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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