Enabling well-informed consumer choice is fundamental. Only if consumers are armed with tools that enable them to choose health plans on the basis of greater value will health plans be motivated to compete on that basis.
These objectives, however, do not define HCFA's role with much precision. Indeed, there appear to be at least three competing views about what HCFA's appropriate role and strategies should be.
- HCFA as a neutral facilitator. In this view, HCFA would have a limited, neutral role in facilitating consumer choice and market evolution. HCFA would send one or two mailings to each beneficiary. These mailings would explain Medicare choices and would offer a basic set of objective information and some public service announcements, as well as a toll-free number and the address of a web site that would offer similar information. For most questions, for example, whether an individual's physician is in a plan, beneficiaries would be referred to a health plan sales department.
- HCFA as an employee benefits office. In this view, HCFA would operate much more like the employee benefits office of a large corporation that successfully managed a rapid transition from fee-for-service to managed care offerings. There would be extensive communications about the benefits of managed care, how it differs from other options, and how to make good decisions, together with a substantial budget and resources for facilitating the transition. There would also be active contract management: Just as in an effective employee benefits office, HCFA would see that health plans took quick action to resolve problems.
- HCFA as a consumer advocate. In this view, HCFA would adopt a vigorous proconsumer role and would support the development of a national infrastructure for Medicare consumer information, advice, and advocacy. This view reflects concern about the potential for Medicare beneficiaries—many of whom are members of vulnerable populations—to have very bad experiences. Such concern is fueled by the consumer backlash against managed care and the documentation of the high degree of variability in the quality of managed care (National Committee for Quality Assurance, 1997; U.S. Department of Health and Human Services, Office of the Inspector General, 1998). Compared to the practice of major employers that can exclude poorer plans from the list of plans from which employees may choose (a form of leverage to promote good performance by health plans), a broader array of plans will be able to market directly to Medicare beneficiaries.
HCFA can hardly be expected to perform all of the roles described above at the same time, particularly in the absence of more legislative guidance and larger appropriations. HCFA does, however, have a range of discretion in choosing how much to blend these three roles, in setting targets and priorities, in defining its contract management philosophy, in developing relationships with a "Medicare helper" industry, and in assisting groups with special needs. HCFA has already done much preparatory work and is considering its future activities related to its new consumer service role. Some ideas and considerations that could enter into an overall HCFA management strategy for consumer service are discussed below.