A behavioral economics assessment of social security disability insurance earnings reporting documents.

BACKGROUND: Social Security Disability Insurance (SSDI) beneficiaries who work are often overpaid, with a median overpayment amount of over $9000. These overpayments occur when the Social Security Administration (SSA) pays benefits to beneficiaries not entitled to them because of work; beneficiaries are required to repay the debt to SSA. Work-related overpayments most often occur because beneficiaries work but do not follow SSDI program rules to report earnings and evidence suggests that SSDI beneficiaries are often unaware of reporting requirements. OBJECTIVE: To assess written earnings reporting reminders that SSA makes available to SSDI beneficiaries as a way of diagnosing a potential barrier to earnings reporting that contributes to overpayments. METHODS: Using insights from the behavioral economics literature, this article provides a comprehensive diagnosis of SSA's written communications that include earnings reporting reminders. RESULTS: Beneficiaries are infrequently notified or reminded of requirements, especially at points in time when that information is actionable; the content is not always clear, salient, and urgent; relevant text can be hard to find; and communications rarely emphasize how easy it is to report, what needs to be reported, deadlines for reporting, and the consequences of failing to report. CONCLUSIONS: Potential shortcomings in written communications may contribute to limited awareness about earning reporting. Policymakers should consider the benefits of improving communications about earnings reporting.

Organizational structure for addressing the attributes of the ideal healthcare delivery system.

The Institute of Medicine's (IOM) report Crossing the Quality Chasm described the aims, characteristics, and components of the ideal healthcare system but did not provide the templates of organizational structures needed to achieve this vision. In this article, we review three principles of effective organizations to inform the design of a facilitative clinical care structure: a focus on the patient and caregiving team, the use of information, and connectivity with executive and operational leadership. These concepts can be realized in an organizational chart that is inverted to place patients and their care providers on top, flat with few degrees of separation between patients and executive leadership, and webbed to reflect connections to the professional and ancillary departments. An example of a recently implemented clinical care infrastructure follows this discussion. This model divides the patient population into nonexclusive subgroups, each with an interdisciplinary collaborative practice team that oversees and advocates the subgroup's clinical care activities. The organization's interdisciplinary practice council, in conjunction with its physician and nursing practice councils, backs these teams, providing a second layer of support. The council layer is connected to the health system board through the clinical oversight group, whose core membership consists of council chairs, the chief executive officer, and the chief medical and nursing officers. Clinical information for planning and evaluation is available at all levels. This model provides a framework for identifying the individuals and processes necessary to achieve IOM's vision.

Expenditures and use of wraparound health insurance for employed people with disabilities.

BACKGROUND: The Affordable Care Act (ACA) provides health insurance to many working-age adults with disabilities, but we do not expect the new coverage or existing insurance options to fully meet their employment-related health care needs. Wraparound services have the potential to foster employment among people with disabilities. OBJECTIVE: We use Massachusetts, which implemented health care reform in 2006, as a case study to estimate the wraparound health care expenditures and use for workers with disabilities. METHODS: We identified a group of employed, working-age people with disabilities whose primary health insurance is Medicare or private insurance and who use the Medicaid Buy-In Program for wraparound coverage. We analyzed claims to estimate expenditures and use. RESULTS: Wraparound expenditures averaged $427 per member per month. Community-based services for both mental and non-mental health, which are generally not covered by Medicare or private insurance, accounted for 63% of all expenditures. The number who used community-based services was low, but the expenditures were high. The majority of the remaining expenditures were for services usually covered by primary insurance including: inpatient and outpatient, pharmacy and professional services. Expenditures were higher for people with Medicare compared to private insurance. CONCLUSIONS: This case study suggests that, from a total program cost perspective, wraparound demand is greatest for community-based services. From a member utilization perspective, the demand is greatest for coverage that alleviates out-of-pocket costs for services provided by primary insurance. Additional analysis is needed to further assess the design options for wraparound programs and their feasibility.

Early interventions to prevent disability for workers with mental health conditions: impacts from the DMIE.

BACKGROUND: As of 2011, over 9 million working-age adults were receiving federal disability benefits and this number is expected to rise steadily. Early intervention programs that seek to maintain employment and forestall the receipt of federal disability benefits offer a promising strategy to reduce the growing number of working-age adults on the disability rolls. OBJECTIVES: Using random assignment, this study examined whether an early intervention program of personal navigators, enhanced medical care, and employment supports can reduce dependence on federal disability benefits for adult workers with mental health conditions. METHODS: The study reports multivariate and descriptive findings based on 2279 participants in the Demonstration to Maintain Independence and Employment (DMIE). Logistic regression analysis was used to estimate program impacts in the treatment group relative to the control group. Data were integrated from state participant surveys and the SSA Ticket Research File. RESULTS: The DMIE intervention significantly reduced the percent of participants who received disability benefits after 12 months of enrollment. Across both states, the difference between the treatment group and control group was 1.1 percentage points (2.5% versus 3.6%, p < 0.01). In Texas, the difference was 1.2 percentage points (3.2% versus 4.4%, p < 0.01). CONCLUSIONS: Early intervention programs with a personal navigator can reduce dependence on federal disability benefits for adult workers with mental health conditions. Future studies on the cost-effectiveness of such programs are needed.