Texas ROBERT MENENDEZ, New Jersey
JOHN THUNE, South Dakota THOMAS R. CARPER, Delaware
RICHARD BURR, North Carolina BENJAMIN L. CARDIN, Maryland
JOHNNY ISAKSON, Georgia SHERROD BROWN, Ohio
ROB PORTMAN, Ohio MICHAEL F. BENNET, Colorado
PATRICK J. TOOMEY, Pennsylvania ROBERT P. CASEY, Jr., Pennsylvania
DEAN HELLER, Nevada MARK R. WARNER, Virginia
TIM SCOTT, South Carolina CLAIRE McCASKILL, Missouri
BILL CASSIDY, Louisiana
Chris Campbell, Staff Director
Joshua Sheinkman, Democratic Staff Director
(ii)
C O N T E N T S
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OPENING STATEMENTS
Page
Hatch, Hon. Orrin G., a U.S. Senator from Utah, chairman,
Committee on Finance........................................... 1
Wyden, Hon. Ron, a U.S. Senator from Oregon...................... 4
CONGRESSIONAL WITNESSES
Donnelly, Hon. Joe, a U.S. Senator from Indiana.................. 6
Young, Hon. Todd, a U.S. Senator from Indiana.................... 7
ADMINISTRATION NOMINEE
Verma, Seema, nominated to be Administrator, Centers for Medicare
and Medicaid Services, Department of Health and Human Services,
Washington, DC................................................. 8
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Donnelly, Hon. Joe:
Testimony.................................................... 6
Enzi, Hon. Michael B.:
Prepared statement........................................... 55
Hatch, Hon. Orrin G.:
Opening statement............................................ 1
Prepared statement with attachments.......................... 55
Heller, Hon. Dean:
Letter from the Nevada Legislature to Senator Heller, January
10, 2017................................................... 62
Verma, Seema:
Testimony.................................................... 8
Prepared statement........................................... 63
Biographical information..................................... 65
Responses to questions from committee members................ 75
Wyden, Hon. Ron:
Opening statement............................................ 4
Prepared statement........................................... 131
Young, Hon. Todd:
Testimony.................................................... 7
(iii)
NOMINATION OF SEEMA VERMA, TO BE.
ADMINISTRATOR, CENTERS FOR MEDICARE
AND MEDICAID SERVICES, DEPARTMENT OF
HEALTH AND HUMAN SERVICES
----------
THURSDAY, FEBRUARY 16, 2017
U.S. Senate,
Committee on Finance,
Washington, DC.
The hearing was convened, pursuant to notice, at 10:02
a.m., in room SD-215, Dirksen Senate Office Building, Hon.
Orrin G. Hatch (chairman of the committee) presiding.
Present: Senators Grassley, Crapo, Roberts, Enzi, Cornyn,
Thune, Burr, Isakson, Portman, Toomey, Heller, Scott, Cassidy,
Wyden, Stabenow, Cantwell, Nelson, Menendez, Cardin, Brown,
Bennet, Casey, Warner, and McCaskill.
Also present: Republican Staff: Chris Campbell, Staff
Director; Kimberly Brandt, Chief Health-care Investigative
Counsel; Brett Baker, Health Policy Advisor; and Erin Dempsey,
Health-care Policy Advisor. Democratic Staff: Joshua Sheinkman,
Staff Director; Michael Evans, General Counsel; Elizabeth
Jurinka, Chief Health Advisor; David Berick, Chief
Investigator; Beth Vrabel, Senior Health Counsel; Ann Dwyer,
Health-care Counsel; Matt Kazan, Health Policy Advisor; and Ian
Nicholson, Investigator.
OPENING STATEMENT OF HON. ORRIN G. HATCH, A U.S. SENATOR FROM
UTAH, CHAIRMAN, COMMITTEE ON FINANCE
The Chairman. The committee will come to order. I would
like to welcome everyone to this morning's hearing. Today we
are going to consider the nomination of Seema Verma to serve as
Administrator of the Centers for Medicare and Medicaid
Services.
Welcome, Ms. Verma. We are so happy to have you here and
your family as well. I appreciate your willingness to lead this
key agency at this critical time. And I see that your family
has joined you here today to lend support, so I extend a warm
welcome to them as well.
CMS is the world's largest health insurer, covering over
one-third of the U.S. population through Medicare and Medicaid
alone. It has a budget of over $1 trillion, and it processes
over 1.2 billion claims a year for services provided to some of
our Nation's most vulnerable citizens.
Ms. Verma, having dealt with CMS extensively in your
capacity as a consultant to numerous State Medicaid programs,
you know full well the challenges the agency deals with on a
daily basis. And I suspect you also know that the job you have
been nominated for is a thankless one, fraught with numerous
challenges.
The good news is that there are opportunities in those
challenges, and I believe you are the right person for the job
and that you will make the most of those opportunities to
improve our health-care system.
The failings of Obamacare are urgent and must be addressed
in short order. Over the past 6 years, we have watched as the
system created under Obamacare has led to increased costs,
higher taxes, fewer choices, reduced competition, and more
strains on our economy. Under Obamacare, health insurance
premiums are up by an average of 25 percent this year alone.
Under Obamacare, Americans, including millions of middle-
class Americans, have been hit with a trillion dollars in new
taxes. And under Obamacare, major insurers are no longer
offering coverage on exchanges. And earlier this week, we
learned that another major carrier will exit the market in
2018.
As Congress works to change course with regard to our
ailing health-care system, CMS will play a major role in
determining our success. I applaud the step the agency took
yesterday under the leadership of HHS Secretary Price with its
proposed rule to help stabilize the individual insurance
markets. But there is much more work to be done, and I am
confident that if you are confirmed, and I expect you to be,
you will be a valuable voice in driving change.
Now, I would like to talk specifically about Medicaid for a
moment. The Medicaid program was destined to be a safety net
for the most vulnerable Americans. As such, I understand and
value the moral and social responsibilities the Federal
Government has in ensuring health-care coverage for our most
needy citizens.
I am committed to working with the States and other
stakeholders, as I think everyone on this committee is, and, of
course, the American public, to improve the quality and ensure
the longevity of the Medicaid program. But we must also
acknowledge that the Medicaid program is three times larger,
both in terms of enrollment and expenditures, than it was just
20 years ago.
Additionally, the Medicaid expansion under Obamacare
exacerbated pressures on the program at a time when many States
were already facing difficult choices about which benefits and
populations to serve. And as a result, we have a responsibility
to consider alternative funding arrangements that could help to
preserve this important program. We also need to consider
various reform proposals that can improve the way Medicaid
operates.
Ms. Verma, we will need your assistance in both of these
efforts. And your experience in this particular area should
serve you well.
On the subject of Ms. Verma's experience, I want to note
for the committee that she has been credited as the creative
force behind the Healthy Indiana Plan, the State's Medicaid
alternative. This program provides access and quality health
care to its enrollees while ensuring that they are engaged in
their care decisions.
The program continues to evolve while hitting key metrics,
and, overall, enrollees are very satisfied with their
experience, as I understand it. And while we may hear
criticisms of this program from the other side of the dais here
today, we should note that HHS and CMS leaders under the Obama
administration repeatedly approved the waiver necessary to make
this program a reality.
Ms. Verma has assisted a number of other State Medicaid
programs as well. Her efforts all have the same focus: getting
needed, high-quality health care to patients and to engage
patients in a fiscally responsible way. This is exactly the
mind-set we need in a CMS Administrator.
Now, Ms. Verma, as if the challenges associated with
Medicaid are not enough to keep you busy as CMS Administrator,
you will also be tasked with helping to ensure the longevity
and solvency of the Medicare trust fund, which is projected to
go bankrupt in 2028. That has already come down from 2032, I
believe.
All told, between now and 2030, 76 million baby boomers
will become eligible for Medicare. Even factoring in deaths
over that period, the program will grow from approximately 47
million beneficiaries today to roughly 80 million in 2030.
Maintaining the solvency of the Medicare program while
continuing to provide care to an ever-expanding beneficiary
base is going to require creative solutions. It will not be
easy, but we cannot put it off forever. And the longer we wait,
the worse it will get.
Now that I have had a chance to discuss the challenges
facing CMS and some of Ms. Verma's qualifications, I would like
to speak more generally about recent events.
We have gone through a pretty rough patch recently on this
committee, particularly as we have dealt with President Trump's
nominations. I do not want to rehash the details of the past
few weeks, but I will say that I hope that recent developments
do not become the new normal for our committee.
As I said before, I am going to do all I can to restore and
maintain the customs and traditions of this committee, which
has always operated with assumptions of bipartisanship, comity,
and good faith.
With regard to considering nominations, that means a robust
and fair vetting process, a rigorous discussion among committee
members, and, of course, a vote in an executive session. On
that note, maybe the icy treatment of nominees is starting to
thaw today; at least I hope it is.
One tradition that has been absent before this session has
been the introduction on many occasions of nominees by Senators
of both parties from the nominees' home State, especially in
cases when the nominee and the home State Senator have a
relationship.
I am pleased to say that the senior Senator from Indiana is
reaffirming that tradition by appearing here today, and so is
our other Senator from Indiana. I thank these Senators for
taking time to appear today and to introduce their constituent.
I will give them a chance to do so in just a few minutes.
With that, I look forward to Ms. Verma sharing her vision
and views here today. I also look forward to what I hope will
be a full and fair committee process that allows us to process
this nomination and report it to the full Senate in short
order.
[The prepared statement of Chairman Hatch appears in the
appendix.]
The Chairman. I will now at this time recognize my co-chair
on this committee, Senator Wyden, for his opening statement.
OPENING STATEMENT OF HON. RON WYDEN,
A U.S. SENATOR FROM OREGON
Senator Wyden. Thank you very much, Mr. Chairman.
And welcome to you, Ms. Verma, and to our colleagues from
Indiana.
I just thought it was worth noting that with the Hoosier
basketball tradition, Ms. Verma, it looks like you have brought
close to two squads of basketball players. [Laughter.]
And we welcome you and your family today.
It is obvious that the health-care post that we are going
to discuss today is not exactly dinner table conversation in
much of America. But the fact is, it is one of the most
consequential positions in government.
The agency is responsible for the health care of over 100
million Americans who count on Medicare and Medicaid. It plays
a key role in implementing the Affordable Care Act. And that is
why CMS needs experienced and qualified people for the job,
people who know the ins and outs of the whole system: Medicare,
Medicaid, and private insurance.
The agency needs a strong and experienced authority. And
this is particularly true now when it does appear that some of
my colleagues on Capitol Hill, many in the administration, are
looking to make radical changes to American health care. In my
view, many of these proposals would take the country back to
the days when health care was mostly for the healthy and the
wealthy.
So we are going to start with the promise of Medicare,
which has always been a promise of guaranteed benefits. That
makes up more than half of the agency's spending, about $2-
billion-plus a day. With more seniors entering the program each
year, there is an awful lot to do to protect and, in my view,
update the Medicare guarantee for this century. That means
addressing the high cost of prescription drugs. It means making
the program work better for those with chronic illnesses, like
heart disease and cancer, which is the majority of the Medicare
spending today. It is going to take bipartisan support.
Privatizing Medicare is the wrong direction in my view. It
is important to hear today, Ms. Verma, how your views differ
from some of the policymakers who are advocating those kinds of
approaches, who would literally be interested in turning the
program into a voucher system.
Additionally, if confirmed, you are going to play a key
role in implementing the Medicare physician payment reforms. It
is essential that they be implemented as intended by the
Congress, because we want to start moving health care from
paying for volume to paying for value.
Also, the agency implements rules of the road in the
private insurance market. And today, many of those rules amount
to bedrock values for health insurance in the country. It means
not discriminating against those with a preexisting condition
no matter what. It means setting the bar for what type of
medical care insurance companies have to cover. And it means
letting young people stay on their parent's policy until 26.
Unfortunately, just yesterday the agency released a
proposed rule that, in my view, goes in the opposite direction.
From where I sit, the message from yesterday's rule is,
insurance companies are back in charge and patients are going
to take a back seat.
The open enrollment period, for example, was cut in half
from 3 months to 6 weeks. If somebody dropped coverage during
the year for any reason, insurance companies could collect back
premiums before an individual can get health insurance again.
And insurance companies would have free reign to offer less
generous coverage at the same or higher cost.
This, again, sounds to me like it is going back to yester-
year when the health-care system really did work for the
healthy and wealthy.
Now the administration has been saying, of course, that the
best is yet to come. The evidence, it seems to me, suggests
otherwise. The President could have taken steps to create more
stability on a bipartisan basis, but instead issued an
executive order on the day he was sworn in that is obviously
now creating market uncertainty and anxiety. And you do not
have to look much further than Humana's decision here in the
last day or so.
So we want to hear from you, Ms. Verma, this morning about
how you are going to implement this program that millions of
Americans count on and how you are going to do it even though
we have Republicans here who want to unravel the law.
In short, I want to see us get beyond what has come to be
known as ``repeal and run.'' And repeal and run goes beyond
disrupting the individual market. It would also end the
Medicaid expansion that brought millions of low-income,
vulnerable Americans into the health-care system. And this is
an area, obviously, where you have extensive experience.
I want to discuss some of the tradeoffs associated with
those efforts. And I am particularly concerned about the
possibility, as I have been informed, that somebody making
barely $12,000 a year would get locked out of health coverage
for no less than 6 months because they could not pay for health
care due to an upcoming rent check, for example, or an
emergency car repair.
There has been an independent evaluation indicating that
2,500 people were bumped from coverage due to situations like
this.
I have also seen in that same report that more than 20,000
persons were pushed into a more expensive, less comprehensive
Medicaid plan because they could not navigate this system that
you all put in place.
Now, I want to wrap up with just two last points, Mr.
Chairman.
One, with respect to taking these ideas on a nationwide
tour, I am not there yet. And I say that respectfully. We will
hear more about the program.
And here is the point with respect to the States--and we
touched on it in the office. We authored section 1332 of the
Affordable Care Act, saying that States can do better. If
States have an idea--better coverage, lower costs--God bless
them, we are all for it, but we cannot use 1332 or any other
provision for the States to do worse.
One last issue that I want to touch on deals with Ms.
Verma's work.
As I understand it, you had a consulting firm. You all were
awarded more than $8.3 million in contracts directly by the
State of Indiana to advise the State. And that was while you
all were managing the programs. In effect, you were the
architect.
At the same time, as has been told to me, you contracted
with at least five other companies that provided hundreds of
millions of dollars of services and products to these programs:
HP Enterprises, Milliman, Maximus, Health Management
Associates, Roche Diagnostics.
And with at least two of these firms, HP and HMA, the terms
of the State contracts appear to have had you, in effect,
overseeing work that the firms performed.
Now, George W. Bush had an ethics lawyer, a fellow named
Richard Painter. He was not exactly a liberal guy, and he said
yesterday that this arrangement, and I will quote him,
``clearly should not happen and is definitely improper.'' He,
in effect, said that you were on both sides of the deal helping
to manage State health programs while being paid by vendors to
the same programs.
He said that was a conflict of interest. I want to hear you
respond to his assertions.
So we are going to want to know more about your work for
companies that did business with the State. And one of the
questions will be, if you are the CMS Administrator, if you are
confirmed, would you recuse yourself from decisions that affect
the companies that were your clients?
We will look forward to your testimony with the two Indiana
Senators. You are running with the right crowd.
And thank you, Mr. Chairman.
The Chairman. Well, thank you, Senator.
[The prepared statement of Senator Wyden appears in the
appendix.]
The Chairman. I am pleased to hand over my normal witness
introduction duties today to a pair of our distinguished
colleagues. That both Senators from the Hoosier State will
introduce Ms. Verma is a statement and a testament to her work
and to her as a person.
I ask that the senior Senator from Indiana, Mr. Donnelly,
start the introduction, and then turn it over to Senator Young.
Senator Donnelly, you go ahead and proceed.
STATEMENT OF HON. JOE DONNELLY,
A U.S. SENATOR FROM INDIANA
Senator Donnelly. Thank you, Mr. Chairman.
Chairman Hatch, Ranking Member Wyden, members of the
committee, thank you for inviting me here today. It is a
pleasure to be here with my friend and colleague Senator Todd
Young to recognize this important accomplishment of a fellow
Hoosier.
As you know, any time the President nominates an individual
for a leadership position in our government, it is an honor and
a reflection of the tremendous trust and respect he has in that
person.
For this reason, I am pleased to be here today to help
recognize Ms. Seema Verma for her nomination to be the next
Administrator for the Centers for Medicare and Medicaid
Services, CMS, and introduce her to this committee for your
consideration.
I have always held a personal belief that we accomplish
more when we work together. In Indiana, we call that Hoosier
common sense. And working collaboratively to help Hoosiers get
access to quality health care is something Ms. Verma and I have
had the opportunity to do together.
As many of you are already aware, Ms. Verma has played a
central role in crafting Medicaid policy in many States,
including our own.
In Indiana, she worked with Governor Daniels and then
Governor Pence, as well as other State and Federal partners, to
take advantage of opportunities made possible by the Affordable
Care Act to expand Medicaid through the Healthy Indiana Plan,
also known as HIP.
Today, HIP 2.0 has helped to lower our State's uninsured
rate, improve health-care outcomes, and has played a critical
role in combating the opioid abuse and heroin use epidemics.
Hundreds of thousands of Hoosiers currently have health
insurance through HIP 2.0. And the program is an example of
what is possible when we work together.
As I have shared with Ms. Verma and I will share with you,
I am deeply concerned about the future of health care in our
country as well as the rhetoric surrounding the current debate.
I firmly believe that maintaining access to critical programs
like Medicaid and Medicare and building upon the progress of
the ACA is fundamental to both the physical and financial well-
being of thousands of Americans across our country.
It is my sincere hope that this administration, working
with this committee and others, will approach Medicare and
Medicaid with the thoughtful and pragmatic consideration these
critical programs deserve.
I have watched Ms. Verma take this common-sense Hoosier
approach, and I hope she uses this opportunity today to share
with you her vision for how she can work together with all of
the members of this committee and Congress as a whole to expand
access to quality health care and protect and build on the
progress we have made over the last several years.
With that, Chairman Hatch, Ranking Member Wyden, members of
the committee, thank you for allowing me to introduce Ms.
Verma.
To Ms. Verma and her family, congratulations on this
tremendous honor. I look forward to Ms. Verma's testimony.
And I thank the committee for your hard work and your
consideration of Ms. Verma for this very important position.
The Chairman. Well, thank you very much.
Senator Young, you now can proceed.
STATEMENT OF HON. TODD YOUNG,
A U.S. SENATOR FROM INDIANA
Senator Young. Well, thank you, Chairman Hatch, Ranking
Member Wyden, and members of the committee. It truly is an
honor to be with you to introduce a fellow Hoosier, Seema
Verma, to be Administrator of the Centers for Medicare and
Medicaid Services.
You know, President Trump simply could not have made a
better choice in selecting Seema to lead what is arguably the
most important office within HHS, an office that covers the
health-care needs of over 100 million Americans, with a budget
of almost $1 trillion.
In her 20-year career as an innovator in the health-care
sector, she has worked extensively with a variety of
stakeholders from both sides of the aisle to deliver better
access to health care.
As president, CEO, and founder of SVC, she helped several
States to redesign their archaic Medicaid systems, including in
my home State of Indiana. Seema revolutionized the Medicaid
program as architect of the Healthy Indiana Plan, which we know
as HIP. It is the Nation's first consumer-directed Medicaid
program. She transformed a complex, rigid Medicaid system into
one where Hoosiers are back in control of their health-care
needs.
Since 2007, HIP has achieved impressive results. Hoosiers
are more likely to seek preventative care, take their
prescription medications, and seek primary care services at
their physician's office, not the emergency room.
Seema's innovative idea is working and is now an important
proof of the concept that Medicaid can be more efficient than a
one-size-fits-all approach. And she accomplished this with the
support and buy-in from people, again, on both sides of the
aisle and at all levels of the process.
By putting the mission above politics, she demonstrated a
willingness to work with anyone--anyone--who was willing to do
the same. She worked with Democrats in the Indiana Statehouse.
She worked with the Obama administration to find common ground
on how to best provide quality health care to hundreds of
thousands of low-income Hoosiers. And it worked.
As CMS Administrator, Seema will have the ability to use
her extensive experience to help other States achieve what we
have in Indiana: better health outcomes for our most
vulnerable. I look forward to working with her.
I thank you, sir.
The Chairman. Well, thanks to both of you, Senators. It is
a real honor for the committee to have both of you come. And I
know Ms. Verma really appreciates it.
Senator Young. Thank you.
The Chairman. We know you are busy, so we will let you go.
Ms. Verma, we are now going to turn to you for your
comments and your feelings on this nomination, and then we will
turn to questions from the Senators up here.
STATEMENT OF SEEMA VERMA, NOMINATED TO BE ADMINISTRATOR,
CENTERS FOR MEDICARE AND MEDICAID SERVICES, DEPARTMENT OF
HEALTH AND HUMAN SERVICES, WASHINGTON, DC
Ms. Verma. Good morning, Chairman Hatch and Ranking Member
Wyden. I appreciate and am grateful for your consideration of
my nomination by President Trump to be the Administrator for
the Centers for Medicare and Medicaid Services. And I thank you
for the time that many of you have spent with me in advance of
the hearing. And I appreciate hearing about your priorities.
Before I begin my statement, I would like to take a moment
to introduce my family. With me today are my parents, Mr. and
Mrs. Verma; my husband Sanjay; my two kids, Maya and Shaan; and
the rest of my family and friends who are here with me. I
really appreciate it; thank you.
I have often been asked by my family and my friends, as
well as many members of this committee, why I would be
interested in this job. I was honored and humbled and accepted
President Trump's call to service because I understand what is
at stake.
I have never stood on the sidelines of our Nation's health-
care debate, merely pointing out what is wrong with our health-
care system. More than 20 years ago when I graduated from
college, I started my career working on national policy on
behalf of people with HIV and AIDS, as well as for low-income
mothers to improve birth outcomes.
I fought for coverage, greater health-care access, and for
improving the quality of care, and I have continued to fight
for these issues for the past 20 years.
But I am deeply concerned about the state of our health-
care system, as there is frustration all around. Many Americans
are not getting the care that they need, and we have a long way
to go in improving the health status of Americans.
Doctors are increasingly frustrated by the number of costly
and time-consuming burdens. Health care continues to grow more
and more expensive, and the American people are tired of
partisan politics. They just want their health-care system to
be fixed. And I know this, not simply because I have worked in
health care, but because of how intimately it has affected my
own personal life.
My mother is a breast cancer survivor, due to early
diagnosis and treatment. And a few years back, my neighbor
Aidan was diagnosed with a stage IV neuroblastoma. He was only
4 years old. A large tumor had been growing for some time,
maybe since he was born, and it was wrapped all around his
kidney. Aiden went through excruciating, painful chemotherapy,
radiation, stem cell treatment, and surgeries, all
experimental.
This May, Aidan will celebrate his 12th birthday. And both
my mom and Aidan are testaments to the grace of God and the
ingenuity of the American health-care system. This is why
people travel from all across the world to get care in the
United States.
I want to be part of the solution, making sure that the
health-care system works for all Americans so that families
like my own and Aidan's have the care that they need. I want to
be able to look my children in the eye and tell them that I did
my part to serve my country and to be a voice for people who
often do not have one.
This is a formidable challenge, but I am no stranger to
achieving success under difficult circumstances.
My father left his entire family to immigrate to the United
States during the 1960s and pursued four degrees while working
to earn money. On my mother's side, my grandmother was married
at the age of 17 with no more than a fifth-grade education, but
my mother went on to be the first woman in her family to finish
a master's degree.
My parents made a lot of sacrifices along the way to
provide me with the opportunities that they did not have and
have taught me the value of hard work and determination.
I am extremely humbled as a first-generation American to be
sitting before this committee after being nominated by the
President of the United States. It is a testament to the fact
that the American dream is very much alive for those willing to
work for it. And it is my dream and my passion to work on the
front lines of health care to improve our system.
Throughout my career, I have brought people together from
all sides of the political spectrum to forge solutions that
worked for everyone. One of my proudest moments in my career
was watching the Indiana legislature pass the Healthy Indiana
Plan, which is a program for the uninsured, with a bipartisan
vote.
CMS is a $1-trillion agency and covers over 100 million
people, many of whom are amongst our Nation's most vulnerable
citizens. Providing high-quality, accessible health care for
these Americans is not just a luxury, it is a necessity and
often a matter of life and death.
Should I be confirmed, I will work with the CMS team to
ensure that the programs are focused on achieving positive
health outcomes and improving the health of the people whom we
serve. To achieve this goal, I will work towards policies that
foster patient-centered approaches that increase competition,
quality, and access, while driving down costs.
Patients and their doctors should be making decisions about
their health care, not the Federal Government. We must find
creative ways to empower people to take ownership for their
health. We should support doctors in providing high-quality
care to their patients and ensuring that CMS's rules and
regulations do not drive doctors and providers from serving the
people, our beneficiaries.
If confirmed, I will work towards modernizing CMS's
programs to address the changing needs of the people they
serve, leveraging innovation and technology to drive better
care. I will ensure that efforts around preventing fraud and
abuse are a priority, because we cannot afford to waste a
single taxpayer dollar. I will work towards ushering in a new
era of State flexibility and leadership to drive better
outcomes.
If I have the honor of being confirmed, I will carry this
vision along with my strong belief in open communication,
collaboration, and bipartisanship. I will work with you, be
responsive to your inquiries and concerns, and value your
counsel.
I thank you for the consideration of my nomination.
The Chairman. Well, thank you so much. We really appreciate
your willingness to serve. And I look forward to getting you
through this process.
[The prepared statement of Ms. Verma appears in the
appendix.]
The Chairman. I have some obligatory questions to ask you.
First, is there anything that you are aware of in your
background that might present a conflict of interest with the
duties of the office to which you have been nominated?
Ms. Verma. Sir, I have met, consulted with the Office of
Ethics, and have indicated any areas where I thought there
would be an issue. And I will be recusing myself of any matters
that would present any potential conflict.
The Chairman. Well, thank you.
Do you know of any reason, personal or otherwise, that
would in any way prevent you from fully and honorably
discharging the responsibilities of the office to which you
have been nominated?
Ms. Verma. I do not.
The Chairman. Do you agree, without reservation, to respond
to any reasonable summons to appear and testify before any duly
constituted committee of the Congress, if you are confirmed?
Ms. Verma. I do not.
The Chairman. You are willing to do that?
Ms. Verma. I am willing to do that.
The Chairman. All right.
Finally, do you commit to provide a prompt response in
writing to any questions addressed to you by any Senator on
this committee?
Ms. Verma. I do.
The Chairman. Well, thank you.
Let me now just get into some questions. I know you are
aware of the historic bipartisan Medicare Access and CHIP
Reauthorization Act of 2015, which I had a lot to do with, or
what is called MACRA. Among other things, the law got rid of
the dreaded SGR formula and made improvements to how Medicare
pays physicians.
And I am pleased that our work on the implementation of
these changes continues to be bipartisan, both in how
Republicans and Democrats in the Congress have worked together
and how Congress had worked with the Obama administration. In
fact, the Obama administration took great pains to engage
physicians and other stakeholders through the initial
implementation phase.
Now, it strikes me that this process of consultation early
and often should be the rule and not the exception.
What is your view on how to engage stakeholders to arrive
at the best policy decisions for Medicare and other CMS
programs?
Ms. Verma. Thank you, Senator. And I applaud Congress's
efforts to pass MACRA. I think it is an important step forward,
not only to providing more stability for providers, but also
moving us towards better outcomes.
You know, in terms of stakeholders, I think that the most
important thing that we can do is engage with stakeholders as
quickly as possible on the front end and all the way through
the process, understanding stakeholder perspective and what
folks are going through on the front end, what their challenges
are. And, as we are developing policies and programs, to have
that open communication I think is helpful towards any
successful implementation. It is not a one-time thing. It is
not just on the front end. It is all the way through the
process.
And even after the program is established, it is always
important to have that dialogue with stakeholders, because they
can tell you what is working and what is not working. And when
you think of new ideas and you are thinking about implementing
them, they can help you figure out whether it is going to work
or not.
I know I have had that experience in my career, and I have
always found it very helpful and an integral part of success.
The Chairman. As the baby boomer generation ages, the
number of persons age 65 and older in the United States is
expected to dramatically increase, fueling an increase in the
demand for long-term services and supports.
Notably, Medicaid is the primary payer of these services.
What changes, if any, should be made to meet the expected
increase in demand while ensuring the fiscal sustainability of
the Medicaid program?
Ms. Verma. I think Medicaid is a very important program. It
has been the safety net for so many vulnerable citizens.
When I think about the Medicaid program, I think about some
of the individuals whom I have met. One person in particular I
think about is a quadriplegic. He is on a breathing machine,
and he requires 24-hour care. I think about the mother of a
disabled child. And this is the face of the Medicaid program.
As we think about the Medicaid program and where we are
today, I think that we can do better. We have the challenge of
making sure that we are providing better care for these
individuals, but the program is not working as well as it can.
This is a very intractable program, it is inflexible; States
are in a situation where they are having to go back and forth
doing reams of paperwork, trying to get approvals from the
Federal Government. And at the end of the day, are we achieving
the outcomes that we want to achieve?
So as I think about the Medicaid program, I think there is
an opportunity to make that program work better so that we are
focusing on improving outcomes for the individuals who are
served by the program.
The Chairman. All right. In 2014, I worked closely with
Senator Wyden and leaders from the House Ways and Means
Committee to enact a bipartisan, bicameral law called the
Improving Medicare Post-Acute Care Transformation, or IMPACT,
Act.
The IMPACT Act serves as a critical building block to
achieve future Medicare post-acute quality measurement and
payment reform.
Specifically, the IMPACT Act requires the collection of
standardized data to help Medicare not only compare quality
across the different post-acute care settings, but also improve
hospital and post-acute discharge planning. And our goal was to
produce data-driven evidence that Congress can use to debate
the best ways to align Medicare post-acute payments that
improve patient outcomes and save taxpayer dollars. And our
intention was to ensure that we are able to do this type of
thing.
We want to ensure that beneficiaries are receiving the
highest-quality post-acute care services in the right setting
at the right time.
Now, will you commit to working with me and members of
Congress and this committee and the post-acute provider
community on the implementation of the IMPACT Act?
Ms. Verma. It would be my pleasure to work with the
committee, stakeholders, and anyone else who is interested in
making that program a success.
The Chairman. Well, thank you.
We will turn to Senator Wyden.
Senator Wyden. Thank you very much, Ms. Verma. And thank
you for your testimony.
I want to start with a comment you made that you were
committed to coverage, which, of course, is what this is all
about.
Unfortunately, what I have seen since the beginning of the
year has been basically about rolling back coverage. And in
fact, Congressman Price sat in your seat a couple of weeks ago
and refused to commit to making sure that no one would be worse
off in terms of coverage.
Now, the President said in his campaign, and I will quote,
``We are going to have insurance for everybody. The American
people are going to have great health care, much less expensive
and much better.'' That is what the President said.
Yesterday, CMS did the exact opposite. The first rule to
come out of the agency--the agency that you would head--after
Secretary Price was confirmed meant less coverage, higher
premiums, and more out-of-pocket costs for working families.
How would you square what President Trump said in the
campaign with what CMS did yesterday?
Ms. Verma. Sir, in terms of the rule that you speak of, I
have not been involved in the development of that rule. Out of
respect for the committee and for the nomination process, I
have not been involved in that, have not been to CMS, so I have
not been involved in that and I cannot speak to that.
What I can tell you is that I am committed to coverage. I
have been fighting on this issue for 20 years. And I will
continue to do that if I am confirmed.
Senator Wyden. But I just read you quotes, and it is not
like, you know, atomic secrets or classified materials. What
the President said is very different than what CMS did
yesterday.
And you read newspapers; you are a very informed person. It
talked about cutting the enrollment period. I am looking at the
headline, ``cut the enrollment period in half,'' which really
is going to limit our ability to get the very people we need
most, the younger, healthier people.
So one more try. How would you square what the President
said with what happened yesterday?
Ms. Verma. I think the President and I are both committed
to coverage. I cannot speak to the rule. I have not had an
opportunity to review that. But again, I think the President
and I both agree that we need to fight for coverage and make
sure that all Americans have access to affordable, high-quality
health care.
Senator Wyden. What troubles me about yesterday is, once
again insurance companies are coming first and patients come
later. Tell me one thing you would change to put patients
first.
Ms. Verma. One thing that I would do is--I think what is
very important is that patients be in charge of their health
care, that patients get to drive the decisions about their
health care, that they get to make the choices about what kind
of health care plan works well for them.
I think it is important that our patients have access to
quality coverage, to their choice of doctors and their choice
of plan.
Senator Wyden. Could you give us a specific on that?
Because that is an admirable philosophy, but I still do not
know----
Yesterday was good for insurance companies, and it was bad
for patients. I would like to have a specific example, and we
will keep the record open, of something you would do to put
patients first.
And I respect the fact that you have articulated a
philosophy, but I really want to know a specific about what you
would do to put patients first.
Let us move on with respect to another area of
responsibility you will have, and that is prescription drugs
and Medicare, because we all know that these prescription costs
are just clobbering families and seniors, the Federal
Government, and a whole variety of stakeholders that you
referred to.
As the Administrator of the agency, you are going to have
an opportunity to address this problem. The President has been
vocal on it. Again, give me a specific change to Medicare Part
D that you would suggest to bring costs down.
Ms. Verma. Well, I think that the issue of drug pricing is
something that all Americans are concerned about. And the
President is concerned about that as well. People want to make
sure that when they need the drugs, when they're going through
an illness--I mean, I think about my mom, I think about my
neighbor Aidan, and when they need the drugs that they need,
they want to know that they have access to them and that they
are affordable. So I think we are all concerned about that
specific issue.
Part D, I think, has been a good program. It has expanded
access to medications for people who did not have them before.
And I think the structure of the program in terms of how it
puts senior citizens in charge of their health care, they can
go on Plan Finder, go online----
Senator Wyden. My time is up, Ms. Verma. I voted for Part
D. I still have the welts on my back to show for it. I asked
you for a specific change going forward that you would do to
help seniors and others hold down their costs.
As you know, there is discussion of making changes so that
Medicare could bargain. Is there one specific you could give
me?
And the reason that the Medicare question is so important
is, not only does this affect older people so dramatically, but
your experience is on the Medicaid side, and I respect that.
People have different experiences. So I very much would like to
hear a specific on this key Medicare issue that you would
actually be for.
Ms. Verma. I would be for policies that continue to put
senior citizens in charge of their health care, that put them
in the driver's seat of making the decisions that work best for
them so that they can figure out what plan covers the
medications that they need, what plan is affordable to them and
allows them to make the decisions about their health care and
that gives them access to the medications that they need, that
doesn't limit that in any way and that is affordable to them.
Senator Wyden. My time has expired.
I still did not get a specific example. I happen to be for
a host of things on transparency, on negotiation, on trying to
make sure that we squeeze more cost savings out of the middle
men.
I am going to hold the record open, but I have asked you
for specifics in two areas: putting patients first and how you
would hold down the costs of Part D. Respectfully, I did not
get a specific. We will hold the record open for it.
I think, Senator Grassley, you are going to call out names
on your side?
Senator Grassley. Got next. [Laughter.]
Senator Wyden. That did not take much time.
Senator Grassley. What I am going to talk to you about is
things that have happened at CMS in the past. And hopefully,
coming from an administration that wants to drain the swamp, I
think I would expect changes to be made under your leadership
in this agency.
And I would suggest that you probably cannot do anything
about the suggestion I am going to give you to respond to the
last question of my colleague, but if you would push doing away
with pay-for-delay programs between brand drugs and generics, I
think it would go a long ways to helping get drugs cheaper.
CMS has told me that it does not have much authority to do
anything about some frauds committed against its programs, even
if those actions are in CMS's own words, quote, unquote, ``a
clear violation of the laws.''
And common sense tells me that if it is a clear violation
of the law, CMS can do something about it. And if that is their
attitude there, I would ask you to see whether the past
interpretation is right by checking that interpretation.
But in a January 28th letter to me about the Medicaid drug
rebate program, CMS said it could tell a manufacturer when its
drugs are misclassified and then, quote, unquote, ``attempt to
reach an agreement.'' In other words, after the money has been
stolen from the taxpayers, it takes some trouble to get it
back, if you can reach an agreement.
But there are a lot of tools that the government has to
fight fraud. And the most effective one we have is the False
Claims Act. Since 1987 when I got that law in place, the
Department of Justice has used the False Claims Act to recover
more than $33.9 billion lost from just health-care fraud alone.
But cooperation between the Department of Justice and the
health-care program administrators is very important in these
cases.
It seems like CMS could at least have picked up the phone
and given the Department of Justice a heads-up when these
manufacturers refused to cooperate and properly classify their
drugs.
So a pretty simple question; it might even be called a
softball question, but it is pretty important to me. Would you
commit to proactively cooperating with the Department of
Justice in fraud cases and to fully supporting the use of the
False Claims Act to combat fraud on government health-care
programs?
Ms. Verma. I will absolutely do that. And I applaud your
efforts on the False Claims Act. I think it has been an
integral component of preventing fraud and recovering dollars
when there is fraud. So I thank you for your service and your
work on that.
Senator Grassley. Next question: in the fall of 2016 and in
January of 2017, I sent several oversight letters to CMS
regarding the steps that it took to hold Mylan accountable for
misclassifying the EpiPen as a generic under the Medicaid drug
rebate program. CMS has publicly stated that it, quote,
``expressly advised Mylan that their classification of the
EpiPen for purposes of the Medicaid drug rebate program was
incorrect.''
However, CMS has failed to fully respond to my oversight
requests and refuses to provide records of communication with
Mylan. CMS has also not been entirely clear as to what has to
be done to correct drug misclassifications. Because of EpiPen's
misclassification, the government and States are owed hundreds
of millions of dollars from Mylan. Congress and the American
people are owed answers.
So if confirmed, would you commit to fully responding to my
oversight request and providing the requested records of
communication between Mylan and CMS? I hope that is a short
``yes.''
Ms. Verma. That is a short ``yes.''
Senator Grassley. All right. In light of EpiPen's
misclassification and potentially other drugs that have been
misclassified under Medicaid, what steps will you take to
ensure that drugs are properly classified under Medicaid?
Ms. Verma. I think what happened with Mylan and the EpiPen
issue is very disturbing. The idea that perhaps Medicaid
programs, which are struggling to pay for those programs, that
they could have potentially received rebates, is disturbing to
me.
And so, if I am confirmed, I would like to review the
processes in place there in terms of the classifications, in
terms of brand and generic, to assure that that type of thing
does not happen again.
Senator Grassley. And what you just said you want to do, I
want to do, and that is why I want those communications from
CMS. I hope you can get them for me.
Ms. Verma. Well, I will be happy to work with you on that,
Senator.
Senator Grassley. Senator Stabenow?
Senator Stabenow. Well, thank you very much.
And welcome. Welcome to you and your family.
First thing--there are many, many questions I have--but
first, regarding Medicare, do you believe that Medicare
programs should negotiate the best price for seniors on
Medicare?
Ms. Verma. I think that we need to do everything that we
can do to make drugs more affordable for seniors. And I am
thankful that we have the PBMs in the Part D program that are
performing that negotiation on behalf of seniors.
Senator Stabenow. Do you believe we could get a better
price if Medicare was negotiating as the V.A. does, as other
private entities do to get the best price for seniors?
Ms. Verma. I think that competition is the key to getting
good prices.
Senator Stabenow. So is that ``yes'' or ``no'' on
negotiation?
Ms. Verma. I do not think that is a simple ``yes'' or
``no'' answer, because I think there are many ways to achieve
that goal. And the goal is to make sure that we are getting
affordable prices for our seniors.
I mean, if we look at the Part D program and the way the
PBMs have negotiated this, we know that when there is a lot of
competition, the price goes down. So I think we have to figure
out ways--and I am happy to work with you on that--that we can
increase our competitiveness and support the Part D program.
What I like about the Part D program is that it puts
seniors in charge of making the decisions about the drugs that
they need. Using the Plan Finder tool, they can go in there,
they can put in the medications that they need, and then they--
--
Senator Stabenow. No, I understand that. I am going to stop
you, just because I do not have a lot of time.
Ms. Verma. Sure.
Senator Stabenow. Under the repeal of the Affordable Care
Act, actually seniors would begin to pay more, because the gap
in coverage for those who use a lot of medicine would appear
again. So we have closed that, no gap for seniors, and that
would reopen.
Do you support that as part of the repeal?
Ms. Verma. I think that, as I said before, it is important
to help seniors get the most affordable drug prices that they
can get.
Senator Stabenow. Do you support returning to a gap in
coverage for seniors under Medicare Part D?
Ms. Verma. I support seniors having access to affordable
medications and the medications that they need, that they
choose.
Senator Stabenow. All right. Let me ask this now to follow
up a little bit more on yesterday's decision regarding CMS.
One of the things that they decided to do yesterday was to
cut in half the open enrollment period for people to be able to
get insurance, from 3 months to 6 weeks. Do you support that?
Ms. Verma. You know, I have not had a chance to review that
rule. I was not involved in the development of that with
respect to the process.
Senator Stabenow. Does it seem like a good idea?
Ms. Verma. I am sorry?
Senator Stabenow. Does it seem like a good idea, from your
standpoint, to shorten the amount of time?
Ms. Verma. You know, I want to review the implications of
that. I was not, as I said before, with respect to this
process, I have not been to HHS, have not been to CMS, and have
not been involved in the development of that rule. So I would
look forward to reviewing that and would be happy to report
back to you after I have had a chance to review that.
Senator Stabenow. When we look at another really important
set of provisions in the Affordable Care Act--it is something I
call patient protections--everybody with insurance, it does not
matter who it is, has more ability right now to get the care
that they are paying for through their insurance. It is not
just the decision of the insurance company.
So there are a number of different things that folks can
now count on. And one is having an essential set of basic
health-care services that is defined so that insurance
companies are betting that everybody knows there is a basic set
of services, that as a woman you will get maternity care, that
mental health will be covered the same as physical health, or
substance abuse services, and so on. So there is a basic set of
services.
Do you support having that basic set of essential services
in our health-care system?
Ms. Verma. I support Americans being in charge of their
health care. I support Americans being able to decide what
benefit package works best for them. I think it is hard to
know. What works for one person might not work for another
person. And I think it is important that people be able to make
the decisions that work best for them and their families.
As a mother of two children, you know, in a family, I know
what we are looking for. But what I am looking for might not
work for another family. And so I support Americans being in
control of their health care and making the decisions that work
best for them and their families.
Senator Stabenow. Do you believe that women should have to
pay more to get prenatal care and basic maternity care, as a
rider, as an extra coverage?
Ms. Verma. You know, I am a woman, so I certainly support
women having access to the care that they need. I have two
children of my own, and I have appreciated that the services
they want----
Senator Stabenow. Should we as women be paying more for
health care because we are women?
Ms. Verma. I think that women should be able to make the
decisions that work best for them.
Senator Stabenow. But if the decision is made by the
insurance company as to what to charge, how do we make that
decision?
Prior to the Affordable Care Act, I have said many times,
about 70 percent of the insurance companies in the private
marketplace did not cover basic maternity care and basically
looked at being a woman as a preexisting condition. Different
kinds of health services that we need were not provided, were
not viewed as essential services.
And that has changed now, where women have what are basic
services for us covered as basic services, where we do not have
to pay extra as a rider in order to get basic care.
And so I am just asking, do you think that makes sense?
Ms. Verma. You know, obviously, I do not want to see women
being discriminated against. I am a woman, and I appreciate
that.
But I also think that women have to make the decisions that
work best for them and their family. Some women might want
maternity coverage and some women might not want it, might not
choose it, might not feel like they need that.
So I think it is up to women to make the decision that
works best for them and their families.
Senator Stabenow. Thank you.
Thank you, Mr. Chairman.
The Chairman. As you can imagine, we are now having two
votes. And there is nobody here to question, so I think what I
will do is recess for about 15 minutes. Sorry to interrupt like
this, but that is the life of a U.S. Senator.
And we surely appreciate you and appreciate your patience.
And I appreciate the way you are answering these questions
straight-up, and your expertise really comes through.
So with that, I will just recess for about 15 minutes.
Hopefully I can get to the second vote and be right back.
Ms. Verma. Thank you.
The Chairman. We will revoke the recess, and we will turn
to Senator Roberts.
Senator Roberts. Well, thank you, Mr. Chairman.
And congratulations on your nomination, Ms. Verma. Thank
you for paying a courtesy call to my office. We had a very,
very good discussion. You have a very impressive record with
regard to Medicaid, more especially pushing for greater
innovation and flexibility in the program.
I must say, your opening statement was not only relevant,
right on point, but inspiring as well. Thank you for that. I
think I would speak for all members of the committee. We need
to make a copy of her statement available, Mr. Chairman, to
virtually every member, maybe test them on it to see if we, you
know, can bring things back together.
The Chairman. I agree with that, and we might do that. All
right.
Senator Roberts. As co-chair of the Senate Rural Health
Care Caucus, I am particularly concerned with how regulations
coming out of your agency work or often do not work for our
small and rural providers. We talked about that.
And I am also interested in how we harness their innovation
to develop payment and delivery models that are better-tailored
to their communities and their needs, given their low volume of
patients and high number of Medicare and Medicaid patients. I
know you are very familiar with that with your work in Indiana.
How do we work to include our small and rural providers in
quality improvement programs without disadvantaging them due to
the unique populations they serve?
Secondly, would rural-relevant quality measures or
different data thresholds be more appropriate to encourage
participation in certain value-based purchasing and/or pay-for-
performance programs?
Ms. Verma. Thank you for your questions, Senator. You know,
rural health providers have very unique and special challenges.
I mean, often they are the only providers in their communities
that are providing services, and so when people come to them,
they are dealing with a variety of different health issues. It
is not just primary care and preventative care. It could be
specialty care. And they do not always have access to those
services.
The challenge for them is that even attracting a workforce
and finding providers to come out to those regions is a
challenge and it is difficult. And because they have those
multiple challenges, it is difficult for them when there are
lots of rules and regulations coming down from the Federal
Government.
As a small-business owner and working with small physician
offices, we sort of understand that it is difficult sometimes
when they are on the front lines and they are trying to manage
such very complex situations. To also deal with rules and
regulations is difficult.
That being said, we want to assure that all Americans have
access to high-quality health care. But I think we have to be
very careful with our rural providers to make sure that we are
not putting additional burdens on them that actually, you know,
impact accessibility to care or quality of care.
So I think when it comes to rural providers, we need to
support them through the process. We need to make sure that
they have the appropriate technical assistance to get where
they need to be and understand that the demands they have on
their time might impact their ability to implement those
regulations.
Senator Roberts. I really appreciate that. I think we have
83, probably more today, critical access hospitals. And I know
you have the same situation in Indiana. Thank you for your
statement.
As a member of both the HELP and Finance Committees, as
many of my colleagues are, we often see a disconnect between
new and exciting therapies that are approved by the FDA and
reimbursement policies from CMS.
Take biosimilars, for example. Last year, only one, one
biosimilar, was approved by the FDA. And guidance documents
were still outstanding. CMS proposed and then finalized a
payment policy that could stifle innovation in this area.
How would you anticipate working with the FDA to ensure CMS
is developing the best payment policies for patients,
providers, and the taxpayer?
Ms. Verma. Well, I think collaboration and coordination are
critical within HHS. I appreciate Secretary Price and his
leadership there. Careful coordination and collaboration
between similar agencies or sister agencies are important.
I think being on the front end and discussing with them,
understanding what their intentions are, what is coming down
the pipeline, and making sure that CMS is prepared and
coordinated with any efforts that the FDA has, is important.
Senator Roberts. I must tell you that, in the rural health
care delivery system, in talking to many of my hospital
administrators and the rural providers--you are in charge of
CMS--the term used a lot in the past has been ``it is a mess.''
I know you are going to fix that.
But there is CMS's Center for Consumer Information and
Insurance Oversight; CCIIO, that is the new acronym. I was not
aware of that. I thought I knew most of them. It has
responsibility for developing and implementing policies and
rules governing and administering the Affordable Care Act's
marketplace.
What role do you see CCIIO playing under your leadership?
Ms. Verma. If I am confirmed as Administrator, my job will
be to implement the law. CCIIO is playing a role with the
current law, and so I would look to Congress and its efforts
around addressing the Affordable Care Act. And my assessment of
the role of CCIIO will depend on what Congress decides to do
with the Affordable Care Act. And so I will make that decision
based on the ultimate outcome of Congress's decisions around
the Affordable Care Act.
Senator Roberts. I must say, Mr. Chairman, that I am
impressed with your statement. I know that we have had several
Senators talk about unraveling Obamacare. We had an entire
insurance company leave the market. We have another one
describing it as a death spiral.
I think we need to see a rescue team to make sure that that
bridge is still there, but build new bridges. And I think that
would be my take on that.
Thank you so much for your testimony. And thank you for the
leadership that I know you are going to bring to CMS.
Ms. Verma. Thank you, Senator.
The Chairman. Well, thank you, Senator.
While we are waiting for other questioners, let me just ask
a question.
One of the issues this committee has focused on over the
past 3 years is the large backlog of Medicare appeals resulting
from audits performed by CMS contractors. At the same time,
improper payments pose a real threat to the financial well-
being of the Medicare and Medicaid programs.
So what are your views on how to balance the need for
robust program integrity and claims accuracy with the need to
ensure timely payment to providers without causing them too
much undue burden?
Ms. Verma. Well, I think that that is a very important
question. Fraud and abuse, if I am confirmed, would be a top
priority. That is what I would call, you know, low-hanging
fruit as we look at the Medicare program and assure its
sustainability over the long term. And given the Medicare
trustees' report about the future of Medicare and running out
of money at some point, we just cannot afford to waste a single
taxpayer dollar.
And so, if I think about fraud and abuse, and especially
fraud prevention, it is looking to have an effort to really be
on the front end, not waiting to do a pay and then chase, but
really addressing fraud on the front end.
And so, as we are developing programs, we need to make sure
that we are putting those procedures and policies in place so
that we can identify fraud and abuse on the front end.
I think the issue that you raise in terms of the backlog
and the burden that it puts on providers is something that
concerns me. And we want to make sure, with CMS's policies,
that we are not preventing providers from participating in the
program and being active in it.
And the backlog and things like that have really made it
difficult for providers when they are not getting paid for
these types of issues. And so I think it is a balance that we
have to strike with being aggressive on fraud and abuse and
focusing our penalty efforts on the bad players without
penalizing providers that are trying to do the right thing.
The Chairman. Well, thank you. States are increasingly
moving their Medicaid programs into a managed care delivery
system, with managed care now representing almost 40 percent of
Federal Medicaid spending.
Now, in the last year, CMS released an updated regulatory
framework for Medicaid managed care. What if any changes do you
believe are important to Federal and State oversight of
Medicaid managed care?
Ms. Verma. Well, I think that managed care has been an
important opportunity for States. It gives them the ability to
set a capitation rate with providers and hold the managed care
companies accountable for meeting that financial demand.
And it is also an opportunity to identify goals and
outcomes and hold these companies accountable for the care and
the outcomes that they provide.
In terms of the regulatory framework and the managed care
role, I think that we probably need to move to an era where we
are holding States accountable for outcomes, but having States
go through pages and pages of regulations--my question would
be, for that regulation, what does it do to improve health
outcomes for the individual?
I am all about wanting to make sure that we are being
appropriate with our health-care dollars and managing resources
effectively. But when we look at a regulation, is that
regulation helping States improve health outcomes?
States will spend millions of dollars implementing that
particular regulation. And I think we have to ask ourselves,
what will we achieve?
So I think there are some important developments within the
managed care regulation, but if I am confirmed, I would want to
take a look at that to make sure that we are not burdening
States with additional regulations.
The Chairman. All right. Let me ask you this. Your written
statement alludes to providers struggling to deal with
administrative burdens. And while we certainly need providers
to be accountable for the care they provide and the associated
government spending, it is crucial to minimize the regulatory
requirements that take time away from treating patients.
Now, we have heard concerns regarding the very specific
requirements that are a part of the Medicare and Medicaid
Electronic Health Record Incentive Program. We also hear that
many other requirements are unneeded or outdated.
So how do you think CMS could best go about the important
task of reducing unnecessary regulations?
Ms. Verma. Well, I think one of the places to start is by
talking to doctors and having open communication and
collaboration with physicians. If I am confirmed, that would be
a priority for me: to touch base with our providers and
understand the issues that are getting in the way of them being
able to provide high-quality care to the patients that they
serve.
I would want to identify the types of regulations and
provisions that are causing providers perhaps to consider maybe
not participating in the program. So I think I would start with
that open communication and dialogue and work with them to
understand what their concerns are.
The Chairman. Well, thank you.
I think I will turn to Senator Wyden for any questions he
has.
Senator Wyden. Thank you very much, Mr. Chairman.
And you know, again, Ms. Verma, I am just trying to get a
sense of how you would approach some of these things. That is
why I asked apropos of what CMS did--just one example, a
specific example about putting patients first. Same thing with
respect to, you know, Medicare Part D.
On this committee, as the chairman touched on, colleagues
touched on, members feel very strongly about rural practices
and rural patients, and we feel very strongly about making sure
that we get MACRA right.
And when I am home in Oregon, I get asked about two key
parts of the new payment system a lot. I get asked about
virtual groups and the definition of ``more than nominal
risk.'' And people say, hey, what is this going to mean for the
small and rural practice?
Now obviously, you know this is not dinner table
conversation either. But for the doctors in rural Oregon, small
practices, they say this is really going to tell us about
whether we are going to get to succeed in this brave new world
of payment systems.
So tell me a little bit about how you as Administrator
would look at something like this. I mean, Senator Thune, for
example, has also been concerned about the virtual groups. How
would you go about structuring and implementing these virtual
groups?
Ms. Verma. I think that, you know, I think small providers,
rural providers, in terms of MACRA, I think it is going to be a
challenge for them. I think it is a worthy goal, but we are
going to have to be supportive of them through the process of
implementing it.
In terms of providers taking risk, and especially smaller
providers, I think that that is a larger mountain to climb. I
think they are going to be reluctant to take risk. When they
are starting out, many small providers and rural providers do
not have large financial reserves that the bigger health
systems have.
And you know, in terms of putting them on the hook, when we
think about health outcomes and holding providers accountable
for outcomes, a lot of that also depends on patients. And I
think thinking about strategies about how we can engage
patients to be a part of that equation so that they have the
same investment, they have some investment to work with their
providers towards achieving outcomes----
But you know, in terms of smaller providers and rural
providers taking on risk, I think that is going to be a
formidable challenge.
Senator Wyden. And on virtual groups, what is your take on,
let us say, the most important thing to make them work?
Ms. Verma. Well, I think that we have to continue to work
with them to understand what their specific concerns are and
try to address them. But I think at the end of the day those
are going to be challenges that we are going to have to work
through with them.
You know, what I have found is, listening to folks,
understanding what their concerns are and trying to see, to the
best of our ability, if we can try to address those concerns--
--
Senator Wyden. And what about the whole question of nominal
risk? And again, I want to keep this open-ended enough so this
is not, you know, I want to hear about paragraph 3, line 2. I
just want to get a general sense of how you would approach it,
because this is what rural physicians and patients are going to
talk to me about. I am going to have town hall meetings in a
couple of days. So how about nominal risk?
Ms. Verma. Well, you know, I think that this is the
challenge here. I do not know that rural providers and small
providers want to take risk at all. And I think that, you know,
when we are designing these programs, we have to keep in mind
their specific needs.
Taking on risk is something that insurance companies have
done, some of the larger health-care systems have done. If we
look at some of the ACO models, we know that very few
providers, even large health-care systems, have been
comfortable taking on risk. So I think this is going to be a
considerable challenge for the smaller providers. Some of them
may not want to do that.
Senator Wyden. So does that mean--when I listen to that, it
sounds to me a little bit like Ms. Verma wants to keep fee-for-
service.
Ms. Verma. You know, I think fee-for-service, there are
definitely some concerns with fee-for-service. That is
rewarding volume over quality and outcomes. And so I am not
suggesting that that works better.
I think that there is something to be said--and I support
efforts to increase coordination of care and to hold providers
accountable for outcomes. I think, though, in terms of also
holding providers accountable for outcomes, it is another thing
altogether to have them accepting risk.
Senator Wyden. So let us do this like we did the other two
questions. I would like in writing--because this is so
important for rural practices, rural providers--I would like
just even one specific that you would pursue to try to address
these issues.
And the reason I am asking is because it is a big lift.
There is no question about that. There is no question that
trying to keep a rural practice open is a big lift.
But these are the questions that providers are going to ask
me. When they see me, they are going to say, ``Ron, you are on
this committee; you deal with these issues. How is the
government going to go about doing it?''
So I will have one additional question later, Mr. Chairman.
But let us add that to the matter of the specifics, both with
respect to putting patients first as opposed to insurance
companies first, as we heard yesterday, and the pharmaceutical
question where I would like a written answer.
And I think, given the fact that these matters are moving
on a fast track, we are going to need to have your answers
certainly within the next 3 days or so. All right?
I will have one additional question later, Mr. Chairman.
Thank you.
The Chairman. Why don't you ask it now since----
Senator Wyden. I think we only have a couple of more
minutes on the vote. That is part of the reason that we have so
few----
The Chairman. Is this the second?
Senator Wyden. Yes, this is the second.
The Chairman. Yes, we both have to go, don't we?
Senator Wyden. Mr. Chairman, if you are willing, we could
do the vote. I have one additional question. I assume you will
want to make a closing statement at the end. And I would like
to too. And we also have some Senators coming back.
The Chairman. Right.
Senator Wyden. So I think we will come back.
The Chairman. We still have 10 minutes on a vote here.
Senator Wyden. We will come back.
The Chairman. All right. Well, let me use a little bit of
this 10 minutes and ask another question.
There is great provider interest in participating in
various Medicare projects that change the way payment is made
to incentivize providers to change the way that they deliver
care. Now, many of these alternative payment arrangements are
being run through the Center for Medicare and Medicaid
Innovation. But others are being conducted independent of it,
such as a good portion of the Accountable Care Organizations
program.
And while all of these programs involve some type of formal
evaluation, there is understandably great interest in knowing
what works and what does not and as soon as possible.
What is your view to testing different Medicare payment
approaches and how to best assess the results?
Ms. Verma. I think--a couple of things. I mean, one, first
of all, I would say that I support efforts around innovation.
It is important that we are always trying to climb the highest
mountain and that we are never satisfied with where we are,
always trying to figure out how to do better, how to get better
quality care, better health outcomes, improved delivery
services. And so innovation is important.
But as we are looking at testing new ideas, I think that
process has to make sure of a couple of things. We need to make
sure that we are not forcing, not mandating individuals to
participate in an experiment or some type of a trial that there
is not consent around. I think that that is very important. So
that is what I would say first off.
In terms of evaluation, evaluation is an important
component. Obviously, that is why we are doing it: to
understand whether that can be transferred or whether it can be
used for a larger population or for policy of the program.
So evaluation is a critical component of that. That needs
to be set up on the front end. It needs to be before the
evaluation goes full scale. I think it should be done on a
small population or on a small frame first before it is
expanded. But that evaluation needs to be done on the front end
and all the way throughout the process.
And I think as it is expanded or before it is expanded,
those results should be shared with stakeholders and I hope
with members of Congress. And there should be discussion about
that before that becomes formal policy.
The Chairman. Well, thank you. Let me just ask one more
question while we are waiting for some of the Senators to get
back, and then I am going to have to go vote again.
Seniors have a choice whether to enroll in the traditional
government-run Medicare fee-for-service program or in an
alternative private insurance option called Medicare Advantage.
According to CMS, approximately 18.5 million people, roughly 32
percent of all Medicare beneficiaries, are estimated to have
signed up for a Medicare Advantage plan this year.
Now, generally, Medicare Advantage plans offer extra
benefits, such as dental, vision, hearing, and wellness or
require smaller copayments or deductibles than traditional
Medicare. Sometimes seniors pay a higher monthly premium to get
these extra benefits. But also, they are financed through the
plan's savings.
Traditional Medicare does not limit the patient out-of-
pocket spending for Part A and Part B services, causing some
seniors to buy supplemental Medicare coverage called Medigap
insurance.
People who do not have retiree coverage or who cannot
afford Medigap supplemental insurance find Medicare Advantage
plans offer the extra benefits traditional Medicare does not
cover and protect them from higher-than-expected out-of-pocket
spending.
I had a lot to do with Medicare Advantage, by the way, so I
will tell you that in advance.
Ms. Verma, can you commit to working with this committee
and Congress to preserve and strengthen the successful Medicare
Advantage program?
Ms. Verma. I can. And it would be my pleasure to work with
you on that.
I think that the Medicare Part C or Medicare Advantage has
been a great program for seniors. What I like about it is that
it is offering choices for seniors. They have the ability to
figure out, again just like in Part D, what plan works best for
them.
And the fact that it provides them the opportunity to have
additional benefits, vision and dental services, I think, is
very important. And the fact that it just provides more choices
for seniors is an important component of the program.
So I would be happy to work with you on that.
The Chairman. Well, thank you.
Now, I notice that Senator Crapo is going to pass and Dr.
Cassidy is here, so I am going to call on him next. And then I
have to have staff follow up on this. All right.
Thank you for being here. I do not think I am going to be
able to even get back, but we will just continue on until we
get this hearing over.
Senator Cassidy?
Senator Cassidy. We are both familiar with the data from
MIT, the National Bureau of Economic Research, that showed the
expansion in some States, that Medicaid expansion, not
necessarily de-expansion, but Medicaid expansion really did not
do much for outcomes. But the Healthy Indiana Plan seems to
have had an effect upon outcomes.
Can you just comment on the nature of the structure of
giving folks health savings accounts, requiring some input on
their part, what that did both for expenses as well as for
outcomes?
Ms. Verma. Thank you for your question. It is always a
pleasure to talk about the Healthy Indiana Plan, so I
appreciate the opportunity.
The Healthy Indiana Plan is about empowering individuals to
take ownership for their health. We believe in the potential of
every individual to make decisions about their health care.
Senator Cassidy. Now, I am going to interrupt you
occasionally. There are some who say that health savings
accounts, even pre-funded, are not appropriate for those who
are lower-income, suggesting they lack the technical ability or
the sophistication with which to handle that.
But you are suggesting that the Healthy Indiana Plan, which
I assume was, what, 100 to 138 percent of Federal poverty
level----
Ms. Verma. The Healthy Indiana Plan actually starts at the
very lowest level of the poverty spectrum, so even people at
zero percent or people who do not have income.
Senator Cassidy. And they were enrolled in your plan as
well.
Ms. Verma. They were enrolled in our plan. What we find is
that, just because individuals are poor does not mean that they
are not capable of making decisions. It does not mean that they
do not want to be able to have choices and that they should not
have those choices.
They are very capable of making decisions about their
health care. And just because somebody is poor does not mean
that they should not have choices and that they are not capable
of making decisions that work best for them and their families.
Senator Cassidy. So what I find intriguing about your plan,
again--it is my understanding that E.R. visits were down,
whereas in other States, when there was an expansion, there was
a bump up in E.R. visits. And in the Healthy Indiana Plan, E.R.
visits actually went down.
But concomitantly, I think you have data that outcomes
improved, unlike the National Bureau of Economic Research,
which found that outcomes did not improve. Do you want to
elaborate, please?
Ms. Verma. Yes. So the Healthy Indiana Plan, what we have
seen is that the individuals who were actively engaged and
making contributions to their health savings accounts had
better outcomes. They had more primary care, more preventative
care; they had lower E.R. use. They were more satisfied with
their care. And we also showed that they had better adherence
to the drug regimens that their doctors prescribed--so, all
across the board.
Senator Cassidy. A skeptic might say that, wait a second,
by splitting it between those who made contributions and those
who did not, you ended up with two different populations, that
the ability to contribute reflected something underlying. I
assume you all did a regression analysis of some sort. Did you
find that to be the case?
Ms. Verma. No. What we found is that the individuals who
were actually making contributions toward their care, they were
actually sicker individuals, so they had more complex
illnesses. And yet, when they were making contributions toward
their care, they actually had better health outcomes than
individuals who were healthier to start with.
Senator Cassidy. Really? So the folks who were sicker,
theoretically with less disposable income--they certainly
cannot work as much--nonetheless valued health care more. This
reflected in their contribution, but there was a positive
correlation between adherence----
Ms. Verma. That is correct. They had better drug adherence.
They had more primary care, more preventative care.
And these were not by small margins, I would add. You know,
when we look at primary care and their preventative care, these
were margins of about 20 percent for primary care and
preventative care. So there were significant differences for
individuals.
And I think what it shows is that we can empower
individuals to take ownership for their health, and that
people, just because they do not have income, does not mean
that they are not capable and that they do not want to have
choices.
We believe in the dignity and the potential for individuals
to make decisions. And they are happy to do that, and they have
better outcomes.
Senator Cassidy. Now, I think the key factor here--I think
in the academic literature, they speak of the ``activated
patient.'' You are using the term ``empowered,'' but that seems
to be the critical factor here.
To what degree is the patient empowered as they partner in
their health? To what degree does she participate? Both related
to each other, but that, in turn, ends up--again, causative
outcomes, lower cost.
Ms. Verma. That is exactly what we have seen. And even with
the Healthy Indiana Plan, if we compare the Healthy Indiana
Plan to other States, we have actually been able to do it. It
costs less, and we have been able to reduce the number of
uninsured in our State at higher levels than other States that
have run more traditional programs.
So we have done it at a lower cost, had better outcomes,
and reduced the number of uninsured.
Senator Cassidy. But inevitably, there is a Federal role in
this. And so is it possible that you could reduce the Federal
role to zero and have a plan such as yours still be viable in a
State with a high poverty rate?
Ms. Verma. So in Indiana, negotiating the Healthy Indiana
Plan and being able to achieve the waivers, I mean, this was
something that Governor Daniels actually asked the Federal
Government: ``Can we use the Healthy Indiana Plan for the
Medicaid expansion?'' And he even asked this before the Supreme
Court decision, which made it optional.
So he wrote that first letter in 2010, and it took the
Federal Government almost 5 years to make a decision about
whether this program could work.
So I think that, you know, that is something that we need
to look at or that I would hope that Congress would want to
work on, because that type of back-and-forth----
Senator Cassidy. So the approval process can be made more
efficient. But again, there are Federal dollars which would
seem essential as well.
Ms. Verma. Exactly.
Senator Cassidy. Thank you. I yield back.
Senator Isakson [presiding]. Thank you, Senator Cassidy.
Senator Nelson?
Senator Nelson. Good morning. I enjoyed talking to you on
the telephone.
Do you support turning the Medicare program into a voucher
system?
Ms. Verma. I support the Medicare program being there for
seniors. People are making contributions into that program.
Senator Nelson. So would that include the voucher system?
Ms. Verma. You know, I think that I do not support that. I
think what I do support is giving choices to seniors and making
sure that that program is in place.
What we have seen is, I think, efforts--I think there is a
lot of concern about the future----
Senator Nelson. Excuse me for interrupting. I did not
understand. The fellow who is now the Secretary of HHS had
taken a position as a Congressman supporting the voucher
system, turning Medicare into a voucher system. Do you support
that?
Ms. Verma. So let me back up with my answer here and try to
explain this a little bit more. You know, I think that what I
have seen in terms of different types of options that are being
discussed around Medicare, those are borne out of individuals
who want to make sure that that program is around. I want to
make sure the program is around for my kids.
And so, you know, what we know from the trustees' report is
that----
Senator Nelson. So to make sure that it would be around,
you are saying that you would consider alternatives.
Ms. Verma. You know, I think that I am not supportive of
that. I think that we need to make--but I think it is important
that we look for ways of making sure that the program is
sustainable for the future.
Senator Nelson. All right, let me give you one of the
alternatives. One of the alternatives is to increase the age
from 65 to 67. Do you support that?
Ms. Verma. You know, I think ultimately what direction that
we go into is up to Congress. As the Administrator of CMS, my
job would be to carry out whatever Congress decides is the best
course of action for the Medicare program.
And I would hope that we would work towards making the
program more sustainable so that it does exist for future
generations and that it is a program that provides high-quality
care, accessible care, and gives seniors options.
Senator Nelson. So you do not think you should be involved
in policy? You said, ``Leave it up to Congress.''
Ms. Verma. I think it is the role of the CMS Administrator
to carry out the laws that are created by Congress.
Senator Nelson. All right, let me ask you--there is another
availability that seniors enjoy, which is that the doughnut
hole was closed, which means that seniors in Florida spend
about a thousand dollars less out of their pockets by drugs
being reimbursed through Medicare.
So in the Medicare prescription drug program--now I know
that you just had a question close to this, but what I need to
know is, do you support the provisions in the ACA that closed
the coverage gap to make prescription drugs more affordable, or
closing the doughnut hole, ``yes'' or ``no''?
Ms. Verma. I support efforts to make the availability of
medications affordable and accessible for seniors. I want to
make sure that they have choices about the medications that
they need and that that coverage is affordable to them. So I
support efforts in terms of----
Senator Nelson. I am running out of time. I am just trying
to get clear your thinking on this. So if a senior, since you
support making drugs affordable to seniors, but if a senior had
to pay a thousand more dollars out of their pocket per year for
their drugs, is that something that you would support?
Ms. Verma. You know, ultimately what happens with the
doughnut hole is really up to Congress and how we move forward
on this.
In the role of Administrator, my job would be to implement
the policy or the legislation that is developed by Congress.
Senator Nelson. All right, so back to the policy by
Congress. All right.
Here is one you may be able to answer. How about--as you
know, on dual-eligibles, the Federal Government gets a discount
from the drug companies for the dual-eligibles who are eligible
through Medicaid until they get to 65, then they get their
drugs from Medicare, but then there is no discount.
Would you support requiring drug manufacturers to pay drug
rebates to Medicare for the dual-eligibles?
Ms. Verma. Yes, as I said before, I support efforts to make
drugs more affordable to seniors. And I think this is an issue
that we are all concerned about, the President is concerned
about as well, that we need to make it more affordable.
And I would look forward to working with Congress on
strategies that can help it be more affordable while
maintaining accessibility and ensuring that our seniors have
access to the drugs that they need.
Senator Nelson. I am sorry that you have the constraints
put on you so that you cannot answer these questions
forthrightly. And those are the questions that I can tell you
senior citizens are begging to hear the answers to.
Because if you had approached this as candidate Trump had,
saying he was going to protect Medicare and Social Security and
not have any cuts, your answers would be different, and they
would be clear. But you have chosen to go the route that you
have, and I am sorry that you have those kind of constraints.
Thank you, Mr. Chairman.
Senator Isakson. Thank you, Senator Nelson.
For the benefit of the members of the committee, the order
remaining of those who have not asked questions is Isakson,
Brown, Heller, and Scott. And that is the order we will go in,
unless someone comes in who is still on the list.
And I will take my time now.
First of all, and I will just make a statement, you do not
have to really comment unless you want to, but words are a
strange thing sometimes. They can be used depending on what you
want the ultimate goal to be.
In the Veterans' Administration--and I am the chairman of
the Veterans' Affairs Committee--3 years ago Republicans and
Democrats joined together to create what is known as the Choice
Program in terms of V.A. health care benefits to try to
expedite veterans getting services and to maximize the use of
the V.A. and the private sector.
In the first year of that program, there were 2 million
more appointments filled through the V.A. than had been in the
previous year, and all those were because the access to the
private sector gave the veterans better access. So the veteran
had the choice and used the private sector and the Veterans'
Administration to do it.
I think that is a good example of where choice made a
difference, delivered health care, did not change the cost,
made accessibility better, and made the program work better. So
``choice'' is not a bad word. Choice can be a very good word.
And the Congress did that 3 years ago in August, and it has
been a program, it has worked ever since.
Are you familiar with that program?
Ms. Verma. I am not familiar with that program. But I do
believe I agree with you that choice is critical. When there
are choices, then there is competition, and we have folks who
are trying to attract our beneficiaries to the system. So
choice and competition are very important to driving better
quality in outcomes and lower cost.
Senator Isakson. In Georgia, we have 1.9 million Georgians
on Medicaid; 1.3 million of those 1.9 million are children.
Half of the children born in my State are born with Medicaid
benefits.
Are you committed, as we go through the reforms and the
enhancements and the improvements of the program, to make sure
we keep children foremost in our mind for coverage?
Ms. Verma. I am, absolutely. As a mother of two children, I
certainly understand the importance of health care for
children. And one of the things that I am reminded of in my
work with the Medicaid program and with the CHIP program--I
remember hearing a story about a woman. And it was after the
CHIP program had been passed. But she talked about how she had
a child who was an infant, probably 1 or 2 years old, maybe an
infant, about 1 year old, and she had gone to the doctor, and
her child had an ear infection. And the doctor gave her a
prescription just for a simple antibiotic to treat the ear
infection.
And she went home that night and she had a choice to make.
If she filled the prescription, she would not have enough money
to pay for meals for the whole family. And so she made the
painful decision of not filling the prescription and feeding
her family for the whole week.
And what happened to that child is that, because of his
untreated ear infection, he ended up losing his hearing and
going deaf. And so I am always reminded of that story. And that
child now needs lots of different services to help him through,
and that is something that could have been prevented.
So it is very important that children have access to high-
quality services. That is really important so that we do not
have situations like that.
Senator Isakson. Thank you for your answer.
Are you familiar with the 21st Century Cures Act that
passed?
Ms. Verma. I am.
Senator Isakson. It is a great piece of legislation. And
Senator Warner and I had one of the provisions in that bill,
which is very important to us, on home health care. It provided
for reimbursement for durable medical equipment under Part B
and home infusion and home health care through Medicare.
And it is something we wanted to make sure we had, because
under the ACA home health care was almost totally removed from
being reimbursed. And having had personal experience, I know
home health care is the best environment to deliver health care
services and the least costly to the government.
I hope you will look closely at that 21st Century Cures Act
and the home infusion provisions we put in it, to see to it
they get implemented.
Ms. Verma. I would be happy to work with you, Senator, on
that. And I agree. I think the Cures Act--and I applaud
Congress for coming together on a bipartisan basis to pass that
law--I think it is going to have a tremendous impact on the
health care of Americans. And I appreciate your efforts on that
and would be happy to work with you.
Senator Isakson. And lastly, just really quickly, when I
was in the State legislature years ago, the biggest thing we
fought was a lot of fraud in Medicare and Medicaid. And that
still is a problem today.
I am very familiar with it from the business I was in. The
verification of eligibility is very important to make sure you
have minimal fraud and minimal waste. Are you committed to
using the commercial resources that are available in the
private sector to verify eligibility where that is important?
Ms. Verma. I am absolutely committed to that.
Senator Isakson. Thank you very much.
Senator Brown, I am sorry to tell you, but Senator Menendez
slipped in, so he is going to be one ahead of you.
Senator Menendez?
Senator Menendez. Thank you, Mr. Chairman.
Ms. Verma, congratulations on your nomination.
One of the successes of the Affordable Care Act was the
establishment of a nationwide benefit standard called the
essential health benefits package. And one of my amendments to
the law, which was adopted by this committee, was to ensure
that coverage for behavioral health services, like therapies
for children with autism, are available in every plan purchased
through the marketplace. That is to ensure that a child in
Georgia or Indiana or New Jersey has equal coverage and equal
access to the care that they need.
I have heard from countless families about the anxiety they
have over losing access to critical autism services through a
change in the essential health benefits that allows insurance
companies to deny coverage, which is especially acute in States
that lack a State-based requirement.
Do you agree that a child's access to insurance that covers
a condition like autism should not be based on what State they
live in?
Ms. Verma. I appreciate your question. My husband is a
child psychiatrist, so he deals with those issues on a day-in
and day-out basis. So I certainly understand the concern.
I have been advised by the Office of Government Ethics not
to participate on issues regarding mental health services
because my husband is a psychiatrist and that it could impact
his practice. And so----
Senator Menendez. Well, with all due respect, autism is not
a mental health issue. Autism is an illness where we are still
trying to develop the essence of its cause. But at the end of
the day, I use it by way of example. Are you suggesting that
you cannot tell the committee a simple answer to the question
that it should not matter where you live in the Nation, that in
fact you should have access to the same coverage as any other
child?
Ms. Verma. I think that all Americans should have access to
the health-care services that they need. However, in the issue
that you are asking me to comment on, I have been advised by
the Office of Government Ethics not to participate on matters
that, because of my relationship, my husband's practice, to not
offer----
Senator Menendez. Did they define to you the list of things
that fall under this category?
Ms. Verma. He does treat children with autism, and so they
have asked me not to engage on matters that involve his
practice.
Senator Menendez. That is pretty amazing to me.
Let me ask you this. As you know, Congress has to act this
year on a package of Medicare extenders. Which of those
Medicare policies do you consider to be your top priority?
Ms. Verma. I have not reviewed that particular regulation,
but I would be happy to review that, if I am confirmed, and
work with you on that.
Senator Menendez. Well, let me just say, Medicare is a big
part of what CMS deals with. And I would have thought that, in
preparation for this hearing, you would have a sense of these
extenders that are almost on an annual basis or a biannual
basis. But it is the heart of giving us a sense of what you as
the potential Administrator would be advocating as it relates
to Medicare.
Your role as the CMS Administrator is more than just
executing simply the laws of the country, which certainly you
would. But it is also a policy development-heavy position that
the President and the Secretary of Health and Human Services
and the Congress rely on when drafting laws that ultimately
would have impact in your parameters.
So you have no idea as to which one you consider the most
significant?
Ms. Verma. At this point, I would want to review that
before I gave you my opinion on that particular area.
Senator Menendez. Let me ask you this. During our meeting
in my office, you referred several times to so-called able-
bodied beneficiaries as we were speaking about Medicaid.
Do you believe that low-income and working-class
individuals who gained access to Medicaid thanks to the
Affordable Care Act's expansion should be eligible for
Medicaid?
Ms. Verma. I think that when I think of----
Senator Menendez. I think that is a simple ``yes'' or
``no,'' because my time is limited. Do you believe that they
should have access to Medicaid eligibility?
Ms. Verma. I think that all Americans should have access to
high-quality health-care services.
Senator Menendez. That is not an answer. That is not
responsive to my question.
Ms. Verma. But I think----
Senator Menendez. I am asking about Medicaid specifically--
--
Ms. Verma. When I think about the Medicaid program, I think
about it almost in two different parts. There is the part of
the Medicaid program that serves the aged and the blind and the
disabled. That is a very different population than some of the
able-bodied individuals.
But at the end of the day, all Americans should have access
to high-quality, affordable health-care coverage.
Senator Menendez. Well, I will just simply say,
``unresponsive to my questions.'' I cannot vote for someone to
be the Administrator of one of the most significant agencies
that affects the health care of people in the country if I
cannot glean from you in an open hearing under oath what your
answers are to these questions. I have no answers, and so it is
very difficult, very difficult. And I have not reflexively been
against the President's nominees. I have voted for several of
them. But you have to give me more than that. I hope that your
responses to written questions will be more enlightening for
me.
Thank you, Mr. Chairman.
Senator Isakson. Senator Cantwell?
Senator Cantwell. Thank you.
Congratulations on your nomination. We had a great
discussion about innovation in the Pacific Northwest, and so I
wanted to follow up on that.
But to my colleague's point, you know, there has been a lot
of discussion about block-granting Medicaid. Are you in favor
of that?
Ms. Verma. You know, when I think about the Medicaid
program, I will say that the Medicaid program as a status quo
is not acceptable. I think that we can do a lot better for the
many people who depend on this program. We are talking about
disabled individuals, quadriplegics, people who are
developmentally disabled, mentally disabled, and we can do a
better job than what we have today in the program.
We know that we are not delivering great health outcomes.
There has been study after study that shows that even people
who do not have Medicaid have better health-care outcomes.
Senator Cantwell. Do you think there are problems with
block-granting Medicaid?
Ms. Verma. I think that, you know, when I look at this, I
think we need to think about how we can make this program work
better. The status quo is not acceptable. This is the United
States of America, and we can do better for our vulnerable
populations. We can hold States accountable for producing
better outcomes.
Senator Cantwell. So are you endorsing block-granting?
Ms. Verma. I am endorsing the program being changed to make
it work better for the citizens who rely on it.
Senator Cantwell. So you are not endorsing block-granting?
I am just trying to understand, because this is the debate du
jour as far as I am concerned. And I know that several of our
colleagues, probably those in the House, are very adamant about
this.
And so I am just trying to understand where you are on that
question, whether you either are for it or against it or have
concerns about it or endorse it. It is a spectrum, so I am
giving you a little more room than my colleague gave you.
Ms. Verma. Well, I appreciate that. Thank you. You know,
what I support is the program working better, and whether
that's a block grant or a per-capita cap, there are many ways
that we can get there.
But at the end of the day, the program is not working as it
should. When you have one State spending $4,000, you have
another State spending $15,000 for the same population, can we
show that the outcomes are better; can we show that that
individual had accessibility to high-quality care?
What we know is going on at the State level is that, you
know, in terms of accessibility, one-third of doctors are not
taking Medicaid patients. And that means for a disabled person
that when they are sick, they call the doctor, and some of the
doctors will not even take them, and the doctors who are taking
them--they are having to wait for a long period of time to get
care.
I mean, I think we can do better for these people. And I
support efforts to get us there.
Senator Cantwell. All right. Well, I would say this. This
whole notion of capitating or block-granting, we know what the
results of those programs have been. We have numbers here that
it has resulted in a 37-percent cut. So if you just
extrapolated that out, unless you assume that you have these
States that would step up and cover those populations--my
colleague Senator Hatch was talking earlier about the increase
in population. The increase in population is what is driving
the cost.
So coming up with a better strategy for that population,
like rebalancing that I had a chance to talk to you about, is
way more cost-effective. In our State, we saved $2.5 billion by
taking people out of nursing home care and putting them in
community-based care. But trying to capitate or say we are
going to block-grant it ends up--you know, if you just said to
my State, well, and the State did not come up with anymore
funds, if you applied that same 37 percent, you would be
cutting over 100,000 people in King County off, or you would be
cutting 43,000 people in Spokane off.
I calculated the numbers, again just in extrapolation, and
with that 37-percent reduction that other block-granting
programs have received over the last 15 years, it would be like
cutting a million people in Ohio off of Medicaid unless the
State came up with more money.
So my point about this is, I hope you will be much more an
advocate for the innovation in Medicaid, that instead of trying
to nickel-and-dime poor people on a copayment or administrative
cost, come up with the strategies, like rebalancing, that give
people real opportunities to deal with this population, save
cost, and keep people in a better, healthier situation.
So that is why I have grave, grave concerns about this
notion of block-granting Medicaid or the capitation, as you
mentioned.
Ms. Verma. Well, you know, I agree with you. This is what
it should be about: innovation. But what is going on in the
Medicaid program today is that we have a very inflexible system
when States are trying to do creative things.
And I agree with you in terms of rebalancing incentives and
giving Medicaid beneficiaries the option of being served in the
community. That is something that we should support and we
should do.
But the way the system is set up is that States have to go
to the Federal Government for any routine changes. Anytime they
want to do something innovative and creative, it can take years
to get a waiver done. And so we need to create a Medicaid
program that allows States to be innovative and to have that
flexibility so that they can focus on producing better outcomes
for individuals.
And I, you know, I strongly do not want to see anyone not
get health services. We are talking about the most disabled and
vulnerable people in our population. And we can do better. We
should be able to deliver better outcomes for these individuals
and hold States accountable for accessibility and high-quality
coverage. This is not about kicking people off the program.
This should be about improving outcomes.
Senator Cantwell. Well, we will have many more chances. My
time has expired, but I just hope you will remember: innovate,
do not capitate. Innovate.
Thank you, Mr. Chairman.
Senator Isakson. Senator Cardin?
Senator Cardin. Thank you, Mr. Chairman.
I am going to follow up on Senator Cantwell's points,
because I think the essence of her comments is absolutely
accurate.
And, Ms. Verma, first of all, welcome. You are a product of
my State of Maryland in education, and we are very proud of
your accomplishments. It is nice to have your family here.
And I want to talk about minority health and health
disparities in this country. Part of the Affordable Care Act
was to put a focus on that. We now have a National Institute
for Minority Health and Health Disparities. And there is a good
reason, because historically minorities have been discriminated
against in our health-care system.
We look at health-care results on diabetes, heart disease,
hepatitis, HIV/AIDS, infant mortality, and other indicators,
and we know we have a problem. And we have been making progress
on that problem, and that is why I want to refer to Senator
Cantwell's point about resources.
Resources are important. And I wish every policy decision
we make in this committee and we make in Congress and make at
the White House was driven by what is the right policy results.
But far too often, it is driven by the budget numbers. And that
is the reality; that is what we deal with.
And Senator Cantwell's point is that, if you move to block-
grant the Medicaid program, the odds are it is going to fill a
budget number, not fill a policy-driven objective. And who is
vulnerable? The most vulnerable people in our society.
In Maryland, almost 70 percent of the Medicaid population
are from communities of color. That is in my State of
Maryland--70 percent. So when we expanded the opportunities for
Medicaid under the Affordable Care Act, it made a big
difference.
You may be familiar with the Greater Baden Health Center in
Prince George's County. You are familiar with that community. I
have been visiting that center for many years, and they are now
able to provide mental health services and pediatric dental
services and give access to care in a vulnerable community
because of the expansion of Medicaid. And if we were to go to a
program that is innovative but does not have the resources to
implement, vulnerable people are going to get hurt.
So I just want to get your understanding as to the
importance of resources. We are not going to improve our
health-care system by telling people of means that they cannot
spend money on health care. They can get the health care that
they need. It is the vulnerable population that is going to be
challenged.
And as tough as budgets are here, budgets in Annapolis and
other State capitals around the Nation are even tougher.
Medicaid is such a large part of the State budget that when you
say, well, we are going to innovate, but we need to invest to
innovate, they do not have the money to invest to innovate. And
then they have to look at, well, let us eliminate dental or let
us eliminate the essential benefits that Senator Menendez was
talking about.
So tell me how you are going to advocate for the poor, how
you are going to advocate for those who are challenged in our
system?
I do not know all the answers of the Indiana system. You
and I had a chance to talk about it, and I applaud you for
looking for innovation in your State. But I know that some
interpret it to mean that those copayments that some have to
pay, they do not have the resources to pay. And then if they do
not pay, they are put into a system where they are denied
certain benefits that they desperately need.
So I am interested as to how you see this system being fair
to our most vulnerable.
Ms. Verma. Well, first of all, I would say I have fought
for coverage, for better outcomes for vulnerable populations,
my entire career, starting with individuals with HIV and AIDS,
working with low-income mothers to improve birth outcomes.
The issues that you raised around minority health are near
and dear to my heart. I am a minority, and I understand that
things are different. You have different cultural norms that
impact how care is delivered and the types of advice that we
give to individuals who are minority. So I certainly understand
that.
You know, you talked about the Healthy Indiana Plan and
making sure people have resources for their health care. You
know, we looked at in the Healthy Indiana Plan--it was all
about choices. We believe in the individual dignity and the
empowerment of individuals to make their choices about their
health care. And what we found is that when we gave people
those choices, they made good choices and they had better
health outcomes.
We saw emergency room usage go down. We saw individuals
having more primary care and more preventative care.
Senator Cardin. And of course, that is what we are seeing
under the expansion of Medicaid in the State of Maryland with
many more people insured. We are seeing less use of emergency
room care, much more preventive health care, because we now
have more people in the Medicaid system, about 250,000 more in
our State.
So yes, the expansion of third-party coverage is critically
important, but the quality of third-party coverage is also
critically important. If you do not have preventive care, if
you do not have pediatric dental, we know what happened. We
know what happened in our own State of Maryland in 2007 with a
tragic death.
So I appreciate that we are looking for innovation, but if
you do not have the basic coverage, if you do not have the
ability to provide the essential services, it is the vulnerable
who are going to suffer.
Ms. Verma. Well, I do not want to see the vulnerable
suffer. Like I said, I have been working on that particular
issue my entire career. I have done this on the local level,
creating programs in Marion County for uninsured individuals,
and I have done that on the State level. And if confirmed, I
will continue that fight.
Senator Cardin. I thank you.
Thank you, Mr. Chairman.
Senator Isakson. Thank you, Senator Cardin.
Senator Brown, you finally made it.
Senator Brown. Thank you. Thank you, Mr. Chairman.
Thank you for your willingness to serve, Ms. Verma. Nice to
see you again. And thanks for coming to my office and speaking.
I was a little disturbed with Senator Nelson's question
about Medicare eligibility age at 67 or even 70, as your future
boss has sponsored legislation on, at least at 67, and he was
not willing to tell the committee that he had changed his mind
or was opposed to it.
And on voucherizing or privatizing Medicare, I was
concerned when you said it is up to Congress. Of course it is,
but I would hope that you would--I am not asking this as a
question, but I would hope that you would look at CMS as a
platform to, one, tell your boss, the Secretary of HHS, and
your ultimate boss, the President--who has said he would not do
those things in the campaign, but then he nominates Congressman
Price--but I would hope you would use that as a platform to
stand up against those two things, because they are devastating
to working-class Americans.
A couple of questions. The first question is simple.
Governor Kasich recently named a new Director for the
Department of Medicaid, former Ohio legislator Barbara Sears.
Governor Kasich, as you know, extended Medicaid in Ohio;
700,000-plus people now have Medicaid coverage. Ohio's former
Medicaid director, John McCarthy, he had an excellent
relationship with CMS.
My question is--this one is the easy one--I would like to
ensure this positive working relationship, and I would like to
ask you to commit to sitting down in person with Director Sears
and perhaps, if she chooses and you choose, a group of Medicaid
administrators from around the country, to discuss my State's
and their States' priorities and concerns when it comes to the
Medicaid program.
And I would like to ask you to do that in the first few
months on the job.
Ms. Verma. That would be my pleasure to do that. I feel
strongly about working with States----
Senator Brown. All right, good. Thank you. All right.
Ms. Verma [continuing]. In an open relationship and
partnership.
Senator Brown. Thank you.
During our meeting, you spoke glowingly about CHIP and what
it has done. In 2010, Congress improved CHIP by streamlining
enrollment processes and increasing outreach efforts and other
things. We now have 95 percent of children in America who have
affordable, comprehensive health insurance. What is not to love
about that?
Secretary Price mentioned in his hearing that he would
support an 8-year--8-year--extension of CHIP, of the current
CHIP program.
It is important that when we upgraded CHIP in 2010 and
streamlined it so it is a clean law now and easily understood--
do you agree with Secretary Price that Congress should act
quickly to pass an 8-year extension? And do you agree that that
should be an 8-year extension of the current CHIP program to
provide certainties for families and State budgets?
And please give me a ``yes'' or ``no.'' Pretty simple, 8
years and clean CHIP.
Ms. Verma. I support the reauthorization of the CHIP
program and agree with Congressman Price that we need to do
this to the fullest extent possible, and I look forward to
working with Congress on that. I have two kids of my own.
Senator Brown. All right. But the questions were more
precise. Do you agree to the 8 years that he suggested?
Ms. Verma. I support the reauthorization as long as
possible.
Senator Brown. All right. Eight years would be possible.
Ms. Verma. Eight years or more.
Senator Brown. I know it is up to Congress, but, I mean,
what you do not either want to acknowledge or do not understand
is, your recommendation to this Congress--you can say it is up
to Congress. Of course, ultimately laws are, but your
recommendation to Congress matters. If you and Secretary Price
would say we want 8 years' extension and you would also say we
want a clean extension, not a rollback, but what we had in
2010, what the present law is now, it would really, really
matter.
And I think you would get every Democrat and you would get
most Republicans, and that would take that off the table. It
would take the uncertainty out of all these programs where we
just kind of limp along, extending them a year or two or three
or five at a time.
So I ask you again, will you recommend 8 years, and will
you recommend a clean CHIP extension?
Ms. Verma. I will recommend and support the reauthorization
of the Children's Health Insurance Program for as long as
possible. I think it is very critical that children have access
to high-quality services.
You and I talked about this in your office, about my
experience with this. So I support children having access to
health coverage.
Senator Brown. It would have been important to me more if
you had said ``yes'' and ``yes,'' but I appreciate the answer.
Beginning March 8th--let me ask you about another issue--
hospitals will be required to give Medicare Outpatient
Observation Notices to applicable Medicare beneficiaries as
required under the NOTICE Act, which Congress, I am sure you
are aware, passed just last year.
If confirmed as the CMS administrator, will you commit to
aggressively enforcing those notice requirements for hospitals,
``yes'' or ``no''?
Ms. Verma. If I am confirmed as the CMS Administrator, it
is my job to follow the law and to implement the programs as
designed by Congress.
Senator Brown. All right. The MOON notice, it is an
important first step towards giving beneficiaries additional
information, but it does not fix the issue of observer status,
the underlying 3-day stay requirement. Hospitals are
increasingly caring for Medicare beneficiaries as outpatients
under observation status as opposed to admitting them as
inpatient patients. While the classification of a hospital stay
does not affect the level of care that a beneficiary receives,
it has significant repercussions for the 3-day requirement and
for Medicare coverage of significant care.
Do you support changes to the 3-day stay requirement?
Ms. Verma. That is something that I would want to review
and would look forward to working with you on that.
Senator Brown. Do you have opinions of the 3-day stay
requirement?
Ms. Verma. I would want to review that in more detail.
Senator Brown. Do you know what it is?
Ms. Verma. I do know what it is----
Senator Brown. Tell me a little about it.
Ms. Verma [continuing]. But I would like to review that at
this point and would be happy to work with you on that.
Senator Brown. All right. Secretary Price, who apparently
knows more about the observation status issue, raised it during
his confirmation hearing. He specifically mentioned he would
like to work on improving this rule. I assume you would work
with him on that.
So can you give me any thoughts on what you would do at CMS
to improve the 3-day requirement?
Ms. Verma. Well, I think we need to work with providers on
this. I know that there have been some issues there in terms
of, you know, skilled nursing facilities and the impact of the
rule on patients' ability to get in with that. So I would want
to review that more carefully and would be happy to give you my
comments.
Senator Brown. All right. That was less than satisfactory,
but I appreciate the effort. Observation status is a huge
concern for beneficiaries across my State. And we get calls, as
I am sure in Indiana some of your counterparts who were doing
Medicare got calls. But I know that Senator Cardin, Senator
Nelson, and others have been working this issue for years. And
I hope we can work on it. Thank you.
Thank you, Mr. Chairman.
Senator Isakson. Senator Heller, I apologize, but Senator
Thune slipped in under the transom, so I am going to have to go
to him next.
Senator Thune?
Senator Thune. Thank you, Mr. Chairman. And I hate it when
that happens when I am down here, so my apologies.
Ms. Verma, thank you for being here. Welcome and thank you
for your willingness to serve.
I know this has been touched on already, but I wanted to
follow up because, when the MACRA final rule was released last
November, I was concerned about the decision to delay
implementation of virtual groups.
And then Acting Administrator Slavitt indicated that
details were being worked out and that CMS was soliciting
feedback from physicians. The rule stated that implementation
would not come until 2018. Well, being from South Dakota, I am
continuously concerned with how we roll out new payment systems
in rural areas.
Will you make it a priority of yours to ensure that virtual
groups are timely and effectively implemented?
Ms. Verma. I would be happy to do that and happy to work
with you on that issue.
Senator Thune. And how do you plan on engaging with those
rural and sole practitioners to ensure that this is a viable
option that they can take advantage of?
Ms. Verma. I think that the rural providers and frontier
providers are in very unique situations. And when we are
thinking about policies, we need to engage with them on the
front end to understand what their concerns are before policies
are rolled out to make sure that we are understanding the
impact on them.
You know, things that work well in an urban community do
not necessarily work well. And I think sometimes living in DC,
we do not have that understanding. So any time I think we have
a policy, we need to work with rural providers, with frontier
providers, on the front end to understand what their concerns
are and what the potential impact could be.
And then, once something is out there, we need to make sure
that we have that continued collaboration and communication so
that if there are problems and if there are issues, we can
address them in a timely way so that we are not impacting
patient care and that we have a commitment to providing high-
quality care and access.
Senator Thune. Yes, I am glad to hear you say that.
Additionally, the GAO had recently released a report, in fact
it was in December, that lists the hurdles that small and rural
practices may face when trying to participate in MACRA's new
payment models.
As CMS moves away from fee-for-service and toward rewarding
quality, I want to ensure that rural providers in my State will
be able to participate in new and innovative methods that
increase quality and reduce costs.
Aside from the previously mentioned virtual groups, the
last question is, how would you go about ensuring that small
and rural providers have access to these programs?
Ms. Verma. Well, I think it is critical that we make sure
in rural areas and frontier communities that we have that high-
quality health care. And again, it goes back to collaborating
with them.
These programs, I think, have enormous promise to deliver
high-quality care and move us in a different direction, but we
need to work with those providers on the front end to make sure
that they can handle these new regulations and rules.
What I find is that, in the rural communities and frontier
communities, I mean, they are stressed in providing care. They
have a lot of enormous burdens. And we need to be careful that
rules and regulations do not prohibit them from providing high-
quality care.
And when you are out there on the front lines and you are
trying to provide care, having to deal with a lot of rules and
regulations can be difficult. And so we need to be supportive
of them by providing technical assistance, making sure that we
are available for communication, and support them throughout
the process of implementation.
Senator Thune. I would like to turn just quickly to one
other issue, and that is the meaningful use program for
electronic health records.
Given the program's somewhat rocky track record, what do
you believe is the future of the meaningful use program at this
point?
Ms. Verma. Well, I think that electronic health records
have enormous promise. And I think they are helpful for
physicians in terms of prompts, in terms of doing data and
evaluation, but it has been a rocky start.
I think, as a patient, I have gone to the doctor's office
and even seen signs in the waiting room that say, you know, we
are going to be delayed or it is going to take a while because
we are still getting used to electronic health records.
I have been in the room with my doctors where they are
staring at their computer instead of looking at me as I tell
them about my health-care issues. And so we need to make sure
that it is working and it is working for providers and
patients.
Interoperability--you know, if we are going to have
electronic health records, then we should make sure that they
fulfill their promise so that if somebody goes to the emergency
room, even if they were in a different hospital or a different
provider system, that the doctors can pull up the information
and that they have those tools about what medications the
person is on. And so we need to make sure that they are
fulfilling their promise and not being more burdensome.
You know, I think there is a lot of potential there, in
terms of prompts. I mean, I hear that physicians like the
ability to, when they are talking to a patient, be able to say,
well, what pharmacy do you like, and immediately send that
script. So there is a lot of value there.
But we need to make sure that it is also fulfilling its
promise and that it is giving us the things that it is supposed
to do, so when you go show up to an emergency room, you
actually have all that information. And sometimes I know we
have come up short on some of those things. So that is
something where I think we need continued efforts around that.
Senator Thune. All right. Final point. I look forward to
working with you. I mentioned in our discussion, our meeting,
better coordination between the Indian Health Service and CMS.
That is an issue that we have had lots of issues and problems
with in my State of South Dakota. And I hope that we can make a
lot of headway there. So thank you.
And thank you, Mr. Chairman.
Senator Isakson. Thank you, Senator Thune.
Senator Heller?
Senator Heller. Mr. Chairman, thank you.
Senator Isakson. Your time has arrived.
Senator Heller. Terrific, terrific. [Laughter.]
Ms. Verma, congratulations to you and also to your whole
family who is there behind you. Your kids are very patient. I
notice that Shaan is getting a little fidgety, so maybe we need
to hurry up just a little bit. [Laughter.]
But we are glad you are here and glad the family is here
also.
Twenty percent of the State's population in Nevada is on
Medicaid and another 15 percent of the population is on
Medicare. And we discussed in my office how important it is for
you to strengthen and protect these programs and how critical
that is for the State of Nevada. I just want you to know I
appreciate the conversation that we did have in my office.
And like everybody else, I would assume on this committee
that everybody is a strong supporter of Medicare. And I share
that.
And I will say also that I have not supported, will not
support legislation that does weaken Medicare.
So before I get started, Mr. Chairman--and I am not quite
sure who is playing Mr. Chairman at this point--I would like to
submit for the record a letter that I received from the Speaker
of the House in the Nevada legislature and also the majority
leader.
I asked Secretary Price if he would----
Senator Wyden [presiding]. Without objection, it will be
made a part of the record.
[The letter appears in the appendix on p. 62.]
Senator Heller. All right, terrific.
All right, let us go to a couple of questions. I want to
maintain the conversation that we have been having here on
Medicaid today, if you do not mind.
Nevada, as you are probably well aware of, is one of 32
States that chose to expand eligibility for the Medicaid
program. Numbers since the expansion: Nevada Medicaid
enrollment increased from 350,000 to over 600,000. As of July
2016, Medicaid enrollment in Nevada is over 200,000 people
greater than what was projected before the expansion.
I have had numerous conversations. I had a conversation
with the Governor. I have had conversations with State
employees. Our State legislature, our hospitals are all very
seriously concerned about moving this program to a block grant.
They are concerned that they will not have the appropriate
funding to cover clearly all 600,000 Nevadans who are on the
program and who are on Medicaid. And they are concerned that
they do not have the staff to implement such significant
changes.
They are also concerned that with a part-time legislature,
the State will not have the time needed to establish
drastically different Medicaid programs. So I guess my question
to you is whether or not you are sympathetic to these concerns
for these block-grant States, these expanded block-grant States
like Nevada. And so you understand those concerns?
Ms. Verma. I absolutely understand those concerns. I have
worked with States for almost 20 years now, so I understand the
concerns. I understand the State budgets. I understand the
States that have expanded and the States that have not
expanded.
You know, I think in terms of the Medicaid program, for me,
the opportunity is about improving health outcomes. We are
talking about a very vulnerable population. You know, these are
individuals who--you know, it is a safety net. Medicaid is a
safety net. They do not have another place to turn. If you are
disabled, if you are a quadriplegic, if you are paralyzed,
Medicaid is the program.
But what we have today does not work well. I mean, we know
that studies after studies have shown that the outcomes are not
great. We know that States are spending different amounts of
money, $4,000 in one State, $12,000 in another State, and do we
know that we are getting better outcomes? Do we ask these
individuals about their care?
So, you know, I think that the conversations that we are
having should all be around improving health outcomes and
trying to do a better job here. I do not want to be about
hurting States. That is where I come from, and that is what I
understand. I have worked with a lot of different Governors,
and I understand, you know, where they are in terms of State
budgets. And there is not a whole lot of extra money.
But I think this is about giving States, putting States in
a leadership role so that they can manage their programs
better. I think that States are closer to the people whom they
serve than the Federal Government and they have a better
understanding of what can work in their State than the Federal
Government.
You know, I think we have heard from some of the Senators
today about rural areas, for example. You know, they have
special challenges there in frontier areas. So some of the
things that are coming down from Washington in terms of a one-
size-fits-all approach do not always work. And I think States
should have that flexibility to design a program that works
better for the people whom they are serving. And they are
better positioned to make those decisions than we are in DC.
So I think that this is an opportunity to create
flexibility so that they are not having to go to the Federal
Government every time they want to make a simple and routine
change.
And what we have seen in the Medicaid program is that, you
know, because it is so inflexible, there is not a whole lot
that you can do in designing your program. And so what States
do often when times are tough is, they cut provider rates.
In 2012, we had over 44 States either freeze or cut
provider rates. And that has an impact on access to care. But
they are doing that not because they do not care about the
people whom they serve; it is because the program is so
inflexible.
So I think an opportunity to give States more flexibility
is an opportunity to improve health outcomes for individuals.
Senator Heller. So is it fair for me to say that you are
pushing a block-grant approach?
Ms. Verma. I am pushing an approach that improves the
Medicaid program, because I do not think the status quo is
acceptable. I think we can do better for disabled people and
for people who are very vulnerable and who are dependent on
this program.
I think we can do better improving outcomes and making sure
that individuals are not receiving health care in the emergency
room and that their health is actually improving.
Senator Heller. All right. My time is up. Are block grants
on the table or off the table?
Ms. Verma. I think anything should be on the table that can
improve health outcomes for this very vulnerable population.
Senator Heller. All right. So it is my understanding then
that block grants are on the table.
Ms. Verma. You know, I think block grants, per-capita caps,
anything that we can do to help improve outcomes and create a
level of accountability for States--I think we should explore
all of those options. And I look forward to working with
Congress on this.
Senator Heller. Ms. Verma, thank you.
Mr. Chairman, thank you.
The Chairman. Senator Scott?
Senator Scott. Thank you, Mr. Chairman.
Thank you, Ms. Verma, for being here. We are excited about
your opportunity that lies before you.
I am the co-chair of the Sickle Cell Caucus. And every
Valentine's Day I have a chance to go to the Children's
Hospital at the Medical University of South Carolina and hang
out with some of the kids who have been hospitalized several
times a year, oftentimes for cancer or a chronic condition that
can consistently resurface. As a matter of fact, the sickle
cell disease has accounted for somewhere around 246,596
emergency room visits as a principal diagnosis in 2014.
The gentlelady behind me, Jordan, who is a student at my
alma mater, Stall High School, she has been in and out of the
hospital as a youngster, 15 years old, a number of times.
And having an opportunity to see the challenges that so
many families face and the necessity of Medicaid as their
primary provider, raises a lot of questions. And one of the
questions I would love to get your input on is, what are your
thoughts about innovative things CMS can do to reduce
readmissions, decrease costs for providers and payers, and
improve care for those with sickle cell and similar chronic
conditions?
Ms. Verma. You know, I think one of the things that we can
do is that, you know, anybody on the Medicaid program, they are
in a vulnerable situation, whether it is being aged, blind,
disabled, or having a disease-specific condition. They are
completely dependent on this program.
And as I said in my opening statement, sometimes this is a
matter of life and death for these individuals. They have no
place to turn. So we need to assure that we have the best
possible program, better quality, better outcomes.
And I think that those decisions and the ability to do that
should come at the State level. And the State has a better
understanding of the delivery system and of the citizens they
serve. So they are in a better position to make those
decisions.
So in terms of, you know, readmissions and really focusing
on outcomes, I think on the Federal level it is important to
establish what are the expectations of the program. What are we
going to hold States accountable for? You know, it should be
quality, and it should be accessibility.
Senator Scott. Have you found, working with the State of
Indiana, that there were a couple of things that you thought
worked really well on the State level that you would like to
see on the national level?
Ms. Verma. Well, you know, first I would say that every
State is different.
Senator Scott. Is different, I know.
Ms. Verma. And you know, as I worked with States--you know,
I am known for the Healthy Indiana Plan--people would say, do
the Healthy Indiana Plan nationally. Every State has a
different opinion. I have never actually had a State that
wanted the Healthy Indiana Plan, you know, in entirety. They
looked at it, they took things that they liked about it and
applied them and they designed their own programs. So I think
that that is why we need to have a program that is flexible and
allows States to do what works best for them.
Senator Scott. There is no doubt that most of us consider
the 50 States the laboratories of our democracy, where good
things happen. Without any question, having a national model
where we have taken the best ideas from those States is an
important part of your responsibility moving forward.
I know that you have consulted with a number of States,
including South Carolina, for programs like the pay-for-success
financing models where Medicaid basically pays for performance,
which I think is a fantastic model.
What do you see as the future of the pay-for-success model
in Medicaid? And what is the appropriate role for CMS in that
process?
Ms. Verma. Well, I think that the concepts around that
program are critical. I think you know, instead of
micromanaging the process, we need to say definitively, here
are the outcomes that we are driving towards. I think right now
what we are doing is, we are managing the process, we are not
holding States accountable.
You know, in terms of South Carolina, one of the very
innovative things that they have done there is the application
of the nurse/family partnership for low-income families or for
low-income first-time mothers. And having that home visiting
program, I think, is an excellent idea.
But again, that program, you know, had a lot of thought. It
took many, many, many months to get that program approved
through CMS. And that is a great example of how the State has
this idea and it is innovative, it has been proven in other
communities. And to be able to do that on a ready basis without
having to go through that long process of approvals, I think
that is an important idea, the importance of having State
flexibility.
Senator Scott. Thank you, Mr. Chairman.
Thank you, Ms. Verma.
The Chairman. Well, thank you, Senator.
Senator Enzi?
Senator Enzi. Thank you, Mr. Chairman.
First of all, I want to thank you for the opportunity I had
to meet with you before. I do want to ask unanimous consent
that a statement that I have could be put in the record.
The Chairman. Without objection.
[The prepared statement of Senator Enzi appears in the
appendix on p. 55.]
Senator Enzi. We do have an outstanding nominee before us
who has had a good life outside of Washington. And she does not
need to be subject to personal attacks or made into a symbol of
partisan discord.
I really get distressed at the way these hearings go, where
we try to push for some things in actual legislation that ought
to be reviewed. And again, be reminded that she gets to make
good suggestions, but we get to pass the final laws.
And since I met with you, I have read a lot more about you.
You have not just studied Medicaid and Medicare and other
health situations, you have actually been hands-on; you have
done things. You have actually helped States to make their
process work better. You have a track record. And it is very
impressive.
I think around here that makes you overqualified,
unfortunately.
You have not been cutting people off of Medicaid and
Medicare. You have experience that has worked at the State
level.
You and I talked about frontier and rural and that has been
emphasized here again, because we have several States
represented that are frontier and rural.
Wyoming has the lowest population in the Nation, and we
have also had a devastating economic hardship because the last
administration did not like energy. And we are the energy
State. And so our State has had to make some very tough
decisions.
A year ago, the legislature, in their biannual budgeting,
had to cut 8 percent. And when the session finished, they found
out that that was not enough, so the Governor had to cut 8
percent. And now they are into the second year on the biannual
budget. And when they came back, they found that revenues are
down so much they have to cut another 8 percent.
And that presents a lot of problems, not just in the
health-care area, but across the board, and education
particularly is being devastated by that. But they are working
through it, and they will get it.
When I met with you, I also talked about Medicare's
competitive bidding program. And we talked about some of the
unique challenges of rural and frontier States.
I want to know if you will be willing to continue to have a
dialogue about how that competitive bidding process can ensure
that people actually get what they think they are getting and
what we think that we are buying.
In your view, is it going to be important for CMS to look
at avoiding putting in place the one-size-fits-all programs?
Ms. Verma. I think that is absolutely critical. And you
know, working for States, what I see is that they are all
different, their delivery systems are different, their patient
population is potentially different. So a Federal one-size-
fits-all approach does not always work.
And I think what you are bringing up in terms of the
competitive bidding is an excellent example where we have some
providers who are being paid--they are rural providers--but
they are being paid at a rate that is more appropriate for an
urban area.
And so I think that is the type of policy where we need to
understand how that is going to impact a rural provider or a
frontier provider on the front end and have that discussion so
that we do not have problems later on down the line.
And if we are having issues, then we need to be responsive
to that, because we want to make sure that we are not impacting
beneficiary access and that seniors and other folks who depend
on CMS programs always have high-quality care and
accessibility.
We do not want to see that our policies and our programs
are actually preventing providers or that we are losing
providers or that they do not want to see Medicaid or Medicare
beneficiaries anymore. We should be very careful with policies
so that we are not pushing providers out of the system, but
that we are actually attracting providers to the program.
When we attract providers to the program, we are giving our
seniors, Medicaid beneficiaries, we are giving them more
choices. And when they have choices, that is what is going to
drive quality in the system and hopefully lower costs.
Senator Enzi. Again, you have demonstrated what you talk
about. You are not just talking about something that you have
studied in a book or that you wrote a Ph.D. paper on.
As you know, dual-eligible individuals are a complex and
expensive patient population. They affect both Medicare and
Medicaid. So are you committed to working at the Federal level
and with States at the State level to address the mounting
financial concerns about the dual-eligible population?
Ms. Verma. I think we must address that issue. I mean, as
we have an aging baby boomer population and we have more and
more folks going to be coming into the Medicaid program and
Medicare program, we are going to need to have closer
collaboration and make sure that we have the incentives in
place to manage that program well and to assure that we are
providing comprehensive, coordinated, quality care to those
individuals.
I think it is difficult and confusing for them when they
are on two different programs. And we need to make sure that
those programs work well for those beneficiaries.
Senator Enzi. Thank you. And thank you for your outstanding
presentation. And your family has to be really impressed, as am
I, with your capability of answering and your vast knowledge.
Thank you.
Ms. Verma. Thank you, Senator.
The Chairman. Thank you, Senator Enzi.
The ranking member would like to ask a question or two, and
then we will wrap it up.
Senator Wyden. Thank you, Mr. Chairman. I do have a couple
of questions and a quick wrap-up.
But let me also say that I very much appreciate how this
hearing has been handled by you. You have made it clear that
Senators get to ask the questions that are important, and that
is the best bipartisan tradition of the Finance Committee.
The Chairman. Thank you.
Senator Wyden. And as we move to wrap up, I just want to
make that clear.
I have two questions for you that remain, Ms. Verma. One
stems from this horrible tragedy you described where the family
was forced to choose between putting food on their table or
paying for a prescription to treat a child's ear infection. And
the family, as you stated, a horrible account, chose food, and
the child lost his hearing permanently.
What I have been told about the Healthy Indiana Plan that
you designed is, if you had an individual who was making barely
$12,000 who had the same kind of choice to make and chose not
to pay their premium, they would be cut off from coverage for 6
months. So that individual would not get treatment for an ear
infection or other such condition.
Is that correct? This is what I have been told, and I would
just like you to tell me if that is correct or not.
Ms. Verma. The Healthy Indiana Plan is about empowering
individuals to take ownership for their health.
Senator Wyden. With all due respect, just is that correct?
Because we looked at the figures with respect to poverty, and,
as I understood it, at $12,000 that person would be cut off. Is
that right?
Ms. Verma. The way the Healthy Indiana Plan works is that
people who are above the poverty level, above 100 percent of
the poverty level, make contributions into their health savings
account. They make those contributions into their savings
account, and they get monthly statements so they can see how
that money is being spent.
If they complete their preventative health-care services,
then they have the ability to roll over that amount that is in
there in their savings account to offset their contributions.
If they have not completed their preventative services,
they can still roll over, because that contribution that they
are making is theirs and they own that.
In terms of what you indicated, if somebody does not make a
contribution into their account or chooses not to make that
contribution, just like it is in the Affordable Care Act, just
like it is in the exchanges for the same population,
individuals make contributions. They have 30 days to make that
contribution. If they do not, they are terminated from
coverage, and they cannot reenter until the open enrollment
period.
So that is the exact same coverage, that is the exact same
policy. In fact, the policy that we have in the Healthy Indiana
Plan gives people 60 days----
Senator Wyden. Whoa, whoa, whoa, whoa. There is a 3-month
grace period in the ACA.
Ms. Verma. There is a 30-day period where they continue
your health coverage, but after that they suspend payment. So
the individual actually does not have payment for their health-
care services, and then they cannot reenter the program until a
special enrollment period.
With the Healthy Indiana Plan, they actually have a 60-day
grace period before they are terminated from the program.
Senator Wyden. I am going to ask for this in writing. But
we have reviewed this, and if they make $12,000, they are
terminated. And I am going to ask you that in writing.
Let me go on to the ethics question. This was reported in
The Indianapolis Star--I guess that is the big paper in your
State--that while you were running the State of Indiana's
Medicaid program, you and your consulting firm were paid
millions of dollars by companies that did business with the
State, including Hewlett-Packard and Milliman and Maximus and
Health Management Associates. And these companies provided
financial, actuarial, administrative, and management services
to Indiana Medicaid.
So the question became, the Indiana ethics regulations on
conflicts of interest do not technically apply to you because
you were a contractor and not a State employee.
But my question deals with essentially basic ethics
principles, because it is hard to see how it is okay to
basically orchestrate the State's health programs and then get
paid by the contractors the State hires to carry out those very
programs.
So let us set aside Indiana law. We understand that, I
understand that those Indiana rules do not technically apply to
you because you are a contractor.
But how is this not a conflict, because you were sitting,
in effect, on both sides of the negotiating table?
Ms. Verma. Let me start by saying that I hold honesty and
integrity and adherence to a high ethical standard as part of
my personal philosophy. That is for me. I demand that of my
employees, and I set that example for my own children.
In terms of the issues that you raise, in Indiana we sought
an ethics opinion, so we sought counsel on this to make sure
that there were no issues. On a practical level, on a day-to-
day level, we were not negotiating for HP. And what we were
doing for HP was helping HP develop communication materials for
when they were putting out system changes so that people
understood what those changes were. So we were helping them
with communications materials.
What we were doing for the State was around policy and
helping them develop programs. And so there was no overlap.
When there was, when there was sort of the potential or
when we were working on programs, we would recuse ourselves. So
we were never in a position where we were negotiating on behalf
of HP or any other contractor with the State that we had a
relationship with.
We were transparent. The State knew about our
relationships. I think that they issued a statement indicating
in a response to The Indianapolis Star article that they were
aware of our relationship, we disclosed that relationship, and
on a practical, day-to-day level we did not engage in anything
that would, you know, put us in a situation where we were
supervising their work, negotiating their contracts. And we
made that very transparent on the front end.
So if there was ever an issue--you know, I have been in
meetings where we were talking about contractors, talking about
implementing a program, and when it came to a vendor that we
had a relationship with, I would recuse myself, I would get up
and leave the meeting so that there was never any issue.
And I think the State has spoken on this. And the work that
we have done with HP and these other vendors has extended over
three separate Governors and over six Secretaries of Health.
Senator Wyden. So the recently ousted head of the State
agency administering your contract told this paper, The Star,
that you once attempted to negotiate with State officials on
behalf of
Hewlett-Packard while being paid by the State.
So let us do this, because obviously there are differences
of opinion. My concern was, it was not just one company. It was
not just Hewlett-Packard, but it was the wide array of
companies that I listed: Milliman, Maximus, and a wide variety
of services.
And my concern is, it is very clear that Indiana ethics
rules do not apply to you in a technical sense because you were
a contractor. No dispute about that. But it sure looks to me
like you were on both sides of the table as a lot of money was
being allocated.
And I think that really leads me to my last kind of point
for today, Ms. Verma.
You have been asked a lot of questions. And my own sense
is--and I have listened carefully to my colleagues--these were
not ``gotcha'' questions. These were questions that were
appropriate given the fact that, if confirmed, you are going to
head an agency that is involved with a trillion dollars of
spending and the health care of 100 million people or
thereabouts.
And I think these questions were designed to get a sense of
how you would approach them. And I felt very strongly--I
enjoyed our conversation, and I decided I was going to try to
give you as much real estate as I could in getting a sense of
how you would approach them. That is why I asked the question
about pharmaceutical prices, which is huge and so important to
people.
And I said, I am going to ask Ms. Verma to give me one
example, just one example of what she would do if confirmed in
this position. And we did not get it in that area and in the
rural area and in a variety of others.
So the chairman will take us through the rules for getting
the questions for the record, but I am going to be reviewing
those questions and responses very carefully. Because what I am
troubled about today is, for questions that I thought were
appropriate for a job like this, a trillion dollars' worth of
spending, we are not really getting much of a sense of how you
would approach them.
And I think that this committee needs answers. I think the
public needs answers. And I will look at your written questions
very carefully and look forward to talking with your further.
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator.
I want to thank Ms. Verma for appearing here today. This
hearing is an important part of our committee vetting process.
And I must say that, not surprisingly, you, Ms. Verma, have
acquitted yourself very well.
I look forward to Ms. Verma being reported out of the
committee and being confirmed by the Senate. And my goal is for
this to all happen expeditiously.
It is critical that we get a strong, skilled leader in as
CMS Administrator. It is essential to our efforts for
collectively addressing our Nation's many health-care
challenges.
Our current Administrator, who is not confirmed, had all
kinds of conflicts, but we allowed him to go forward, a very
bright guy who had a lot on the ball. And here you are as
somebody who really has proven to be a tremendous leader in
health care, not just in Indiana, but as an example to the rest
of the States. And all I can say is that you will be a strong,
skilled leader as CMS Administrator.
Now, it is essential for our efforts for collectively
addressing our Nation's many health-care challenges that we get
you there.
Senator Wyden. Senator Portman is over there.
The Chairman. Oh, Senator Portman, do you still have some
questions? [Laughter.]
I did not notice that you came in. I am ready to wrap up.
Senator Portman. I am not very noticeable, I guess, Mr.
Chairman.
I apologize, Mr. Chairman. I have been here twice,
listening dutifully, and I have had separate hearings going on
at the same exact time, so I have been bouncing back and forth.
But I would like the opportunity to ask my questions. I have
not had a chance to do that yet.
The Chairman. Then go ahead; proceed.
Senator Portman. Thank you, and I apologize.
Thanks for your patience mostly, Ms. Verma, to your
children who have been very patient. I have been watching them.
Amazing. At their age my kids never could have done that.
So I heard a lot of the back-and-forth earlier. And let me
just go to some of these issues.
First of all, I like what you are saying about patients
taking more responsibility for their own health and how you can
have a health-care system that encourages that. I think we
talked about innovation earlier. Part of the innovation has to
do with that. We want people to lead healthier, stronger lives,
and part of that is providing that incentive within our health-
care system.
We talked about leveraging technology and innovation. I
like that. And many of us in our States are doing some things
that are innovative.
As you know, the State of Ohio has an innovative health-
care director whom I know you have worked with before. And a
lot of this is about taking the existing dollars and using them
more effectively to create better care. And I think that is a
great opportunity, frankly, in a health-care system that is in
need of more innovation.
And the technology part can be exciting; it can also be
very expensive. So it has to be dealt with appropriately.
You said more State flexibility. And later you talked about
holding States accountable for health outcomes--so looking not
at the input as much and the volume, but looking at the output
and the quality. And I think that is something where you are
going to find a lot of agreement on both sides of the aisle
here.
You also made the comment with regard to Medicaid that it
sometimes can take years to get a waiver. And I have to say it
is worse than that. Sometimes you cannot get a waiver. And as
you know, because you were involved in putting together Ohio's
waiver, we were not able to get a waiver to be able to give the
State the flexibility that it wanted to be able to provide more
innovation, better quality care, more holistic care, focusing
more on prevention and wellness and getting people into the
health-care system, not just when they have an emergency, but
to have a better health outcome by having primary care
physicians, and so on.
And that is something that concerns me, that it is not just
about how it takes too much time often to go through this
process, but literally we cannot get these waivers sometimes.
And the Obama administration HHS rejected the Ohio application.
The Healthy Indiana Plan was accepted, and you were very
involved, not just in developing that, but in implementing
that.
So if you could just speak briefly about what is the best
thing about the Healthy Indiana Plan. Is it some of these
characteristics I talked about earlier or others? And how could
that be taken nationally? And then I want to talk to you about
Medicaid expansion specifically.
Ms. Verma. All right. You know, I think about the Healthy
Indiana Plan, and what it has done is that it gives dignity to
individuals. It empowers them. It recognizes their potential to
fulfill their dreams. We do not assume just because somebody is
poor that they do not want choices about their health care,
they do not deserve choices, that they do not want to be
involved, that they are not capable of making decisions.
And what we have found is that when we do that, when we
create a situation, they are actually more engaged in their
health care and their engagement leads to better outcomes. It
leads to lower emergency room usage, more primary care, more
preventative care, higher satisfaction, and better drug
adherence.
Senator Portman. All right. Now, that is what I want to
hear, because that is what we should all hope for, that people
have access to affordable care and that the results are, you
know, better health outcomes because they are taking more
responsibility for their own health and have the ability to do
that, including access to primary care.
So here is the situation in Ohio. We have about 200,000
people who get coverage through the exchange, 212,000 as of
yesterday, but we have over 700,000 people in Medicaid
expansion. So when people talk about the Affordable Care Act in
Ohio, they talk about it in terms of some of the mandates on
small businesses, some of the issues obviously that have
resulted in higher costs to provide health care, the higher
premiums.
We have gone up 91 percent in the individual markets just
in the last 4 years; 82 percent for small businesses. I mean,
you know, people just cannot afford it.
But there is a lot of focus here in Washington on the
exchanges, which are important in Ohio, but frankly in Ohio,
what is more important for us is those over 700,000 people who
are in expanded Medicaid. And again, you have talked a lot
about this today and what you might support and not support in
terms of how you give more authority and responsibility back to
the States.
So that is my question for you. I am very concerned that we
not move forward too quickly with the replacement and leave
those people behind. I am also very supportive of a better
system, including much more State flexibility, along the lines
of what Governor Kasich wanted with his waiver request that was
rejected.
So help me to understand how we can ensure that we do
provide coverage to these people, particularly in my State. You
know, the prescription drug, heroin, now fentanyl issue is
huge. And the treatment that is provided to people in Ohio is
often now through Medicaid expansion. And we want people to get
into this treatment. Again, that provides them better health
outcomes in every respect.
So talk to me just briefly about that. I know you do not
have much time thanks to me being at the end here. But how can
we ensure we can get a good, flexible plan to cover those
people and even a better way than they are currently getting
under Medicaid expansion?
Ms. Verma. Well, I think that, first of all, I support
coverage. And I think that, you know, the individuals who are
being served in Medicaid, served through the exchange, I
support people having coverage for the issues that you raised.
I mean, as people are facing substance abuse, opioid addiction,
they are going to need coverage, and we need to address that
issue.
But if we look at what the Affordable Care Act has done,
and people talk about coverage--well, coverage does not
necessarily translate to access to care.
You know, I was today with an Uber driver and asking him
about his coverage. And he said he had gotten coverage through
the exchanges, through the Affordable Care Act, but he said,
``I cannot do anything with it because my deductible is $6,000.
And, you know, I cannot get to the doctor. I still cannot
afford it.''
And so I think that that is a great story of how coverage
does not necessarily translate into access. And so, you know,
as we move to a different system, I think those are things that
we need to keep in mind, whether that is through the Medicaid
program or through another coverage vehicle. And we need to
make sure that we are providing high-quality care and also
providing accessible care.
Senator Portman. Thank you. And we look forward to
continuing that conversation. And I know I am over time, but I
do think this is going to be the key issue for us in Ohio: how
do we ensure in that transition that we provide that coverage?
Thank you, Mr. Chairman.
The Chairman. Thank you, Senator.
Ms. Verma, you have been very patient, and you very
intelligently have answered these questions of my colleagues.
And the committee has received several letters in support
of Ms. Verma's nomination that I ask to be added to the record,
without objection.
[The letters appear in the appendix beginning on p. 57.]
The Chairman. And finally, I would ask that any written
questions for the record be submitted by 5 p.m. tomorrow,
February 17, 2017.
With that, we want to thank you for being here. Thank you
for your answers. Thank you for your patience.
And we will adjourn this hearing. Thanks so much.
Ms. Verma. Thank you, Senator.
The Chairman. You bet.
[Whereupon, at 12:51 p.m., the hearing was concluded.]
A P P E N D I X
Additional Material Submitted for the Record
----------
Prepared Statement of Hon. Michael B. Enzi,
a U.S. Senator From Wyoming
Thank you for the opportunity to say a few words, Mr. Chairman. The
nominee before us today is someone who has the background, the
knowledge, and skill set to be an outstanding Administrator of the
Centers for Medicare and Medicaid Services.
Ms. Verma is a talented person who is eminently qualified to
oversee CMS. Her experience with State Medicaid programs has given her
insight into the functional side of CMS. She knows the frustrations of
interacting with the agency and can see where changes could make
meaningful improvements for State flexibility and in improving
processes throughout CMS.
I am hopeful that, under her leadership, CMS can emerge as a place
where health-care innovation can thrive and, more importantly, a
government agency that does not slow down or stop innovation.
I have spoken to Ms. Verma about the challenges facing both
Medicare and Medicaid in a rural and frontier State like Wyoming, and
she understands the importance of not creating one-size-fits all
programs that leave rural communities without access to vital health-
care services.
I look forward to working with Ms. Verma in the future and am
excited to see someone with her qualifications and background willing
to step away from her great success in the private sector to serve her
country in this capacity.
I'd like to just focus on that, because we are in the nominations
business right now, and there has been a degree of rancor in the
nominations process which is unfortunate. I sometimes wonder why
anybody would want to put themselves through this grueling process.
We have before us a nominee who has a good life outside of
Washington. She doesn't need to be subject to personal attacks or made
into a symbol of partisan discord. But, she is willing to be under an
extremely high level of scrutiny to do what she thinks is the right
thing.
Ms. Verma is impressive; she has practical, not just theoretical,
knowledge of our Federal health care programs, and I particularly
appreciate what she has said about the need to focus on the outcome for
patients. At the end of the day, that should be our primary objective.
I look forward to working with her as CMS Administrator.
Thank you, Mr. Chairman.
______
Prepared Statement of Hon. Orrin G. Hatch,
a U.S. Senator From Utah
WASHINGTON--Senate Finance Committee Chairman Orrin Hatch (R-Utah)
today delivered the following opening statement at a hearing to
consider the nomination of Seema Verma to head the Centers for Medicare
and Medicaid Services (CMS):
Today we will consider the nomination of Seema Verma to serve as
Administrator of the Centers for Medicare and Medicaid Services.
Welcome, Ms. Verma, to the Finance Committee. I appreciate your
willingness to lead this key agency at this critical time. I see that
your family has joined you here today to lend support. I extend a warm
welcome to them as well.
CMS is the world's largest health insurer, covering over one-third
of the U.S. population through Medicare and Medicaid alone. It has a
budget of over $1 trillion, and it processes over 1.2 billion claims a
year for services provided to some of our Nation's most vulnerable
citizens.
Ms. Verma, having dealt with CMS extensively in your capacity as a
consultant to numerous State Medicaid programs, you know full well the
challenges the agency deals with on daily basis.
I suspect you also know that the job you've been nominated for is a
thankless one, fraught with numerous challenges.
The good news is that there are opportunities in those challenges,
and I believe you are the right person for the job and that you will
make the most of those opportunities to improve our health-care system.
The failings of Obamacare are urgent and must be addressed in short
order.
Over the past 6 years, we have watched as the system created under
Obamacare has led to increased costs, higher taxes, fewer choices,
reduced competition, and more strains on our economy.
Under Obamacare, health insurance premiums are up by an average of
25 percent this year alone.
Under Obamacare, Americans, including millions of middle-class
Americans, have been hit with $1 trillion in new taxes.
And, under Obamacare, major insurers are no longer offering
coverage on exchanges, and earlier this week, we learned that another
major carrier will exit the market in 2018.
As Congress works to change course with regard to our ailing
health-care system, CMS will play a major role in determining our
success. I applaud the step the agency took yesterday under the
leadership of HHS Secretary Price with its proposed rule to help
stabilize the individual insurance markets, but there is much more work
to be done and I am confident that, if you are confirmed, you will be a
valuable voice in driving change.
I'd like to talk specifically about Medicaid for a moment.
The Medicaid program was designed to be a safety net for the most
vulnerable Americans. As such, I understand and value the moral and
social responsibilities the Federal Government has in ensuring health-
care coverage for our most needy citizens. I am committed to working
with States and other stakeholders, and the American public to improve
the quality and ensure the longevity of the Medicaid program.
But we must also acknowledge that the Medicaid program is three
times larger--both in terms of enrollment and expenditures--than it was
just 20 years ago. Additionally, the Medicaid expansion under Obamacare
exacerbated pressures on the program at a time when many States were
already facing difficult choices about which benefits and populations
to serve. As a result, we have a responsibility to consider alternative
funding arrangements that could help to preserve this important
program.
We also need to consider various reform proposals that can improve
the way Medicaid operates. Ms. Verma, we will need your assistance in
both of these efforts, and your experience in this particular area
should serve you well.
On the subject of Ms. Verma's experience, I want to note for the
committee that she has been credited as the creative force behind the
Healthy Indiana Plan, the State's Medicaid alternative. This program
provides access and quality health care to its enrollees, while
ensuring that they are engaged in their care decisions. The program
continues to evolve while hitting key metrics and, overall, enrollees
are very satisfied with their experience.
While we may hear criticisms of this program from the other side of
the dais here today, we should note that HHS and CMS leaders under the
Obama administration repeatedly approved the waiver necessary to make
this program a reality.
Ms. Verma has assisted a number of other State Medicaid programs as
well. Her efforts all have the same focus--getting needed, high-quality
care to engaged patients in a fiscally responsible way. This is exactly
the mind-set we need in a CMS Administrator.
Now, Ms. Verma, as if the challenges associated with Medicaid are
not enough to keep you busy as CMS Administrator, you will also be
tasked with helping to ensure the longevity and solvency of the
Medicare trust fund, which is projected to go bankrupt in 2028.
All told, between now and 2030, 76 million baby boomers will become
eligible for Medicare. Even factoring in deaths over that period, the
program will grow from approximately 47 million beneficiaries today to
roughly 80 million in 2030.
Maintaining the solvency of the Medicare program while continuing
to provide care to an ever expanding beneficiary base is going to
require creative solutions. It will not be easy. But, we can't put it
off forever, and the longer we wait, the worse it will get.
Now that I've had a chance to discuss the challenges facing CMS and
some of Ms. Verma's qualifications, I want to speak more generally
about recent events.
We've gone through a pretty rough patch recently on this committee,
particularly as we've dealt with President Trump's nominations. I don't
want to rehash the details of the past few weeks, but I will say that I
hope that recent developments do not become the new normal for our
committee.
As I've said before, I'm going to do all I can to restore and
maintain the customs and traditions of this committee, which has always
operated with assumptions of bipartisanship, comity, and good faith.
With regard to considering nominations, that means a robust and fair
vetting process, a rigorous discussion among committee members, and a
vote in an Executive Session.
On that note, maybe the icy treatment of nominees is starting to
thaw today, at least I hope it is. One tradition that has been absent
here this session has been the introduction, on many occasions, of
nominees by Senators of both parties from the nominees' home States,
especially in cases when the nominee and the home State Senator have a
relationship. I'm pleased to say that the Senior Senator from Indiana
is re-affirming that tradition by appearing here today. I thank the
Senator for taking the time to appear today and introduce his
constituent. I'll give him a chance to do so in just a few minutes.
With that, I look forward to Ms. Verma sharing her vision and views
here today. I also look forward to what I hope will be a full and fair
committee process that allows us to process this nomination and report
it to the full Senate in short order.
______
America's Essential Hospitals
401 Ninth St., NW, Suite 900
Washington DC 20004
t: 202-585-0100
f: 202-585-0101
e: [email protected]
https://essentialhospitals.org/
February 15, 2017
The Honorable Orrin Hatch The Honorable Ron Wyden
Chairman Ranking Member
U.S. Senate U.S. Senate
Committee on Finance Committee on Finance
Washington, DC 20510 Washington, DC 20510
Dear Chairman Hatch and Senator Wyden:
On behalf of America's Essential Hospitals and its nearly 300 member
hospitals across the country, I write to support the appointment of
Seema Verma, MPH, as administrator of the Centers for Medicare and
Medicaid Services (CMS).
America's Essential Hospitals is the leading association and champion
for hospitals and health systems dedicated to high-quality care for
all, including the vulnerable. Our members are cornerstones of care in
their communities, providing primary care through trauma care, disaster
response, health care workforce training, research, public health
programs, and other vital services. But they do more than keep people
healthy and productive--they bolster the economic health of their
communities. Each year, our members generate more than $165 billion of
economic activity for their respective State economies and contribute
to more than 1.25 million jobs nationally.
We believe Ms. Verma is well-qualified to lead CMS, given her deep
understanding of both health-care delivery and policymaking. Through
her work at essential hospitals, she has firsthand experience
delivering care to low-income and other vulnerable people. She
previously served as vice president of planning for the Health and
Hospital Corporation of Marion County, an association member in
Indiana, and as a director for the Association of State and Territorial
Health Officials, in Washington, DC. In 2001, she graduated from
America's Essential Hospitals' Fellows Program, which helps rising
health-care leaders transform the culture of care. Also of note, Ms.
Verma served as Indiana's health reform lead, a role in which she
oversaw implementation of the State's Medicaid expansion waiver under
then-Governor Mike Pence.
Ms. Verma will contribute an important, State-level perspective on
Medicaid, insurance, health-care delivery, and public health. As States
grapple with options for the future of their Medicaid program, Verma's
background in innovative waivers and her proven ability to work
effectively with States will engender confidence in the agency's
actions.
We stand at a crossroads for health care. As CMS leads the charge for
high-quality care at lower costs and with better health outcomes for
all people, the agency's role and responsibilities take on heightened
importance. At this critical juncture, Ms. Verma would contribute
needed and valuable knowledge about Medicaid and Medicare, the complex
programs on which our Nation's vulnerable people and their hospitals
depend.
We look forward to working with Ms. Verma to ensure essential hospitals
can sustain their commitment to those in need and to underserved
communities, and to continue national efforts to foster innovation and
reduce disparities in care.
We urge the committee to swiftly confirm Ms. Verma.
Sincerely,
Bruce Siegel, M.D., MPH
President and CEO
______
February 13, 2017
The Honorable Orrin G. Hatch
Chairman
U.S. Senate
Committee on Finance
The Honorable Ron Wyden
Ranking Member
U.S. Senate
Committee on Finance
Re: Nomination of Seema Verma to be Administrator, Centers for
Medicare and Medicaid Services
Dear Chairman Hatch and Ranking Member Wyden:
In previous Republican administrations, we all had the honor of leading
the agency now known as the Centers for Medicare and Medicaid Services
(CMS). With expenditures of $1 trillion per year and oversight over the
Medicare, Medicaid, SCRIP, and now ACA programs, CMS's 5,000 employees
are responsible for managing and regulating the largest health
insurance program in the country. At the top of this critical agency
sits the Administrator.
Regardless of how you might feel about each of these programs and the
administration's policy initiatives, effective leadership of the agency
is essential. Being CMS Administrator is a critical job in the
executive branch, helping to assure that CMS is able to continue
improving its payment capabilities, better support providers and
beneficiaries, assist States, implement a wide range of broadly-
supported legislative initiatives such as the major reforms in Medicare
physician payments, and respond to beneficiary and Congressional
requests. Having someone who understands its mission, is an expert in
health policy, and has experience working with the agency is important
to being a successful leader.
Seema Verma has the traits necessary to be a successful CMS
Administrator. The heart and soul of the agency's work is supporting
beneficiaries--seniors, low-income mothers, children or those seeking
insurance through the exchanges. Seema understands that all CMS
employees come to work every day with the mission of serving these
diverse groups, and that the Administrator plays a critical role in
supporting CMS employees in that mission.
But at the same time, to best serve beneficiaries, the policies and
regulations guiding these programs must be market-based, calling upon
and encouraging the best ideas of the private sector for delivering
care. CMS must be a good primer to the health care sector as realized
by fair and realistic regulation, to improve the quality of our
country's health care while at the same time keeping tighter control of
costs. Providers and patients work to get the right care at the right
time, but no agency can do as much as CMS to help or hinder those
efforts. Therefore the Administrator must understand the complexity and
competition within the health care system, including the all-important
dynamic that exists between payers and providers.
The Administrator must assure that the agency makes timely and coherent
decisions in the best interests of the beneficiary and taxpayer with a
focus on making health care more affordable for all. And of course, it
is important to both the employees of CMS and to the public that there
be a strong degree of transparency in the decisions and actions of the
Administrator and her senior advisors. With trillions of dollars and
the health of millions of beneficiaries at stake, taxpayers and elected
officials must understand the process and rationale for CMS decisions
and actions. This is particularly important for decisions related to
the implementation of new legislation--and CMS has many such decisions
ahead, including countless decisions to assure the effective
implementation of physician payment reform and changes in the ACA.
While all of us might have our preferred policies and ideas for how CMS
can improve the health care delivery system, Seema Verma has the kind
of health policy leadership experience needed to carry out these
essential responsibilities. Through her interactions with CMS as she
negotiated Indiana's Medicaid waiver and other state reform proposals,
she understands the kind of leadership and commitment needed to make
the agency work well. Through her career-long commitment to improving
the well-being of beneficiaries and the quality and efficiency of
insurance programs, she has the heart to succeed as well.
For these reasons, most importantly for the over 100 million Americans
served by CMS and for American taxpayers, we support Seema Verma's
confirmation as soon as possible. We believe CMS and its critical
responsibilities will be in good hands.
Sincerely,
William L. Roper
Gail R. Wilensky
Leslie V. Norwalk
Mark B. McClellan
Thomas A. Scully
______
February 15, 2017
The Honorable Orrin G. Hatch
Chairman
U.S. Senate
Committee on Finance
Washington, DC 20510
Dear Chairman Hatch:
We write to endorse without reservation the nomination by President
Donald J. Trump of Ms. Seema Verma for the position of Administrator of
the Centers for Medicaid and Medicare Services. Ms. Verma has decades
of experience working with State health care and industry leaders to
reform and improve services for the most vulnerable in our communities.
There are few professionals in the Nation who possess the respect,
hands-on experience, and relationships with State leaders that will be
critical as the Congress and administration work to repeal and replace
the Affordable Care Act. Medicaid represents an enormous burden on
State budgets combined with an unprecedented opportunity to reform a
Federal entitlement program long in need of structural changes. Ms.
Verma is the ideal candidate to oversee the reform of Medicaid design
and ensuring pending State waivers are fast-tracked and with the
underlying premise that Medicaid is a State-Federal partnership.
As a consultant working alongside States and industry leaders
throughout the legislative process and implementation of the Affordable
Care Act, Ms. Verma has a unique understanding of the nexus between the
health insurance marketplace and the States and the impact of the ACA
on coverage and cost.
President Trump and Vice President Pence have made an inspired choice
for CMS Administrator in Ms. Seema Verma. We look forward to working
with Congress and the administration to truly reform health-care
delivery and insurance coverage in our great Nation.
Sincerely,
Governor Eric Holcomb Governor Robert Bentley Governor Douglas A.
Indiana Alabama Ducey
Arizona
Governor Asa Hutchinson Governor Nathan Deal Governor Edward J.
Arkansas Georgia Baza Calvo
Guam
Governor Sam Brownback Governor Matt Bevin Governor Paul R.
Kansas Kentucky LePage
Maine
Governor Rick Snyder Governor Phil Bryant Governor Eric R.
Michigan Mississippi Greitens
Missouri
Governor Chris Christie Governor Doug Burgum Governor John R.
New Jersey North Dakota Kasich
Ohio
Governor Mary Fallin Governor Dennis Governor Bill Haslam
Oklahoma Daugaard Tennessee
South Dakota
Governor Greg Abbott Governor Gary R. Governor Scott Walker
Texas Herbert Wisconsin
Utah
______
Commonwealth of Kentucky
Office of the Governor
700 Capitol Avenue, Suite 100
Frankfort, KY 40601
(502) 564-2611
Fax: (502) 564-2517
KentuckyUnbridledSpirit.com
February 15, 2017
The Honorable Orrin G. Hatch
Chairman
U.S. Senate
Committee on Finance
Washington, DC 20515
Dear Chairman Hatch:
I want to personally reach out to you and offer my unequivocal
endorsement of Ms. Seema Verma who was nominated by President Donald J.
Trump to serve in the position of Administrator of the Centers for
Medicaid and Medicare Services (CMS). As Governor of Kentucky, I look
for three key attributes when making appointments to my cabinets--
character, competence, and commitment. Ms. Verma will unquestionably
bring these positive characteristics and much more to the position.
Ms. Verma is well positioned and uniquely qualified to serve in her
role. As you are aware, the administration of the Medicaid program is a
partnership between the State and the Federal Government--specifically,
CMS; however, in recent years, it has not felt this way. The Affordable
Care Act (ACA) was forced upon Americans with minimal input from States
or the public. CMS, under the former administration, gave very little
flexibility to States to be innovative or tailor Medicaid programs to
fit the needs of their unique populations or obtain relief from the
burdens of the ACA. During this time, Ms. Verma successfully navigated
mountains of regulation to guide States through the frustrating process
of getting permission to enact innovative policies. Ms. Verma is
ideally suited to eliminate unnecessary red tape and to grant much
needed flexibility to States to develop solutions for their
populations.
In fact, I can speak to this first hand as I was fortunate enough
to work with Ms. Verma in the development of Kentucky HEALTH, an
innovative section 1115 waiver designed to improve health outcomes and
create fiscal sustainability for Kentucky's Medicaid program. Ms.
Verma's deep understanding of the Medicaid program and her experience
navigating CMS, was invaluable as we made policy decisions in crafting
our waiver. This understanding and experience will be especially
valuable to the Trump administration and Congress as much needed
changes to America's health system are considered.
Additionally, I am especially appreciative of her understanding of
Medicaid from the State's perspective. Such perspective is critical as
policies and regulations are crafted that will impact how States
administer the Medicaid program.
For these reasons, and many more, I enthusiastically encourage the
Senate to confirm the appointment of Ms. Seema Verma. Kentucky looks
forward to working with Congress, President Trump, Vice President
Pence, and the new leadership at the U.S. Department of Health and
Human Services on much-needed and meaningful healthcare reform.
Sincerely,
Matthew G. Bevin
Governor of Kentucky
______
Partnership for Quality Home Healthcare
February 15, 2017
The Honorable Orrin G. Hatch
Chairman
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510-6200
The Honorable Ron Wyden
Ranking Member
U.S. Senate
Committee on Finance
219 Dirksen Senate Office Building
Washington, DC 20510-6200
Dear Chairman Hatch and Ranking Member Wyden:
On behalf of the Partnership for Quality Home Healthcare (Partnership),
we are writing in strong support of the nomination of Seema Verma to
serve as Administrator of the Centers for Medicare and Medicaid
Services (CMS).
As the nation's premier association of leading skilled home health
agencies, the Partnership is committed to delivering high quality
health-care services in the home, offering value to taxpayers and to
families. Our nurses, therapists and caregivers provide essential
skilled care services in an increasingly complex regulatory environment
that is unnecessarily duplicative, burdensome and challenging.
The Partnership supports Ms. Verma's nomination because of her
extensive experience in the private sector health-care field, which we
believe contributes to her understanding of the complexity of
delivering care in such a highly regulated and tightly controlled
environment. The Partnership is eager to work with Ms. Verma on common-
sense solutions to reduce regulatory burden and make Medicare's home
health benefit more accessible to seniors in need. We also believe that
it is critical that the largest health-care payer in the Nation have a
confirmed, permanent Administrator.
Accordingly, we enthusiastically support Ms. Verma's nomination and
urge her expeditious confirmation.
Very Truly Yours,
Colin Roskey
Executive Vice President
______
Letter Submitted by Hon. Dean Heller, a U.S. Senator From Nevada
Nevada Legislature
January 10, 2017
The Honorable Dean Heller
324 Hart Senate Office Building
Washington, DC 20510
Dear Senator Heller:
We are writing to express our concern regarding plans to repeal the
Affordable Care Act. Specifically, we are concerned that Republicans in
Congress are pushing ahead with a repeal of the Affordable Care Act
despite having no viable replacement legislation ready to enact.
Failure to immediately enact replacement legislation risks creating
uncertainty in the insurance marketplace. Such uncertainty will likely
result in higher out-of-
pocket costs and fewer insurance options for Nevada's families while
simultaneously placing an increased burden on our State budget.
As you are aware, Governor Sandoval worked closely with the Legislature
and ultimately signed legislation creating the Silver State Health
Exchange in 2011. Subsequently, more than 300,000 Nevadans have gained
access to health-care coverage, either by purchasing it on the exchange
or by meeting the expanded Medicaid eligibility requirements.
In light of these facts, we hope that you will address the following
questions regarding the planned repeal of the Affordable Care Act:
1. What steps do you plan to take to ensure that the more than
88,000 Nevadans who have purchased health insurance through the Silver
State Health Exchange continue to have the ability to purchase health
insurance with adequate coverage in a transparent marketplace?
2. What steps do you plan to take to ensure that the more than
77,000 Nevadans who are eligible for Federal tax credits under the
Affordable Care Act to help purchase private insurance will continue to
have access to affordable health insurance options with adequate
coverage?
3. What steps do you plan to take to ensure that the 217,000
Nevadans who are receiving health care under the Medicaid expansion
remain covered?
4. The Affordable Care Act guarantees coverage vital to
preventative services for women, including cancer screenings and birth
control. What steps do you plan to take to ensure that the Affordable
Care Act's coverage guarantees remain intact for women's health?
5. The Affordable Care Act guarantees that Nevadans with pre-
existing conditions will not be denied health care and ends lifetime
minimums on coverage. It also allows younger people, many of whom are
saddled with college debt and cannot afford insurance, to stay on their
parents' insurance until they are 26. What steps do you plan to take to
preserve those coverage guarantees?
The lack of clarity regarding viable alternatives to the Affordable
Care Act from the incoming administration and Republican congressional
leadership is troubling. While Congress has expended considerable time
and energy over the past several years talking about the law, hundreds
of thousands of Nevadans have relied in good faith on the Affordable
Care Act to obtain health insurance. Repealing the law without
implementing an adequate replacement will put those Nevadans' health
and well-being at risk.
Further, any congressional action that creates a large gap in insurance
coverage will likely result in more Nevadans relying on State-funded
social service programs. Most of these programs are already under
resourced. Nevada cannot afford to shoulder this new financial burden
created by politicians in Washington failing to live up to guarantees
that the Federal Government previously made to our citizens.
We hope you will use your position as Nevada's senior United States
Senator and a member of the majority party to protect the thousands of
Nevada families who are now at risk of losing their health insurance.
We also hope you will take steps to ensure that our State does not bear
any unfair and unnecessary costs of caring for people who stand to lose
that coverage in the near future.
We look forward to your prompt reply.
Sincerely,
Aaron D. Ford Jason Frierson
Majority Leader Speaker
Nevada State Senate Nevada State Assembly
______
Prepared Statement of Seema Verma, Nominated to be Administrator,
Centers for Medicare and Medicaid Services, Department of Health and
Human Services
Chairman Hatch, Ranking Member Wyden, members of the committee,
thank you for allowing me to appear before you today. I am deeply
honored to be here, and am grateful for your consideration of my
nomination by President Trump to be Administrator of the Centers for
Medicare and Medicaid Services. I appreciate the time many of you and
your staffs have taken to meet with me in advance of this hearing.
Before I begin my statement, I would like to take a moment to
introduce my family. I am truly grateful for the love and support of my
parents Mr. and Mrs. Verma, my husband Sanjay Mishra and my two
children Maya and Shaan.
I have often been asked, by my family as well as by the members of
this committee, why I would be interested in a job as complex and
difficult as running a trillion dollar government agency such as CMS.
I humbly accepted President Trump's call to service because I
understand what is at stake. I have never stood on the sidelines of our
Nation's health-care debate, merely pointing out what is wrong with our
health-care system. I have spent my entire life helping the most
disadvantaged in our society receive the kind of accessible, affordable
and competent health-care service that our country's health-care system
is renowned for.
More than 20 years ago, when I graduated from college, I started my
career working on national policy on behalf of people with HIV and
AIDS, as well as low-income mothers to improve birth outcomes. I fought
for coverage, for greater health-care access and for improving the
quality of care--and have continued to fight for these issues for the
past 20 years.
But, sadly, I am deeply concerned about our health-care system.
There is frustration all around. Doctors are increasingly frustrated by
a number of costly and time-consuming burdens, and quite frankly, many
Americans are not getting the care that they need.
We have a long way to go in improving health outcomes. Health care
continues to grow more and more expensive, and the American people are
tired of partisan politics. They just want their health-care system
fixed.
And I know this, not simply because I have worked in health care,
but because of how intimately it has affected my personal life.
Two people I truly love have been immensely affected by enormous
health-care challenges.
My own mother is a breast cancer survivor due to early diagnosis
and treatment, and I thank God that she is with me today.
Also, a few years back, my neighbor was diagnosed with a stage 4
neuroblastoma. A large tumor had been growing for some time, wrapping
around his kidney. Aidan went through excruciating chemotherapy,
radiation, stem cell treatment, surgeries, and countless trips to the
hospitals and doctors. Experimental treatments were used by his medical
team. This treatment regimen would be excruciating for anyone to
endure, but Aidan was only 4 years old. At such a young age, we didn't
know if he would live or die.
But this May Aidan will celebrate his 12th birthday.
Both my mom and Aidan are testaments to the ingenuity of the
American medical system that saved their lives, as well as to the grace
of God. This is why people travel from around the world to get care
here in the United States.
I want to be part of the solution making the system work for all
Americans. I want to be able to look my children in the eye and tell
them I did my part to serve my country and make things better for
people who often do not have a voice. I want to tell my children that I
fought to ensure that all American families, like Aidan's and my own,
have the care that they need.
This is a formidable challenge, but I am no stranger to achieving
success under difficult circumstances.
My father left his entire family to immigrate to the United States
during the 1960s to pursue four degrees while he worked to earn money
to pay for school, as well as to provide for his family.
On my mother's side, my grandmother was married at the age of 17
with no more than a 5th-grade education, but my mother was the first
woman in her family to finish a master's degree.
My parents made a lot of sacrifices along the way to provide me
with opportunities they didn't have.
I am extremely humbled as a first-generation American to be sitting
before this committee after being nominated by the President of the
United States. It is a testament to the fact that the American Dream is
very much alive for those willing to work for it.
And it is my passion to continue to work on the front lines of
health care, changing and improving this country's health care delivery
system.
Throughout my career, I have brought people together from all sides
of the political spectrum to forge solutions that worked for everyone.
These consensus efforts have resulted in programs that have provided
health-care coverage to over a million vulnerable Americans. One of the
proudest moments of my career was watching the Indiana legislature pass
the Healthy Indiana Plan with a bipartisan vote.
For me, today's hearing is not simply a matter of finding a good
executive to run a large government bureaucracy. It is about bringing
someone to the table who fundamentally understands that the future of
our country's health care is at stake.
CMS is a $1 trillion agency, and through Medicare, Medicaid, the
Children's Health Insurance Program, and the Health Insurance
Marketplace, it covers over 100 million people, many of whom are among
our most vulnerable citizens. Providing high quality, accessible health
care for these Americans isn't just a luxury, it's a necessity and
often a matter of life and death.
Should I be confirmed, I will work to ensure that CMS's programs
are focused on achieving positive outcomes. As the Nation's largest
purchaser of health care, we must do more, achieve more than the mere
distribution of insurance cards. We can use these programs to truly
make a difference in people's lives to prevent and cure disease, manage
chronic illnesses, and promote healthy lifestyles and independence from
government assistance.
In order to achieve our goals, I will work toward policies that
foster patient-centered care and increase competition, quality, and
access while driving down costs.
Patients and their doctors should be making decisions about their
health care, not the Federal Government. We need to ensure that people
have choices about their care. We shouldn't assume that all vulnerable
or low income populations don't want choices or aren't capable of
making the best decisions for themselves and their families. We must
find creative ways to empower people to take ownership of their health
and be engaged in making cost and quality decisions as they seek care.
CMS's rules and regulations shouldn't drive doctors and providers away
or crowd out care, but should instead support them in delivering high
quality care to their patients.
If confirmed, I will work toward modernizing CMS's programs to
address the changing needs of the people they serve, leveraging
innovation and technology to drive coordinated, cost effective care. I
will ensure that efforts around preventing fraud and abuse are a
priority, since we cannot afford to waste a single taxpayer dollar.
Ultimately, while we strive to provide the highest level of care to our
current beneficiaries, we must solidify the programs' sustainability
for future generations.
I will work toward ushering in a new era of State flexibility and
leadership. For too long our State partners have been sharing in the
cost but have not been allowed to have a meaningful role in decision
making. We need to guarantee that appropriate protections are in the
place for our most vulnerable populations and hold States accountable
for achieving outcomes around quality and access, but we also need to
create an environment that incentivizes innovation over paper-pushing,
so that we can find new and better ways of achieving our mutual goals.
If I have the honor of being confirmed, I will carry this vision,
along with my strong belief in open communication, collaboration, and
bipartisanship with me to CMS. I will work with you, be responsive to
your inquiries and concerns, and value your counsel.
I will do everything I can to ensure that your constituents are
being properly served by the programs at CMS, and that these programs
operate in an efficient and transparent manner.
I thank you for your consideration of my nomination.
______
SENATE FINANCE COMMITTEE
STATEMENT OF INFORMATION REQUESTED
OF NOMINEE
A. BIOGRAPHICAL INFORMATION
1. Name (include any former names used): Seema Verma.
2. Position to which nominated: Administrator, Centers for Medicare
and Medicaid Services.
3. Date of nomination: January 20, 2017
4. Address (list current residence, office, and mailing addresses):
5. Date and place of birth: September 27, 1970, Portsmouth, Virginia.
6. Marital status (include maiden name of wife or husband's name):
7. Names and ages of children:
8. Education (list secondary and higher education institutions, dates
attended, degree received, and date degree granted): Johns Hopkins
School of Hygiene and Public Health, Baltimore, MD, Master of Public
Health--Health Policy and Management, 1996; University of Maryland,
College Park 1988-1993, Bachelor of Science, Life Sciences, 1993.
9. Employment record (list all jobs held since college, including the
title or description of job, name of employer, location of work, and
dates of employment): Founder, president, and CEO, SVC Inc.,
Indianapolis, IN (2001-present); vice president, corporate planning,
Health and Hospital Corporation, Indianapolis, IN (1999-2001); Director
of Program Development/Healthy Babies Initiative, Marion County Health
Department, Indianapolis, IN (1997-1999); Project Director HIV/AIDS and
Consultant, Association of State and Territorial Health Officials
(ASTHO), Washington DC (1993-1997).
10. Government experience (list any advisory, consultative, honorary,
or other part-time service or positions with Federal, State, or local
governments, other than those listed above): As stated in Item 9 above,
from 1997-1999, I was employed by the Marion County Health Department.
Attachment 1 includes a list of consulting projects in which I have
engaged on behalf of various State government agencies through prime
contracts or subcontracts awarded to SVC, Inc.
11. Business relationships (list all positions held as an officer,
director, trustee, partner, proprietor, agent, representative, or
consultant of any corporation, company, firm, partnership, other
business enterprise, or educational or other institution): Owner,
president, and CEO of SVC, Inc. Please also refer to Attachment 1 for
consulting projects in which I have engaged through SVC.
12. Memberships (list all memberships and offices held in
professional, fraternal, scholarly, civic, business, charitable, and
other organizations): I no longer hold positions with any such
organizations. In 2016 I held the following positions with these
organizations, from which I recently resigned: board member, Aidan
Brown Foundation; chair of the International Festival, Teacher
Luncheon's, Sycamore School.
13. Political affiliations and activities:
a. List all public offices for which you have been a candidate.
N/A.
b. List all memberships and offices held in and services rendered
to all political parties or election committees during the last 10
years.
N/A.
c. Itemize all political contributions to any individual, campaign
organization, political party, political action committee, or similar
entity of $50 or more for the past 10 years.
Individual Contributions
------------------------------------------------------------------------
Recipient Amount Date of Contribution
------------------------------------------------------------------------
Mitch for Governor Campaign $1,001 March 21, 2007
Committee
------------------------------------------------------------------------
Mitch for Governor Campaign $1,001 March 21, 2007
Committee
------------------------------------------------------------------------
Mitch for Governor Campaign $1,000 June 10, 2008
Committee
------------------------------------------------------------------------
Eric Holcomb for Indiana $300 June 10, 2015
------------------------------------------------------------------------
Friends of Susan Brooks $1,000 November 16, 2015
------------------------------------------------------------------------
Eric Holcomb for Indiana $351 January 27, 2016
------------------------------------------------------------------------
Erin Houchin for Congress $750 March 31, 2016
------------------------------------------------------------------------
Friends of Susan Brooks $250 October 12, 2016
------------------------------------------------------------------------
Friends of Todd Young $500 October 18, 2016
------------------------------------------------------------------------
SVC, Inc. Contributions
------------------------------------------------------------------------
Recipient Amount Date of Contribution
------------------------------------------------------------------------
Aiming Higher $5,000 May 16, 2012
------------------------------------------------------------------------
Mike Pence for Indiana $500 June 12, 2012
------------------------------------------------------------------------
Turner for State Representative $500 June 13, 2012
------------------------------------------------------------------------
Turner for State Representative $300 December 20, 2013
------------------------------------------------------------------------
Eric Holcomb for Indiana $200 October 5, 2016
------------------------------------------------------------------------
14. Honors and awards (list all scholarships, fellowships, honorary
degrees, honorary society memberships, military medals, and any other
special recognitions for outstanding service or achievement): Sagamore
of the Wabash, an Indiana honorary award given to me by Vice President
and former Governor of Indiana Mike Pence.
15. Published writings (list the titles, publishers, and dates of all
books, articles, reports, or other published materials you have
written):
``Election Headlines Bury Need for a Discussion on Future of
Health Care,'' The Hill, and Real Clear Health, October 22, 2016.
``Healthy Indiana 2.0 Is Challenging Medicaid Norms,'' Health
Affairs, August 29, 2016.
``IN: Health Care Reform Amidst Colliding Values,'' Health
Affairs, May 1, 2008.
16. Speeches (list all formal speeches you have delivered during the
past 5 years which are on topics relevant to the position for which you
have been nominated):
Testimony, Energy and Commerce Health Committee, June 12, 2013
(attached at Attachment 2).
I have given numerous speeches on the Affordable Care Act and
Medicaid Reform. There are no formal transcripts, but PowerPoint
presentations were previously provided.
Lily Speakers Bureau
America's Health Insurance Plans
National Association of State Health Policy
IU Life Sciences Collaborative
Docs4Patient Care
Civic Federation
AHEC
A-TriAcc
Republican Governor's Association
National Governor's Association
Ascension Health Care Conference
Energy and Commerce Medicaid Task Force
17. Qualifications (state what, in your opinion, qualifies you to
serve in the position to which you have been nominated):
For over 20 years I have worked with government health-care
programs on the Federal, State, and local level, and I started my own
health-care consulting company 15 years ago. In this capacity, I have
worked with a variety of health-care organizations on a range of issues
from public health, insurance, and Medicaid giving me broad-based
health-care expertise.
I have spent my career working in the health-care sector trying to
improve access to quality health-care services for vulnerable
populations, including those with HIV/AIDS and pregnant women and their
babies. More recently, I have worked extensively with Governors'
offices across the Nation to develop market-driven approaches that
empower individuals to engage in improving their health to achieve
better health outcomes.
I developed Governor Daniels's Healthy Indiana Plan and was named
his Health Care Reform Lead. In this role, I was responsible for
Indiana's response to the Affordable Care Act, across all State
agencies. In addition, I advised Governor Pence on health-care issues.
Following the election, I was asked to design and implement his
signature health plan, the Healthy Indiana Plan 2.0. I supported
negotiations with the Health and Human Services Agency (HHS) and
coordinated the agency's successful implementation plan, execution, and
launch of the program. In addition, I have worked with Governors Bevin,
Branstad, Haslam, and Otter to develop their health-care programs, and
was also involved in crafting Ohio's Medicaid waiver.
Over the last 6 years, I have worked with a variety of State
governments and other organizations to implement the Affordable Care
Act, both on the Medicaid and insurance sides. I have developed a
working knowledge of thousands of pages of regulations and have been on
the front lines of implementation.
The Medicare program is a critical and important program. I will
bring my strong knowledge of health insurance and delivery of health-
care services to ensuring high quality health care for American's
seniors.
It would be an honor to serve my country as the Centers for
Medicare and Medicaid Services Administrator, and I look forward to the
opportunity.
B. FUTURE EMPLOYMENT RELATIONSHIPS
1. Will you sever all connections with your present employers,
business firms, associations, or organizations if you are confirmed by
the Senate? If not, provide details.
Yes.
2. Do you have any plans, commitments, or agreements to pursue
outside employment, with or without compensation, during your service
with the government? If so, provide details.
No.
3. Has any person or entity made a commitment or agreement to employ
your services in any capacity after you leave government service? If
so, provide details.
No.
4. If you are confirmed by the Senate, do you expect to serve out
your full term or until the next presidential election, whichever is
applicable? If not, explain.
Yes.
C. POTENTIAL CONFLICTS OF INTEREST
1. Indicate any investments, obligations, liabilities, or other
relationships which could involve potential conflicts of interest in
the position to which you have been nominated.
In consultation with the ethics officials of the Department of
Health and Human Services and the Office of Government Ethics, I have
identified certain investments that I will divest to avoid potential
conflicts of interest. In addition, I will recuse myself from matters
involving my former employer, SVC, Inc. and a number of its consulting
clients, and I am arranging for the purchase of SVC, which I plan to
sell if confirmed by the Senate; and I also will recuse myself from
issues that may pose a conflict with my husband's psychiatric medical
practice.
2. Describe any business relationship, dealing, or financial
transaction which you have had during the last 10 years, whether for
yourself, on behalf of a client, or acting as an agent, that could in
any way constitute or result in a possible conflict of interest in the
position to which you have been nominated.
As stated in my response to Item C.1, I have consulted with the
ethics officials of the Department of Health and Human Services and the
Office of Government Ethics to identify potential conflicts of
interest, and have agreed to address those conflicts in an Ethics
Agreement, attached as Attachment 3.
3. Describe any activity during the past 10 years in which you have
engaged for the purpose of directly or indirectly influencing the
passage, defeat, or modification of any legislation or affecting the
administration and execution of law or public policy. Activities
performed as an employee of the Federal Government need not be listed.
I worked on the passage of the Healthy Indiana Plan and amendments
to the law in the State of Indiana, as an advisor to the State/
Governor's offices.
4. Explain how you will resolve any potential conflict of interest,
including any that may be disclosed by your responses to the above
items. (Provide the committee with two copies of any trust or other
agreements.)
As stated in my responses to Items C.1 and C.2, above, I have
consulted with the ethics officials of the Department of Health and
Human Services and the Office of Government Ethics to identify
potential conflicts of interest, and have agreed to address those
conflicts in an Ethics Agreement. In the course of performing my
duties, I will abide by any recommendations made to me by agency ethics
officials.
5. Two copies of written opinions should be provided directly to the
committee by the designated agency ethics officer of the agency to
which you have been nominated and by the Office of Government Ethics
concerning potential conflicts of interest or any legal impediments to
your serving in this position.
My Ethics Agreement is included as Attachment 3.
D. LEGAL AND OTHER MATTERS
1. Have you ever been the subject of a complaint or been
investigated, disciplined, or otherwise cited for a breach of ethics
for unprofessional conduct before any court, administrative agency,
professional association, disciplinary committee, or other professional
group? If so, provide details.
No.
2. Have you ever been investigated, arrested, charged, or held by any
Federal, State, or other law enforcement authority for a violation of
any Federal, State, county, or municipal law, regulation, or ordinance,
other than a minor traffic offense? If so, provide details.
No.
5. Have you ever been involved as a party in interest in any
administrative agency proceeding or civil litigation? If so, provide
details.
No.
6. Have you ever been convicted (including pleas of guilty or nolo
contendere) of any criminal violation other than a minor traffic
offense? If so, provide details.
No.
7. Please advise the committee of any additional information,
favorable or unfavorable, which you feel should be considered in
connection with your nomination.
None.
E. TESTIFYING BEFORE CONGRESS
1. If you are confirmed by the Senate, are you willing to appear and
testify before any duly constituted committee of the Congress on such
occasions as you may be reasonably requested to do so?
Yes.
2. If you are confirmed by the Senate, are you willing to provide
such information as is requested by such committees?
Yes.
______
Attachment 1
Below are two charts setting forth information about consulting work
done by SVC, Inc. The first chart shows direct contracts, and the
second chart shows subcontracts.
Direct Contracts
------------------------------------------------------------------------
State or Entity Agency Period
------------------------------------------------------------------------
Indiana Family Social Services 2002-Present
Association, Indiana
State Department of
Health
------------------------------------------------------------------------
Virginia Department of Health, 2015-2016
OMPP
------------------------------------------------------------------------
Nebraska Department of Insurance 2012-2013
------------------------------------------------------------------------
Tennessee Health Care Finance and 2014-2015
Administration
------------------------------------------------------------------------
Maine Department of Health and 2012-2013
Human Services
------------------------------------------------------------------------
Richard M. Fairbanks 2015-Present
Foundation
------------------------------------------------------------------------
First Data 2013-2014
------------------------------------------------------------------------
Lilly USA 2013
------------------------------------------------------------------------
Eli Lilly and Company 2013-2014
------------------------------------------------------------------------
Health Management 2009-2012
Associates
------------------------------------------------------------------------
IN Hemophilia and 2015
Thrombosis
------------------------------------------------------------------------
Indiana State Medical 2014
Association
------------------------------------------------------------------------
HSA Coalition 2014-2016
------------------------------------------------------------------------
Indiana Hand to Shoulder 2014-2015
Surgery Associates
------------------------------------------------------------------------
National AHEC 2014
Organization
------------------------------------------------------------------------
Maximus 2016-Present
------------------------------------------------------------------------
Roche Diagnostics 2010-2012
------------------------------------------------------------------------
Indiana Dental 2012
Association
------------------------------------------------------------------------
Subcontracts
------------------------------------------------------------------------
Prime Contractor State or Entity Agency Period
------------------------------------------------------------------------
Milliman Actuaries Iowa Department of 2013-Present
Human Services
------------------------------------------------------------------------
Milliman Actuaries South Carolina Department of 2012-Present
Health and
Human Services
------------------------------------------------------------------------
Milliman Actuaries Ohio Department of 2015-Present
Medicaid
------------------------------------------------------------------------
Milliman Actuaries Michigan Department of 2013-2014
Community
Benefit
------------------------------------------------------------------------
Milliman Actuaries Jefferson 2014-2015
County, AL
------------------------------------------------------------------------
Hewlett Packard Indiana FSSA 2008-Present
Enterprises
------------------------------------------------------------------------
Hewlett Packard Arkansas Department of 2015-Present
Enterprises Human Services
------------------------------------------------------------------------
Hewlett Packard Kentucky Cabinet of 2016-Present
Enterprises Health and
Family
Services
------------------------------------------------------------------------
Boise State Idaho Department of 2013
University Health and
Welfare
------------------------------------------------------------------------
Health Management Indiana FSSA and 2006-2011
Associates Lawrence
County
Community
Health and
Wellness
Center
------------------------------------------------------------------------
High Point Global Federal CMS 2016-Present
Government
------------------------------------------------------------------------
______
Attachment 2
The Need for Medicaid Reform: A State Perspective
_______________________________________________________________________
Testimony Presented by Seema Verma
SVC, Inc.
June 12, 2013
Summary
Medicaid has undoubtedly played a considerable role in the lives of
many, providing access to health care for our Nation's most vulnerable
populations. There is no question it has helped many of its
participants. However, designed in 1965, the program has not kept pace
with the modern health-care market. Its rigid, complex rules designed
to protect enrollees have created an intractable program that does not
foster efficiency, quality, or personal responsibility for improvement
in health status. Escalating State costs have not translated into
quality or consistent outcomes.
Failure to reform the program will jeopardize States' ability to care
for those Medicaid was envisioned to serve, including low-income
children, pregnant women, and the aged, blind, and disabled. While the
program is jointly funded by the State and Federal Government, it is
not jointly managed. States are largely dependent on Federal policy,
regulation, and permission to operate their programs. Administrative
review and approval processes add layers of administrative bureaucracy
to the program that thwart States' ability to innovate.
Notwithstanding the cumbersome regulatory review process, there are
many examples of State innovation that have emerged. To transform
Medicaid, States must be given the flexibility and opportunity to
innovate without these undue Federal constraints. Reform efforts should
center, at minimum, around encouraging consumer participation in health
care, holding States accountable based on quality outcomes versus
compliance with bureaucratic requirements, encouraging flexible managed
care approaches, and allowing States to use flexible funding
mechanisms.
INTRODUCTION
Good morning, members of the committee. My name is Seema Verma. I am
the president of SVC, Inc., a policy consulting company, and in this
role have been advising Governor offices, State Medicaid programs, and
State Departments of Health and Insurance. I have worked in a variety
of States including Indiana, South Carolina, Maine, Nebraska, Iowa, and
Idaho. I am also the architect of former Indiana Governor Mitch
Daniels's Healthy Indiana Plan, the Nation's first consumer-
directed health plan for Medicaid beneficiaries.
OVERVIEW
Designed in 1965 for our most vulnerable populations, the Medicaid
program has not kept pace with the modern health-care market. Its
rigid, complex rules designed to protect enrollees have also created an
intractable program that does not foster efficiency, quality, or
personal responsibility. The impact of these issues is more pronounced
as States are entrenched in the fierce debate around Medicaid
expansion. Reluctance to expand is not indifference to the plight of
the uninsured, but trepidation for the fiscal sustainability of the
program and knowledge that expanding without reform will have serious
consequences on Medicaid's core mission to serve the neediest of
Americans.
INCREASING COSTS OF MEDICAID AND STATE BUDGETS
Medicaid comprises nearly 24% \1\ of State budgets, and its costs are
growing.\2\ This is due to enrollment growth, population demographics,
and Federal requirements. The aging baby boomer population will soon
require expensive long-term care. The Affordable Care Act (ACA)
requires maintenance of effort and implementation of hospital
presumptive eligibility, Modified Adjusted Gross Income which
eliminates asset tests for the non-disabled, and the ACA insurer tax
will cost States an estimated $13 to $14.9 billion.\3\ Additionally,
there is the clawback provision burden where States have an
unprecedented requirement to finance the Medicare program.
---------------------------------------------------------------------------
\1\ National Governors Association and National Association of
State Budget Officers (2012). The Fiscal Survey of States. Retrieved
online: http://www.nasbo.org/sites/default/files/
Fall%202012%20Fiscal%20Survey.pdf.
\2\ Deloitte (2010). Issue Brief: Medicaid Long-Term Care: The
Ticking Time Bomb. Retrieved online: http://www.deloitte.com/assets/
Dcom-UnitedStates/local%20Assets/Documents/US_
CHS_2010LTCinMedicaid_062210.pdf.
\3\ Milliman (2012). PPACA Health Insurer Fee Estimated Impact on
State Medicaid Programs and Medicaid Health Plans. Retrieved online:
http://publications.milliman.com/publications/health-published/pdfs/
ppaca-health-insurer-fee.pdf.
---------------------------------------------------------------------------
ACCESS AND QUALITY
Despite growing outlays of public funds, a Medicaid card does not
guarantee access or quality of care. In a survey of primary care
providers, only 31% indicated willingness to accept new Medicaid
patients.\4\ In 2012, 45 States froze or reduced provider reimbursement
rates,\5\ Medicaid access issues are tied to under-compensation of
providers; on average Medicaid payments are 66% of Medicare rates,\6\
and many providers lose money seeing Medicaid patients. Medicaid
beneficiaries struggle to schedule appointments, face longer wait
times, and have difficulty obtaining specialty care.\7\ These access
challenges will be more pronounced as Medicaid recipients compete with
the tens of millions of newly insured under the ACA. Studies also show
Medicaid coverage does not generate significant improvements in health
outcomes,\8\ decrease emergency room (ER) visits or hospital
admissions,\9\ and participants have higher ER utilization rates than
other insured populations.
---------------------------------------------------------------------------
\4\ Decker, S. (2012). In 2011 Nearly One-Third of Physicians Said
They Would Not Accept New Medicaid Patients, But Rising Fees May Help.
Health Affairs, 31(8), 1673-79. Retrieved online: http://
content.healthaffairs.org/content/31/8/1673.abstract.
\5\ The Henry J. Kaiser Family Foundation (2012). Medicaid Today;
Preparing for Tomorrow: A Look at State Medicaid Program Spending,
Enrollment, and Policy Trends. Results from a 50-State Medicaid Budget
Survey for State Fiscal Years 2012 and 2013. Retrieved online: http://
kaiserfamilyfoundation.files.wordpress.com/2013/01/8380.pdf.
\6\ Kaiser Family Foundation. Medicaid-to-Medicare Fee Index.
Retrieved online: http://kff.org/medicaid/state-indicator/medicaid-to-
medicare-fee-index/.
\7\ Bisgaier, J., and Rhodes, K. (2011). Auditing Access to
Specialty Care for Children with Public Insurance. The New England
Journal of Medicine, 324(24), 2324-33. Retrieved online: http://
www.nejm.org/doi/pdf/10.1056/NEJMsa1013285.
\8\ Baicker, K., Taubman, S., Allen, H., Bernstein, M., Gruber, J.,
Newhouse, J., Schnelder, E., Wright, B., Zaslavsky, A., and
Finkelstein, A. (2013). The Oregon Experiment--Effects of Medicaid on
Clinical Outcomes. New England Journal of Medicine, 368, 1712-22.
Retrieved online: http://www.nejm.org/doi/full/10.1056/
NEJMsa1212321#t=abstract.
\9\ Ibid.
---------------------------------------------------------------------------
STATE CONSTRAINTS
At Medicaid's core is a flawed structure. While jointly funded, by the
Federal and State governments, it is not jointly managed. States are
burdened by Federal policy and endure lengthy permission processes to
make routine changes. Notwithstanding the cumbersome procedure, 1115
waivers provide a pathway for State innovation. However, the approval
route is so daunting that States often abandon promising ideas if a
waiver is necessary. Absent are evaluation guidelines, required
timelines, and there is a capricious nature to the approvals, as
waivers do not transfer from one State to another. Even with positive
outcomes, a new administration has the authority to terminate a waiver.
Despite intense Federal oversight, results vary substantially, and
there are no incentives for States to achieve quality outcomes. For
example, the average cost to cover an aged Medicaid enrollee is $5,247
in New Mexico versus $24,761 in Connecticut,\10\ and annual growth
rates also very.\11\ Replacing oversight of day-to-day administrative
processes, the Federal and State governments should collaborate to
identify program standards and incentives. States should be provided
with flexibility to achieve these goals, and successful States should
be rewarded with reduced oversight.
---------------------------------------------------------------------------
\10\ Based on Kaiser Commission on Medicaid and the Uninsured and
Urban Institute estimates based on data from FY 2009 MSIS and CMS-64
reports. Retrieved online: http://kff.org/medicaid/state-indicator/
medicaid-payments-per-enrollee-fy2009/.
\11\ Based on Urban Institute estimates from CMS Form 64. Retrieved
online: http://kff.org/medicaid/state-indicator/growth-in-medicaid-
spending-fy90-fy10/.
Medicaid's uncompromising cost-sharing policies are illustrative of a
key failure. These regulations disempower individuals from taking
responsibility for their health, allow utilization of services without
regard for the public cost, and foster dependency. While some policies
may be appropriate for certain populations, in an era of expansion to
non-disabled adults, they must be revisited. Revised cost-sharing
policies should consider value-based benefit design and incent
enrollees to evaluate cost, quality, and adopt positive health
behaviors. Indiana's Healthy Indiana Plan (HIP) waiver applied
principles of consumerism with remarkable results; lowering
inappropriate ER use and increasing prevention.
CONCLUSION
Congress should reform Medicaid to assure long-term fiscal
sustainability and access to quality services that improve the health
of enrollees. A fundamental paradigm shift in management is required,
and the program should be reengineered away from compliance with
bureaucratic policies that do not change results to aligning incentives
for States, providers, and recipients to improve outcomes. States are
best positioned to develop policies that reflect the local values of
the people they serve and should be given the flexibility to do so.
______
Attachment 3
January 31, 2017
Ms. Elizabeth Fischmann
Associate General Counsel for Ethics
Designated Agency Ethics Official
U.S. Department of Health and Human Services
Hubert H. Humphrey Building, Room 710-E
200 Independence Avenue, SW
Washington, DC 20201
Dear Ms. Fischmann:
The purpose of this letter is to describe the steps that I will
take to avoid any actual or apparent conflict of interest in the event
that I am confirmed for the position of Administrator, Centers for
Medicare and Medicaid Services (CMS), U.S. Department of Health and
Human Services.
As required by 18 U.S.C.Sec. 208(a), I will not participate
personally and substantially in any particular matter in which I know
that I have a financial interest directly and predictably affected by
the matter, or in which I know that a person whose interests are
imputed to me has a financial interest directly and predictably
affected by the matter, unless I first obtain a written waiver,
pursuant to 18 U.S.C. Sec. 208(b)(1), or qualify for a regulatory
exemption, pursuant to 18 U.S.C. Sec. 208(b)(2). I understand that the
interests of the following persons are imputed to me: any spouse or
minor child of mine; any general partner of a partnership in which I am
a limited or general partner; any organization in which I serve as
officer, director, trustee, general partner, or employee; and any
person or organization with which I am negotiating or have an
arrangement concerning prospective employment.
Upon confirmation, I will resign from my position with SVC, Inc. I
will divest my financial interest in SVC, Inc. within 90 days of my
confirmation. I will not participate personally and substantially in
any particular matter that to my knowledge has a direct and predictable
effect on the financial interests of this entity until I have divested
it, unless I first obtain a written waiver, pursuant to 18 U.S.C.
Sec. 208(b)(1), or qualify for a regulatory exemption, pursuant to 18
U.S.C. Sec. 208(b)(2). During my appointment as Administrator, I will
not provide any services to SVC, Inc., except to the extent that I may
need to comply with any requirements involving legal filings, taxes,
fees, or similar matters relating to divesting my financial interests
in SVC, Inc. or winding it down. For a period of 1 year after I divest
my financial interest in SVC, Inc., I will not participate personally
and substantially in any particular matter involving specific parties
in which I know SVC, Inc. or the purchaser of SVC, Inc. is a party or
represents a party, unless I am first authorized to participate,
pursuant to 5 CFR Sec. 2635.502(d). In addition, I will not participate
personally and substantially in any particular matter involving
specific parties in which I know a former client of mine is a party or
represents a party, for a period of 1 year after I last provided
service to that client, unless I am first authorized to participate,
pursuant to 5 CFR Sec. 2635.502(d). Until I have received full payment
from the purchaser for the sale of SVC, Inc., I will not participate
personally and substantially in any particular matter that to my
knowledge has a direct and predictable effect on the ability or
willingness of the purchaser to make full payment to me, unless I first
obtain a written waiver, pursuant to 18 U.S.C. Sec. 208(b)(1).
I provided consulting services to the States of Arkansas, Indiana,
Iowa, Kentucky, Ohio, South Carolina, and Virginia through SVC, Inc.
Pursuant to 5 CFR Sec. 2635.502(d), I will seek a written authorization
to participate personally and substantially in particular matters
involving specific parties in which I know the States of Arkansas,
Indiana, Iowa, Kentucky, Ohio, South Carolina, and Virginia are a party
or represent a party.
Additionally, following my appointment, my spouse and I will divest
our interests in the following entities within 90 days of my
confirmation:
Alphabet Inc. Class A
Alphabet Inc. Class C
Biogen Inc.
Columbia Seligman Communications and Information Fund
Credit Suisse SPSIOP Index Market Linked Note (MLZKV)
Exxon Mobile Corp.
Fidelity Canada Fund
General Electric
Halliburton Company
International Business Machines Corp.
Johnson and Johnson
McDonalds Corp.
Merck and Company, Inc.
Oracle Corp.
Procter and Gamble Co.
Schlumberger Limited
Spectra Energy Corp.
Travelers Companies Inc.
Unilever PLC New ADR
Vanguard Energy Fund
With regard to each of these entities, I will not participate
personally and substantially in any particular matter that to my
knowledge has a direct and predictable effect on the financial
interests of the entity until I have divested it, unless I first obtain
a written waiver, pursuant to 18 U.S.C. Sec. 208(b)(1), or qualify for
a regulatory exemption, pursuant to 18 U.S.C. Sec. 208(b)(2).
I understand that I may be eligible to request a Certificate of
Divestiture for qualifying assets and that a Certificate of Divestiture
is effective only if obtained prior to divestiture. Regardless of
whether I receive a Certificate of Divestiture, I will ensure that all
divestitures discussed in this agreement occur within the agreed-upon
time frames and that all proceeds are invested in non-conflicting
assets.
My spouse practices medicine as a psychiatrist with the Indiana
Health Group, Indianapolis, IN. Additionally, he holds a financial
interest in the Indiana Health Group. As Administrator, I will not
participate personally and substantially in any particular matter that
to my knowledge has a direct and predictable effect on the financial
interests of the Indiana Health Group, unless I first obtain a written
waiver, pursuant to 18 U.S.C. Sec. 208(b)(1).
In order to avoid potential conflicts of interest during my
appointment as Administrator, I, my spouse, or any minor children of
mine will not acquire any direct financial interest in entities listed
on the FDA prohibited holdings list or in entities involved, directly
or through subsidiaries, in the following industries: (1) research,
development, manufacture, distribution, or sale of pharmaceutical,
biotechnology, or medical devices, equipment, preparations, treatment,
or products; (2) veterinary products; (3) health-care management or
delivery; (4) health, disability, or workers compensation insurance or
related services; (5) food and/or beverage production, processing, or
distribution; (6) communications media; (7) computer hardware, computer
software, and related Internet technologies; (8) wireless
communications; (9) social sciences and economic research
organizations; (10) energy or utilities; (11) commercial airlines,
railroads, shiplines, and cargo carriers; or (12) sector mutual funds
that concentrate their portfolios on one country other than the United
States. In addition, we will not acquire any interests in sector mutual
funds that concentrate in any of these sectors.
I have been advised that this ethics agreement will be posted
publicly, consistent with 5 U.S.C. Sec. 552, on the website of the U.S.
Office of Government Ethics with ethics agreements of other
presidential nominees who file public financial disclosure reports.
I understand that as an appointee I will be required to sign the
Ethics Pledge required under the executive order dated January 28, 2017
(``Ethics Commitments by Executive Branch Appointees'') and that I will
be bound by the requirements and restrictions therein in addition to
the commitments I have made in this ethics agreement.
______
Questions Submitted for the Record to Seema Verma
Questions Submitted by Hon. Chuck Grassley
Question. Thirty million Americans suffer from a rare disease and
many of these patients have no therapeutic option to address their
condition. Timely access to innovative therapies for these patients
with no other viable therapeutic options is critical. How can we ensure
that Medicaid drug coverage processes include reviews by clinicians
with expert knowledge and experience with the particular rare disease
and its patient population?
Answer. If confirmed, I commit to working with you and your
colleagues in Congress as well as the FDA and other Federal agencies to
prioritize access to innovative therapies for patients, especially our
most vulnerable citizens who have unmet medical needs. I look forward
to working with clinical experts and relevant Federal entities to
ensure patients' needs are at the center of decision making.
Question. CMS invests heavily in the training expenses of
psychiatry residents serving in both institutions for mental disease
(IMD) and general medical inpatient psychiatric units. But IMDs rules
either prohibit the small number of IMD teaching hospitals from serving
adults with Medicaid, or restrict IMDs from caring for the most
severely ill who need care for slightly longer lengths of stay (15-20)
days.
This rule exacerbates the severe national shortage of treatment for
people with severe mental illness. Resolving this issue would help with
the shortage and would also provide psychiatrists in training with
invaluable experience.
How can CMS maximize its psychiatry training investments in IMD
teaching hospital settings?
Answer. As you know, the nationwide shortage of physicians and the
more general health-care workforce policy questions are central to the
health-care challenges our country faces. If confirmed, I look forward
to implementing policies to address our Nation's opioid epidemic and
improving Americans' access to psychiatric care. As such, I will
carefully review and evaluate IMD rules. I should also note that in
accordance with my Ethics Agreement, which was previously provided to
the Senate, because of my husband's practice as a psychiatrist with the
Indiana Health Group, Indianapolis, IN, and his financial interest in
the Indiana Health Group, I have agreed not to participate personally
and substantially in any particular matter that to my knowledge has a
direct and predictable effect on the financial interests of the Indiana
Health Group, unless I first obtain a written waiver, pursuant to 18
U.S.C. Sec. 208(b)(1). Under the Federal ethics regulations, I am not
required to recuse from consideration or adoption of broad policy
options that are directed to a large and diverse group of persons. I
will be required to recuse myself from matters that involve
deliberation, decision or action that is focused upon the interests of
the Indiana Health Group, or the discrete and identifiable class of
persons or entities that includes Indiana Health Group. To the extent
that I have questions on how to apply my recusal obligations to a
particular matter, I will consult with the HHS Ethics Office for
guidance on the scope of my recusal obligations.
______
Questions Submitted by Hon. Pat Roberts
Question. Health providers continue to ask for relief from the
sheer amount of regulations that they must comply with, but also raise
the issue of inconsistency in the application of rules and penalties
that they are assessed. This is particularly true for our nursing
homes. Ensuring program integrity and protecting our scarce taxpayers
dollars are extremely important priorities for the agency. How do we
balance those priorities so that we are striving toward quality
improvements as opposed to our current enforcement system that is
focused more on penalties? How would you work to provide more
consistency in how regulations are applied?
Answer. I agree that program integrity and the safeguarding of our
scarce taxpayer dollars must be a top priority for CMS. Additionally,
the enforcement of rules that health-care providers follow must be done
consistently and fairly. In order to better treat and deliver high
quality care to patients, health-care providers are better served
spending more of their time on health care, and less of it trying to
guess which laws and regulations will be enforced at the discretion of
a Federal agency. The fair and consistent application and enforcement
of the law will not only protect taxpayer dollars, but it will help
enable health-care providers to do what they do best.
Question. Critical access hospitals are required to provide acute
inpatient care for a period that does not exceed, on an annual average
basis, 96 hours per patient. This Condition of Participation was long
established and well understood by these key rural safety net
providers. However, in the FY 2014 hospitals IPPS final rule, CMS
clarified they will also begin enforcing the condition of payment
requiring physician certification that each patient will stay for 96
hours or less. Will you commit to reviewing this condition of payment
and the effect it has had on our hospitals and beneficiaries in rural
areas?
Answer. If confirmed, I look forward to working with you and your
colleagues in Congress to ensure that critical access hospitals are
best enabled to serve rural populations with the highest possible
quality of care. I commit to working with you to review the impact of
regulation on hospitals and beneficiaries, especially in rural and
frontier areas. Rural providers and their beneficiaries face unique
challenges, and CMS should prioritize communication and collaboration
with rural providers and stakeholders early on in the regulatory
process.
______
Questions Submitted by Hon. John Cornyn
Question. Many States are using section 1115 Medicaid waivers to
provide flexibility and modernize their Medicaid program. It can take
an average of 323 days from submission to approval, and have a lack of
transparency during negotiations which leaves States and stakeholders
in limbo.
What do you think can be done to shorten this time frame for
approval?
What can be done to make the approval/renewal process more
transparent between CMS and States?
What, if anything, should be done to improve oversight of section
1115 waivers?
Answer. The uncertainty around the waiver approval process must
change. The flexibility and incentives for States to innovate must be a
top priority if we are to better care for our most needy citizens. If I
am confirmed, I look forward to working with you to shorten and
streamline the waiver approval process. Unfortunately, with the way the
system is set up, States must report back to and receive permission
from the Federal Government for even routine changes to their Medicaid
programs. As a small business owner involved in the waiver process, I
can attest that the uncertainty and lack of transparency you describe
deters further innovations. As States are forced to spend a great deal
of time and resources to receive approval for routine changes or
updates to their program, far too often they decide that they don't
have the resources or time to pursue more innovative approaches. This
is especially important in a State like Texas, which is home to some of
the most innovative health-care thinkers and actors in the country.
Allowing those health-care organizations the flexibility to innovate,
while being accountable to taxpayers and the citizens they serve, will
reward reforms that work for patients. I look forward to working with
you to improve the waiver process for Texas and other States seeking
greater flexibility and consistency in waiver decisions.
Question. Many States have been using waivers or demonstrations to
operate portions of their Medicaid programs for years, sometimes
decades. HHS estimates that a third of all Federal Medicaid spending is
made under demonstrations. Please outline your thoughts (a) on the
importance of evaluating the extent to which demonstrations are
achieving the objectives of the Medicaid program, and (b) whether
continued review and approval of long-standing demonstration projects
are necessary.
Answer. If I am confirmed, I will be committed to improving the
waiver process and incentivizing innovation over redundant paper-
pushing. We will review the extent and role of evaluations as well as
the need for waivers for long-standing demonstration waivers that are
performing well. States are best equipped to design and understand the
unique needs of their own populations, so it is crucial to ensure the
successful innovations continue and that even more innovations that
prioritize patients' access to quality care are encouraged and tried
without duplicative or unnecessary paperwork.
______
Questions Submitted Hon. Richard Burr
Question. Last October, the Centers for Medicare and Medicaid
Service (CMS) issued a final rule titled, ``Medicare and Medicaid
Programs; Reform of Requirements for Long-Term Care Facilities.'' The
rule was designed to ensure protections are in place for seniors
receiving care through these facilities. However, CMS's analysis shows
that the cost of implementing these regulations will exceed $800
million in the first year of implementation alone, which could create
access issues for patients currently receiving this care.
As Administrator, how do you plan to balance the need for seniors
to have access to safe high quality care, while ensuring that health-
care providers, including nursing homes and skilled nursing facilities,
are able to continue to provide this care to beneficiaries?
What solutions, if any, do you see to decrease compliance costs and
ensure access to care and needed protections for seniors?
Answer. I have fought throughout my career for access to quality
care, and I appreciate that an insurance card does not equal health
care by itself. If confirmed as CMS Administrator, I look forward to
working with you to ensure that seniors have access to safe, quality
care while also considering the impact of government actions on health-
care providers and their ability to serve their patients. It is
essential that all CMS actions carefully consider the impact they have
on health-care providers and their ability to deliver quality care. I
look forward to working with you to implement laws that allow health-
care providers to do what they do best: treat their patients. I will
work with all parties and stakeholders to protect the doctor-patient
relationship and root out inefficiencies so that greater care for
patients and innovation may occur.
Question. As you may know, the Patient Access and Medicare
Protection Act of 2015 included a provision requiring the Secretary of
Health and Human Services (HHS) to submit a report to Congress on the
development of an alternative payment model (APM) for certain radiation
therapy services this year. As Administrator of the Centers for
Medicare and Medicaid Services (CMS), how will you ensure that the
agency is engaging with the provider and patient community as it works
on this report, and during the development of options for this APM and
other APMs for specialty care?
Answer. Communication with providers on the development of the
report is paramount to ensuring that the report is successfully
completed, and, if confirmed, I will ensure that CMS engages with the
stakeholder community.
Questions Submitted by Hon. Johnny Isakson
Question. As part of 21st Century Cures, Senator Warner and I
worked to include a provision that would provide a home infusion
services payment for drugs administered through Durable Medical
Equipment (DME) covered under Part B. CMS played a critical role in
this success by providing thorough technical expertise to assist in the
construction of this benefit. This was an enormous first step in
allowing patients to receive care in their home at a lower cost than
the hospital. I have seen the benefits of home infusion first hand and
it is my hope that we will work together this year to expand this
policy to antibiotics. I look forward to working with you and your
staff to get the data needed to inform the inclusion of infused
antibiotic drugs so as to further benefit patients that require home
infusion therapy.
Answer. Thank you, Senator Isakson and Senator Warner. If
confirmed, I also look forward to working with you both on this
priority.
Question. There has been a lot of discussion around value-based
pricing as a possible approach to addressing some cost barriers to
drugs some patients are experiencing. As you know, currently any drug
manufacturers must offer State Medicaid programs the lowest price it
offers any other payer, except for Medicare Part D which is exempt from
best price.
Do you think value-based drug pricing in Medicaid and other
programs should also be made exempt from Medicaid Best Price?
Answer. If confirmed, I look forward to implementing payment
reforms enacted by Congress to increase patients' access to medical
therapies. I understand the importance of patients having access to
life-saving and life-improving innovations. CMS should serve as a
faithful steward of taxpayer dollars as it fulfills its role in
ensuring Medicaid beneficiaries' access to care.
Question. We are entering a new era where precision medicine can
tailor treatments based on an individual's unique genetic makeup and
target diseases that impact less than 1,000 patients per year, saving
and lengthening lives while reducing unnecessary utilization. This type
of innovation especially is critical for patients with rare diseases
because in some instances a few extra weeks or months can mean so much
to those patients and their families. A concern is that the Medicare
prospective payment systems, which have been the underlying Medicare
payment structure since the early 1980s, is ill equipped to support our
beneficiaries in this new era. My congressional colleagues previously
have recognized this shortcoming, and now Medicare has some tools,
including New Technology Add-On Payments and Pass-Through Payments for
outpatient drugs. However, these programs are temporary fixes lasting
only 2 or 3 years.
How can Medicare better incentivize the utilization and remove
patient access barriers of innovative treatments currently on the
market for rare and ultra-rare diseases?
Does Medicare's current under-reimbursement of innovative therapies
for rare diseases send a signal to the patient and provider community
that Medicare does not prioritize access and treatment of rare
diseases?
Answer. If confirmed, I will work closely with Congress, the FDA,
and other entities to ensure that the Medicare program has clear
pathways for innovations that benefit patients including the millions
of Americans suffering from rare diseases. I appreciate that Medicare
should be a partner when it comes to ensuring that beneficiaries have
access to cutting-edge therapies. Making sure that Medicare provides
access to innovative treatments will be a top priority for CMS if I am
confirmed.
Question. I have heard from rehabilitation hospital facilities in
Georgia that are concerned about the impact that the implementation of
ICD-10 coding is having on a regulation applicable to them called the
60 percent rule. CMS has said there is monitoring of the issue, however
there have been no changes made. I would appreciate if once confirmed,
CMS review this more closely.
Answer. If confirmed I will review this policy closely and look
forward to working with you and your staff to better understand how
this impacts health-care providers in Georgia and around the country.
______
Question Submitted by Hon. Patrick J. Toomey
Question. Since 2005, the Centers for Medicare and Medicaid
Services have sought to restrict long-term care hospitals, known as
LTCHs, from receiving more than 25 percent of their patients from a
single acute care hospital. Worried that this arbitrary threshold would
undermine access for very sick seniors to specialty hospitals,
especially in non-urban communities, Congress has repeatedly intervened
to block this proposal. Most recently, as part of the 21st Century
Cures Act, Congress enacted legislation that I authored with Senator
Bennet and Nelson to block the 25 percent rule through September.
Beginning later this year, LTCHs will be paid on the basis of a
patient's physical condition. This new patient-specific criteria
obviates any need to restrict payment on the basis of where the patient
came from.
Will you commit to working with my office and other interested
lawmakers to make sure that the implementation of the new payment
criteria does not include a return to arbitrary thresholds like the 25
percent rule?
Answer. If I am confirmed, I look forward to working with you and
your office as well as other members of Congress to develop and
implement sound payment policies in accordance with the law. Patient
access to quality care in the most appropriate setting for the patient
and doctor must be a top priority for CMS.
______
Questions Submitted by Hon. Dean Heller
medicaid block grants and per capita allotment
Question. Do you understand why States like Nevada are so concerned
with the block grant approach?
How would you design a block grant that would still protect access
to care for the Medicaid expansion population?
What is your opinion on reforming Medicaid, so funding is based on
a per beneficiary allotment?
Would you take into consideration population growth?
Would you take into consideration the cost of care in rural areas?
Answer. If confirmed, I look forward to working with your office to
implement any reform, whether it involves Medicaid block grants, per
beneficiary allotments or other innovative ideas, which empowers our
most needy citizens with access to quality health care, while
supporting innovation efforts at the State level. At the same time,
States must be held accountable to standards that result in better
health-care quality and access. Ultimately, Congress will decide on any
proposals to strengthen the safety net for our most vulnerable
citizens, and I look forward to providing any technical assistance that
your office or other members of Congress seek in the development of
legislative reforms to the Medicaid program.
medicaid waivers
Question. What types of reforms have you worked on through the
waiver process that you believe has increased coverage for those
respective States?
How would you make it easier for States, like Nevada, that did not
originally seek a waiver to go through that process and approve the
types of reforms needed to protect the 600,000 Nevadans on Medicaid--
including 200,000 Nevadans that were eligible through the expansion?
Answer. Innovation starts locally, so if confirmed my job will be
to work with Nevada and other States to tailor their Medicaid programs
to the unique needs of their citizens. Working through the waiver
process at the State level has provided me with the experience to know
what works best and what doesn't work as well. I've also been able to
learn what the Federal Government asks for and how they ask for it can
slow or stop innovation. My experience at the State level reminds me
that Washington often doesn't know best; in fact, Nevadans know better
how to structure their programs and deliver care to their most needy
citizens. I will make it a priority to ensure that Nevada is able to
understand the process from beginning to end. Communication and
collaboration with your office, other members of your delegation and
stakeholders from around the State is crucial. I commit to working
closely with you as early and often as needed.
questions from state legislature
Question. What steps do you plan to take to ensure that the more
than 88,000 Nevadans who have purchased health insurance through the
Silver State Health Exchange continue to have the ability to purchase
health insurance with adequate coverage in a transparent marketplace?
What steps do you plan to take to ensure that the more than 77,000
Nevadans who are eligible for Federal tax credits under the Affordable
Care Act to help purchase private insurance will continue to have
access to affordable health-insurance options with adequate coverage?
What steps do you plan to take to ensure that the 217,000 Nevadans
who are receiving health care under the Medicaid expansion remain
covered?
The Affordable Care Act guarantees coverage vital to preventative
services for women, including cancer screenings and birth control. What
steps do you plan to take to ensure that the Affordable Care Act's
coverage guarantees remain intact for women's health?
The Affordable Care Act guarantees that Nevadans with pre-existing
conditions will not be denied health care and ends lifetime minimums on
coverage. It also allows younger people, many of whom are saddled with
college debt and cannot afford insurance, to stay on their parents'
insurance until they are 26. What steps do you plan to take to preserve
those coverage guarantees?
Answer. If confirmed, I will work to ensure that any legislation
enacted by Congress is implemented with the utmost care for Nevadans. I
am fully committed to ensuring all Americans have access to affordable
health care of the highest quality that meets the unique and important
needs of their families.
______
Questions Submitted by Hon. Ron Wyden
corporate relationships
Question. As discussed in the hearing and in news media accounts,
you and your firm, SVC, Inc., contracted with the following firms:
Electronic Data Systems (EDS), Hewlett Packard Enterprises (HP),
Milliman, Inc., Highpoint Global, Roche Diagnostics, Health Management
Associates (HMA), and Maximus, which provide health-program services
and products to the State of Indiana, or represent that they have.\1\
Please provide the following for each of these corporate relationships:
---------------------------------------------------------------------------
\1\ Inside Health Policy, February 10, 2017; IndyStar, August 26,
2014; Associated Press, February 15, 2017.
The dates you or your firm entered into contracts or subcontracts
---------------------------------------------------------------------------
with each of these companies.
The scope of work you or your firm performed for each contract or
subcontract with these companies.
The amount of money you or your firm were paid for work that was
completed under each such contract or subcontract.
---------------------------------------------------------------------------
\2\ Due to the age of this work, specific responsive information
was not located.
Answer.
------------------------------------------------------------------------
Approximate
Firm Dates Scope Revenue
------------------------------------------------------------------------
Electronic Data
PSystems (EDS)
\2\
------------------------------------------------------------------------
Hewlett Packard 2008-Present Training, $725,000
PEnterprises communications, (invoices 2011
analysis of Federal/ to present
State actions only)
------------------------------------------------------------------------
Hewlett Packard 2015-Present Communications $100,000
PEnterprises assistance specific
to Federal/State
regulations and
compliance
------------------------------------------------------------------------
Milliman 2013-Present Development of 1115 $1,500,000
Actuaries and 1915c/b waivers
------------------------------------------------------------------------
Milliman 2012-Present 1915 waiver $5,000
Actuaries development, ACA
impact analysis, and
policy
implementation
support
------------------------------------------------------------------------
Milliman 2015-Present 1115 waiver drafting $150,000
Actuaries and managed care
regulation impact
analysis
------------------------------------------------------------------------
Milliman 2013-2014 Technical assistance $10,000
Actuaries for waiver
implementation
------------------------------------------------------------------------
Highpoint 2016-Present Provide subject $350,000
Global matter expertise for
training materials
with CMS Assister
Program
------------------------------------------------------------------------
Roche 2010-2012 Development of launch $30,000
Diagnostics plan related to Accu-
Chek platform
------------------------------------------------------------------------
Health 2006-2011 Development of $300,000
Management uninsured program
Associates
(HMA)
------------------------------------------------------------------------
Maximus 2016-Present Provide curriculum $10,000
development support
for Maximus Training
Services
------------------------------------------------------------------------
corporate ethics agreements/disclosures
Question. For each of the corporate relationships identified in
Question 1, please provide the following:
Copies of any ethics agreements you entered into with these
companies, or ethics guidelines or contract terms you received from
these companies, governing conflicts of interest for your engagement
with them.
Answer. There were no separate ethics agreements entered into with
these companies.
Question. Any documentation showing the processes you were to
follow if and when you were to recuse yourself with regard to conflicts
of interest involving each company.
Answer. None, and none was required.
Question. Any documentation showing any situations in which you
actually recused yourself from matters related to these companies
pursuant to these policies, guidelines, or terms.
Answer. None. Other than with respect to HP, there was not a
situation for which my recusal was appropriate. I did not supervise any
of the work performed by these other companies.
post-confirmation corporate recusals
Question. In its annual report to the Securities and Exchange
Commission, Maximus says they are the largest provider of Medicaid and
CHIP enrollment services in the United States.\3\ In the same filing,
Maximus states that HP is one of their major competitors in the health
services sector. You have current contracts with both of them. As
you've reported on OGE Form 278, you also have current contracts with
HighPoint Global and Milliman, Inc. All four engage in activities
funded through CMS. Your Ethics Agreement states you will need to get
special approval to consider matters involving seven of the States for
which you did consulting work, but it is completely silent on the
question of what is required for you to consider matters involving your
consulting work for these companies. The only specific corporate
recusal in your Ethics Agreement relates to HMA, which is buying your
consulting firm. Please describe your understanding of the extent to
which you would need to recuse yourself from matters involving these
other four companies.
---------------------------------------------------------------------------
\3\ Maximus, Inc. SEC 10-K, November 21, 2016.
Answer. My understanding is as stated in my Ethics Agreement and
the Ethics Pledge. These documents are quite specific regarding my
ethical obligations with respect to these four companies. My Ethics
Agreement states: ``I will not participate personally and substantially
in any particular matter involving specific parties in which I know a
former client of mine is a party or represents a party, for a period of
1 year after I last provided service to the client, unless I am first
authorized to participate pursuant to 5 CFR Sec. 2635.502(d)''
(emphasis added). The Ethics Pledge states: ``I will not for a period
of 2 years from the date of my appointment participate in any
particular matter involving specific parties that is directly and
substantially related to my former employer or former clients,
including regulations and contracts.''
state of indiana contracts
Question. Please identify, by contract number and date, each of
your contracts with the State of Indiana and any related amendments
thereto. Also, please provide the total award value of those contracts,
to the present, and the total revenue amount from those contracts, to
the present.
Answer.
------------------------------------------------------------------------
Contract
Number Date Amendment(s) Award Value
------------------------------------------------------------------------
57464-000 July 19, 57464-001 $2,978,527
2011 57464-002
57464-003
57464-004
57464-005
57464-006
------------------------------------------------------------------------
80287-000 July 23, 80287-001 $4,851,400
2014 80287-002
80287-003
------------------------------------------------------------------------
The approximate revenue from these contracts to date is $5.3
million.
oversight of contractors in indiana
Question. According to a recent press report, you were a member of
a ``group of health officials'' that unsuccessfully pitched former
Governor Mitch Daniels on health reform in 2006. You were also
identified as ``leading'' that same group when it later successfully
convinced Daniels to move forward with health-care reform.\4\ In your
biographical materials, you have also discussed your role as the
architect of the Healthy Indiana Plan (HIP). As discussed in the
hearing, it appears that you were advising the State at the same time
that you had contracts with other vendors, including HMA. You also
provided the committee with a statement from then-
Secretary of the Indiana Family and Social Services Administration
(FSSA) John J. Wernert, which included the sentence: ``Additionally, no
consultant is allowed to oversee the work of a contractor with whom
they have a separate professional relationship.''
---------------------------------------------------------------------------
\4\ CNN, February 16, 2017.
It appears that on or about May 1, 2006, you and your firm became a
subcontractor to HMA on a contract HMA held with the State of Indiana
to provide consulting services to FSSA. A May 1, 2008 amendment to a
contract between Indiana and HMA shows that you received payments from
the consulting firm for subcontract work beginning May 1, 2006.\5\ The
original May 1, 2006 contract does not appear to be available in the
State's public disclosure database. Please provide a copy of the
original HMA contract with the State and a description of the scope of
work HMA performed and that you performed under that contract, as well
as under the subsequent contract amendment.
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\5\ Indiana SVC Contract (EDS: A129-6-49-06-XE-2020).
Answer. A copy of the contract has been provided to the committee.
Under that contract, HMA developed an uninsured program for the State
of Indiana. The scope of work that SVC performed solely included
provision to HMA of professional consulting services related to HMA's
development of that uninsured program. I did not oversee HMA's work on
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this contract.
Question. On or about January 22, 2007, your firm received a sole
source FSSA contract for coordinating development of a Request for
Proposal to procure the services of a vendor to administer the
``Governor's Plan for a Healthier Indiana.'' \6\ That same day, HMA
received a sole source FSSA contract to develop and draft the Request
for Proposal for the ``Governor's Health Care Plan.'' \7\ It appears
that the work scope in your contract required you to oversee the work
of HMA contrary to FSSA policy. Please provide the following:
---------------------------------------------------------------------------
\6\ Indiana SVC Contract (EDS: A129-7-49-07-XE-2730).
\7\ Indiana Health Management Associates Contract (EDS: A129-7-49-
07-XE-2020).
A description of the work you performed under your contract with
---------------------------------------------------------------------------
the State.
Answer. It is not correct that the scope of work in the SVC
contract included oversight of the HMA work under its contract. SVC and
HMA had parallel but distinct roles, both under the oversight of State
officials. Through SVC, I provided consulting services regarding
preparation of an RFP for a vendor to administer the Governor's Plan
for a Healthier Indiana. I provided project management services,
technical assistance to contractors and to FSSA, and other assistance
to the State in its development of the RFP, including reviews of drafts
of the RFP.
Question. The justification provided for SVC, Inc. having been
awarded a non-competitive contract.
Answer. The justification, as drafted and approved by State
officials, was: ``The contractor has been involved in the development
of The Governor's Plan for a Healthier Indiana from its inception, and
has intimate knowledge of its many parts. With the rapid timeframe
required to develop the RFP, the State does not have the resources to
bring another consultant up to speed. SeemaVerma Consulting is Indiana-
based and has keen knowledge of the Indiana health care market place,
which will be critical to developing the RFP. We have worked with her
over the past 2 years and feel very comfortable with the quality of her
work product.''
Question. A description of your understanding of the scope of work
that HMA was to perform and an explanation of how you interacted with
HMA on this task.
Answer. As stated in HMA's contract, HMA was to ``[D]evelop the
draft and final version of the `Request for Proposal' for the
Governor's Health-Care Plan. The contractor will review current
commercial carrier Health Savings Account Plan structures, propose
alternatives and opinions, conduct research as necessary, assure
compliance and coordination with existing FSSA regulations, and provide
technical assistance as required by FSSA or its contractors.''
Question. A description of any role you played, if any, in the
award of this HMA contract, including any documentation of any recusals
related to the award or performance of this contract.
Answer. I had no role in the award of the HMA contract.
Question. Please explain how you coordinated development of the
State's RFP for HIP while HMA--with whom you had a prior financial
relationship--drafted that RFP, without violating FSSA policy as
described in Secretary Wernert's statement.
Answer. As the contracts make clear, I worked in conjunction with
HMA on this effort, but I did not oversee its work. When the State of
Indiana develops RFPs for something as large and important as the
Governor's Health-Care Plan, it often procures services from several
vendors who are assigned distinct tasks; that was the case here, such
as actuarial services, and procurement specialists.
Question. A fourth amendment to the HMA contract, prepared on April
20, 2012, appears to show that HMA billed Indiana for work with the
Office of Medicaid Policy and Planning (OMPP) including for your firm's
hourly rate from May 1, 2010 to June 30, 2011.\8\ Please provide the
following:
---------------------------------------------------------------------------
\8\ Indiana SVC Contract (EDS: A129-6-49-06-XE-2020).
Question. A description of the consulting work performed under this
---------------------------------------------------------------------------
contract by HMA for OMPP.
Answer. HMA provided ``financial and/or business consulting
services related to health-care services to four (4) divisions of
FSSA.'' Full details of the scope of these services are provided in the
amendment to the contract.
Question. Confirmation of whether you and your firm were an active
subcontractor on this contract during this period, or in the
alternative, please provide the period of performance by you and your
firm.
Answer. Confirmed.
Question. A detailed description of the scope of work SVC, Inc.
performed under this contract, specifically with OMPP between May 2010
and June 2011, and revenue received.
Answer. HMA and its subcontractors provided consulting services to
Indiana Family and Social Services Administration in four areas:
Transformation of Aging Services and operational and programmatic work
for the Division of Aging; operational and financial management
services for the Division of Mental Health and Addiction; and waiver
system administration for the Office of Medicaid Policy and Procedures.
The revenue received by SVC, Inc. between May 2010 and June 2011 for
this subcontract was approximately $500,000.
Question. Any documentation showing if you recused yourself when
potential conflicts arose under this contract.
Answer. None. There was no potential conflict for which recusal was
necessary or appropriate. SVC's separate work for FSSA did not involve
oversight of this HMA contract, and SVC played no role in FSSA's
decision to award the contract to HMA.
Question. In December 2007, EDS was awarded a contract to ``provide
fiscal agent services for the Medicaid program for FSSA.'' You were
included in the EDS contract, and paid through this contract as a
subcontractor.\9\ These contracts were subsequently continued through
HP. On February 21, 2012, an existing 2011 SVC, Inc. contract was
increased by $475,000 and amended to broadly increase the scope of
SVC's work, including specifically overseeing ``MMIS (HP) technical
changes.'' \10\ It appears that the scope of work in this expanded
contract required you to oversee work performed by HP contrary to FSSA
policy. Please provide the following:
---------------------------------------------------------------------------
\9\ Id.
\10\ IN Contract EDS: A129-1-29-11-ZN-1758 (first amendment).
A description of the work, you performed under this contract with
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the State of Indiana with regard to MMIS.
Answer. Regarding MMIS, SVC worked with the State of Indiana and
its vendors, including HP, to design systems for implementation of the
Healthy Indiana Plan. We helped vendors translate the policy and waiver
language into system operations. We did not oversee HP or any other
vendor in this regard, and did not negotiate or participate in change
orders or contract amendments. To the best of my recollection, State
officials participated in all meetings with HP regarding the Healthy
Indiana Plan work at which SVC representatives were also present.
Question. A description of your understanding of the scope of work
that HP was to perform and an explanation of how you and your firm
carried out your work regarding HP on this task.
Answer. HP prepared systems for the implementation of the Healthy
Indiana Plan and all Medicaid programs. My firm and I worked with HP
and the State's other vendors on this task, helping them to understand
the program so they could make the appropriate technical changes to the
system. In addition, please see the previous answer.
Question. A description of the work you and your firm performed
under the EDS/HP contracts.
Answer. My firm and I performed a substantial amount of work on a
variety of subjects; a comprehensive description of the scope of work
is contained in the contract.
Question. Documentation of any recusals related to the performance
of your State of Indiana contract with regard to EDS/HP.
Answer. None, and none was required.
state of indiana ethics procedures
Question. In response to Senator Wyden's question regarding
conflicts of interest during your time working with the State of
Indiana, you responded that you recused yourself from meetings in which
a potential conflict could arise: ``I've been in meetings, where we
were talking about contractors and talking about implementing a
program. And when it came to a vendor that we had a relationship with,
I would recuse myself. I would get up and leave the meeting so that
there was never any issue.''
In a written response--to the 2014 Indianapolis Star article
regarding Hewlett Packard--provided to the committee, you similarly
stated ``(i)f any issue between HP and the State presented a conflict
between the two, I recused myself from the process.''
Please describe the process for determining when a matter
constituted a conflict. What agency official or officials determined
such a conflict existed?
Answer. Consistent with the ethics opinion that I received, I
recused myself from any matters related to HP's contract, the scope of
its work, any change orders, its compensation, etc. Agency officials
were fully aware of and supported this approach. I do not recall any
other formal determinations regarding potential conflicts.
Question. Please provide any written policies, agreements, or other
communications documenting the nature of this conflicts process.
Answer. None.
Question. Did this process apply to all of your clients, namely
EDS, HP, Milliman, HMA, Roche Diagnostics, and Maximus? If not, which
clients were not subject to this process and why?
Answer. Yes, I was alert to potential conflicts regarding all of my
clients.
Question. You have stated that you did recuse yourself. In which
instances did you do so? Were these recusals documented? And if so,
please provide this documentation.
Answer. I recused myself from any matters related to HP's contract,
the scope of its work, management issues, any change orders, etc. If
these issues arose during a meeting, I would remind the State employees
of my relationship with HP and made clear that I would not be involved,
and would leave the meeting.
Question. In 2012, you requested an ethics opinion from the Indiana
Ethics Commission with respect to your work for Hewlett Packard. Did
you request ethics opinions for your work with EDS, Milliman, Inc.,
HMA, Roche Diagnostics, or Maximus? If so please provide copies of
those opinions.
Answer. No. The scope of SVC's work for those other companies was
narrower than the work involving HP.
Question. Please provide copies of any ethics agreements you
entered into or ethics guidelines or contract terms you received from
the State of Indiana for your work with the State governing conflicts
of interest.
Answer. None, other than that previously provided.
representation before state agencies
Question. In two separate news articles, the former head of the
FSSA in Indiana, Debra Minott, indicated that you represented Hewlett
Packard in a billing dispute before a State agency--FSSA--for which you
were a consultant. In an Indianapolis Star article, dated August 26,
2014, which Senator Wyden quoted in the hearing, Ms. Minott is herself
quoted:
``We had delayed paying an HP invoice because of an issue we were
trying to resolve, and HP sent Seema to our CFO to resolve the issue on
their behalf,'' Minott said. ``I was troubled because I thought Seema
was our consultant.''
That article was updated and republished on November 29, 2016. More
recently, the Associated Press published a story on Feb. 14, 2017, in
which Ms. Minott reiterated that you had represented HP in this
dispute. The AP article states:
``It was never clear to me until that moment that she, in essence,
was representing both the agency and one of our very key contractors,''
said Minot(t), who was removed as head of the agency by Pence over her
disagreements with Verma. ``It was just shocking to me that she could
play both sides.''
Did you represent HP in a billing dispute with the FSSA as
reported?
Answer. No. The only source for this allegation is Ms. Minott, a
disgruntled former employee; to my knowledge, no one else has provided
support for her assertions. Indeed, HP has made clear, as stated in the
same AP article, that ``it can find no one in its company with any
recollection of such a meeting.'' \11\ Further, Ms. Minott participated
in a tour and briefing at HP's facilities on November 21, 2013 in which
the HP-SVC partnership was specifically discussed and written materials
were provided that documented the relationship. With that knowledge,
Minott approved increases in the amount of SVC's contracts with the
State thereafter. At no time during her tenure at FSSA did Ms. Minott
ever express any concerns to me about SVC's work for HP.
---------------------------------------------------------------------------
\11\ http://www.indystar.com/story/news/politics/2014/08/25/
powerful-state-healthcare-consultant-serves-two-bosses/14468683/.
Question. Did you ever represent HP in any other matter before any
---------------------------------------------------------------------------
Indiana agency or office? If so, when and in what capacity?
Answer. No.
Question. Did you ever represent any other client, specifically
EDS, HMA, Milliman, Roche Diagnostics, or Maximus, in any matter before
FSSA or any other State agency or office? If so, when and in what
capacity?
Answer. No.
waiver transparency
Question. The ACA required HHS to issue regulations that ensure the
public has a meaningful opportunity to provide input on proposed
section 1115 waivers, including new applications and applications for
waiver extensions. The rule HHS promulgated in February 2012 requires
States to provide a 30-day public notice and comment period, set up a
website for their proposal, and hold public hearings around the State,
among other provisions. States are also required to submit an annual
report to HHS that includes an evaluation of the changes' impact.
Do you believe that the details of a State's waiver request should
be made available to the public in advance of the State submitting the
waiver request to CMS?
Do you support requirements for the State and CMS to obtain and
respond to public comments prior to a State deciding on whether to
submit or CMS to approve or deny the request?
Will you maintain the section 1115 transparency provisions that
seek to improve public accountability and bring waiver negotiations
from behind closed doors?
What additional steps will you take to ensure public participation
in the waiver process and transparency in the negotiations between CMS
and States seeking waivers?
Will you continue CMS's current practice of timely posting of
waiver applications, approvals, and all supporting documents on the CMS
website?
Will you require that every waiver application at a minimum provide
a description of the demonstration and a specific listing of the waiver
authorities requested and the intended use of the waiver requested?
When issuing approvals, will you require that these approvals
specifically list the waiver authorities that are approved and their
approved use?
Do you think amendments should be subject to the same transparency
requirements?
Answer. If confirmed, transparency and consistency in the waiver
process will be priorities for CMS. It is imperative that States are
able to partner with CMS in a joint effort to update and modify their
Medicaid programs to better serve their citizens. Clear and fair rules
of the road are crucial for States' planning purposes as well as for
the longevity and success of their Medicaid programs. If States are
mired in paperwork and forced to redirect resources to unnecessary
Federal requirements, that means less resources are available to their
most needy citizens. I pledge to work with States to make this process
easier, more transparent and more efficient for both States and all
impacted parties. Additionally, it is crucial that stakeholders receive
an opportunity to provide input, so I look forward to communicating and
collaborating with them, whenever appropriate.
president's january 20th executive order
Question. On January 20th, the President issued an executive order
instructing the Secretary of Health and Human Services and the heads of
all agencies--which includes the CMS Administrator--to do everything
possible to roll back the Affordable Care Act (ACA). If confirmed as
CMS Administrator, you will be responsible for carrying out this
executive order.
Based on your understanding, what are the specific actions that the
CMS Administrator could take to carry out the President's January 20th
executive order regarding the ACA?
If confirmed, which of those actions would you take as CMS
Administrator to carry out the President's order?
Answer. If I am confirmed, I plan to review prospective options
with CMS staff and others within HHS and the administration to better
determine what can be done to undo or mitigate the harms created by the
ACA. Once I evaluate the options, we will act accordingly to help
Americans suffering from higher costs, fewer choices, and less access
to quality care.
prescription drug prices
Question. Ms. Verma, during your nomination hearing I asked for one
specific action you would take as CMS Administrator to curb the rising
prices of prescription drugs, but you did not provide one specific
idea.
As CMS Administrator you will have broad power, independent of
Congress, to impact the cost of prescription drugs. For example, each
year CMS publishes the Part D Call Letter and Rate Notice and also is
able to propose changes to regulations regarding payment for physician
administered drugs. Within CMS, the Center for Medicare and Medicaid
Innovation also has broad authority to test new payment models that
could involve prescription drugs.
Please provide one specific action you would take as Administer to
address the rising costs of prescription drugs.
Answer. I appreciate that drug costs are an important pocket-book
issue for many Americans. If confirmed, I will work with the CMS staff
to evaluate potential options and ensure that beneficiaries' access to
high quality and affordable drugs is a top priority for CMS. I look
forward to reviewing relevant implementation issues, including items
such as PBM contracts, when appropriate.
medicaid reform and opioids/suds
Question. Opioid abuse (including heroin and prescription pain
relievers) is contributing to a public health epidemic of significant
consequence. In 2015, there were 20,101 prescription drug-related
overdose deaths and 12,990 heroin-related overdose deaths. Medicaid is
the primary payer for all substance use disorder services in the
country and will be critical in the fight against the opioid epidemic.
Thanks to Medicaid expansion under the Affordable Care Act (ACA),
an additional 11 million adults now have access to Medicaid. Over one
million of these adults gained access to treatment for opioid abuse and
other substance use disorders (SUDs). In States that expanded Medicaid,
there are more physicians who can prescribe the drugs needed (e.g.,
buprenorphine) to help individuals overcome their addiction to opioids.
Without the Medicaid expansion, fewer people would have access to
Medication-Assisted Treatment (MAT) for opioid abuse and other
substance abuse treatment. Furthermore, the ACA included addiction
treatment as an essential health benefit that must be covered in all
health plans.
Will you commit to advising against repeal of the Medicaid
expansion resulting in over a million Americans with SUDs losing access
to essential addiction treatment services?
Answer. It is critical that all Americans suffering from mental
health and substance abuse disorders have access to the care they need.
If confirmed, to the extent I am not required to recuse from a
particular matter under the terms of my Ethics Agreement, I am
committed to ensuring that access is not diminished.
Question. Will you commit to advising against cuts to State
Medicaid programs through block grants and per capita caps that put
individuals struggling with SUDs at risk of losing access to their
Medicaid coverage or benefits?
Answer. I support ensuring Americans have access to quality health
care. It is critical that all Americans suffering from substance abuse
disorders have access to the care they need. If confirmed, to the
extent I am not required to recuse from a particular matter under the
terms of my Ethics Agreement, I am committed to ensuring that access is
not diminished.
Question. Will you commit to ensuring States are required to cover
behavioral health benefits such as treatment for SUDs as they cover
services for physical health conditions?
Answer. If confirmed, I will implement the law as designed by
Congress and I look forward to realizing reforms that put patients and
their doctors in charge of their health care decisions, whether they
involve physical or mental health conditions. As noted in my Ethics
Agreement, referenced above, because of my husband's practice as a
psychiatrist with the Indiana Health Group, Indianapolis, IN, and his
financial interest in the Indiana Health Group, I have agreed not to
participate personally and substantially in any particular matter that
to my knowledge has a direct and predictable effect on the financial
interests of the Indiana Health Group, unless I first obtain a written
waiver, pursuant to 18 U.S.C. Sec. 208(b)(1). Under the Federal ethics
regulations, I am not required to recuse from consideration or adoption
of broad policy options that are directed to a large and diverse group
of persons. I will be required to recuse myself from matters that
involve deliberation, decision or action that is focused upon the
interests of the Indiana Health Group, or the discrete and identifiable
class of persons or entities that includes the Indiana Health Group. To
the extent that I have questions on how to apply my recusal obligations
to a particular matter, I will consult with the HHS Ethics Office for
guidance on the scope of my recusal obligations.
Question. What are your specific plans to address the opioid
epidemic? What role should CMS play in this fight?
Answer. If confirmed, I will work with CMS to ensure that Americans
suffering from mental health and substance abuse disorders have access
to the care they need. Americans in CMS programs should have access to
high quality health care and I look forward to partnering with HHS and
other departments and agencies to address the opioid epidemic.
medicaid lock-out
Question. During your nominations hearing, I asked about your
Healthy Indiana Plan (HIP) 2.0.
Will Indiana be able to maintain eligibility under HIP 2.0 if the
Medicaid expansion is repealed or if Federal financial support of the
expansion population is drastically reduced?
Answer. I cannot speculate as to what impact legislative changes
that Congress has yet to make will have on Indiana's Medicaid program.
Question. To clarify for the record, does your Healthy Indiana Plan
2.0 lock out an individual making $12,000 a year from coverage if they
cannot pay their premium for 2 months?
Answer. The State of Indiana's Healthy Indiana Plan's contribution
requirements are not designed as a punitive measure but as a way to
promote personal responsibility among members which has resulted in
better health outcomes than traditional Medicaid. Only members above
the poverty line are at risk of losing coverage for non-payment. Where
HIP members are locked out of coverage for 6 months for non-payment,
those who fail to pay Marketplace premiums may have to wait until the
next open enrollment period to regain coverage, which can be up to 9
months, unless they have a change in circumstance that makes them
eligible for a special enrollment period. On whole, HIP's non-payment
policies for individuals above the poverty line are at least comparable
to, if not more lenient than, the policies governing the Marketplace.
Moreover, only 5 percent of former HIP members indicated they left the
program due to affordability issues. Additionally, more than 80% of HIP
members have indicated they would be willing to pay more to stay in the
program, while more than half of those who left the program due to non-
payment successfully transitioned to private health insurance coverage.
family planning
Question. Medicaid is the largest payer of reproductive health care
and provides coverage to approximately one in five women of
reproductive age. Family planning services and supplies, in particular,
are provided special protections under the law. Not only are family
planning services and supplies a mandatory covered service for both
traditional and expansion populations, but Federal law also protects
the ability of Medicaid beneficiaries to choose any qualified family
planning provider who participates in the Medicaid program, even if
they are not in a health plan's network. The Federal Government matches
family planning services at a rate of 90 percent to ensure that States
provide robust coverage of birth control methods and related services.
Do you commit to maintaining the requirement that Medicaid
beneficiaries have the freedom to choose their family planning service
provider?
Answer. As a woman, I support ensuring access to health care for
both women and men and a health-care system that will provide access to
quality care while ensuring patients are able to make decisions that
work best for them.
Question. Do you commit to ensuring that family planning services,
including access to a person's preferred contraceptive methods,
including IUDs, birth control pills, and implants, will remain
available to all women?
Answer. I support a health-care system that will allow women to
make the decisions about what works best for them.
Question. Do you commit to maintain the 90-percent Federal matching
rate for family planning services?
Answer. Changes in the Federal matching rate are determined by
Congress, so I look forward to enforcing the law as written by
Congress.
behavioral health
Question. Ms. Verma, during your nomination hearing you did not
answer Senator Menendez's question regarding essential health benefits
and children with autism because you are recusing yourself from the
topic of behavioral health due to your husband's profession as a
psychiatrist, pursuant to your Ethics Agreement. In order to clarify
the issue, please answer the following:
What specific actions as Administrator will you be required to
recuse yourself from that involve behavioral health? For example,
implementation of MACRA involves physicians treating patients with
behavioral health. How would you separate behavioral health issues from
other patient groups while working on physician payment issues?
Answer. As noted in my Ethics Agreement, which was previously
provided to the Senate, because of my husband's practice as a
psychiatrist with the Indiana Health Group, Indianapolis, IN, and his
financial interest in the Indiana Health Group, I have agreed not to
participate personally and substantially in any particular matter that
to my knowledge has a direct and predictable effect on the financial
interests of the Indiana Health Group, unless I first obtain a written
waiver, pursuant to 18 U.S.C. Sec. 208(b)(1). Under the Federal ethics
regulations, I am not required to recuse from consideration or adoption
of broad policy options that are directed to a large and diverse group
of persons. I will be required to recuse from matters that involve
deliberation, decision or action that is focused upon the interests of
the Indiana Health Group, or the discrete and identifiable class of
persons or entities that includes Indiana Health Group. To the extent
that I have questions on how to apply my recusal obligations to a
particular matter, I will consult with the HHS Ethics Office for
guidance on the scope of my recusal obligations.
Question. Will you meet with advocates for and providers of
behavioral health care?
Answer. If confirmed, there will be certain situations where I
would be able to meet with a particular provider of behavioral health
care (or its advocates) and certain situations where I will be required
to recuse. For example, if one specific provider of behavioral health-
care services, that is not the Indiana Health Group, requests a meeting
to discuss settlement of litigation against that provider, I would be
able to meet and listen to that provider's concerns. On the other hand,
if a group of behavioral health-care providers, requests a meeting with
me to discuss health insurance coverage in the small group market for
mental health services as an essential health benefit (EHB), I would
recuse from this meeting. If I have questions on how to apply my
recusal obligations to a particular matter, I will consult with the HHS
Ethics Office for guidance on the scope of my recusal obligations.
Question. Behavioral health also includes substance abuse,
including addiction to opioids. Are you recusing yourself from any
issue related to opioid abuse?
Answer. As noted above, under the Federal ethics regulations, I am
not required to recuse from consideration or adoption of broad policy
options that are directed to a large and diverse group of persons. I
will be required to recuse from matters that involve deliberation,
decision or action that is focused upon the interests of the Indiana
Health Group, or the discrete and identifiable class of persons or
entities that includes Indiana Health Group. There will be certain
situations where I would be able to participate in substance abuse
matters and certain situations where I will be required to recuse. The
analysis of my recusal obligation for a particular matter will be made
on a case by case basis. To the extent that I have questions on how to
apply my recusal obligations to a particular matter, I will consult
with the HHS Ethics Office for guidance on the scope of my recusal
obligations.
Question. What other specific patient types and/or issues will you
recuse yourself from because of your husband's medical practice?
Answer. If confirmed, because of my husband's practice as a
psychiatrist with the Indiana Health Group, Indianapolis, IN, and his
financial interest in the Indiana Health Group, I have agreed not to
participate personally and substantially in any particular matter that
to my knowledge has a direct and predictable effect on the financial
interests of the Indiana Health Group, unless I first obtain a written
waiver, pursuant to 18 U.S.C. Sec. 208(b)(1). Under the Federal ethics
regulations, I am not required to recuse from consideration or adoption
of broad policy options that are directed to a large and diverse group
of persons. I will be required to recuse from matters that involve
deliberation, decision or action that is focused upon the interests of
the Indiana Health Group, or the discrete and identifiable class of
persons or entities that includes Indiana Health Group. To the extent
that I have questions on how to apply my recusal obligations to a
particular matter, I will consult with the HHS Ethics Office for
guidance on the scope of my recusal obligations.
Question. For each area you are recusing yourself, please provide
the names and/or positions of the individual to whom you expect to
delegate responsibility for such issue on behalf of CMS, or do you
intend to seek waivers from the recusal requirement?
Answer. If confirmed, matters from which I am recused will be
elevated to the HHS Deputy Secretary or the HHS Chief of Staff, as
appropriate, for disposition without my input or recommendation.
Additionally, once they are appointed I would designate certain members
of my administrative staff and other appropriate CMS officials within
my immediate office to screen matters that are covered by my recusal
obligation, so that these matters are not given to me for action.
alternative payment models in medicare
Question. The previous administration set a goal of tying 30
percent of traditional, or fee-for-service, Medicare payments to
quality or value through alternative payment models, such as
Accountable Care Organizations (ACOs) or bundled payments by the end of
2016 and tying 50 percent of those payments to alternative payment
models by the end of 2018. CMS achieved its goal to alternative payment
models into 30 percent of Medicare payments in March 2016--9 months
earlier than expected.
Will you commit to supporting the previous administration's goal of
making 50 percent of Medicare payments through alternative payment
models by 2018?
If so, what specific actions will you take--if confirmed as CMS
Administrator--to reach that goal?
Answer. I look forward to reviewing the actions taken by health-
care providers and CMS to achieve this goal in order to determine what
has worked and what we can improve upon going forward. Additionally, it
is crucial that we communicate with providers and stakeholders and seek
their input as early in the process as appropriate.
actuarial soundness and network adequacy in medicaid managed care
Question. In the final Medicaid Managed Care rule, released in May
2016, CMS strengthened actuarial soundness requirements for plans that
contract with State Medicaid programs to provide health-care services.
The actuarial soundness provision requires States to pay health plans
at a rate that is sufficient to provide, ``for all reasonable,
appropriate, and attainable costs,'' that are required under the terms
of the contract and for successful operation of a managed care entity
providing services to Medicaid beneficiaries. The final Medicaid
Managed Care rule included provisions to increase the transparency and
accountability in the development of health plans' capitation rates.
The final rule also includes important beneficiary protections. The
new rule proposes important changes to increase the adequacy of
provider networks in Medicaid managed care. States are required to set
``time and distance'' standards to limit how long or how far a Medicaid
beneficiary has to travel in order to receive services from all types
of providers. For long-term services and supports (LTSS) providers, who
travel to beneficiaries, States must set similar time and distance
standards. In addition, States must establish continuity of care
policies for beneficiary transitions into or between managed care
plans.
Do you commit to maintaining the actuarial soundness requirements
in the provision of Medicaid managed care?
Do you commit to maintaining the increase in transparency and
accountability in the capitation rate development process?
Do you commit to maintaining time and distance standards to
strengthen network adequacy for Medicaid managed care enrollees?
Do you commit to maintaining the requirement for time and distance
standards to be applicable to the 11 categories of providers specified
in the final rule?
Do you commit to maintain the requirement for States to consider
the number of network providers who are not accepting new patients, the
geographic location of network providers, the ability of network
providers to communicate in non-English languages, and the ability of
network providers to ensure accessible, culturally competent care to
people with disabilities when setting their time and distance
standards?
What specific actions will you take to assure proper oversight of
the implementation of the final Medicaid Managed Care rule?
Answer. If confirmed, I commit to thoroughly reviewing the rule
with the utmost regard for the accessibility of high-quality health
care for all impacted Medicaid beneficiaries as well as State
flexibility, efficiency, and cost effectiveness.
periodic updates regarding affordable care act outreach and enrollment
Question. At Marilyn Tavenner's confirmation hearing for CMS
Administrator, Chairman Hatch asked her to commit to providing bi-
weekly updates on the establishment of the Affordable Care Act (ACA)'s
Exchanges and on enrollment. I request that you make a similar
commitment to provide periodic updates to the Finance Committee.
Will you commit to providing the members of the Finance Committee
with periodic updates--both written progress reports and briefings--in
the months leading up to and during ACA open enrollment periods?
In addition to any available enrollment numbers, I would ask that
those updates address technology functioning; marketing and outreach
plans; operation of the call center, in-person assistance and staff
working with the States; and any improvements or changes being made to
the enrollment process. Do you agree?
Answer. If confirmed, I am committed to working with Congress to
ensure you are updated on CMS activities. If I am confirmed,
communication and collaboration with Congress will be a major priority
for me and the agency.
1115 waivers
Question. Under section 1115 of the Social Security Act, the
Secretary of Health and Human Services may waive certain statutory
requirements of major health programs such as Medicaid as long as they
further the purposes of the program. States have historically used
waivers to expand coverage, strengthen benefits, and innovate in
payment and delivery systems.
Do you agree that section 1115 experimental projects must ``promote
the objectives of the Medicaid Act?''
Do you agree that the objective of the Medicaid Act is to furnish
medical assistance to low-income people and to furnish ``rehabilitation
and other services to help such . . . individuals attain or retain
capability for independence or self-care?'' (42 U.S.C. Sec. 1396-1).
Do you agree that a proposal that will clearly reduce access to
medical assistance is inconsistent with the objectives of Medicaid?
Do you agree with the criteria the Centers for Medicare and
Medicaid Services (CMS) currently uses to evaluate when a demonstration
project promotes the objectives of Medicaid--that the demonstration
will: increase and strengthen overall coverage of low-income
individuals in the State; increase access to, stabilize, and strengthen
providers and provider networks available to serve Medicaid and low-
income populations in the State; improve health outcomes for Medicaid
and other low-income populations in the State; or increase the
efficiency and quality of care for Medicaid and other low-income
populations through initiatives to transform service delivery networks?
Answer. I agree that experimental projects and demonstrations
within the Medicaid program should reflect the overall objectives of
the program, as defined by Congress. If confirmed, I look forward to
reviewing any proposal put before me to determine whether and how it
could impact beneficiaries in addition to ensuring the demonstration
project is budget neutral to the Federal Government.
president's january 30th executive order
Question. On January 30th, the President signed an executive order
requiring the Federal agencies revoke two existing regulations during
fiscal year 2017 for every new rule they issue.
On Wednesday, February 15th, CMS released a proposed rule regarding
the individual and small group health insurance markets.
If confirmed as CMS Administrator, which two existing CMS rules or
regulations would you repeal to account for the release of this
proposed rule?
For additional rules that CMS is statutorily required to publish
this year, if confirmed as CMS Administrator, would you require that
CMS publicly identify which two regulations it plans to repeal at the
same time as the new rule is proposed? If not, within what timeframe
will those two regulations be identified?
What are some examples of current rules you would eliminate to
comply with the arbitrary two for one rule reduction requirement? Would
you rescind rules to comply with the executive order that protect
public health or patient safety? How would you determine which rules
would be rescinded when new rules are issued?
Answer. If confirmed, I will work with HHS and CMS staff to review
all rules and regulations and ensure compliance with the President's
executive order.
home- and community-based services
Question. Federal Medicaid law provides States with flexibility to
provide long-term services and supports (LTSS) through home- and
community-based services (HCBS) rather than in nursing homes or other
long-term care facilities. To date, almost every State offers HCBS
services to older adults and people with disabilities through waivers.
HCBS waiver programs have helped 1.5 million Americans stay at home
rather than move into a nursing home.
Section 2401 of the Affordable Care Act also authorized the
Community First Choice Option to provide home- and community-based
services for people who otherwise would have to move into a nursing
home. To encourage States to adopt the program, Federal financial
participation is increased by 6 percent. Today, 8 States, including
Oregon, and over 300,000 people are served by the program.
Baby boomers are reaching retirement age, and Americans are living
longer. By 2030, older Americans will account for 20 percent of the
Nation's population. As a result, the demand for long-term services and
supports including those offered at home and in the community is
expected to increase dramatically.
Do you think the Federal Government should help States address the
needs of a high-cost, aging population?
How do you think HCBS wait lists will fair with a 30-plus-percent
cut to Medicaid funding through block grants or per capita caps, which
HHS Secretary Price proposed in his 2017 budget proposal as House
Budget Committee chairman?
Do you support extending the Money Follows the Person program at
current funding levels?
Do you support the Community First Choice State option with the
current Federal matching levels?
Answer. Long-term services and supports are a vital part of the
Medicaid program and will increase with the aging baby boomer
population. I look forward to reviewing CMS's previous actions and
prospective options to ensure our commitment to Americans with long-
term care needs is met and that States have the flexibility to
implement innovative programs that work best for the populations they
serve.
______
Questions Submitted by Hon. Debbie Stabenow
Question. Because of Medicaid expansion in Michigan, 650,000 people
have insurance, and uncompensated care has been cut by at least 50%.
Thirty thousand jobs have been created, and the State will end the year
with $432 million more than it invested in the program. Unfortunately,
the one thing in common about every Republican proposal in front of
Congress right now is cuts to Medicaid funding.
Do you support cutting funding to States to run Medicaid programs?
Answer. I support ensuring all Americans have access to quality
health care. Medicaid's financing structure is determined by Congress,
so I look forward to collaborating with Congress and implementing the
law as written.
Question. A repeal of Medicaid expansion in addition to the block
grant proposal supported by Speaker Ryan, Secretary Price, and many
others would cut about $2 trillion from the Medicaid program over the
next 10 years.
Having worked closely with States and State budgets, including
working with Michigan during implementation, if the Medicaid program
was cut by $2 trillion how would you advise Michigan absorb the loss?
Do you think it is possible to do without dropping eligibility,
cutting services and providers, or raising State taxes?
Waivers are used to promote innovation--how do you innovate without
harming people if your budget is being decimated?
When you talked about State flexibility from Federal regulations,
should that include the ability to not follow Federal mental health
parity law?
Can you commit that you would not approve any waiver or regulation
that reduces mental health protections under the Medicaid program?
Answer. If confirmed, to the extent that I am not required to
recuse from a specific waiver or regulation under the Ethics Agreement
I signed on January 31, 2017, I would evaluate each waiver that is
elevated to the level of the CMS Administrator to ensure it meets the
requirements set out by law and to evaluate its impact on beneficiary
access as well as budget neutrality requirements.
Question. During the ACA debate, I was the lead sponsor of a
provision that ensured maternity and newborn coverage would be
guaranteed for women and their babies. Last Congress I led a bill with
Senator Grassley called the Quality Care for Moms and Babies Act, which
passed the Finance Committee. The bill would address performance
measurement gaps in Medicaid and CHIP and create maternity care quality
collaborates to share and adopt best practices.
Can you commit to work with me on this legislation, and work on
driving down the maternal mortality rate?
Answer. If confirmed, CMS will be happy to provide technical
assistance related to this legislation as well as other priorities of
yours. Improving maternal and child health outcomes has been something
I have focused on in my career, so I look forward to working closely
with your office on matters of great importance, such as the maternal
mortality rate.
Question. More generally, do you agree that it is critical to
continue investing in health-care-quality improvement and measurement?
How would you engage stakeholders from across the health-care system to
participate in the effort?
Answer. I believe that we should constantly be monitoring data and
outcomes to ensure that patients are receiving quality care that
improves health-care outcomes.
Question. One of the greatest threats to the Medicare program is
Alzheimer's disease. We need a cure and research dollars to help us get
there, but we also need the Medicare program to provide coordinated,
thoughtful care to people living with Alzheimer's disease and their
caregivers who shoulder so much of the burden. We made progress last
year, as I was able to get a care planning benefit included in the
program, which will help ensure better delivery of care.
Do you agree we could help shore up Medicare financing by tackling
Alzheimer's disease care?
What steps would you take as CMS Administrator to help families
struggling with the diagnosis of Alzheimer's disease?
Answer. If confirmed, I stand ready to partner with Congress, the
FDA, NIH, and stakeholders to ensure that Medicare beneficiaries
suffering from Alzheimer's are treated with dignity and compassion.
Curing Alzheimer's would revolutionize the American health-care system
for the millions of families impacted by this disease.
Question. The Patient Access and Medicare Protection Act helped
stabilize patient access to radiation oncology services delivered in
community-based clinics. The legislation also requested a report from
CMS on the development of alternative payment models in radiation
oncology by this summer. Radiation oncologists in my State are
currently working to develop alternative payment models that
incentivize high-
quality care for cancer patients.
As Administrator, how would you consult with radiation oncology
stakeholders, and others, on the development of APMs to ensure
stability, patient access, and appropriate reimbursement?
Answer. If confirmed, I would ensure that CMS is consistently
engaging stakeholders as policies and programs are developed and
implemented to ensure we are achieving the best outcomes for patients.
It is critical that we have open communication to understand their
perspective, what they are going through, and what their challenges
are.
Question. How would changes to the Medicaid financing structure,
such as a block grant system, affect Indian health programs?
Answer. Every State is unique with a different population and
different needs. Congress ultimately decides how to reform Medicaid's
financing structure, and I look forward to implementing whichever
reforms they enact with the utmost care for those affected by those
changes, including families in Indian health programs.
Question. Would you protect the 100% FMAP for services provided
through an IHS/Tribal facility?
Answer. If confirmed, I look forward to implementing the law as
written by Congress. Questions related to the percentage of Federal
assistance are determined by Congress, so I stand ready to work with
you and the rest of Congress to ensure the law is implemented
appropriately.
Question. In 2010, then-Secretary Sebelius established the
``Secretary's Tribal Advisory Committee'' for HHS to hear directly from
tribes on departmental policy development and budget proposals.
What, if any, input would you seek from tribes and urban Indian
health organizations about proposed administrative changes to the
Medicaid and Medicare programs?
As CMS Administrator, what methods would you employ to ensure
proper consultation occurs?
Answer. If confirmed, I will proactively engage stakeholders,
including tribes and urban Indian health organizations, on the front-
end regarding proposed administrative changes to the Medicaid and
Medicare programs. Additional perspective on how CMS policy could
impact their beneficiaries and families is of great value to CMS.
Communication and collaboration early on in the process ensures that
caregivers and families have an opportunity to discuss their
priorities, questions or concerns.
Question. In November 2016, the IHS released the outline of its
plan to improve care at its facilities. The framework includes 5
priorities--strengthening organizational capacity, maintaining facility
accreditation, improving patient experiences, ensuring patient safety,
and identifying potential risks earlier.
What role do you see CMS having in these efforts as the framework
moves forward?
Answer. If confirmed as Administrator of CMS, I will diligently
collaborate and coordinate with all HHS sister agencies, including the
Indian Health Service. CMS will continue to conduct Medicare
certification surveys for IHS hospitals, and will stand ready to
provide technical assistance or other support whenever appropriate.
______
Question Submitted by Hon. Debbie Stabenow
and Hon. Michael F. Bennet
Question. The Protecting Access to Medicare Act (PAMA) included
requirements that ordering physicians consult appropriate use criteria
prior to referring Medicare patients for advanced diagnostic imaging
services.
If confirmed, do you intend to implement the appropriate use
criteria provisions according to existing statute? Would you start the
program on January 1, 2018?
Answer. If confirmed, I will follow the laws as passed by Congress
and implement them accordingly. I look forward to closely monitoring
challenges associated with this implementation process, while
identifying and evaluating specific burdens that have the potential to
limit patient access.
______
Questions Submitted by Hon. Maria Cantwell
medicaid
Question. You have worked extensively on State Medicaid policy and
financing issues. In your view, when States face budget shortfalls,
what do they typically do to reduce costs in their Medicaid programs,
in the absence of additional Federal or State revenue? In other words,
what are the ``levers'' available to States to reduce Medicaid costs?
Moreover, which of these levers are most frequently used?
Answer. The current system is inflexible, with States required to
receive CMS approval for routine changes. We need to allow States to be
innovative and deliver better outcomes while holding States
accountable. If confirmed as Administrator of CMS, I will work to allow
more flexibility to the States, allowing for innovation in the Medicaid
waiver process.
Question. You have stated that Medicaid does not always produce
good outcomes for patients. In your view, what specific outcomes--
clinical, financial, or otherwise--should States strive for in their
Medicaid programs?
Answer. I support State innovations to increase coordination of
care, improve access to preventative care, improve drug adherence and
lower emergency room usage, all with the goal of improving access to
high quality health care and improving patients' outcomes. Outcomes can
be measured in a variety of ways but should focus on the patient
experience and impact of the program on beneficiaries. I look forward
to working with you to reach these goals, if confirmed as Administrator
of CMS.
Question. Does the Federal Government have a role to play in
encouraging those outcomes, and if so, what is that role?
Answer. We can do better to improve health outcomes. Our goal is to
ensure that all Americans have access to high-quality health care with
choices that fit their needs and the needs of their family. If
confirmed, I look forward to working with you to realize better health
outcomes through encouraging innovation, reducing redundant paperwork,
and allowing for providers to spend more of their time on their
patients while also holding States and providers accountable.
long-term care
Question. Do you support Federal ``rebalancing'' initiatives, such
as the Balancing Incentives and Money Follows the Person programs in
the Affordable Care Act?
Answer. I support Americans being in charge of their health care
and choosing what works best for themselves and their family. Every
State is unique with a different population, different needs and
different challenges. If confirmed, I am committed to working to
provide States more flexibility to pursue measures that fit the needs
of their citizens.
Question. Do you believe that, if well-implemented, ``rebalancing''
programs such as the Balancing Incentives Program can improve the care
experience for patients and reduce State Medicaid costs?
Answer. Every State is unique, and design flexibility is an
important component. What works in one State may not work as well in
other parts of the country, so if confirmed, I am committed to working
to provide States more flexibility to pursue innovative measures that
allow States to make the most of available resources and serve their
citizens with the highest quality of care.
basic health program
Question. The Basic Health Program (section 1331 of the Affordable
Care Act) is a State option that is providing health insurance and
access to care to more than 750,000 working low-income individuals in
New York and Minnesota. States that have taken advantage of this
voluntary program are seeing lower costs for beneficiaries, higher
enrollment, and net State budget savings, compared to not implementing
the program. Through the Basic Health Program, States are price-makers,
not price-takers. Do you support the Basic Health Program as a way to
empower States to negotiate a better deal on health insurance for their
citizens?
Answer. I support State innovation to make the most of available
resources and serve their citizens with the highest quality of care.
Programs that work well in one State might not translate to other parts
of the country. From my experience working with States, I learned that
one-size-fits-all solutions won't work so I am committed to increased
State innovation and accountability to the citizens they represent.
Question. If confirmed, will you commit to funding and
administering the Basic Health Program as required under current
Federal law?
Answer. If confirmed, I will follow the laws as passed by Congress
and implement them accordingly.
Question. If Congress repeals parts of the Affordable Care Act,
will you commit to ``not pulling the rug out'' from the 750,000 low-
income individuals who are benefiting from the Basic Health Program?
Answer. I support Americans being in charge of their health care
and choosing what works best for themselves and their family. Our goal
is to ensure that all Americans have access to high-quality health care
with choices that fit their needs and the needs of their family. I am
committed to implementing the law as written and I am committed to
implementing it with careful attention to those Americans who may be
impacted.
Question. Will you use your administrative discretion as CMS
Administrator to not rescind funding for State Basic Health Programs,
unless a rescission of that funding is explicitly required by a change
to the statute?
Answer. If confirmed as Administrator of CMS, I will follow the
laws as passed by Congress and implement them accordingly, including
the directions from Congress related to appropriations measures and
other sources of funding for health care programs.
delivery system reform
Question. Washington State and the Pacific Northwest have led the
way in pioneering nationally recognized innovations in the delivery of
health care--whether it is the Qliance Direct Primary Care medical home
model, Group Health Cooperative's highly popular integrated coverage
and care model, the Everett Clinic's price transparency initiatives,
Boeing's Accountable Care Organizations, or Virginia Mason's team-based
care. Despite their innovations, health-care providers in my State are
paid nearly $2,000 less (per Medicare enrollee, per year) than the
national average, based on CMS spending data compiled by the Kaiser
Family Foundation. I would argue that, due to our current volume-based
system, my constituents are paid less specifically because they are
efficient and because they do a good job of keeping patients healthy.
Should the Federal Government reward such high-value health-care
providers, as long as we clearly define and agree upon metrics for what
constitutes ``high-value'' care?
Answer. If confirmed as Administrator of CMS, I will follow and
implement laws, such as MACRA, related to payment to high-value health-
care providers.
Question. Does the current fee-for-service system encourage
unnecessary health-care spending? If so, can you please explain
specifically how this system encourages unnecessary health-care
spending, including in which specialties of medicine, and in which
settings of care?
Answer. The current system can encourage unnecessary spending by
putting too many health-care decisions in the hands of a distant
Federal bureaucracy rather than in the hands of doctors and their
patients. All health-care providers, from primary care providers to
specialists, should be encouraged to provide value to their patients.
Question. Under the Obama administration, HHS Secretary Burwell and
CMS Administrator Slavitt set a goal of providing 50 percent of
Medicare fee-for-service spending through alternative payment models.
If confirmed, will you continue, rescind, or modify that goal?
Answer. If confirmed, I look forward to reviewing the actions taken
by health-care providers and CMS to achieve the initial goal to better
understand what has worked and what we can improve upon in the
implementation of laws such as MACRA. Additionally, it is crucial to
communicate and collaborate with providers and stakeholders throughout
the process.
Question. In 2015 Congress passed and President Obama signed into
law the Medicare Access and CHIP Reauthorization Act (MACRA). MACRA
incorporated the Value-Based Payment Modifier, which I authored in the
Affordable Care Act, into Medicare's new physician payment system, the
Quality Payment Program. Will you commit to working with Washington
State health-care providers to help them succeed in Medicare's Quality
Payment Program, as outlined in regulations by CMS, including Advanced
Alternative Payment Models?
Answer. If confirmed, I am committed to working closely with the
Secretary of HHS to ensure MACRA is implemented fairly and so that it
is easy to understand and minimizes burdens, especially on smaller and
rural providers.
Question. Will you commit to fund and administer Medicare's
Accountable Care Organizations, including the Medicare Shared Savings
Program under section 3022 of the Affordable Care Act, and will you
commit to helping health-care providers participate in these models,
should they choose to do so? Will you commit to not taking any
administrative action that would make it more difficult for Medicare
beneficiaries or health-care providers to participate in this voluntary
program?
Answer. If confirmed, I will follow the laws set forth by Congress
related to Medicare's ACOs, and I intend to work with the Secretary of
HHS to ensure, as we move forward, that we learn from the results of
ACOs and chart a path forward based on an understanding of what is and
what is not working.
Question. Will you commit to fully fund approved grants under the
Center for Medicare and Medicaid Innovation (CMMI), and will you
continue to fund and administer future payment initiatives under CMMI,
consistent with the legislative intent of Congress in the Affordable
Care Act?
Answer. I look forward to reviewing current CMMI projects,
consistent with congressional actions.
Question. Health-care researchers and providers in Washington
State, such as the AIMS Center at the University of Washington and Iora
Health, are working to integrate behavioral health services into the
primary care experience in order to provide a more seamless care
experience, reduce the stigma of behavioral health conditions, and fill
historical gaps in access to care. Do you support the integration of
primary care and behavioral health into the same care setting?
Answer. If confirmed, to the extent I am not required to recuse
from a particular matter under the terms of my Ethics Agreement, I will
work to implement the laws passed by Congress. I support flexibility
for States to design innovative care programs that improve health
outcomes. Both primary and behavioral health care are key components to
providing comprehensive care to patients and I support innovative
approaches that drive better health care.
specific health care legislation
Question. I have authored bipartisan legislation (S. 2259 in the
114th Congress) to make it easier for rural health-care providers to
participate in the Medicare Shared Savings Program by allowing CMS to
adopt a broader beneficiary assignment method than is provided under
current law. Will you commit to providing me and my office responsive
and accurate technical assistance on this legislation?
Answer. I am committed to open communication, collaboration, and
bipartisanship. If confirmed, I will work with you and be responsive to
your inquiries and concerns and provide information on the beneficiary
assignment for the Medicare Shared Savings Program.
Question. I have authored bipartisan legislation (S. 2373 in the
114th Congress) to require CMS to cover an essential preventive
product, compression therapy items, for Medicare beneficiaries who
experience swelling from lymphedema. Will you commit to providing me
and my office responsive and accurate technical assistance on this
legislation?
Answer. I am committed to open communication, collaboration, and
bipartisanship. If confirmed, I will work with you and be responsive to
your inquiries and concerns and provide information on the Medicare
coverage and payment process.
Question. I have cosponsored bipartisan legislation (S. 3129 in the
114th Congress) to preserve patient access to outpatient therapeutic
services in Critical Access Hospitals and other rural hospitals.
Similar legislation has been signed into law the last 3 years. Will you
commit to working with me, my staff, and bill sponsors and cosponsors,
on this issue?
Answer. I am committed to open communication, collaboration, and
bipartisanship. If confirmed, I will work with you and be responsive to
your inquiries and concerns to ensure that critical access hospitals
continue to provide quality health care to rural populations.
Question. Will you commit to providing me and my office responsive
and accurate technical assistance on any future legislation I author or
on which I seek assistance?
Answer. I am committed to open communication, collaboration, and
bipartisanship. If confirmed, I will work with you and be responsive to
your inquiries and concerns.
washington state's section 1115 medicaid waiver
Question. On January 9, 2017, CMS approved Washington State's
proposed Medicaid waiver (``Medicaid Transformation Project, No. 11-W-
00304/0) under section 1115(a) of the Social Security Act. In securing
agreement on this waiver, Washington State health officials and CMS
spent countless hours over more than a year in good-faith negotiations.
This approved waiver will help Washington State pursue a smarter and
more innovative Medicaid program that reflects changes in health-care
delivery, technology, and the preferences of patients. Specifically,
the waiver will help my State integrate behavioral health and primary
care services, and re-orient the care experience away from higher-cost
institutional settings to lower-cost community based settings. Will you
commit to honor this approved waiver and not take any administrative
action to rescind, weaken, or de-fund its components?
Answer. If confirmed, I am committed to working to provide States
more flexibility to pursue innovative waivers that fit the needs of
their citizens. Our goal is ensure that all Americans have access to
have high quality health care with choices that fit their needs and the
needs of their family.
graduate medical education
Question. The vast majority of Washington State counties are Health
Professional Shortage Areas (HPSAs) according to HHS's HRSA. In
response to an aging population and impending physician shortages, two
new medical schools have opened in Washington, each focused on training
more physicians to practice in shortage specialties and in medically-
underserved communities. Do you agree with an established body of
research illustrating that there are physician shortages in the United
States, especially in primary care specialties and in rural
communities?
Answer. Coverage doesn't always translate to access, and access to
care is a critical issue in many areas of our country, especially in
our rural areas where there are challenges in attracting workforce. If
confirmed, I will work with the Congress, the Secretary of HHS, and the
Health Resources and Services Administration (HRSA) to address
physician shortages as they relate to Medicare and Medicaid programs.
Question. Given your experience in health-care policy, what is your
view of the role the Federal Government should play to promote an
adequate and balanced physician workforce in the United States? Or
should that role be left to the States?
Answer. When considering new rules and regulations, we all (Federal
and State) should be mindful of the workforce shortage, particularly in
our rural areas where there are unique challenges in attracting medical
providers. We all should proactively engage providers on the front end
for valuable feedback and take into account the fact that they may have
limited time and resources to implement regulations.
Question. As the practice of medicine transforms, how should
Medicare's financial support for graduate medical education (GME)
adapt, or should it remain the same?
Answer. If confirmed, I look forward to working with you and other
members of Congress on your priorities to see that our GME programs
work well for a 21st-
century medical work force.
medicare reimbursement
Question. CMS recently finalized a regulation implementing section
603 of the Bipartisan Budget Act, which effectively reduces Medicare
payment rates for certain newly established, off-campus hospital
outpatient departments to the payment level under the physician fee
schedule or ambulatory surgery center fee schedule. If confirmed, how
will you approach implementation and interpretation of section 603 of
the Bipartisan Budget Act?
What exceptions, if any, are appropriate to ``site-neutral''
payment reductions?
Do you support ``site-neutral'' payment policies in Medicare? If
you do in part, could you explain in what settings they are
appropriate, and in what settings they are not?
Answer. If confirmed, I will support the implementation of the
site-neutral payment rules that Congress has enacted or will enact.
Ensuring that patients can access quality care in all kinds of health-
care settings is a priority for Congress, CMS and the American people.
It is essential that beneficiaries have robust choices in their
providers and I look forward to implementing policies that ensure we
attract providers to deliver quality care.
______
Questions Submitted by Hon. Bill Nelson
Question. On January 30th, President Trump issued an executive
order that requires some Federal agencies to repeal two regulations for
every new one issued. Given the sheer number of rules and regulations
that CMS must issue every year, how do you envision this executive
order functioning so that CMS can continue to do its job? Can you give
me examples of two specific regulations that you would repeal as CMS
Administrator?
Answer. If confirmed as Administrator of CMS, I look forward to
reviewing existing regulations and any new proposed regulations to
determine applicability to the President's Executive order.
Question. Over 4 million seniors in Florida rely on the health and
financial security provided by the Medicare program. I've consistently
opposed efforts to convert Medicare to voucher program, which would
fundamentally change the program and leave seniors exposed to higher
out-of-pocket costs. How would you propose to help people on Medicare
and their families with the rising cost of medical care and long-term
care?
Answer. I support offering choices for seniors and opportunities
for additional benefits. Ultimately, the direction of Medicare is up to
Congress and if confirmed as Administrator of CMS, I will follow the
laws as passed by Congress and implement them accordingly. I hope we
can work together to make the program more sustainable.
Question. Then-Congressman Price introduced a bill (the Medicare
Patient Empowerment Act) to allow practitioners to enter into private
contracts with their Medicare patients and charge higher fees than what
is currently allowed under the Medicare program. Currently, when
seniors in Medicare see their doctors they are responsible for a set
amount of costs and physicians participating in Medicare cannot bill
their patients for any outstanding costs. Do you support this change in
policy?
Answer. I support offering choices for seniors and putting
Americans in charge of their health care and choosing what works best
for them and their family. Medicare policy-making is in large part done
by Congress, so I look forward to working with you on Medicare issues.
Question. The ACA includes provisions designed to improve
treatments for people with substance use disorders, including opioid
addiction. It included mental health and substance use disorder
treatment as essential health benefits; it expanded access to treatment
services; it eliminated lifetime limits on behavioral health services;
and ended discrimination by insurers based upon pre-existing
conditions.
According to the CBPP, 1.3 million people with serious mental
illness and 2.8 million people with substance use disorders would lose
health coverage under ACA repeal. Would you recommend that President
Trump and congressional Republicans maintain the provisions listed
above in any replacement plan? Beyond keeping the ban on discriminating
against people with pre-existing conditions, what are the elements that
any replacement plan must include?
Answer. My goal is to ensure that all Americans have access to high
quality health care with choices that fit their needs and the needs of
their family. If confirmed, I will follow the laws as passed by
Congress and implement them accordingly.
Question. As CMS Administrator, what administrative actions would
you take to address the opioid epidemic?
Answer. If confirmed as Administrator of CMS, to the extent I am
not required to recuse from a particular matter under the terms of my
Ethics agreement, I will work closely with the Secretary and the
Substance Abuse and Mental Health Services Administration (SAMHSA)
whose duty is to advance behavioral health and reduce the impact of
substance abuse and mental illness on America's communities. It is
critical that all Americans suffering from mental health and substance
abuse disorders have access to the care they need.
Question. The Medicare Advantage program is an affordable option
offering out-of-pocket spending caps, additional benefits like vision
and dental, and often prescription drug coverage at no additional cost
for many of my constituents. As Administrator, what specific actions
would you take to strengthen and build upon this vital part of the
Medicare program? How will you ensure that the 1.6 million seniors in
Florida, and the 18 million that enrolled across the Nation are
protected?
Answer. I am committed to preserving and strengthening the Medicare
Advantage program as it offers additional benefits and provides
additional choices to seniors. If confirmed, I look forward to working
with you and other members of Congress to support the program.
Question. A CMS Medicare Graduate Medical Education (GME) rule
prevents a number of hospitals that hosted--for a very brief period of
time--medical residents from another facility's teaching program from
establishing their own full-time Medicare support residency programs.
Under current CMS policy, hospitals considered by CMS as ``new''
teaching hospitals are permitted to establish a permanent full-time
(FTE) resident cap and per resident amount (PRA), which allows for
reimbursement by CMS for Medicare's share of the hospital's training
costs. I have heard from a small number of community hospitals in my
State that inadvertently triggered a very low resident and/or PRA
though hosting resident rotators for short periods of time. Do you
commit to working with me to fix this glitch? Does CMS have the
authority to fix this problem without congressional action?
Answer. If confirmed, I commit to looking into this issue with you
and helping you evaluate the options at both the legislative and
executive level.
Question. In 2016, CMS announced a new pre-claim review
demonstration (PCRD) for home health services in five States. The
demonstration began in Illinois in August, with plans to expand to
Florida, Texas, Michigan and Massachusetts. Because of problems
experienced by beneficiaries and providers in Illinois, program
expansion was delayed. It is now scheduled to be implemented in Florida
on April 1st, without any changes. Do you plan to continue this
demonstration in Illinois? Do you plan to move forward with the
demonstration in Florida? If so, will you amend the scale of the
demonstration and provide additional safeguards for providers?
Answer. If confirmed, I would review current demonstrations as well
as the results of other similar demonstrations to understand the
challenges and any lessons learned that may be applied to the Pre-
Claims Review Demonstration. I look forward to working with you to
address your concerns.
Question. When the Medicaid program was created in 1965, there were
fewer service delivery settings and options available for consumers. As
a result, nursing home care was made a mandatory benefit within the
program. Since then, service innovations and technologies have enabled
care to be safely and effectively delivered in home and community-based
settings, yet the Medicaid program still retains the mandate for
nursing home placement. States must seek a waiver in order to enable
consumers to receive home and community-based care. How do you intend
to use administrative power to facilitate beneficiaries have access to
high-quality, cost-
effective home and community-based services? How would cuts to State
Medicaid programs through block grants and per capita caps impact the
ability of States to deliver high quality home and community-based
services to an aging baby boomer population that wants to receive long-
term services and supports at home and in their communities?
Answer. I support Americans being in charge of their health care
and choosing what works best for themselves and their family. Every
State is unique with a different population and different needs and the
Medicaid program should be more flexible to address the changing
health-care landscape and population needs with the goal of improving
health outcomes. If confirmed, I am committed to working with States,
in accordance with the laws passed by Congress, to provide more
flexibility to pursue innovative measures that fit the needs of their
citizens. At the same time, States must be held accountable to
standards that result in better health-care quality and access. Our
goal is to ensure that all Americans have access to high quality health
care with choices that fit their needs and the needs of their family.
______
Questions Submitted by Hon. Bill Nelson
and Hon. Robert Menendez
Question. Puerto Rico's economic recession has caused the number of
Puerto Rico residents migrating to the States to reach staggering
levels. The situation is made worse by physician shortages, a Medicaid
program facing chronic funding shortfalls, and across-the-board
disparities in Federal health programs.
Puerto Rico's Medicaid program serves about 1.4 million residents--
over 40 percent of the island's population. The Affordable Care Act
provided Puerto Rico with a one-time funding boost of $6.4 billion set
to expire at the end of fiscal year 2019. This funding will be depleted
in 2017. Once this money is gone, Puerto Rico will go back to receiving
its annual set Medicaid allotment, about $350 million in FY 2018.
Do you believe Puerto Rico should be treated the same as States
under Federal Medicaid laws?
Answer. As you acknowledge in your question, Puerto Rico's fiscal
challenges are much broader than those pertaining to their Medicaid
program. It is my hope that leaders in the Commonwealth and in Congress
will be able to adequately fund Puerto Rico's Medicaid program while
addressing their overall fiscal situation. If confirmed, I will follow
the laws as passed by Congress and implement the law accordingly.
Question. Do you support extending the Medicare Part D LIS program
to seniors residing in Puerto Rico and the other territories? If you do
not believe low-income seniors in Puerto Rico should have access to the
LIS program, why?
Answer. Extending the Medicare Part D LIS program to seniors
residing in Puerto Rico and other territories would require a change in
statute. Therefore, this is a legislative matter and I defer to
Congress to address this issue. I will faithfully administer the
Medicare Part D program as written in statute.
Question. In order to use their supplemental allotment, the Puerto
Rico Government must pay a 45 percent local match. During the last 3
years, the Puerto Rico Government drew down only half of its Federal
allotment funds because it could not generate its match. Do you believe
CMS should remove or waive the local matching requirement so that
Puerto Rico can fully access the allotment funding? If you do not
believe this matching requirement should not be waived, why?
Answer. Access to quality health care for the people of Puerto Rico
is an important issue that I look forward to working with Congress and
the Commonwealth to appropriately address in accordance with the law.
Puerto Rico's broader economic challenges impact the Commonwealth's
health care financing capabilities, so I am hopeful that these issues
can be addressed in order to make Puerto Rico fiscally sound and
healthy.
Question. Last year, we had the honor of serving on the bipartisan,
bicameral congressional Task Force on Economic Growth in Puerto Rico.
The Task Force was responsible for identifying steps to help stabilize
and grow Puerto Rico's economy. The Task Force recommended that
Congress enact fiscally-responsible legislation to address the Medicaid
cliff established by the ACA. Will you commit to taking up the Task
Force's recommendation to ensure that going forward Federal financing
of the Medicaid program in Puerto Rico should be more closely tied to
the size and needs of the territory's low-income population? What
specific actions would you take to help achieve this goal?
Answer. I look forward to reviewing the Task Force's
recommendations and implementing the laws as designed by Congress
related to the financing of Puerto Rico's Medicaid program.
Question. Will you commit to enacting the Task Force's
recommendation that CMS undertake any additional administrative steps
necessary to ensure that Medicare Advantage plans in Puerto Rico are
being fairly and properly compensated for the services they provide to
beneficiaries? What specific administrative steps will you recommend
CMS take?
Answer. Every effort should be made to ensure that Medicare
Advantage plans in Puerto Rico are being fairly and properly
compensated for the services they provide. If confirmed, I will
carefully study and consider the Task Force's recommendations, and work
closely with members of Congress in order to determine how best to
proceed on this important matter.
Question. The Obama administration established a working group that
included HHS and CMS officials and Puerto Rico health-care stakeholders
to jointly propose solutions to the ways in which the funding crisis is
manifested. This includes, among other critical policies, dealing with
the statutory cap on Medicaid expenditures and the lack of a low-income
drug subsidy. Do you commit to ensuring CMS continues its focused and
meaningful participation in this working group to ensure that we
address Puerto Rico's disparate treatment under Federal health
programs?
Answer. I commit to working with you and all parties involved to
ensure that the people of Puerto Rico are able to access high quality
health-care plans and receive the proper attention of CMS as we
evaluate our options and provide technical assistance for legislative
matters as appropriate.
______
Questions Submitted by Hon. Robert Menendez
recusal from mental health issues
Question. In the hearing I asked you a question about the ACA's
Essential Health Benefit package as it pertains to coverage of
behavioral health services, specifically for autism services. In your
response you mentioned that you were recusing yourself from mental
health policy in light of your husband's work as a psychiatrist.
According to your letter to the Associate General Counsel for
Ethics at the Department of Health and Human Services, you say that you
``will not participate personally and substantially in any particular
matter that to (your) knowledge has a direct and predictable effect on
the financial interest of the Indian Health Group'' at which your
husband practices.
Can you provide more detail about exactly what you plan to recuse
yourself from, if confirmed?
Answer. As noted in my Ethics Agreement, which you reference above,
because of my husband's practice as a psychiatrist with the Indiana
Health Group, Indianapolis, IN, and his financial interest in the
Indiana Health Group, I have agreed not to participate personally and
substantially in any particular matter that to my knowledge has a
direct and predictable effect on the financial interests of the Indiana
Health Group, unless I first obtain a written waiver, pursuant to 18
U.S.C. Sec. 208(b)(1). Under the Federal ethics regulations, I am not
required to recuse from consideration or adoption of broad policy
options that are directed to a large and diverse group of persons. I
will be required to recuse from matters that involve deliberation,
decision or action that is focused upon the interests of the Indiana
Health Group, or the discrete and identifiable class of persons or
entities that includes the Indiana Health Group. To the extent that I
have questions on how to apply my recusal obligations to a particular
matter, I will consult with the HHS Ethics Office for guidance on the
scope of my recusal obligations.
Question. Does this recusal include your work on any/all work to
oversee and enforce Federal mental health parity laws?
Answer. Although I will consult with the HHS Ethics Office as
needed for guidance, the mental health parity rules are focused on
insurance coverage for mental health services and/or substance use
disorder services, these rules may impact entities such as the Indiana
Health Group and service providers in the Group, including my husband,
that receive insurance reimbursement for mental health and substance
use disorder services. Accordingly, I will recuse from this work.
Question. Will you recuse yourself from dealing with any Medicaid
waiver applications that include mental health components, such as the
Comprehensive 1115 Waiver in New Jersey which is largely about the ID/
DD population?
This is of particular importance given the massive changes to the
Medicaid program you have previously championed and will, presumably,
continue promoting. Seeing as the Indiana Health Group refuses to treat
individuals enrolled in Medicare, Medicaid and CHIP, can you confirm
your recusal from these issues?
Answer. The 1115 Medicaid Waiver application for New Jersey is a
particular matter involving New Jersey as a specific party. Resolution
of that waiver will be State-specific. Accordingly, under the ethics
regulations, my ethics obligation will not require my recusal from this
waiver.
Question. Since my question during the hearing was actually about
insurance benefit design generally, not about anything specific to do
with payment to providers of any kind, can you clarify your views on
whether or not a child's access to insurance coverage (not only for
behavioral health and autism services, but any health service) should
be based on the State in which they live?
Answer. Children are some of our most vulnerable citizens and I
support ensuring that they receive quality health care through the most
effective means available.
medicare packaged payment policies
Question. As you may be aware, Medicare Part B hospital and
ambulatory surgery center payments account for medications which cost
more than a nominal amount to be reimbursed ``at cost'' rather than
getting ``packaged'' into the procedure code payment. This is because,
according to CMS, because packaging certain types of drugs ``might
result in inadequate payments to hospitals, which could adversely
affect Medicare beneficiary access to medically necessary services.''
However, in recent years, CMS seemed to forget this rationale and
finalized a series of rules to package certain ``drugs that function as
a supply when used in a surgical procedure'' and that ``function as a
supply in a diagnostic procedure.'' This package payment policy, which
has nothing to do with the actual price of the drug or the amount
Medicare pays for the drug, has made several critical treatment options
out of reach for beneficiaries due to the sharp decrease in
reimbursement resulting from the packaging policy.
If confirmed as Administrator, will you commit to revisiting this
policy in the upcoming rulemaking cycle and conduct an in-depth
evaluation of the impact this packaging payment policy has had on
beneficiary access to the services the current regulations single-out
for packaged reimbursement?
Additionally, if this evaluation demonstrates decreased access to
care for Medicare beneficiaries or an increased burden on providers
that make providing these services more difficult, will you commit to
make changes to ensure access is restored?
Answer. If confirmed, I commit to thoroughly reviewing the rules to
ensure they are implemented consistently with the law and with the
utmost regard for the accessibility of high quality health care for all
impacted Medicare beneficiaries.
proper oversight of medicare contractors
Question. As you might know, CMS contracts out several
administrative activities, such as processing Fee for Service claims,
medical record review, provider enrollment and the establishment of
local coverage determinations (LCDs), to Medicare Administrative
Contractors (MACs). MACs are divided up by region and serve as the
agency's primary contact agent with Medicare providers. It has recently
come to my attention that the MAC covering New Jersey is implementing a
prior-authorization requirement for certain services, specifically
hyperbaric oxygen therapy (HOBT). While I generally support the idea of
prior-authorization in certain cases, the New Jersey MAC has issued an
LCD, and further guidance on its website through a Frequently Asked
Questions page, that is having a significant impact on beneficiaries'
ability to receive this important therapy and that contradicts well-
established medical and scientific practices. Additionally, it appears
that the MAC is implementing this prior-authorization differently in
New Jersey than other MACs in other States, causing provider confusion
and unequal access to care across the country.
If confirmed as Administrator, will you work to provide the
necessary oversight of MACs and other contractors to ensure the
policies they implement are both consistent across the country and
consistent with medical best practices?
Answer. I will strive to do so. If confirmed, I would be pleased to
work with you on this issue. Our goal is to offer seniors access to the
care they need. I appreciate the need to engage in oversight to
identify and evaluate challenges associated with MACs and LCDs more
generally.
children's health insurance program (chip)
Question. Since 1997, the Children's Health Insurance Program
(CHIP) has been essential for children and pregnant women in working
families who cannot afford private health insurance. Today, CHIP
provides affordable health coverage to over 8 million children and
hundreds of thousands of pregnant women across the country. Taken
together, CHIP and Medicaid have combined to reduce the number of low-
income, uninsured children across the country by half. At the same
time, the program has improved health outcomes and access to care.
As was mentioned during your hearing, the CHIP program needs to be
reauthorized by Congress this year, and now-Secretary Tom Price stated
that he supported an extension of up to 8 years.
If confirmed as Administrator, will you commit to working with
Congress to enact a long-term reauthorization of the CHIP program and
to do so in a manner that maintains the program's success at providing
comprehensive coverage to pregnant women and children and does not
limit funding, coverage, access or quality?
Answer: It is important that every child has access to high-quality
health coverage, and CHIP plays an important role in accomplishing this
objective. CHIP plays a major role in this, but there is also a need to
focus on family coverage in the private market and employer plans, and
on giving States needed flexibility. Each State has different needs,
and I believe CMS needs to work with States to ensure that, consistent
with those needs, the CHIP program provide possible coverage to their
residents. If confirmed, I would work with Congress on CHIP
reauthorization with these principles in mind.
home visiting programs
Question. As you may know, evidence-based home visiting programs,
working in conjunction with FQHCs, promote support and expand access to
children and families, specifically those eligible for, or enrolled in,
Medicaid. One such program is the Maternal, Infant, and Early Childhood
Home Visitation (MIECHV) program. In 2015 alone, MIECHV provided
services to nearly 150,000 parents and children in more than 800
counties in all 50 States, all five territories, and the District of
Columbia. However, coordination between MIECHV grantees and Medicaid is
often difficult given that Medicaid is the payer of last resort in all
cases except those with a specific exemption in law, such as what
exists under the Maternal and Child Health Services Block Grant,
Special Supplemental Nutrition Program for Women, Infants and Children
and services provided as part of an Individualized Education Program or
Individualized Family Service plan under the IDEA. Currently, MIECHV
services do not have that explicit exemption, despite being focused on
maternal and child health as the other exempted programs are. There has
been no effort on the part of CMS to meaningfully address the issue of
benefit coordination, causing confusion among service providers and
impeding access for beneficiaries.
If confirmed as Administrator, will you commit to clarifying the
funding relationship between the MIECHV and Medicaid programs?
Answer. If confirmed, I commit to working with you to better
understand this relationship and to evaluate all options to address
MIECHV and Medicaid issues at both the legislative and executive level
with the goal of improving the health and well-being of mothers and
their children.
______
Questions Submitted by Hon. Robert Menendez, Hon. Sherrod Brown,
Hon. Ron Wyden, Hon. Michael F. Bennet, and Hon. Robert P. Casey, Jr.
Question. Congress passed the Protecting Access to Medicare Act
(PAMA) in 2014. This bipartisan law included policies to update and
change the way Medicare reimburses clinical laboratories under the
Clinical Laboratory Fee Schedule (CLFS), moving the reimbursements
towards a market-based payment methodology. Under the law, all
``applicable'' laboratories are required to report to CMS the payment
rates and test volumes for their private payers.
CMS finalized PAMA regulations in June 2016, and released further
guidance in September 2016, which impose an unrealistic reporting
timeline for laboratories. Additionally, we have heard from our
regional and community-based laboratories about significant concerns
they have about their ability to report accurate data and how the
current rules' exclusion of market data from hospital outreach labs and
definition of ``applicable laboratory'' will impact the accuracy of
CMS's data.
If confirmed, will you commit to looking at the current PAMA
regulations and reporting requirements to ensure that independent,
physician and hospital laboratories are appropriately and accurately
accounted for in the market price data?
Answer. I appreciate your concerns regarding the implementation of
PAMA. Certainly, we should strive for accuracy in this market data
collection process. It is important that patients have access to
community-based labs. Accordingly, I look forward to closely monitoring
challenges associated with this implementation process, while
identifying and evaluating specific burdens that have the potential to
limit patient access.
Question. Further, will you commit to evaluating the need to extend
the March 31, 2017, reporting deadline to ensure that laboratories--
especially smaller, community laboratories--are able to successfully
collect and report the data required under the regulations?
Answer. I look forward to following up with CMS staff and regional
and community-based laboratories to discuss workable solutions.
______
Questions Submitted by Hon. Thomas R. Carper
experience with private health insurance markets
Question. As you know, the House and the Senate recently passed
budget resolutions to repeal the Affordable Care Act and cut Medicaid
funding by more than $1 trillion. More than 20 million Americans gained
health insurance as a result of the Affordable Care Act. Can you share
your experience and background working with the individual and small
group health insurance markets? If confirmed as Administrator of the
Centers of Medicare and Medicaid Services (CMS), what specific actions
will you take to ``fix'' our State insurance markets and ensure access
to health insurance for the millions of Americans who gained coverage
under the ACA?
Answer. I worked with States in preparing for the changes brought
about by the ACA including working with State insurance departments and
reviewing and implementing ACA regulations. If confirmed as CMS
Administrator, I will work to ensure that every State insurance
commissioner has as much flexibility as possible to repair their
respective insurance markets.
medicare
Question. Ms. Verma, you noted in your testimony that the American
people are tired of politics and just want their health-care system
fixed. As you already know, we recently passed bipartisan legislation
to reform the way Medicare reimburses physicians, moving from a fee-
for-service system to payment based on better quality and improved
outcomes. In your experience, what kinds of reimbursement systems do
you believe are best suited to improving health outcomes and driving
down costs? In your opinion, what are the strengths and weaknesses of
accountable care organizations, bundled payments, and patient-centered
medical homes? What other types of payment reforms should be
implemented in Medicare to improve the quality of health care while
reducing unnecessary costs?
Answer. We share the goal of improving Medicare by empowering
providers to be creative and developing payment models that best suit
the unique needs of their patients to ultimately improve patient care.
For instance, the Medicare Access and CHIP Reauthorization Act of 2015
(MACRA) establishes the Physician-Focused Payment Model Technical
Advisory Committee to review proposals for physician-focused payment
models that can ultimately be adopted by CMS. More generally, a
fundamental principle for payment reforms is the centrality of the
patient in the system and their ability to make choices about their
care in consultation with their doctor and that we drive toward better
coordination and improving quality and health outcomes.
medicaid
Question. In the Healthy Indiana program, you strongly promoted the
use of personal responsibility such as the use of co-pays and cost-
sharing for Medicaid beneficiaries. For some extremely poor Medicaid
beneficiaries, the premiums and co-pays are just $1, which does not
seem unreasonable. When one of these beneficiaries fails to pay their
$1 premium, how much does Indiana spend to collect this bad debt? Do
beneficiaries with no income through no fault of their own, for example
if their employer goes out of business, still have to pay premiums for
their Medicaid benefits? When Medicaid beneficiaries lose their
Medicaid benefits because of their inability to pay their premiums and
goes to the hospital emergency room for care, what does it cost Indiana
and American taxpayers? Does Indiana's Medicaid program fully recoup
the dollars spent on managing this program?
Answer. The Healthy Indiana Plan's contribution requirements are
not designed as a punitive measure but as a way to promote personal
responsibility in members which has resulted in better health outcomes,
including lower ER use, higher patient satisfaction, drug adherence and
more primary and preventative care. Only members above the poverty line
are at risk of losing coverage for non-payment. Where HIP members are
locked out of coverage for 6 months for non-payment, those who fail to
pay Marketplace premiums may have to wait until the next open
enrollment period to regain coverage, which can be up to 9 months,
unless they have a change in circumstance that makes them eligible for
a special enrollment period. On the whole, HIP's non-payment policies
for individuals above the poverty line are at least comparable, if not
more lenient, than the policies governing the Marketplace. Moreover,
only 5 percent of former HIP members indicated they left the program
due to affordability issues. Additionally, more than 80% of HIP members
have indicated they would be willing to pay more to stay in the
program, while more than half of those who left the program due to non-
payment successfully transitioned to private health insurance coverage.
obesity
Question. We know that the disease of obesity costs the health-care
system hundreds of billions of dollars a year in needless and
potentially unnecessary treatments. The States you have worked with,
such as Indiana, Kentucky, Tennessee and Iowa, have some of the highest
rates of obesity in the country. It is long past the time that CMS
adopt an ``all-in'' approach to fighting obesity. As CMS Administrator,
how will you seek to maximize current obesity treatment programs and
increase the treatments available to overweight or obese patients?
Specifically, how would you increase access to nutritional counseling
for overweight and obese individuals in the Medicare and Medicaid
programs?
Answer. Obesity is a chronic condition, and I agree that it is an
important priority for our health-care system to address this condition
for both children and adults. We need to strengthen the relationship
between patient and doctor in order to address this disease on the
front end and support providers in identifying best practices as well
as supplying technical assistance as providers address this critical
issue.
program of all-inclusive care for the elderly (pace)
Question. In Medicare, Medicaid, and the private sector, we are
seeing significant and accelerating change towards value-based care and
reimbursement based on better quality and outcomes. Yet the Program of
All-Inclusive Care for the Elderly (or PACE), which pioneered so many
of the features we now seek to build into our health-care system, is
being constrained by outdated regulations. If confirmed, what will do
you do to ensure that CMS updates these regulations quickly to provide
more flexibility to PACE and to expand access to this program for
medically frail seniors?
Answer. I look forward to reviewing the regulations currently in
place and changes outlined in the proposed rule and working with
Congress to eliminate any regulations that hinder efficiency or access
to quality care.
Question. It is important for CMS to issue a final rule that would
update and improve the Program of All-Inclusive Care for the Elderly
(PACE). A proposed rule to update PACE was issued in August 2016 to
increase access to care, remove inefficiencies in the system and assure
continuous care to many of the most vulnerable patients. An important
change in the proposed rule would explicitly allow physician assistants
(PAs) to be employees or contracted providers for PACE programs. While
PAs currently provide high quality medical care and chronic care
management to Medicare and Medicaid beneficiaries throughout the
country, current CMS rules exclude PAs from being an employee or
contracted provider in the PACE program. Will you continue work to
strengthen the PACE program and ensure it is modernized in a way that
effectively uses PAs and other health-care providers, who provide high
quality, affordable health-care services?
Answer. I look forward to reviewing the changes outlined in the
proposed rule, and I agree that PAs are a vital part of our health-care
system and should be used to provide high quality, affordable health-
care services.
improving the value of health care
Question. Improving the value of health care has been a shared
bipartisan priority for several decades, as the share of our economy
dedicated to health care has continued to rise, but not necessarily in
sync with the overall quality of health care and health outcomes.
Implementation of the quality reporting and performance programs is an
important tool for increasing the quality of health care, improving
health outcomes and lower unnecessary costs. How will you advance
health care quality reporting and value-based purchasing programs in
Medicare, Medicaid, and in private health insurance plans?
Answer. I look forward to reviewing our current quality reporting
and performance programs to ensure that they provide the data needed to
improve patient outcomes while not becoming so burdensome that they
reduce providers' ability to give quality care. Ensuring transparency
so that patients can make informed decisions about the care they
receive is a crucial component of this and I look forward to working
with Congress on this issue.
health-care costs and quality
Question. The United States spends nearly twice as much on health
care as other developed countries, such as Japan, but fails to provide
insurance coverage for all Americans. Health outcomes and quality, such
as infant mortality, preventive care, and overall lifespans, often lag
behind other countries as well. What are three specific health-care
programs or public health strategies utilized by other countries'
health-care systems that you would seek to emulate in the Medicare,
Medicaid, and private health insurance programs and how would you adapt
them to fit demographic trends, cultural norms, and logistical
challenges unique to the United States.
Answer. The United States is a world leader in medical research and
medical innovation and performs well in key health indicators, such as
cancer survival rates. We should focus on how we can provide access to
quality health care for all Americans with local solutions that work
best for individual patients and their families. Data-driven decisions
based on price and quality transparency should be afforded to American
patients as we learn from other countries and their efforts in those
areas.
affordability
Question. For many Americans, the affordability of health insurance
continues to be a significant barrier to accessing basic health care.
How would you seek to increase the affordability of health insurance,
lower insurance premiums, and reduce deductibles and co-pays, while
also ensuring that all Americans have comprehensive, high quality, and
dependable health insurance plans? Do you think that health insurance
plans should be able to apply annual and lifetime limits on health
insurance coverage?
Answer. As this is a matter for Congress, I look forward to working
with Congress to make sure that every American has access to affordable
health care.
federally-qualified health centers
Question. Federally-qualified health centers (FQHCs) play
fundamental roles in communities across the United States providing
individuals and families with access to high quality health care who
might otherwise find access to health care to be unaffordable. How will
you work to protect reimbursement rates to FQHCs in Medicare, Medicaid,
and private health insurance plans? How will you work to increase the
number of FQHCs throughout the country?
Answer. I look forward to working with Congress to implement
reimbursement policies that expand health-care access to all Americans
in a wide range of health-care settings, including FQHCs, which play an
important role in our health care safety net.
contraception
Question. Do you believe that all women should have access to all
forms of contraception and family planning services without additional
cost? How would you seek to expand access to and increase utilization
of contraception for all women and their families in the United States?
Answer. Women should have the health care that they need and want.
As we work to replace the ACA, we should build on a system that gives
women affordable options, not mandates, and puts women at the center of
their own health care.
______
Question Submitted by Hon. Thomas R. Carper
and Hon. Robert P. Casey, Jr.
nutrition and malnutrition
Question. Improving nutrition and lowering malnutrition are two
areas that do not receive sufficient attention in Medicare, Medicaid,
and private health insurance quality reporting programs. For example,
even though there are many quality measures in place for other health
conditions, there are no measures in place relating to malnutrition.
How do you view the role of nutrition in improving health care, and how
do we prioritize nutrition and malnutrition care as low cost solutions
in improving clinical health outcomes? Do you believe that nutrition/
malnutrition care should be part of the quality reporting and
performance programs for Medicare, Medicaid, and private health
insurance plans?
Answer. I agree that nutrition is an important part of overall
health, and I look forward to reviewing current reporting and
performance programs for Medicare, Medicaid, and private health
insurance plans to make sure that we get the data we need to improve
health outcomes and to understand the impact of determinants of health,
such as nutrition.
______
Questions Submitted by Hon. Benjamin L. Cardin
center on medicare and medicaid innovation (cmmi)
Question. Do you support continuing the work of the Center on
Medicare and Medicaid Innovation (CMMI) to identify alternative payment
models (APMs) which achieve savings and improve quality of care?
Will you allow CMMI to continue implementing the various
demonstration projects currently underway and expand them if they prove
successful at reducing costs without harming quality of care?
Answer. I support innovation in whatever format it can be
encouraged in accordance with the law. I also believe that we should
work in partnership with the States and that CMMI demonstration
projects should be carefully considered on criteria involving their
scale and the voluntary nature of the respective demonstration. I look
forward to reviewing current CMMI projects, consistent with
congressional actions.
children's health coverage in medicaid
Question. Medicaid is one of the largest and most important
components of the Nation's health care safety net, offering a pathway
to health coverage for low-
income and medically vulnerable Americans. In my home State of
Maryland, over 478,000 children receive essential health care through
the program. That's one in three children in my State who can see a
provider when they are sick and get the preventive health screenings
they need to stay healthy.
I am particularly concerned about the impact of a Medicaid block
grant or per capita cap on the program's Early Periodic Screening,
Diagnostic, and Treatment (EPSDT) benefit, under which children
enrolled in the program receive both regular wellness visits,
preventive services, and coverage for all medically necessary
treatments, for example pediatric dental care, that a child needs. In
FY 2014, over 40 million children nationwide were eligible for EPSDT
benefits. In Maryland, over 705,500 children were eligible for EPSDT
benefits in 2015--more than 171,000 of whom became eligible through the
Patient Protection and Affordable Care Act's Children's Health
Insurance Program (CHIP)--Medicaid expansion.
Experts contend that if Medicaid expansion is repealed, States
would no longer be required to provide coverage of this comprehensive
benefit for children, and/or could eliminate the requirement that EPSDT
services be provided without a copayment.
If confirmed as CMS Administrator, do you commit to ensuring the
Medicaid EPSDT benefit and coverage for vital pediatric services remain
intact for the millions of children who rely on it?
Answer. Our goal is to ensure every single American has access to
the coverage they want for themselves or their children and dependents,
and children are, and will continue to be, a high-priority population
within the Medicaid program. States are well-positioned to determine
the most appropriate ways to ensure access to the highest quality care
for children, which may include diagnosis and screening procedures and
the illnesses and conditions they uncover. As this is a matter for
Congress, I look forward to working with Congress to improve our
Medicaid system.
emergency health services
Question. The Balanced Budget Act of 1997 requires Medicaid managed
care organizations (MCOs) and others, to cover emergency services
without prior authorization and established a Federal ``prudent
layperson standard.'' This standard defines an ``emergency medical
condition'' as one that manifests itself by acute symptoms of
sufficient severity (including severe pain) such that a prudent
layperson, who possess an average knowledge of health and medicine,
could reasonably expect the absence of immediate medical attention to
result in placing the health of the individual in serious jeopardy,
serious bodily functions, or serious dysfunction of any bodily organ or
part.
Do you support this Federal policy?
Will you ensure the Centers for Medicare and Medicaid Services
continues to enforce the prudent layperson standard for all Medicaid
MCOs?
Answer. If confirmed, it would be my duty to implement the law as
passed by Congress.
kidney care
Question. The 2011 revisions of the end-stage renal disease (ESRD)
payment system stressed the importance of protecting access to all
treatment modalities and transplant for dialysis patients in the
Medicare program. I share the concerns of many dialysis patients in my
State, that efforts to repeal or replace the Patient Protection and
Affordable Care Act will limit access to the modality of their choice
or the full scope of transplant options.
In recent years, CMS has reduced the in-center dialysis payment
rate to increase an add-on for home dialysis training. I support the
ability of ESRD patients to successfully manage their disease at home
and while it may be appropriate to increase the rate for training home
dialysis patients, we must find a way to ensure that individuals who
require care at dialysis centers are able to do so.
What will your approach be to protecting access to all dialysis
modalities, as well as transplantation?
Answer. As this is a matter for Congress, I look forward to working
with Congress to make sure that patients with renal disease have access
to high quality, affordable treatment.
______
Questions Submitted by Hon. Benjamin L. Cardin
and Hon. Bill Nelson
Question. The 21st Century Cures Act, which was recently enacted
into law, includes a provision I authored with Senators Crapo and
Nelson, which requires Medicare Advantage (MA) plans to accept
individuals with end-stage renal disease (ESRD). Federal law concerning
when Medicare Supplemental Insurance carriers (Medigap) must be offered
to individuals, does not require insurers to offer plans to people
under the age of 65, including those with ESRD (although some States do
require this).
Do you believe that Medigap coverage should similarly be extended
to those under the age of 65, including individuals with ESRD?
Answer. As this is a matter for Congress, if confirmed, I will
implement the laws passed by Congress and I look forward to providing
any technical assistance which might be needed as Congress considers
reforms.
medicare
Question. People under the age of 65 with disabilities generally
have a 2-year waiting period from when they first start receiving
Social Security Disability Insurance (SSDI) before they are eligible
for Medicare coverage. The Patient Protection and Affordable Care Act
(ACA) provided an important protection for people in this waiting
period who otherwise could not obtain coverage. If the ACA is repealed,
do you think these individuals should be forced to again fend for
themselves until Medicare coverage kicks in?
Answer. As this is a matter for Congress, if confirmed, I will
implement the law as passed by Congress.
notice act
Question. With our growing, aging population, Medicare must evolve
to meet the country's most pressing health-care demands. One issue
we've started to address is hospital observation status for Medicare
beneficiaries. Often, Medicare beneficiaries who receive care in
hospitals, even for several days, may be surprised to learn that they
have not actually been admitted as inpatients. Instead, these patients
are classified as ``observation status'' or outpatients.
Observation status is particularly concerning for Medicare
beneficiaries who may require skilled nursing facility (SNF) care after
being discharged from the hospital. Currently, Medicare only covers SNF
care for patients who have a 3-day inpatient hospital stay.
Do you believe that seniors deserve to know when their hospital
care is classified as ``observation status''?
Answer. If confirmed, I look forward to working with Congress to
ensure that seniors have the information available to make the best
decisions about their care, including CMS's implementation of the
NOTICE Act, which requires hospitals to notify patients of their
observation status.
Question. Last Congress, my colleague Senator Enzi and I introduced
the Notice of Observation Treatment and Implication for Care
Eligibility (NOTICE) Act, which became law in December 2015. This
legislation requires hospitals to give each Medicare patient who
receives observation services as an outpatient for more than 24 hours
an adequate oral and written notification within 36 hours.
In December 2016, CMS finalized the NOTICE Act rule requiring
hospitals to give patients the standardized Medicare Outpatient
Observation Notice (MOON) beginning March 8, 2017. CMS anticipates that
more than 1 million patients will receive the MOON annually.
Will you commit to implementing this final rule to ensure that
seniors are able to make informed health-care decisions?
Answer. If confirmed, I look forward to reviewing that rule to make
sure that CMS acts in accordance with Federal law and to working with
you on any concerns you may have.
______
Questions Submitted by Hon. Benjamin L. Cardin
and Hon. Debbie Stabenow
oral health
Question. Oral health and related illnesses have a significant
impact on the severity of chronic diseases, which are the most
burdensome for older people and people with disabilities, and costly
for the Federal Government. The serious health risks and costs
associated with untreated oral disease are increasingly apparent. For
example, because they heighten the risk of systemic infection,
unresolved oral health problems can preclude, delay, and even
jeopardize the outcome of medical treatments such as organ and stem
cell transplantation, heart valve repair or replacement, cancer
chemotherapies, and placement of orthopedic prostheses. The
relationship between periodontal disease and chronic conditions such as
diabetes, arthritis, and heart disease is also well established.
While Medicare statue precludes coverage of ``routine'' dental
services, would you agree that untreated oral health problems, in these
examples at least, would be medically necessary rather than
``routine''?
Answer. If confirmed, I will review what services have been
classified as ``routine'' and what services have not.
Question. Are you committed to using your authority as the CMS
Administrator to ensure that Medicare covers medically necessary oral
health care, as currently allowed by the statute?
Answer. If confirmed, it will be my duty to follow Federal law
including the implementation of laws related to Medicare Advantage
plans which can provide quality oral health care.
Question. Will you commit to evaluating proposals to expand oral
health coverage for Medicare beneficiaries more broadly?
Answer. I would be happy to evaluate any proposal that will lead to
affordable, high quality health care.
______
Questions Submitted by Hon Benjamin L. Cardin
and Hon. Thomas R. Carper
program for all-inclusive care for the elderly (pace)
Question. Johns Hopkins has been on the forefront of innovative
care for the most fragile and complex individuals. The Program for All-
inclusive Care for the Elderly (PACE) is widely recognized as the gold
standard for fully-integrated, comprehensive care. Researchers have
shown that the community-based, comprehensive and accountable care
offered by PACE delivers quality care, improved health, and value for
the health-care system. For over 30 years, regulations have limited the
population served by the program.
Given our growing, aging population, would you please describe in
detail how you plan to enhance the successful work of PACE and other
models to ensure that frail elderly patients who want community-based
care, as opposed to institutional care, can get it.
Answer. I look forward to working with the staff at CMS to get
their input on how we can better serve our aging population as we
implement PACE or other related policies enacted by Congress.
payment reforms
Question. Patients, providers, as well as public and private payers
benefit when valid, reliable, and risk-adjusted scientific measures are
used to assess functional outcomes, support evidence-based clinical
decision-making, and measure quality. Using these tools also assures
the best value for dollars spent. Under your leadership will CMS
continue to pursue further expansion of the Merit Based Incentive
Payment System (MIPS) to other eligible providers such as physical and
occupational therapists?
Answer. I look forward to working with providers to implement MACRA
as designed by Congress. I will work with the staff at CMS and
providers to evaluate whether the MIPS program is achieving Congress's
goals while ensuring that the impact on patients and the providers who
care for them are at the center of any future reform efforts. It is
especially important that we carefully consider feedback from providers
on the frontlines of health care, especially those smaller providers or
those providers in rural settings.
prescription drugs
Question. The Patient Protection and Affordable Care Act's numerous
patient protections have greatly helped beneficiaries, especially those
living with chronic and serious health conditions such as HIV/AIDS and
hepatitis, access the care they need to stay healthy. Of particular
importance to the patients I represent, the regulations implementing
the law's Essential Health Benefits (EHBs) and Non-discrimination
provisions require health plans to use Pharmacy and Therapeutics
committees to develop and regularly update their formularies; cover a
minimum number of drugs in each therapeutic class; provide cost-
sharing, tiering, and utilization management information to enrollees
and potential enrollees; have an exceptions and appeals process for
accessing non-formulary drugs; and design and implement their benefits
in a way that does not discriminate against or discourage enrollment by
individuals living with particular health conditions.
As CMS administrator, would you ensure that the critical patient
protections afforded by the ACA remain and are enforced at the Federal
level?
Answer. If confirmed, it will be my duty to implement the laws
passed by Congress and I look forward to evaluating the impact on
patients and working with you to ensure patients are able to access
high quality care.
______
Questions Submitted by Hon. Benjamin L. Cardin, Hon. Robert P. Casey,
Jr.,
and Hon. Sherrod Brown
therapy caps
Question. As you may know, limits on outpatient rehabilitation
therapy services under Medicare were first imposed in 1997 as part of
the Balanced Budget Act without regard to its impact to access on
needed therapy services. Congress has acted several times to prevent
the caps from going into effect by passing moratoria. Later in 2006,
Congress created an ``exceptions process'' for beneficiaries whose
conditions required more care than the annual limits would allow and at
the end of 2015 year, Congress again extended the exceptions process by
1 year. The current therapy cap for occupational therapy (OT) is $1,920
and the combined cap for physical therapy (PT) and speech-language
pathology services (SLP) is $1,920.
What is the impact on seniors that hit the cap?
Answer. If confirmed, I look forward to looking into the impacts of
these statutory caps on seniors. It may be that other approaches to
therapy provide greater quality care at reduced cost with more respect
for the individual needs of each patient in consultation with their
doctor. If confirmed, I will look at our Medicare system holistically
to make sure that we are delivering access to quality, affordable
health care to our citizens.
Question. Do you support repealing the Medicare cap on therapy
services?
Answer. If confirmed, I look forward to working with Congress on
this issue and providing technical assistance that you or others
interested in Medicare therapy caps may need.
______
Questions Submitted by Hon. Sherrod Brown
medicaid expansion and addiction treatment in ohio
Question. Your consulting firm, SVC, has played a role in
developing Medicaid waiver proposals for a number of States including
Ohio's proposal, the Healthy Ohio Program, last year.
As you know, CMS denied Ohio's waiver application, citing concern
that monthly premiums and late payment penalties would ``not support
the objectives of the Medicaid program, because (they) could lead to a
substantial population without access to affordable coverage.''
At a time when Ohio is at the height of an opioid epidemic, it is
important to maintain coverage and access to care for the more than
500,000 Ohioans receiving mental health and addiction treatment through
Medicaid--including more than 150,000 who now have coverage through
Medicaid expansion.
When Ohio submitted its waiver plan, data included in its
application estimated that the policies proposed would lead to more
than 125,000 Ohioans losing coverage.
Given the opioid epidemic across the Nation and the critical role
Medicaid plays in helping individuals access needed care, including
medication assisted treatment, it is critical that the Administrator of
CMS evaluate State waiver requests to ensure that no individual
struggling with addiction or a mental health condition loses coverage
or access to affordable coverage.
Would you approve a State's Medicaid waiver request if the
resulting waiver would result in a loss of coverage or access to
coverage for individuals struggling with addiction or other mental
health conditions--``yes'' or ``no''?
Answer. To the extent I am not required to recuse from a particular
matter under the terms of my Ethics agreement, I will carefully review
any waivers on a case-by-case basis. I will consider all factors as
required by law including evaluating the State's waiver request to
ensure that all individuals struggling with addiction or a mental
health condition continue to have access to treatment.
Question. If confirmed, will you continue to support innovative
models to improve treatment outcomes for individuals seeking addiction
treatment, such as through the 1115 waivers, home health models, and
the Innovation Accelerator Program?
Answer. To the extent I am not required to recuse from a particular
matter under the terms of my Ethics agreement, I will support
effective, best practice, innovative treatment models. Opioid addiction
has had a severe and devastating impact on communities and families
across the country. If confirmed, I am committed to working with States
to protect access to treatments and help low-income adults with mental
health and substance use disorders through existing and evidence-based
innovative solutions for these problems. To the extent I am not
required to recuse from a particular matter under the terms of my
Ethics agreement, I will work with States to ensure that access to
treatment is not diminished.
infant mortality and tobacco
Question. Ohio has one of the highest infant mortality rates in the
country. In 2015 our State ranked 42nd in the Nation for infant
mortality, and even worse for African American babies.
We don't know exactly why Ohio does so poorly when it comes to
infant mortality, but one thing that we do know is that health
complications caused by preterm births are the leading causes of infant
mortality.
We also know that a major factor in premature births is tobacco
use, and Ohio's smoking rate among pregnant women is nearly twice the
national rate.
In addition to providing coverage to an additional 20 million
Americans, the Affordable Care Act also strengthened Medicaid coverage
of services that help tobacco users to quit. Local groups have taken
advantage of these provisions in their fight against infant mortality.
Medicaid covers nearly 50% of births in this country.
Do you support the current requirement that State Medicaid programs
provide pregnant women with effective tobacco cessation services
without cost sharing--``yes'' or ``no''?
Will you work within the administration and with Congress to
maintain this requirement so that all pregnant women--regardless of
their income--have access to tobacco cessation services--``yes'' or
``no''?
Answer. The science is clear that tobacco use during pregnancy is
risky for both moms and babies. States should have maximum flexibility
to prioritize critical health risks such as smoking during pregnancy.
The decision to maintain this requirement, however, is a legislative
matter that rests with Congress.
fair pay/homecare workers
Question. The majority of the home care workforce--or those
individuals who provide services to older Americans and individuals
with disabilities who receive home and community-based services through
Medicaid--is made up of female workers.
If confirmed as CMS Administrator, will you commit to working with
your colleagues at the Department of Labor to support and advance
policies to ensure women across the health-care workforce and
reimbursed by CMS are paid fairly--and treated equally as compared to
their male counterparts--regardless of their job--``yes'' or ``no''?
The homecare workforce is primarily paid through Medicaid and, on
average, States pay these workers just $13,000 a year. This means that
those women caring for the disabled and elderly are often forced to
rely on Medicaid themselves.
In order to provide the highest level of quality care to our most
vulnerable Americans--the elderly and those with disabilities--do you
agree that those home care workers providing this care full-time should
be paid more than $13,000 a year by their State Medicaid program--
``yes'' or ``no''?
Past leadership at CMS committed in writing to exploring Federal
actions under its current authority that could work with States to
strengthen and support home care workers. It is important to me that
this issue remain a priority for the current administration.
If confirmed, will you commit to continuing this work to ensure
fair pay and advancement opportunities for the home care workforce--
``yes'' or ``no''?
Answer. I firmly believe that women should be compensated based on
their ability and their contribution to the workforce, not based on
their sex. If confirmed, I look forward to working with HHS and CMS
staff as well as the Department of Labor to evaluate these important
issues.
epsdt
Question. The Early and Periodic Screening, Diagnostic, and
Treatment (EPSDT) benefit became an additional benefit for children in
the Medicaid program in 1967. The EPSDT benefit establishes guidelines
which ensure unlimited access to medically necessary, age-appropriate
screenings and preventive care for children, including well-child
exams.
Providing preventive care services through EPSDT is essential for
ensuring that every child has the opportunity to become a healthy
adult. Are you committed to maintaining existing standards for child
health care in the Medicaid program?
Are you committed to ensuring that States enforce EPSDT so that
children are able to access the services they need?
One major threat to the EPSDT benefit and the health of children in
this country is the possibility of restructuring Medicaid into a block
grant or per capita cap, proposals which you have supported.
If confirmed, can you guarantee that you will uphold the current
standards of coverage, affordability, and especially of pediatric-
appropriate benefits for children through the Medicaid program?
Answer. Our goal is to ensure every single American has access to
the coverage they want for themselves or their children and dependents,
and children are, and will continue to be, a high-priority population
within the Medicaid program. States are well-positioned to determine
the most appropriate ways to ensure access to the highest quality care
for children, which may include diagnosis and screening procedures and
the illnesses and conditions they uncover. As this is a matter for
Congress, I look forward to working with Congress to improve our
Medicaid system.
epsdt lead testing standards
Question. One important provision in the EPSDT benefit is screening
and testing for lead poisoning. More than a half a million children
between the ages of 1 and 5 are estimated to have blood lead levels
above the level at which the CDC recommends public health actions be
taken.
Despite these numbers, millions of at-risk children are never
screened and tested for high lead levels despite early childhood lead
screening and testing requirements. In fact, a Reuter's investigation
last year found that less than half of the 1- and 2-year-olds enrolled
in Medicaid--just 41 percent--are tested for lead exposure as required.
Last year, I was the lead author of a letter sent to CMS with more
than 40 of my Senate colleagues to urge the agency to improve lead
screening and testing across at-risk communities and do everything it
can to help health-care providers quickly identify and track children
who have been exposed to lead.
Administrator Slavitt responded positively to that letter, and CMS
put out an informational bulletin at the end of the year to help States
improve their screening rates.
If confirmed as Administrator of CMS, what specific next steps will
you take to improve blood lead testing covered by the Medicaid program
and ensure adherence to the EPSDT benefit for both screenings and
follow-up treatment services?
Answer. The Flint water crisis has highlighted the inherent dangers
of lead poisoning and the importance of avoiding such exposure
particularly for the young, elderly, and infirm. If confirmed as CMS
Administrator, I look forward to working with my CMS colleagues to
learn more about potential deficiencies in the EPSDT's lead testing
standards and potential solutions for such problems.
preventive services with medicare
Question. As you know, the ACA eliminated cost-sharing for
preventive services covered under Medicare. Since the change took
effect in 2011, Ohio seniors have benefited from access to life-saving
screenings and wellness visits at no cost to them. In fact, more than
885,000 Ohio seniors had at least one preventive Medicare service in
2015.
Are you in favor of repealing the ACA provisions that expanded
cost-free preventive services in Medicare? If so, do you acknowledge
that this will increase Medicare beneficiaries' out of pocket expenses?
Which preventive services that are currently provided to Medicare
beneficiaries without any copay do you believe should continue to be
offered at no out-of-pocket cost?
Considering President Trump's executive order to ``ease the
burden'' of the ACA, how will you ensure that Medicare beneficiaries do
not lose coverage of services they have relied upon--and in some cases,
services that have saved lives--for the last 6 years?
Answer. Should I be confirmed as Administrator of CMS, my duty will
be to execute the law as passed by Congress and signed by the
President. Ultimately, the question of ACA repeal is a legislative
matter for Congress to decide.
medicare advantage under the aca
Question. Your history in Indiana shows an interest in expanding
the use of private insurance in the Medicaid space. This option is
increasingly utilized in Medicare through Medicare Advantage plans.
Previously, Medicare Advantage plans paid over 110% of the cost of a
service compared to traditional Medicare spending, but this provision
was removed through the ACA. If the ACA is repealed, it is assumed that
these spending differences would be re-instated.
Do you believe that Medicare Advantage plans should be paid more
than what traditional Medicare spends on a given patient? Why or why
not?
Will you support or allow unequal reimbursement as compared to FFS
Medicare through overpayments by CMS to Medicare Advantage plans?
What will you do to ensure taxpayer dollars are utilized
appropriately under the Medicare program when it comes to parity
between FFS Medicare and MA?
Answer. Medicare Advantage provides an important option for
Medicare beneficiaries to access coordinated care and greater benefits.
If confirmed as CMS Administrator, I would seek to ensure Medicare
Advantage remains a stable option for beneficiaries and that Medicare
Advantage issuers are afforded the flexibility to design plans that
beneficiaries want and give them the coverage they want. It is my
intention to fairly and accurately monitor the quality and
effectiveness of our entire care system, including Medicare Advantage
and original FFS Medicare.
medicare advantage bill of rights
Question. As you know, the Medicare Advantage population is
approaching one-third of all Medicare enrollees, and continues to grow.
Last month, CMS published a review of more than 50 Medicare Advantage
organizations that showed widespread inaccuracies in their provider
directories published online.
Inaccuracies ranged from listing the wrong location for a provider
to including providers who were not accepting new patients even though
the website said they were. This is a clear problem for an increasing
number of consumers that should be addressed.
If confirmed, what tools will you use to hold Medicare Advantage
plans responsible for complying with program rules?
Since oversight is one of the primary responsibilities of the
Administrator for CMS, what specific proposals do you have to
strengthen consumer protections in Medicare Advantage?
In addition to getting away with publishing inaccurate provider
directories, Medicare Advantage plans can also drop providers mid-year
without warning their beneficiaries.
That's why I have previously introduced legislation, the Medicare
Advantage Bill of Rights, to prohibit Medicare Advantage from dropping
providers without cause mid-year. It would also require Medicare
Advantage plans to finalize their provider networks 60 days before open
enrollment so that patients have the information they need before
signing up for a plan. This fix does not require legislation. CMS can
actually make this change on its own.
Will you commit to strengthening beneficiary protections in
Medicare Advantage by ensuring Medicare Advantage insurers are
prohibited from dropping providers mid-plan year without cause?
Answer. Medicare Advantage provides an important option for
Medicare beneficiaries to access coordinated care and greater benefits.
CMS should always make sure that seniors are in the driver's seat of
their health care and have necessary, timely, and accurate information
to make health-care decisions. Oversight is an important responsibility
of CMS. If confirmed as CMS Administrator, I would seek to ensure
Medicare Advantage plans comply with regulations and laws to ensure it
remains a stable option for beneficiaries and that Medicare Advantage
issuers are afforded the flexibility to design plans that beneficiaries
want and give them the coverage they want.
I would also look forward to working with my CMS colleagues to
learn more about the options for strengthening beneficiary protections
in Medicare Advantage, including improving the accuracy of provider
directories. I welcome recommendations, particularly those that are
evidence-based, that would achieve these results.
______
Question Submitted by Hon. Sherrod Brown
and Hon. Rob Portman
nursing education
Question. The demand for nurses is on the rise, and the Bureau of
Labor Statistics estimates that the United States will face a 1.2
million nurse shortage by 2020. Ohio is home to 12 hospital-based
nursing programs that receive Medicare pass-through funding for nursing
education, which will help supply qualified professionals to meet the
demands for the growing nursing workforce. Unfortunately, these
hospital-based institutions are in jeopardy as they face competing
qualifications between CMS's regulations and evolving accreditation
requirements.
To combat this threat to the funding of nursing education, we have
introduced legislation in past Congresses--the MEND Act--which would
simply ensure continued CMS support of nursing education through pass-
through funding at hospital-based nursing schools.
If confirmed, will you commit to working with us on ways to ensure
these institutions do not lose access to their pass-through funding,
both through administrative action and through working with legislators
to craft and quickly implement a solution that will allow for the
continued education of nurses at hospital-based nursing programs?
Answer. I look forward to working with you on this issue to share
feedback and technical assistance on policies relating to nursing
education funding, which has a broad geographic scope and impact. If
the laws on the issue are enacted, and if confirmed, I will work to
implement the laws on the timeline Congress imposes.
______
Questions Submitted by Hon. Sherrod Brown, Hon. Robert Menendez,
Hon. Michael F. Bennet, Hon. Robert P. Casey, Jr., and Hon. Ron Wyden
laboratory payments under pama
Question. Congress passed the Protecting Access to Medicare Act
(PAMA) in 2014. This bipartisan law included policies to update and
change the way Medicare reimburses clinical laboratories under the
Clinical Laboratory Fee Schedule (CLFS), moving the reimbursements
towards a market-based payment methodology. Under the law, all
``applicable'' laboratories are required to report to CMS the payment
rates and test volumes for their private payers.
CMS finalized PAMA regulations in June 2016, and released further
guidance in September 2016, which impose an unrealistic reporting
timeline for laboratories. Additionally, we have heard from our
regional and community-based laboratories about significant concerns
they have about their ability to report accurate data and how the
current rules' exclusion of market data from hospital outreach labs and
definition of ``applicable laboratory'' will impact the accuracy of
CMS's data.
If confirmed, will you commit to looking at the current PAMA
regulations and reporting requirements to ensure that independent,
physician and hospital laboratories are appropriately and accurately
accounted for in the market price data? Further, will you commit to
evaluating the need to extend the March 31, 2017, reporting deadline to
ensure that laboratories--especially smaller, community laboratories--
are able to successfully collect and report the data required under the
regulations?
Answer. Accuracy in reporting and data collection is essential for
a market to thrive. In this case, we should certainly strive for
accuracy in this market data collection process. I look forward to
following up with CMS staff and regional and community-based
laboratories to discuss workable solutions.
cds under pama
Question. In addition to the issue in my previous question related
to PAMA, I have heard from Ohio constituents who have concerns over the
clinical decision support (CDS) mechanisms included in PAMA as it
relates to advanced diagnostic imaging tests for Medicare Part B,
including the use of appropriate use criteria (AUC) in the decision-
making process. I have heard concerns that CMS's new regulation
threatens PAMA by putting severe limitations on the diagnostic imaging
provision by limiting CDS to just 8 priority clinical areas (PCAs).
Given your knowledge and previous work with CDS, if confirmed, will
you work to implement CDS as fully intended by Congress? What specific
actions will you take to ensure uptake of CDS in all PCAs?
Answer. If confirmed as CMS Administrator, I would have a duty to
implement laws as passed by Congress.
dir fees
Question. In your hearing, you mentioned that Pharmacy Benefit
Managers (PBMs) are negotiating prices for Part D, and you're glad that
they do. I think that more can be done to negotiate lower drug prices
for our seniors, and there is a lack of transparency with the status
quo. This lack of transparency and limited capacity to negotiate
results in higher costs for consumers and can result in significant
challenges for small community pharmacies and long-term care
pharmacies. These pharmacies are facing increased uncertainty because
of Direct and Indirect Remuneration (DIR) fees imposed by PBMs.
CMS has recognized some of these issues, and in January released a
fact sheet showing that the use of DIR fees by Part D sponsors has been
``growing significantly in recent years'' and has led to an increase in
beneficiary cost-sharing, an increase in subsidy payments made by
Medicare, and an overall decrease in plan liability for total drug
costs.
What role do you believe retroactive DIR fees have on exacerbating
closures and consolidation across the delivery system?
If confirmed, what specific steps would you take to improve
transparency between plans and pharmacies in the use of DIR fees in the
Medicare program?
Would you make it a priority to re-visit the September 2014
proposed guidance (Proposed Guidance on Direct and Indirect
Remuneration and Pharmacy Price Concessions) to standardize the timing
of how these fees are reported, that has not yet been finalized?
Answer. If confirmed, I will welcome the opportunity to work with
Congress and all stakeholders, including small community pharmacies and
long-term care pharmacies, to preserve seniors' access to drugs.
Additionally, I look forward to working with you to consider how to
resolve this pending guidance issue. I would be happy to discuss the
September 2014 Proposed Guidance on Direct and Indirect Remuneration
and Pharmacy Price Concessions and other related issues with you.
provider status
Question. It is estimated that by 2020, the United States will face
a shortage of more than 91,000 doctors, which will be particularly
painful in rural underserved areas like we have in Ohio and you in
Indiana. I am an original cosponsor on a recently introduced
bipartisan, bicameral bill, the Pharmacy and Medically Underserved
Areas Enhancement Act, which would recognize pharmacists as providers
in the Medicare program. This would allow pharmacists to serve
beneficiaries in underserved areas by utilizing their advanced
education, training, and consultation abilities to provide many
Medicare services in addition to their essential role in administering
and educating patients about their prescription medications.
As CMS Administrator, what will you do to support the utilization
of pharmacists to their full scope as a way to improve access to care
and keep costs low for Medicare beneficiaries in underserved areas?
Answer. If confirmed, I would be open to various solutions to
address the impact of the ongoing physician shortage in underserved
areas. Where permitted by law, I would consider the possibility that
paying pharmacists in rural areas to engage in certain medical services
could work well in those States where pharmacists have such licensure
and a setting appropriate for the services, where primary care doctors
continue to be involved in care, and where there is a patient and
consumer demand for such services.
observation status
Question. During your hearing, I tried to engage you on the issue
of observation status for Medicare beneficiaries. As I mentioned, the
NOTICE Act will initiate MOON notice requirements in just a couple of
weeks, but this legislation does not address the underlying problem
imposed by the 3-day stay rule.
To follow up from the hearing, I hope you have had time to review
the obstacles facing our seniors' access to affordable care in SNFs
under current regulations. My Improving Access to Medicare Coverage
Act, which I plan to reintroduce next month, would enable time that
beneficiaries spend in the hospital under observation to count toward
the 3-day requirement for Medicare coverage. I appreciate that you are
willing to work with me on this huge issue for Ohioans, and hope that
you will support my legislative efforts with this reintroduction.
Have you had time to review this provision of law and provide some
suggestions on ways to improve this issue for Medicare beneficiaries?
Should you be confirmed, will you commit to swiftly issuing an
opinion on CMS's authority in this regard?
If confirmed, will you work to administratively correct this
billing technicality that adversely impacts Medicare beneficiaries and
work with Congress to correct this issue via legislation, if necessary?
Answer. If confirmed, I will monitor the implementation of the
NOTICE Act and the utilization of the Medicare Outpatient Observation
Notice (MOON). I will also work to identify if more may need to be done
with regard to this observation status issue to improve seniors' access
to care in SNFs. And if the best path forward involves legislation, I
would be pleased to work with you and provide technical assistance on
that as well.
medicaid and chip quality of care
Question. Over a decade ago, Congress enacted legislation to begin
shifting the metrics in our health system away from paying for volume
to paying for quality and safety. In recent years, this shift towards
quality has shown improvement in important areas like rates of hospital
acquired infections and hospital readmission.
However, there is still much work to be done, especially for our
most vulnerable populations. That's why I have introduced the Medicaid
and CHIP Quality Improvement Act (MCQA) in past Congresses, to
encourage data collection and define quality assessments for the more
than 80 million Americans who currently receive care through these
programs with no structured quality measures.
I know that you understand the value of quality measures and
holding States accountable for improving quality for Medicaid
beneficiaries. I also know that you understand how collecting data for
quality assessments of the Medicaid and CHIP populations is
tremendously challenging given the wide variation across States.
Do you believe that Congress and the administration should know the
defined quality of care that State Medicaid and CHIP programs are
delivering for that investment?
Answer. Yes, and we should hold States accountable for achieving
outcomes. To this end, we must ensure that State Medicaid programs are
not beset by unnecessary administrative burdens that could impede
progress on achieving this goal.
Question. Would you be willing to work with Congress to try to
implement and improve quality measurements for these vulnerable
Americans across different structures and delivery mechanisms of the
program?
Answer. Yes. If confirmed as CMS Administrator, ensuring high-
quality care in Medicaid and CHIP will be one of my top priorities.
medicare quality of care
Question. If confirmed, as Administrator of CMS, you would also
have authority over the Medicare program and its budget of close to
$600 billion dollars. This includes the ability to enact regulations
and establish guidelines for reporting requirements.
How would you specifically encourage collaboration between the
Federal Government and individual States to identify program standards
and incentives in Medicare programs?
Some plans, including my MCQA legislation, champion incentivizing
State performance in quality metrics. How would you oversee any such
incentives programs?
Answer. The States are well positioned to provide for the unique
health-care needs of their residents. If confirmed, I would work to see
that CMS is a helpful resource to the States. CMS can offer clarity
regarding State flexibility, technical assistance, and provide support
as needed to promote effective policies and practices.
accountability
Question. In your work with SVP you have worked with States to
craft Medicaid programs that require beneficiaries to pay premiums and
potentially lock individuals out of coverage if they do not pay. Your
website states that you have developed reform programs and waivers for
other States, including Kentucky.
Last year, Kentucky Governor Matt Bevin submitted a proposal
modeled on Indiana's Medicaid expansion waiver that would go even
further than Indiana's proposal by instituting a work requirement as a
condition of eligibility for some beneficiaries. CMS has not approved
this waiver, and has stated that work requirements are not consistent
with the original intent of the Medicaid program or consistent with
Federal Medicaid law.
Studies have shown that the main effect of work requirements likely
would be the loss of health coverage for substantial numbers of people
who are unable to work or face major barriers that prevent them from
holding part-time or full-time employment. Additionally, State Medicaid
agencies would be stretched just covering the basic costs of
administering and enforcing these requirements.
As CMS Administrator do you plan to uphold the agencies previous
decisions of not approving work requirements under Federal Medicaid
law?
Do you believe a child should be held responsible--and potentially
lose health insurance coverage--if their parent does not pay a Medicaid
premium or participate in a work requirement as required under some of
the programs you have helped draft?
Answer. Studies have confirmed the value of work to individual
health and sense of well-being, and Medicaid has an historic role as
part of a broader anti-poverty effort. If confirmed, I look forward to
working with States to consider innovative strategies that improve
outcomes. Every potential policy should consider the impact on the
different Medicaid populations, while ensuring appropriate protections
are in place for vulnerable populations like children.
cmmi
Question. As acknowledged during both your and Secretary Price's
testimonies, CMMI is an important tool that exists within CMS for the
testing and development of new, patient-centric, value-based payment
models. These models will be critical to informing the future of care
delivery.
Are you committed to preserving CMMI?
Answer. If confirmed, I plan to work with the Secretary to ensure
that CMMI, or the ``Innovation Center,''--after consultation with
Congress, the States, health-care stakeholders, and Innovation Center
staff--tests appropriate innovative models that reduce costs and
improve quality for Medicare and Medicaid beneficiaries. As such, I
look forward to reviewing current CMMI projects, consistent with
congressional actions.
Question. How do you plan to involve both stakeholders and Congress
in the development and implementation of models?
Answer. Stakeholder engagement is crucial in the development of
innovative models. For instance, the Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA) establishes the Physician-Focused
Payment Model Technical Advisory Committee, to review proposals for
physician-focused payment models that can ultimately be adopted through
the Innovation Center. Communication and collaboration with Congress
and stakeholders throughout the process is a major priority as CMS
moves forward with implementing the law and fostering innovation.
dual eligibility/cmmi/medicare standards
Question. ASPE recently released a report that concludes dual
status is one of the most powerful predictors of outcomes and that,
with time, outcomes can be improved.
What additional actions can and should CMS take to do more to help
support programs and the integration of Medicare and Medicaid for
duals?
Answer. Sound integration between Medicare and Medicaid requires
that regulations and administrative processes properly align. If
confirmed, I will work to ensure that CMS continues to make progress in
this area.
medicare/health system transformation
Question. As Congress and the administration work to incentivize
new models of care, it is important that we collect information from
States and providers to help inform policy decisions and ensure quality
and access.
If confirmed, how will you ensure CMS is monitoring beneficiary
access to care across new delivery system models? What factors will you
use to measure access to care?
Answer. Our goal is to ensure access to affordable, quality health
care for all Americans, including individuals in rural or underserved
areas. Accordingly, the best metric in the end is one that measures the
extent of access to actual care, not just coverage, and the quality of
that care as determined by patients working individually with their
doctors. I look forward to partnering with States to best determine the
real-life impact of health-care policy at the local level. We must hold
States and providers accountable for enabling access to quality care.
Question. If beneficiary access is hindered, how do you envision
addressing these issues and ensuring access to care?
Answer. I intend to work expediently with the Congress, the
Secretary and CMS colleagues to strive for improved access to care,
especially when access to care may be threatened. Our decisions must be
data-driven and made with a focus on addressing the unique needs of the
patients in question.
Question. What advocacy organizations--and specifically consumer
groups--will you engage in evaluating these alternative payment models
throughout the stages of development and implementation?
Answer. I appreciate feedback across the health-care industry to
ensure workable payment models are being pursued. Organizations that
represent consumer groups are especially important to engage with to
understand the impact of the models on beneficiary care, both on the
front end and throughout the development and implementation of the
models.
Question. How will you ensure CMS hears directly from impacted
beneficiaries and resolves issues immediately so that access is not
affected?
Answer. The fundamental metric for knowing that our system is on
the right track is the centrality of the patient in the system and
their ability to make choices about their care in consultation with
their doctor. Restrictions on access to care threaten this principle
and ought to be swiftly examined. I look forward to working with CMS to
ensure we have an open line of communication with beneficiaries.
out-of-pocket protections for medicare population
Question. Seniors are often on fixed incomes, and their yearly
income certainly does not grow at the rate of medical inflation,
however, out-of-pocket costs as a share of income continues to rise for
Medicare beneficiaries each year. While the ACA helped protect
Americans from caps on annual and lifetime out-of-pocket caps, this
consumer protection does not exist for Medicare beneficiaries.
What will you do, if confirmed, to help keep costs low for
beneficiaries and protect seniors on fixed incomes from growing out-of-
pocket costs?
Answer. I would convey to Medicare beneficiaries that I look
forward to working with Congress to make certain that we preserve and
strengthen Medicare for seniors.
medicare 2-year waiting period
Question. As I'm sure you know, individuals who are under the age
of 65 with a disability are generally required to wait for 2 years
after receiving SSDI before they are eligible for Medicare coverage.
Thanks to the ACA, individuals who are waiting for Medicare based on
SSDI eligibility can sign up for insurance through the individual
exchanges while they are waiting for Medicare eligibility to kick-in.
If the ACA is repealed, what will you do as Administrator of CMS to
ensure coverage options for these vulnerable individuals?
Answer. Our goal is to ensure access to affordable, quality health
care for all citizens, including individuals with disabilities. As
such, I look forward to implementing the laws passed by Congress to
enable affordable, quality care for individuals with disabilities.
medicare prescription drug prices
Question. During your hearing, Senator Wyden asked you about
soaring drug prices affecting seniors through Medicare Part D. I think
you agree with many of us, and many Americans as you noted, that the
prices of these prescription drugs are out of control and it should be
a goal to make these drugs accessible and affordable to all Medicare
beneficiaries.
It is imperative that the American public and legislators know, if
confirmed as CMS Administrator, how (specifically) will you address
this drug pricing issue?
Do you intend to use CMMI authority to test new methods to bring
down Medicare drug spending? If so, how might you direct this
authority?
Answer. The issue of drug costs is one of great concern to all
Americans. You have my commitment that I will work with you and others
to make certain that Americans have access to the medications that they
need. I share your concern regarding the importance of individuals and
families being able to afford the prescription drugs they need. If
confirmed, I look forward to working with HHS, CMS, and FDA to consider
potential options to address the issue of access to, and the
affordability of, prescription drugs.
medicaid churn
Question. Medicaid churn--or the continual disenrollment and re-
enrollment, which can be caused by changes in income or changing life
circumstances--can interrupt continuity of care and access to important
services in the Medicaid population. This can be particularly
disruptive for Medicaid beneficiaries using care coordination and care
management services, which are interrupted every time a beneficiary is
disenrolled.
In your work with Medicaid, how have you helped mitigate the
negative impacts of churning?
Answer. One way to mitigate the impact of Medicaid churn is to
institute enrollment and payment policies and procedures that are as
consistent as possible with the commercial health insurance market.
Coordination between State workforce development programs that help
Medicaid members become more upwardly mobile can also help eliminate
churn.
Question. How will you ensure that eligible individuals will remain
covered in Medicaid, even when there are changes in their life
circumstances at no fault of their own?
Answer. It is important that Medicaid's enrollment and payment
policies strike the right balance between fairness and responsibility
and contain the appropriate safeguards that consider changing
circumstances for families.
physician reimbursement
Question. On average, Medicaid pays providers about 70 percent of
what a Medicare provider receives for the same service. The only
difference is the age of the patient being served.
There are 45 million children and 30 million adults enrolled in
Medicaid. As you noted in your hearing, you want all patients to be
able to access any doctor they choose, but typically low Medicaid
payments--that are set by States--can impede the ability of providers
to accept more patients--both pediatric and adult--covered through this
program.
Along with Senator Murray, I have worked to introduce the Ensuring
Access to Primary Care for Women and Children Act in past Congresses,
legislation that would solidify parity between Medicare and Medicaid
reimbursements for primary care. If confirmed, you would oversee the
budgets of both Medicare and Medicaid, and would be looked to for
guidance on the issue of appropriate Medicaid reimbursement rates.
Do you believe that a child's care should be valued at only 70% of
that of an adult?
Answer. No. Medicaid has a complex financing and payment system
that includes base rates set by States, supplemental payments to
providers, and other Federal and State funding sources for care to the
Medicaid or uninsured populations.
Question. If a State's Medicaid budget is cut by a per-capita-cap
or block grant proposal, how will you prevent States from cutting
reimbursement rates for providers to even worse than they are now?
Answer. I look forward to working with Congress on the specifics of
any new Medicaid financing and payment proposals in order to hold
States accountable to ensure patient access to high quality health
care.
preexisting conditions
Question. As Senator Wyden said during your confirmation hearing,
Americans cannot afford to go back to the days of when health care was
only for the healthy and wealthy. I strongly believe that if pieces of
the ACA are repealed, any replacement must ensure that every American--
regardless of whether they are a woman, have cancer, ESRD, or any other
condition or preexisting condition--has access to affordable,
comprehensive coverage equal to or better than coverage options
currently available through the ACA, regardless of their income.
I'm concerned that a one-sized-fits-all approach, like high risk
pools, leaves those who truly need high quality and affordable health
care out of luck.
How will you ensure that those with the greatest needs will have
continued access to high-quality health care?
Answer. I believe it is important that we as a nation make sure
that every American has access to the kind of health care and health
coverage that best meets their needs. Additionally, it is imperative
that all Americans have access to affordable coverage and that no one
is priced out of the market due to their diagnosis. Nobody ought to
lose insurance because they get a bad diagnosis. If confirmed as CMS
Administrator, I intend to implement the laws passed by Congress to
ensure access for all, including those with pre-existing conditions, is
affordable.
medicaid guardrails
Question. Through your work at SVC, you have helped several States
attempt to change their Medicaid plans.
In your experiences, what evidence have you seen that Medicaid
guardrails help beneficiaries gain employment, transition off of
Medicaid onto different health insurance coverage, and achieve other
Stated goals of the individual programs?
Is there any evidence that these requirements increase burdens by
adding costs to the programs or by increasing administrative challenges
and inefficiencies?
Answer. I have been fortunate to be involved in many proposals and
initiatives to help Medicaid beneficiaries along the lines described.
In my experience, meeting Federal requirements like guardrails can be a
limitation on State innovations and do not necessarily improve health
outcomes. If confirmed as Administrator, I would endeavor to ensure
States are given the flexibility to pursue innovative approaches that
fit their needs while ensuring access to care.
biosimilars
Question. During your hearing, Senator Roberts asked you about the
need for CMS and FDA to work together to promote the uptake of
biosimilars and enhance innovation across agencies to reduce costs of
prescription drugs. I agree collaboration between agencies on this
issue is important. I have also introduced legislation in the past that
would help achieve this by shortening the patent exclusivity period for
expensive, brand-name biologic drugs and allow biosimilars to enter the
market sooner. Biosimilars, which are equivalent in safety and efficacy
to their reference biologics, have the capacity to reduce prescription
drug costs, yet physicians must be willing to prescribe them and
patients need the information necessary for them to be confident in
taking them.
As CMS Administrator, how would you work with FDA to develop this
burgeoning market and promote biosimilar uptake?
As you mentioned multiple times in your hearing, you want to make
sure all patients have access to the drugs that they want to take.
Because the costs of drugs is an important factor in that decision,
increasing the availability of biosimilars is an important step in that
process and will ensure beneficiaries have access to choices when it
comes to their prescription drugs.
Educating patients and providers is an important component to
ensure the widespread use of biosimilars. It is vital that providers
are well informed about how a biosimilar can be prescribed, and how and
when an interchangeable product can be substituted for another
biological product. Simultaneously, it is imperative that patients,
too, have confidence in the safety and efficacy of a given FDA-approved
biosimilar.
Please describe specific examples of patient and provider education
efforts that you will encourage the FDA to engage in regarding
biosimilars, if you are confirmed.
Answer. If confirmed, under my leadership, CMS will work with the
FDA to help ensure that Medicare and Medicaid beneficiaries have
guidance on biosimilars. I understand that this will be increasingly
important as more of these products are expected to become available to
U.S. patients in the coming years.
______
Question Submitted by Hon. Sherrod Brown
and Hon. Benjamin L. Cardin
therapy caps
Question. As you may know, limits on outpatient rehabilitation
therapy services under Medicare were first imposed in 1997 as part of
the Balanced Budget Act without regard to its impact to access on
needed therapy services. Congress has acted several times to prevent
the caps from going into effect by passing moratoria. Later in 2006,
Congress created an ``exceptions process'' for beneficiaries whose
conditions required more care than the annual limits would allow and at
the end of 2015 year, Congress again extended the exceptions process by
1 year. The current therapy cap for occupational therapy (OT) is $1,920
and the combined cap for physical therapy (PT) and speech-language
pathology services (SLP) is $1,920.
What is the impact on seniors that hit the cap?
Do you support repealing the Medicare cap on therapy services?
Answer. If confirmed, I look forward to reviewing the impact of the
statutory caps on seniors. It may be that other approaches to therapy
provide greater quality care at reduced cost with more respect for the
individual needs of each patient in consultation with their doctor. If
confirmed, I will look at our Medicare system holistically to make sure
that we are delivering quality, affordable health care to our citizens.
______
Questions Submitted by Hon. Michael F. Bennet
Question. This week, I worked with Senator Grassley to reintroduce
the Advancing Care for Exceptional (ACE) Kids Act. The bill would help
hospitals and other providers coordinate and standardize care across
State lines for children with complex medical conditions. As you may
know, Medicaid covers about two-thirds of the 3 million children with
complex medical conditions. This represents nearly 40% of Medicaid
costs for children. The bill is expected to reduce the burden on
families who are often managing multiple specialists, improve outcomes,
and lower costs.
Does the administration support this concept? What are some other
ways the administration may seek to help families who must care for
children with complex medical conditions.
Answer. If confirmed, I would support efforts to help coordinate
care. I would start by working with my colleagues across the Department
to identify all the ways in which HHS aims to help these children in
need. And I would hope to encourage our use of existing authorities and
funding to better align resources to meet this challenge, especially at
CMS. I would also work with you and other members of Congress on their
ideas on this important topic.
Question. I worked with Senator Portman to introduce the Medicare
PLUS Act, which would set up a pilot program to help the top 15% of the
highest-cost Medicare beneficiaries by coordinating their health care
needs. As you may know, 15% of Medicare beneficiaries have six or more
chronic conditions and account for 50% of total Medicare spending.
Would the administration consider piloting such a program through
the CMS Innovation Center?
Answer. If confirmed, I would explore what voluntary options we can
make available to the Medicare beneficiaries with the greatest needs
and their physicians. I think many will appreciate the opportunity to
work with a care manager and possibly others who will spend the time
and effort needed to help the patient make different choices to manage
their own care. I would seek to work with you on your proposal to
explore how it and others like it can be a path to empowering those who
are subjected to the most uncoordinated and challenging aspects of our
health care system.
Question. Colorado has a strong commitment to community living and
home and community based services. This includes a Community Mental
Health Supports waiver, an Elderly, Blind, and Disabled waiver, and a
Children with Autism waiver. We have several others that support the
most vulnerable in the community.
How can we support older Americans and individuals with
disabilities who choose to live in the community?
What additional flexibility do States need to innovate through
waivers?
Answer. The goal of CMS is to ensure access to affordable, quality
health care for all citizens. This, of course, includes people with
disabilities who depend on Medicaid. If confirmed, I hope to implement
the law so as to allow States the flexibility to approach this
population in a way that makes sense for their program and its
beneficiaries, so long as it is done in accordance with Federal law.
Question. Colorado has participated in many multi-payer initiatives
like the Comprehensive Primary Care Initiative and the State Innovation
Model and has worked closely with the Center for Medicare and Medicaid
Innovation. Our Medicaid program is also participating in the
demonstration project for individuals dually enrolled in Medicare and
Medicaid. The State also has a highly successful Accountable Care
Collaborative delivery system model.
Moving forward, how do you foresee CMS preserving these types of
innovations?
What steps will you take to ensure that CMMI models increase
quality and access to care for patients?
How will you ensure that innovative demonstrations are developed
with input from clinical experts and interested stakeholders?
Answer. While I cannot comment on specific demonstrations at this
time, if confirmed, I plan to work with the Secretary to ensure that
the Innovation Center--after consultation with Congress, the States,
healthcare stakeholders, and Innovation Center staff--tests appropriate
innovative models that reduce costs and improve quality for Medicare
and Medicaid beneficiaries. As such, I look forward to reviewing all
current CMMI projects, consistent with congressional actions.
Question. Over 700,000 Coloradans live in a rural community. The
Medicaid Expansion provided some financial stability to rural hospitals
that were on the brink of closure before the Affordable Care Act. In
fact, hospitals in Colorado saw a 30% drop in uncompensated care. I
have heard from rural hospitals in our State that several will face
significant financial challenges if the law is repealed. This is
concerning, considering that there are counties in Colorado without
access to a clinic or a hospital.
Would you support an Affordable Care Act replacement bill that
reduced access to health care in rural communities?
How would a replacement ensure that these communities continue to
have access to quality health care?
Answer. Oftentimes rural health-care providers and patients are
overlooked in the broader discussion of national health-care issues.
Significant health disparities exist for rural populations for a
variety of reasons, including challenges with access to affordable
coverage and health-care services. Moreover, small rural providers face
a unique set of challenges depending on where they are, who they serve
and what Federal and State requirements they are subject to. If
confirmed, I will work tirelessly to address the health-care needs of
all Americans, rural or urban. I look forward to working with Congress
to implement the laws they pass to ensure every single American has
access to the coverage they want for themselves and that individuals
who lost coverage under the Affordable Care Act get or maintain
coverage. This of course includes individuals who access care at rural
hospitals or clinics.
Question. A Colorado-based orthopedic practice is participating in
one of CMMI's voluntary demonstration projects, the Bundled Payments
for Care Improvement (BPCI) program. Under the program, health-care
organizations enter into payment arrangements that include a new
revenue structure based on financial and performance accountability for
entire episodes of care, in this case joint replacements. The program
is showing promise for Colorado patients, who are seeing improved
outcomes.
There are concerns with the implementation of the program,
specifically the National Trend Factor, which continuously updates the
target prices set by CMS. Providers have asked for increasing clarity
from CMS and CMMI.
As CMS Administrator, how would you address these issues so that
providers continue to participate in voluntary demonstration projects
that improve outcomes for patients?
Answer. If confirmed, I plan to work to ensure that the Innovation
Center--after appropriate consultation with Congress, the States,
health-care stakeholders, and Innovation Center staff--address such
concerns in testing innovative models that reduce costs and improve
quality for Medicare and Medicaid beneficiaries. I look forward to
reviewing current CMMI projects, consistent with congressional actions.
Question. Reforming the Stark Law has been a topic of discussion
over the past few years as we move toward alternative payment models
that pay for value.
In your role as CMS Administrator, will you recommend updates to
Stark Law when alternative payment models are used?
Answer. While there are a number of legitimate concerns regarding
physician referrals and compensation, I think it may be appropriate to
examine regulations implementing the Stark Law and its impact on reform
efforts. In some cases, the Stark Law may discourage coordination of
care, and lead to a more fractured health-care system. I would consider
these situations closely, in consultation with Congress and in context
when considering what changes might be needed. I look forward to
working with Congress to implement the law on critical issues related
to APMs and the Stark Law.
Question. Current CMS health-reform efforts are based on the
concept of the triple aim--improving the patient health-care
experience, improving the health of the population at large, and
reducing the per capita costs of health care.
If confirmed as CMS Administrator, will the triple aim remain a
central tenant of CMS efforts?
What metrics will you use to ensure these goals are met?
Answer. The triple aim includes the goals we all share for our
health-care system and, if confirmed, I would work to ensure its
elements would remain important to CMS's work. The fundamental metric
for knowing that our system is on the right track is the centrality of
the patient in the system and their ability to make choices about their
care in consultation with their doctor. Without that, the most
impressive facilities and technology are not serving our people's
needs, nor is the most efficient system doing what is most important.
With the patient at the center of the system as a foundation, all else
is possible and achievable.
Question. Physicians have noted that the lack of interoperability
between electronic health record (EHR) systems has been a key barrier
to complying with requirements for meaningful use of health IT.
How do you plan to address the ongoing challenges related to EHR
interoperability?
How do you plan on restructuring the incentives for meaningfully
using EHRs?
Answer. If confirmed, I look forward to working with Congress to
implement laws related to improving the use of EHRs. Patients and
providers depend on the fast exchange of information across health
systems. Having access to a patient's complete medical record enables a
medical professional to better diagnose and treat a patient. Doctors
know best how to treat their patients and we should think of EHRs as a
means to enable that better care. As Congress considers options to
improve the interoperability of this system so that the burdens on
physicians do not hinder their ability to practice medicine, I will
stand ready to provide technical assistance and support through that
process.
______
Questions Submitted by Hon. Robert P. Casey, Jr.
Question. Elected officials on both sides of the aisle have said
they strongly support the ACA's provision allowing young adults to stay
on their parents' insurance until age 26. As you know, there is a
parallel provision in Medicaid law allowing youth aging out of foster
care to maintain health coverage until they turn 26, given they have no
parents to provide that benefit for them.
Do you agree that foster youth--children who were removed from
their homes due to abuse and neglect--should have the same Federal
health coverage protections as children who are fortunate enough to be
able to stay on their parents' health coverage?
Answer. This would be a part of the new legislation that Congress
will be voting on, so that decision is in Congress' hands. If
confirmed, I will work to ensure that CMS appropriately implements the
statutes within its purview.
Question. The Children's Health Insurance Program (CHIP) has been
an enormously successful program and has helped, along with Medicaid
and the Affordable Care Act, to bring children's insurance rates up to
95 percent--the highest rate ever. The program currently covers about 8
million children per year, is popular, and has enjoyed significant
bipartisan support from Congress. It is also due to be reauthorized
this year.
Will you pledge to work with Congress to reauthorize and fully fund
the CHIP program in a timely manner?
If confirmed, will you guarantee that under your leadership, CHIP
will continue to be a viable option for America's children, and that it
will continue to cover medically necessary care for the children who
are enrolled?
Answer. It is important that every child has access to high-quality
health coverage. CHIP plays an important role in accomplishing this
objective, but there is also a need to focus on family coverage in the
private market and employer plans, and on giving States needed
flexibility. Each State has different needs, and I believe CMS needs to
work with States to ensure that, consistent with those needs, the CHIP
program provides the best possible coverage to their residents. If
confirmed, I look forward to working with you on this issue to share
feedback and technical assistance on policies relating to CHIP. I will
work to implement CHIP reauthorization as passed by Congress.
Question. At the end of last year, the HHS Assistant Secretary for
Planning and Evaluation (ASPE) put out a report that I and other
members requested on the impact of socioeconomic status (SES) on the
Medicare quality programs like hospital readmissions and the Medicare
Advantage star ratings. All these ratings either reward or penalize
monetarily for good or bad results and those that serve a high number
of low SES individuals have a harder time achieving high quality
ratings because of the complications of the populations. In this report
ASPE discussed options on how to improve the quality programs and more
accurately account for these populations.
What do you think we need to do, to improve how Medicare accounts
for SES in the quality programs?
Answer. My work with vulnerable populations has highlighted for me
the impact of social determinants of health and the role of life
choices in managing one's own health. At the end of the day, health-
care programs for this population ought to empower and enable ownership
of one's health care. If confirmed, we ought to explore ways that SES
as well as the way other important factors impact quality programs and
design the programs with the goal of ensuing patient empowerment front
and center.
Question. Many people with disabilities want to work and can do so
with the services only available through Medicaid, to help them work.
These services include supported employment for people with mental
health disabilities or personal care attendants for those with
intellectual or physical disabilities. Without these services, many
people with disabilities will be unable to work.
How will you ensure that a person with a disability, mental health,
intellectual, physical, sensory, or any other type of disability as
defined by the Americans with Disabilities Act, has access to the
services currently available through Medicaid?
Answer. Our goal is to ensure access to affordable, quality health
care for all citizens. This, of course, includes people with
disabilities who depend on Medicaid. Towards this end, I support the
principles of community integration, beneficiary autonomy in decision
making, and person-centered planning articulated in CMS's approach to
Home and Community Based Services and the HCBS Settings Rule (with a
compliance date in March 2019). If confirmed as CMS Administrator, I
would rely on these principles in making decisions appropriate to CMS'
role in administering Medicaid and working with Congress to implement
and support efforts that help people work.
Question. The Center for Medicare and Medicaid Innovation (CMMI)
was created to test new payment models and encourage the Medicare and
Medicaid programs to look beyond traditional payment systems and find
new ways to help individuals benefit from the many advances of modern
medicine. These advances have been seen in the clinical setting and in
the form of new, innovative therapies, some of which even offer
potential cures for diseases that previously could only be managed with
chronic therapies.
Would you be willing to work with Congress to develop alternative
payment models that test these advances and examine the benefits these
advances could have on Medicaid and Medicare beneficiaries, as well as
how such alternative payment models could affect the cost of care over
a decade or more, and work with Congress to remove any obstacles that
might prevent those models from moving forward?
Answer. If confirmed, I plan to work to ensure that the Innovation
Center--after appropriate consultation with Congress, the States,
health-care stakeholders, and Innovation Center staff--tests innovative
models that reduce costs and improve quality for Medicare, Medicaid,
and CHIP beneficiaries. I look forward to reviewing current CMMI
projects, consistent with congressional actions.
______
Questions Submitted by Hon. Mark R. Warner
Question. Eleven percent of Virginians rely on Medicaid for their
health insurance, even without Medicaid expansion. This coverage is
more efficient than most other forms of insurance; Virginia also
operates the 3rd most efficient Medicaid program in the country,
receives the lowest allowable Federal matching rate, and the vast
majority of beneficiaries are enrolled in a managed care plan. Block
granting or imposing a cap on Medicaid would be damaging to States like
Virginia. Do you oppose structural changes to Medicaid that shift costs
onto the States like block granting or per capita caps?
Answer. If confirmed as Administrator, I intend to work with States
and Congress to improve Medicaid and implement the laws enacted by
Congress. From demographic and budgetary concerns to ensuring access
for special populations, each State faces different challenges in
Medicaid. A one-size-fits-all approach will not work and that is why
flexibility for States in how they design their Medicaid programs is
crucial. At the same time, States must be held accountable to standards
that result in better health-care quality and access. The mechanics of
Medicaid reform will be a legislative decision that will need to
account for how to encourage States to work together on making
improvements to the program while increasing flexibility.
Question. Seventy-seven percent of Virginia Medicaid enrollees are
in families where at least one individual is employed, and
unfortunately many of the rest are forced to rely on the program not by
choice, but because they are unable to work--perhaps requiring child
care or job training, or have a disability. The evidence shows that
imposing a work requirement actually has a limited impact on
employment, especially in the long-term. Do you intend to require
States, or make it easier through the waiver process, to include work
requirements as a condition to receive Medicaid services? If you were
to impose work requirements in Medicaid, would you also commit to
supporting those enrollees who need access to child care,
transportation, or job training?
Answer. If confirmed, I will coordinate with States to provide
greater flexibility for determining how to care for their most needy
citizens as we encourage work and opportunity.
Question. Do you agree with President Trump's statement on the
campaign trail that he would not reduce Medicare benefits, or make
major changes to Medicare outside of eliminating waste, fraud and
abuse? Would structural changes to Medicare maintain the basic Medicare
guarantee, while also strengthening the program's solvency?
Answer. If confirmed, I will serve at the pleasure of the President
and will support his policy initiatives within the bounds of the law.
As Congress considers structural changes to Medicare, I will stand
ready to provide technical assistance as needed if I am confirmed.
Ultimately, the decision whether to enact structural changes to the
program is the province of Congress. Whatever reforms are considered,
CMS will put the patient first in our implementation of the reform in
question.
Question. I have worked with bipartisan members of the Finance
committee to expand the use of telehealth, especially in Medicare,
which lags most State Medicaid programs and the commercial sector. CMS
already has the authority to lower some barriers for telehealth and
remote patient monitoring in Medicare without Congress. What actions,
especially around alternative payment models such as ACOs, should CMS
take to increase the utilization of technology in a way that improves
quality while maintaining fiscal integrity? Under what circumstances
should fee-for-service Medicare cover telehealth services? What
evidence does CMS need to similarly increase access to remote patient
monitoring services in fee-for-service Medicare?
Answer. I share your interest in promoting telehealth. Telehealth
can provide innovative means of making health care more flexible and
patient-centric. Innovation within the telehealth space could help to
expand access within rural and underserved areas. If confirmed, I look
forward to continued discussions on telehealth, including on the best
means to offer patients increased access, greater control and more
choices that fit their medical needs.
Question. Despite the ACA lowering the percentage of uninsured by 8
percentage points in rural counties, rural hospitals are still facing
immense challenges, serving older, sometimes more economically
disadvantaged populations challenged by less access to primary, dental,
and family health care than their urban counterparts. CMS threatened to
reclassify Page Memorial Hospital in Luray so that it would no longer
serve as a Critical Access Hospital, which would have effectively led
to the hospital significantly reducing services such as treatments for
heart disease and diabetes, which occur in Page County at far higher
rates than statewide. I worked with CMS to ensure that Page kept its
Critical Access Hospital classification As CMS Administrator, what
improvements to the hospital classification system will implement to
ensure that Critical Access Hospitals like Luray are adequately funded?
Answer. As you may be aware, roughly one-third of America's
counties now have only one health insurer offering coverage on the
individual market Exchange. The problem is especially acute in rural
counties, as insurers continue to exit the market and costs continue to
rise, making coverage less affordable and reducing choices for
patients. Moving forward, our goal must be to ensure every American has
access to the coverage they need, including those who access care at
rural or Critical Access Hospitals. I believe the best metric in the
end is one that measures the extent of access to care rather than
simply looking at coverage. If confirmed, I look forward to working
with CMS staff to evaluate the hospital classification system and to
understanding the unique issues for your State and its hospitals.
Question. The Obama administration made significant progress to
better align fee-for-service Medicare payments with value and quality,
and I have spent the better part of 2 years working with bipartisan
members of this committee to improve care for Medicare beneficiaries
with chronic illness. In what sector of the Medicare program will you
focus on accelerating value-based purchasing or the broader move to
align with value and quality?
Answer. If confirmed, I plan to evaluate the respective sectors of
the Medicare program to understand how payment reforms are working--or
not working--for providers and their patients, especially as we
implement MACRA in accordance with the law. Measuring value and quality
is a challenge that requires careful planning and broad collaboration
among all involved stakeholders, especially the beneficiaries who are
impacted most.
Question. By moving toward a consolidated quality-reporting and
payment system under MACRA, Physicians are incentivized through payment
adjustments into alternative payment models, and those who remain in
fee-for-service report on quality, resource use, clinical practice
improvement, and use of electronic health records. Which of these
metrics do you expect to be most challenging for providers to meet, and
how quickly would you anticipate payment adjustments moving providers
into alternative payment models?
Answer. For small providers, especially in rural Virginia and other
rural locations around the country, change can be difficult. The
implementation challenges created by new government-directed programs
are different and oftentimes more significant for smaller health-care
providers than they are for larger providers who might have the
resources and personnel to handle such changes. As we move forward with
the implementation of MACRA it is critical that we collaborate and
communicate with all providers on the frontlines to better understand
what challenges they are facing and how we can support them through its
implementation.
Question. The Obama administration made significant progress to
better align fee-for-service Medicare payments with value and quality,
and I have spent the better part of 2 years working with bipartisan
members of this committee to improve care for Medicare beneficiaries
with chronic illness. The Annual Wellness Visit, or AWV, is an
important preventative benefit for Medicare beneficiaries. One of the
key required components of this visit is an assessment of the
beneficiary's cognitive functioning, which could be particularly useful
in detecting early signs of Alzheimer's or other forms of dementia,
helping beneficiaries receive a timely diagnosis and access additional
services and supports, like the new assessment and care planning
services for beneficiaries. Despite existing for 6 years, as of last
year fewer than 20 percent of Medicare beneficiaries utilized the
Annual Wellness Visit. What concrete steps will CMS take to increase
access to the Medicare Wellness Visit?
Answer. If confirmed, I look forward to working with you to enable
better access to preventative care for Medicare beneficiaries. First,
we should evaluate what is working well and what the areas are for
improvement. Your counsel as we move forward in evaluating the AWV will
be critical.
Question. Effectively caring for patients at all stages of illness
is an important part of moving Medicare into the 21st century. I have
worked with Senator Isakson and others to ensure that conversations
between patients and the care team help patients to navigate this
difficult process: improvements to care planning would give individuals
and their families the ability to make smarter decisions, and provide
information and support so they can make informed choices based upon
their own values and goals. One CMMI demonstration provides hospice
beneficiaries with the option to receive supportive care services
typically provided by hospice while continuing to receive curative
services, called Medicare Care Choices. What additional steps would you
take to expand timely access to concurrent curative care and hospice
services? What other steps would you explore to expand access to
hospice and palliative care?
Answer. As you know, the Medicare hospice benefit covers services
designed to provide palliative care and management of a terminal
illness, including drugs and medical and support services. Under the
current structure, hospice care is provided in lieu of most other
Medicare services related to the curative treatment of the terminal
illness. Through the Medicare Care Choices Model, the Innovation Center
is piloting a new option for Medicare beneficiaries to receive hospice-
like support services from certain hospice providers while concurrently
receiving services provided by their curative care providers. Should I
be confirmed as Administrator, I intend to carefully examine this
Innovation Center model as well as look at other options for expanding
access to hospice and palliative care.
Question. The Center for Medicare and Medicaid Innovation (CMMI) is
conducting several demonstration projects for alternative payment
models in Medicare with the potential to save taxpayer dollars while
maintaining or improving the quality of care for beneficiaries,
including bundled payments for cardiac care, competitive bidding and
value-based insurance design. With a voluntary approach, only those who
are already efficient or performing well may participate. Out of the
over 75 CMMI demonstrations, which 2 do you think have the most
potential to improve care and lower cost? Please specify two additional
demonstrations you would plan to build upon, if confirmed as CMS
Administrator?
Answer. The Innovation Center provides significant opportunity for
testing new models for health-care financing and delivery. I cannot
comment on specific demonstrations at this time, without examining the
outcome data. However, if confirmed, I intend to examine the range of
demonstrations currently underway, as well as look for potential new
initiatives to explore innovative approaches to lower health-care costs
and improve quality for Medicare and Medicaid beneficiaries. I look
forward to reviewing current CMMI projects, consistent with
congressional actions.
Question. The Affordable Care Act included many provisions with
budget savings, including increased revenue and Medicare savings. Fully
repealing the Affordable Care Act, including revenue provisions and
Medicare savings, would add significantly to the national debt, cost
$350 billion over 10 years under conventional scoring, and hasten
Medicare's insolvency by 5 years. Are you in favor of an ACA repeal
that will contribute to our national debt and deficit? Do you believe
the revenues in ACA, much of which funded the coverage expansion,
should be retained, set aside for a possible replacement, or fully
repealed?
Answer. Should I be confirmed as Administrator of CMS, my duty will
be to execute the law as passed by Congress and signed by the
President. This includes ensuring that the Medicare program is well
administered, effective, and available for eligible beneficiaries, and
that it is sustainable for the future.
Question. While we are moving towards paying for value in many
areas of health care, in the drug space we have largely lagged behind.
In the past year, some insurers and drug manufacturers piloted value-
based arrangements that hold the manufacturer accountable for how their
product performs in the real world on an agreed upon set of metrics. In
2015, I was the lead author of a letter to CMS asking them to examine
the potential of using value-based arrangements in Medicare and other
public programs. Will you commit to working with me to identify
potential policy barriers that Congress should review in order to move
towards reimbursement for value rather than volume in the drug space?
Answer. If confirmed, I look forward to working with you and
providing technical assistance, when appropriate, as Congress considers
legislation that impacts CMS and the beneficiaries served by Medicare
and Medicaid.
Question. As Governor of Virginia, I prioritized the Commonwealth's
Children's Health Insurance Program (FAMIS), and streamlined the
program so that it could fund coverage for 200,000 Virginia children
each year, almost 98% of eligible children. ACA repeal could result in
the loss of $114 million from Virginia's Children's Health Insurance
Program, and increase the uninsured rate among Virginia kids from 3% to
8%. Block granting or capping Medicaid would also damage the
Commonwealth's ability to cover children, who represent half of
Virginia Medicaid enrollees but only 20% of costs. Will you support any
policy, regulation, or proposal that would increase the uninsured rate
among children?
Answer. It is important that every child has access to high-quality
health coverage, and CHIP plays an important role in accomplishing this
objective. CHIP plays a major role in this, but there is also a need to
focus on family coverage in the private market and employer plans, and
giving States needed flexibility. Each State has different needs, and I
believe CMS needs to work with States to ensure that, consistent with
those needs, the CHIP program provide the best possible coverage to
their residents. If confirmed, I would work with Congress on CHIP
reauthorization with these principles in mind.
______
Question Submitted by Hon. Mark R. Warner
and Hon. Johnny Isakson
Question. Over the past 3 decades, rural hospitals in Virginia and
Georgia have lost out on millions of dollars of Medicare payments
annually because of this skewed wage index formula. I worked with
Senator Isakson and others to help rural hospitals in many parts of the
country receive fair Medicare reimbursement, by introducing the
bipartisan Fair Medicare Hospital Payments Act. The bill would level
the playing field for at least 19 hospitals in rural Virginia and over
100 in Georgia. As CMS Administrator will you work with us to correct
the gaming of the Medicare wage index, and ensure that we shore up
rural hospitals nationwide?
Answer. If confirmed as Administrator, I intend to examine the
impact of the statutory wage index, as well as the range of issues
facing Medicare, as we look for ways to improve the program and make it
sustainable for the future.
______
Questions Submitted by Hon. Claire McCaskill
Question. Before the passage of the ACA, it was legal for insurers
in some States to use being a survivor of domestic violence as a pre-
existing condition.
Do you have a plan to ensure that survivors of sexual assault have
access to affordable comprehensive insurance coverage and that they are
not subject to discrimination or higher prices?
Answer. No one should have to pay higher health insurance rates due
to being a victim of domestic violence or sexual assault. If confirmed,
I look forward to taking steps to increase access to affordable,
quality health care for all Americans, including those who are victims
of domestic violence or sexual assault.
Question. Do you believe that the Federal Government should have
access to State data in order to perform evaluations of the Medicaid
program generally and Medicaid demonstration projects specifically?
Answer. If confirmed, I will work within the confines of the law to
partner with States to exchange appropriate data in order to evaluate
and improve our health care delivery systems. I am a strong proponent
of State innovation and flexibility--and States must also be held
accountable for ensuring the programs they operate provide access to
high-quality care.
Question. Earlier this month, the CDC released data showing that
the uninsured rate was 8.8 percent for the first 9 months of 2016,
which was a historic low.
Will you advise against measures that increase the number of people
without insurance?
Answer. I have fought for coverage and greater access to health
care throughout my career. If confirmed, I will work with you and your
office, the Congress and all interested parties to increase access to
high-quality health care. However, we should not assume that just
because people have an insurance card that they have access to health
care. Many people have out of pocket expenses they cannot afford and
others face limitations on the providers they can see. If confirmed, I
will do everything I can to ensure that coverage results in better
access to care.
______
Prepared Statement of Hon. Ron Wyden,
a U.S. Senator From Oregon
The health-care post the Finance Committee is going to discuss this
morning might not be dinner-table conversation, but it's one of the
most consequential roles in American government--the Administrator of
the Centers for Medicare and Medicaid Services.
CMS is responsible for the health care of over 100 million
Americans who count on Medicare and Medicaid. It also plays a big role
in implementing the ACA. That's a weighty responsibility, and that's
why CMS needs the most experienced and qualified people for the job--
people who know the ins and outs of health-care policy across the
entire system: Medicare, Medicaid, and the private insurance market.
CMS needs to have a strong and experienced authority on policy at a
time when many in the administration, as well as some of my colleagues
on Capitol Hill, are pushing to make radical changes to America's
health-care system. In my view, many of these proposals would take the
country back to the days when health care was mostly for the healthy
and the wealthy. I'll be listening closely to see if Ms. Verma is up to
the task.
I'd like to start off with the promise of Medicare--the promise of
guaranteed health benefits for seniors. Medicare makes up more than
half of CMS's spending--roughly $2.2 billion a day. With more seniors
entering the program every year, there's a lot of work that needs to be
done to protect and update the Medicare guarantee for the 21st century.
Updating Medicare means addressing the high and rising cost of
prescription drugs that are putting a big time strain on seniors'
budgets. It means making the program work better for people who have to
manage multiple chronic diseases, like heart disease, cancer, diabetes
and stroke that constitute the vast majority of the Medicare dollar
today. Those are the kind of bipartisan concerns Congress and CMS
should be collaborating on.
Privatizing Medicare is the wrong direction for people across the
country who expect the program to be there for them in their later
years. I want to hear how Ms. Verma's views differ from those of the
policymakers, including now-Secretary Price, who want to turn the
entire program into a voucher system.
Additionally, if confirmed, Ms. Verma will play a key role in
implementing the bipartisan Medicare physician payment reforms. It's
essential that she implement the law as intended by Congress as
America's health-care system continues the long-needed shift from
paying for volume to paying for value.
CMS also implements and oversees the rules of the road in the
private insurance market established by the ACA. Today, many of those
rules amount to bedrock values for health insurance in America:
Not discriminating against those with pre-existing
conditions no matter what;
Setting the bar for what type of medical care insurance
companies must cover; and
Letting young adults keep their parent's insurance until 26.
However, just yesterday, CMS released a proposed rule affecting
insurance coverage next year. From where I sit, the message from that
rule is clear: insurance companies are back in charge, and patients are
taking a back seat. The open enrollment period was cut in half, from 3
months to 6 weeks. If someone dropped coverage during the year for any
reason, insurance companies could collect back-premiums before an
individual is able to get health insurance again. And insurance
companies will have free reign to offer less generous coverage at the
same or higher costs. All of this sounds to me like a step backward
towards health care only for the healthy and wealthy.
This administration has been saying--on repeat--that the best is
yet to come, but the evidence suggests otherwise. The President could
have taken steps to create more stability on a bipartisan basis, but
instead issued an Executive order on the day he was sworn in that is
creating market uncertainty and anxiety. You don't need to look further
than Humana's recent decision to leave the market to see that
confidence in the President's promise is low.
So it will be important to hear from Ms. Verma this morning about
how she plans to implement this program that millions of Americans
count on as Republicans in Congress actively discuss, even today, how
they will begin to unravel the law. I hope Ms. Verma will use her
position if confirmed to move beyond the tired ``repeal and run'' ideas
that look increasingly impossible.
The repeal and run scheme goes beyond disrupting the individual
market. It would also end the Medicaid expansion that has brought
millions of low-income, vulnerable Americans into the health-care
system, many for the first time in their lives. This is the area where
Ms. Verma has had most of her health-care experience. The project she
is known best for is what's called ``Healthy Indiana 2.0,'' which
expanded Medicaid in her home State.
The tradeoff for that expansion is something I'd like to focus on
in more detail. I'm particularly concerned about the possibility that
someone making barely $12,000 dollars a year would get locked out of
health coverage for no less than 6 months because they couldn't pay for
health care due to an upcoming rent check, for example, or an emergency
car repair.
According to an independent evaluation commissioned by the State of
Indiana, more than 2,500 people were bumped from coverage due to a
situation like this. I'm also concerned about data from the same report
that found more than 20,000 people were pushed onto a more expensive,
less comprehensive Medicaid plans because they couldn't pay or navigate
the complicated system Ms. Verma put in place. These complex rules
apply no matter your situation: homeless, suffering from a mental
health crisis, or without a regular income, to name a few.
I have great reservations about taking these questionable ideas on
a nationwide tour. Flexibility for States to pursue policies that work
well for them is something I've always championed. But I'm in favor of
flexibility for States when it helps them do better, not when it helps
them do worse. I'm proud to say my home State has one of the leading
Medicaid programs in the country--and it just got a renewed waiver.
States should not be denied the opportunity to do what they want
because they don't pursue policies like Indiana's.
However, Ms. Verma will not only be responsible for the 11 million
individuals who gained coverage under the expansion, but also for the
60 plus million Americans who rely on Medicaid: to help pay for nursing
and home-based care; to provide comprehensive coverage for one out of
three children; and to help people live healthy lives in their
communities. All of them are at risk under Republican proposals to
slash the social safety net through block grants or caps.
Before I wrap up, I'd like to discuss one more issue that relates
to Ms. Verma's work in Indiana. Ms. Verma and her consulting firm were
awarded more than $8.3 million in contracts directly by the State of
Indiana to advise the State and help manage its health-care programs.
In effect, she was the policy architect. At the same time, she
contracted with at least five other companies that provided hundreds of
millions of dollars of services and products to those very programs--HP
Enterprises, Milliman, Inc., Maximus, Health Management Associates (or
HMA), and Roche Diagnostics. In the case of at least two of these
firms--HP and HMA--the terms of her State contracts appear to have had
her directly overseeing work these firms performed.
Instead of offering my own views on this arrangement, I'll quote
President George W. Bush's ethics lawyer Richard Painter, hardly a
liberal, who yesterday said that this arrangement, quote, ``clearly
should not happen and is definitely improper.'' Ms. Verma is on both
sides of the deal, helping manage state's health programs while being
paid by vendors to those same programs. Richard Painter called that a
``conflict of interest.'' I agree.
These companies she consults with--HP, Maximus, Milliman, and
HighPoint Global--also work with CMS, which she'd be running if
confirmed. While her ethics agreement specifically requires recusal
with regard to HMA, it does not specifically address the question of
her recusal obligations with regard to these other companies.
I think the committee has an obligation to find out more about Ms.
Verma's work for companies that did business with the State while she
worked for the State. Senators also need to be assured that if she
becomes the CMS Administrator, she will recuse herself from decisions
that affect the companies that were her clients.
Ms. Verma, I thank you for joining the committee this morning, and
I appreciate your willingness to serve. I look forward to your
testimony.
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