Ep 66: Effective, Efficient Public Service

[00:00:18] Sanjula Jain, Ph.D.: Welcome back to Her Story. I’m Sanjula Jain, Chief Research Officer at Trilliant Health and a member of the Her Story advisory council. And today it’s my pleasure to welcome Seema Verma, former administrator of the Centers for Medicare and Medicaid Services. Seema, thanks so much for being with us today.

[00:00:33] Seema Verma: My pleasure. It’s great to be here.

[00:00:35] Sanjula Jain, Ph.D.: You have just a phenomenal career and have managed to establish yourself as one of the nation’s preeminent health policy leaders from your work in Indiana to CMS and everything in between. I’m curious, as you think about your foray into healthcare leadership, do you consider your path to be more accidental or intentional?

[00:00:54] Seema Verma: Yeah, it’s a great question. You know, sort of, how did you get to where you got and did you plan this all the way through? I don’t think there’s any little girl in the country that wakes up and says, I want to be the CMS administrator. I think for me, I’ve just been very passionate about healthcare and improving healthcare for so many Americans across the country. There are so many problems to be fixed in healthcare and I’ve just been passionate about it. And so, I think what’s led me down the various pathways that I’ve had, or the things that I’ve done is just that passion around healthcare. I think a lot of it has been some good luck, meeting some very incredible supportive mentors that helped me out along the way. And I’ve been very fortunate to have that. That being said, I think it’s really just been driven by that passion and, you know, I started my career on the local level, was working at a local health department and public hospital system. So they had community health centers, the health department and the hospital. And so there, you’re really seeing things from a patient perspective and you understand the trials and tribulations really at every level, from the providers, the challenges that they face. And I think what I realized there is that not all of the problems could be solved there, right? So then I started working with the state governments and you realize that not all the problems can be solved there. And so it just seems like this has been a journey around improving healthcare and recognizing that you had to maybe go to a different place to see the type of improvement that I wanted to see.

[00:02:27] Sanjula Jain, Ph.D.: And so as you mentioned, a lot of that is driven by this passion that you have for improving healthcare and specifically also working in health policy. Where did the interest to go pursue formal studies in that area and then a career accordingly, even stem from?

[00:02:41] Seema Verma: Sure. Well like many immigrant children, my parents were very focused on, you should go to med school. And so I always thought that that’s what I wanted to do. When I got to college, I actually finished my degree in life sciences and took the biology courses in chemistry and physics. And I’d just kind of sit there and my eyes would glaze over. It wasn’t necessarily hard, but I didn’t find it as interesting. And then somewhere in college, I started to get very active in student government. I started to take different courses like sociology and government courses, which actually were way more interesting to me and it didn’t feel like homework. I was enjoying what I was doing. And I think that, coupled with some of the work that I was doing in student government, led me to think more in terms of public policy. But I still really enjoyed health and healthcare. And so it was a way to sort of combine these different passions, the health, the science, as well as the policy and more of the social sciences.

[00:03:41] Sanjula Jain, Ph.D.: Well, so as a fellow, south Asian women, you and I have actually a lot of parallels in that story. And so I’m curious, when you kind of told your family that you were going to pursue this non-medicine path, or something that was not as the norm in our culture and many cultures actually. Were you met with any resistance, like, what are you going to do in public health or public policy? What was that like?

[00:04:00] Seema Verma: Yeah, definitely a lot of resistance. I think the first part about it was that they just didn’t understand what it was. I think for them, they looked at the more traditional career paths. You know, either you go into business, you can be an accountant, an engineer, or a doctor. But it was hard for them to really understand exactly what I would be doing. I remember my dad introducing me to his friends. And he’d say, this is Seema and she’s majoring in, we don’t know what, it’s something like basket weaving, because I think he thought of it in terms of, you go to school and you have a very tangible skill, and whereas the work that we’re doing isn’t so clear in terms of what the skill set that you’re developing out of your formal education.

[00:04:40] Sanjula Jain, Ph.D.: How did you just mentally embrace that, right? That that’s kind of hard to go off on your own to pursue your passion, but also it’s not as recognized, right? And you’re having to explain to others along the way while figuring it out, I mean, what advice do you have for others who are similarly trying to navigate that dynamic?

[00:04:59] Seema Verma: You know, I think there’s always going to be the naysayers and you have to understand the motivations of the naysayers. You know, obviously your parents want what’s best for you, but I also recognize that they may not understand what I was trying to get into. They may not understand this field. I think the other thing for immigrant parents, at least my parents in particular, they really felt like, because we are immigrants, we don’t have those connections. We don’t have an established network of people that we can rely on. And the only way we’re going to be successful is having the skillset. Being a doctor, you can fix somebody’s broken leg, and that they’ll always be a need for people that have that very deep science technology background, that that’s what was needed in the market. And that a career that relied more on network and relationships and things like that, they said, not that you can’t do it, but as immigrants, we don’t have anything to offer you. We can’t call somebody and say, “hey, my kid’s looking for an internship. We can’t help you at all”. And so it was really hard. I remember graduating from college and had to go look for a job. And literally that concept of pounding the pavement, just contacting people. I didn’t have any help. That being said, I think I’ve never been a person to let the naysayers really influence my decision making. I think from the very beginning, if I feel like I know that something is right and I feel strongly about it, I’m going to do that no matter what. And you know, there’ll be people along the way, and certainly when I was at CMS trying to pursue different policy pieces. There were people along the way that didn’t like them or had issues with it put a lawsuit or try to sue you. But you know, when you feel strongly about something and you’re passionate, you just keep going. You always have a vision of the future. And you have to understand, there will be barriers. There will be hurdles and they just need to be overcome in order to meet your goals.

[00:06:54] Sanjula Jain, Ph.D.: Well, so while you were also blazing the trail as building your subject matter expertise, you also started your own kind of consulting company and were being entrepreneurial. What was some of the most challenging parts of that in those early days of reconciling the two?

[00:07:08] Seema Verma: Sure. So I don’t think I started out wanting to be an entrepreneur. Me starting my own business was really more about wanting more flexibility with my family. I had young children and my husband was a busy physician worrying about his patients and I just needed the flexibility tha,t unfortunately at that time, corporate America really just didn’t offer. And so that’s why I started the business. And it’s funny, along the way, a lot of the folks that we recruited were a lot of other women that were looking for the same thing that I needed, which was flexibility. You know, we wanted to be able to pick our kids up after school and get dinner on the table. And you know what, we can get back to work at about nine o’clock. And so what I recognized, what I needed for myself and for my employees, was that flexibility. So a lot of the entrepreneurship really came from a need to have the flexibility, still wanting to pursue a career, but understanding that I just needed to do it a little differently.

[00:08:09] Sanjula Jain, Ph.D.: And so as part of that consulting work that you did, you did a lot of incredible work within the state of Indiana and beyond, and we’d have to have a whole separate episode just to unpack all of that. But, let’s skip ahead a little bit. What led to CMS? How did you go from Indiana to CMS?

[00:08:26] Seema Verma: Sure. So I was sort of in between Indiana and CMS was sort of enlarging that consulting practice. And we were starting to work with a lot of different states, and also private companies. So we were getting a sense of what the national issues were. At that time, Obamacare had passed in 2010. And so a lot of what we were doing was responding to a lot of the new regulations that were coming out, giving our feedback and commentary. And as I was doing that work for Indiana, we also were helping other states. And as you know, a lot of the states would kind of band together on responses. And so I was very active in that sphere. Ultimately I got involved in this because I felt like the path that we were on wasn’t working well and I was really worried about the direction that the country was heading in, in terms of having more government control over our lives, over our healthcare decisions. And again, it kind of comes from that passion of, how can I make the system better? What can I do? And I got involved in the campaign. Obviously my relationship with then-Governor Pence, that also helped a little bit. I had actually joined the campaign, or wanted to join the campaign, before President Trump asked him to be the Vice President, or his running mate at that point. And so I was already sort of working on that anyway, but then once he became the running mate, then that also helped. And I started working on the campaign and developing our responses, and ultimately was the person that put together the Trump healthcare agenda.

[00:10:00] Sanjula Jain, Ph.D.: Wow. So tell us a little bit about how it felt. So you get the appointment and you’re preparing yourself for the role. You’re making this big transition going from more behind the scenes, private sector life, to being on the national stage. What was that like for you and your family?

[00:10:17] Seema Verma: That was a huge adjustment because you’re right. I was sort of behind the scenes. And even though I had been around it, I had worked for many governors by this time, you are the person behind the scenes. You’re the person that’s putting together the talking points and the speeches. And then all of a sudden you go to, you are delivering the speech. You know, it was great to actually be around all those governors because I realized that you actually picked up a lot of tips from the way that they conducted themselves. So I really appreciate the time that I had with them. I don’t know that anybody can really be prepared for something like that. There’s so many different things from just having your life managed by so many other people. Your schedule is managed every minute of the day. Even on your quote-unquote “off time”, you have to report it and they need to know where you are. There’s a big succession plan. And so they need to know if there’s a national emergency, they need to know, exactly where you’re at. So you’re always having people that are involved in your life at a very micro level. And I’m a very private person. So, that was it was a lot to, every move you make is now being scrutinized. And I think we had to kind of turn inward as a family because you just, it wasn’t easy to just go to a cocktail party and have casual conversation. You started to worry about what you’re saying and who you’re saying it to, and where that can go. So you know, I never want to complain about it because it really was the experience of a lifetime and such a wonderful opportunity to serve my country and give back. And I’m really proud of all the work that we did. So while I may not have been as prepared as I would today after doing that job for four years, for hook or crook, we kind of muddled through it and you know, got a lot of good work done.

[00:12:03] Sanjula Jain, Ph.D.: Absolutely. Well, you all did just a phenomenal job and we’re going to dig into some of that. So being a leader, and particularly of that type of organization, is always a balance of the goals of the administration, the goals of the nation, but also, your individual goals, right? You had talked about, your whole career, you had seen all these gaps in healthcare and things. I’m sure you had a list of initiatives you wanted to tackle. As a leader who is responsible for setting the agenda and executing it and balancing those two priorities, how do you determine what to prioritize and what the team works on?

[00:12:34] Seema Verma: Sure. I think one of the strongest areas was communicating with people about what the priorities should be. So you’re right. You come in with a few ideas. But I think it was really important to hear from everybody. You know, one of the things that we did very early on at CMS was do a nationwide listening tour and it was very informative. You know, we went across the country. We would talk to innovators, we would talk to frontline providers, we would talk to patients, kind of understand what are the concerns people are having? What are the issues that they’re faced with? What are they challenged with? And that really helped me understand, basically having a poll, the pulse of the healthcare community and patients. I think from a leadership perspective, and especially at CMS, you are working on a tremendous number of issues. You know, anything from drug pricing, to a Medicaid waiver, to, how are we going to pay for durable medical equipment? And so the range of issues and things that we’re working on is gigantic: Medicare, Medicaid, CMMI, we are responsible for all the innovative models. We also had the exchanges and we also were responsible for all of the quality and safety regulations for every part of the healthcare sector. So it is massive. I think that what I tried to do is take a lot of this input in, and we really tried to focus on those areas that I thought would, not only solve one problem, but it would solve multiple problems and it would address many people’s concerns. So one area, for example, that we were very focused on was interoperability and people having the right and access to their electronic medical record. And on its surface, you think, okay, well, this is great, great for the patient. They don’t have a bunch of paper records. It’s also very important for the provider, right? We reduce a lot of duplicate tests. So we’re lowering healthcare costs, which is always a big priority. And then the other part of it was that it created efficiency in the system. As people are going through the healthcare system, they’re leaving the hospital, they’re being discharged. All of that data and information is with them. But moreover, it also would give rise to the new generation of innovation and technology when we start to have medical records that are portable, that stay with us from the time we’re born through every healthcare event. The power of that is very critical. I would say everything that we worked on was focused on solving what I think is the biggest healthcare problem in America. And that is the cost of healthcare. So everything that we did sort of tied to that, that we had to figure out how to lower the growth in healthcare and, how do we make sure that it’s not higher than the GDP, which is what it has traditionally been. And we started to think about, what are the big strategies, what are the big initiatives that we can take that are going to address that. And it’s funny how a lot of that stuff starts to overlap. Like if you think about it in terms of interoperability, it’s efficiency. The other big piece that we were very focused on was value-based care. And I didn’t come in as a huge proponent of value-based care, but we studied it. We got a lot of input. And to me, given my time now on value-based care, I think it’s sort of the only hope that we have to control healthcare spending and to actually move away from being a sick care system to something that really focuses on making people healthier and lead better lives and keeping them out of the hospital. And so when we try to push on value based care to lower healthcare costs, what you recognize is that, well, in order to do value based care, there’s a lot of things that we don’t have in place. One of those issues was interoperability. The other one was price transparency. Price transparency was not only to help patients, but it was also to create a more competitive marketplace, which again, would help lower costs. So there really was a theme to what we were doing and that everything had to fit in into that realm. So like you said, you get approached by a lot of people, a lot of advocates, a lot of great ideas out there, but the ones that we would actually pursue are the ones that were consistent with the vision of lowering healthcare costs, improving quality and access.

[00:16:45] Sanjula Jain, Ph.D.: Well, it sounds like there was a lot of intentionality into having that clear focus. But, as all of us that touch healthcare know, change also takes time, right? And so a lot of the initiatives you put in place, you kind of see these immediate returns. But a lot of it is going to reduce the cost curve over 10, 20 years. And so from a policy perspective, how do you kind of determine what is going to be an effective policy and/or kind of evaluate in the moment what needs to be adjusted or additional initiatives to build on to know that that longer-term view is going to meet those objectives you set out.

[00:17:22] Seema Verma: Sure. And I think, I mean, that’s sort of the nature of politics is you’re usually in there for a very short time, but hopefully you are doing things that are going to have an impact over many years and an impact on the entire system. So I don’t think, from my perspective, that we were just looking for quick wins. We announced a lot of initiatives that, to your point, are going to take time to be implemented. I don’t think that anything that we did won’t require some tweaking. Anything that you do, and I think we’ve seen that with all the major pieces of legislation from the Affordable Care Act to all of the work that was done with Part D because sometimes you get it out there and that’s, to me, the accomplishment is at least starting it, laying that foundation. And then over time, as we experience it, we’re going to say, okay, well this needs to be changed or this needs to be tweaked. I think that that’s natural and that’s normal. That’s just good government. I don’t think it was ever an objective to get it right on the first try. I think the idea is to really get things out there that are going to move the needle and they will take time. Price transparency, interoperability, we laid the foundation for that. They’re starting to be implemented and we’re just starting to see the implications of the policy that’s being implemented.

[00:18:39] Sanjula Jain, Ph.D.: I don’t know how it works on the inside, but I’m curious. To your point, these tenures are very short-lived and it takes time and it builds over time, but are there things that you can do to help with the, I guess, the continuity of some of these initiatives and the information to ensure that, as tweaks and adjustments and additional initiatives are built on in the next set of administrations? You know, there is that, I don’t know if continuity is the right word, but that there is some understanding so people are not reinventing the wheel or they know where to pick up.

[00:19:12] Seema Verma: Sure. And that’s the value of the career staff and CMS was really fortunate. They have an incredible group of very hardworking, talented people, and that’s really, they are sort of the continuity for the organization. I will say that, when I first started at CMS, I had a lot of policy initiatives that I wanted to get done and we started to move through them. However as the, you know, CEO of CMS, what I started to understand after the first couple of years was that, in order for us to really accomplish what we want and where we need to go, that we needed to change the agency in and of itself. And you know, this isn’t something that gets a lot of publicity. You can put an announcement out there, but no one’s really going to cover that. We really did reorganize CMS quite a bit. You know, one of the things, I don’t think that people realize this, is CMS has 10 regional offices. And there’s a lot of bright, talented people that are on the front lines. And they really weren’t integrated in the national, the larger Baltimore focused policymaking. And so we had huge reorganizations. We changed the way Medicaid operates. It used to be that you would go to your region and you needed a waiver or a state plan amendment for your Medicaid program. And you would go to the region. Well, as you can imagine, some regions were better than others and we didn’t have expertise on a particular type of waiver. It may go really fast in one state, but not in the other. And so we completely reorganized. So now we have centers of excellence and, if you need X type of waiver, you go to this team and it doesn’t really matter where you’re from. We made changes just in terms of our communications and really kind of integrating our regions moreso with the central team, Not super fun healthcare policy, but it was good business practices that I think will help the current administration and future administrations by inheriting an organization that works more effectively for whoever the CEO is.

[00:21:14] Sanjula Jain, Ph.D.: To your point, I mean, CEOs have to think about strategy just as much as the day to day execution and subsequent expertise. So those are really key initiatives to bring that all together. Now that you have been more than a year out transitioning out of the role, you’ve probably had a lot of time to reflect and think. What are some new things that you’ve learned about yourself after going through that experience?

[00:21:37] Seema Verma: I think I’ve learned, when I looked back on it, I was a lot more resilient than I thought I was, a lot tougher than I thought I was going into it. And if I wasn’t going in, then I learned those skills. I think that’s probably the two more personal characteristics. I think I gained a lot of great business skills. I mean, running an organization with 6,000 people, it’s not just about, as the head of the agency, to say, I want to get this done, but how do you really lead the organization? How do you bring people on board? You know, I still get notes. I got one just this week from somebody on the team that said, “hey, we just want to thank you for your leadership. We’re really proud of the work that we got done during that time.” And you know, those types of notes and things like that, they really mean a lot because I think, behind the scenes, most people just see, what is CMS doing today? But behind the scenes, really leading the organization to accomplish, to get these things done, because if you don’t have your team behind you, you can dream up all the policy you want, it’s not going to get executed. So I think I feel like I improved as a leader and learned a lot more about how to manage a large organization.

[00:22:48] Sanjula Jain, Ph.D.: So as you think about, I know you’re spending your time these days on a variety of different initiatives, but you know, you’re getting calls every day from different opportunities and organizations that are wanting to now take advantage of your expertise and what you can bring. How do you think about how to allocate your time as part of this next chapter, because there’s only so many things that you can take on.

[00:23:10] Seema Verma: Right. Well I would say that my passion for healthcare has continued. You’ll probably see me be a little bit more vocal on policy initiatives and things like that. I think it’s important. You know, there’s a part of me that really enjoyed sort of just the quiet where Twitter’s not going off. And I certainly don’t miss all the nasty Twitter hate that’s out there. But I do think it’s important to have a voice. And sometimes when you’re not talking about issues and, by virtue of having the CMS role, you do have a platform, a national platform. And if you’re not saying something, if you’re not pushing back, then you’re not influencing what goes on. And as much as there’s a part of me that just wants to go back to my knitting, so to speak, I feel that moral obligation to the country to give a voice to certain topics and also give solutions. I mean, I think there’s a lot of complaining and finger-pointing that goes on in healthcare, but I hope that I can use the new things that I’m doing, working with a lot of businesses, working more on the private side, to identify solutions for our policy makers.

[00:24:24] Sanjula Jain, Ph.D.: You also serve on a number of boards. And as you know, we all know that women generally are under-representative on boards. What is your experience been as being kind of one of the few female leaders on a board, but also advice to other women who are serving on boards?

[00:24:38] Seema Verma: You know, it hasn’t been, I would say, a big deal. I don’t think that I’ve gone into any of these meetings and felt, oh my gosh, I’m the only woman here. I just, quite frankly, haven’t really noticed it. And that might be the case. What’s refreshing to see is that the boards are changing, compositions are changing. But also the leadership teams are changing as well. So you may go to the board meeting and you might be, because the boards are small, the only female there. But, the leadership team, inevitably, there’s a lot of women on the leadership team. So that’s great to see them in the C suite. So I’m not alone by any stretch of the imagination. To be honest with you, it’s not something that I give a lot of thought to. I go in and there’s my fellow board members, and we have things in common, and they’ve all made me feel incredibly welcomed. So, it hasn’t really been an issue.

[00:25:31] Sanjula Jain, Ph.D.: That’s good. Well, it sounds like healthcare is a unifying purpose for a lot of that work anyhow. You know, you mentioned earlier about the role that mentors have played in your career path and I’m sure, whether it’s a mentor or a manager or someone else, you’ve received a lot of feedback over your career as well. What’s one piece of difficult feedback you’ve received over the years and how did you overcome it?

[00:25:52] Seema Verma: You know, I would sa,y early on in my career, I remember talking to one of my supervisors and I was kind of laying out, and this is wrong and this is wrong and this doesn’t work and this doesn’t work. And I was young. I was probably in my twenties and I remember he kind of looked back at me and was sort of like, yeah, and here are my problems and I’ve got this and I’ve got this. It was really helpful because, I think a lot of times, we sit in our position and there’s always a lot to complain about in any environment. This doesn’t work well. That doesn’t work well. And he said it in a much more diplomatic way, but it was sort of like, okay, quit your whining and let’s just, I mean, you kind of just have to say, yeah, there’s some things that don’t work well, but I’m going to, what can you get done? Let’s focus on what we can do and try to get things across the finish line, regardless of the barriers. No matter where you’re going to be, there’s some level of dysfunction. there’s always going to be barriers. I think the people that are successful are able to take their environment and navigate it, whatever that environment is, because there’s going to be hurdles, there’s going to be barriers. Your job is to figure out how to get over them and how to go around them to accomplish the goal.

[00:27:09] Sanjula Jain, Ph.D.: So going back to where we started, I’d be curious, after all the work that you’ve accomplished, how would your parents introduce you to their friends today?

[00:27:19] Seema Verma: You know, that’s a funny one. I think that they were you know, now they’d have a way better understanding and, you know, I still wonder if my mom’s mad that I didn’t go to medical school. You know, I think that they have kind of come around and they tell you that they’re proud, which is a big deal for them. They don’t usually like to give out those accomplishments. But as a daughter of immigrants, you also recognize what an enormous sacrifice that they made and what they went through to give you a better life and to bring us to this country. That’s not lost on me at all. Hat an incredible opportunity that a daughter, first-generation can do great things. And it’s not just me. There’s plenty of other examples of Indian Americans, African-Americans, so many people of different backgrounds that are able to accomplish so much in this country. So, I’m very grateful to the sacrifices that they made to get me to this point. And I’m glad that they can finally say that they’re proud.

[00:28:23] Sanjula Jain, Ph.D.: And I think that I can speak on behalf of everyone to really thank you and your team’s leadership for everything that you’ve done to take advantage of that opportunity because I think that that really shows in the work that you do. And so, Seema, I guess I’ll end with one final question. You’ve made the US healthcare system incrementally so much better and the work that you’ve done will continue to improve the system going forward. And you still have many more chapters of your book to write with the work that you’ll continue to do. But what’s one piece of advice you’d give your younger self?

[00:28:53] Seema Verma: You know, I think that sometimes I just got too caught up in the day-to-day and really let the stress get to me and this happened and so-and-so said this, and so-and-so said that. To really just take a step back that what’s going on in your immediate day, your immediate month or two, isn’t the longterm plan. That everything will pass. Things will get better. And to just really keep my eye on the ball, on the big picture, and not get caught up in the small things. And also to recognize that sometimes you’re in a position and you’re thinking, this isn’t where I want to be. This isn’t the job that I want to have. This isn’t exactly it. And I think I’ve started to realize that, instead of being negative, to really use those opportunities to say, okay, this is what I have in front of me. How can I make the best of it? How can I learn from this person and that person? Even if you have a bad boss, that’s actually an incredible learning experience because you can learn everything that you don’t want to be. So to basically take every experience as an opportunity to learn and to grow.

[00:30:06] Sanjula Jain, Ph.D.: That’s very well said. Well, Seema, this has just been phenomenal and thank you again for all the work that you’ve done, but thank you for being so willing to share your experiences and, for so many of us in the audience to kind of learn from that, it’s going to go a long way in empowering the next generation of leaders. So thank you.

[00:30:20] Seema Verma: My pleasure and thanks for having me.