"Medicare Choices for New Yorkers—Know What Matters!" is a counseling guide designed for Medicare intermediaries with the knowledge they need to help seniors make informed choices about their Medicare health coverage. Prepared by the Baruch College School of Public Affairs and Medicare Rights Center.
I. Medicare: The Need for Objective, User-friendly Information
II. About the Project
III. The Content of the Booklets for People on Medicare
IV. How to Use the Booklets: The Role of Counseling
V. Assessment and Counseling
a. Connecting with the Person Who May Need Help
b. Assessing Health Care Needs
c. Understanding How Medicare HMOs Work
d. Gathering and Distributing Information
e. Making the Decision
f. Empowering Clients to be Self-advocates
Appendices
A. Details on Data and Data Sources
B. Definitions
The Baruch College School of Public Affairs has developed a set of new booklets entitled Medicare Choices for New Yorkers—Know What Matters! The booklets are part of a larger effort to develop and test new and improved ways to provide people on Medicare with objective information to help them choose health plans. Baruch College is now working, in collaboration with the Medicare Rights Center, to provide these booklets to people on Medicare who are considering a change in their health care coverage. Rather than just send booklets out to people who may not be interested in them, or who do not understand how to use them, our strategy is to work with those who are already known and trusted by people on Medicare in New York City. Specifically, we are reaching out to and involving community-based agencies throughout the city who work with seniors and people with disabilities and asking them to participate with us in sharing these new tools with those who really need and want them. In addition to providing the booklets, however, we are providing two additional supports to the agencies with whom we are working. First, we are offering selected agencies training for staff and volunteers who work on the front lines helping people on Medicare to understand the Medicare+Choice program. Second, we are providing this guide to using our materials. Both the training and the guide, together, are designed to provide guidance as you help clients make informed decisions.
This summary guide on the booklets covers:
The guide was written with a diverse range of counseling staff in mind, including direct service staff, volunteers and paraprofessionals who work with people on Medicare. It is also intended to be a useful resource for counselors and supervisors who may already be familiar with Medicare HMOs in New York City.
Choosing a health plan can be one of the most important decisions made by older Americans and people with disabilities. People on Medicare face greater challenges in choosing their Medicare plan than ever before. Starting in the early 1980's, "risk-contract" HMOs were offered to people on Medicare. Medicare HMOs, as they are called, got off the ground slowly in some parts of the country, and have only become a significant part of the New York scene over the last few years. Most people on Medicare do not understand how HMOs work, how they are different from the traditional Medicare fee for service program, and what those differences mean for them. To add to the confusion, the 1997 Balanced Budget Act (BBA), with its Medicare+Choice strategy, further expanded the types of health insurance options that might be available to people on Medicare. Medicare+Choice lets more private insurance companies offer coverage to people with Medicare. These plans are, nevertheless, part of the Medicare program. While few insurance companies have actually offered these new kinds of plans, changes are taking place in the New York market. For example, in the Year 2000, for the first time, one company will be offering a "Point of Service" (PoS) option to its Medicare HMO. And if people on Medicare don't understand the usual HMO, they certainly understand this new option even less!
These changes in Medicare, in combination with intense marketing efforts by Medigap plans and Medicare HMOs and the lack of comprehensive and comprehensible information, leave people on Medicare confused and more likely to make a decision that may not be right for them. Consequently, some people enroll in a Medicare HMO without realizing what it means about what doctors and hospitals they can and cannot use. Many don't realize they are still in Medicare when they join a Medicare HMO, which means they also don't realize they get the same protections they had under the traditional program. Even worse, some people find out they have unintentionally enrolled in a new plan. Meanwhile, horror stories about HMOs in the press and recent withdrawals by Medicare HMOs in some communities have raised anxieties.
The Medicare+Choice strategy cannot work unless people on Medicare are reasonably well informed about their options. In response, the Medicare program has dramatically increased the attention and resources aimed at improving one's ability to choose the best Medicare health plan that meets their needs. The Health Care Financing Administration (HCFA), which runs Medicare, has sent out printed materials and set up a Web site, http://www.medicare.gov. They have also required all Medicare HMOs to participate in efforts to collect information about the real-life experience of their members, so it can be shared with other people on Medicare. Unfortunately, most of this quality information is not easily available. In addition, people on Medicare often find the printed materials that HCFA distributes difficult to understand and use without help. And right now, very few older Americans use the Internet, so they rarely get a chance to see the Web site.
Given this state of confusion, it is even more important that people on Medicare gain access to objective information and be given the tools to help them understand what each plan offers and how to decide which plan is best for them.
The Commonwealth Fund has supported the Baruch College School of Public Affairs to develop independent, user-friendly information on health plans offered to people on Medicare here in New York City. The Commonwealth Fund is a private foundation in New York City that works to improve the health of older Americans. No one who worked on the booklets has anything to gain from a person's decision to join a Medicare HMO. Rather, the intention is to help people on Medicare make a good decision.
The booklets were developed by Dr. Shoshanna Sofaer and her staff, not by Medicare HMOs, insurance companies, or even the Federal Government. Dr. Sofaer is a National expert in health care consumer information and a Professor at Baruch College School of Public Affairs. For over 15 years, Dr. Sofaer has conducted research on how best to inform individual consumers, especially people on Medicare, about the performance of the health care system, so that their perspective, as well as those of professionals and government officials, influences its direction.
During Phase I of our project with The Commonwealth Fund, we actually developed the set of booklets. Working with the Medicare Rights Center, the Baruch project reached out to people on Medicare, and to community-based agencies that serve their health and social service needs, to "reality test" our materials. The Medicare Rights Center (MRC), a National not-for-profit consumer service organization, was established in 1989 to ensure that seniors and people with disabilities receive quality, affordable health care. Through hotline counseling, education and public policy, MRC works to educate the public about Medicare; identify and address systemic problems in the Medicare program; and empower people on Medicare to help themselves and, where necessary, take corrective action on their behalf. As part of our "reality test," we conducted interviews and focus groups with people on Medicare and with staff and volunteers at several community-based agencies that serve older Americans and people with disabilities. Community-based feedback was used to design clear and unbiased materials that were pleasant and easy to read. Community-based input was also critical to making sure that the booklets addressed the issues that people on Medicare say are most important to them, such as premiums, services covered, providers and health plan quality.
Many people who help older Americans told us they needed simple, accurate and complete materials they could use to help their clients decide whether to join an HMO Medicare health plan. They also said that many older Americans and people with disabilities would need their assistance to fully understand the materials, process them and put them to use in making decisions. In response to these needs, the booklets were written with two audiences in mind—people on Medicare and agency staff, like you, who assist people on Medicare. In Phase II of the project (which is happening now!), we finalized our booklets, selected a group of agencies to disseminate the booklets to their clients on Medicare, and designed, with the Medicare Rights Center, a training curriculum for their staff and volunteers and this Counseling Guide to support people who participate in the training, especially once they are working with their clients. Training, conducted by Medicare Rights Center staff, began in April 2000.
Background
Objective of the Booklets
The Counseling Process
These booklets were designed to help older Americans and people with disabilities determine whether it would be a good idea for them to join a Medicare HMO, and if so, to select the HMO that best meets their needs. The booklets not only provide information but they also offer practical advice to help people on Medicare undertake the often daunting task of choosing a health plan. A lot of the information that is needed to compare choices has been gathered in these booklets.
The booklets incorporate three main sources of information about health plans that are not easily available elsewhere. The first source of information, on the premiums, covered services and "ground rules" of each Medicare HMO offered in the Year 2000 in New York City from the HCFA Medicare Compare Web site, supplemented by more detailed information disseminated by the plans themselves. (Later this year, when information on premiums and covered services for the Year 2001 become available, we will be updating and reprinting the relevant booklets.) Researchers at Baruch College, School of Public Affairs clarified any inconsistencies and gaps in the information with plan representatives. This data can be found in the green booklet, What services are covered and what are their costs?
The other two sources of data grow out of new HCFA requirements that all Medicare HMOs participate in two important new initiatives to gather objective data on health plan quality. One source of data comes from a survey developed by the Consumer Assessment of Health Plans Study (CAHPS® ®) specifically to get information from Medicare HMO members about their experiences in their plan, and their assessment of their plan's performance in providing access to quality health care. HCFA mandated the development of this special Medicare Managed Care version of CAHPS® ® and has contracted with an independent group to collect CAHPS® ® survey data from all Medicare HMOs in the country. A second source of data is information that Medicare HMOs have provided to HCFA on particular quality measures included in the National Committee on Quality Assurance's (NCQA) Health Plan Employer Data and Information Set (HEDIS). These quality measures address whether Medicare HMOs provided their members with specific clinical services that are considered by experts to be critical for preventing illness, catching it early, and treating it appropriately. It is important to note that in addition to requiring Medicare HMOs to provide these HEDIS data, HCFA has also audited the plans to make sure the data they provide are accurate. In fact, when the data have not been found sufficiently accurate, we do not report it. Appendix A has additional detail on the CAHPS® ® and HEDIS measures that are included in the booklet and how the data are collected. Although the CAHPS® ® and HEDIS data was collected in 1998, it represents the most recent information available on the plans. Unfortunately, because large-scale surveys require significant time for data collection and presentation, there is usually a time lag.
Taken together, these three sources of data let people on Medicare compare plans in terms of costs, covered services, and access to quality care. In addition, the booklets educate people on Medicare about the range and types of health insurance options now available in New York City and explain the significance of the comparison ratings on the quality of different HMOs.
The CAHPS® ® and HEDIS data are contained in four booklets: Getting Health Care—Easily; Getting a Plan with Good Doctors; Prescription Coverage; and Staying Healthy and Getting Better. In each of these booklets, comparative data are presented in easy-to-read charts that highlight the critical differences among plans and important features to consider. Star charts and bar graphs are used to simplify complicated summary information on how well the plans perform on important quality measures. The star charts show how well the scores of each Medicare HMO compare to the average scores for all NYC Medicare HMOs in the survey. Segmented bar charts with legends are used in two booklets, Getting Health Care—Easily and Getting a Plan with Good Doctors. These charts provide more detail on the information contained in the star charts, for example on how well doctors communicate with their patients and how easy it is to get health care without long waits. Not all plans provided CAHPS® ® or HEDIS data, primarily because not all Medicare HMOs currently available in NYC were in operation for at least a year when the member survey was conducted in 1998, or have had members on Medicare long enough to collect the HEDIS data. Footnotes explain the reason(s) why not all HMOs are included in every chart. There are also tables and charts in Thinking about joining an HMO, which we sometimes call "the Introductory Booklet," that compare:
Medicare Choices for New Yorkers—Know What Matters! consists of six booklets. Before reading further, please familiarize yourself with the content of all the booklets as well as the charts. Review the booklets and see how health plans are rated by people who are using each plan, based on the results from independent studies. Each booklet is color-coded in order to make it easier to use:
By familiarizing yourself with the booklets, you will be better prepared to answer questions and locate the most relevant information for a particular client. When people on Medicare, for example, come to you for help because they can no longer afford their prescription coverage, you will then know where to find critical information comparing the prescription costs and coverage for each HMO plan. If a HMO plan has denied someone an important service recommended by their primary care doctor, you will know that the booklet Thinking about joining an HMO? (the blue and red booklet) provides information about individual rights and grievance procedures. It also provides phone numbers of organizations that can help resolve such problems. But the booklets also go beyond the basic facts. They inform the reader about how features of individual HMO plans can affect access to care and the quality of care received.
The following gives an overview of what each booklet covers.
Thinking about joining an HMO? The Blue and Red booklet
Area of Interest: This introductory booklet gives background information comparing original Medicare to Medicare HMOs. It describes the differences between a basic HMO plan and a new Point of Service, or POS, option. In addition, it identifies several things to consider when choosing a new plan and lists nine steps that are critical to making an informed decision. Information available in the other booklets is previewed. A worksheet is provided to help people examine and compare the different plans. It also covers consumer rights, grievance procedures, and important sources for information or assistance.
What Services are Covered and What are the Costs The Green booklet
Area of Interest: This booklet shows you what NYC Medicare HMOs have in common, and how they differ, in terms of their premiums, the services they cover, and what it costs when a person visits the doctor, uses an emergency room, fills prescriptions, goes to a skilled nursing facility, stays in a mental hospital, or gets outpatient mental health care.
Prescriptions and Premiums The Burgundy booklet
Area of Interest: This booklet provides greater detail on prescription drugs. There is also a chart on prescription coverage that includes the costs for premiums. Another chart gives information from the CAHPS® ® survey about how easy members said it was to get prescriptions through the HMO plan. These charts are particularly helpful for people on a limited budget.
Getting the Health Care You Need—Easily The Light Blue booklet
Area of Interest: This important booklet on access provides data from CAHPS® ® on the real-life experience of Medicare HMO members. The data describes how easy it was to get a referral, to get the care they needed, and to get service without long waits. The information also describes whether customer service was efficient and helpful and how often getting approvals was hassle-free. Overall ratings on each Medicare HMO are also provided.
Getting a Plan with Good Doctors The Purple booklet
Area of Interest: This booklet provides information from CAHPS® ® surveys about how well doctors in different plans communicate with their patients and whether they spend enough time with them. It also compares member ratings of the health care in each Medicare HMO and reports on the HEDIS measure that shows the percentage of specialists in each plan that are board certified.
Staying Healthy and Getting Better The Yellow booklet
Area of Interest: This booklet reports on HEDIS measures and CAHPS® ® survey questions that show how well different plans (1) help members to say healthy and (2) take care of them when they are sick. This includes measures of important preventive care, such as breast screens and flu shots and measures showing how often plans prescribe the right drugs to prevent more heart attacks and how often people with diabetes receive eye exams.