How to Be the Chief Medical Officer for a MAC – A PNC Classic from 2020

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Transcription PNC Podcast Episode 408

How to Be the Chief Medical Officer for a MAC - A PNC Classic from 2020

John: Dr. Meredith Loveless, welcome to the PNC podcast.

Dr. Meredith Loveless:Thank you, it's great to be with you today.

John: I was really looking forward to this, because it's one thing to interview someone about a job that they've seen dozens of times, like in the Facebook group and things like that, but when I came across what you're doing, I thought, oh, I really want to know about this job. Part of it probably harkens back to the fact that I was a CMO at a hospital, and I worked back in the day with fiscal intermediaries, and then they switched over to Macs, and we'll get into a little bit of that. So again, thanks a lot for being here.

Dr. Meredith Loveless: Thank you very much, thanks for having me.

John: I did do a little bit of an intro that's separate from our interview here, so the listeners will know a little bit about you, but the short version that I'm going to say is that your background is as an OB-GYN, and I think you were more or less an academic situation, wrote some scientific articles and so forth, and then all of a sudden, I see that you're working for Medicare, either directly or indirectly, and that's what we're going to talk about today, and it, to me, is very interesting.

Dr. Meredith Loveless: Thank you.

John: Okay, to get things rolling, why don't you start, tell us a little bit about your education, your clinical background, and then maybe just kind of segue into how and why and when you decided to do something a little different.

Dr. Meredith Loveless: All right, I did my medical school at University of South Alabama in Mobile, and then my residency in OB-GYN at Virginia Commonwealth University in Richmond, and then from residency, I went on faculty at Johns Hopkins University in Baltimore, and I started up their pediatric and adolescent gynecology program, and I was on faculty there for five years, and my husband was a resident there at the time, so once he finished his residency and we were getting established in Baltimore, we decided to move to Louisville, Kentucky for different opportunities, and I joined the faculty at University of Louisville and stayed on the faculty at University of Louisville for a couple of years, and then our program, our pediatric and adolescent gynecology program became part of the Norton Healthcare System, so we continued to run a fellowship and have a teaching program, but under the umbrella of the Norton Healthcare System and kept my clinical professorship with University of Louisville, and I did that for nine more years in that practice.

John: Let me jump in there if I can. Yeah. Just wondering because we hear about consolidation and mergers and different things like that. That sounds like it could have been a pretty interesting transition, but did it affect you much or did it negative or positive?

Dr. Meredith Loveless: Well, at that time, it was really a choice that we made in order to maintain the ability to keep our fellowship. The pediatric programs have subsequently merged completely under Norton, so the UofL and Norton Pediatric Programs are now all together, but at that point, we were the first pediatric program to be put under the Norton umbrella. Initially, it didn't affect a lot.

We were able to maintain our fellowship, maintain the academic mission, but over time, that became a lot more challenging, and there was a lot of I think the pressures of RVU and clinical practice, trying to balance that with the ability to teach, and gradually, it became much more difficult to maintain a fellowship, and so when our fellowship was no longer working out, we lost a lot of workforce because we went from five physicians to two in that process.

We lost a faculty, two fellows, and that made the call distribution 15 to 16 days a month, and that was the decision that I just decided was more call than I wanted to take as a mother with three children, and so that was really what kind of pushed me to explore options outside of clinical.

John: Okay, I'd be interested to hear what types of things you considered before making your decision to go work for a MAC, so how did that kind of transpire?

Dr. Meredith Loveless: The whole thing, I wish I could say I had some great plan. I had a non-compete clause, so I was trying to figure out what I could do during this transition, and being a subspecialist, because I had not done obstetrics in almost 10 years, and so I was trying to figure out, okay, well, where am I going to fit in in the private practice world, and just started looking at all different options, and I got on, and I'm looking for, I had a lot of medical writing experience as an academician.

I had done paid medical writing on and off throughout times for CME and other things. I had that writing experience. I was like, well, I might be able to find something using those skills while I figure out where I'm going to go next, and I came across the job opportunity with CGS administrators, who is whom I work for, and they're a Medicare administrative contractor, and the position was that they needed somebody for policy writing, as a medical director with a focus on policy writing, and that was, I was like, oh, policy writing, now that's something that's interesting, and I had, during my career, I've been involved with ACOG since I was a resident, and I had been a junior fellow officer, and then I served on multiple different ACOG committees.

I served as chairman of the Adolescent Health Committee, and I'm still working with ACOG on document reviews. I'll be the chairman of that in the upcoming year, and so, and also in that role, I had become liaison to ACOG for American Academy of Pediatrics on their Adolescent Health Committee, and so through both, so I did policy work with that, and then did a lot of the ACOG committee opinions, and I've done practice bulletins, so I had a lot of experience in kind of what goes into development of clinical policy, so I felt that my skillset and writing experience aligned well with the need for this position, and so I applied, and it turned out that my skillset aligned very much with what they needed, and that it ended up being a great fit. I mean, I really enjoy the work, and it's been an excellent work-life balance for myself and my family, and it keeps me challenged, but not overwhelmed, so it's really been an excellent transition.

John: Well, that sounds really interesting and really fortuitous, but it really aligned with what you had already done, so, but I want to make sure I understand exactly how that worked. So you were working on policies for the, for ACOG, or your professional organization that related to changes in clinical care, basically as new clinical approaches or policies on whatever procedure it might be, then you're working, and then this is with, also with the AAP, joint policies about how physicians should approach things or do things, is that the gist of it?

Dr. Meredith Loveless: Yes, the AAP was a lot more policy statements. I was on the committee that published multiple policy statements from the Adolescent Health Committee. With ACOG, I worked more on practice bulletins and committee opinions, which are more evidence-based guidance for providers in best practices, and so the role that I largely do in Medicare is that I work on writing policy.

For those familiar with the Medicare terminology, the local coverage determinations are the policies that help to determine what's reasonable and necessary for Medicare coverage, and the 21st Century Cures Act went into effect that mandated that the Medicare policies are evidence-based and more transparent of a process than how policies were written in the past.

And so, the Medicare administrative contractor, CGS administrators felt that they wanted to bring somebody on board with a writing background and a background in evidence-based medicine in order to fulfill that obligation and be able to produce high-quality work in the policy development side. And that's where I stepped in. And so, my role is that there's a lot of different ways that Medicare might come to evaluate something for a policy. It can be from external requests that people ask for a policy.

Sometimes often that's stakeholders that are looking to have something covered in Medicare. It may come from evaluation of internal needs based on data analysis. It might come from a variety of different sources, and then those policies are developed really like writing a review paper almost to the level of a systematic review to go through carefully that evidence and weigh the pros and cons, and sometimes we'll have to seek input from subject matter experts to get that expertise in the development of the policy, so part of my job would be to run those meetings where we recruit subject matter experts and get their input, and every step is very transparent. Every meeting, every CAC, it's called a CAC meeting when we bring together the subject matter experts.

That would be available by audio so anyone can listen in. It's open to the public. Whenever we write a policy, that's available to the public, so there's a lot of public interfacing and interaction in my role as well.

John: Well, I want to hear more about that in a second, but I just want to understand, too, some of the skills that you had. So you came into it, you were on numerous committees, and you were chairing at least one, and now you're going to chair another, and you're a professional society or in some of those activities, so I'm assuming a lot of those same skills you would use in getting together with colleagues or other, like you said, experts on a particular policy and sort of putting together a project and that sort of thing, a lot of leadership and negotiation and team building, that sort of thing?

Dr. Meredith Loveless: Yes. Okay. Yeah, it really allowed me to tap into leadership skills that were skillsets that I always wanted to explore and develop but hard to do in a clinical role, so I really enjoyed being able to be part of, being part of work groups, leading work groups, organizing some of these national-level meetings, so it's been a really exciting process for me to gain and use those skills as I develop them.

John: Okay. Now, when I think of a MAC as a physician that used to be in the hospital setting, now I haven't been in a hospital, actually working in a hospital for about six years, but what I remember is they were the ones that really made, well, they had the policies and they also kind of, not implemented, but we had to interact with MAC and say, hey, you're not agreeing that we can do this. Administrative law judges occasionally get involved. I mean, there's a direct conflict or communication between the UM staff or the medical director for UM and a MAC or somebody from a MAC. Is that still how it works and is that a separate section from what the policy makers are doing?

Dr. Meredith Loveless: Yeah, for me, I did not have an insurance background, which is unusual for my position. Most people that come into a CMD role with Medicare have a pretty extensive background in the insurance world. They've worked as medical reviewers or they've worked in other capacities within CMS, maybe on local levels, but most people have a pretty good terminology of the insurance world.

I definitely felt like an intern. Getting started, my first meeting where I got together with the other medical directors from across the country was in my first week. And I was literally on my iPhone trying to look up the acronyms to figure out what they were talking about because they speak in acronyms and I did not know the language at that point.

There was definitely a learning curve. I was fortunate in that they needed a writer. So that was the skillset that I was bringing in that the other medical directors that I worked with did, felt like they wanted somebody who had that as their focus.

And then along the way, I'm learning the other aspects of being part of the Medicare administrative contract that you're speaking of, kind of the backside of education and coding and pricing and data analysis and which departments that trickles out to when there's problems.

John: Okay. Now, can you give us a little explanation or a description of the scope? So CGS is one of... I gather several.

Dr. Meredith Loveless: Seven, one of seven. Well, this is for part AB. And that's the thing about Medicare. It's so complicated that even the people who have been in it for 15, 20 years will tell you they're still learning. And when I started, everyone said, it's going to be a year before you understand what you're doing. And I think that that's pretty accurate.

It's an extraordinarily complicated system that changes on a regular basis. So just when you think you know what you're doing, then the rules are going to change. So it takes, you have to be flexible.

You've got to and so you have to be, you can't be too rigid in this role knowing that things may change. So that, but I like that. And I think people that are OBGYN tend to like lots of things going on at once anyway.

John: Yeah, yeah. Well, like there's multiple territories, right? I mean, you're covering one section of the country. I'm just trying to get an idea of the number of, let's say, medical director positions similar to what you're doing.

Dr. Meredith Loveless: Yeah, I work for CGS administrators. I'm J15, which represents Kentucky and Ohio. And I cover part A, B, which would mean that for those who aren't familiar, part B would be all the outpatient side of Medicare, part A would be the inpatient side.

And then we also have home health and hospice contracts in our division. The CGS administrators also holds the durable medical equipment contracts. So actually when I interviewed, I interviewed for three positions.

I interviewed for the ABMAC, for the durable medical equipment, and for administrative law judge. So I actually interviewed for all three physician roles when I went through the process. And the ABMAC happened to be the best fit for me, because that was the one that had a lot of new technology, surgical stuff that really kind of fell under my interest and experience.

But medical directors would be represented in all those areas. So some of the MACs have multiple, have more states under their ABMAC. So you might have one MAC that has six, seven, 10 states that they're managing the ABMAC, but they might not be doing durable medical equipment. So, they try to distribute it fairly over the country. So physician roles may be in ABMAC, durable medical equipment, administrative law judge.

There's physicians who work within what's called Moldex. Moldex develops a lot of the molecular diagnostic policies. So there's pathologists that are involved in that, that work on writing and developing those policies. There's physicians that are involved in some of the national editing, which is how different billing, it's part of the billing and coding world, but there's physician roles in that.

There's physicians that are in the other parts of Medicare. So fraud and abuse and investigations, physicians that work directly for CMS. So there's quite a representation of physicians within the CMS and the Medicare program.

John: Well, that sounds really kind of, it's a good thing. I mean, it sounds like there's a lot of opportunities, potentially, when you were looking, you said there were three potential positions. So, I mean, I have to imagine if you really start looking across the country, if you're willing to travel or move or whatever, there should be at least a fair number to consider applying for if they're interested. All right, that's cool. I guess I can't help myself. In the ALJ section, what would a physician do?

Dr. Meredith Loveless: I'm not as familiar with ALJ, but they would defend the contractor. So if a case is going to court and the contractor's made a decision regarding the case, then the ALJ would be the physician representative for the contractor to defend the contractor's decision regarding that claim. All right. They would review what's often, from what I understand, a large body of medical records and then represent the contractor in the case.

John: Well, that makes sense. I have a friend that frequently talks in front of, on the phone to an ALJ. So obviously there's someone on the other side that's saying, well, no, this is why we did what we did. This is why we think it should go this way. So very interesting.

Dr. Meredith Loveless: Yeah, they have to be very familiar with the policies and everything else in order to defend the decisions and be able to help make those cases.

John: Okay, now tell us what your kind of average day or week might look like in this position.

Dr. Meredith Loveless: I think that can vary from the different MACs and how each MAC has different leadership. They have different internal structure. So we all may have similar instructions, but how we go about accomplishing that can be different from company to company.

I'm fortunate in that I'm in a company that I have a fair amount of autonomy and flexibility within my schedule. My position is a 40 hour a week position. I'm typically on, logged in between eight and five. But if I need to make some adjustments, then I can do so. And that'll go to voicemail in just a second. We can edit that out, right?

John: Yeah.

Dr. Meredith Loveless: Sorry. There it goes. So I have some flexibility, like being able to do the interview in the middle of the day. And I can notify them when I have a break. But I'm typically on during business hours, during the week. There's not a lot of night or weekend work.

And it's always a full day. Things come in from Medicare constantly. So you think you're going to do X, Y, and Z, and then you realize that there's actually five other tasks that have come in during the week that need to be addressed. So there's always new stuff coming in.

John: Now you're still writing quite a bit, is that correct?

Dr. Meredith Loveless: Yes.

John: Are there some big projects, like major policy changes or documents that are like, okay, take weeks and weeks and months to work on? How does that feel?

Dr. Meredith Loveless: Weeks would be, nothing happens fast in Medicare.

John: Okay.

Dr. Meredith Loveless: To take a policy from start to finish would be, six months would be the absolute minimum that that could happen. But typically that would be nine months and or even longer, depending on what challenges may come up regarding that policy process. And some of these we might work on as one MAC because it's addressing needs within our jurisdiction.

But a lot of times we may be collaborating and discussing and working together with other MACs, especially with an interest in more uniform coverage across the country from the Medicare program.

John: Now, before we get on the recording here, you did mention that you're doing, I think most, if not all your work from home. So are there places where it would require going into an office? Is this just because of COVID? Tell us a little bit about that.

Dr. Meredith Loveless: My position was work from home from the beginning. So I was very grateful to be in that position, especially going into COVID and having three students that are now on learning from home. So that was very unfortunate. I'd say it's probably splits a lot. Some of the medical directors do go into a home-based office and work from their office. Some of them do part from home, part from the office.

And then a good number of medical directors work from home. When there's no COVID, there is a fair amount of travel. I would take, probably about, I had a year that there was travel and I think I took eight trips that year.

Most of the trips are quick. Our headquarters are in Nashville. So that was an easy one for me coming from Louisville, but most of them were one to two nights, but we also would go to CMS multiple times a year for onsite CMS meetings, in addition to going to Nashville for our parent company.

And then I did some training in grade with a medical evidence criteria, the grade criteria and how evidence is graded. So I participated in several grade workshops, just advancing my skillset in that area. So I traveled for those and the company was supportive in helping me gain those skills.

John: Was there a formal training period at the very beginning?

Dr. Meredith Loveless: Not currently, not at this moment, but there are several. The 21st Century Cures Act really, I think, created some of the new positions for Medicare because the workload really became a lot higher in the development, this whole much more rigorous process for policy development. So they actually are working on a more formalized training program for new CMDs that some of the more senior CMDs are rolling out to help train the younger CMDs.

And I'm fortunate in that I work with two experienced CMDs who have been fabulous at training me, being patient, just taking me through the ropes on everything and really good on the job training.

John: Now, we talked earlier about sort of the language and all that, we're not going to get into that, but I have heard things that I need clarification on because I've heard, I've seen CMD, I've seen CMO, I've seen medical director. These all different roles, the same role?

Dr. Meredith Loveless: Yeah, the Medicare administrative contract calls their physician directors contract medical directors.

John: Ah, okay.

Dr. Meredith Loveless: And the company, CGS and Palmetto is our sister company, calls us chief medical officers.

John: Okay.

Dr. Meredith Loveless: It's the same role, but with different titles within the two organizations.

John: Okay, yeah. Well, every organization has its own specific language and vernacular, I guess. That's interesting. Good to know because then people can feel a little more familiar with what questions might come up, let's say in an interview or something, you know? Exactly. They should do some research, obviously, if they're going to apply for a job like this. Well, let's see. What else would you like to tell us about this position? Maybe what you hate about it, hopefully nothing, what you really like about it and everything in between.

Dr. Meredith Loveless: Well, first off, I wrote papers myself. I really enjoyed the process of writing. So being able to make that part of my, I'd say that's probably 50% of my job, but I love that that is 50% of my job. And I really enjoy being able to work in a leadership role and build on that. I enjoy the contact with physicians in the community, stakeholders, working with subject matter experts. That's all, it's been really fascinating going from a specialty in one organ system to knowing, learning a little bit about many organ systems.

I could be working on eyes one day and heart the next day. And at first that was intimidating, but I think we all have that basic fund of knowledge in med school. And I think it really, it's there when you tap into it and you need to use it.

I think that's been fun to kind of explore that. I think for me, the most challenging thing is that it takes a long time to get things done. And I'd like for things to be done. I'm one of those people, I like to be able to check that box and have that done. And that's not how things work. And so things often take quite a while in Medicare.

And especially when you have stakeholders or people that are waiting for this policy or waiting for decisions, and there's a lot of rules. You can't say, oh we're going to work on that policy and it'll be out in the fall. There's all, there's a lot of hush hush and internal things as there should be in Medicare, but that gets people frustrated. So that's probably the biggest challenge is lots of rules and it takes a long time.

John: Yeah, I think physicians in general, they're kind of, they like to see the results of their work, like right away, like immediately or the next day or the week the patient's in the hospital or the recovery from surgery and to have to, I got that a lot with just the hospital administration, which I was doing. It's like, yeah, it's like a big bureaucracy, but I think it's probably a small bureaucracy compared to Medicare.

John: It's like, yeah, it's like a big bureaucracy, but I think it's probably a small bureaucracy compared to Medicare. So I can imagine.

Dr. Meredith Loveless: Yeah, lots of moving parts.

John: All right. Okay, any sort of advice for those that are listening? Oh, wow I didn't realize, to me, this is almost like part of it. 50% of it, like you said, could be actually a different type of writing job. If you're into writing technical, professional policies is great. But there's a lot more to it, obviously. So what kind of advice would you have for someone who might be interested? There's thinking I'm getting out of clinical, maybe or at least coming back?

Dr. Meredith Loveless: What would they first off, it's not a job for people who are fresh out of training and don't have a lot of clinical experience that are looking for a non-clinical position. I don't think any, I can't speak for every max hiring process, but most CMDs are experienced physicians, and they're looking for that clinical experience to have that insight when it comes to making these decisions.

Most medical directors, if you have somebody that was looking into breaking into this field, any experience in the insurance world, I think would really help them to build a resume that would help them to break into the Medicare world. Like my position, I think there's more and more demand for good writing. So people with writing experience, I think that that's going to become more and more of an asset as time goes on.

And then for people who are interested, I think that being familiar with the different Medicare contractors, you'd be going to their websites to see if there's opportunities, trying to, you can go directly to CMS and see what kind of opportunities come up. I don't know of any right now. But things that CM at everything is very transparent.

So everything gets posted publicly. And, and, and so those would be avenues to, and then also just learning as much as they can about the Medicare program. And the Medicare operates on something called the internet only manual. And it's on the Medicare website, and it's all the rules. So if somebody really was interested, being familiar with some of the basic rules of the Medicare program would be a great start to start to build "Is this something I'm really interested in and getting a fund of knowledge in it?"

John: Now, I'm going to ask a question, which is going to show my ignorance, but there are certain types of Medicare patients that are covered on some sort of an, I don't know if it's an HMO, or these other plans, are those like carved out completely from a Mac? Or is there overlap? How does that fit in?

Dr. Meredith Loveless: A and B are the parts of Medicare that's covered by the Mac. And when somebody chooses, it's called typically called an advantage plan. So they're choosing a commercial Medicare plan, then they're choosing a plan that's being covered under a might be Anthem or United or another company. And so, those patients, their Medicare would be being managed by that commercial side.

John: And opinion on if you were given the choice, and you were at that age, which way you go, I'm on Medicare right now, I shouldn't tell my age, but I have I'm not, I have no intention of really opting into some HMO or some advantage plan, I just need a little bit of help to pay for some of my medical bills. And I take no medicines, basically. So I don't have any advice.

Dr. Meredith Loveless: Well, it's also again, everything with Medicare is complex. So talking to somebody that can look at the specific plans. So a lot of people are covered by a B and they have a supplemental advantage type plan. It would cover what's not covered by the A B, I think that's ideal. Because a B is great coverage. Medicare is a really good insurance plan. They cover most things they really try to have access to cutting edge technologies. We asked that they were proven to be safe and beneficial to cover them. But for the most part there, I think Medicare often leads the way to new technologies and coverage. I think the ad really does a great job in providing certain appropriate coverage for the beneficiary. So I think that those A B plans have quite a bit to offer.

John: Well, Meredith, that makes me think about when you're talking about the intellectual challenge. And we always talk about fulfillment. So really, part of what you're doing on top of that is getting that personal challenge that is that if you can make Medicare better than you're basically helping thousands, if not 10s of thousands of patients.

Dr. Meredith Loveless: Yes, it's, you really can see an impact in terms of it may, it might not be that the same satisfaction that you get is working with a patient who's really grateful. And that's pretty awesome. But at the end of the day all right, I've evaluated this and it's really not quite ready for prime time.

And we want to make sure that it's safe for, for people, or this is an awesome cutting edge technology that might improve people's lives and to be able to play a part of that. And then we're working as an advocate really for beneficiaries and physicians on the Medicare side is a rewarding role. And I think some people have the impression insurance is always trying to cut everything and save, save the dollar.

And I really don't think that that's how it is all the time. I think that they are trying to make sure, trying to reduce burden, trying to make physicians lives better, trying to make sure people are getting paid for what they do, while at the same time, trying to protect from fraud and abuse, which is an unfortunate problem.

John: Right, right. Well, this has been very interesting, I think very informative. People are going to get motivated, I think, to look at this and maybe had never thought about it before. I really appreciate the time and the information that you've provided us today.

Dr. Meredith Loveless: My pleasure.

John: This has been great. I thank you for that. And you don't have anything to sell. I don't really have any website or anything. But I do think I can't take anything from anybody. You can't, right?

Dr. Meredith Loveless: No.

John: But anyway, people may have questions beyond what I can answer or they can get out of this. So I'm thinking LinkedIn could be a place for them to track you down.

Dr. Meredith Loveless: Yes.

John: Send a message if they have a burning issue that they just need a little more advice on. Otherwise, they should just dig in and start looking around at the different jobs.

Dr. Meredith Loveless: And I think if there's not opportunities at the time, just getting some experience, knowing insurance language, whatever experience they can get could help be a ground building ground for creating a good application.

John: Okay. Yeah, definitely a little bit of research, a little background, get familiar. Well, that's great advice. And you can look at for Dr. Meredith Loveless on LinkedIn. I'll have a link in the show notes, but I'm sure you might get a few questions. And I guess with that, I better let you get back to your work. Thanks a lot and goodbye.

Dr. Meredith Loveless: Thank you. Bye-bye.

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