Susan Bartlett Foote, J.D.

At a time when the number of Medicare beneficiaries is growing and resources to support the program shrinking, HCFO grantee Susan Bartlett Foote, J.D. is helping to inform policymakers who struggle with the challenge of how to decide whether to approve coverage for the steady flow of emerging new health care procedures and technologies.

In her first HCFO study, Foote examined how Medicare makes coverage policy at the local level. While Medicare has a national coverage process for items and services, most coverage policies, called local medical review policies, are made by the 49 contractors (fiscal intermediaries and carriers) locally. Foote notes that tension exists between those who would centralize the development of coverage policies at the national level and those who support a decentralized system, but little data supports either side of the debate. Through her study, Foote traced the evolution of authority to make local policies, and factors that contributed to a decline in the number of contractors (see Foote, S.B. “Focus on Locus: The Evolution of Medicare’s Local Coverage Policy,” Health Affairs, Vol. 22, No. 4, July/August 2003, pp. 137-46). She also documented extensive variation in contractor resources, expertise, and policy output. Among her key contributions is categorization of the 9,000 local policies into utilization management policies affecting use of common services, policies affecting new technologies, and policies extending relatively new technologies to new uses. Because each category requires different expertise and resources, Foote suggests ways to allocate policy decisions based on technology characteristics.

Foote notes that, “fundamental policy issues of access, equity and quality come into play when considering the breadth of coverage for the Medicare population. These issues are complicated by the fact that Americans expect and demand the best health care available.”

In her current HCFO project, Foote is examining a variety of health care technologies that are covered by a mix of national and local coverage policies. She will examine whether utilization changes as a function of the implementation of a local or national coverage policy. Foote explains, “By looking at Medicare claims data, we can compare utilization pre- and post-policy. We can learn more about how coverage policies affect physician behavior and patient access.”

While Foote’s research interests include administrative regulation and Medicare generally, her expertise is medical technology, particularly coverage and reimbursement issues. Foote says that interest groups and government agencies have engaged in an intense debate about whether to centralize coverage policy or support the current decentralized structure. This research is providing data on many aspects of the coverage process in Medicare. In the recent Medicare Modernization Act (MMA), Congress directed CMS to consider how to allocate coverage decisions and to reform the contractor process. This data can assist CMS in addressing these concerns in the future.

Foote has authored numerous journal publications on technology-related issues. She is also the author of Managing the Medical Arms Race: Innovation and Public Policy in the Medical Device Industry, (1992) Berkeley: University of California Press. Foote currently serves as the Division Head of the Division of Health Services Research and Policy at the University of Minnesota, where she is an Associate Professor. She also serves on the Board of the Medical Technology Leadership Forum, and has served as an advisor to the FDA, the Office of Technology Assessment (OTA) and the NIH. She is currently on the CMS Medicare Coverage Advisory Committee.

Foote received her B.A. and M.A. from Case Western Reserve and her J.D. from Boalt Hall School of Law, University of California, Berkeley.

Articles from HCFO-funded projects

Foote, S.B. “Why Medicare Cannot Promulgate a National Coverage Rule: A Case of Regula Mortis,” J Health Polit Policy Law, Vol. 27, No. 5, October 2002, pp. 707-30.

Foote, S.B. “Focus on Locus: The Evolution of Medicare’s Local Coverage Policy,” Health Affairs, Vol. 22, No. 4, July/August 2003, pp. 137-46.

Foote, S.B. “Medicare Inequity: The Case of Local Coverage Policy,” Minnesota Physician, XVII(4):1, 2003, pp.12-13.

Foote, S.B., et al.“Resolving the Tug of War Between Medicare’s National and Local Coverage,” under review at Health Affairs.