A few weeks ago Anita Lai and Shannon Crane sat down with Norma Coe. Norma Coe is an Associate Professor of Medical Ethics and Health Policy at the Perelman School of Medicine. She is also a PSC Research Associate and a LDI Senior Fellow.
SHANNON: Thank you so much for coming to meet with us today! Let's begin with what brought you to Penn.
Norma: Basically, the people. The quality of the research is second to none. People still manage to find time for mentoring and have an open door policy. It’s a unique combination to have that level of rigor and that level of friendliness.
SHANNON: Definitely. So how long have you been at Penn?
Norma: I started in September of 2017.
SHANNON: Where were you before?
Norma: I came from the University of Washington in Seattle.
SHANNON: What projects are you currently working on? I know that you gave a colloquium talk last semester. Any updates on that research?
Norma: The two big projects that I'm currently working on are estimating the cost of Alzheimer's disease and looking at how healthcare delivery systems, mainly fee for service versus Medicare advantage plans, change the incremental cost of Alzheimer's care. We want to estimate a forecasting model so that we know going forward what we can expect to spend on people with Alzheimer's and related Dementias. We then could use the forecasting model to help value innovations, such as a drug that delayed onset for a year or another therapy that changed the trajectory of the disease.
The other big project that I was awarded the grant for, two weeks after I got here, which was a nice welcome, is estimating of the quality of informal care. There is a lot of emphasis in the policy world to get people out of institutions and let them age in their home for as long as they can. Consequently we’d be saving Medicaid money because they're no longer paying for an institution, they're staying at home; however, it implicitly assumes that there's going to be somebody there who can help that person in the house. We've spent a lot of time in the last few years estimating the cost of that time provided by spouses and children. In a paper recently published in Journal of the American Geriatrics Society, we show that informal care costs the caregiver about $180,000 over the course of two years, which is almost the same price as a nursing home. This begs the question of: what is better for the health and well-being? We just launched a four-year project trying to figure that out. LDI did one of their briefs on the article.
SHANNON: Awesome! I love the LDI briefs.
Norma: I used to work at the Boston College Center for Retirement Research that did a similar thing. They tried to take academic work and actually make it accessible to a non-academic audience. It was surprisingly difficult because, of course, I think what I write is understandable and then when you actually step back and think about it, it's like, no, five people can understand this. It's hard to do, so I'm impressed with what LDI does.
SHANNON: It is difficult! How did that inform your process of disseminating about your own research? What has and has not worked for you?
Norma: I think the brief idea is amazing. Still to this day my parents wonder what I do. They're very excited to have LDI so that they can figure it out (laughter). Having a great dissemination arm is something that is truly unique and I think in general undervalued.
SHANNON: Yeah. I mean, I can also imagine it must be hard to talk about these giant institutions like Medicaid where I think people can get confused quickly.
ANITA: Navigating that is difficult and figuring it out for your parents too.
Norma: Yeah. It's like the Jimmy Kimmel man on the street bit. He goes and asks people, do you like the Affordable Care Act? And the answers show there was clearly some miscommunication. In this paper that just came out, the econometrics are quite difficult. It's called the structural model, an approach where we estimate utility functions. We're really trying to figure out what people value. We wrote the appendix first. Then I sat down, rewrote it, and said to myself, how would I explain this to my mother?
"The more you learn, the more you know what people don't know. That, in and of itself, keeps me motivated to ask the next big question."
SHANNON: I'm excited to read it! There are larger implications of your research and I think you touched on that a little bit, but what does that mean if we have an aging global population?
Norma: Overall, I think in general my research is about long-term care, as opposed to the acute care setting where you actually expect to recover or hope to recover from whatever the illness is. Long-term care, which is essentially the process in which you have a disability and you become unable to take care of yourself or live independently, either due to a health event or just aging in general. I think the implications of my research show that we have this fragmented system, which leads to terrible insurance protections against long-term care needs. My work points out the big hole we have in our insurance and in our social safety net, and estimates the effect on the economy as a whole. We are finding that children are living closer to the parents and are working less because of the fear that there will be a long-term care need that they will have to provide in the future. I think because most of it isn't actual money exchanging hands, we forget about it. My work has been to try to put a price tag on it.
ANITA: Yeah. It seems like it really takes a toll on the economy as you said. People are not moving across the country to support themselves. They're staying close to home to support their families and their parents.
Norma: Exactly. We actually find that they're more likely to be working part-time instead of full-time. It's not even just the quality of their job, it’s also the hours of their job. Part of the ACA did have a long-term care insurance component. It was never enacted because it was never financially feasible, but I think bringing it to the forefront and making sure policymakers are still thinking about it is important. It’s not just the baby boomers, we all get old.
SHANNON: I know you mentioned mentoring when you were talking about coming to Penn, but tell us a little bit about your teaching experience.
Norma: Sure. This is my fourth institution post Ph.D. My first job was in the Netherlands, then Boston College, University of Washington, and now I’m here. I've taught from the undergraduate level to the Ph.D. level. Most recently, I have been teaching economics to non-econ students, which is really fun and rewarding. As fun as it is to teach complex economics, I think it is important to teach people who aren't studying economics the fundamentals so that they can go and be productive members of society, knowing a little bit more about the economics.
"My work points out the big hole we have in our insurance and in our social safety net, and estimates the effect on the economy as a whole."
SHANNON: What advice would you give someone who is starting his or her career?
Norma: I usually tell my Ph.D. students and postdocs a couple of things. First, the world is smaller than you think. Even if you're in a job interview today and it doesn't work out, the connections you're making could pay off in the future. The other thing is to keep an open mind. In Economics, we have the luxury of having very different career trajectories even within academia. I've been in an economics department, in a business school, in a school of public health, and now in a medical school. It's important to keep in mind that you can make an impact in a lot of different places, and there are many options – you need to find where the fit is going to be better for you, your work style, and how you like to get things done.
ANITA: What motivates or inspires you to continue to achieve success in your career? How does one stick true to themselves as a researcher and a scholar? What has helped you persevere through those hard first early years too?
Norma: I do a lot of policy relevant work and there are so many unanswered questions. When I was at University of Washington, they became an accountable care organization. I was talking to some of the doctors there and I remember they were just learning about the variation in nursing homes. I was like, yeah. Why do you not know that? You should know that they provide different levels of care and some of them specialize in different things. The more you learn, the more you know what people don't know. That, in and of itself, keeps me motivated to ask the next big question. Hopefully, we can get ahead of the curve instead of following the curve. What does a lawmaker working on long-term care insurance reform need to know? What are all the facts they need to know about this market? How to set up a market for long-term care insurance?
SHANNON: What advice would you give someone who is planning to write a grant proposal? What have you learned from writing grant proposals?
Norma: There is a piece of general advice to read the RFP and make sure you're writing something that matches what they actually want to fund. Second, get as many people to read your grant as feasible. I was very fortunate to have Rachel Werner read my latest grant proposal. She basically destroyed my specific aims page three times to get it to the point where it was ready to submit. I think the hardest thing to do in a grant is to know all of the details and then explain it to 20 people from different academic backgrounds sitting in a room that are reading 50 grants. It is crucial to get that specific aims page absolutely crystal clear.
SHANNON: Yeah. It's very true. That's definitely the first thing that I read.
ANITA: How has networking impacted your career and are you a member of any professional organizations?
Norma: I am a member of professional organizations, but I think that's separate from networking, at least in my experience. I consider myself pretty introverted, but I still think networking has had a huge impact on my career. It literally brought me across the country and back again. When I was debating whether to leave Boston College, I saw an advertisement at the University of Washington. I didn't really know much about it other than that Anirban Basu was there, who I'd met at conferences. I called them up and just asked, what's the deal with the job? Is this a good place to work? And, sure enough, he was the head of the search committee and he hired me. It gets back into the advice that you just never know what is going to come from a job interview or a presentation at a conference. You don't know who's sitting in the audience. It could turn into something that's fundamentally career changing because you've made this connection or someone knows your name. When you can get into the smaller conferences that are 30 to 50 people, one-day conferences, the payoffs are huge because you can really make a lot of connections and really get to know people in those settings.
SHANNON: Tell us something about yourself that most people might not know.
Norma: I am an avid scuba diver and I spend more time underwater than above water on vacations. I’ve essentially traveled the globe underwater from Australia, Asia, Middle East, Micronesia, Hawaii, West coast, East coast, Honduras.
ANITA: Favorite spot?
Norma: Galapagos by far. I swam with 200 hammerhead sharks. We were hooked on a rock and it was sunny and then all of a sudden it just got dark -- a “baby” whale shark, about the size of a school bus, was above us and blocked out the sun.
SHANNON: That's pretty much one of the coolest things I’ve ever heard. Thank you for sharing that!
ANITA: Lastly, what are you looking forward to in the next year?
Norma: Hopefully, my latest grant application will get funded! I think it's an exciting time, there’s lots of work to do and questions to start chipping away at.