CMS departures leave open key Medicaid jobs

Two of Medicaid's top leaders are leaving the federal government, opening vacancies for chief regulatory positions amid a booming period of evolution in the program.

At the end of 2014, two senior officials at the Centers for Medicare & Medicaid Services announced their plans to depart the agency: Cindy Mann, deputy administrator and director of the Center for Medicaid and CHIP, and Melanie Bella, director of the Medicare-Medicaid Coordination Office.

Bella and Mann's time at the agency saw new growth and policy directions in Medicaid, and their departures come in last quarter of the Obama Administration, with two years left to solidify a foundation for states to embrace and continue expanded Medicaid eligibility and improve services for dual eligible seniors.

The next two years will also test new states policies for new Medicaid beneficiaries and Medicare-Medicaid dual eligibles, each population creating new opportunities for insurers -- and new challenges that could affect states' propensity for managed care contracting.

Mann first worked at CMS between 1999 and 2001, implementing the updated pediatric version of Medicaid, the State Children's Health Insurance Program. After eight years in a research professorship at Georgetown, Mann came back in 2009 to oversee Medicaid in the Obama Administration.

Not long after taking the helm of the Center for Medicaid and CHIP Services, the Affordable Care Act was enacted with Medicaid designed to be a key leg of universal coverage, as the health plan for millions of previously-ineligible low-income adults and working families.

The Supreme Court's 2012 ruling, of course, greatly complicated that universal coverage pathway, and created a new challenge for Mann, HHS Secretary Kathleen Sebelius and CMS administrator Marilyn Tavenner -- convincing Republican Governors to choose to expand Medicaid eligibility and negotiating more private sector-based policies that still met the beneficiary guarantees in the law.

"All states can be laboratories for healthcare reform," Mann wrote in a blog post last summer, announcing a new $100 million grant program for states to develop Medicaid payment and service delivery models.

As Mann noted, 15 state Medicaid units have started medical home programs for beneficiaries with multiple chronic conditions, 13 are testing delivery and payment models for dual eligibles, 25 are considering new approaches as part of the State Innovation Models initiative, and some, like Colorado, are even trying ambitious shared savings and accountable care approaches.

In the beginning of 2015, almost 20 percent of the American population -- more than 66 million people -- are covered by Medicaid and CHIP, after the ACA's first open enrollment added nearly 10 million.

If the new HHS Secretary Sylvia Mathews Burwell and Tavenner are able to convince other GOP Governors in states like Texas and Florida, Medicaid's enrollment and spending will surge even more, and likely involve the introduction or expansion of managed care policies.

With Medicaid already challenging state budgets and worrying an increasingly entitlement-averse Congress, the great challenge for regulators and managed care organizations is covering more people, with essential health benefits, on a more efficient per-capita basis. CMS is looking for a replacement for Mann, while Vikki Wachino, deputy director of the Center for Medicaid and SCHIP, serves as acting director in the interim.

In the 9 million-plus population of dual-eligibles, who account for some 40 percent of Medicaid spending and 27 percent of Medicare spending, the future has similarly high stakes, as Melanie Bella departs her job as director of the four-year-old Medicare-Medicaid Coordination Office.

When Bella came to CMS in 2010 she was charged with overseeing the ACA-directed integration of Medicare and Medicaid benefits for dual-eligibles -- an experience long-criticized as too dysfunctional for beneficiaries and at the same time too expensive for taxpayers.

Bella had previously been the senior VP at a quality improvement organization, the Center for Health Care Strategies, and from 2001 to 2005 the Medicaid director in Indiana, where she spearheaded the Indiana Chronic Disease Management Program. Based on expanded access to primary care and self-management, the effort has shown a good deal of promise, with one study of diabetes and heart failure patients finding a decline in the rate of cost growth after implementation.

Replicating that on a national scale for the dual eligible population -- whose combined costs to Medicare and Medicaid is almost $350 billion annually -- is another matter, but under Bella's leadership, CMS has approved 13 state-led demonstrations that experiment with new financing models.

California, Illinois, Massachusetts, Michigan, New York, Ohio, South Carolina, Texas, and Virginia are testing a capitated model. Colorado is trying a managed fee-for-service approach, Washington both a capitated model and managed FFS model, and Minnesota an integration of administration but not financing.

"These initiatives," Bella said in 2012, "have been designed to enhance care coordination and advance person-centered care programs, focus on increased access to needed beneficiary services, promote keeping individuals in their homes and community, support a much needed focus on improving the quality of care received by beneficiaries, and achieve health care savings for both states and the federal government."

It's a tall order. Some states have run into challenges. In California, patient advocates have criticized the enrollment of seniors into managed care plans as too disruptive, sometimes changing long-established provider relations, while in Massachusetts, the first year is likely to have come in with spending above estimates.

Nonetheless, the National Association of Medicaid Directors believe the demonstrations are on the right path, and that "evaluations will reveal early successes, areas for improvement and other opportunities."

As Bella leaves, though, state Medicaid directors are "eager to understand CMS' long-range work plan" for the dual eligible demonstrations, the NAMD said recently. Tim Engelhardt, the director of the Medicare-Medicaid Coordination Office's models, demonstrations and analysis group, will serve as acting director.

Neither Bella nor Mann have announced their next career moves. The last top CMS regulator to leave, former principal deputy administrator Jonathan Blum, recently joined CareFirst BlueCross BlueShield as executive vice president for medical affairs.