H

Reaching and Educating Medicare Beneficiaries About Choice

Carol Cronin*

Introduction

Every month approximately 225,000 Americans turn age 65 and become eligible for Medicare, the largest health insurance program in the country. Traditionally, although the financing of beneficiary health insurance changed at age 65—from the private sector to the public sector—the actual delivery of health care services was little affected. With the introduction of managed care over the last 10 years, Medicare beneficiaries are increasingly faced with choices about the way in which they will receive their health care. Recent and proposed legislation will further increase the options available to beneficiaries by allowing additional types of health care arrangements such as preferred provider organizations, point-of-service plans, and provider service networks. The introduction of managed care as a choice in the public sector reflects the growth of managed care offerings to active workers by many private sector employers. According to an annual survey of employers, the number of employees enrolled in some form of managed care rose from 52

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--> H Reaching and Educating Medicare Beneficiaries About Choice Carol Cronin* Introduction Every month approximately 225,000 Americans turn age 65 and become eligible for Medicare, the largest health insurance program in the country. Traditionally, although the financing of beneficiary health insurance changed at age 65—from the private sector to the public sector—the actual delivery of health care services was little affected. With the introduction of managed care over the last 10 years, Medicare beneficiaries are increasingly faced with choices about the way in which they will receive their health care. Recent and proposed legislation will further increase the options available to beneficiaries by allowing additional types of health care arrangements such as preferred provider organizations, point-of-service plans, and provider service networks. The introduction of managed care as a choice in the public sector reflects the growth of managed care offerings to active workers by many private sector employers. According to an annual survey of employers, the number of employees enrolled in some form of managed care rose from 52 *   Health Pages, New York, New York.

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--> percent in 1993 to 63 percent in 1994, the largest increase seen in the 9-year history of the survey (Foster Higgins, 1994). With the changing options available under the Medicare program comes the need to clearly inform and educate beneficiaries about their choices in order for them to make a decision that best meets their personal needs. This paper focuses on communicating with Medicare beneficiaries over age 65 about their health plan options, with an emphasis on communicating about the topic of managed care. Information on reaching and educating disabled beneficiaries under 65 is not addressed in this paper. The paper first reviews the literature with reference to communicating with older adults in general, including an analysis of the preferred media. The literature on communicating with older adults about health care, and managed care in particular, will then be presented. The balance of the paper includes case examples of different communications channels, including print, telephone, broadcast, video, electronic, and person-to-person, approaches used to disseminate information about health, managed care, or health plan choices. Wherever possible the examples given pertain to Medicare beneficiaries or older adults; however, in some cases they apply to all health care consumers. The case examples, largely drawn from telephone interviews and a review of program materials, are organized by information source including public agencies (such as the Health Care Financing Administration or public libraries), nonprofit organizations, private companies, employers, and health plans. The paper is not meant to be a complete description of what these organizations do, nor is it meant to be a comprehensive review of all of the organizations that use these types of media, but rather, it is meant to highlight the range of organizations communicating with older adults about health care and the types of media that they use. Communicating With Older Adults: Media Approaches A discussion of the literature on communicating with older adults includes two bodies of work. The first deals with the literature relating to the use of various media to educate older

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--> adults about a topic and the second deals with marketing to the ''mature market," a relatively new aspect of business interest that has emerged with the growing size and potential purchasing power of older adults. In the context of health care choices, the purpose of education is generally to assist an individual in making an informed choice, often through the presentation of complete and easy-to-obtain information (Davidson, 1988). This is particularly important in the context of Medicare beneficiary choices about health care, because the consequences of a poor choice can be particularly devastating. On the other hand, marketing generally involves four major elements, known as the four P's: product (the good or service being offered), place (the location where it can be purchased), price (the value to the consumer), and promotion (the ways in which potential purchasers are made aware of and encouraged to buy the product) (Dychtwald et al., 1990). A good definition of marketing, particularly in the context of Medicare managed care, can be found in the Health Care Financing Administration (HCFA) policy manual regarding marketing conducted by health maintenance organizations (HMOs) and competitive medical plans (CMPs) with Medicare contracts: "Marketing includes activities undertaken by an HMO/CMP to generate good will, encourage individuals to enroll in or remain in a prepaid health plan, or to provide information on plan benefits or costs and membership rules" (Health Care Financing Administration, 1992a). The following review of the literature focuses primarily on the use of media preferred by older adults rather than the content of the media or its purpose (educational versus marketing). However, as further discussed in the conclusion, the question of content and purpose are key issues that will need to be addressed in the context of public policy discussions. Older adults are active users of mass media of all types. Television is the most widely used medium among adults age 55 or older (Moschis, 1992). A special report for American Association of Retired Persons' (AARP's) Modern Maturity Magazine conducted by the Roper Organization (Modern Maturity/The Roper Organization, 1992), indicated that adults over age 50 spend a median of 161 minutes per day watching television, four

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--> to five times more than the time spent with any other media. Older adults' television viewing increases dramatically around prime time but is also high during the daytime hours (National Council on the Aging, 1985). Entertainment and relaxation are the chief reasons for watching television (36 percent); this is followed closely by news (32 percent) (Johnson & Johnson, 1988). In 1992, more than half of households with individuals over age 50 had cable television (53 percent) and owned a VCR (56 percent), up from 49 and 43 percent, respectively, in 1988 (Modern Maturity/The Roper Organization, 1992). Proportionately fewer older adults than younger adults listen to radio, with approximately 20 to 25 percent of the adult radio audience comprising adults over age 55 (compared with 45 percent of adults ages 18 to 34) (Menchin, 1989). However, in this medium, station formats are varied and older audiences can be reached by carefully selecting the appropriate type of programming such as news or easy listening formats (FIND/SVP, 1993). With reference to print media, older Americans are more likely to read newspapers on a daily basis compared with all adults (84 percent of adults over age 50 compared to 78 percent of all adults) (Modern Maturity/The Roper Organization, 1992), with readership remaining high even among those age 80 and older (Moschis, 1992). Newspaper magazine supplements, such as Parade, are noted to be particularly effective in reaching older adults, as are the growing numbers of newspapers for senior citizens which serve as "the trade journal of the retiree" (Menchin, 1989). Most adults over age 50 (70 percent) are magazine readers (Modern Maturity/The Roper Organization, 1992), and households with subscribers over age 55 account for 40 percent or more of the subscribers to a large number of magazines such as Prevention, Golf Digest, Southern Living, and Yankee (FIND/SVP, 1993). Many women's magazines are widely read by older women and, similar to senior newspaper, senior magazines such as Modern Maturity and Lears are increasingly available (Menchin, 1989). With reference to newer forms of media and communications vehicles, a recent study of on-line computer users indicated that

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--> only 2 percent of those age 65 and older and 9 percent of those ages 50 to 64 report ever having been on-line (Shannon, 1995). Looking at the entire population, barely 15 percent of the population can be considered on-line users, although 76 percent of the American public identifies on-line service use as "the wave of the future" and 50 percent of people who don't even own computers today see themselves on-line by the end of 1997. The Modern Maturity/Roper survey indicated that adults over age 50 are generally quite positive toward both print and television advertising, with advertising that has verifiable claims and appeals to their intelligence and sense of fairness taken more seriously than those that rely on gimmickry. Of the different approaches, advertising that promises the security of a money-back guarantee if the customer is not satisfied is considered believable, whereas about half trust advertisements that carry the approval of well-respected health or medical organizations such as the American Medical Association. In contrast, older adults are skeptical of ads that carry celebrity endorsements and those that use slogans such as "new and improved" (Modern Maturity/The Roper Organization, 1992). Direct mail advertising and communication have also been described as effective in reaching older adults because they allow for a longer message and a presentation pace controlled by the reader and can reach older adults with timed precision (around when they need to make a decision) (Menchin, 1989). Many writers on reaching and communicating with older adults note that mature consumers do not constitute a homogeneous age segment (Lumpkin et al., 1989). Education, age, income, and living arrangements have been related to communication channel selection, with elderly people who did not complete high school less inclined to select any communication channels and age, income, and living arrangements affecting the preferred type of communication channel used (Goodman, 1992). A number of marketing efforts have been developed to segment the older population with reference to such factors as demographics, attitudes, values, and/or behaviors. Older adults are arrayed into distinct segments on the basis of such psychological factors as ability to cope with external changes/internal changes and their levels of independence/dependence or intro-

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--> version/extroversion (FIND/SVP, 1993). For example, Strategic Directions, a Minneapolis-based consulting firm, has conducted research that has resulted in the definition of four segments of the older population specifically related to health: the proactive adult who seeks out a great deal of information about how to stay in good health, the faithful patient who relies on doctors and medication, the optimist who never gets sick, and the disillusioned who are least trusting of their doctors and seek out information (Morgan, 1993). Different communication strategies would then be used to reach each of these segments. Communicating With Older Adults About Managed Care and Medicare Choices Review of the Literature A discussion about communicating with Medicare beneficiaries about their health care options, including managed care, should begin with a discussion of the extent of their knowledge about the Medicare program in general. If older adults do not understand the basic Medicare program, it is not likely that they can be informed enough to understand their health care options beyond the basic program. Several studies have shown that Medicare beneficiaries have limited knowledge of their Medicare benefits (Cafferata, 1984; LaTour et al., 1986), with beneficiaries generally more aware of the services most often used, such as physician care and prescription drugs, and less knowledgeable about less frequently used services, such as hospital and nursing home care (McCall et al., 1986). With regard to their knowledge of health insurance, Medicare beneficiaries are not that different from younger adults. A nationwide survey of more than 1,000 consumers in 1990 found that privately insured Americans have an uneven knowledge of their health coverage. They seem to understand basic elements of their health plans (hospital and physician coverage), but have less understanding of coverage for such items as mental health or long-term care (Garnick et al., 1993). It is interesting to note, in addition, that all of the HMOs interviewed for this paper began their conversations with the author with the observation that a first task of the health plan

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--> in communicating with Medicare beneficiaries is to "educate them about Medicare." As will be further discussed in the conclusion, the finding that many Medicare beneficiaries lack basic knowledge about the Medicare program may have important implications for policy makers interested in communicating with beneficiaries about health plan choice. When communicating specifically about health topics and choices to older adults, another more informal communication channel becomes important: family and friends. Although studies show that about half of adults over age 55 report awareness of medical and health information through magazines/newspapers and radio and television advertisements and programs, many also rely on friends/acquaintances and spouses (Moschis, 1994). With specific reference to communication with older adults about HMOs, one study that conducted structured interviews with 260 older adults concluded that only a relatively small number of people pay attention to brochures received in the mail, in contrast to the power of word of mouth by an HMO member (Titus, 1982). Another study looked at both how beneficiaries learned about HMOs and the most influential sources of information in enrollment decisions about HMOs (Brown et al., 1987). The most often cited sources of information in learning about Medicare HMOs were the media (55 percent), a friend or relative (50 percent), personal contact with an HMO representative at an open house (48 percent), and direct mail (41 percent). With reference to which among the various sources of information was the most influential in their decision to enroll in an HMO, the most frequently cited sources were friends and relatives (31 percent), an open house (23 percent), direct mail (19 percent), direct contact with an HMO representative (11 percent), television (5 percent), and newspapers (4 percent). The researchers also found substantial differences in source of information and influential information among enrollees and nonenrollees and the level of previous knowledge about local HMOs. A final study found similar results when surveying Medicare HMO and social/health maintenance organization (S/HMO) enrollees (a S/HMO is a health plan that combines Medicare HMO coverage with chronic care benefits and services such as per-

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--> sonal care and homemaker services) (Newcomer et al., 1990). Among the HMOs, the vast majority of enrollees cited referrals from family and friends as being the most important source in learning about the health plan. The second most frequently cited source was health professionals; this was followed closely by direct mail contacts. In contrast, S/HMOs did not have the advantage of widespread communication through informal referrals such as family and friends. Instead, they appeared to have relied more on direct mail and telemarketing and on the dissemination of requested plan materials and advertising. Another body of literature looks at communicating with Medicare beneficiaries about managed care from the perspective of the managed care plan. Because traditional HMO marketing targets employed populations and is characterized by marketing to groups, rather than the marketing approach to individuals required in the Medicare program (Prasad and Javalgi, 1992), HMOs need to change their organizational culture to address the specific needs of a mature population (Gilmartin, 1993). The importance of understanding and addressing the needs of older adults to help them make informed decisions about joining an HMO was the subject of a brochure developed by the Group Health Association of America (GHAA), the trade association of HMOs based in Washington, D.C. (Group Health Association of America, 1991). The brochure includes tips on conducting a thorough enrollment presentation and tips for talking to or writing for older adults, as well as outlining the perceived advantages of HMOs for older adults. Focus Group Research Another source of information about preferred sources of information about Medicare and health plan options comes from recent focus groups and structured interviews held with Medicare beneficiaries. A series of 15 focus groups conducted in the fall of 1993 for the Kaiser Family Foundation looked at a series of issues related to the overall Medicare program (Mellman, Lazarus & Lake, 1994). The focus group report concluded that the biggest problems with Medicare have to do with communication and coverage. When asked about specific ideas for improving communication about Medicare, focus group participants

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--> indicated the greatest interest in a toll-free number answered by a knowledgeable operator who could answer specific questions. They were also interested in seminars, again because of the opportunity to obtain answers to specific questions. Participants were mixed in their reactions to the use of videos and were less enthusiastic about a cable television show as a means of distributing information about Medicare. Another series of focus groups, again held for the Kaiser Family Foundation, looked more specifically at issues related to managed care and Medicare (Frederick/Schneiders, Inc., 1995). This series of 14 focus groups held in eight locations in early 1995 explored the issue of how Medicare beneficiaries seek information, how they make their choices, and how they would prefer to receive information. A range of preferred information sources was mentioned by participants, including printed brochures, one-on-one sessions with HMO representatives, and meetings. Word of mouth was viewed as important by many of the participants with reference to the actual choice of an HMO, whereas there appeared to be less interest in videos. The Setting Priorities for Retirement Years (SPRY) Foundation, a consumer-oriented, Washington D.C.-based nonprofit organization, conducted a series of 28 interviews for HCFA in June 1995. The purpose of the interviews was to seek insight into the views and preferences of older adults on their Medicare choices and to test their reactions to printed materials addressing these issues (Jorgensen et al., 1995). Among other things, the participants were asked where they would go if they wanted more information on Medicare managed care. The most common response was that they would call Medicare directly, although none of the respondents mentioned the HCFA toll-free hotline specifically (discussed below). Other preferred sources of information included seniors centers, public libraries, post offices, county aging service agencies, and Social Security offices. With reference to format, the majority of participants preferred a brochure printed on plain paper in large type with areas of white space to include some boxes and illustrations. A final set of recent focus groups with Medicare beneficiaries was conducted by the Research Triangle Institute under contract for HCFA (Research Triangle Institute, 1995). Consistent

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--> with the findings obtained with other focus groups, when asked about different ways in which information for health plan choice could be presented to them, participants stated an overwhelming preference for personal presentations, either as a group presentation with opportunities for questions afterward or as a personal counseling session. Other participants recommended that written material be used in conjunction with the presentations. There was some interest in telephone hotlines, videos, and computer models, but concern was expressed over the technological aspects of each of these media. When asked about information sources, respondents noted that input from friends and relatives was seen as highly credible, insurance plan representatives were not likely to be trustworthy, and impartial information sources, such as Consumer Reports, were viewed as credible sources. Additional focus groups that may shed further light on communicating with Medicare beneficiaries about their health plan choices are planned. A series of Medicare focus groups will be conducted by the National Committee for Quality Assurance (NCQA) in the course of a Commonwealth Foundation-funded project looking at consumer information. In addition, the teams of organizations funded under the federal Agency for Health Care Policy and Research's Consumer Assessments of Health Plans Study (CAHPS) are also planning to hold focus groups of adults (that may include Medicare beneficiaries) to look at the effectiveness of particular information strategies such as print materials and videos. Case Examples of Different Media Used to Distribute Information About Health Plan Choice and Managed Care Print Media: Pamphlets, Reports, and Guides Public Agencies To date, most of the information distributed to Medicare beneficiaries by HCFA about health care choices and managed care has been in a print format. Federal information dissemination about Medicare health care options is tiered. Approximately

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--> 3 months prior to turning age 65, the age of eligibility for Medicare and Social Security, an individual receives an initial enrollment package from the Social Security Administration consisting of an enrollment card, a letter, and pamphlets about Medicare ("What You Need to Know about Medicare and Other Health Insurance") and Social Security. The Medicare brochure includes a brief description about Medicare and managed care, Medigap insurance, and other private coverage that might be available to the beneficiary (employer coverage, workers' compensation) (Social Security Administration, 1994). The brochure's managed care narrative refers the reader interested in learning more to the Medicare Handbook (Health Care Financing Administration, 1995a) or to another HCFA brochure entitled "Medicare Managed Care Plans" (Health Care Financing Administration, 1995b), available through the Consumer Information Center in Pueblo, Colorado. The latter is a 15-page brochure that discusses how managed care works, enrollment issues, selection of doctors and hospitals, advantages and disadvantages of HMOs, disenrollment, and appeals. In a separate mailing to the newly eligible Medicare beneficiary that occurs up to 3 months before or after the 65th birthday, HCFA sends the Medicare Handbook, currently a 57-page document available in English or Spanish, that covers all aspects of the program (Parts A and B, appeals, noncovered services, etc.). Two pages of the Handbook discuss Medicare managed care and the reader is given a toll-free number to call to see if there is an HMO in his of her area (currently, approximately 75 percent of Medicare beneficiaries have access to an HMO in their areas). The Handbook also includes all of the telephone numbers for state health insurance counseling programs (see below). Current Medicare beneficiaries interested in managed care would probably only know about managed care options if they took the initiative to find out more themselves by calling the Medicare Hotline (see below), an HCFA regional or central office, or a senior counseling program or if they heard about HMOs through plan advertisements or family and friends. There are several additional print materials that are available by request from HCFA on managed care and health care options including the following:

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--> to apply for Medicare, eligibility and benefit coverage, and Medicare HMOs in the area. The kiosks are located in public libraries, food stores, a national discount store chain, and state and federal public office locations. The kiosk text is available in Spanish, Vietnamese, and Navajo, in addition to English. An average of 40 to 50 people access each kiosk daily for information. The specific interest in Medicare information varies from location to location, with approximately 20 inquiries about Medicare of a monthly total of 3,335 (<1 percent) at the Wal-Mart kiosk, compared with 225 of 2,733 (8 percent) at the Social Security office kiosk. SSA staff will evaluate the kiosk program in 1996 for possible replication in other areas and are also talking about making the kiosk software available for replication to other states (Georgia and North Carolina) that maintain, or that are thinking of developing, their own kiosks. Private Sector Healthtouch is a touch-screen computer housed in a kiosk that contains a database on medications, health, and lifestyles. Healthtouch computer kiosks are located in about 1,500 retail pharmacies throughout the United States as a value-added service of Cardinal Health, a Columbus, Ohio-based pharmaceutical distributor. Using the touch screen to select a topic and specific files, a consumer can retrieve, read, and print out information on various topics. Most topics are in a question-and-answer format, and many are available in English and Spanish. Organizations such as the American Heart Association, the Centers for Disease Control and Prevention, and the SPRY Foundation contribute files to the database on topics of interest to older adults. Information on the topic of managed care is available under the category ''health information." On the basis of research conducted by Health touch in the first quarter of 1994, consumers accessed the database 1.35 million times, printing out information to take with them in more than 60 percent of the cases. About 35 percent of the users were age 65 and over.

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--> Community Meetings Nonprofit Organizations Under a 1985-1987 cooperative agreement with HCFA, HealthChoice, Inc. (HCI), which is the nonprofit arm of Portland, Oregon-based Benova, implemented a demonstration "independent broker" program at three sites: Los Angeles, Portland, and San Francisco. The demonstration was initiated to test the efficacy of having an independent broker work cooperatively with participating health plans to inform and educate Medicare beneficiaries about the health service options available to them. HCI coordinated HMO fairs, produced and distributed comparative information, and performed beneficiary counseling and enrollment and received remuneration from HMOs for beneficiaries who enrolled as a result of their efforts (Davidson, 1988). In an evaluation of the demonstration at the Los Angeles and San Francisco sites, researchers found an increase in the level of knowledge of key HMO concepts among beneficiaries attending HCI health fairs; however, they had little or no impact on enrollment behavior (Langwell et al., 1989). Researchers also found differing objectives: the HMOs viewed HCI as a marketing tool, whereas HCFA perceived it as an educational program. They concluded that independent brokers were not effective in markets (such as the two evaluated) where HMO penetration was high, although they may be effective in markets where the HMO option is just being introduced. In addition to disseminating information to consumers through the newspaper (referenced above), the Minnesota Health Data Institute also held a series of three community meetings to present the findings on consumer satisfaction with Minnesota health plans. The meetings, which were coordinated with the state office of AARP, were held in Duluth, Rochester, and St. Cloud, Minnesota, in October 1995. In St. Cloud and Rochester, information on health plan survey results was included on the agenda of already planned conferences, whereas in Duluth, the information was presented as part of a health fair sponsored by a local television station. According to staff in-

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--> volved in the meetings, attendance was good at the St. Cloud and Rochester meetings (200-400 attendees), whereas the Duluth meeting had a lower turnout. Another example of a community education effort was a 1-day seminar entitled "Managed Care: What Is at Stake for Older Adults?" held on October 30, 1995, in Research Triangle Park, North Carolina. The seminar, cosponsored by the Leadership in an Aging Society Program of the Duke University Long-Term Care Resources Program and the North Carolina Division of Aging, was attended by 100 older adult leaders, state officials, and other interested stakeholders. The topics discussed included quality, access, financing, and long-term care and included perspectives from other states. Health Plans Health plans extensively use community meetings as a way to interest Medicare beneficiaries in their HMO product. Often, these meetings are held at public sites such as restaurants or hotels. Plan representatives give a prepared presentation about their HMO product, often supplemented by print materials and in some cases a videotape. Representatives are also available to answer participants' questions. Some plans indicated that they use current plan enrollees in these community presentations as the best "ambassadors" for their program. One-on-One Counseling Public Agencies As mentioned previously, Medicare beneficiaries have access in every state to an Information, Counseling and Assistance (ICA) program. In addition to telephone hotline counseling, the primary mode of delivering services to Medicare beneficiaries is through one-on-one counseling. In such a counseling session, the beneficiary usually goes to a central meeting place, such as a senior center, Social Security office, library, or Area Agency on Aging to discuss his or her questions or concerns with a trained counselor. According to a 1994 evaluation (McCormack et al., 1994), three fourths of all counties nation-

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--> wide have at least one local counseling site. The program is primarily staffed by trained volunteers, with close to 10,500 individuals across the country volunteering with ICA programs. The ICA program served approximately 192,212 individuals via phone or one-on-one counseling during a 1-year reporting period (April 1, 1993, to March 31, 1994), with more than 400,000 people participating in a presentation or seminar. This translates to a national average of 12 persons served per 1,000 persons over age 65, although there was substantial variation by state, with proportionately high numbers of older adults served in Idaho, Montana, and New Mexico and proportionately low numbers served in Alabama, Alaska, Hawaii, and South Carolina. Five percent of the total health insurance issues raised during counseling encounters dealt with managed care questions, although states with a high level of penetration into managed care, such as California, Massachusetts, and Oregon, had higher percentages. Private Sector The feasibility of a counseling program is being explored under an HCFA Small Business Innovation Research (SBIR) program that funds feasibility studies for small businesses. The project is being conducted by USHC Development Corporation, a for-profit subsidiary of the United Seniors Health Cooperative (USHC), a nonprofit organization that, since 1986, has helped older persons in metropolitan Washington, D.C., be informed consumers. The project will specifically explore the feasibility of providing a counseling service and related products designed to provide unbiased consumer information to Medicare consumers who are in the process of choosing a managed care plan, as well as a self-assessment instrument and related publications. Included in the study is an investigation of potential markets for the counseling and related products, such as the ICA programs, employers, unions, professional and retiree associations, and managed care organizations.

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--> Health Plans One-on-one counseling with Medicare beneficiaries is also an important component of most health plans' marketing strategies. Under federal law, plans are prohibited from door-to-door marketing; however, they may go to a beneficiary's home if they are invited. Plans may also meet with interested beneficiaries in other settings such as plan offices. Conclusion and Key Findings A review of the literature and case examples regarding communicating with Medicare beneficiaries about their health plan choices results in several key findings. A first finding is that any effort to communicate with beneficiaries about the choices that they now have or expanded future choices must be done in the context of low levels of Medicare beneficiary understanding of how the basic Medicare program works. Any discussion about the preferred communications channels for reaching older adults about their health plan options must therefore be preceded by a strategic understanding of what Medicare beneficiaries currently know. Second, with reference to preferred media, older adults, as with their counterparts under age 65, are active users of media of all types. Television and print media, such as newspapers, are used by many older adults in general, although the literature also suggests that different segments of the older adult population may prefer different communications channels depending on sociodemographic and attitudinal factors. Focus groups and limited research seem to indicate that newer communications channels such as cable television, videotapes, and computer on-line services are less appealing to or used by older adults. However, market research has also indicated that the levels of ownership of VCRs and the numbers of cable television subscribers have increased among those over age 50. In addition, as adults age into the Medicare program, it can be expected that they will do so with a higher degree of exposure to newer forms of communication Finally, although not explored in this paper, the use of a variety of communications channels to reach the middle-aged children of current and future older adults who

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--> are asked to assist in Medicare choices might involve the use of different communications channels. A third key finding is that there are a range of organizations now communicating with Medicare beneficiaries about their health plan choices. Some of the organizations, such as HCFA, public libraries, nonprofit organizations, newspapers and magazines, and the seniors' counseling programs, are attempting to educate beneficiaries generally, or specifically in the case of counseling, about their health plan choices. Other organizations, such as health plans with Medicare contracts, are attempting not only to educate but also to enroll beneficiaries in their plans. Given the growing number of HMOs with Medicare contracts and the relative resources that they will most likely devote to marketing to older adults, it is probable that many current and future Medicare beneficiaries will have their first contact with the idea of managed care and health plan choice through some type of plan marketing activity such as an advertisement or direct mail piece. As with reactions to marketing efforts for other types of purchases, it can be expected that some beneficiaries will completely ignore this information, whereas it may stimulate interest and awareness of choice with others. Some Medicare beneficiaries may want additional information, possibly from an unbiased source or from family and friends to evaluate the materials, and finally, others may only be confused or fearful about the information, particularly in light of recent media attention to Medicare "change," which may leave the impression that choice is being taken away, not expanded. Unlike the purchase of other consumer goods and services, the choice of a health plan and the corresponding coverage and plan rules that they impose have significant consequences for the health and well-being of older adults and their families. This has important implications for public policy makers interested in expanding plan choice. Public oversight of marketing materials to ensure the accuracy of the messages presented is certainly one part of a strategy to ensure informed choice. Access to publicly available, objective, comparative information at both a broad level (i.e., the choice between having Medicare alone, Medicare with a Medigap policy, or a managed care plan) and a specific health plan level (the choice between Medigap

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--> plan A versus Medigap plan B or HMO plan A versus HMO plan B) must also be ensured. The tenets of social marketing may be one approach used to address the tension between communicating for educational purposes and marketing to sell a specific product. Social marketing builds on the concept that social aspirations can be sold through the strategic use of marketing techniques. Used to address such public health topics as smoking and cardiovascular risk reduction, social marketing generally involves three broad principles: (1) the process of marketing is disciplined and objectives are clearly stated; (2) the consumer audience is understood along several psychosocial and demographic dimensions; and (3) the product is responsive on the basis of iterative research into consumers' wants and needs (Walsh et al., 1993). Application of social marketing principles to the objective of increasing a Medicare beneficiary's knowledge and understanding of health plan choices is probably a more complex task than application of those principles in campaigns targeted at changing a health behavior. The clear and unequivocal message in an antismoking campaign, for example, might differ substantially from the message in a campaign with the objective of increasing a Medicare beneficiary's knowledge about both his or her health plan choices and how those choices affect the individual's situation. The techniques, however, may still warrant further exploration. A final key finding from the literature review, focus groups, and case example interviews is that older adults are particularly oriented toward communications channels that involve person-to-person exchange. Family and friends have been found to be a key means both of learning about health plan choices and in influencing selection. In addition, the opportunity to talk with informed others was also viewed as important. There are several implications of this finding. The first is that "family and friends" should probably also be the target of any information campaigns to help older adults make informed decisions about their health plan choices. Second, the person-to-person outreach widely used by Medicare HMOs in the form of group and individual meetings is probably particularly persuasive in interesting older adults in managed care. Given that these presenta-

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--> tions are less conducive to public oversight, it is important that older adults and their families have reasonable access to similar person-to-person methods of providing more objective information about their choices, such as hotlines, group presentations, or individual counseling, all staffed by individuals capable of providing answers to general and specific questions. A final implication of the significance of person-to-person communications channels for older adults with reference to health care is that if managed care plans and other emerging health plans can reach, satisfy, and retain Medicare beneficiaries with their range of benefits and services, provider networks, quality of care, and customer satisfaction, the word-of-mouth value of their success will probably be their best marketing tool. References American Association of Retired Persons. 1995a. Managed Care: An AARP Guide. Washington, D.C.: American Association of Retired Persons. American Association of Retired Persons. 1995b. Healthy Questions: How to Talk to and Select Physicians, Pharmacists Dentists & Vision Care Specialists. Washington, D.C.: American Association of Retired Persons. Arizona Senior World. 1995. HMOs Which Assume Responsibility for Medicare Coverage. Arizona Senior World, April, 1995, pg. 18. Brown, R., K. Langwell, and A. Ciemnecki. 1987. Medicare Beneficiaries' Responses to HMO Marketing in Single and Multiple HMO Markets. Pp. 477-490 in Managing Quality Health Care in a Dynamic Era. Proceedings of the 37th Annual Group Health Institute. Washington, D.C.: Group Health Association of America. Cafferata, G. 1984. Knowledge of Their Health Insurance by the Elderly. Medical Care 22: 835-847. Center for Health Care Rights. 1995. HMO Members Vote With Their Feet. The Medicare Advocate 5: 2-3. Davidson, B. 1988. Designing Health Insurance Information for the Medicare Beneficiary: A Policy Synthesis. Health Services Research 23: 686-719. Dychtwald, K., M. Zitter and J. Levison. 1990. Implementing Eldercare Services: Strategies that Work. New York: McGraw Hill. FIND/SVP. 1993. The Maturity Market. New York: FIND/SVP. Foster Higgins. 1994. National Survey of Employer-Sponsored Health Plans. New York: Foster Higgins. Frederick/Schneiders, Inc. 1995. Analysis of Focus Groups Concerning Managed Care and Medicare. Prepared for the Henry J. Kaiser Family Foundation. Washington, D.C.: Frederick/Schneiders.

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--> Titus, S. 1982. Barriers to the Health Maintenance Organization for the Over 65s. Social Science and Medicine 16:1767-1774. Walsh, D.C., R. Rudd, B. Moeykens, and T. Moloney. 1993. Social Marketing for Public Health. Health Affairs 12(2):105-119. Winslow, R. 1994. Employers Try to Get Retirees to Join HMOs. Wall St. Journal, December 16, 1994.