An Offer from the Office of the ASPE

Just got off the phone with Don Moulds, who says that they would love to have me join their team at the Office of the ASPE, which I mentioned earlier. I am really jazzed: these are the folks who make policy recommendations to the Secretary, which she either accepts or discusses more. They have a lot on their plate right now, and will have a lot more. They think that my breadth of experience is just what they need.

Wow.

This could be an amazing experience. I would get to know all of HHS, from the CDC in Atlanta to CMS in Baltimore. I would help to shape the way in which health reform is operationalized, in ways that I could not do on the legislative side. I would get to be involved in cross-departmental initiatives (like a mental health-education thing that they have just started). I would be tested in ways that I can't possibly imagine.

I asked to be able to think on it over Christmas, and to get back to him next week. I'll probably take it, but I want to think a little bit about the Senate, and to talk with Marie, if I can.

It is nice to be wanted.

Executive Branch is Looking Up: The Office of the ASPE

On Wednesday and this morning, I had good meetings with some of the people who are workig really hard to restore the Office of the Assistant Secretary for Planning and Evaluation to it's former glory. APSE is a funny thing- it is supposed to be the Secretary's "Think Tank", the folks who generate ideas and help the Secretary "pull it together". One can tell a lot about an Administration's approach to the Health and Human Services issues by looking at how they staff the ASPE. I've met with 4 of the senior leadership, and it was great. I've got that "I would take a bullet for these people" look in my eye, coming out out of those meetings. I'll try to summarize:

1) Pat Conway: "Medical Director" with a loose portfolio to work on a variety of areas of interest. 3 years out of a RWJ Clinical Scholars program, got a Presidential Fellowship under Mike Leavitt in the Bush Administration, and has been retained in office since the change last year. He is a go getter, interested in CER and EMR and other things, and is involved in lots of discussions. And he was my entre to the rest of these folks.

2) Don Moulds: "Deputy ASPE": Former California Medicaid Policy guy, brought in a year ago to be the Civil Servant paired with the new ASPE to make the system work. Neat guy, curious about lots of things, clicked when we met.

3) Dara Corrigan: Lawyer, former Inspector General for CMS, Directors the Health Policy shop within the ASPE, and someone with whom I would be working. Neat lady, heavily involved in Children's Issues, including cross Department initiatives. Seemed interested in my work with Medical-Legal Partnerships.

4) Richard Franks, Director of Long-Term Services: Genius from Harvard, with a long history in the mental health world. He's spoke with me of working on a newly stood up project involving collaboration with the Department of Education.

Responses from these folks are positive so far.

From Don:

From: "Moulds, Donald (HHS/ASPE)"
Date: Thu, 17 Dec 2009 11:07:02 -0500
Subject: RE: Yesterday's meeting

Dear David,
It was a pleasure meeting you as well. Margaret is (and may have already succeeded in) working to schedule you with Richard, who I think you will enjoy. I look forward to talking again in the next few days.
Best,
Don

From Dara:

From: "Corrigan, Dara (HHS/ASPE)"
Date: Thu, 17 Dec 2009 15:42:36 -0500
Subject: RE: Thanks for meeting yesterday
David:
It was lovely to meet with you. It is inspiring to meet physicians like you who personally take the time to care for kids and fight on the policy side as well. I would welcome the opportunity to talk about medical-legal partnerships.
I look forward to speaking with you soon.
Dara

Very hopeful. I'll see how the next phase goes. Also got a "ping" from the Rockefeller people, which is also hopeful. We will see.

When I was in college, I auditioned for all 4 a cappella groups that were available to Princeton undergraduates whenever there were open auditions during my Freshman and Sophomore years. I had sung with the "Guys and Dolls" at Roger Ludlowe, hadn't I? I could do the same in college. Besides, in college, these groups went on trips and made recordings- all very cool things. The auditions had two parts: first, was a vocal audition. I passed that, and made it to the finals for several of the groups. Then the second audition- you went to the "practice room", usually in the basement of one of the dormitories, spent a few hours with the group, learned a piece and performed it. After each one of those experiences, I felt good about the singing, and felt like I had gotten along with the others reasonably well. But I never got to experience the joy of being awoken at midnight and being "sung" into the group.

That's a lot like what the current process feels like.

Just had breakfast with Diane Meier, a Health and Aging Fellow who just accepted a placement on the HELP committee. A few salient details:

1) She got her interview when a friend, Dan Smith of the American Cancer Society, was named Chief of Staff for the committee. He got her the interview with Jenelle Krishnamoorthy, who apparently is staying on as staff. Might be worth a following up.

2) She had an offer from Rockefeller that she turned down yesterday. Perhaps that will open something for the rest of us.

The CMS Office of Policy

So, I now found another place within CMS that is interested in having me on board: the Office of Policy. This is essentially the Administrator's think tank, and suffers a bit from the current lack of an Administrator. Karen Milgate, with whom we met a long tome ago in a faraway galaxy, is optimistic that there will be an administrator soon, and that, once that happens, they will be moving ahead.

Working here would be much more akin to working as a graduate student; I would be given several projects, on one of which I would be the lead, and I would go forth. Most of what they are working on right now is Medicare related, looking at geographic variations and the relationship between cost variation and service delivery, some work on the issue of dual eligibles, some things related to CER, EHR and other hot topics. They are really interested in the idea of having a clinical person work with them on these projects, and offer insights into that process. They freely admit that they don't have a lot to do with CMSO at present, but the the new director of that Center does have an agenda that she is trying to push actively. And they want me to come to visit.

I asked a bit about how Health Reform was going to work its way through CMS. They said that the Office of Legislation would have little to do with it; that we would more likely see activity in Baltimore, with some input from the Office of Policy providing background research to inform the decisions. All of this, of course, would depend on the Administrator.

Tomorrow, I will be meeting the acting ASPE. And I continue to wait on the Hill. We will see.

Been a While: Why Didn't I Write Over the Weekend?

Nerves, I guess. I had my last interview on Thursday, with Chris Schloesser, the Legislative Director at the Rockefeller office. It went well; Chris seemed very interested in having me come on board. I spoke of my need to be rooted in place, and how the Senator's relocation in West Virginia and long term commitment to the place matched my practice in Webster, and how I was able to thrive there. I left feeling really good about the interview; I felt like I had a good alternative to Senate Finance. But I then realized that I had not met Jocelyn, the Health LA with whom I would be working, and also realizing that everything on the Hill is about who knows who (and nobody is really anybody's friend). So, unless I get the call to come by to meet Jocelyn, they are not serious interested. So, then I wasn't sure what to think. And, my anxiety is simply building on itself. 4 days later, no call from Jocelyn.

Similarly, no call from Senate Finance. It was a week ago that Marie sent her message to Liz Fowler. Nothing. Now, objectively, the Senate is really busy right now. And maybe they don't have time. But Shale has an offer from Debbie Stabenow's office, as well as Nicky Lurie's office and House Ways and Means. And Barb is negotiating with Rima Cohen and Dora Hughes, as well as something else that she didn't want to talk about, which I am guessing is Rockefeller's office. So, until they settle, it is likely that I will hear nothing.

I'm not alone. Gustavo, Sheldon, Gregg and I all seem to be in the second tier of RWJ Fellows. Granted, that is not a bad second tier to be in (kind of like getting your third choice for residency and having it be Hopkins- how is this a bad thing?). But this sort of thing generates much anxiety. So, on Tuesday, I will talk with the CMS Office of Policy (the CMS Policy Think Tank) and on Wednesday, I am talking to the Office of the ASPE (HHS's think tank for the whole Department). Both would be incredibly relevant to me, going back to UMass and let me learn what it is that a policy shop does. So I shouldn't complain. I checked in with the Office of Legislation- they are still interested. That is a good thing.

Still, I've now been rejected by 5 of the 8 places that I have interviewed. And I have no idea what that means.

And the knot in the pit of my stomach continues. I think that I will go to sleep.

Met a Senator today

This morning, I interviewed with Oliver Kim, a very soft spoken, very smart health policy guy who works for the junior Senator from Michigan, Debbie Stabenow. While waiting for the interview, Senator Stabenow walked in, and immediately asked if I was being helped. We shook hands and I introduced myself, complimenting her on her speech on the floor of the Senate last Saturday. Pretty cool.

The interview with Oliver Kim went well. He is very cool, very thoughtful and he works for a Senator who is very engaged, and wants to make a difference. Mental health services are something that she has identified as a priority, and the current fellow has done some work at helping them to create a strategic approach to mental health services that they are implementing in the current environment. He outlined 5 things that they are looking for in a Fellow, including multitasking, written clarity, sense of humor, ability to work with independently and to talk with constitutents. Those all fit me; the office would be a perfectly good fit. He also asked for references (first person to do that).

But it just didn't seem exciting enough- I am not sure what I was looking for, but I wanted just a bit more. I wasn't sure that we "clicked". It stays low on the list, and we will see where if an offer comes in. And we will see how the meeting with Rockefeller's office goes tomorrow.

And I got to meet a Senator. So, not a bad day.

---------------

Addendum: Shale and Mark were offered positions at Ways and Means. Janet is going with Nicky Lurie. 5 placed. I am feeling a little left behind, but I also know that this is irrational. It will happen.

Waiting and Talking.

Talked to Marie today and got more feedback; she thinks that I am doing fine so far, but I have a few traits that may get in the way. My e-mails are too long and too many, which Hill folk will perceive as being "more work" than I am worth. Apparently, on the Hill, one is expected to swim without a lot of support. She made me promise brevity and to be low maintenance; with that in mind, she sent an e-mail to Liz Fowler recommending me to the Senate Finance Committee. We will see if that goes through. She also told me that CMS is really interested in having me come over to work with them, and they are bothering me a lot.

In the meantime, I had a chat today with Dora Hughes, the other Counselor in the Immediate Office of the Secretary, who has been holding the Department together while the Secretary gathers her forces and gets her leadership team in place. Dora is an internist, probably one of the highest ranked doctors in the government, who worked the Obama campaign after working six years in the Senate (Kennedy's office and then Obama's office), after working for the Commonwealth Fund out of residency. She talks really fast, but has experience with Fellows in the Senate and would love to have on in her office. She says that her "level" doesn't get involved in something until it represents a problem; she is the one sent in to solve it, particularly when it involves interagency conflict (CDC vs NIH vs AHRQ) for example. Rima has Medicare/Medicaid/CHIPRA; Dora has most everything else health related (there is a third counselor who has the Human Services portfolio. They have space, they have interest and they are in the Humphrey Building.

I am having a little trouble reaching Rockefeller's office- one e-mail address keeps bouncing. I will work on it. Interview with Stabenow tomorrow. Should be resolved soon.

A Sighting of Andrew Hu: The Process Continues

Julie has been in town since Thursday evening, and we've been having a wonderful time. Yesterday, we went over to the Senate to watch the floor action for a bit, and I spotted Andrew Hu, the Finance staffer who organized our Fellows' interviews, on the floor, joking with one of the other staffers instead of answering my e-mails. And so we continue to wait. Some updates:

1) Interview with Rima Cohen, Counselor to the Underscretary of Health Policy on Friday. I thought that it went well. Rima was a Daschle staffer who has been Director fo HHS for the City of New York for the last few years (she knew Lynn Silver), who came down here on temporary assignment more than a year ago, and still commutes home to see her 6 year old daughter on a somewhat regular basis. She described an office that is involved in discussions with the White House, the ASPE, AHRQ and the NIH over comparative effectiveness research, works with Medicaid on the big State conflicts and Medicare on just about everything, and how a Fellow could make her life easier. Her big job right now, however, is preparing HHS to hit the ground running on health reform. She will be a player when that happens. She's worked with RWJ Fellows in the Senate so she knows the program pretty well. Another Counselor, Dora Hughes, is in the same office- it sounds like they work quite closely together.

As I said, the interview went well, and late Friday, I was invited to come and meet with Dora Hughes, so perhaps they are interested. It would be a place to get a broader view of the work of HHS than would the CMS placement, and would get me involved in a broader range of agencies. We will see.

2) Putting an offer on hold. I responded to CMS, and got a nice response back:

David,

Thanks for your note. We are excited at the possibilities for you coming to OL. You bring so many strengths that we would capitalize on and we have some pretty interesting substance for you to learn in the laws, regulations, and guidance of the Medicaid program as well as the Executive branch perspective working with Congress.

We look forward to hearing from you soon.

Regards,

Jennifer

From: KELLER,DAVID [mailto:david.keller@umassmemorial.org]
Sent: Friday, December 04, 2009 7:24 AM
To: Orris, Allison B. (CMS/OL)
Cc: Boulanger, Jennifer L. (CMS); Marie Michnich
Subject: Re: Great to meet with you today.
My apologies for the slow reply; we are in the midst of a 4 day course on Congressional procedure, which has left me a bit dazed, and slow to respond to email. I am excited by the opportunity to work with you and your team; it really sounds like you will be in the thick of the coming changes, and it would be a way for me to better understand what is going on, and to be able to make a substantial contribution to the evolving system. As you suggest, I am in the midst of “exploring other options”; I should be done with all of my currently scheduled interviews by the middle of next week, and will be sitting down with our Fellowship Director Marie Michnich to discuss all of my options before deciding on a final placement. I will get back to you soon with any questions I have, although I think that we discussed most of the important issues during my visit. Thanks again for opening your doors to our Fellowship, and for this chance to learn by doing.

David

So that can wait a week, while I sort out the rest of this stuff.

3) Senate Finance. Sent two e-mails to Andrew Hu, as mentioned above, but he was busy and I have not made any progress with them. But Marie says that she wants to get me in there, and that she will talk to Liz Fowler next week.

Like watching the Senate in session, I guess this is progess.

Someone else got the ring, but I got an offer!

Long ago, when I was applying to Medical School, I was rejected by Yale and Columbia on the same day that I was accepted at Harvard. Today, we found out that Peggy will be working with Wendall in the Speaker's office. She is pleased, and she should be; it is a perfect match. I, on the other hand, got this today.

"Orris, Allison B. (CMS/OL)"
Date: Wed, 2 Dec 2009 14:11:07 -0500
To: "KELLER,DAVID"
Cc: "Boulanger, Jennifer L. (CMS)"
Conversation: Great to meet with you today.
Subject: RE: Great to meet with you today.


David,
It was very nice to meet you too. Thank you for your interest in learning more about OL and for taking the time to share with us your experiences and background. On our end, we would love to have you join us. We think we could put together a good portfolio of issues that would expose you to health reform implementation, the work we do with the rest of CMS to keep Medicaid running smoothly, and the daily interaction with Hill staff on pending legislative issues. We would of course be happy to continue the conversation as you also explore other options, but we do think having you join OL would be a good fit! Of course, we are still sorting through logistics on our end but are confident that we can work them out.

We look forward to hearing from you. Feel free to call either of us with questions anytime.

Allison
Director, Low Income Programs Analysis Group
CMS Office of Legislation
202-690-7762

From: KELLER,DAVID [mailto:david.keller@umassmemorial.org]
Sent: Tuesday, December 01, 2009 12:26 AM
To: Boulanger, Jennifer L. (CMS); Orris, Allison B. (CMS/OL)
Subject: Great to meet with you today.

Office of Legislation
CMS
Washington DC


Dear Jennifer and Allison:

Thank you so much for your time and thoughtful discussion of the possible role of a Fellow in the Office of Legislation at CMS this year. I loved your description of CMS as an Agency that gets of lot done with few resources. Many of us in academic practices have faced similar circumstances, and know how it feels to be under-resourced. CMS will be in an interesting position when Health Reform passes. The legislation is quite complex, and it will be challenging to work within the Federal system to unravel and define the steps needed to implement the new systems. The challenges to both Medicare and Medicaid are enormous, and it would exciting to work with the people who know how to tackle them. I think that it would be helpful to have people with real clinical experience involved in the discussion. It would likely help to keep any new system that we build “real”, which is an important part of ensuring that this implementation goes smoothly.

I think that this could be a fit for me, particularly within the given my interest in children’s issues and my state and local experience with my own state Medicaid system and the State Legislature. I would be interested in continuing our conversations as I continue to explore opportunities within the Legislative and Executive Branches of government. I understand that you will need to figure out how a Fellow would fit into your unique environment, with the personnel office and the security people; please remember that, with the RWJ Fellows, salary, benefits and further training are covered by our Fellowship. Your costs are space, connectivity, a full and interesting portfolio and mentoring.

I look forward to hearing from you in the near future. Thanks again for meeting with me today.

David Keller MD
Clinical Associate Professor of Pediatrics
UMass Medical School
2009-10 RWJ Health Policy Fellow
Institute of Medicine

Guess this is an offer. My first. Feels pretty good.

I also had a meeting today with Kate Gross, one the Health Aides in Senator Rockefeller's office. Senator Rockefeller is on Senate Finance, and is likely to be participating in the conference committee when Health Reform moves on. He is passionate about children's issues, access issues, primary care issues, dental issues and making sure that the people of West Virginia are cared for. They liked that I had been to West Virginia several times; we spoke of my TA visit to Huntington W.Va. and the way in which health care has to be molded to fit into the social mileau in in which it is practiced. They talked about how CHIPRA is going to be a major issue in the coming times. They seem a great office; she plans to interview several other candidates and we will see.

So, one offer, waiting to hear from several other places. And I know someone in the Speaker's office. It will keep getting better and better.