CMS's Consumer Information Efforts

Introduction and Background

In this issue of the Health Care Financing Review, we focus on consumer information for the Medicare population. Over the last several years the Centers for Medicare & Medicaid Services (CMS) has increased its efforts to provide clear and useful information to Medicare beneficiaries to help them make more informed health care decisions. The emphasis on consumer information increased dramatically in fall 1998 with the implementation of the National Medicare Education Program (NMEP) called Medicare & You. The goals of the NMEP are to educate Medicare beneficiaries to help them make more informed decisions about Medicare program benefits; health plan choices; supplemental health insurance; beneficiary rights, responsibilities, and protections; and health behaviors. CMS phased-in the initial implementation of the NMEP in five States—Arizona, Florida, Ohio, Oregon, and Washington State—in order to obtain feedback from beneficiaries and make improvements prior to the national implementation.

As part of CMS's ongoing education effort, social marketing techniques have been incorporated into its consumer information activities. For example, beneficiaries are now routinely asked directly what type of information they want and how they would like to receive it, as well as their reaction to developed materials. More effort is now being spent on the part of CMS determining who the target audiences are for different information and targeting specific materials to those groups. In addition, CMS is also spending a lot of time and resources assessing the effectiveness of the education efforts in order to make future improvements.

Educating nearly 40 million Medicare beneficiaries so that they can make informed decisions about their health care coverage has proven to be challenging. The Medicare population is quite diverse in terms of education and literacy, and a large part of the beneficiary population is not currently well informed about Medicare-related topics. Thirty-eight percent of the Medicare population has less than 12 years of education; about 23 percent has less than 9 years. Approximately 44 percent of adults age 65 or over are considered to have limited reading skills (Kirsch et al., 1993). Almost 57 percent of beneficiaries report that they know little or almost none of what they need to know about the availability and benefits of Medicare health maintenance organizations (HMOs) (Centers for Medicare & Medicaid Services, 1999).

Assessment of the NMEP

The article by Goldstein, Teichman, Crawley, Gaumer, Joseph, and Reardon provides background about the National Medicare & You Education Program. It also includes a description of some of the key assessment activities to date, lessons learned from these activities, and improvements made in the education program as a result of the feedback received. Some of the key findings include that a large segment of the population lacks a basic understanding of Medicare, beneficiaries only want information when a specific situation arises such as plans pulling out of the Medicare program, and those most vulnerable (such as older and less educated beneficiaries) are less likely to seek information. As a result of these findings, a number of changes have occurred in the education program. For example, there is now an increased focus on ensuring that information is available when needed and that beneficiaries and those acting on their behalf are aware of where to access Medicare information when specific situations arise; the Medicare & You handbook now is written as a reference document; and health fairs and presentations are now targeting specific situations.

As previously mentioned, CMS phased-in the implementation of the NMEP in order to make adjustments based on lessons learned prior to the national implementation. The Medicare & You 1999 handbook was sent to beneficiaries in five States that included Arizona, Florida, Ohio, Oregon, and Washington State and the Kansas City metropolitan statistical area (MSA) in fall 1998. A number of assessment activities were launched by CMS to obtain feedback from beneficiaries who received the handbook.

This issue includes two articles based on an evaluation of the impact of sending the handbook and Consumer Assessment of Health Plans (CAHPS^®) survey reports to Medicare beneficiaries in the Kansas City MSA. The first article by Harris-Kojetin, McCormack, Jaël, and Lissey discusses beneficiaries' reaction to the Medicare & You 1999 handbook and the CAHPS^® report based on focus groups. The findings from these groups highlight the importance of targeting information to specific groups of beneficiaries and to specific situations, as well as the need to have both formal and informal information intermediaries to help Medicare beneficiaries use and understand information provided through the education campaign. The second article by McCormack, Garfinkel, Hibbard, Kilpatrick, and Kalsbeek complements the first article by presenting survey findings that provide descriptive and multivariate information about beneficiaries' reactions to the handbook and CAHPS^® report. Although beneficiaries found the materials useful overall, the authors point out areas in need of improvement based on beneficiary reaction to the pilot version of the handbook.

As part of the evaluation of the Medicare & You handbook, two randomized experiments were conducted to assess how the handbook has impacted beneficiaries' knowledge of the Medicare program and their health insurance options. McCormack, Anderson, Kuo, Daugherty, Brown, and Hibbard describe both experiments in this issue. The first experiment was based on the 1999 handbook in the Kansas City MSA, while the second experiment was a national evaluation of the 2000 handbook. Both experiments suggest small but significant gains in knowledge as a result of reading both editions of the Medicare & You handbook. The evaluation also confirms other assessment work suggesting overall levels of Medicare knowledge among beneficiaries still remains low.

Consumer Testing

Most of the materials for the Medicare education program undergo some consumer testing. CMS conducts both formative research to obtain input from consumers prior to a document or product being developed, and product testing to obtain feedback from consumers after a draft document or product is produced. Consumer testing of information materials has consistently shown that there is a lot of confusion over the term “Original” Medicare plan—the term used to describe the fee-for-service (FFS) component of Medicare in CMS documents, including the Medicare & You handbook. Beneficiaries either do not know what Original Medicare is or they think it describes Medicare back in 1965 when it was originally established. Using focus group and Q-sort methodology, Fyock, Koepke, Meitl, Sutton, Thompson, and Engelberg attempt to determine a name for Medicare FFS that better resonates with Medicare beneficiaries. Most participants associated Medicare with FFS and tend to choose between supplemental insurance and a managed care product when making a choice. In addition to suggesting some possible names for FFS, the authors conclude in their article that renaming Medicare FFS needs to be part of a broader strategy of creating an identity for the Medicare program overall.

Recently, the Federal Government has launched an effort to educate consumers about actions that they can take to prevent medical errors. The Agency for Healthcare Research and Quality has identified 20 activities that consumers could potentially engage in to reduce errors (Agency for Healthcare Research and Quality, 2000). These 20 actions have been reduced down to Five Steps to Safer Health Care by several Federal agencies and private organizations (Quality Interagency Coordination Task Force, 2000). Given that CMS has adopted a social marketing approach to health communications, a study was conducted to see whether Medicare beneficiaries would be interested in and willing to listen to messages about how to reduce medical errors. Swift, Koepke, Ferrer, and Miranda describe the findings from this study based on eight focus groups with Medicare beneficiaries. Their findings suggest that a campaign for Medicare beneficiaries will be more successful if the messages encourage patients to work with health care providers—not challenge them—and the messages must provide specific actions to take to prevent errors. This information will be used as CMS crafts a strategy for educating beneficiaries about the prevention of medical errors.

Targeting of Information

One lesson that CMS has learned in the initial stages of their education program is how important it is to target the information provided to specific segments of the beneficiary population. Last year CMS adopted in its outreach activities at the regional level an information seeking model that segments beneficiaries into passive, reactive, and active information seekers. This model is currently being used to better target the educational activities conducted by the regional offices. In their article Levesque, Prochaska, Cummins, Terrell, and Miranda explore whether the Transtheoretical Model would be an alternative method for segmenting beneficiaries. They specifically study (through the Medicare Current Beneficiary Survey) beneficiary readiness to learn about the Medicare program, and in reviewing different health plan options. The authors find that 15 percent of beneficiaries are in the precontemplation stage for learning about the Medicare program, and 60 percent are in the precontemplation stage for reviewing different health plan options. Not surprisingly, beneficiaries are the most prepared to become more informed about the Medicare program and are the least prepared to become more active in reviewing different health plan options. One of the next steps for this research is developing stage-matched interventions to help beneficiaries move along the stages of change. If these interventions are successful, this will be one method CMS can use to help target future education efforts.

Information Intermediaries

No matter how much time and effort is spent simplifying and targeting information materials for people with Medicare, there will be a subset of beneficiaries who will be unable to use and understand these materials. It is therefore essential to develop other avenues of assistance. For example, CMS is beginning to work more closely with information intermediaries such as State Health Insurance Assistance Program counselors and family members who can assist people with Medicare in using this information. When making health care decisions, we know people with Medicare often turn to family members and friends to help them. The article by Sofaer, Kreling, Kenney, Swift, and Dewart describes findings from focus groups with family members and friends to obtain insight into how they help Medicare beneficiaries make decisions, what type of information they currently use to assist, and what other information would be useful for them to assist Medicare beneficiaries. The findings suggest that most participants feel that they are not receiving enough information to fulfill their assistance role and that most are unaware of the material that is currently available from CMS. It is clear however, that CMS will need to continue to work more closely with family members and friends to ensure that they have the information they need to help Medicare beneficiaries make health decisions.

Conclusion

The consumer education efforts thus far point to the many challenges that lie ahead in providing information to beneficiaries so that they can make more informed health care decisions. Currently, many beneficiaries lack a basic understanding of the Medicare program and how it works. Additionally, beneficiaries only want information when specific needs arise. Some beneficiaries due to their levels of education and literacy and cognitive impairments are unable to understand basic information about the Medicare program. The articles in this issue of the Review highlight the need for additional work related to simplifying materials; changing some of the terminology used in order to make the information more understandable; targeting materials to specific groups of beneficiaries and situations; making beneficiaries and those who help beneficiaries aware of the information resources available; and working more closely with family members, friends, health care providers, and others who help beneficiaries make health decisions.