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Lead role

Marilyn Tavenner talks about her role at CMS

Monday February 20, 2012
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Since her days as an ICU nurse, Marilyn Tavenner, RN, BSN, MHA, who is President Obama's choice to lead the Centers for Medicare and Medicaid Services, has received accolades for her unwavering focus on patients. If confirmed as the agency's administrator, Tavenner stands to bring that focus along with her other nursing skills — clinical knowledge, assessment, organization and holistic vision — to improve healthcare for all Americans.

"The country is lucky she is there," said her former boss, Donald Berwick, MD, who headed CMS for 18 months, with Tavenner as his deputy. "She is very well-suited to run that department."

The $820 billion federal agency administers Medicare and oversees state Medicaid programs and the Children's Health Insurance Program, which together provide healthcare coverage for some 100 million Americans. Through the Affordable Care Act, passed in 2010, it is charged with setting up coverage for millions more.

In an exclusive interview with Nurse.com, Tavenner talked about her goals at CMS, her dedication to healthcare access and quality and how her nursing roots provided a foundation for her work in healthcare policy.

A nurse's view

"I feel it's very important to have access to care," said Tavenner, speaking by phone from her office in Washington, D.C. "I think prevention is the name of the game. The earlier we get involved, the better the outcomes for the individual." She left a job as a high-level executive at the Hospital Corporation of America (which continues to pay her annual pension) to work on ways to make care more accessible and affordable and to improve early intervention to avoid hospitalization, she said.

"Certainly the Affordable Care Act is trying to do all those [things], so it's kind of a natural fit for me. There are a lot of things that over time we will learn and we will modify as we go forward, working with Congress," Tavenner said.

The ACA and CMS have had their share of political controversy. Berwick, Obama's first choice, resigned in December after Senate Republicans vowed to block his confirmation. Tavenner has been praised by lawmakers from both parties, but the Senate has not set a hearing date for her confirmation. Republicans in Congress have vowed to repeal or defund the Affordable Care Act, and some states are suing to have its requirement for mandatory health insurance by 2014 struck down as unconstitutional.

In the meantime, Tavenner is running CMS in keeping with her nurse training. "I think one of the things that is so critical about how nurses view the world," she said, "is that you are looking at how do you get everybody involved in the process, whether it's family, whether it's staff." She encourages discussion and is open to hearing all sides, but once a decision is made, she said, "We all move forward together."

Building consensus

Tavenner insists she was mostly in the right place at the right time throughout her career. "I can't really say I ever had this idea I would be in the federal government," she said. "It's just like one job led to the other."

After leaving her hometown of Fieldale, Va., Tavenner attended a diploma nursing school at Roanoke Memorial Hospital, got her RN license and specialized in intensive care. While working and raising a family, she earned a BSN and a master's in health administration. She took on increasing leadership and managerial roles to become CEO at Johnston-Willis, an HCA hospital in Richmond, Va., and eventually became group president of outpatient services at HCA's national offices in Nashville, Tenn.

Trula E. Minton, RN, MS, now CNO at CJW Medical Center in Richmond, worked with Tavenner as a staff nurse in the mid-1970s. "Her confidence in herself and her strengths as a clinical nurse and an advocate for patients, all those years ago, made an impression on me," Minton said. Twenty years later, they worked together again as nurse executives during a difficult merger between two HCA hospitals. Minton recalls Tavenner's willingness to talk extensively to people with differing views, assuring them the hospitals could serve patients better by complementing each other rather than duplicating services. Loressa Cole, RN, BSN, MBA, CNO of Montgomery Regional, also an HCA hospital, said Tavenner was ahead of her time in making the connection between compensation and quality in healthcare.

"If someone presented something — a new program or a new policy — she always asked probing, analytical questions ... 'What will this change?' 'How will this improve things?' 'What will be the result if we do this?' " Cole said.

Patients lead to politics

At Johnston-Willis, Tavenner was struck by the plight of uninsured patients. She and her staff worked to make sure they got the care they needed, she said, setting up payment schedules and discounting bills. "But I always wondered about those I never saw."

About that time she met Tim Kaine, a Richmond city councilman and later mayor. They worked together on fundraisers and local healthcare issues. When Kaine became governor in 2006, he asked Tavenner to serve as secretary of health and human resources. Four years later, when his term and her job ended, she was hired as principal deputy administrator at CMS.

Six months after her arrival, Obama appointed Berwick during a congressional recess. Berwick and Tavenner worked well together. They set up the Center for Medicare and Medicaid Innovation to test new healthcare models and oversaw the development of state and federal insurance exchanges. Their strengths were different but complementary. "Don is very creative, very visionary," Tavenner said. "I, on the other hand, tended to like to keep the trains running."

Berwick appreciated Tavenner's managerial abilities and clinical expertise, as well as her political skills. Sometimes they disagreed on how to get something approved, he said, but never about what they wanted: quality improvements based on evidence, controlling costs through greater efficiency and improvements and coordinated, patient-centered care, accessible to everyone.

Building a better system

She is proud of the agency's accomplishments, including expanding coverage of preventive services for Medicare beneficiaries, extending parental coverage to young adults under 26 and creating state-run, high-risk insurance pools. She talked enthusiastically about one of her biggest challenges, setting up federal and state insurance exchanges to help consumers buy federally mandated health insurance by 2014. "That part's been fun," she said, referring to working with states on grants to set up the exchanges.

Tavenner has gone on record as opposing a Republican-supported plan to turn Medicaid into a block grant that would limit federal funding to states. "I want to see us build on our current system," she said, "and that's why we're so focused on delivery system reform and coordinated care."

As healthcare reform rolls out, she sees tremendous opportunities for nurses as leaders of coordinated care. Tavenner understands nurses must work in teams with other healthcare professionals, whether in direct care settings or on policy issues, said Shirley Gibson, RN, MSHA, FACHE, associate vice president of nursing at the Virginia Commonwealth University Health System and president of the Virginia Nurses Association.

As secretary of health in Virginia, Tavenner suggested the VNA expand a proposal for a long-desired nursing workforce data center into a center to study all healthcare professions and helped get it funded, Gibson said.

Tavenner makes a point of maintaining connections to colleagues, patients, providers and the public.

"Obviously when you're in the hospital, you just get on an elevator and go meet folks," she said. "But when you get into federal government, it becomes a little more difficult." CMS regularly solicits feedback from patients and families on new policy and payment systems, and Tavenner seldom turns down a meeting to hear concerns and learn what is and isn't working. "I have great managers," she said. "I depend on them. But every now and then, I make sure I reach out and talk to someone who's out there experiencing it on the other side." •


Cathryn Domrose is a staff writer.Write to editor@nurse.com or post a comment below.
Healthcare groups support Tavenner

National nursing groups and the American Medical Association are on record supporting the nomination of Marilyn Tavenner, RN, BSN, MHA, to head the Centers for Medicare and Medicaid Services.
“We all hope she makes it,” said Susan B. Hassmiller, RN, PhD, FAAN, senior adviser for nursing at the Robert Wood Johnson Foundation. “There are people on both sides who feel that she is very qualified. She’s a good administrator, and she’s very competent.”
“She brings the right experience and leadership skills to lead the agency,” said Laura Caramanica, RN, PhD, CENP, FACHE, president of the American Organization of Nurse Executives. “She is a strong patient advocate, and she has been in the seat of having to plan for care and administer it.”
“It’s a wonderful choice. We’re looking forward to working with her,” said Karen Daley, RN, PhD, MPH, FAAN, president of the American Nurses Association, adding that Tavenner joins Mary Wakefield, RN, PhD, administrator of the Health Resources and Services Administration; Judy Murphy, RN, FACMI, FHIMSS, FAAN, deputy national coordinator for programs and policy at the Office of the National Coordinator for Health IT; and Army Surgeon General Lt. Gen. Patricia D. Horoho, RN, MSN, MS, as nurses who have become national leaders in recent years. “Nurses are becoming more prominent on the national level,” Daley said. “I think nurses across the country should be inspired by [Tavenner’s] nomination. To see her in this position as head of CMS speaks very highly of nursing’s capacity to lead.”