Reforming Medicare to protect the health of an aging and vulnerable population is a pressing policy concern. To share some perspective, Dr. Mary Naylor led a panel entitled “Shaping the Future of Medicare” at Penn LDI’s 50^th Anniversary Symposium.

The panelists addressed several core themes, including cost-effective personal care in the home, end-of-life care, Medicare payment reforms, and reimagining care for families of an aging population.

Randi Roy, chief strategy officer of VillageCare, noted that cost-effective home care could prevent readmission to the hospital if providers collaborate across settings. For homebound people with chronic conditions, technology in the home could predict crises and avoid or slow declines in functional status. As Roy noted, these measures could help contain health care costs.

David Stevenson, associate professor of health policy at Vanderbilt University School of Medicine, discussed the important role Medicare plays in end-of-life care. About 20-25 percent of Medicare spending is spent on the last year of life. It is important to ensure that care is not only cost effective, but meaningful to the patient. He called for changes in the way Medicare pays for hospice and palliative care to make it more aligned with families’ needs and more integrated with other clinical care.

Michael Chernew, professor of health care policy at Harvard University, stressed the opportunity to improve Medicare’s payment system by overcoming organizational silos that do not encourage integration of care. For example, payment reforms that reward Medicare Advantage plans for addressing population-based health needs could incentivize providers to make appropriate clinical decisions, rather than making payments through siloed bundles.

Terry Fulmer, president of the John A. Hartford Foundation, described the ongoing need to reimagine care for families facing end of life and serious illnesses through age-friendly health systems, in which nursing would play a large role. For older adults, age-friendly health systems consist of providers focusing on four major areas: (1) what matters most to patients, (2) medications, (3) mobility, and (4) mentation. She called for applying existing evidence to health systems to assess “what efficiencies are in front of us right now” related to nursing. For example, it would be more efficient for nurses caring for older adults to have autonomy for determining hospital discharge times and appropriateness to avoid costly readmissions. These evidenced-based practices can lead to significant cost reductions.

Medicare as a complex adaptive system

One overarching theme in the session was that modifications to Medicare could spark unpredictable, spontaneous changes. I believe it is helpful to view Medicare as a complex adaptive system that requires change to serve societal needs over time. For example, Medicare needs reform to support a rise in health care use by aging baby boomers, a crucial step to contain health care costs. 

According to organizational theory, complex adaptive systems feature four main characteristics: (1) self-organization among sub-systems, (2) predetermined behavior based upon an existing deterministic system, (3) interchange of interactions among sub-systems indicative of borderline chaos, and (4) adaptation over time.

Redesigning Medicare will involve components of self-organization among sub-systems, (such as home care). It will involve understanding the existing system that predetermines the delivery of end-of-life care. The chaotic nature of interactions among subsystems of home, outpatient, hospital, and hospice care, and how payment reform could take on a life all its own within the complex system that is Medicare. Finally, Dr. Fulmer explained how changes to Medicare should adapt over time, noting the need to continue to reimagine care. The answer to the question, “What matters most to the patient?” will evolve as societal values change over time.

This thought-provoking session provided rich perspectives on Medicare reform needed to protect a vulnerable, aging U.S. population, and was a reminder to consider how Medicare must adapt for a changing society.