Seema Verma's bold initiatives land her in No. 1 Most Influential spot

Seema Verma doesn’t shrink from a fight, and she’s had plenty of them since she became CMS administrator in March 2017.

The former Medicaid consultant has championed many policy initiatives that have polarized the healthcare world.

While her agenda and personal style elicit controversy, veteran CMS watchers give Verma credit for boldly articulating and pursuing her vision of strengthening market forces to improve healthcare quality and access, and reduce costs. That includes goosing the sluggish transition to value-based payment.

“A lot of people underestimated her,” said Dr. Avik Roy, president of the Foundation for Research on Equal Opportunity, a free-market think tank. “She has turned out to have a pretty thick skin and strong will to be effective,” adding that the CMS under Verma “has been much more important than in the past in terms of being an engine of policy change.”

“If you are trying to make real, lasting, consequential changes to the healthcare system—changes that will actually help patients—you’ll never make everyone happy,” Verma said in an emailed response to questions.

It’s unclear how many of her initiatives will ultimately survive court battles, however. She’s also become embroiled in controversies surrounding the agency’s use of public relations firms and has a reportedly strained relationship with HHS Secretary Alex Azar, which, according to an article in Politico, disrupted Trump administration healthcare initiatives.

Nevertheless, her efforts have placed her in the top spot on Modern Healthcare’s ranking of the 100 Most Influential People in Healthcare, the first CMS administrator to hold the position.

Bernard Tyson, Kaiser Permanente’s late CEO, was selected for the second slot on the Most Influential list. Tyson, who died of a heart attack last month after heading the giant hospital and insurance system for seven years, was named to the list for pioneering the movement of health systems to address the social determinants of health.

Appearing together at the TIME 100 Health Summit in October, Verma and Tyson agreed that the industry needs to move more rapidly toward a value-based design. Tyson, though, countered Verma’s frequent attacks on the Affordable Care Act, arguing instead that policymakers should fix what’s broken in the law rather than “blow up” the current system.

Verma and the CMS have charged ahead on Medicaid work requirements, expansion of short-term health plans lacking consumer protections, Medicaid block grants, and narrower nondiscrimination protections for people based on sex and race. The agency also pursued rules around offering price transparency, reducing 340B drug payments, and establishing site-neutral Medicare payments.

Many of those initiatives have been blocked wholly or partly by the courts, or face pending legal challenges.

“You don’t have to like it, but her work on giving states more flexibility to require community engagement and work is the most ambitious attempt I’ve seen to let states change the way they handle their Medicaid programs,” said Joseph Antos, a healthcare scholar at the American Enterprise Institute.

Verma also has drawn attention for her frequent speeches bluntly criticizing: the Affordable Care Act; providers and drugmakers that charge too much; Medicare for all proposals; cumbersome regulations; and wasteful spending.

“If we don’t forcefully explain what makes (Medicare for all) proposals fatally flawed today … they may wreck our healthcare system tomorrow,” she said.

“In terms of pursuing the Trump administration’s priorities, she has undoubtedly been influential and reasonably bold, and I give her credit for that,” said Billy Wynne, a Democratic health policy consultant. He praises her agency’s proposals for reducing drug prices while criticizing her Medicaid moves as endangering coverage.

Meanwhile, HHS’ Office of Inspector General announced in June that it’s investigating whether the CMS’ millions of dollars in contracts to hire Republican media and political consultants to serve as Verma’s communications aides complied with federal law and HHS policies. That office said its findings are due in early 2020.

Her office more recently has come under fire for its expensive campaign to boost Verma’s visibility through interviews, speeches and appearances in prestigious forums.

In addition, Politico reported that feuding and personal rivalry between Verma and Azar has disrupted Trump administration healthcare initiatives, including release of an ACA replacement plan.

Verma’s approach to implementing the CMS’ reforms has triggered numerous court battles. Earlier this year, a federal judge ruled that the CMS’ approval of state work requirement waivers was inconsistent with the Medicaid law’s objective of furnishing coverage; an appellate ruling is pending.

Another federal judge held that the CMS exceeded its authority in ordering Medicare to pay hospital-owned clinics the same rates as it pays to independent physicians for evaluation and management services.

And last week, the American Hospital Association, the Association of American Medical Colleges, the Children’s Hospital Association, and the Federation of American Hospitals sued the agency over its final rule mandating that hospitals disclose the confidential rates they negotiate with insurers, calling it a violation of the First Amendment and of laws protecting trade secrets.

Verma said she considers this transparency rule, along with a proposed rule requiring health plans to disclose the rates they pay hospitals and physicians, “the biggest thing we’ve done to lower healthcare costs” because it will boost competition.

Some question the emphasis on price disclosure. Dr. Gary Kaplan, who is ranked 89th on the list for his role as chairman and CEO of Virginia Mason Health System in Seattle, said he favors greater transparency but doubts the CMS proposal is going to do much to solve the big issues in healthcare.

“We’ve got a responsibility to make care delivery more efficient and affordable and improve the healthcare experience for patients and providers,” he said. “The CMS needs to help us with that, but it’s questionable if that’s really happening.”

But Roy said Verma’s work on price transparency is potentially “transformative” if price data are used to drive better deals and lower-cost services. “She’s incredibly passionate about this initiative, and she’s eager to take the fight to providers,” he said. “She sees this as her legacy.”

Verma also stressed her agency’s moves to accelerate value-based payment, including a proposed rule creating a safe harbor that protects providers forming coordinated-care arrangements from Stark anti-kickback scrutiny.

Despite many legal setbacks, she hasn’t retreated, blasting those who have sued to block the work requirement and other initiatives. “We cannot allow those who prefer the status quo to weaponize the legal system against badly needed innovation at all levels of government,” she said.

But critics say her tough talk hasn’t been matched by successes in curbing overall costs or expanding coverage. Indeed, the national uninsured rate, including for children, climbed last year, which some attribute at least partly to Verma’s focus on tightening the Medicaid eligibility redetermination process. Democrats say she has spearheaded multiple efforts to undermine the ACA markets.

She strongly disputes that, touting an increase in the number of insurers offering individual plans in the Affordable Care Act markets, and 4% lower average premiums in 2020 for silver plans sold on the federal exchange—even as she supports scrapping the ACA.

One of her most ambitious and contentious goals is to transform Medicaid financing, promising to issue guidance giving states broad flexibility to reshape their Medicaid programs under a capped federal payment model. But so far she’s been frustrated in that quest.

Others are pleased she hasn’t yet achieved that goal. “When that block-grant guidance was withdrawn, I breathed a little sigh of relief,” said Susan Feigin Harris, a Morgan Lewis attorney who represents providers and health plans. “There would be litigation on that, and there will be litigation on the transparency stuff. There’s litigation about everything.”

Verma’s frequent public speeches—including attacks on the ACA as a “failed” law—have raised concerns that she has gone further than previous CMS chiefs in serving as a political spokesperson for the presidential administration. “Using her pulpit, time and authority to criticize preliminary proposals from Democratic candidates speaks to her prioritizing ideology over the core mission of the agency,” Wynne argued.

But others say her rhetoric hasn’t affected her or the CMS’ adherence to statutory law in running the huge public healthcare programs.

“Is she more aggressive politically? Yeah,” said Tom Scully, a Republican who served as CMS administrator during the George W. Bush administration. “But this administration is way more aggressive politically. She’s presenting these arguments the way the administration wants her to. I’m certain she’s doing what they want her to do.”

Verma sees her role as a needed truth-teller and champion for patients making choices in a free market.

“For too long, the health system has catered to the demands of special interests and left patients as an afterthought,” she said. “We are trying to flip that on its head and restore patients to their rightful place at the center of American healthcare.”

AWARDS: 100 Most Influential People in Healthcare - 2019