8
Implementation Issues*

Two major activities need to take place before the Health Care Financing Administration's (HCFA's) November 1998 mailing: (1) Several different types of plans (health maintenance organization, point-of-service, provider-sponsored organization, provider service network, medical savings account, and private fee-for-service) need to be defined and (2) during the fall of 1998, 39 million beneficiaries must be reached and educated about Medicare+Choice before they receive HCFA's mailing. November 1998 will mark the largest open-enrollment season ever attempted, although the first true open enrollment will take place in 2002, when the beneficiaries will be locked in to the choices that they have made until the next open-enrollment season a year later. Presentations over the course of the workshop indicated that the chances of getting the information infrastructure in place by the fall of 1998 is very low, not because those implementing the program are not competent but because the task is so cumbersome.

To move from operational theory to implementation, the development of information in six areas should be examined.

  1. The conflict between making something understandable and accessible to the public and to various subgroups versus making something legally and technically correct and complete. There has been a traditional emphasis on making information as legally and technically correct as possible, often sacrificing the information's accessibility to the public. Experts need to learn that more information is not necessarily better information. Also, the visual presentation of the information is almost as important as the content.
  2. There is a difference between making people aware of information and helping them understand it. Helping people understand information and providing a context and creating an infrastructure that assists people in making informed choices involve more time and money and greater human resources. If a clear understanding of the Medicare+Choice and traditional Medicare programs does not exist, beneficiaries will be afraid and anxious.
  3. The presentation of data is key. The first round of data available to beneficiaries will focus on benefits and costs. However, more data on quality will need to be included as time progresses. The key issue becomes how to present the data so that it is usable. Organizations are moving beyond just including Health Plan Employer Data and Information Set (HEDIS) data and
  4. *  

    This chapter is based upon remarks by Carol Cronin, Helen Darling, Lynn Etheredge, Vicki Gregg, and Leonard Schaeffer.



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--> 8 Implementation Issues* Two major activities need to take place before the Health Care Financing Administration's (HCFA's) November 1998 mailing: (1) Several different types of plans (health maintenance organization, point-of-service, provider-sponsored organization, provider service network, medical savings account, and private fee-for-service) need to be defined and (2) during the fall of 1998, 39 million beneficiaries must be reached and educated about Medicare+Choice before they receive HCFA's mailing. November 1998 will mark the largest open-enrollment season ever attempted, although the first true open enrollment will take place in 2002, when the beneficiaries will be locked in to the choices that they have made until the next open-enrollment season a year later. Presentations over the course of the workshop indicated that the chances of getting the information infrastructure in place by the fall of 1998 is very low, not because those implementing the program are not competent but because the task is so cumbersome. To move from operational theory to implementation, the development of information in six areas should be examined. The conflict between making something understandable and accessible to the public and to various subgroups versus making something legally and technically correct and complete. There has been a traditional emphasis on making information as legally and technically correct as possible, often sacrificing the information's accessibility to the public. Experts need to learn that more information is not necessarily better information. Also, the visual presentation of the information is almost as important as the content. There is a difference between making people aware of information and helping them understand it. Helping people understand information and providing a context and creating an infrastructure that assists people in making informed choices involve more time and money and greater human resources. If a clear understanding of the Medicare+Choice and traditional Medicare programs does not exist, beneficiaries will be afraid and anxious. The presentation of data is key. The first round of data available to beneficiaries will focus on benefits and costs. However, more data on quality will need to be included as time progresses. The key issue becomes how to present the data so that it is usable. Organizations are moving beyond just including Health Plan Employer Data and Information Set (HEDIS) data and *   This chapter is based upon remarks by Carol Cronin, Helen Darling, Lynn Etheredge, Vicki Gregg, and Leonard Schaeffer.

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--> are beginning to organize information in terms of groups of information, for example, including all data on women's health indicators (e.g., mammography rates) together. Eventually, organizations will be presenting qualitative data using an evaluative approach in which algorithms and weighting systems will be applied to the data. These systems will allow some plans to be favored over others. This final way of presenting information is being developed by the Foundation for Accountability and other similar organizations. The issue of using standardized information versus customized information. Throughout the workshop the notion of "mass customization" was mentioned. With mass customization, information is tailored to appeal to the interests and concerns of different groups of Medicare beneficiaries. Information experts argued that this type of information dissemination is easier to do over the Internet than in print. The senior population at present, however, favors print materials over the Internet's resources. The committee was advised to tell HCFA to establish prototypes for displaying and disseminating information that would encourage private-sector creativity but that would still enable plans to let beneficiaries know that "we are standard in these ways, but not in these." Targeting of the correct audience is important. The Medicare population is very heterogeneous. When disseminating information it is critical to avoid stereotyping, particularly by age, dependency status, and health status. Research indicates that those with technically poor health status sometimes perceive their own health to be better than it really is. Developing information for the short term versus the longer term. Creating information for the immediate deadline of November 1998 is a first step. The real issues will be played out over the next 5 years. It is critical not to do anything in the short term that must be undone in order to do it right in the long-term. Some information experts encouraged the committee to look at the development of information in generational terms. The expectations of the generation currently in or just entering Medicare will be vastly different from those of the baby boomers and younger generations when they enter the Medicare program.* Accountability Contract management is a critical issue for HCFA. Under Medicare+Choice, many new plans (and types of plans) will be entering the Medicare marketplace. Several of these plans will be small and largely untested. The potential for error is great. Presenters examining the implementation issues for Medicare+Choice encouraged HCFA to tighten its contract management procedures so that it could quickly step into a bad situation. HCFA was also encouraged to follow the example of the Office of Personnel Management and the Federal Employees' Health Benefits Plan and put more of the burden for good performance and conduct on the health plans themselves. The plans need to be accountable for providing good and complete information to beneficiaries. If people are not getting the medical care they need, the language translation services promised to them, or the disease management program advertised to them, it should be the plan's responsibility to correct these errors before HCFA steps in with severe punitive measures. The committee heard that it is unreasonable to expect a government agency to manage with a slim *   Carol Cronin.

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--> $95 million budget an industry with a $1.5 billion marketing budget and to manage effectively the enrollment features of the Medicare+Choice program. Implementation Lessons from TennCare Tennessee's Medicaid program, TennCare, offers some valuable implementation lessons for HCFA's Medicare+Choice program. Like Medicare+Choice, TennCare was a 5-year phased-in program that moved large numbers of people into managed care programs. Twenty-five percent of Tennessee's population of 5 million people is enrolled in TennCare, including one-quarter of the elderly population. A presenter familiar with TennCare* offered HCFA four pieces of advice. First, identify the most vulnerable among the Medicare population and offer them as much personal assistance as possible. In Tennessee, case managers were assigned to the at-risk population. TennCare's use of case managers during the transition period was highly effective. Second, use simple information. Whereas experts may understand and use HEDIS information, for example, the general public does not want to deal with that level of detail. It is more important to synthesize this information effectively and to reproduce it in a way that is easily accessible and understandable. Third, recognize the limited lifetime of educational information. TennCare found that the educational information shared with their beneficiaries had a lifetime of 90 days. If participants in Medicare+Choice do not use their health plan every 3 months or so, they need to be reminded of the basic tenets of the program. Fourth, involve the states and local advocacy groups. It is critical to effectively use people at the state level who understand the senior population. Throughout the workshop, the committee heard that health care is local and that information should be tailored to the community level, if possible. HCFA should not limit its partnerships to community advocacy groups, however. Although these groups are proficient in solving an individual's problems or in sounding any alarms that may be needed, through its regulatory powers the state government ultimately has more power over a health plan. Use of an Advisory Council Over the course of the workshop, presenters referred back to the Health Insurance Benefits Advisory Council which was established at the time of Medicare's establishment. The council involved senior officials committed to making Medicare work. The council was able to provide advice and counsel to HCFA on important issues that the agency might not have the time or resources to examine carefully. The establishment of a new advisory council that would assist HCFA with the Medicare+Choice program would be a positive step in creating good public-private partnerships. *   Vicki Gregg.

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--> Political Considerations The Balanced Budget Act of 1997 stipulates that materials from HCFA be sent to beneficiaries in October 1998, one month before a general election. Presenters felt that congressional phone lines would be overwhelmed by confused and anxious beneficiaries and their family members. Speakers cautioned that political rhetoric emanating from any beneficiary confusion might mitigate long-term efforts. HCFA was urged to consider dedicating additional personnel to working with congressional offices.