EP. 29: ON LEADING MEDICARE

Sep 21

WITH MEENA SESHAMANI, MD, PHD

An otolaryngologist discusses how she came to lead the most important health insurance provider in the United States.

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Episode Summary

With around 63 million beneficiaries, Medicare is the single largest provider of health insurance in the United States, serving Americans aged 65 or older, as well as some younger patients who have certain disabilities. Directing this massive program is Dr. Meena Seshamani, an otolaryngologist and former Vice President of Clinical Care Transformation at MedStar Health, a large health care organization primarily operating in the Baltimore-Washington metropolitan area. There, she led initiatives in palliative care, geriatrics, and community health. She has also served as Director of the Office of Health Reform at the US Department of Health and Human Services. In this episode, Dr. Seshamani discusses her path from surgeon to health policy leader, what draws her to caring for older adults, and her vision for a better, more sustainable health care of the future.

Meena Seshamani, MD, PhD is the current Deputy Administrator and Director of the Center for Medicare. Her diverse background as a health care executive, health economist, physician and health policy expert has given her a unique perspective on how health policy impacts the real lives of patients. She most recently served as Vice President of Clinical Care Transformation at MedStar Health, where she conceptualized, designed, and implemented population health and value-based care initiatives and served on the senior leadership of the 10 hospital, 300+ outpatient care site health system. The care models and service lines under her leadership, including community health, geriatrics, and palliative care, have been nationally recognized by the Institute for Healthcare Improvement and others. She also cared for patients as an Assistant Professor of Otolaryngology-Head and Neck Surgery at the Georgetown University School of Medicine.
Dr. Seshamani also brings decades of policy experience to her role, including recently serving on the leadership of the Biden-Harris Transition HHS Agency Review Team. Prior to MedStar Health, she was Director of the Office of Health Reform at the US Department of Health and Human Services, where she drove strategy and led implementation of the Affordable Care Act across the Department, including coverage policy, delivery system reform, and public health policy. She received her B.A. with Honors in Business Economics from Brown University, her M.D. from the University of Pennsylvania School of Medicine, and her Ph.D. in Health Economics from the University of Oxford, where she was a Marshall Scholar. She completed her residency training in Otolaryngology-Head and Neck Surgery at the Johns Hopkins University School of Medicine, and practiced as a head and neck surgeon at Kaiser Permanente in San Francisco.
In this episode, you will hear about:
• Dr. Seshamani’s enthusiasm for medicine at a young age and the diverse career trajectory that followed - 2:08
• A discussion of Dr. Seshamani’s past leadership roles, including those at the Office of Health Reform under the Obama administration and at MedStar Health - 6:27
• Balancing the need for clinicians to work collaboratively and the inclination of physicians to value autonomy - 10:20
• An explanation of Medicare’s role in the US healthcare ecosystem - 14:51
• What draws Dr. Seshamani to focus on the care of older adults - 17:39
• The crisis of burnout in the medical profession and Dr. Seshamani’s vision for how this can be addressed - 21:00
• The fee-for-service mechanism of healthcare reimbursement, accountable care relationships, and the value of preventative care - 25:33
• The pay disparity between specialists and primary care physicians, and the role Medicare can play - 30:40
• How the growing population of aging Americans impacts the future sustainability of the Medicare program - 38:41
• How Medicare is reforming its allocation of resources to promote health equity - 42:02
• Dr. Seshamani’s advice to students and clinicians on engaging in meaningful work as they advance in their careers - 48:24
Henry Bair: [00:00:01] Hi. I'm Henry Bair.

Tyler Johnson: [00:00:03] And I'm Tyler Johnson.

Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?

Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom, probing the moral heart that beats at the core of medicine. We will hear stories that are, by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.

Henry Bair: [00:01:04] With more than 60 million beneficiaries, Medicare is a single largest provider of health insurance in the United States, serving Americans age 65 or older, as well as some younger patients who have certain disabilities. Today, we are delighted to be joined by Dr. Meena Seshamani, an otolaryngologist and head and neck surgeon, who is the Director of Medicare. Prior to her current position, Dr. Seshamani was the Vice President of Clinical Care Transformation at MedStar Health, a large health care organization primarily operating in the Baltimore-Washington metropolitan area. There she led initiatives in palliative care, geriatrics and community health. She has also served as director of the Office of Health Reform at the US Department of Health and Human Services. In this episode, Dr. Seshamani discusses her diverse medical career, what draws her to caring for older adults, lessons learned on health care leadership and her vision for a better, more sustainable health care of the future. Dr. Seshamani, welcome to the show and thanks for being here.

Meena Seshamani: [00:02:05] It's great to be here. Thank you for having me.

Henry Bair: [00:02:08] So your career has spanned academia, public service, and be an executive at a large health organization. But can you take us all the way back to the start and tell us what first drew you to a medical career?

Meena Seshamani: [00:02:22] Well, when I was six years old, I thought that if you took care of people who are sick, you wouldn't get sick yourself. So that's really where it all started. Clearly, I was wrong, but in all seriousness, I think during middle school, high school, I did my volunteer work at a local hospital and just really enjoyed that ability to interact with people and to be able to care for people. And that carried through my undergraduate and ultimately led me to want to be in health care and to be in an area where you can take care of others as part of your job.

Henry Bair: [00:02:58] And what drew you in particular to being an E-N-T surgeon?

Meena Seshamani: [00:03:03] Well, when I started medical school, I thought that I was going to be a full time practicing pediatrician. Clearly, that is not what happened. Then I had developed an interest in economics, ended up doing an economics graduate degree. I thought, okay, the people who do health policy work, who are physicians tend to be in internal medicine. So I will go into internal medicine. And I planned my medical school rotations. Right? So I did kind of surgery first. So then I would really knock it out of the park with my internal medicine rotation. And I did my surgery rotation and I really enjoyed it. I loved being in the O.R., I loved interacting with patients in that way, pre-op through the O.R. and post-op. And I thought, Oh my gosh, if I'm having this much fun on my surgery rotation, my internal medicine rotation is just going to be incredible. And when I did my internal medicine rotation, my third year resident, when I did my surgery rotation, that third year resident, I ended up calling a general surgery consult on one of my internal medicine patients when I was on my internal medicine rotation. And she came to evaluate the patient and she was going to take the patient to the O.R. and I was like, "Can I go to the O.R. with you?" And she said, "No, you're on a different rotation." So, I mean, I really I realized that I really enjoyed that aspect of medicine, and I also did enjoy my internal medicine rotation. And so someone at some point mentioned to me, you should look into otolaryngology because you can do both care in the clinic -you do both medical care and surgical care of patients- and so I did an elective in otolaryngology and just absolutely loved the field. You know, the variety of procedures you do, big soft tissue procedures, microscopic endoscopic, and you do get to see that breadth where you're caring for people in the clinic and caring for people in the O.R. So then it came to the existential crisis of, oh my goodness, all of my mentors or anyone that I had worked with in the health policy research, I'd done health economics work, were all pretty much in internal medicine. And one of my mentors, the late Sandy Schwartz, I remember talking to him and saying, I don't know what I should do. I really like E-N-T. And he said, Well, then you know what you should do? You should go into E-N-T and you will figure out a way to make all of these things work, all of your various interests. You will find a way to bring it all together. Fast forward, when I was interviewing for residency, your dean now, Lloyd Miner, was the chair of the otolaryngology department at Hopkins. And I remember during my interview talking with him about the research I was doing, which again was very atypical for someone applying an otolaryngology. And he said, it's really important that we have more surgeons involved in health policy and health care management and that it's really important that we extend the breadth of the expertise of people in our field.

Tyler Johnson: [00:06:13] Just for the record, I hate to tell you this, at this stage, internal medicine was actually the right answer. So in case you were wondering, that was what you were really supposed to go into. But I'm sure that E-N-T is also nice.

Henry Bair: [00:06:27] As you have alluded to, you have a lot of interests beyond the operating room. You have done work in health policy. You have studied health economics. And in one of your most prominent roles, you were on the health care leadership team of MedStar Health, which is this large health care organization that operates many hospitals on the East Coast of the United States. Can you connect the dots for us and tell us how you went from clinician to all of these other leadership roles and in what ways your clinical career have informed your leadership?

Meena Seshamani: [00:07:04] Sure. So again, I'll take it back a few steps. When I started college. I thought I was going to be a biology major. And my second semester freshman year, I took an intro economics course and I absolutely loved it. And I thought, okay, what does this mean? I took more economics courses. I ended up majoring in business economics. I took in particular a health economics course towards the end of my economics studies and did my undergraduate thesis in Health Economics and looking at how nonclinical factors play into whether a woman has a VBAC - vaginal birth after cesarean. I developed this interest in economics still tied to health care because again, as we talked about, my heart really was in how you can take care of people and keep them healthy. And that was something that really has always been a personal passion of mine. So through the course from that undergrad time, from that first econ course, I really have been bringing together these two passions and interests, both about how do we take better care of people and keep them healthy, both from that personal one on one aspect through medical school training, residency training, practice. And how do you do it on a macro level where you are creating a system in which that one on one relationship is possible? And so being able to take my health economics learnings, I ended up doing a PhD in health economics and doing all of my research, looking at how the system does or does not lead to improved outcomes, smarter spending of the health care dollar, improved health of our populations, and being able to marry my personal experiences, taking care of patients as well as my experiences and leadership roles and policy roles to be able to really drive at that ultimate issue.

Meena Seshamani: [00:09:06] And so I worked in the Obama administration on the Affordable Care Act. I led the Office of Health Reform, really with the implementation of the expansion in coverage that occurred and also delivery system reform. How do we create more holistic care models that, again, think in a new way about what it means to provide health care? And I took that with me to MedStar Health, where I developed a new department, a clinical care transformation to really bring population health and these holistic care models on the ground in a large health system, ten hospitals, 300 plus outpatient site health system. And so in that role, I practiced as an otolaryngologist at Georgetown and also led community health care managers, geriatrics, palliative care, various chronic condition, disease management pathways. So again, being able to bring the various experiences together so that you can not only care for someone one on one, but you can create an environment in which that improved care is possible, both on the individual level and at the population level.

Tyler Johnson: [00:10:20] There was a great article now probably a couple of decades ago by Atul Gawande. I think it was called something like "The Cowboy and the Pit Crew," where he talks about how there's this sort of old model of medicine, which is that the doctor is this kind of lone ranger sort of off doing their own thing and almost this heroic mystique, right, about the doctors sort of doing their own thing and providing this really amazing care just by virtue of their own wits and skill. Right. And the point that he was making this was a commencement address many years ago was that we necessarily are moving away from that towards an understanding of doctor or any other care provider being just one member of a team, like a member of a pit crew. And that the point here is to optimize the efficiency of the pit crew, as you were talking about, to get eventually the best outcomes.

Tyler Johnson: [00:11:06] But I feel like in the United States, in the medical world here, there's still always this inherent tension between those two ideals. Right. At least I know in our hospital, any time the administration starts to come down and say, well, we need the doctors to do fill in the blank, even if the thing that they're asking for is something that all the doctors agree with. Everybody starts to chafe right and gets defensive and kind of gets their hackles up. Like, we don't want you telling us what to do, basically. Right. So as the person who has held some of the most senior and most powerful positions in the country, in effect, if you will, telling doctors what to do --I know that's not exactly probably how you would phrase it, but that's probably how some doctors think about it-- How do you think about the ways that that tension plays out? Do you think that that makes your job harder? Do you think that there's some merit to those ideas that some doctors have? Or how do you think about that?

Meena Seshamani: [00:12:00] You raise a good point and ask a good question. And I think it comes back a little bit to leadership philosophy. You know, I view very much when I was on the senior leadership at MedStar Health, when I'm in my role now leading the Medicare program, I view what I do as I am here to support everyone who has gone into health care, who wants to do good by the people that we're serving. I think a lot of us, when we go into health care, you go into health care because a lot of times there's a personal reason there's a mission. And I really view what I do as empowering, facilitating, enabling people to be able to take better care and to serve those around them. And that's how I approached the work at MedStar, and that's how I approach my work now. And to give you an example of what you were describing, I think COVID absolutely has shown that one person cannot do it alone. Right. I mean, it really is about it's not just a health care system. It's a health care ecosystem because it's about the communities. It's about the social situations of the people who are caring for. It's about trusted partners. And, you know, a good example, when I was at MedStar Health, when the vaccines came out, there wasn't good take up of vaccines, particularly in underserved areas and populations that maybe didn't trust health care providers and physicians.

Meena Seshamani: [00:13:26] And one of the things that we did was we leverage our mobile clinics that we had that we were going to use for primary care. And we staffed it with our community health workers and sent those mobile vans into largely black neighborhoods, inner city Baltimore senior centers, to be able to provide information counseling on COVID vaccines and provide COVID vaccines where people live in their communities. And we had, I think, 75% take up rate for COVID vaccines. And this was at the start of vaccinations because again, I think that team based approach is what then enabled everyone to feel like you are able to do what you needed to do to keep your community safe and healthy. And so how do we leverage that moving forward when we think about issues of health care, workforce burnout, right. Like the cowboy approach can only take you so far when we're dealing with people who are really struggling. Right. I think all of us there's a behavioral health crisis in our country and people who work in health care are no exception. And so where there are opportunities to create more of that team based approach where you can leverage the skills and experiences of those around you so that it's not all on your shoulders. It is working together as a team so that everyone can bring forth what their strengths are in being able to care for people in the most effective way possible.

Tyler Johnson: [00:14:51] And we should back up. I probably should have asked this question first, but just because our listeners span the gamut, right? So some of them are doctors, others of them are medical students or haven't even gone into medicine yet. But even for doctors and especially for for younger listeners, can you just describe what is Medicare? Right. Everybody everybody's heard of Medicare. Everybody sort of knows it's some shadowy force that does lots of important things. But I think if you were to actually sit even most doctors down and say, well, what does Medicare actually do? They would probably have a hard time articulating that. So can you help us to better understand what Medicare's role in the US health ecosystem is?

Meena Seshamani: [00:15:28] Absolutely so. Medicare is health insurance for more than 63 million Americans, so it's people age 65 and older people with disabilities and people with end stage renal disease, end stage kidney disease. That's who Medicare covers. It is run by the federal government. We pay, I think, $900 billion in health care claims each year. We account for one out of every $5 in the US health care system. We partner with more than a million clinicians who are providing care to the 63 million people in our program more than 6000 hospitals, skilled nursing facilities, home health agencies. So it really is, quite frankly, a huge program. And that is a tremendous opportunity because where you make a change in the Medicare program, it has ripple effects throughout the entire. System. So where we create a new code or where we create a new care model, those are things that other health insurance companies, physicians, nurses are looking at because it really moves a lot of the health care system just due to the size of the program. I think the other important thing about the Medicare program, it comes back to Tyler, what you are mentioning in our last conversation. I know all too well that Medicare cannot do its work alone. There are 63 million people who rely on our program, and that is the partnership of the private plans that we partner with, with Medicare Advantage, the physicians, nurses, other health care providers that are providing care to those patients, to the community, organizations that are providing social support to device, pharma. I mean, it it really is all the innovators and entrepreneurs in the care delivery space. It really is a partnership across that ecosystem that I want to make sure we are maximizing so that we can provide the best care to those 63 million people who rely on the program.

Henry Bair: [00:17:39] I'd like to explore your interest in the Medicare population. As you've mentioned, Medicare focuses on helping American adults aged 65 and over. During your time at MedStar Health. I know that a lot of the initiatives you worked on focused on palliative care, geriatrics and end of life care, which is quite different from otolaryngology, the medical specialty that you were trained in. Can you tell us what eventually drew you to caring for older patients?

Meena Seshamani: [00:18:14] Well, I think those fields and that population is part of a larger theme around how do we provide whole person care and care for people as people rather than someone coming into an office visit where they're going to have an ICD ten code and then you bill an ENM code or a CPT code and then you send them on their way instead. Everyone who comes in has a story, they have history, they have a whole myriad of experiences that are impacting their health. And that, I think, is what really drives me in a lot of the work that I have done just to share. I mean, I think all of us in health care have examples, right? And I'm no exception there of people who I have cared for that really motivate what I do now. And when I was a resident, there was one gentleman who came in. He had a very large tumor in his throat. He was coming in to have the tumor resected and to have reconstructive surgery done. And when I was reading the clinic notes, it said that he drank 33 beers a day and this was still in the time of like handwritten notes. I thought, okay, maybe this is like, you know, just was written wrong. And so he came into the hospital for surgery in the pre-op area. I said, Hello, sir, you know, I'm going to be taking care of you. And I just want to check, you know, do you drink 33 beers a day? And he said, yes.

Meena Seshamani: [00:19:41] And he said it was like the big heat he calculated because it's like the big cans anyway, 33 beers a day. He had his surgery and had to go to the ICU. Right. Had to be put on a drip to prevent the alcohol withdrawal. So to be kind of detoxed in the ICU after the surgery, his nutrition was horrible because when you're drinking that much, you're not going to be getting appropriate nutrition, which meant that his wounds couldn't really heal, so his wounds completely opened up. We were doing all of this very complex packing of his neck. He did not have much family support because, again, someone who's drinking 33 meals a day, chances are that there are other issues going on as well. And we spent a lot of time trying to figure out, okay, how do we support him now he has this large wound. How do we get him to a facility who is around to also help him and support him? And I think examples like that, I mean, just really drive home that we have to think about people in a more holistic way when we take care of them. And that really drives a lot of what I do. It drives a lot of what some of the fields that that you mentioned are involved in. When we think about community health and we think about that team based approach, that's what it really comes down to.

Tyler Johnson: [00:21:00] So I'm curious, one thing that we talk a lot about on the podcast, you already mentioned the crisis of meaning in medicine, right? And I think there's a wide spread recognition now that there is an epidemic of burnout and that the emotional well-being of practitioners is increasingly in jeopardy. Now, we, of course, recognize that that operates on multiple levels at the very least. Right. There are probably systematic factors that affect the entire US health care system. And then of course there are also personal factors. But again, you are in this very unusual position. Not that you're being a director does not mean you're a dictator, right? So it's not like you can just sign something and have the change implemented immediately, but nonetheless, you arguably have as much influence over the direction of US health care as just about anybody else out there. Right? And so I guess what I'm wondering is if you were to sort of combine your doctor and your health care economist hats and you were to try to make a diagnosis as to what's driving the crisis of meaning or lack of meaning in health care. And then you were to try to prescribe a treatment for whatever your diagnosis is. What would that look like?

Meena Seshamani: [00:22:13] Well, I think I would approach it again from that more holistic avenue where I don't think that there is one factor at play. I think there are multiple factors at play and I think it differs for different people. I think that we have a crisis of caregiving where you have people who are serving as double caregivers, where they're caregivers in their job. Right, taking care of other people as part of their job. And maybe they're in the sandwich generation where they're also taking care of older parents and children at home and being able to understand that everybody brings all of themselves to their work. So there are a variety of ways as a result that I think we can support people who are in the health care arena in terms of levers that I have, in particular that the Medicare program has in particular, I think administrative burden is definitely one area you may have seen in our physician fee schedule, which is one of our regulations. We have proposed further streamlining of documentation. So there was streamlining of documentation for office visits done recently, and we've extended that to other areas, other settings where physicians are providing care so that it can just be the same across all aspects and be in this more streamlined way. So that's like one very tangible example. But I think coming back to some of what we've been talking about, I see more of these holistic care models as another opportunity to hopefully address some burnout where people, again, don't have to feel like they have to do everything themselves in 15 minutes or less, where you can have a team that is supporting the patient together so that then everyone is able to do what they can do to help.

Meena Seshamani: [00:24:06] So like as an example, in this physician fee schedule I mentioned, we're also proposing to pay social workers or psychologists when they provide behavioral health care during a primary care office setting. So again, so that it's not all on the primary care doctor to do everything themselves, you can create more of that team based approach that can then potentially help with burnout and also have care be more effective. So I think that hopefully provides some examples of where we are looking at it. I will say that we also partner very closely with other parts of the Department of Health and Human Services. So for example, the Health Resources and Services Administration, they have distributed workforce wellness grants to health care providers to again provide funding, provide assistance, and how you can support health care practitioners as they are caring for patients, working with the surgeon general's office as well, because the behavioral health crisis and specifically that for the health care workforce is a priority for the office of the Surgeon General. So we also partner with other parts of Health and Human Services so that we make sure that the levers that each of us has individually is going to be so much more impactful when they are brought to bear in a coordinated fashion.

Henry Bair: [00:25:33] Speaking of burnout, whenever this issue comes up, whether it's talking to our colleagues or past guests on this program, many of them attribute burnout to the "fee for service" payment model that dominates American medicine today. Fee for service, of course, refers to the mechanism by which health care providers are paid based on the performance of specific services such as surgical procedure or a diagnostic test. This system encourages excessive volume of services and patients. The more services you provide, the greater the income to the hospital. Many detractors of Medicare point to it as a primary reason why this fee for service mechanism and the resultant high patient throughput mentality are so entrenched in the system that we have now. How would you respond to this criticism and in what ways is Medicare seeking to improve this aspect of American medicine?

Meena Seshamani: [00:26:30] Yeah, that's a great question. I have a vision for Medicare that I wrote in Health Affairs back in January, and there were kind of four main pillars advancing health equity, expanding access to coverage and care, driving innovation. So we have more whole person care and being good stewards of the program, again, coming back to their 63 million people who rely on us. And I think that innovation side really gets to some of what you're talking about, where the traditional fee for service way of doing things, where someone comes into your office or someone comes into the hospital and you give them a diagnosis, you do something to them either an E and M code or a CPT code, and then you send them on their way. Can create some of that, what you were talking about in terms of that throughput and also doesn't get to what we've been discussing about how you can best care for people and care for people in a way that's rewarding. And so we have a goal by 2030 to have 100% of people in our traditional Medicare program to be in what's called an accountable care relationship. That's where you have practitioners who are taking that more holistic approach to care, where if they keep people healthy, that's what matters. And so it's not about a head in a bed in a hospital, right? So that you can then charge for that hospitalization.

Meena Seshamani: [00:27:56] It really is about are you keeping people healthy? And as a result, are you keeping them out of the hospital and out of the emergency room, which then actually saves the program money and then you share in the savings. And so these models, accountable care organizations have you have groups of providers who health care providers who say, okay, I want to be accountable for the quality and cost of this population, which then gives flexibility to practice the way that you want. Then we waive a whole bunch of some of these administrative things so that you can have this more team based approach, be able to tailor what you're doing to what the needs of your communities are. So that really is a focus of ours to move away from fee for service towards these more holistic models. And in that regulation that I mentioned, we actually are proposing to also provide upfront dollars because one of the things that I've been hearing, I mean, one of the favorite parts of my job is being able to go and visit with health care practitioners, members of the community, other people involved in the health care ecosystem to hear what's going well, what's not going well, what can I do to help? And one of the things that I heard loud and clear from meeting with rural family practice docs in New Mexico to an accountable care organization caring for an intellectually and developmentally disabled population in New York was We want to practice medicine and we want to provide health care in a different way, but we need upfront money to be able to invest, to develop that infrastructure, to hire the people, to have that team based approach.

Meena Seshamani: [00:29:39] And so we're proposing to provide upfront investment dollars that small providers, particularly people who are practicing in rural and underserved areas, can use to develop their teams, to develop data infrastructure, electronic medical records. So then they can provide that kind of care. Because we have found through this program that's been in place, it's the Medicare shared savings program. We have found that those health care practitioners who care for people in underserved areas and rural populations actually are some of the most successful in the program because there's so much good that you can do when you can then reach out to people in the community where providing food for patients who live in a food desert may be more effective for managing diabetes than just continually instructing people on how to inject insulin, right? And so being able to take that more holistic approach, that's what the purpose of a lot of these models are.

Tyler Johnson: [00:30:40] So can I ask a rather pointed question, which maybe maybe it's an uncomfortable question? I don't know. But I'm genuinely curious. And we don't get to speak to the director of Medicare every day. So I guess I better take my chance while I have it. I love The West Wing, the old television show. And there's this great scene in The West Wing where Sam Seaborn, who's one of the presidential speechwriters, goes off on this very impassioned tangent about how schools should be castles, and we should be showering the schools and the teachers with money. Right. They should be making six figure salaries right out of school and etc., etc., which I love that scene because it reminds me that we can say whatever we want about how much we value something. But as a society, the way that we actually show how much we value things is by how much we pay people to do them right. And so it is sort of hypocritical to say, oh, of course, we value teachers. They're the most some of the most important people in our society. But then if you pay them 30 or 40,000 a year, I mean, how are they supposed to believe that? Right. Or how are we as a society supposed to believe that? And I was thinking about that recently when we talked to Dr. Pearle, who's the previous CEO of the Kaiser Health Care System, in a recent interview. One of the things that we talked about in detail with him is the comparative salaries that different kinds of physicians make. Right. And we are still in this model where even in some cases people who have gone whose post-graduate training has been roughly similar, if they are in a procedurally based specialty, they make sometimes two or three or four times as much as somebody who is in a thinking based specialty.

Tyler Johnson: [00:32:19] Right, with the most obvious and glaringly problematic, in my view. Example being primary care doctors, right? Anybody who has spent very much time around primary care doctors knows that they have one of the hardest jobs in medicine. Right. They are the hub of the wheel that is supposed to coordinate between all of the different aspects of a person's care, whether that's psychiatric care or post-op recovery or getting better from their recent heart attack or whatever. And yet they make less money than almost any other person in medicine. Right. And largely because they don't get to charge for particular procedures or for giving people chemotherapy or for other things that tend to bring a lot of money in. So I guess I'm wondering, as the director of Medicare, are there any efforts underway to try to decrease that discrepancy? Because I think if you just making it up out of whole cloth, right, it doesn't really make sense. And this is nothing I mean, I as a as a medical oncologist, I have nothing but the utmost respect and admiration for my surgical colleagues who do miraculous things. And yet it seems unfair that primary care doctors should make a third or a half or a fourth or even less than that of what many of our surgical colleagues make. So I guess I wonder, is there is there any effort underfoot to try to fix that discrepancy or at least lessen it?

Meena Seshamani: [00:33:41] So I may in addressing this issue, actually, if it's okay, take us back a step. You had asked earlier, like, let me take a step back and can you explain what Medicare is? Right. So I'm going to go back to to that, because I think it's important and you'll see why. So when people think about the Medicare program, they're actually like three layers, if you will, to the Medicare program. First, there's the Medicare statute. So there is law, right, that Congress writes that says this is what the Medicare program shall do. Can do, cannot do, is require to do, etc.. So there's Medicare statute that's maybe at like the 50,000 foot level where it will say, here are kind of the broad things that are allowed, things that are not allowed in the program. Then based on that, you get to kind of where I sit, which is the regulatory, administrative aspects of the program. So where there is a statute saying Medicare will do such and such, then we do regulations that follow that statute that then give further detail on how things work. So maybe that's like the 20 to 25000 foot level. And then you have how care actually plays out on the ground, right? That last mile, ground zero where you have all of our operations, you know, paying claims or supporting these the kinds of activities where someone is caring for one of our Medicare enrollees on the ground. I start with that, because that's a framework that really guides everything that we do in the Medicare program.

Meena Seshamani: [00:35:22] So when we think about things like physician fee schedule, there are requirements in the Medicare statute that the Center for Medicare has to follow, but we don't have any choice over because it is in the Medicare statute. So one technical there's something called a conversion factor. I'm not even going to get into what it is, but the conversion factor is something that is in the Medicare statute. We have no control over it. There are other things that we do have ability to do. Like I was mentioning, being able to pay psychologists and social workers for primary care visits. The things that I was mentioning around providing those upfront investment dollars, how we update the data that's used for determining the fee schedule for what health care providers are paid, that's where we have that discretion and that ability. And I will say supporting primary care in behavioral health is absolutely a priority for the Medicare program and for the administration. You know, when you think about the pillars that I mentioned, advancing health equity, expanding access to coverage and care, supporting high quality whole person care, being good stewards of the program, primary care and behavioral health is foundational for all of those. And so it absolutely is a priority for us as we do our work. And I could give more examples, but those were just a few that we've already discussed that I think show where we want to be able to invest to make sure that people are able to provide the care they want to provide.

Tyler Johnson: [00:36:59] So is that all to say? I just want to make sure that as a non health economist that I'm understanding this right. If society wanted to get it in its head that primary care doctors should be paid more. What you're saying is that basically that would insofar as Medicare has any ability to influence that, it would literally be an act of Congress to change the fee schedule upon which Medicare bases what it does.

Meena Seshamani: [00:37:22] No, I would say that it's a combination across all three layers. There are players there. All three layers play a role together in ultimately determining what happens on the ground.

Tyler Johnson: [00:37:35] I'm curious. Would you be supportive of that idea or something along the lines of that idea or not? Not even so much of any one specific proposal. But I guess what I'm trying to ask is from where I sit and I say this as a medical oncologist, right. Among internists, medical oncologists are, as far as I know, among the best salaried of the internal medicine doctors. So this is not like a personal complaint, but I'm saying that on behalf of both general internists and to a lesser degree general hospitalists, this strikes me as an issue that would probably help with burnout to some degree. Right. So I guess on a not in terms of a specific policy, but in terms of principles, do you think that there's work to be done there?

Meena Seshamani: [00:38:20] I think absolutely there is work to be done on what we've been discussing. Right. Like how do you make care more holistic and supporting primary care and behavioral health is absolutely a key part of that. And I can't speak to specific proposals, but I think that is a priority for this administration.

Henry Bair: [00:38:41] Thank you for delving into that for us. I have another question about cost, and that's regarding the future of Medicare. A lot of people are concerned about the sustainability of Medicare, in large part because of the growing proportion of older adults in America. The number of people who are over 65 years old is projected to double within the next 40 years. So in light of this, what do you think is the future of Medicare and how do we address this issue of sustainability?

Meena Seshamani: [00:39:16] You know, it comes back to some of what we were talking about that where especially with these holistic care models, we can take better care of people so that we're providing better care and you're having better outcomes and you're keeping people healthy. That leads money to be spent in a smarter way because you're spending money on health care rather than sick care, right? You're spending money to keep people healthy and that prevents things down the road that ultimately are more expensive. So a lot of what we've been talking about with these holistic care models really get at that. And our Medicare shared savings program has saved billions of dollars for the Medicare program and giving money back to the health care practitioners who are caring for these patients. As just one example, you know, fiscal stewardship is one of our strategic pillars. To really be able to make sure that this program is sustainable, is affordable, and is there for generations to come. And so I think one aspect of that is what we've been talking about. How do you change care delivery in a way that spends money in a smarter way and provides better care and better outcomes? The other is really thinking about data and transparency and how do you make the market work better? How do you encourage competition? You know, there's an executive order from the president on increasing competition in the American economy, and health care is no exception there.

Meena Seshamani: [00:40:43] Where are there opportunities that you can utilize data and have more transparency that can help guide decisions across the ecosystem? So some examples there are we have our hospital price transparency efforts. There's insurance price transparency efforts, there's the No Surprises Act. So a lot on transparency. We are now requiring for the first time that Medicare Advantage plans. So this is a part of the Medicare program where Medicare pays private plans, who then enroll people with Medicare and care for them. We are requiring Medicare Advantage plans to report on how they're spending the Medicare dollar, not just on traditional health care services, but also on things like meal support, housing, transportation, because it's a learning opportunity for all of us where you can see when you invest in this area, does it work? Does it not work? And so really being able to bring that data and transparency culture to bear in creating a continuous learning environment that will again get to our goals of better care, spending money in a smarter way, and ultimately having healthier populations.

Henry Bair: [00:42:02] One of the things that you've already mentioned several times is the focus on equity of Medicare under your guidance. Now, that's something that I, I think I didn't even think about that when I was starting medical school. It wasn't until I started working in the hospital that I realized that, as you also mentioned, patients overall health in many instances is impacted more by the non traditionally medical things that we can do for them and more related to the environment they find themselves in. And these might include things like educational attainment, their job stability, food security, housing status, transportation, all these things. And when I've worked in clinical settings where we recognize that was a large factor in the quality of a patient's life, it can can feel frustrating because there just seems to be so little that doctors and other clinicians can do to address those problems. You've mentioned that Medicare is trying to address those problems by, for instance, compensating community based care providers, social workers. I'm just wondering what what are some other things that you hope to accomplish through Medicare in addressing this problem?

Meena Seshamani: [00:43:19] Again to if it's okay to take a step back, I think it's worth asking what do we mean when we say health equity? And for CMS, when we talk about health equity, we're talking about making sure that everyone has a fair and just opportunity to attain their optimal health regardless of socioeconomic situation, geography, race, ethnicity, sexual orientation, gender identity, language, culture, the numerous factors that go into what makes someone healthy or not. So with that in mind, you mentioned a few things that we are working on. For example, those upfront payments to providers to create these more holistic care models, these accountable care organizations, particularly in rural and underserved areas. We're proposing to allow those dollars to be used for social needs. It's the first time that the Medicare program is going to be potentially using these dollars for social needs. Being able to think in a more team based approach. So in this physician fee schedule regulation, we're actually asking for ideas for community health workers and what role can they play in the Medicare program again? So we can open the aperture of how we're viewing health of our populations and the health care that we provide to them. And I think another aspect of it is that we're doing this very much in partnership with other parts of Health and Human Services. As I mentioned before, with burnout. This is another example where we're working very closely, for example, with the Health Resources and Services Administration, where they invest money through grants in communities. And we want to partner with them so that as we're working with the health care practitioners, it's not in a vacuum because there's also support going to the community in which that person is practicing.

Meena Seshamani: [00:45:19] So that way you can really make sure that you are addressing the full needs of our populations. I think one more point since this is medical and medical student audience as well. Medicare also has the graduate medical education funding for the country. So that's also under GMI is also under Medicare's purview. And again, this is an example, Tyler, coming back to what we're talking about with the three layers of how the Medicare program works. So Congress. Passed legislation to create 1000 new graduate medical education training slots in the country to be scaled over five years. So 200 new slots a year for five years. So then it comes to US Center for Medicare. Oc How is this going to work? And we're rolling it out now. The first 200 slots will be rolled out. We are prioritizing those training programs in rural and underserved areas because where people. Henry It comes back to what some of what you were saying your experiences right in the hospital in training where people train they learn the needs of those communities and they're more likely to stay in practice there after they finish their training. And so we're prioritizing these slots to rural and underserved areas. So that hopefully gives some examples of how we really are bringing equity into absolutely every part of our program. Our operations are oversight, requiring multi language inserts, supporting cultural and language access standards in health care, really bringing equity into absolutely everything that we do in our program.

Tyler Johnson: [00:47:12] So I'm curious. As we've acknowledged previously, while your position is one of great power, it also operates in this very complicated ecosystem where there are lots of checks and balances, both within your administrative team and also obviously from Congress and the president and everything else. But having said all of that, let's say that you just had a magic pen for a day and you could write up a change, however big or small, that you would like to, the way that the health care system in the United States operates. And it could be anything that you want. You know, one or two things that you think if we did these two, one, two, three, whatever it is, things that that would make the biggest difference. What what would be at the top of your list?

Meena Seshamani: [00:47:58] I think I would come back to something we've been talking about that I actually don't think that there is a magic solution in any one part of our health care system. I think it would be to have much stronger partnerships to break down the silos that exist in our health care system so that everybody really is rowing in the same direction and caring for people as people with the myriad of experiences that impact our health.

Tyler Johnson: [00:48:24] You have been so generous with your time and we want to be respectful of that. I think the one thing that we always like to ask our guests at the end, you know, you've had this really impressive, but even more than being impressive, it sounds like you've had this career that would have been very difficult to predict. Right. You thought you were going in one direction and then ended up going in this other direction, which took you to this other thing, which took you to this place that it sounds like you sort of never really imagined. As you look back over your journey through your education and then your career, if you were going to sit down with a person who maybe is just starting to study for the MCAT, just getting ready to go into medical school, and you were to give them some advice. What what do you think are the most important things for that person who's just starting out to know?

Meena Seshamani: [00:49:08] Yeah. So clearly I did not become the biology major who then became a full time practicing pediatrician. Right. But it just goes to show, I think you just have to keep your eyes open and listen to your heart where there are things that drive you, that bring you joy in, what you're able to do to impact the community around you, to bring your skills to bear. Keeping an open mind as you progress through your education, through your training, to where those aha moments are for you personally and where those doors open. It takes a little bit of bravery, right, when you think you're going to do one thing and then all of a sudden like, Oh, wait a second, there is this other opportunity, but it's a little bit different. It's going to be a change. It does take some courage, I think, to keep yourself open in that way, to keep your mind and your heart open. But I think that's ultimately how you end up feeling the most fulfilled and being able to deliver the highest impact through your career.

Henry Bair: [00:50:11] Well with those inspiring thoughts. We want to thank you again, Dr. Satcher, money for taking the time to join us in conversation.

Tyler Johnson: [00:50:18] Thanks so much.

Meena Seshamani: [00:50:19] Thank you again for having me.

Henry Bair: [00:50:24] Thank you for joining our conversation on this week's episode of The Doctors Art. You can find program notes and transcripts of all episodes at the Doctors Art. If you enjoyed the episode, please subscribe, rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.

Tyler Johnson: [00:50:43] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.

Henry Bair: [00:50:57] I'm Henry Bair.

Tyler Johnson: [00:50:58] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.