Banning all undesirable marketing practices might not be feasible because of First Amendment issues. There are ways to mitigate potential problems, however. Some voluntary purchasing cooperatives use agents and brokers to address the small group and individual markets. They train and certify the agents and brokers who are licensed to sell their product before they are permitted to sell the product. The purchasing cooperative provides the information that the agents and the brokers use, and the information is bound together so that agents or brokers cannot pull out only the information that they would like the consumer to see. This packet of information outlines all the health plan options that a consumer has.40

The purchasing cooperatives also review and approve any marketing materials that participating plans wish to distribute. Furthermore, the compensation for agents is structured so that an agent's commission does not vary according to which plan a consumer chooses. The amount of the commission also is disclosed to the payer.

To ensure that Medicare beneficiaries are not dependent on the information provided through marketing, it is important that they have access to other sources of unbiased information. Competing against the marketing resources of commercial companies, however, may prove to be an issue. Although HCFA may spend $10 million on consumer education and all of the states combined may spend the same amount, health plans devote far greater amounts to marketing activities.

Grievance and Appeals Procedures

The majority of appeals filed with HCFA by Medicare beneficiaries are over disputes over payment for services provided by nonplan providers and emergency care (Network Design Group, 1995). Studies have documented problems with access to rehabilitative services, especially following hospitalization. HMOs may deny authorization for short-term skilled nursing facility services, home health care, and physical, speech, or occupational therapy, even though these services are covered un-


Material presented by Richard E. Curtis.

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