While the booklets can be very useful, they need to be introduced in a way that will help people on Medicare understand why this particular information is relevant to them and how it can help them in deciding which health plan to join or evaluating how well their plan compares to others. Because people on Medicare are not use to getting significant levels of objective comparative information about their health care coverage options, they need to be told that such information is available from credible sources. They need to have key messages reinforced about the meaning of quality care and they need good navigational assistance about how and where to find important information. Many people will need help in understanding how the health care system is changing and how to use new comparative quality data to make real life choices. You can help identify information that is relevant to the issues that are most important to them, in our booklets and from other sources. The person may need additional help to understand the comparative information we provide on topics of interest.
Once it is clear that a Medicare HMO may be a viable option, you will need to assess the person's knowledge of HMOs versus traditional Medicare. There are clear advantages to HMOs but they also have their own rules and conditions that can limit individual choice. When counseling people on Medicare about their choices, use the chart on Page 3 of the blue and red booklet, Thinking about Joining an HMO to make sure that the person on Medicare understands the differences between original Medicare and a Medicare HMO. Make sure the person fully understands the implications of his/her decision before joining a new plan. This will entail reviewing the differences between the original Medicare fee-for-service program and a Medicare HMO. It also requires that the person understand that there is a new option now available, the POS. Many issues need to be considered before joining an HMO. This is not to say that there are not lots of people for whom a Medicare HMO is a good choice. It is to say that people will be more satisfied with their HMO, and their choice in general, if they make it "with eyes open."
This process may require that you help clients understand basic facts about Medicare or the health care delivery system. You may also need to clarify misconceptions, explain the features of individual plans and the terminology used by health insurance companies. Everyone should know what is at stake when they choose a Medicare HMO.
HMOs also use a lot of terminology that may not be familiar to people on original Medicare. In order to help you explain the terminology, Appendix B in this guide provides definitions of the jargon commonly used by health plans.
Several other issues need to be considered when assessing people's understanding of the materials. How familiar are they with Medicare + Choice? How much new information can they handle at one time? Here are questions for you to answer regarding a person's understanding of the materials:
Consider how well people on Medicare understand the materials:
The next section addresses the context in which the booklets can be distributed and how to distribute the booklets, without overwhelming people on Medicare.
As already mentioned, you should learn why the person is seeking help and what the person cares about before providing a lot of information. In general, you should begin with the introductory blue and red booklet, Thinking about Joining an HMO? Depending on the person's interest, the other booklets can be referred to as a whole for background information or individual booklets can be used to answer specific questions or concerns. Find the information on the features of the plan that are most important to your client, such as whether you can see a specialist, get appointments without long delays, whether the doctor spends enough time with you. These issues are all covered in the light blue booklet, Getting the Health Care You Need—Easily. You can put all the information together to find the plan that best meets that person's needs and priorities. If someone wants to remain with his/her existing provider, for example, then you could begin with the Getting a Plan with Good Doctors booklet, the purple booklet. This booklet addresses that issue but also broadens the issues to include other information associated with the quality of care doctors provide in different HMO plans.
While all the booklets can be selectively used during the previous stages, by the end of Stage 3 it should be clear which booklets are most relevant to the needs and interests of your client. By this point, the client should know that the booklets are for them to take home to read or to refer at a later point. People should also be encouraged to come back or call to get other booklets of interest or to have issues further clarified.
You do not want to give people more information than they can handle. Otherwise you may just add to their confusion and anxiety. You may need to reassess whether the person is ready for more information that broadens the discussion to include different aspects about quality of care. The complete set of concepts, messages, and information may, therefore, need to be disaggregated into less daunting "chunks" and delivered over time. That's why we created a set of booklets rather than one single booklet!
Another very useful tool is the worksheet contained in the introductory booklet. You can use the worksheet when counseling people on Medicare. In order to use the worksheet in Thinking about Joining an HMO? the blue and red booklet, the person will first need to:
Once the worksheet is completed it should be easier to make a choice among plans. The booklet takes them step-by-step through the decision making process. It is organized into questions to narrow choices by identifying which health plan did well on topics that are of high importance to the individual. It identifies things to think about as you review the information about benefits, coverage, costs, doctors, and quality of care. This process can help people on Medicare organize information to clarify the pros and cons of each plan. The "summary chart" allows people, at times with your assistance, to check off the plans that did well on the topics that match their needs and concerns. It can also help you focus your interactions with people on Medicare from the outset or after other concerns have been addressed.
There are several important distinctions to be made between assisting someone and making explicit recommendations that may bias the information. Exploring health plan options takes time and involves having the person thoughtfully consider what is important to them. While you can help them to get important information and weigh their option, you need to remain neutral. Neutrality involves being forthright in pointing out both the positive and negative interpretations of comparative performance data. This is true both for a specific piece of information and for an entire set of information on different topics.
Helping someone to make an informed decision is not easy. There are no right answers and it would be unusual for a plan to perfectly match someone's particular needs. There are, however, plans that may be a better match than others. In the end, the Medicare plan that is likely to work best for an individual is the one that matches the person's own needs and values. If a person on Medicare highly values preventive care, for example, it would be important to ensure that these types of services are covered. On the other hand, if financial cost and preventive care represent a daily concern, then plans that provide excellent preventive services but high premiums may not be appropriate.
An important step in helping your clients become their own advocates is reviewing their consumer rights. In an effort to better educate and inform people on Medicare as consumers, the last section of the introductory booklet contains a list of names and numbers to call for further information and reviews the rights and responsibilities of people on Medicare. People in a Medicare HMO are, for example, entitled to all services covered by original Medicare. They will not, however, be covered for care that they get from doctors not in the network, unless there is an emergency. Once enrolled in a Medicare HMO, people have the right to leave the HMO or switch to another HMO or return to original Medicare. Medicare HMOs also have appeals procedures for those who feel that they have been wrongly denied services or coverage. Under the standard appeals process, the HMO must review your case within 30 days. If you think your health could be seriously harmed by waiting for a decision about the appeal, you can request a fast decision to be made and they must answer you within 72 hours.
An informed public can help to improve the overall quality of our health care system by encouraging a health care market place that rewards coverage options that provide real value. Individual consumers, as well as communities, can play a significant role in shaping the health care system to be more responsive to individual needs and the overall quality of care.
In response to the growing demand for information regarding the quality of health care in general, and Medicare HMOs in particular, HCFA has mandated that all Medicare HMOs participate in two important quality information initiatives, known familiarly as CAHPS® (for Consumer Assessment of Health Plans Study) and HEDIS® (for Health Plan Employer Data and Information Set). In the following paragraphs, we describe the background on each of these initiatives, so that you can be confident that the data in the booklets are meaningful and come from objective sources. In the next section, we will specify, booklet by booklet, details about each of the quality measures included, and how the data are presented.
CAHPS® is a multi-year effort initiated in 1995 by the Agency for Healthcare Policy and Research (AHCPR), which is now known as the Agency for Health Care Research and Quality (AHRQ). The goal of CAHPS® is (1) to develop surveys of people in various health insurance plans to get feedback from them on important aspects of their experience and (2) to develop ways of sharing that feedback with people like them who are trying to make a health care coverage decision. The topics included on the CAHPS® survey were chosen based on research with consumers that (1) identified the issues consumers cared about and (2) identified the issues they wanted to hear about from other consumers. Consumers are smart: they know other consumers can't tell them much about the outcomes of their surgeries, but that they would be the real "experts" on issues like access to care and the quality of their communications with doctors, medical office staff and health plan customer relations departments.
Shortly after CAHPS® began, HCFA decided that it needed a way to assess how people on Medicare were responding to their health care experiences, especially those enrolled in Medicare HMOs. They therefore supported the development of a CAHPS® survey designed specifically for people on Medicare enrolled in HMOs. (HCFA has, more recently, supported the development of a CAHPS® survey for people on Medicare who remain in the fee-for-service system. The data from these surveys would, of course, be very helpful to people trying to decide whether an HMO is a good idea for them at all. Unfortunately, however, it will be a couple of years before data from this survey will be available for all communities across the country.) They also contracted with a major survey research firm to actually conduct the survey. The booklets report information from the second administration of the CAHPS® surveys across the United States. HCFA has included a very limited number of CAHPS® items on its Web site and in its publication Medicare & You. Our booklets include all the CAHPS® items on which there were enough responses from consumers to ensure that the results are reliable. We also follow the model of reporting used by the CAHPS® project Nationally, which is, in most cases, to combine questions on a particular topic into a "composite" score. This reduces the number of "data points" that anyone has to look at, which helps keep people on Medicare (and you!) from being overwhelmed. However, in the chart below, we will give you the details about the specific questions included in each composite, so that you can provide more information to your clients if they are interested.
The number of people surveyed in each Medicare HMO, and how the sample is drawn for the survey, are specified and consistent across all Medicare HMOs; the sample is large enough to make sure the results are reliable and representative of Medicare plan members as a whole. Statisticians associated with CAHPS® have spelled out these details and they are rigorously followed in implementing the survey. In addition, the survey results have been adjusted to account for differences that exist in the mix of people in each Medicare HMO. Thus, for example, some HMOs avoid enrolling really sick people while others do not. Since it is often the case that sicker people are less satisfied with their health care, no matter where they get it, the CAHPS® results are adjusted so that plans that actually enroll sick people are not penalized and those who put up barriers to sick people are not rewarded.
The other main source of comparative data on individual health plans in New York City is based on the work of the National Committee for Quality Assurance (NCQA), which has developed a set of measures of the performance of HMOs called the Health plan Employer Data and Information Set (HEDIS). Initially, HEDIS measures were not designed to address people on Medicare. In 1995, however, when the last major revision of this measurement set was undertaken, NCQA decided to expand the scope of HEDIS to include items of particular interest to older Americans. HCFA staff were active participants in the effort to pick measures of this kind; Dr. Sofaer also tested measures NCQA was considering to make sure they were of interest, and meaningful, to people on Medicare. One component of HEDIS are measures of clinical effectiveness. HCFA has selected several measures from this group that they believe will be of greatest interest to people on Medicare (as well as to themselves in their role of monitor of HMO performance); they have mandated that all Medicare HMOs submit data on these measures annually. The data for these measures are typically drawn from the administrative or clinical records of HMOs. The way these data are collected, and how the measures are calculated, have been carefully specified by NCQA. In addition, HCFA has "audited" the HMOs to make sure they have actually submitted accurate data. We have selected, from among the measures on which data are mandated, those that we believe, based on our testing with consumers, are of greatest relevance and interest, and those on which there is confidence that the HMO data are reliable.
Our experience indicates that while consumers generally understand the meaning and importance of CAHPS® data, they need more help in understanding the meaning and importance of HEDIS information. The booklets therefore provide, for each HEDIS measure, a "plain English" version of the measure, a brief statement of why it is important and another brief statement of what it shows you about a Medicare HMO. Note that people often don't realize that a health plan (rather than their doctor) can have a big impact on the quality of care. These statements help them to understand how the health plan can have such an impact.
If you have questions about the data in the booklets, or if a client asks a question you can't answer, please do not hesitate to call the staff of the project at Baruch to get an answer. You can call Tracey Dewart at 212-802-5979 or Shoshanna Sofaer at 212-802-5980.Introduction: Thinking About Joining an HMO The Blue and Red booklet
There are no CAHPS® or HEDIS data in this booklet.
What Services are Covered and What are the Costs? The Green booklet
There are no CAHPS® or HEDIS data in this booklet. All the information comes from the Medicare Compare Web site, from Medicare HMO brochures, and from follow-up research on ambiguous or confusing items.
Prescription Coverage The Burgundy booklet
There are two kinds of information in this booklet. One kind is traditional data on prescription coverage and premiums in each of the Medicare HMOs in New York City; it is the same as the data in the general booklet on premiums and services covered. In addition, however, this booklet includes information from CAHPS® , in the form of a star rating that compares what members of each HMO say about getting prescriptions through their Medicare HMO. We report a composite measure consisting of two questions:
The data was recoded to have the response options "Never and Sometimes," "Usually" and "Always."
Getting a Plan with Good Doctors The Purple booklet
This booklet contains both CAHPS® and HEDIS data. The first three charts report CAHPS® data; the last chart reports one HEDIS item.
Chart 1 presents Star ratings from information on different CAHPS® items, as described below:
Was it easy to find a doctor you like, represents responses to a single CAHPS® item, "With the choices the HMO plan gave you, how much of a problem, if any, was it to get a personal doctor or nurse you are happy with?" with the response options: 1. A big problem. 2. A small problem 3. Not a problem.
How well do HMO doctors communicate represents a composite of four questions, asking how often the person's doctor or health care provider:
All these questions have the same response options: 1. Never 2. Sometimes 3. Usually 4. Always.
Rating of the HMO Health Care providers represents a single question: "We want to know your rating of your personal doctor or nurse. Use any number from 0-10 where 0 is the worst personal doctor or nurse possible and 10 is the best personal doctor or nurse possible. How would you rate your personal doctor or nurse now?"
Chart 2 Was it easy to find a doctor you like, represents a bar chart of the responses to a single item "With the choices the HMO plan gave you, how much of a problem, if any, was it to get a personal doctor or nurse you are happy with?" with the response options: 1. A big problem. 2. A small problem. 3. Not a problem.
Chart 3 How well do HMO doctors communicate represents a bar chart with legends of the composite data in the 2nd column of chart 1 on whether HMO doctors communicate well. The legends include: "Never and Sometimes," "Usually," and "Always."
Chart 4 Board certification reflects the data collected by HEDIS. It asks "The percentage of board-certified primary care doctors in each Medicare managed care plan."
Getting the Health Care You Need—Easily The Light Blue booklet
Chart 1 presents star ratings from information on different CAHPS® items, as described below:
Was it easy to get referrals to specialists, represents responses to a single item "In the last 6 months, how much of a problem, if any, was it to get a referral to see a specialist?" with the response options: 1. A big problem 2. A small problem 3. Not a problem.
Was it easy to get other care needed represents a composite of three questions, asking:
The data was recoded to have the response options "Never and Sometimes," "Usually" and "Always."
Was easy to get care without long waits represents a composite of four questions, asking:
The data was recoded to have the response options "Never and Sometimes," "Usually" and "Always."
Chart 2 presents star ratings from information on different CAHPS® items, as described below:
Rating of HMO customer service represents a single question: "How much of a problem, if any, was it to get the help you needed when you called the HMO's customer service?" with the response options: 1. A big problem 2. A small problem 3. Not a problem
HMO Paper work and approvals represents responses from people who had experience with paper work from the health plan to the question "How much of a problem, if any, did you have with paperwork with health plan?" with the response options: 1. A big problem 2. A small problem 3. Not a problem.
Health Plan Rating represents a single question: "We want to know your rating of all your experience with your health plan. Use any number from 0-10 where 0 is the worst health plan possible and 10 is the best health care possible. How would you rate your health plan now?"
Chart 3 presents information from the first column in Chart 1 on:
Was it easy to get referrals to specialists? It represents a bar chart of the single item "In the last 6 months, how much of a problem, if any, was it to get a referral to see a specialist?" The bars represent the percentage of respondents who indicated that it was not a problem with the response options: 1. A big problem 2. A small problem 3. Not a problem.
Chart 4 presents information from the 2nd column in Chart 1 on:
Was it easy to get other care needed? It represents a bar chart with the legends "Never and Sometimes," "Usually" and "Always."
Chart 5 presents information from the 3rd column from Chart 1 on:
How easy it was to get care without long waits. It represents a bar chart with the legends "Never and Sometimes," "Usually," and "Always."
Staying Health and Getting Better The Yellow booklet
Chart 1 Percent of women who got tested for breast cancer is a HEDIS measure. It shows the "percentage of women in each HMO between the ages of 52 and 69 who got an x-ray to check for breast cancer (called a mammogram) in the past 2 years."
Chart 2 Percent of members who got a flu shot last year represents CAHPS® data. The CAHPS® question asks "Did you get a flu shot last year from September-December 1997?"
Chart 3 Eye exams for people with diabetes is a HEDIS measure. It shows the "percentage of plan members with diabetes mellitus in each Medicare HMO plan who got an eye exam to make sure their eyes were healthy."
Chart 4 Prescribing the right drugs to prevent more heart attacks is a HEDIS measure. It shows the "percent of members in each HMO who got Beta blocker after a hospital stay for a heart attack".
Accreditation: The process under which health plans are reviewed and judged for quality by an outside organization, such as the National Committee for Quality Assurance.
Capitation: A method of payment for health care services in which providers are paid a fixed monthly rate for each plan member they have as a patient regardless of the amount of care the member receives.
Co-payment: A small set fee you pay for a service (e.g. $5 co-payment for a visit to a doctor). Members typically pay a co-payment ranging from $5-$15 every time they visit the doctor, have test done, or have a prescription filled.
Deductible: The amount per year you must pay for services before insurance begins to cover costs. This feature is more common with traditional insurance.
Disenrollment: The procedure you must follow to cancel your membership in a plan.
Exclusion: Health services that are not covered by your health plan or specific circumstances under which your plan will not pay for services.
Experimental procedures or services: Services that are not recognized under generally accepted medical standards as effective for treating a particular condition. In some instances, health insurers may differ on their determination of what is "experimental " and what is not.
Fee-for-service: The traditional method of paying for medical services where doctors and hospitals are paid for each service they provide.
Formulary: A list of approved drugs under a health plan's prescription drug benefits.
HMO: Health plans that provide comprehensive health care services to members for a fixed fee. Members are generally limited to using doctors and hospitals designated by the HMO.
Medical group: A professional organization of physicians that contract with a health plan to deliver both primary—or basic—and specialty care to plan members.
Medically necessary: A term used by insurance companies and health plans to describe care that is appropriate and provided according to general standards of medical care.
Network: The doctors, clinics, hospitals and other medical providers that a health plan contracts with to provide health care to its members.
Out-of-Pocket: Your out-of-pocket costs are the amount you pay for your health care. The costs depend on the health plan you choose, how often you need care, the type of care you need and the extra benefits covered by the plan.
Point of service: An option provided by some HMOs that allows members to go outside the plan's physician and hospital network for care, but requires that they pay higher costs for sharing than they would for network providers.
Premium: Yearly cost for the insurance. Supplemental insurance usually has a premium but HMOs usually have no premium.
Primary care physician (PCP): Primary care physicians are trained to give basic care. In an HMO, they often coordinate and give you most of your care. In order to see a specialist, you will have to see your primary care physician to get a referral, unless you are in a Point of Service plan (POS). When you join an HMO, you select your primary care physician from a list of doctors who are participating in the Plan. If you already have a doctor you want to continue to see, make sure that s/he is in the plan and is accepting new patients under that plan.
Referral: Authorization for a member of a managed care plan to receive care from a specialist or hospital. The member's primary care physician is responsible for making the referral.
Specialist: A physician with training or expertise in an area of medicine. HMO members usually need approval from their primary care physician to see a specialist.
Utilization review: A process used by health plans and medical groups to reduce what they deem to be unnecessary and ineffective care and to hold down medical costs. It's also used to prevent unnecessary hospital admissions and reduce lengths of hospital stay.
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