From Medicare to Maryland: Dr. Meena Seshamani on Making Healthcare Human Again

Speaker A: One of the things that I really feel very honored to have led was standing up the Medicare drug price negotiation program when I was at the federal level. So Omer, as you mentioned, Medicare was founded in 1965. The Part D portion of Medicare, the prescription drug program, um, was stood up in 2003 and there was no negotiating ability put into the Medicare law at that point. While I was leading Medicare, Congress passed and President Biden signed into law the Inflation Reduction act which gave Medicare the authority to be able to negotiate the price of high cost drugs. And this for me was incredible. Coming at it both as a clinician and a health economist.

Speaker B: Homer, we're back together for another episode of the Value Health Voices podcast. You know one of the goals of this podcast is education. Education about, about uh, healthcare policy, about healthcare finance and you know sometimes you and I do that together, just you and me. But a lot of times more and more we do this with great guests, people in key roles at ah, state level, at the federal level with payers, with health systems and today's no exception. We have uh, really a Great uh, leader, Dr. Amina Sheshamani, who is the secretary of the Maryland Department of Health currently and she was before this at the federal level she was the former deputy administrator and director of uh, the center for Medicare and Medicaid Services, cms and right now she's going to talk to us about her experience at CMS but leading Maryland, the health activities in Maryland. She oversees a $20 billion budget there. Your state is pretty huge. You know think of it as large geographically but a lot of people, a lot of economic activity, big complex state. And so she oversees public health, Medicaid, behavioral health, disability services and of course like all the other states, the public or state hospitals done amazing work healthcare innovation at the federal level, we'll get into all that and leading uh, what is truly state uh level innovation, the state of Maryland regarding your all payer model and the transitions to that model, a number of exciting community health programs and great work that she's doing there. And uh, we would be remiss to mention that she's like us, she's a trained physician. She in fact is a board certified head and neck surgeon. One thing that's not like us, she's also Oxford trained. I don't know about you, I didn't get an Oxford degree but she's an Oxford trained health economist and uh, also a health system executive. So she's done it all and she's a friend of yours. So I'm excited to See, the two of you as fellow Marylanders, Is, uh, that what you guys are called, uh, talking about your issues in your state? Because you guys know it very well.

Speaker C: I'm Dr. Amaravari.

Speaker B: And I'm Dr. Anthony Parafati. We are physician executives, and we're the hosts of the Value Health Voices podcast.

Speaker C: We started this podcast to break down the business and policy forces shaping American healthcare today.

Speaker B: And the system is complex, driven by incentives, regulations, and payment models that aren't always easy to see.

Speaker C: On this show, we cut through that noise and focus on what actually matters, from Medicare reimbursement and PBMs to 340B and private equity.

Speaker B: We talk with the people shaping these decisions, and we bring a perspective from both the front lines of patient care and the C Suite.

Speaker C: Our goal is simple, give you clear, practical insights to help you lead in a system that's constantly changing.

Speaker B: So if you're a physician executive, a, uh, hospital administrator, benefits consultant, or a policy professional, this show is built for you.

Speaker C: So, um, Mina, you have one of the most interesting resumes and, you know, definitely a mentor to me. Uh, head and neck surgeon, Oxford trained economist. You ran Medicare for the entire country as head of CMS and head of Medicare. And then you came to Maryland, where I practice now, and you are Secretary of Health there. And so you went from kind of steering 170 million Americans to with Medicare to now operating at a state level. So I'm curious to hear your perspective on what was that transition like in those first six months as being Secretary of our state.

Speaker A: Well, thanks for having me, Amar. Um, I. I have lived in Maryland longer than I've lived anywhere else. I moved to Maryland in 2005 for my residency training and have raised my kids here in Maryland. My older son travels across the country playing volleyball for a Maryland team, complete with Maryland flags and Maryland pom poms. And it's just really been great to feel like I can serve my state and serve Marylanders, really, with the mission to protect and advance the health and well being of everyone in our state. It's been great to travel the state. I've been to every region of the state and almost every county. We have mountains, we have beaches, we have rural areas, urban areas. Um, it's really a microcosm of the country. And that also is just really interesting in terms of getting to know different communities, getting to know their healthcare needs, really being able to partner with them, particularly in such a time of change.

Speaker B: Yeah. And, you know, we're going to have. That was a really Nice introduction to, of the characteristics of Maryland. We're going to have uh, a chance also later on in our chat to talk about some of the healthcare specific characteristics of Maryland because it is such an important state, a huge economy, hugely productive, growing economy and uh, also very particular unusual from a healthcare standpoint. And before we get to some of the Maryland stuff, just kind of going chronologically, some of the Maryland healthcare topics. Going chronologically. I'm curious from your experience in cms, now of course you're in a, in a healthcare leadership role at a state level. How did you think about uh, this, this, this state does things this way or that state does things this way? Did. Was that ever front of mind in terms of applying policy? Of course nationwide, but wondering about how it would play out on a state by state level?

Speaker A: Well, it's interesting you mentioned that Anthony, because before I went to lead Medicare I was practicing as a clinician in MedStar Health, which is a big health system, you know, in the D.C. maryland, Virginia area and leading care transformation for the health system. And as you, as you both know, when you are practicing medicine, you are in it, you are on the ground, you are interacting with patients one on one and you just see why. It's really called the art of medicine. It's called practicing the art of medicine for a reason. Because m. Healthcare is so personal and has so many nuances to it and I think it's a very humbling experience to engage with people in that way. And I brought that with me through national policy realizing that it's not one size fits all, that everybody has different perspectives and different inputs that are really important in order to make policies that can work best for people. So it was always really important to me when I was at the national level, uh, that I was engaging patients and clinicians and health plans and pharmaceutical manufacturers. And I think moving from that national scale to a state level has been really exciting for me as I mentioned, not only because I'm now taking care of people in my home state, but, but you're that much closer to the ground where you can really see that tangible impact in the lives of people around you. And states have uh, an agility. Right. That the federal government doesn't necessarily have. I mean states are known as a laboratory of innovation and that's one of the things that I found very exciting at the state level as well.

Speaker C: Yeah. And as we will talk about later, the innovation that uh, happens in Maryland is really unique. But sticking on this, this national focus, you know, when you were at cms you ran, uh, one of, I mean, you caused one of the biggest transformations in how we negotiate drug pricing within Medicare. Before, you know, Medicare, uh, was not able to do those negotiations. And in the next decade it's projected to potentially save billions, uh, of dollars through uh, negotiations for at least 10 drugs. I'm wondering if you can talk, uh, to our listeners a little bit about that program and also what it means on a state level now that in

Speaker A: that, yeah, one of the things that I really feel very honored to have led was standing up the Medicare drug price negotiation program when I was at the federal level. So Amar, as you mentioned, Medicare was founded in 1965. The Part D portion of Medicare, the prescription drug program, um, was stood up in 2003 and there was no negotiating ability put into the Medicare law at that point. While I was leading Medicare, Congress passed and President Biden signed into law the Inflation Reduction act, which gave Medicare the authority to be able to negotiate the price of high cost drugs. And this for me was incredible. Coming at it, both as a clinician and a health economist, to really have an opportunity, piggybacking off of what we were talking about earlier, to have an opportunity to bring patients, clinicians, biotech, pharmaceutical manufacturers, health plans, all to the table to say what is working in innovation in drug delivery? Where are areas for improvement in the drug pricing market? And what came through loud and clear was that, uh, everyone had a common goal, have innovative cures and therapies that people can access and afford. And with that basis, we were able to stand up a negotiation program that really incorporates real world data, um, to be able to say what is the benefit that a drug is providing to someone in their community and also what is the impact of that drug on things like future healthcare costs? So it really was an opportunity to bring that conversation to bear. And you know, we, as you mentioned, the first 10 drugs that we negotiated, we achieved an estimated $6 billion in savings. And I think importantly, that translated to $1.5 billion in savings for Medicare beneficiaries for people out of their own pocket, which is really gratifying. As a physician, I know you both have experienced this, right? I mean, I had one patient where I was getting on my phone on Goodrx with her to try to figure out what antibiotic I could prescribe her that she could afford. I mean, being able to put in place these changes really is life saving for people who otherwise would feel boxed out of being able to take drugs that can make them, um, feel better and keep them healthy. And you Asked at a state level what it means. Well, Maryland has a prescription drug Affordability board. And in fact our prescription drug affordability board is one of the most forward leaning in the country in that it can set prices, upper payment limits for drugs that are not just for Medicaid, but also for the commercial market. So it really extends to all markets. And the first two drugs that Maryland, uh, negotiated were Ozempic and Jardiance. Ozempic, GLP1 and Jardiance Diabetes Medicine. And for Ozempic, we estimate saving $5.8 million in one year. So again, and when I came to be health secretary and I met with the pdap, as we call it, they were so excited because when I was in Medicare, we published, you know, our basic methodologies of how we did the drug negotiation. And that's something that now others are using, right, to be able to see. Okay, how do you go about having a methodical way that you're incorporating data to be able to determine a, uh, price for, for a drug?

Speaker B: Mina, I'm curious, uh, when you all were designing that, did you look to examples of other countries like Switzerland with their value based drug purchasing, uh, schema, or even elsewhere around the world to, to build ours? Or was it something like, okay, we need to, we need to do our own approach? How did that come together?

Speaker A: Well, in the, in the statute, in the law, it prohibited us from using the prices of other countries. So what we did was we really went back to fundamentals. We met with drug manufacturers and asked, what are the things that you think are important to be considered in drug negotiation? We asked health plans, how do you do negotiation? We asked patients and clinicians, what are the things that are important to you? And importantly, I had the good fortune of being able to bring in incredible expertise, uh, from the outside. So the people who were, who built, who helped stand up the negotiation team came from pharmaceutical companies, from uh, health insurance companies, we had pharmacists on board. And so they brought with them them their experience having done drug price negotiation, drug development in industry. And that was also very helpful to bring to bear where it really was then, an opportunity to fix things that people had seen could stand for improvement in the drug pricing market.

Speaker B: We're getting to some of the solutions. Amar, I just want to call out for a minute, I mean I explain this, but just to really put a pin in it for the audience is that, you know, we have Medicare, which is the largest payer, the biggest purchaser of medic medical care, but also drugs in the United States who Launched a drug program passed into law in 2003 with no mechanism whatsoever to use its power as the biggest purchaser to bring prices down. Which is, which is pretty remarkable. And we're getting to, through Mina's leadership and the team during her time at cms to beginning to solve that problem. And I assume this is, you know, a little bit before our time. I was an undergraduate in 2003, but. And so I wasn't exactly plugged into this, but I assume, you know, that it was necessary to get Medicare Part D over the line to get, to get the law passed, that probably there was an appetite for negotiation at that time. Is that, was that the story? Is that how we ended up in the situation? Or is there something else to it that you recall that?

Speaker A: I'm not sure what the reasoning was at that time, but I think what's really important is that now we have a program in place that is lasting. Right. Like we stood up under the Biden administration, we stood up drug price negotiation. And importantly those foundational elements of really using data, using real world evidence is carrying over into another administration. We have that sustainability, um, of the program now in third cycle.

Speaker C: One of the other things you, you uh, helped transform during your time there was ways we pay, uh, I would call em broadly wraparound services, um, through the physician, uh, fee schedule. So, you know, we're all cancer doctors in one aspect or another. Right. And you know, we, these wraparound services include navigation services, social work, community health workers, other caregivers. And so, uh, can you talk to us a little bit about what was those kind of expanded payments that you helped institute at cms?

Speaker A: Well, Amar, um, I'll pick up on something you said about how we all as clinicians have experienced. Right. The benefit of those services. So when I was practicing at MedStar Health, one of the areas under my purview was community health. And we had so many examples of where a community health worker could make such a difference in someone's life and also then start spend the healthcare dollar in a smarter way. Like there was one woman who came into our Baltimore Hospital, our ER, 17 times in three months for exacerbation of lung disease. And we assigned a community health worker to her who went out to her house and it turned out that her electricity kept going out so her nebulizer wasn't working and that's why she kept coming into the hospital. Right? So community health worker addresses the issue of the utilities and she doesn't get sick and come into the hospital. And one of the things I realized when I was working at the health system was there was no way that the, the healthcare market as an economist was rewarding that very smart investment in someone's care. So I brought that lesson learned with me to the Medicare program to say, hey, if we provide payments up front, that creates a cash flow that primary care docs and others can actually employ the services of a community health worker as part of a patient's care plan that we know is going to keep the person healthier because it's meeting them where they are in the community. Right. We all know 80% of health is determined outside of the four walls of a clinic or a hospital. So let's keep the person healthy and that'll also prevent downstream health care costs. So that's behind the community health, the community health payment that we created, the care navigation payment that, that we created principal illness navigation as it's called, um, and also training for family caregivers because again as a surgeon, how many times I would round at some ungodly hour, 5:30 in the morning, right, doing, addressing change. Okay, now someone is ready to go home. Who's going to be taking care of that wound when someone goes home. And the, the potentially avoidable post op infection and new nutrition issues and other things that really our country's family caregivers, unpaid caregivers really are the backbone for a lot of the care that happens. That making that bit of investment upfront can really lead to significant improvements in someone's health.

Speaker B: So Mina, yeah. Your, your experience as a, as a surgeon, you know, it was easy for you probably to make that connection of how important those services are. Amar, I want to just call out for the listeners. You know, we covered this extensively in the early days of our podcast explaining what the Medicare physician fee schedule is. And you know, there's some people who think the Medicare physician fee schedule does a, uh, is a great structure to value the work of physicians. It's been around and used for a long time. Some people think it's not so good. Well, it wasn't designed at all for what Mina was just talking about all these other services. And so that's what we're talking about here, the innovation, the leadership to realize the value of these services and create a reimbursement structure for them. Because if they're not reimbursed, I mean they might happen in some really sort of well off advantage hospitals, but in a plurality of clinical settings, not going to happen. So that's the difference, uh, that she's talking about and that she made there if I can move Amer. Uh, um, and Nina, if you don't mind to a question about Medicaid, um, because you know, always in the, in the, in the news, in the healthcare news and the health policy conversation these days, uh, we've covered extensively on this show even in real time last summer as HR1, also known as the One Big Beautiful Bill act was being passed. And a key part of that, Mina and Amar, is that the law, and then federal rulemaking pursuant to the law makes the determination, uh, and redetermination of eligibility for Medicaid. It uh, really transformed it and makes it more restrictive than it used to be. And so people who previously qualified for Medicaid beneficiaries may find themselves not qualifying. And so I want to hear about what that's like in Maryland and how you all are preparing for that new reality.

Speaker A: Yeah, I'm glad that you asked about HR1 because it does bring some of the biggest changes to the Medicaid program in recent years. And as you mentioned it, it makes the requirements more stringent for being enrolled in Medicaid, particularly for the population of people. That was the ACA expansion population. So with Obamacare, Medicaid was expanded to childless adults going higher in the federal poverty level. In Maryland, that's about 300,000 people who instead of as it has been having to go through an eligibility process once a year starting January 1, 2020, um, seven, they'll have to go through an eligibility determination process every six months. And also importantly they will now have what CMS calls community engagement requirements where they need to demonstrate some sort of volunteering working um, a minimum of 80 hours a month. For us in Maryland, the key to our implementation is that we want everyone who is eligible for Medicaid to stay enrolled in Medicaid. Previous studies on work requirements and even the analysis of the Congressional Budget Office on the law showed that people who drop out of Medicaid through, through this kind of a process, a lot of times it's because they just couldn't make it through the bureaucracy and the paperwork. So we have really been focused in Maryland on making things as streamlined and automated as possible. So for example, we have a one stop shop application platform called Maryland Benefits where someone can apply for Medicaid for snap, for tanf, for liheap. And we're leveraging that one stop shop platform for the eligibility um, requirements of the new federal law. We are doing things like drawing in data from the National Student Data Clearinghouse so that if we can know automatically if someone Is a student automatically. They don't have to satisfy work requirements. We're also pulling in data from our health information exchange. Maryland has a very advanced, you know, data lake that collects information from all of the various electronic medical records in the state. So we have a repository of the diagnoses of people, which is important because if someone has certain conditions, then they can qualify for a medical frailty exemption where they won't have to satisfy work requirements. So being able to automatically pull that kind of information to enable people to very quickly and seamlessly have their eligibility determined. So those are some of the things we're doing on the technology side, I think equally important is the fact that this is impacting the lives of people. Right. The uncertainty and anxiety that has been created. From the time that the law passed, there were people who thought that their Medicaid had already ended. And we had to do outreach and say, no, nothing has changed. The law has not gone into effect, and we have your back. We're going to help you and walk through the process with you. We have already started an outreach campaign partnering with healthcare providers, our, uh, health plans, community organizations, with information for everyone. We call it the Medicaid check in, where we tell people there are changes coming from new federal law. We are here to help make sure that we have your updated contact information. Stay tuned for more information so that way we can have a drumbeat of information for people so that they, they can know what's coming and then we can help them to navigate. Because I think that's going to be equally important for people to be able to navigate the changes.

Speaker C: Yeah. And. And for our listeners, what, what Mina's speaking, uh, all about is that this law doesn't necessarily. It's not all about workforce participation because most of these beneficiaries are already working, like you're saying. Right. And it's the eligibility that's. That's the issue here, because they moved, they missed a letter, they didn't upload their documentation. And so it sounds like what you're doing in Maryland is really helping to reduce those administrative barriers and automate things to allow this redetermination process to not have beneficiaries fall off the Medicaid rolls. So that's. That's amazing. I have a question for you around provider taxes a little bit. So, you know, many states use provider taxes to help finance Medicaid. Hospitals often pay a tax that helps generate the federal matching funds. I was wondering how significant is the changes to the provider taxes in Maryland, uh, with this legislation I mean that

Speaker A: is another thing that we are navigating as a state. Maryland is not one of the states known to have, you know, a very large provider tax. I think this is another example of where it's been really important for us as we are evaluating the law and as we are reading regulations that come out, that we are working closely with the healthcare ecosystem to make sure that everybody can navigate as is possible. I mean it is a huge change coming, right? I mentioned 300,000 people, um, in that ACA expansion population. We didn't talk about the immigration changes. We have about 15,000 people in Maryland who are on Medicaid, who are asylees or refugees who are going to lose coverage starting October 1st. And you know, all told, we estimated that Maryland could lose up to $2 billion in federal Medicaid funding. So this is something that we are working through very diligently with all of our partners across the state really to try to make sure that we are implementing the law in the best way possible to be able to preserve coverage for people who are eligible and to be able to navigate all of these changes, minimizing as much disruption as possible.

Speaker B: And Mina and Amar, if you don't mind, I'll just remind our listeners in a couple of episodes, we've actually done three episodes with Dr. Eric Bricker, who is a excellent, um, social media, uh, purveyor of high quality healthcare policy and finance information. And back in those episodes we described what we were talking about about what provider taxes are. They have different names and different mechanisms. And so but just to remind everybody, essentially funds from hospital systems and even multi specialty, uh, I think medical groups can. These funds can be set aside to some local government entities such as a county. Those funds are pooled, they're transferred to uh, the state through a mechanism called like an intergovernmental transfer. And then those monies are presented to the federal government, say look, here's the money that we taxed, um, the providers, here's the money we put set aside from the providers. And now federal government, please match that money. And so then that money goes in back to the hospital systems to provide care of Medicaid patients. So that's what a just a quick and dirty. I mean if I got anything wrong, because you're expert in this, correct me, but that's what a provider tax is. It's not a tax in the traditional sense. It's just partitioning some money and then some extra money arrives from the federal government to supplement uh, Medicaid reimbursement. All right, so. Oh yeah, so we talked quite a lot about Medicaid. Want to talk a little bit about rural health, another big topic in the news. And you know, in your introductory remarks about Maryland, you talked about the varying, uh, demographics of your state, the urban areas, uh, large suburban areas, and then your interior, which is quite rural. And I understand through your efforts through World Health Transformation that the state of Maryland has secured substantial funding. I think I have the figure right at 180, $168 million in the first year alone here of the federal Health Transformation Program. Tell us about that, your securing of those funds, uh, how you're implementing now, the use of those funds and what that means for your, for your state citizens there in Maryland.

Speaker A: Yeah, it is very exciting. So, yes, we got $168 million in the first year, which is twice the average national average per capita dollar amount for people in rural areas. This was quite a race because we were basically given six weeks to put together our application. And we did an RFI where we got 350 suggestions from our rural communities. We held 17 listening sessions across the rural parts of our state to be able to get suggestions. And I think that really formed the basis of what ended up being a very successful application. We have three buckets of funding, um, and within each bucket we are investing in both shovel ready projects so that we can show immediate impact and longer term as we're calling them transformation funds. The first bucket is healthcare workforce, which we know is a huge pain point in rural areas. So we are investing in programs that already exist in partnership with our Department of Labor around training for peer recovery coaches and expanding that to not only train more peer recovery coaches, but also to train community health workers and care navigators. You know, Amar, um, like we were talking about, who are people who really form some of the backbone of, in our communities. And then we are also investing in opening a new area health education center in Southern Maryland. We already have one in Western Maryland. We have one on the Eastern Shore. And Southern Maryland was an area that we didn't have in ahec and so we're investing in, uh, developing an A HAC there. Our second bucket is around care Innovation to bring care where people are. We released an RFA for 70, 73 million called the Rooted and Resilient Program to be able to invest in things like mobile health, telebehavioral health, and really to enable that expansion of access to care utilizing these technologies. And then the third bucket is around having Marylanders eat for health. And this is an area where we are not only investing in nutrition outreach, um, you know, being able to educate people on nutrition, but we are investing in local agriculture in our rural communities. So investing in food aggregators and distribution hubs, cold storage, because it's important to have people eat healthy. We should also have that food coming from our local farms because that way you are supporting the main economic driver in rural communities. And we know that one of the key indicators of health is economic well being. And economic well being directly impacts health and then health impacts economic well being. So it really is an area where we are connecting the dots to really make sure that we are putting our money towards the best use. And importantly, we are coupling those investments in healthy food with a tailored food is medicine program that we are funding through our innovative payment model in Maryland, which I'm sure we'll, we'll talk about soon. So again, where we are both investing in the healthy food, but then also in that source of that food. So that you're lifting community.

Speaker C: Yeah, no, what's, what's, what's great about this program that you spearheaded is that it's not just subsidizing the status quo, as you said, it's truly is changes to workforce, population, health and even, and a lot of the fixed capital costs that these rural hospitals have to deal with, no matter what patient volume they have. So it's, it's really remarkable all the, the steps that you took both on the national level and within Maryland. And speaking of the Maryland model, let's talk a little bit about it because it's, it's a very unique model. Right. We have an all payer model. And so, so what does that mean? And I'm going to say my interpretation and you as the health economist and the Secretary of health, please uh, go into further details. But you know, Maryland has this unique au pair model since the 70s where hospitals are paid under rates established through the state's rate setting process through a uh, committee called the hscrc. So while other uh, states, hospitals have to negotiate individual rates with different commercial payers and Medicare here, Medicare pays similar rates. Medicaid pays similar rates. Commercial insurers pay similar rates. So the ideal focus of this is shifting away from price and toward quality and efficiency. So can you tell us a little bit more about that and the Maryland model in general?

Speaker A: Amar, you did a great job.

Speaker C: Thank you. Hire me, please.

Speaker A: The model has been through several iterations. As you mentioned, it was started decades ago. Um, more recent iterations was the total cost of care model where as you mentioned all payers are aligned. So reimbursement is agnostic for what payer, uh, a patient has. And hospitals are given a global budget. So based on their population, they are given a set amount of money regardless of how many admissions happen, how much volume happens, and it's tied to quality metrics. So what that means is that keeping someone healthy and out of the hospital actually leads to success in the model. Importantly, having that kind of model led to, in less than a decade, $1.6 billion in savings to the Medicare program. The reason that that is especially powerful in Maryland is because, you know, traditionally when each payer and each hospital is doing their own negotiation, you could squeeze one end of the balloon and another end would just pop open right here because everything is aligned. When you are saving money, you are saving money in the system because it is both the Medicare side, the commercial side, and it's tied to these quality metrics where we found decreases in preventable, uh, ED use, preventable hospitalizations. So now we are the first state that has entered a, and negotiated a new payment model with the current federal government called the ahead model, where we are continuing this all payer alignment. We negotiated first aid to negotiate the ahead model. So we have, uh, all payer alignment. The hospitals have global budgets and we are continuing to move forward in population health innovations including we have a primary care investment target where there will be a certain amount, a uh, target of money that all payers are investing in primary care. We have a population health improvement fund where some of the money in this all payer system is in a fund that gets used for population health. So I had mentioned earlier about our food is medicine work. We took $10 million basically from traditional healthcare and we're funding healthy food which is traditionally public health. It really shows how with an innovative payment model, you break down these artificial barriers to really focus on where do we invest money in a smart way to keep people healthy and keep them out of the hospital. So those are some examples of the work that we're doing now with the most recent iteration of the Maryland model.

Speaker C: Yeah, and you know, as someone who practices in Maryland, this, uh, the criticism I hear about the Maryland model and that we sometimes see, and I wanted to hear your thoughts about it, is that it definitely controls total cost of care, which was the goal. But the worry is around innovation and investments in new technology because to acquire more funds, uh, you have to show that the volume that your patient volume that your hospital is receiving is growing from outside your region to increase your global budget. And so it's not that just you can invest in a new technology and then get the gains from that. It has to be a new inflow of population. So I was curious about, to hear, to uh, hear your thoughts about that and whether, what do you think about innovation within the Maryland model?

Speaker A: I think there's, I mean Maryland has had incredible innovation including that you have you know, some of the most innovative surgeries that are happening coming out of Hopkins and University of Maryland. You know, Maryland has one of the largest sickle cell populations and innovations in sickle cell treatment. AstraZeneca just uh, expanded its footprint for developing cell therapies in, in Maryland, actually in my home county, in Montgomery County. I think where and where a lot of the innovation comes to root in terms of the savings is things in population health. Right where we can look at how can you utilize, you uh, know, for example technologies to be able to monitor someone remotely and then be able to provide care more expediently. Like how do we engage and harness a more team based approach to care so that people stay healthy and they don't end up bouncing back to the hospital. So I think innovation can take multiple different forms and I think all are not only possible but encouraged in this model where it really is about how do we meet our quality metrics, how do we avoid unnecessary utilization.

Speaker B: So as an outsider, as a non Marylander, what I'm hearing is you all have achieved a degree of value based care that the rest of the country with our, let's say fee for service and fee for volume and not having a total uh, an all payer model that's focused on total cost of care that holds us back. Is that a fair reading or my giving you guys too much credit? As a, you know, the grass is greener kind of a viewpoint, I will

Speaker A: say that there are a lot of states that look at the Maryland model and they say oh, how do we you know, try to get there? And I will say that CMS is currently talking with several states about expanding the ahead uh, model, you know, to other states. I think one of the key things in doing an all payer model is that it is going to require co development between a uh, state and cms. You know this comes back to where our conversation started about some of the, the nuances that occur locally that at a federal level you don't necessarily know. Right. I mean all payer means that you have to incorporate the specific nuances of each health care market in each state. Right. You'll have different pay you a different Medicaid program. And that's one of the things that I think is an opportunity for CMS and for a state to be able to partner together to say okay, what makes sense in our state in order to align in the way that we've been talking about so that you can really direct meaningful improvements in cost and quality.

Speaker B: Yeah, you're making our job easy here because a lot of the follow up questions I wanted to ask you are, uh, we wanted to ask you, you, you're, you're recovering but I, if I could, and maybe I just missed it. I'd like the listeners to understand what is the big change between the existing all payer model that you all have and then coming into a head mainly from the perspective of if patients and benef, you know, citizens are going to feel any difference.

Speaker A: I think uh, there are, there are a few changes. One is that in this new version of the AHEAD model, CMS is setting the global budget for Medicare payments and the state is setting the global budgets for other payers and they're being done in concert. Um, and it, so it really is that global budget framework. The primary care investment target is another very important part, part of this model that again to the point of what would patients see? If you invest in primary care that means you've got someone who has maybe a community health worker or a 247 nurse line, has extended hours so that people can really stay healthy and um, have an easier way of being able to stay healthy and navigate the system. And we also have a population health accountability plan where we are being held to metrics around diabetes management and follow up after hospitalization and prevention of unnecessary, you know, avoidable ER utilization. So those are all things that everybody would want to stay well controlled with their diabetes, not go to the hospital unless absolutely necessary. And so it's really enabling us to focus on those things that matter for people and to do so in a way that keeps healthcare affordable. Right. I mean we all know that affordability is one of the prime issues not only with healthcare but for the economy overall. You know the, our governor is so, is very focused on growing business in Maryland. What's the number one cost that businesses deal with? It's the healthcare premiums for their employees. And so by having a system that's rewarding smarter spending of the health care dollar that's going to help businesses in our state and people in our state writ large, not just, you know, a single patient in a, you know, clinic, that's tremendous.

Speaker B: I'm getting very much very good good governance Vibes from you, Mina, and from Maryland, that you guys really take it seriously. You know, you, you. Somebody might take issue with this, with this, um, comparison I'm going to draw, but very north Europe here, very efficient, uh, you know, good governance as, as a central theme of how you operate your state. And I, I just love to hear that. And it makes a huge difference for the people there. And it's a virtuous cycle, I suspect, is that you have low bureaucracy, easy to navigate. You know, business loves that. They love not having surprises. Of course, you got. You're in such a key location in the country geographically, a lot of talented people there. So it all just feeds on itself and makes you all stronger. It's really exciting, and I'm, I'm happy for, for Marylanders.

Speaker C: And speaking of location, I think that gets us to our final lightning round of questions. If you're ready, Mina, to answer a few quick questions.

Speaker A: Okay.

Speaker C: All right. So Washington or Annapolis? Where can you actually get more done for patients?

Speaker A: And why am I allowed to say both? Uh, here's the reason, though. Uh, because Washington, right. Medicare is a program for 60. I think it's now 67 million Americans. Right. So you can do something. And this tremendous breadth and scope of impact. Some of the things that I described that we're doing here in Maryland, like connecting the dots between local farmers and providing medically tailored meals to diabetics who got admitted to the hospital. That connection, that agility, is something that's really possible at a state level to test out that then hopefully, you know, federal government can spread scale. But that's why I think it really is both. They're just different.

Speaker B: And if you had a magic wand, you could wave it and command, any policy would be exactly. Perfectly designed. What would it be? No political constraints. What would you change?

Speaker A: Well, the thing that I would change right now is bringing back the advanced, uh, premium tax credits in the, um, Obamacare marketplaces. You know, I chair the board of our, um, State Health Exchange in Maryland. And Maryland, just like other country, other states in the country are seeing drops, um, in enrollment because of, uh, lack of affordability. It comes back to affordability. And we as a state have some additional reinsurance and subsidy programs to help mitigate the blow. But we're still feeling it.

Speaker C: All right. You wear three hats. You, uh, know, or actually you wear more than three hats, but I'm just going to name your three hats, you know, a surgeon, economist, and kind of a governance regulator. Which one do you think, uh, is the first one you use when your hard problem hits your desk, I'm gonna

Speaker A: go with a different answer, which is as a person.

Speaker B: Okay.

Speaker A: I mean, honestly, Right. Healthcare is so. It's complex and it's so personal. And I think when you're tackling tough things that really impact people, I really think about, I'm a mom, I'm a caregiver. Right. And, like, what are the things that are important to people and what resonates with people? And what do people need to see to know that someone has their back? And so I think that the clinical side, the economic side, the policy side, those are the things that are more of the enabling, like, substance to get to the humanity that is healthcare. That I think is the reason that all of us into the field.

Speaker B: I think this might. I think this might be our last one. Uh, after everything, the different roles you had. Amar mentioned, the three and three plus hats that you've worn, uh, are you still an optimist about the direction of the American healthcare system? And if you are, what, uh, why should other people agree and be an optimist? What should they hang their hat on for that optimism?

Speaker A: I am definitely an optimist. I've always been, um, an optimist. But I'd like to think that I'm a pragmatic optimist. Right. Uh, it comes back, Anthony, to what you were saying about just good governance. Right. I think there is healthcare. There's so many different organizations, people involved in the ecosystem, and I think that is a. It's a source of complexity. It's also a source of strength for us. And I think especially as we are navigating challenging times, being able to tap into that humanity, tap into the mission of why we all went into healthcare, is really our strength that enables us to navigate things moving forward. And, you know, I'll come back to what we were talking about with implementation of HR1. The improvements that we're making to the Medicaid Program for HR1 are improvements to the entire Medicaid program. Yes. We're doing it because we want to make sure that we are minimizing as much as possible the coverage losses that are coming from these federal Medicaid cuts. And at the same time, these are improvements in streamlining and automating eligibility and enrollment that's going to help anyone who is trying to enroll in the Medicaid program. So really tapping into where, as we face challenges that are coming at us, where are there opportunities to do things differently, to do things better, to constantly be improving?

Speaker C: Yeah. Well, thank you so much for coming on. Um, Mina, uh, we love to have you on, and it, uh, was great to learn everything about you've done at the national level and at Maryland. And, uh, as I said, as somebody who I see as a mentor, really appreciate you taking the time to come on this podcast.

Speaker A: Oh, uh, thank you so much. This was wonderful conversation.

Speaker B: My pleasure.

Speaker A: Thank you.