Far from the dueling legislative approaches to “reforming” Medicare, hidden away in a large office building just outside the Baltimore Beltway, lies the nation’s largest health insurer. What was once plainly and unambiguously called the Health Care Financing Administration (HCFA ... always pronounced acronymically as HICK-fuh) was reorganized, restructured, and renamed early in Bush’s term. Health and Human Services Secretary Tommy Thompson introduced the new moniker on June 14, 2001. Henceforth, the agency would become the Centers for Medicare & Medicaid Services, and its abbreviation (not acronym, since all you can do is spell it out rather than make into a sorta-word) would become CMS.
Parenthetically, from day 1 of the new name, wags (myself among them) have wondered which of the two Ms—Medicare or Medicaid—drew the short straw when that abbreviation was created. For the record, no federal government agency used (or uses) CMMS as its abbreviation, and both cmms.gov and cmms.hhs.gov were available domain names at the time. In fact, even now the latter domain name appears to be unused, while the former merely mirrors the real http://cms.hhs.gov site.
George W. Bush’s first (and only, so far) selection as Administrator of HCFA CMS is Thomas A. Scully. Mr. Scully is not one to pussyfoot around or mince words; bureaucratic temperance is decidedly not Tom Scully’s management style. Early in his tenure, the Administrator apparently perused a collection of the agency’s education/information materials and then dashed off a memo expressing support for one or two of them, but demanding the immediate removal of all the rest from their catalogue. He declared unequivocally that all brochures other than the personal favorites he’d chosen in his 30 minutes or so of evaluation were “TOAST!” That pronouncement, then and now referred to as the “toast memo”, saw wide and rapid (and unauthorized) distribution across the network of agency staffers and contractors.
In recent days, Tom Scully has again found himself in hot water. Once again, the scalding is basically self-inflicted. And if his bosses—Messrs. Thompson and Bush—had an iota of integrity, he would be booted out of his office suite in a millisecond.
I refer you to a hot-off-the-presses report from the GAO, titled CMS Contracting Issues: Concerning Administrator’s Decision to Exclude Subcontractor. The report describes the shenanigans surrounding a CMS contract awarded to RAND and its subcontractor, the University of Wisconsin’s Center for Health Systems Research and Analysis (CHSRA). Last September, on the same day that Medicare staff approved the contract, Scully personally canceled some $1.6 million of the agreed-upon funding ... that portion of the contract earmarked for work by CHSRA.
It seems that Scully doesn’t like CHSRA’s director, David Zimmerman, who has questioned several aspects of CMS’s Nursing Home Quality Initiative, which includes both public reporting of so-called “quality measures” and interventions aimed to raise the quality of nursing home care. Two days before the contract was awarded, in fact, Zimmerman had written a letter to Scully strongly suggesting changes in the public reporting comparison standards.
Zimmerman’s objections include questioning Scully’s personal decision—unsupported by scientific evidence—to give the label of measures to what are at best sketchy and unfocused indicators of care patterns. To a scientist like Zimmerman, the term “measure” is reserved for quantities that are far better defined and far better validated than the rates generated from nursing home reports. Zimmerman knows whereof he speaks, because CHSRA tested and developed the standard set of quality indicators that nursing homes have used and reported for many years.
Scully’s handling of this situation has been, to put it in the most polite light, high-handed and capricious. He told RAND that they could have the contract only if they dropped CHSRA as a subcontractor. When RAND refused to remove CHSRA from their proposal, he simply withheld the sum earmarked for the subcontractor, personally informing CMS staffers that the agency “had no intention” to restore those funds to the contract for CHSRA. Continuing his penchant for pithily astonishing email communications, several Scully messages are quoted in the GAO report. Excerpts:
There is no entitlement to government contracts—especially when you try to sandbag the agency you contract with.
If you want to continue to yank my chain, I will continue to disconnect you from this agency.
While the GAO dispassionately lays out the facts of the Scully-Zimmerman
contretemps, Senator Charles Grassley (R-IA), who is more knowledgeable on nursing home matters than any two other legislators (and also one of the few Republicans in Congress who occasionally reconnects with objective reality on other issues), is royally pissed off. In a letter to HHS Secretary Thompson (who, I must note, was once the governor of Wisconsin and perhaps holds a less-than-favorable opinion of those research-types in Badgerland), Grassley characterizes Scully’s machinations as “
an intolerable threat to the integrity of the procurement process”.
Well, no kidding.
But doesn’t this just reek of the same sort of stench we see in the Halliburton contracts, the recently-unearthed Executive Order 13303 that may offer carte blanche to Big Oil to do as they please in Iraq, and a thousand other examples of Dubya’s complete fealty to his fat cat big-corporate donors and supporters? And doesn’t Tom Scully sound like a guy who learned his management and public relations skills at whichever dark academy spawned Don Rumsfeld?
It would seem that a stink such as this should finish off Tom Scully. But he stayed around through the “toast memo” fallout, and he has continued to serve as CMS Administrator while fighting a lawsuit brought by the Gallup Organization, in which it is alleged that he retaliated against a senior official of Gallup following the company’s attempts to inform OMB about “potential collusion” between CMS and a competing survey research firm.
So, despite what looks for all the world like a pattern of improprieties, perhaps Mr. Scully will once again avoid becoming “toast” himself. And perhaps the broadbased, multidimensional trashing of American ethics, values, and rectitude that is the administration of George W. Bush will continue to inflict its wounds upon what few shreds remain of our nation’s former reputation for integrity and square-dealing.
Scully has already served far longer than most HCFA/CMS Administrators do; the average is somewhere in the 18-month range. Can he survive these latest revelations?
UPDATE—On rereading this entry, I realize that I didn’t clearly state the important point about the Scully-Zimmerman dustup. Zimmerman and CHSRA were attempting to engage in scientific discourse, offering their reasoned critiques and interpretations of the NHQI approach. Scully perceived that as a frontal attack on the course he had encouraged, pushed for, and personally decided upon, and (over)reacted by applying direct executive power against those who had dared to cross him.
If that’s not a textbook example of the Dubya-esque “if you ain’t with us, you’re agin us” cancer that’s afflicting the executive branch, I don’t know what is.
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