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Ten Questions About Marilyn Tavenner

By John Reichard, Nellie Bristol and Jane Norman, CQ HealthBeat Staff

November 28, 2011 -- The announcement last week by Donald M. Berwick that he will step down Dec. 2 as administrator of the Centers for Medicare and Medicaid Services, and the selection of Marilyn Tavenner, his principal deputy, as his successor, raises many questions—about not just the future of Medicare and Medicaid, but also oversight of the wider health system.

As head of CMS, Berwick has advocated innovative programs to improve the quality and efficiency of treatment in Medicare and Medicaid. He launched efforts to reorganize and more closely monitor the insurance industry. And he was determined to improve patient safety. But the overriding task of his agency since the health care overhaul passed has been to prepare for and begin implementing the sweeping law.

Tavenner will carry on that work on an acting basis and, if she is confirmed by the Senate, as permanent CMS administrator. Can she fill Berwick's shoes? Does she have strengths he doesn't? How will CMS change? Here's our take on what lies ahead at CMS as new leadership takes over next week.

1. Don Berwick is a passionate and articulate advocate for the health care law. Marilyn Tavenner seems more reserved and has kept a lower profile. Will there be hiccups in the implementation of the overhaul now that Berwick is leaving?
Berwick moves audiences with his descriptions of how he thinks the health law can change medicine for the better. He is an articulate champion of the idea that change is not only possible but achievable—based on the work he has done developing patient safety programs, measuring quality and setting performance goals, and identifying promising community programs that can be implemented on a national scale. It's unlikely Tavenner will capture crowds as Berwick does. But those who have worked with her during her tenure as Virginia's secretary of health and human services and as an executive with Hospital Corp. of America say she always has shown a strong commitment to patient care.

Erik Swensson, who led the department of surgery at Johnston-Willis hospital outside Richmond when Tavenner rose up through the ranks of the HCA facility from head of nursing to become its CEO, emphasizes Tavenner's skills as a pragmatic manager. But he describes her as a visionary, too—but perhaps one more grounded in the real world of health care.

"I may not agree with all his policies, but this guy has got big ideas," he says of Berwick. "And personally, some of them I think would be very difficult, if not impossible, to accomplish. Whereas Marilyn would also be a visionary. But she's also a pragmatist. She knows doctors, and she knows nurses, and she knows hospitals. Marilyn will know if you can get from X to Y. And sometimes, from the outside of the Washington Beltway, I wonder whether the people know, can you get from X to Y? This isn't a reference to anyone else, but her head is not going to be in the clouds." The other point about Tavenner is that she is no stranger to implementing the health care law (PL 111-148, PL 111-152). She's been doing it since she was appointed principal deputy administrator in February 2010.

2. When is the administration likely to formally send up her nomination? Will just the Senate Finance Committee handle the confirmation or will the HELP panel have a say?
There's still lots of unknowns. The White House hasn't yet formally sent the nomination to the Senate. When it does arrive, the Finance Committee would handle the confirmation hearings. But there's no word from Chairman Max Baucus, D-Mont., or Senate leadership on their plans or the timing. Republicans have sent the signal that they expect confirmation through the committee process—in other words, no rerun of the Berwick recess appointment that circumvented the Senate. As for the Health, Education, Labor and Pensions Committee, it's doubtful it would get involved.

3. How well will Tavenner perform in hearings? Will she be responsive to lawmakers while still serving as an effective advocate for the health care law?
Tavenner is still pretty much an unknown when it comes to speechifying and testifying in Washington as well as dealing with the press.

During an appearance on C-SPAN in November 2010, she appeared to deny that the health care law includes $500 billion in Medicare and Medicaid cuts, which it does. Tavenner seemed to be trying to frame the question to her advantage, as if the question had been whether the health care law would reduce Medicare benefits, and said it wouldn't. But a viewer might have thought the health care law doesn't cut Medicare, which it does. As Virginia's secretary for health and human services, Tavenner wouldn't respond to questions about allegations that she and then-Gov. Tim Kaine suppressed the findings of a state task force report (see question below).

On the other hand, Tavenner appears to have handled herself well in hearings and in meetings with lawmakers in the Virginia Legislature—and, before that, in other political challenges. "When she was health and human services secretary at the beginning point of the recession, it was really essential that all the agencies under the Cabinet would operate as efficiently as possible," says Jill Hanken, a staff attorney with the Virginia Poverty Law Center. "She was involved in delicately using the scalpel to cut programs for fiscal reasons. But at the same time, there were some important steps forward in terms of prenatal care, protection of safety net programs for the uninsured, and improvements for foster care children."

Terry Dickinson, executive director of the Virginia Dental Association, credits Tavenner with helping to get a measure through the Legislature allowing dental hygienists to take on some of the responsibilities of dentists in delivering care in medically underserved, impoverished parts of southwestern Virginia. Tavenner met with dentists in the Virginia Dental Association's house of delegates to address their concerns about the measure. "She understood the political reality of how we needed to walk that line," Dickinson recalls. "You have to think about the big picture, and how do you get health care to these folks," Dickinson recalls Tavenner as saying. "She just had a great way of talking with the group."

And Tavenner managed turf wars skillfully in world of hospital politics, says Jay Grinney, CEO of the rehabilitation chain HealthSouth. In a HealthBeat profile of Tavenner in May, Grinney said that when he first became Tavenner's boss at HCA she was the CEO of Chippenham hospital in the southern part of Richmond, Va. He put her in charge of creating a merged doctor network with HCA's nearby Johnston-Willis facility. The two facilities had different medical staffs, cultures, and markets. Company insiders doubted she could pull it off. But Tavenner worked through the issues and successfully brought together the two sites, Grinney says.

4. Allegedly, when she worked for Virginia Gov. Tim Kaine, they suppressed the findings of a Virginia state task force report saying that 800 kids in state-run psych facilities wouldn't have treatment options close to home if the state followed through on a plan to close the facilities. Then she wouldn't talk more about the issue with the press. Is that going to cause her confirmation trouble? What does it say about her management style?
If Republicans want to make trouble for Tavenner in a confirmation hearing, it's logical that they will ask about the handling of the task force report.

"What happened with the Commonwealth Center really, I think, caught people off guard," Mira Signer, executive director of the Virginia branch of the National Alliance for the Mentally Ill, said in the profile of Tavenner earlier this year. Advocates scrambled to keep the facility from being shut down, and it remained open.

Tavenner backers typically draw a blank when asked about the task force report, which appears to be an anomaly in a career noted for concern with promoting access to care. Does it reflect a closed way of doing business? "In my dealings with her, she was pretty transparent," says Hanken, who describes Tavenner as having had "an open-door policy."

5. What about morale at CMS? People say Berwick really fired up the troops with his vision that improving quality is a way to lower costs. Will Tavenner have the same impact?
Tavenner has earned much staff goodwill during her tenure at the agency, CMS insiders say. Tavenner too appears to be a motivator, although no one is likely to match Berwick's particular brand of charisma.

Swennson says, "The attitude and the atmosphere that I felt within the hospital was a very functional one. The hospital and the doctors for the most part got along, and the nurses did, and they were very attentive to what the patients needed." There was a feeling "throughout the hospital that we had good management, that if we had a problem we could go to Marilyn and she would take care of it. There wasn't any ideology. There weren't any personal issues. It was just a very clean way to do business. And it was very effective."

6. Would Tavenner bring her own people with her to fill management slots? Should we expect other top people at CMS to leave after Berwick's departure?
Tavenner has been in Washington now for more than 18 months, so don't expect anything big anytime soon. Berwick devotees say they are committed to staying and carrying on the work he has started at the agency. Some changes in the administrator's office seem inevitable at some point. But don't expect any big shakeup in the wider agency.

7. Tavenner oversaw a state Medicaid program, something unusual for the top CMS official. How much difference is that going to make in running the agency?
"It's great to have somebody in that broader role who knows Medicaid," said Matt Salo, executive director of the National Association of Medicaid Directors. Salo said Tavenner's state experience could help ensure Medicaid is "viewed as just as important as Medicare when thinking about the big picture."

Among pressing issues for the program is how to move a care improvement agenda in an era of tight budgets at both the state and federal level. That will involve a change in culture, Salo said, to provide greater focus on innovating and outcomes rather than process and paperwork. Movement in that direction often is slowed by the constant tensions between state and federal administrators, he said. Tavenner will understand the dynamic from both sides.

Former Medicare and Medicaid administrator Gail Wilensky, now a senior fellow at Project HOPE, agrees, saying Tavenner "is likely to be especially sensitive to the issues and sometimes frustrations that states historically have had with the agency," including "timeliness or lack thereof" on decisions relating to waivers and other issues. Diane Rowland, executive director of the Kaiser Family Foundation's Commission on Medicaid and the Uninsured, said Tavenner's experience also will help in establishing state-based aspects of the health care overhaul. "It will help her to have a grasp on the state challenges as health reform is implemented," Rowland said.

8. A lot has been said about Berwick's vision and ideas. What about health care is Tavenner most passionate about?
Unlike Berwick, Tavenner doesn't have a signature set of specific issues that she has championed. Those who have worked with her talk about her unwavering commitment to patient care and to ensuring that patients have access to the care they need and that providers are paid in a way that promotes that access.

"She's a pragmatic person who wants to make things work and has patients at heart," Debbie Oswalt, executive director of the Virginia Health Care Foundation, told HealthBeat in May. 

9. How are health industry stakeholders responding to the Tavenner nomination?
So far, so good for Tavenner. In fact, some of the reaction was nearly ecstatic.

Chip Kahn, president and CEO of the Federation of American Hospitals, said she has served "skillfully and with distinction" as deputy administrator. "Ms. Tavenner's successful career is characterized by her willingness to go the extra mile and to reach across the aisle to achieve results. She is an ideal candidate to head CMS, and we encourage the Senate to approve her nomination quickly," said Kahn.

Tavenner is a former hospital chief executive and president of the Virginia Hospital Association, and she spent 10 years in executive-level positions with the Hospital Corporation of America.

Rich Umbdenstock, president and CEO of the American Hospital Association, where Tavenner has served as a board member, said she is a "very capable administrator" with a varied and rich background. "We have no doubt that she will provide strong leadership in these challenging times," he said.

The doctors like her, too. The American Medical Association issued a statement strongly supporting her.

"We have worked extensively with her in her role as deputy administrator, and she has been fair, knowledgeable and open to dialogue," said Peter W. Carmel, AMA president. "With all the changes and challenges facing the Medicare and Medicaid programs, CMS needs stable leadership, and Marilyn Tavenner has the skills and experience to provide it."

Those representing skilled-nursing facilities (SNFs) praised Tavenner's understanding of the connections between Medicare and Medicaid when it comes to delivering quality care to residents of nursing homes. That came when she was health secretary in Virginia, they said.

"Marilyn Tavenner is a strong choice to lead CMS because of her reputation as a smart, competent administrator, and because she has a strong working knowledge of how Medicare and Medicaid funding adequacy are both integral to the ongoing ability of SNFs to provide high quality long term and post-acute care to U.S. seniors," said Alan G. Rosenbloom, president of the Alliance for Quality Nursing Home Care.

10. What about Berwick's future?
Right now, no one seems to know what his plans are. Or at least they're not saying. When he announced his resignation last week, Berwick did not address his future. Those close to him at the agency said he was expected to return to his home in Boston and spend time with his family before deciding his next move.

Rumors are rampant that Berwick ultimately may stay at HHS in a non-political, technical position, either in the secretary's office or at the Center for Medicare and Medicaid Innovation. The Institute for Healthcare Improvement, where Berwick was CEO and president before moving to CMS last year, is referring press calls back to CMS, at least until after he leaves office.

IHI's CEO and president, Maureen Bisognano, said in an email that she is confident Berwick will continue to contribute to the national agenda of redesigning health care delivery and financing. "That is his life's work, mission and passion," she added.

Kaiser's Rowland expects Berwick will be very much in demand. Many places respect him, she said, and would want him, and he's "very committed to seeing things through." Rowland is sure he will "continue to be an advocate for these reforms."

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