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Monday, July 21, 2014

A Proposition for Improving Value in Health Care: Improve Coordination for Those Transitioning into Medicare

Kirstin Woody Scott, Harvard University

Within the world of health policy, it is quite uncontroversial (repetitive, and perhaps even uninteresting) to say that our $2.8 trillion health care system needs to be improved.  There is a robust body of evidence that shows how the U.S. system underperforms in terms of value.  In other words, there is a growing awareness that more health benefit should stem from this hefty societal investment in health care.  As I try to explain to my family (who understandably look puzzled by what their daughter – a health policy PhD student - actually does) – we simply feel that we should be getting more bang for our buck.

A recent New England Journal of Medicine and Harvard Business Review collaboration explored this concern about value and the need for innovation in health care more deeply.  The essays written for this collaboration demonstrate that there is a great deal of enthusiasm around current efforts to reform the delivery and payment mechanisms of our costly health care system, including improving the coordination of care.  Many (though certainly not all) of these “new” initiatives – including Accountable Care Organizations and other care coordination demonstration programs – relate directly to the Affordable Care Act (ACA).  None are a panacea unto themselves, but they are moving the needle in health care.  Whether the movement of the needle is heading in a “good” or “good enough” direction or the reverse, may be influenced by your views on the ACA, which continues to be quite the political football (including in terms of public opinion) and will be front and center to many campaigns in the approaching November 2014 midterm election. Nonetheless, whether or not you may find yourself on the proposition or opposition side of the “ACA is a step in the right direction” debate, it seems also rather uncontroversial to say that the health care system is going through some pretty remarkable changes right now. And about one-fifth of that $2.8 trillion health care pie – the Medicare program – is all but immune to these changes.

It was the discussions regarding this major $570+ billion social insurance program that caught my attention at this year’s National Academy of Social Insurance (NASI) annual conference, which focused on “strengthening the web of financial and retirement security”. While most of my health policy training to date has focused on topics related to improving care coordination and delivery of high quality care for today’s 47 million Medicare beneficiaries – including how medically-complex needs are coordinated by providers (e.g., hospitals and physicians) – the presentations at NASI exposed me to yet another critical area that will require improved coordination: supporting future Medicare beneficiaries and their families as they transition into the Medicare program.

Representatives from a variety of Medicare advocacy and patient organizations – including the Center for Medicare Advocacy and the Medicare Rights Center – provided thoughtful and instructive presentations during their roundtable discussion on “transition issues” that are emerging due to changing demographics as well as new provisions of the health reform law. People are working longer, there are fewer workers per beneficiary, more people are dually-eligible for both Medicaid and Medicare, and many other factors that make what has traditionally seemed to be a straightforward enrollment process, a more complicated endeavor.

The presenters reminded us that these are indeed the individuals who are on the other end of the phone when Medicare beneficiaries or their loved ones call looking for help or advice as they navigate complicated paperwork or policies. In my humble view, it is these advocates who are among the first to know of the real system-wide impact of any policy change in Medicare, whether it be intended or unintended. Among the most memorable (and perhaps unsettling) of these presentations was that from Rafael Gonzalez of Gould & Lamb, which provided the audience with a jaw-dropping account of how complicated compliance can be with the Medicare Secondary Payer policy (which seems logical on paper, but likely needs to be revisited in terms of how it is enforced).  Improving the coordination of a beneficiary’s entrance into the Medicare program – especially in relation to this policy and especially for the most vulnerable of patients – may help mitigate seemingly unnecessary emotional or financial strain for current and future beneficiaries.

Overall, the discussions in this roundtable as well as other fascinating presentations at NASI helped expand my own conceptualization of care coordination for Medicare beneficiaries.  Consequently, this broadened my enthusiasm for how policymakers (and health services researchers) can be innovative in improving value in our health care system. To improve our ability to understand the gaps in coordination at the transition into Medicare (which 10,000 Americans are experiencing a day) and how to fill them in a smart way – data around this transition period will be necessary.  Improving coordination at this level in a data-driven way seems to be a high-value proposition as we aim to strengthen both financial and retirement security for Americans in the future.


Kirstin Woody Scott is a Ph.D. candidate in Health Policy at Harvard University in the political analysis track and a National Science Foundation Graduate Research Fellow.  She received her Master of Philosophy in Public Health from Cambridge University and formerly served as the Public Health Advisor to a County Supervisor in her home state of California. Her research in healthcare politics and quality focuses on physician-hospital integration, the role of health policy in elections as well as the prioritization of quality on the global health agenda. She is also an avid endurance runner and volunteers for an organization in Nicaragua, where she formerly served as a Rotary Ambassadorial Scholar. Woody Scott was one of six students and young professionals awarded a scholarship to attend NASI’s 26th annual policy research conference January 28- 29, 2014, in Washington, DC.

Posted on July 21, 2014  |  Write the first comment
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