National Academies Press: OpenBook

Improving the Medicare Market: Adding Choice and Protections (1996)

Chapter: H Reaching and Educating Medicare Benificiaries About Choice

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Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
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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

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Health Pages, New York, New York.

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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-

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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-

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

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:

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
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  • Medicare Coordinated Care Questions and Answers, an 11-page report which includes 27 questions and answers about Medicare and HMOs (Health Care Financing Administration, 1992b).
  • 1995 Guide to Health Insurance for People with Medicare, a 35-page report, developed jointly with the National Association of Insurance Commissioners, which covers a range of topics primarily related to what Medicare does not cover and private health insurance options for covering those gaps. Medicare managed care is described as one of the private health insurance options that covers Medicare gaps along with Medigap policies, continuation of employer coverage, long-term-care insurance, hospital indemnity policies, and specific disease policies (Health Care Financing Administration, 1995c).
  • Medicare Managed Care Directory, which lists Medicare managed care plans by state including the telephone number, address, and counties covered (Health Care Financing Administration, 1995d).

In addition, HCFA Office of Managed Care staff interviewed for this paper mentioned several other initiatives related to the dissemination of print information for Medicare beneficiaries about their health plan options. The 1996 Medicare Handbook was revised to include a clearer statement on page 1 that Medicare beneficiaries have choices about the ways in which they can participate with the program. This new handbook was mailed to all Medicare beneficiaries during early 1996 (the last time that the handbook was sent to all beneficiaries, not just those who were newly eligible, was in the late 1980s). In addition, HCFA staff have developed a draft of a new brochure about Medicare choices discussing the pros and cons of fee-for-service and managed care systems. The agency hopes to include the brochure in the initial enrollment package mailed to beneficiaries by the Social Security Administration. HCFA also updated its current 15-page "Medicare Managed Care Plans" brochure for distribution primarily through the Medicare Hotline and the Consumer Information Center in Pueblo, Colorado. Finally, HCFA has hired a contractor to evaluate the effectiveness of publications for Medicare beneficiaries.

Another HCFA print initiative was developed by the Califor-

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

nia regional office and consists of a trifold 1995 HMO Benefits Comparison chart for each of three areas: Northern California, Southern California, and Arizona/Nevada (Health Care Financing Administration, 1995e). The charts briefly discuss considerations for beneficiaries thinking about enrolling in a Medicare HMO and then provide comparative information about the costs (e.g., monthly premium and copayments for doctor visits) and benefits (e.g., pharmacy and dental) offered by each of the plans in the three areas. The comparison chart is distributed primarily through Social Security offices and senior health insurance counseling programs and directly to approximately 1,500 beneficiaries who have requested it. HCFA is in the process of developing similar comparative charts for other regions that they plan to have available in disc format and on-line for regional offices and other interested organizations by early next year.

Libraries

Libraries are another potential public source of information for Medicare beneficiaries about their health plan choices. There are approximately 9,000 public libraries nationwide, with 16,000 outlets (G. Needham, Public Library Association, Chicago, Illinois, personal communication, 1995). A 1991 library public use survey indicated that approximately one third of adults over age 65 are library users (Scheppke, 1994). Some libraries, such as the Wheaton Regional Public Library in Montgomery County, Maryland, maintain Health Information Centers staffed by librarians. The Centers provide area residents with access to health books, journals, and pamphlets. Center staff report that they do get some questions requesting information about managed care, particularly information about the availability of HMO or preferred provider organizations (PPO) ratings. However, it appears to be a relatively small percentage of the almost 550 questions per week fielded by the staff (S. Unger, Wheaton Regional Public Library, Wheaton, Maryland, personal communication, 1995).

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×
Nonprofit Organizations

Several nonprofit organizations have developed educational print materials to help their members/constituencies understand more about Medicare managed care and their health care options. AARP has published a report titled Managed Care: An AARP Guide (American Association of Retired Persons, 1995a), a 21-page guide that discusses the differences between traditional insurance and managed care, the advantages and disadvantages of managed care, questions to ask, and a comparison worksheet that the reader can use to compare plan benefits. More than 80,000 copies of the guide were distributed in 1995. Several questions about managed care plans are also included in another AARP publication entitled Healthy Questions: How to Talk to and Select Physicians, Pharmacists, Dentists & Vision Care Specialists (American Association of Retired Persons, 1995b).

The Medicare Beneficiaries Defense Fund, a New York City-based nonprofit organization dedicated to ensuring the rights of seniors and people with disabilities, has developed a series of brochures about the Medicare program for consumers. Their Medicare managed care piece entitled ''Medicare Health Maintenance Organizations: Are They Right For You?," is a 10-page pocket-size brochure that provides an overview of Medicare HMOs and that discusses how they work, what a beneficiary should consider before enrolling, enrollment/disenrollment procedures, and the complaints/appeals processes (Medicare Beneficiaries Defense Fund, 1994).

The Center for Health Care Rights has also developed print materials that provide an overview of HMOs for Medicare beneficiaries. In addition to a four-page brochure that describes the details of joining an HMO, the Los Angeles-based organization has also published and distributed 1995 Medicare HMO disenrollment data for Medicare HMOs in California (Center for Health Care Rights, 1995).

Employers

Increasingly employers are exploring the introduction of Medicare HMOs as an option for their retirees. For example,

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

Towers Perrin, an employee benefit consulting firm, has organized a consortium of large employers such as Nynex, Union Carbide, and LTV in a project to offer HMOs to their Medicare retirees (Winslow, 1994). Print information about Medicare HMOs available to corporate retirees is a key part of the communication effort used in the project, including a generic company announcement letter, an HMO highlights brochure, and a comparison grid that could then be customized to a participating employer's individual corporate needs (L. Guthridge, Towers Perrin, Los Angeles, California, personal communication, 1995).

Another employer, Bethlehem Steel, which introduced managed care for its retirees this fall, began its communication with an introductory letter to all eligible retirees from the chairman of the company; this was followed by additional information from the employee benefits department. The actual plan materials were sent directly to retirees by the plan; however, they were sent in a Bethlehem Steel envelope to increase the likelihood that they would be read. In addition, a key part of the communications strategy, coordinated by UltraLink -a network management company working with large employers-involved holding meetings in several states where retirees could learn more about the HMO option and have their questions answered by Bethlehem Steel employee benefits staff. A telephone hotline was also available to (and used by) retirees for questions or concerns (Howard Matsukane, UltraLink, Costa Mesa, California, personal communication, 1995).

Health Plans

Managed care plans that offer products for Medicare beneficiaries use print media in a number of ways to communicate with older adults about their products. All plans have brochures and marketing materials that generally describe how an HMO operates and provide information, often in a comparative chart format, about the specific benefits that they offer and how they compare to regular Medicare coverage.

The marketing materials used by health plans must be approved by HCFA before use. HCFA does not mandate a format or style for a plan's Medicare marketing materials; however,

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

plans are instructed on the content of the pre-enrollment materials sent to a beneficiary. Materials must include an explanation of the plan's rules and other information sufficient for the beneficiary to make an informed decision about enrollment. This includes information on eligibility requirements, how and where to receive services, benefits, and premiums/copayments. Marketing materials must describe all restrictions on out-of-plan and in-plan service use, including an accentuated discussion of lock-in restrictions and clearly stated information about plan coverage of emergency and out-of-area urgently needed services. Prohibited marketing activities include any marketing attempts that discourage participation on the basis of actual or perceived health status (i.e., attempts to enroll beneficiaries from high-income areas, etc.); activities that mislead, confuse, or misrepresent; gifts or payments to induce enrollment (although plans may give gifts of nominal value—under $10.00—to all beneficiaries who attend a marketing presentation), door-to-door solicitation; and distribution of disapproved marketing materials.

Discussions with several Medicare HMO plans indicated that plans often use direct mail to disseminate printed marketing information about their products to older adults' homes. The direct mail material might encourage the recipient to send for more information, call a toll-free plan number for more information, or attend a meeting where additional information about the product will be presented by their representatives.

Print Materials: Newspapers and Magazines
Nonprofit Organizations

The Minnesota Health Data Institute, a nonprofit public-private organization created by the Minnesota State Legislature in 1993 with the overall goal of improving the quality of health care services available to Minnesotans, has recently released the results of a statewide survey of consumers on their satisfaction with health plans (Minnesota Health Data Institute, 1995). The results included the satisfaction of Medicare beneficiaries with the five Medicare HMOs available in the state. Survey results were distributed by using two unique dissemination methods: an insert in the major Minneapolis/St. Paul news-

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
×

paper and affiliated papers and a series of three community meetings held throughout the state (further discussed below). The 16-page newspaper-sized insert was included in the October 6, 1995, edition of the Minneapolis Star Tribune, as well as 60 other newspapers statewide. The Minnesota Health Data Institute estimates that approximately 912,000 copies of the report were distributed to Minnesota residents. The Institute will be doing follow-up focus groups with various constituencies, including Medicare beneficiaries, to test specific reactions to the format and information.

Private Sector

Health Pages, a New York City-based consumer health magazine, provides both general information and community-specific information geared for the entire family. The magazine is published in eight areas nationwide: Atlanta, Cincinnati/Columbus/Dayton, Denver, Los Angeles, Miami/Ft. Lauderdale/West Palm Beach, Phoenix, Pittsburgh, and St. Louis. In five areas (Denver, Phoenix, Pittsburgh, South Florida, and St. Louis), the fall 1995 edition of the magazine included a six-page article on Medicare and the Managed Care Option. The article in the South Florida Health Pages for example, provided a four-page narrative overview of Medicare managed care and two pages of charts providing fairly detailed comparative information on the eight HMOs available to Medicare beneficiaries in that area (Health Pages, 1995). The magazine is primarily distributed to employees and retirees by large employers or business health coalitions in the cities. It is also available to the public at newsstands. In some cities, grants to health care coalitions have resulted in free copies being distributed to Area Agencies on Aging and their programs (including the senior health insurance counseling programs). The magazine is now exploring the on-line distribution of information.

Local senior citizens' newspapers are another potential source of information for Medicare beneficiaries about local health plan and managed care options. The April 1995 edition of Arizona Senior World, for example, included a comparison chart of HMOs available to Arizona residents (Arizona Senior World, 1995). There are over 100 senior citizens' newspapers

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
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throughout the country, with circulations ranging from 2,500 to more than 100,000 (Menchin, 1989).

Health Plans

Health Plans use print advertising to reach older adults, often advertising in metropolitan newspapers, senior citizens' newspapers, and other local print media. The purpose of the advertising is generally to build a positive image or reputation and to build name recognition (Harrington et al., 1988). Advertisements are generally upbeat, show older adults in active or intergenerational roles, or highlight the experience and credentials of the health plan. One advertisement for a Portland Medicare plan is built around an "Ask Helen" theme, Helen being an older woman experienced with Medicare HMOs who becomes the "personality" of the plan in their advertising efforts (Pickens, 1992).

Telephone
Public Agencies

HCFA staffs a Medicare Hotline (1-800-638-6833, TDD 1800-820-1202) that is widely publicized to Medicare beneficiaries through most of their print materials. The Hotline is available from 8 a.m. to 8 p.m. EST Monday through Friday. The main purpose of the Hotline is to distribute information to callers on selected topics or to refer them to other resources. There are no live operators to answer specific questions on the Hotline. Callers with touch-tone phones are presented with a list of seven prerecorded options including an option for "information about health maintenance organizations or HMOs." Callers who press this option are asked to state their name and address, and information about HMOs and the plans in their areas will be sent to them. They then receive the "Medicare Managed Care Plans" brochure and the Managed Care Directory.

According to HCFA staff overseeing the Medicare Hotline, during the most recent 6-month period of April 1, 1995, to September 29, 1995, the Hotline received 265,406 calls, with 9,673 callers (4 percent) pressing the option on HMOs. The largest

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
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requests to the Hotline are for options dealing with "information about claims" and "general information about Medicare."

Senior Health Insurance Counseling Programs

Legislation passed in 1990 established federally funded, state-managed information, counseling, and assistance (ICA) programs for Medicare beneficiaries. The purpose of the program was to assist Medicare beneficiaries in making decisions regarding their health insurance coverage. The ICA programs are administered primarily through state Departments on Aging (two thirds) or Departments of Insurance (one third). In addition to basic funding, states with Medicare HMOs received additional funding to promote the availability and understanding of these health plan options.

A recent evaluation of the ICA program conducted by the Research Triangle Institute (McCormack et al., 1994) indicated that 45 states maintain telephone hotlines, although only 22 of these hotlines are operated specifically by the ICA program (the rest are maintained by their host state agencies). Some of the telephone hotlines provide actual counseling to Medicare beneficiaries with questions, whereas others are used primarily to make referrals to ICA program counselors for follow-up.

Health Plans

Although none of the plans interviewed for this paper mentioned using telemarketing—or cold calling—as a marketing strategy, it is not prohibited under the HCFA marketing guidelines. Many plans use the telephone to follow-up with beneficiaries who have expressed interest by attending a plan presentation or sending for more information.

Health plans, or any other entity conducting telemarketing, would now be subject to Federal Trade Commission regulations prohibiting deceptive and abusive telemarketing practices under the 1994 Telemarketing Act. Among other things, the regulations limit the time of day that individuals may be called, requires disclosure that the purpose of the call is to sell goods or services, and prohibits unsolicited calls that are coercive or abusive.

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
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Television and Radio
Public Agencies

HCFA is involved in a number of activities involving broadcast or cable television and radio, including the production of audio or visual public service announcements (PSAs) (Health Care Financing Administration, 1995f). Few of the PSAs or cable television programs appear to deal directly with information related to managed care; however, many refer viewers to local ICA programs where they can get information about managed care and their health care choices. Several of the radio efforts target specific ethnic communities including Spanish-speaking and Chinese-American Medicare beneficiaries.

The HCFA Office of Research and Demonstration is currently funding a contract to develop a beneficiary information, education, and marketing strategy to support a proposed demonstration on expanded choice of Medicare health plan options. Benova, a Portland, Oregon-based health communications company, won the contract to develop multiple prototype products for the pilot, including a suggested marketing/public relations strategy that is expected to include proposed scripts for radio and television PSAs. Benova is also exploring the use of cable television, as well as print materials.

Health Plans

Health plans also use TV and radio advertising, again as part of their marketing strategies to reach older adults. The purpose of the advertisements is to elicit interest and follow-up requests for information by calling a toll-free number or to encourage attendance at a presentation sponsored by the plan.

Videos
Public Agencies

Several years ago the HCFA Office of Managed Care produced a video on Medicare managed care. The 11-minute video, hosted by Hugh Downs, used a television anchor/guest expert

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
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format to discuss managed care. More than 1,600 copies of the video were distributed and used in a variety of settings including ICA program and HCFA presentations and in Social Security offices. The use of the tape has now expired.

As part of an HCFA-funded project titled "Information Needs for Consumer Choice," the Research Triangle Institute and its contractor, Benova, will be developing a video for Medicare beneficiaries that includes older actors in a shopping market making grocery selections and talking about consumer choice of health plans. The script also introduces the concept of managed care report cards. A similar video is also being developed for the Medicaid population.

Employers

The employee benefits consulting firm Towers Perrin, in conjunction with GHAA, has developed a 13-minute videotape as part of the multiemployer, multicity retiree project described above. The videotape uses an older female narrator speaking words from actual letters that senior citizens have sent to health plans. In addition, interviews with Karen Ignagni, President of GHAA, and physicians from managed care plans are also included. The video is primarily used by employers in presentations with retirees about managed care.

Computer/Electronic Media
Public Agencies

HCFA launched a home page on the Internet's World Wide Web approximately 1 year ago. The home page includes access to a wide range of information including an overview of Medicare, HCFA testimony, an HCFA staff phone directory, proposed regulations, and research. Several HCFA publications for Medicare beneficiaries are also available on-line, including the Medicare Handbook, the "Guide to Health Insurance for People with Medicare," and, of particular relevance to beneficiaries interested in managed care, the "Medicare Managed Care Plans" brochure and the Managed Care Directory. HCFA staff oversee-

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
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ing the Web site report approximately 2000 people access the site daily, though it is not possible to know what they are viewing or using.

Libraries

Libraries are increasingly making the Internet available to an area's residents. For example, Sailor is a statewide, citizen access project that provides Maryland residents with no-charge access to Internet resources. The system, funded by the federal and state Departments of Education, can be used either by going to a library branch equipped with the appropriate computers or by dialing into the system using a modem from home, office, or school. Sailor maintains a listing of health and medicine resources that are primarily organized under general health information topics (federal agency fact sheets, toll-free telephone numbers) and by disease category. Managed care is not yet a topic in the resource listing; however, through Sailor one could use these words to search for information. The health and medicine information is a combination of references to other relevant World Wide Web sites and Sailor-generated information (for example, on breast cancer). The information on Sailor is developed by a group of volunteers who browse the Internet and cull what is thought to be most useful to consumers.

Nonprofit Organizations

Several nonprofit organizations for senior citizens are involved in the dissemination of on-line health information to older adults. One of the oldest is SeniorNet, a 9-year-old nonprofit membership organization based in San Francisco. With 18,000 members, SeniorNet is designed to introduce adults over age 55 to the on-line computer world. The organization maintains sites for older adults on two of the commercial on-line services: America Online ($9.95/month allows unlimited access to SeniorNet plus 1 free hour to the rest of the offerings) and the Microsoft Network ($4.95/month for 3 free hours; additional hours are $2.50/hour). SeniorNet also has a site on the Internet.

SeniorNet has a chat room available to members and also provides access to a bulletin board where members can exchange

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
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information. Users have a choice of seven topic areas, or forums, including the Health & Wellness Forum. Subtopics within a forum are largely driven by SeniorNet members, who identify areas of interest such as Alzheimer's disease, depression, exercise and fitness, or arthritis. The topic titled Medicare or managed care had more than 200 messages during a 5-month period in 1995 (compared with topics such as Alcoholics Anonymous, death and dying, or hearing, which had twice as many messages).

The Retirement Living Forum is an information resource also designed for older adults available through another commercial on-line service, CompuServe. Since 1994, the forum has been operated by the SPRY Foundation in Washington, D.C. The forum is structured in three distinct parts: a message/bulletin board, a library, and a conference center. A subscriber using the message/bulletin board can leave a question to be answered by an expert or leave a message for a private individual. Currently, there are several message sections dealing with health including health and medicine, Medicare/Medigap, and medication management. In the library, subscribers can locate and review information on any one of 19 topics including such topics as health and medicine and Medicare. Information can also be printed out for personal use. Finally, conferences are scheduled periodically with experts in various subject areas. HCFA staff participated in an on-line conference on managed care earlier this year. The Retirement Living Forum currently has approximately 15,000 subscribers. CompuServe subscribers pay $9.95 a month, which includes 5 free hours of on-line access to a basic package of information services. Additional hours are billed at the rate of $2.95/hour.

Information Kiosks
Public Agencies

The Social Security Administration (SSA) has initiated a pilot kiosk project in Albuquerque, New Mexico, which began in the spring of 1995. The 13 kiosks provide information primarily about the Social Security program. There is, however, a section about the Medicare program, including information about how

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
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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.

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
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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-

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
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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-

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
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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.

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
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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

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
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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

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
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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-

Suggested Citation:"H Reaching and Educating Medicare Benificiaries About Choice." Institute of Medicine. 1996. Improving the Medicare Market: Adding Choice and Protections. Washington, DC: The National Academies Press. doi: 10.17226/5299.
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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.

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Medicare beneficiaries are rapidly moving into managed care, as attempts to restrain the growth of this costly entitlement program progress.

However, advocates for patients question whether the necessary information and structures are in place to enable Medicare consumers to select wisely among private-sector managed care options. Improving the Medicare Market examines how to give Medicare beneficiaries the same choice of health plan options enjoyed in the private sector—yet protect them as consumers and patients.

This book recommends approaches to ensuring accountability and informed purchasing for Medicare beneficiaries in an environment of broader choice and managed care—how the government should evaluate and approve plans, what role the traditional Medicare program should play, how to help to elderly understand their options, and many other practical matters.

The committee discusses the information requirements of Medicare beneficiaries and explores in detail how best to respond to their special needs. And it examines the procedures that should be developed to provide the necessary protections for the elderly in a managed care system.

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