HCFA's consumer information commitment.

This article provides examples of how the Health Care Financing Administration is providing Medicare and Medicaid beneficiaries with information that will allow them to become more active participants in decisions affecting their health and well-being. The article emphasizes how HCFA has incorporated a beneficiary-centered focus and social marketing techniques in its consumer information activities. The work described in this article represents a cross section of the innovative and excellent work being done by staff throughout the Agency and by our partners and agents in meeting the information needs of beneficiaries.

Introduction

HCFA's mission is to assure health care security for Medicare and Medicaid beneficiaries. As part of assuring health care security for beneficiaries, HCFA is committed to providing clear and useful information to assist them in making health care decisions. This commitment was reaffirmed in HCFA's recent evaluation of how the Agency will successfully meet current and future challenges in realizing its mission, known as the HCFA of Tomorrow initiative. As a part of this initiative, HCFA has defined its core role to be a beneficiary-centered purchaser. In fact, HCFA's planned reorganization emphasizes this beneficiary-centered focus by having, for the first time, a principal operational component explicitly dedicated to understanding and meeting the needs of beneficiaries.

This beneficiary focus and the use of social marketing techniques are incorporated in HCFA's consumer information activities. HCFA's basic approach to achieving its consumer information goal is to first assess the needs of these populations affected by HCFA programs, e.g., asking beneficiaries, both directly and through their representatives, to tell HCFA what information they need and how well we are responding to these needs. Then, we design communication interventions to address these needs. This step includes emphasis on understanding the requirements of populations with special communications needs (e.g., vision impaired or non-English speaking beneficiaries). And finally, we measure the effectiveness and efficiency of the intervention in meeting the specified goal. This performance information provides feedback needed to continuously improve the communications we have with beneficiaries. Examples of HCFA's beneficiary focused communication activities follow.

Your Medicare Handbook

The HCFA publication entitled, Your Medicare Handbook, is intended to educate beneficiaries on the basics of Medicare, including: who is eligible, how to enroll in Medicare, and Part A and Part B benefits, coverage, and limitations. The Handbook also provides beneficiaries with the information they need on their rights and obligations under Medicare, information on Medicare and managed care, and access information to organizations that may be contacted for additional assistance with Medicare and related matters.

For the past several years, this Handbook has been mailed only to new enrollees because of budget constraints. However, in 1996 the Handbook was sent out to 37 million Medicare beneficiaries. HCFA sent this universal mailing in response to feedback obtained from beneficiaries that the Handbook is a critical source of information on program benefits and policies. This general mailing of the Handbook demonstrates the importance that HCFA places on providing beneficiaries with information on their benefits and health care choices. As part of a continued commitment to provide this information, HCFA is investigating the use of a variety of distribution channels to reach the broader audience, including beneficiaries, their families and advocacy groups.

Health Status Consumer Information Program

In 1994, HCFA initiated the Health Status Consumer Information Program (CIP). This program provides information to improve the healthy behaviors and health status of Medicare and Medicaid beneficiaries. CIP marked a notable change in HCFA's level of commitment, from providing information for awareness to promoting interventions for improving healthy behaviors and the health status of the populations HCFA serves. The objectives of this program are to:

Provide current, useful health information to beneficiaries.

Convey simple, customer-friendly, health education messages.

Be sensitive to differences among beneficiaries, including cultural diversity.

Document measurable improvement in healthy behaviors and the health status of beneficiaries.

Work in partnership with public and private organizations which share our purpose.

Reach the maximum achievable targeted audience.

HCFA is applying social marketing techniques to the CIP activities. This approach uses commercial marketing techniques in the research, planning, execution, and evaluation of programs designed to influence the voluntary behavior of target audiences to improve their health. These techniques emphasize a consumer-centered approach, audience segmentation, and use of demographic and social/behavioral data from various sources.

CIP projects focus on areas where there is scientific evidence that specific behavior will improve the health status of a population, and where there are data which indicates that there is room for improvement. HCFA's CIP campaigns are long-term commitments focused at the community level. The first step is to pilot the targeted interventions prior to committing to undertake the campaign nationwide. These pilots and national campaigns are lead by staff in the HCFA Regional Offices, and are done in partnership with other Federal agencies, health care providers and practitioners, national and local health organizations, and various field organizations.

Current CIP activities address the need to increase: influenza and pneumococcal immunization rates of aged Medicare beneficiaries, the rate at which aged female Medicare beneficiaries receive mammograms, and the adequacy of dialysis of adult hemodialysis patients. These activities include design and distribution of brochures and other information for beneficiaries and interventions aimed at providers (e.g. office reminders, simplified billing) and community coalitions for health status improvements. In recognition of the racial disparities in the use of preventive services, the Horizons pilot project was initiated in 1996. Horizons represents community level partnerships, notably among HCFA, HCFA funded Quality Improvement Organizations, and Historically Black Colleges and Universities, to target the African American population in southeastern States to encourage both their use of flu and pneumococcal immunizations and of mammograms.

HCFA's major Medicaid CIP project targets the problem of maternal aquired immunodeficiency syndrome (AIDS). The project alerts Medicaid-eligible, pregnant women, and women of childbearing age, of the benefits to the unborn child of AZT therapy for human immunodeficiency virus (HIV) infected women, before and during pregnancy, and for their children during the first 6 weeks of their lives. The materials also inform these women that they may be eligible for Medicaid, which also covers this treatment. The goal of this project is to ensure that these women have both access to appropriate care and have all the information necessary to allow them to make an informed decision regarding HIV treatment and AZT therapy for themselves and their children.

Information Materials for Health Plan Choice

As health care delivery systems evolve, the choice between fee-for-service (FFS) and managed care becomes more complex, as does choice of health care plan or provider. HCFA is working to increase the ability of Medicare and Medicaid beneficiaries to become informed and discriminating consumers of health care.

HCFA is pursuing a variety of approaches to providing Medicare beneficiaries clear and comparative health insurance information. In 1994, the San Francisco Regional Office produced beneficiary information comparing benefits and costs of the managed care plans for each State in the region. In 1996, this information was published in both English and Spanish. Also in 1996, similar plan comparison information was published by the Boston and Philadelphia Regional Offices. In 1997, HCFA will implement a national database on the Medicare managed care plans. This database will combine information of a general nature (plan model, type of contract, location, phone numbers) with benefit-specific information. Common definitions and beneficiary-oriented language will be used. This database will support the production of general reports, such as those published by the regional offices, and will be made available to the public via the Internet.

HCFA has developed and tested with focus groups comparative insurance information covering FFS, medigap, and managed care plans. This “Beneficiary Information, Education, and Marketing Strategy” research project is designed to inform all Medicare beneficiaries of new and existing plan choices in a planned demonstration market where all managed care plans will compete for Medicare consumers in an special enrollment period. HCFA is also designing and testing prototype comparative plan information with performance measures for quality of care and consumer satisfaction. This research project, “Information Needs for Consumer Choice” first examined the types of information consumers find most useful in selecting health insurance plans. Prototype information materials for hypothetical but realistic managed care plans using performance measures have been developed and are now undergoing cognitive testing in both Medicare and Medicaid populations.

Comparative Data on Health Plans

HCFA is also building on the efforts of the private sector and developing comparative information on tested performance measures pertinent to the Medicare and Medicaid populations. The National Center for Quality Assurance (NCQA) and HCFA worked together to modify HEDIS to the needs of Medicare and Medicaid beneficiaries. HEDIS 3.0, the current version, permits integration of measurement across the public and private sectors by including indicators relevant to Medicare, Medicaid, and the privately insured populations. Starting in mid-1997, HCFA will require all Medicare managed care plans to report the relevant HEDIS 3.0 measures. For example, to monitor health status of seniors, plans will collect self-reported data on Medicare beneficiaries' functional status as measured by the SF-36 questionnaire over a 2-year period. All Medicare managed care plans will be required to participate in an independently administered survey using the Medicare version of the Consumer Assessment of Health Plans Study. The HEDIS and consumer satisfaction survey data are expected to be available to beneficiaries for selection of Medicare managed care plans starting in late 1997.

Medicaid HEDIS, released in February 1996, preceded the current HEDIS 3.0. It was the first step in the development of a set of standardized performance measures for capitated Medicaid managed care plans. Several State Medicaid agencies are currently collecting some Medicaid HEDIS measures, and many plan to use it or HEDIS 3.0 in the future. States will use these data for monitoring quality, but the information also could be provided to Medicaid beneficiaries for assistance in selecting a managed care plan. In 1995, Minnesota was the first State to survey members' satisfaction with different health plans (both FFS and managed care) throughout the State for Medicaid, Medicare and privately insured populations and disseminated the findings to them.

HCFA also is working to operationalize three outcome measures developed by the Foundation for Accountability (FACCT) common to both FFS and managed care systems. HCFA is participating with FACCT, along with many other large public and private health care purchasers who joined together to find ways to help consumers and purchasers make more informed choices about health care quality. HCFA recently awarded a 4-year contract to the RAND Corporation to build upon work from FACCT by applying and pilot testing the FACCT measures for breast cancer, diabetes, and depression. RAND will also develop strategies for using these measures to improve the quality of patient care. These collaborative efforts with FACCT and NCQA avoid duplication of private sector activities and limit the burden on plans and providers.

Other HCFA Communication Activities

Beneficiary Counseling

HCFA has provided grant funds to States since 1992 to help Medicare beneficiaries obtain free and unbiased information on health insurance options and to assist with claims forms and appeals. States use individual counseling, group seminars, and a variety of materials to provide information to seniors. HCFA, particularly the Regional Offices, work with these State-based entities to support direct counseling and assistance. An example of this type of collaboration is the Health Benefits Information and Resources Directory compiled by the Massachusetts Beneficiary Services Workgroup for Medicare and Medicaid beneficiaries in that State.

HCFA On-line

HCFA On-Line is a strategy to modernize the way HCFA communicates with beneficiaries and other constituents. This plan will integrate existing communications efforts, build on these initiatives, and explore more efficient methods of communication. A variety of technologies, ranging from low to high technology, will be tested to determine appropriateness. The major dimensions of the On-Line approach are to: undertake market research to study the information needs of the Agency's constituents; improve customer service functions, including re-engineering programmatic communications; and to evaluate, document, and provide feedback on the results of HCFA communications to improve the quality and efficiency of our consumer information program. The ultimate result of the On-Line communication strategy will be improved access to health care and information and increased user awareness and satisfaction.

In 1996, HCFA implemented a market research program to provide an ongoing assessment of the information needs of beneficiaries, providers, and other stakeholders. HCFA will examine what information these groups want and need from HCFA, and how such information can best be communicated to them. HCFA is putting emphasis on understanding the requirements of subgroups who may have special communication needs (e.g., vision impaired or non-English speaking beneficiaries). The research consists of multiple phases, including:

Conducting inventories of existing information in communication strategies relevant to beneficiaries, providers, and other stakeholders.

Conducting focus groups to explore the information needs of these groups.

Collecting and analyzing survey data on information needs in these populations.

This research will help guide the development of HCFA's communication activities to ensure that constituents' information needs and customer service expectations are being met.

Customer Service 1-800-Single Point of Access for Medicare Beneficiaries

HCFA is investigating approaches to provide a single toll-free, number for beneficiaries to have as sole point of telephone access regarding Medicare benefits and general health care information. HCFA began a pilot test in 1996 for beneficiaries in Maryland to respond to a variety of inquiries including: Medicare claims questions, how to contact a Medicaid State Agency, and information on Medicare eligibility and coverage. Callers have the option to talk to a person or follow an automated menu of choices. This effort consolidates several toll-free telephone numbers into one. Current telephone services, including ongoing fiscal agent systems and teleservice pilots, are being studied. Findings will be included in recommendations for a consolidated single point of access and customer service strategy.

Redesign of the Initial Enrollment Package

HCFA is redesigning the initial Medicare enrollment package, which notifies beneficiaries that they will be automatically enrolled in Medicare Part B (with the premium deducted from their Social Security checks) unless they decline. It provides additional information about the Medicare program 3 months prior to start of enrollment. This package is being examined to assess its clarity and usefulness to Medicare beneficiaries. Focus groups and interviews are being used to test the redesigned package. In a later project phase, other changes to the initial enrollment process will be considered. The desired outcome is a package and dissemination process that allows beneficiaries to make more informed insurance choices.

Your Medicare Center

“Your Medicare Center” is a pilot project in Philadelphia to better understand customer service and information needs of Medicare beneficiaries. Six days a week, Medicare beneficiaries have direct access to trained HCFA Regional Office staff providing information and assistance to resolve Medicare issues. The center has a cooperative arrangement for the local beneficiary insurance counseling program staff to come to the center several days a week to provide one-on-one advice about Medicare supplemental insurance; otherwise, the center makes referrals to the State counseling programs for such questions. Feedback will be used to improve HCFA customer service systems.

Summary of Activities

As mentioned in the introduction to this article, HCFA is undergoing a major restructuring. The changes are needed to help the Agency adapt to changes in the health care market and to provide consumers in both managed care organizations and who receive services in FFS settings pertinent information to make decisions about their health and well-being. HCFA as a beneficiary-centered purchaser will use its market influence to obtain the “best value” for Medicare and Medicaid beneficiaries. “Best value” means working to improve quality of care while controlling costs. Beneficiary-centered purchasing also means that HCFA will help beneficiaries become informed health care consumers; use its market influence proactively to protect and serve beneficiaries; and ensure beneficiaries continue to receive the benefits they are entitled. While this role clearly necessitates a shift for HCFA, it also creates a different role for beneficiaries and their advocates—who must assume a more active role in defining information needs and in making health care choices.