As mentioned previously in this report, recent research has examined how well Medicare beneficiaries understand the differences between the fee-for-service and managed care forms of Medicare. The task that beneficiaries face is one of choice, but the question is how well they understand the differences and similarities between these two health care delivery systems. A recent study by the American Association of Retired Persons (Hibbard and Jewett, 1998) looked at how well beneficiaries understood the differences between the traditional Medicare program and health maintenance organizations (HMOs). For example, what is a "primary care physician" or a "network of providers," how does one obtain emergency care, and what are the grievance and appeals procedures? The research has also examined how well beneficiaries understand the implications of these concepts for cost, choice, and care.
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--> 5 Role of Third Parties in the Information Infrastructure* The Health Care Financing Administration's (HCFA's) task of disseminating high-quality and accessible information to beneficiaries is difficult because, to a large extent, it is catch-up work. For many years, consumer advocates and information experts have urged HCFA to do a more effective job of educating its Medicare beneficiaries about the Medicare program. When the agency began to move the Medicare population into managed care arrangements starting in the mid-1980s, advocates again cautioned that better information about these plans needed to be disseminated to the beneficiaries. As HCFA moves toward the full implementation of the provisions of the Balanced Budget Act of 1997 over the next 5 years (1998 to 2003), many third parties will need to play an integral role in facilitating the information dissemination process. Participants at the March 1998 workshop addressed the multiple roles of public- and private-sector intermediaries and information brokers and also looked at the potential liability that such groups and organizations could face because of their roles in assisting Medicare beneficiaries with choosing their health plans. How Consumers Use Information for Decision Making When learning about their health plan options, beneficiaries consult an average of three information sources. As mentioned previously in this report, recent research has examined how well Medicare beneficiaries understand the differences between the fee-for-service and managed care forms of Medicare. The task that beneficiaries face is one of choice, but the question is how well they understand the differences and similarities between these two health care delivery systems. A recent study by the American Association of Retired Persons (Hibbard and Jewett, 1998) looked at how well beneficiaries understood the differences between the traditional Medicare program and health maintenance organizations (HMOs). For example, what is a "primary care physician" or a "network of providers," how does one obtain emergency care, and what are the grievance and appeals procedures? The research has also examined how well beneficiaries understand the implications of these concepts for cost, choice, and care. * This chapter is based on the remarks of Aileen Harper, Judith Hibbard, and Gail Povar.
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--> Judith Hibbard discussed with the committee her research and findings. The study surveyed Medicare beneficiaries in five markets with high levels of enrollment in managed care and used as a total sample equal numbers of beneficiaries enrolled in the traditional Medicare program and in Medicare managed care. Among all the respondents, only 11 percent were deemed to have "adequate" knowledge to make an informed health plan choice. What Affects the Level of Knowledge? Judith Hibbard indicated that the most significant predictors of knowledge are levels of income and education. Enrollees in HMOs were found to have lower incomes and lower levels of education than enrollees in the traditional form of Medicare. Therefore, those exercising choice are often the least well able to make the key distinctions between traditional Medicare and Medicare managed care plans. When learning about their health plan options, beneficiaries consult an average of three information sources. Consulting with more sources results in an increased ability to differentiate between critical elements of traditional and managed care Medicare. The most common sources that beneficiaries turn to are managed care plan advertisements. Results from a series of focus groups for the National Academy of Social Insurance's Restructuring Medicare for the Long-Term project showed that beneficiaries preferred getting plan information from newspapers and print advertisements because the information seemed clearer to them. However, the beneficiaries did not distinguish a preference between advertisements and news stories (Kleimann, 1998b). Supporting the Decision-Making Process HCFA and all parties disseminating information to Medicare beneficiaries need to engage in active education programs that seek out beneficiaries. The tasks given to Medicare beneficiaries in the Balanced Budget Act of 1997 are highly cognitive ones and would be difficult for any population (Hibbard et al., 1997; Kleimann, 1998a). The responsibilities that Medicare beneficiaries are being asked to assume under Medicare+Choice require them to analyze several different categories of variables and then multiple variables within each category. For these tasks to be completed effectively, the committee found that good decision support counseling is necessary. Intermediaries who disseminate information will need to be more than just information brokers. They also will need to assume the role of an educator so that they are able to help beneficiaries understand the differences between the different plans and the differences between the plans and traditional Medicare. In addition, a decision-making framework must also be developed around categories of plans (preferred provider organizations, provider-sponsored organizations, HMOs, etc.). The committee was told that the provisions of the Medicare+Choice program will necessitate an upgrading of intermediaries' skills. Participants urged information counselors to move beyond merely describing a plan's features to explaining what a particular feature may mean for
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--> a beneficiary's costs, treatments, and freedom of choice.* Throughout the life of the Medicare+Choice program other organizations will need to step in and provide specially tailored products and services to the intermediaries to assist them in their role of providing information to beneficiaries. A Proposed Important First Step Judith Hibbard articulated the need to take a concrete first step in the development of a good information infrastructure. According to consumer information experts at the workshop, the development and dissemination of a list of answers to key questions that beneficiaries must know to make an informed choice would be the best first step. The Role of the HICAP** Model health insurance counseling and assistance programs (HICAPs) have multiple roles. The first is that of an impartial information disseminator. Many beneficiaries seek out HICAPs precisely because these programs are not affiliated with HCFA and because they are interested in receiving a second opinion on the information that the government sends to them. This type of information brokering needs to be accurate and unbiased. Second, model HICAPs are more than information disseminators; they also help frame the information given to beneficiaries, including (1) organizing the information in a way so that it makes sense to the beneficiary and (2) putting the information in perspective without getting into biases and decision making. The way that information is framed needs to vary by Medicare population subgroup. Third, effective HICAPs are able to empower beneficiaries by providing them with knowledge. How to Best Provide Beneficiaries with This Information The Center for Health Care Rights, considered a model HICAP, serves more than 15,000 Medicare beneficiaries in the Los Angeles, California, area each year and has an annual budget of $650,000. More than 30 percent of the center's constituents are currently in Medicare managed care. The center takes a three-pronged approach to disseminating information to beneficiaries: use of a telephone hot line; use of volunteers spread throughout the community; and use of community education programs. * Aileen Harper. ** Aileen Harper.
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--> These three approaches are used together. The center has found that merely giving educational materials to the senior population is not very useful, even for well-educated beneficiaries. The information becomes more meaningful when a volunteer walks the beneficiary through the information in a one-on-one situation. The volunteer network needs to be supported by a professional staff that is strong on the technical details of Medicare managed care. Even under the best circumstances, however, this three-pronged approach is not always adequate. The Center for Health Care Rights is continuously assessing how it can better reach underserved populations in particular. Well-funded and well-staffed HICAPs like the Center for Health Care Rights also invest a good deal of money on library materials, subscriptions to journals, and manuals published by HCFA. Inadequate community support and funding can seriously hamper a HICAP's ability to provide the best and most recent information to its clients. Liability Issues The committee heard that it is necessary for those who provide information, counseling, and assistance to beneficiaries to develop ways to protect their organizations if a beneficiary or a beneficiary's family member determines that the counselor should be held liable for a poor health plan choice. It is incumbent on community-based organizations to provide their volunteers and staff with ongoing training in the more technical issues facing beneficiaries. Otherwise, they may easily find themselves disseminating poor or incomplete information to those they are trying to assist and leave themselves open to legal action. Consumer counselors present at the workshop noted that HICAP employee bias could also leave an organization open to criticism. Once a third-party information broker moves beyond being a channel for comparative information and into helping beneficiaries understand what the information may mean to them, the broker's judgment becomes an issue. The Role of Providers: An Issue of Trust* Of necessity, physicians and other health care providers have multiple agendas related to the practice of medicine: to carry out their definition of an effective doctor-patient or health care provider-patient relationship, to try to advance with medicine patients' visions of how they wish to live their lives, and to keep a practice viable and in business. All three of these competing agendas are operating whenever a patient enters a health care provider's office. With the advance of managed care, more health care providers are finding that their patients also expect them to be experts on health care policy, health plans, and health insurance programs. Patients often ask their providers for the provider's opinion about which managed care organization the patient should join. Patients tend to seek out their providers' advice because providers tend to be trusted figures. If, however, a patient is new to the provider's practice, he or she may question the provider's motives, particularly if the patient is seeing the provider through a managed care arrangement, because such patients have a tendency to view such a pro * Gail Povar.
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--> fessional's advice as a means of advancing the provider's economic agenda (Edgman-Levitan and Gerteis, 1998). In addition, providers attest that it is becoming increasingly difficult for them to establish trust with their patients. From the information on patient-provider relationships presented above, it appears that in today's practices, patients either are overly trusting or are suspicious of the health care enterprise in general. Both ends of the spectrum interfere with a provider's attempt to create an optimal health care-related partnership between patient and provider. The Future Information Dissemination Infrastructure What needs to be accomplished over the next 5 years to ensure that the Medicare+Choice program works as it is intended? An initial mailing to a subset of 5.5 million of HCFA's 39 million Medicare beneficiaries was scheduled in November 1998. At the same time, public-sector groups and private-sector companies began their information and marketing campaigns targeted to beneficiaries and their families. The private-sector campaigns will be localized and customized, but to support the development of the information infrastructure adequately, the efforts of all organizations will need to be localized. In addition, to ensure that beneficiaries are getting the best and most useful information, third parties assisting beneficiaries and their families with the choice process will need to be viewed as independent. A fledgling information dissemination infrastructure already exists in most communities. It typically consists of HICAPs, although most of these have small staffs and budgets (the U.S. Congress has allocated about $10 million to these organizations that address the myriad information dissemination problems surrounding consumer education and counseling). Protective and advocacy organizations for those people with disabilities are also part of the infrastructure. Each state and many communities have long-term-care ombudsman programs. In addition, many national organizations such as the American Association of Retired Persons and the Alzheimer's Association have active local affiliates. The committee heard that the marshaling of all of these existing local resources may be the best way to develop a viable information dissemination infrastructure. Conditioning the Market To prepare beneficiaries for the rush of new information regarding Medicare+Choice, beneficiaries and their families need to understand several key issues: the changes that are taking place in the health care market; the trade-offs that a beneficiary will face when switching from one health plan to another; and how the system is best navigated once a beneficiary chooses a health plan.
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--> By necessity, once beneficiaries become better educated about the basic elements of managed care and traditional Medicare, information brokers will need to become more thoroughly trained to provide more refined assistance. To implement the key components of an effective information infrastructure, additional resources will be needed. The Center for Health Care Rights, under the direction of Peter Lee, is in the process of conducting research that looks at how much effective counseling programs cost. The research, however, is still in an early stage. In the meantime, panelists stressed the need for continued and increasing public-private partnerships, such as the provision of computers to seniors centers so that beneficiaries can access HCFA's Medicare web site. Spreading the costs for funding of the information infrastructure and the development of partnerships beginning at the local level would minimize the amount of funding that would ultimately be needed.
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