By Cathryn Domrose
In mid-January, the nursing community learned one of its champions in the federal government, Marilyn Tavenner, MHA, RN, was leaving her position as administrator of the Centers for Medicare & Medicaid Services. Before being confirmed as head of CMS in 2013, Tavenner had served as the agency’s acting administrator since 2011, and before that as principal deputy administrator. She oversaw the rollout of the Affordable Care Act’s healthcare exchanges and Medicaid expansion; the development of new healthcare payment and delivery models, such as accountable care organizations and patient-centered medical homes; and cost-reduction and quality improvements in Medicaid and Medicare programs. A few days before leaving CMS, Tavenner talked with Nurse.com by phone about her time at the agency, and the importance of nurses being involved in healthcare policy at all levels.
Q: Why are you leaving CMS?
A: It’s been five years, believe it or not, and when I first came here, the agreement was for two or three. I felt like it was either leave now or stay until the end of this administration, and that would have been seven-plus years. Seven years is a long time, and I’m anxious to go back home and live full time with my family. I also wanted to leave with enough time for [President Obama] to bring in someone else, so that person would have a long enough tenure to be beneficial for CMS and this administration.
Q: Did you feel stressed at times with all the political and media turmoil over the rollout of the healthcare insurance reform?
A: Yes, of course. But when I look back, it’s been very successful and I’m very pleased with the last five years. I feel like I’m leaving at a good time, when things are as calm as this work will ever be. We’ve finished the second round of open enrollment, and we’ve got Medicare policy and innovation work well under way. It’s a good time to depart.
Q: How did you manage the political situation?
A: I think I’ve got strong relationships with both sides. A lot of people only see what’s on television, which is a lot of the political agenda, but underneath all of that is day-to-day activity that helps build relationships. When I first got here, working as a deputy, many members of Congress had constituent or policy issues they were concerned about. So as I met with them and their constituents, then helped them solve a problem, they got to know me in a way that was not political. You’re just trying to help someone out, or maybe you can’t, depending on the case, but either way you give them an answer, you try to solve the problem, or you’re pretty straight with them about why not. It’s very much a nursing trait.
Q: What do you see as your greatest accomplishments at CMS from a nursing point of view?
A: I think the greatest accomplishment, nursing or non-nursing, was the ability to insure more individuals, whether through Medicare or Medicaid or the marketplace. Part of the reason I left the private sector and went into government work was the issue of access. I watched a lot of individuals face financial ruin and loss of security due to their inability to afford insurance or be able to get insurance in any way. That was my No. 1 goal in being here, and I think that was our No. 1 success. One of the things I’m most proud of from a nursing perspective has to do with getting nursing involved — either leading or participating — in every care delivery aspect of what we’re doing [at CMS]. There’s certainly more progress to be made, but I think we made a great deal of progress there.
Q: What do you wish you could have accomplished?
A: There’s such a learning curve when you come into CMS. I got to know and work with a lot of the staff, but I regret I didn’t have more time inside the fabric of the agency, more time talking about some of the things that aren’t on the front page of the newspaper every day, such as how do we have the agency run more efficiently, how do we ensure greater workforce morale, that sort of thing. I got a lot done in that respect, but there was always room for more. It’s a big agency and there was a tremendous amount of activity in the last five years.
Q: How has your nursing experience helped in your work at the agency?
A: A lot goes on inside CMS where a clinical background is helpful, whether you’re a nurse or a physician. When we were making coverage decisions about things from new medications to new types of therapies, having that clinical background and being able to talk with [staff from] the clinical arm of CMS on a peer-to-peer level was very beneficial. Also, as we were making changes in delivery system reform, we were able to talk about the role of the nurse. From the beginning we wanted to have people participate and function at their highest level, and coming from a nursing background I actually understood what that meant. We were able to say we wanted RNs involved in everything, but not just involved — we talked about where they can actually lead or where they need to be supportive. Yesterday I got a letter from the nursing community signed by 60-some different nursing support groups, thanking me for my work. I can’t tell you how much that meant to me.
Q: What role do you see for nurses in leading government agencies such as CMS? Do you expect to see more of them in these roles?
A: I’m not the first nurse to run CMS and I’m certainly not going to be the last, I think. A lot of people don’t realize it, but we have well over 100 nurses in CMS doing various roles, either leadership or support. Nurses can actually bring a lot to the table with their clinical background and leadership skills they get either through post-graduate work or otherwise. I see lots of roles both inside and outside government.
Q: What are the top five healthcare policy issues all nurses should know about, in your opinion?
A: Access is huge. It’s important at the state level, with Medicaid expansion and state-based exchanges, but it’s also important at the federal level. Delivery system reform is important, everything from medical homes to ACOs to post-acute care. Nursing is going to have a bigger role in those programs as that’s a wheel in motion. The third area is the link between quality and payment. Nurses need to understand how they can improve their quality and maximize their individual payment. The fourth and fifth areas — they’re kind of connected — are data and health IT. We’re going to see more nurses practicing independently, and as they do so they’re going to fall under the same rules and regulations as physicians, particularly in primary care.
Q: What, if anything, might you do differently if you could travel back in time to when you first joined CMS?
A: We spent a lot of time with hospitals and medical and nursing groups. We spent a lot of time with advocates. But if we had it to do over again, I would spend more time with our business partners, helping employers, particularly mid-size employers, understand what was going to change and not going to change for them, because I still think there’s a great deal of confusion there. Some things we put in place about pre-existing conditions and extending insurance to children up to age 26, this sort of thing benefited large employers and we didn’t do a good job (of explaining this to them). We were moving quickly — I’m not being critical of our work. Now we’re trying to spend time with employers and bring them up to speed, tell them what affects them and what doesn’t.
Q: What’s next for you, after taking a rest and being with your family? Are you going to come back?
A: Probably go to the private sector. I’ve spent almost 10 years in government now, so I feel like between state and federal, I have a good understanding, as well as anyone ever has of how government works. I’d like to go back to the private sector and support the work that’s gone on here from the outside because I think there’s a lot that can be done to continue to push the engine. I don’t know exactly what that is yet, but I know I have to do something, it’s just in my personality. Not managing hospitals, as much as I love them. I’d probably want to do more on the consulting side, maybe work on some boards, it’s kind of wide open at this point. First I’m going to take a nice vacation, then I’ll think about it.
Cathryn Domrose is a staff writer.