Health, Medicare+Choice, Beneficiaries, Health Plan Choice by xin18998



       September 2001, Number 5

Informed Health Plan Choice for Vulnerable
Subgroups of Medicare Beneficiaries                                                                                     by Marsha Gold and Beth Stevens

        nder the Medicare+Choice program,           Factors Generating Vulnerability                        et al., 2001). Others are disabled or have

U       beneficiaries are required to make
        decisions about the kind of Medicare
coverage they enroll in as well as any addi-
                                                    Several personal characteristics of Medicare
                                                    beneficiaries can limit their ability to access
                                                    coverage information and make effective
                                                                                                            certain health conditions that magnify the
                                                                                                            importance of medical care. The combination
                                                                                                            of above average expenditures and the
tional insurance they select to supplement          choices about different options. These                  greater probability that Medicare beneficia-
that coverage. All beneficiaries are not equal      include:                                                ries may be subject to unexpected and
in their capacity to make these decisions. It       • cognitive and/or perceptual limitations;              potentially very high medical expenses
is more difficult for those with little educa-      • lack of support during the decision process;          means that making the right choice about
tion, a low level of literacy, or limited cogni-    • inability to access information;                      different types of Medicare plans is critical to
tive ability to obtain relevant information.        • inability to afford some or many of the               their health.
                                                       choices;                                                 Medicare beneficiaries also are more vul-
                                                    • mismatch between information prefer-                  nerable to the challenges of making a choice
                                                       ences and information dissemination;                 because they tend to have modest incomes.
 Just as there is no average                           and/or                                               This heightens the role of price in choices
    Medicare beneficiary,                           • not seeing insurance decisions as a prior-            and narrows the number of choices that are
                                                       ity in one’s life.                                   practical. More than a quarter (27 percent) of
 subgroups of beneficiaries                                                                                 beneficiaries have household incomes of
                                                         Just as there is no average beneficiary,
  vary considerably in their                        there is substantial variation across sub-              $10,000 or less, and 33 percent have
     characteristics and                            groups and their needs for information about            incomes between $10,001 and $20,000. Low
   need for information on                          Medicare choices. A good information infra-             to moderate incomes limit the ability of ben-
      Medicare choices.                             structure recognizes the points at which                eficiaries to finance health care coverage,
                                                    effective choice can be constrained and                 because payments for health care services
This, in turn, compromises their capacity to        responds with appropriate interventions for             compete with other basic needs. Of those
make decisions. Health status and personal          particular beneficiary subgroups.                       without supplemental coverage, more than
circumstances may make other beneficiaries                                                                  half say they do not have it because they
more vulnerable because they are more likely        Heightened Vulnerability                                cannot afford it.
to suffer negative consequences if they make        Medicare beneficiaries, on average, are more                In addition, Medicare beneficiaries are
an inappropriate choice. This Operational           vulnerable when making choices than the                 vulnerable in an environment of choice
Insights discusses the diverse capacities           general population. The vast majority of                because they were educated when academic
and vulnerabilities of Medicare beneficiaries       Americans qualify for Medicare because they             achievement was less relevant and
and how well current information strategies         are age 65 or older, and typically use more             advanced schooling less available than it is
address their needs.                                medical care than younger people do (Lubitz             now. Forty-four percent of those over age 65

                                        The Monitoring Medicare+Choice Project of Mathematica Policy Research, Inc., seeks to provide credible and timely
                                        information on insurance decisions made by Medicare beneficiaries. It is funded by The Robert Wood Johnson Foundation.
                                                                                                                           inappropriate choice of health plan are more
    Figure 1
                                                                                                                           serious for them than for others. They also
Selected Vulnerable Subgroups of Medicare Beneficiaries, 2000                                                              are vulnerable because they have relatively
Disabled under age 65                                 12%                                                                  few choices. Their incomes are particularly
Age 85 and older                                     11%                                                                   low, and fewer Medigap insurers offer poli-
Fair/poor health                                 11%                                  36%                                  cies to the disabled. As a result, 31 percent
Needs help 1+ areas                                        11%                          37%                                lack supplemental Medicare coverage—a
Less than high school                                      11%            26%
                                                                                                                           rate almost twice as high as that of the over-
African American                               9%
                                                                                                                           all Medicare population (see Table 1).
Other races                             5%
                                                                                                                               Informing disabled beneficiaries about
Hispanic                               4%
                                                                                                                           their Medicare choices is challenging. They
$20,000 income or less                                                                 11%                         60%
                                                                                                                           are less likely to have finished high school
SOURCE: MPR Survey of Medicare Beneficiaries, 2000
                                                                                                                           and more likely to have medical conditions
score at the lowest levels of literacy (Kirsch                         Disability. Thirteen percent of Medicare ben-       involving perceptual and cognitive difficul-
et al., 1993). Written materials about various                         eficiaries are under age 65 and qualify for         ties. Materials are often written for those
options can be a challenge for these people                            Medicare benefits because they have a dis-          with higher levels of literacy and in a type
to interpret, making it more difficult for them                        ability (Gold and Stevens, 2001). Sixty-two         size or font that is difficult for some disabled
to understand complex insurance informa-                               percent are in fair or poor health, and 68 per-     to read. Also, those with mobility problems
tion and make crucial decisions.                                       cent have a chronic condition, defined as           can find it difficult to attend workshops and
    This Operational Insights looks at five                            lasting at least six months and for which they      health fairs intended to educate beneficia-
markers of vulnerability among Medicare                                have taken a prescription medication for            ries. Furthermore, disabled beneficiaries are
beneficiaries: disability, age 85 and older,                           three months or more and see a doctor at            less likely to get support from a spouse in
fair or poor health status, limited education,                         least twice a year. These beneficiaries are         making their decisions: 45 percent are
and racial and ethnic minorities (see Figure 1).                       vulnerable because the consequences of an           divorced, separated, or have never been

    Table 1

Selected Characteristics of Coverage and Choice for Specific Subgroups of Medicare Beneficiaries, 2000
                                                           All             Disabled       Age 85       Fair/Poor      Less than      African      Other Races     Hispanic
                                                       Beneficiaries      under Age      and Older      Health       High School    American

Percent with no supplemental coverage                        17%                31%           19%         23%            23%           38%            14 %          23%
Experience with current coverage (1-10)
    Mean                                                      8                  8             8           8              8             8              8             8
    4 or less (worst)                                         5%                 6%            2%          5%             5%           10%             4%            6%
    9 or 10 (best)                                           45                 40            50          41             44            41             41            37
Worry about ability to pay bills this year versus last
    More                                               30%                      34%           25%         46%            35%           29%            34 %          44%
    Same                                               61                       52            63          47             56            61             51            52
    Less                                                9                       14            12           7              9            10             15             4
Ever used Internet for anything                              19%                23%           16%         15%             8%           13%            22 %          16%
Know of unbiased source of counseling                        19%                19%           13%         20%            15%           16%            26 %          13%
Choice salient in 2000                                       14%                26%           10%         20%            17%           18%            13 %          14%
Among those for whom choice was salient
   Made decision alone                                       60%                78%           42%         54%            43%           53%            45 %          43%
   Decision somewhat or very hard                            48%                45%           30%         55%            50%           52%            60 %          39%
   Very confident about choice                               64%                45%           66%         59%            58%           56%            68 %          63%
   Very likely to use unbiased source of
      counseling if need information                         47%                60%           42%         59%            32%           59%            44 %          31%
SOURCE: MPR Survey of Medicare Beneficiaries, 2000
married, compared with 8 percent of those        interview; only 12 percent of younger elders       health provider notes, food package labels,
age 65-84 and 7 percent of those age 85 and      required a proxy. The most common reason           recipes, and books. Seventeen percent
older. More than three-quarters of those to      for use of proxies was limitations in cognitive    reported problems with three or more.
whom choice was salient said they made           or mental ability; the second most common          Moreover, these kinds of problems are likely
their decision alone. Not surprising, com-       reason was being very ill or having a hearing      to be underreported (Baker et al., 1996).
pared to other beneficiaries, this subgroup is   problem.                                               While knowledge about the Medicare pro-
more likely to view the decision as a hard one                                                      gram is limited among all beneficiaries, it is
and to be less confident in the choices they     Fair or Poor Health Status. Thirty-six per-        lower for individuals with less education.
make. (Choice is considered salient when         cent of Medicare beneficiaries of all ages say     Those without a high school diploma averaged
beneficiaries actually selected a new health     their health status is fair or poor. Poor health   2.3 correct answers in a set of five questions
plan or when they seriously considered mak-      makes them more vulnerable because the             testing their knowledge about Medicare in
ing a change from their current plan.)           consequences of inappropriate choice are           contrast to 3.3 correct answers for those with
                                                 more severe. Among beneficiaries age 65-           more than a high school education.
The Oldest-Old. Eleven percent of Medicare
beneficiaries are age 85 or older—the                                                               Racial and Ethnic Minorities. While
fastest growing segment of the aged popula-                                                         Medicare beneficiaries are less diverse than
tion. Several characteristics of those born at   Race and ethnicity influence                       the general population, diversity still exists.
the beginning of the last century combine to                                                        Nationally, 87 percent of Medicare beneficia-
                                                 the way in which beneficia-
generate difficulties in their obtaining and                                                        ries report they are white, 9 percent are
using relevant information to make Medicare
                                                    ries seek and interpret                         African American, 1 percent each are Asian
choices.                                          information and affect the                        or American Indian/Alaska natives, and 2
    Compared with younger elders, the old-       kinds of sources they trust.                       percent are "something else." When directly
est-old are more likely to have low incomes:                                                        asked, 4 percent consider themselves to be
39 percent have incomes of $10,000 or less       84, 32 percent are in fair or poor health, and     of Hispanic or Latino origin, such as Mexican,
(versus 22 percent for those age 65-84). As      27 percent needed help in at least one of the      Puerto Rican, or other Spanish background.
befits a cohort growing up in an era when        three areas of routine daily activities asked           Racial and ethnic groups tend to be geo-
educational attainment was less important        about.                                             graphically concentrated, and while small in
to success than it is now, only 56 percent           Almost half (48 percent) of all Medicare       proportion nationally, they comprise a signif-
have completed high school. Few people in        beneficiaries have chronic conditions, and         icant number of people in some communi-
the generation that retired 20 years ago or      more than a third have some limitation in          ties. For example, Hispanics account for 28
more had experience with managed care—           activity and independence. While only 14           percent of Medicare beneficiaries in
an important component of understanding          percent report needing help for personal           Albuquerque, and African Americans are 28
the range of Medicare choices. Also, the old-    care, 30 percent need help with routine daily      percent and 19 percent of beneficiaries in
est-old have health problems that affect         activities such as household chores, and 29        New Orleans and Baltimore, respectively. In
their capacity to obtain information. For        percent have a condition that could interfere      Orange County, 15 percent of beneficiaries
example, 22 percent of this group have vision    with independence. Overall, 37 percent             report their race as other than African
problems and 22 percent have hearing prob-       report at least one of these circumstances,        American or white. (This group likely includes
lems—about three times higher than               and 11 percent report all three.                   a sizeable concentration of beneficiaries of
younger elders.                                                                                     Asian descent.)
      Processing information can be difficult    Limited Education. Twenty-six percent of                Race and ethnicity influence the way in
for the oldest-old. Of those without a high      current Medicare beneficiaries have not            which beneficiaries seek and interpret infor-
school degree (but without poor vision), 24      graduated from high school, and more than          mation and affect the kinds of sources they
percent have difficulty reading three or more    half of this group had fewer than eight years      trust (Stevens and Mittler, 2000). Language
common items, such as newspapers and             of formal education. Of those who did not          differences are the most obvious source of
directions for taking medicine. Of those         graduate from high school, 41 percent report       vulnerability, especially because beneficia-
responding to the MPR survey, 35 percent         problems reading at least one of the follow-       ries who do not speak English find it more
needed to use a proxy to help them with the      ing: newspaper, directions for medicine,           difficult to obtain information. Four percent of
respondents reported speaking another lan-                                                                                                         ciaries changed their coverage or considered
guage than English at home. Cultural back-                                            Ways to Reduce                                               a change seriously. For some, this reflects
ground also affects beneficiaries’ under-                                        Beneficiaries’ Vulnerability                                      satisfaction with coverage. Yet even those
standing of the concept of insurance, their                                     s   Improve the salience of Medicare                               who may not be satisfied tend to report low
attitudes toward government programs, and                                           information                                                    levels of salience in choosing a Medicare
their willingness to trust government infor-                                    s   Better match Medicare information                              option.
mation about Medicare (Stevens, Yee, and                                            to beneficiaries’ diverse styles of                                One way to increase salience is to
Ortiz, 2001).                                                                       seeking and using information                                  improve basic messages about Medicare so
     Minorities in the six communities we                                                                                                          that information is seen as more relevant by
studied often do not actively seek informa-                                                                                                        beneficiaries. For example, the Medicare pro-
tion about public programs until a trusted                                   between the information they need and what                            gram and other groups, such as state health
acquaintance or family member has had a                                      is popularly disseminated.                                            insurance information programs (SHIPs) and
successful experience in learning about                                                                                                            local aging organizations, could change the
these programs or has actually received ben-                                 The Role of Salience. Perhaps the most                                format of the messages and even how infor-
efits. In communities with a history of dis-                                 subtle, yet critical, cause of vulnerability is                       mation is disseminated.
crimination, minorities primarily use word of                                the fact that beneficiaries may not recognize
mouth and informal channels of communica-                                    that they have choices about Medicare                                 Information Mismatches. Survey and inter-
tion for information.                                                        options. If they do not know that they have                           view data suggest that current information
                                                                             choices or that choice is important, they are                         efforts to do not completely match the informa-
Sources of Vulnerability                                                     not likely to assess their options or seek                            tion styles of many beneficiaries. There is a gap
Two sources of vulnerability that are open to                                information on alternatives. Most Medicare                            between the information challenges beneficia-
policymakers are that beneficiaries do not                                   beneficiaries do not even think about choice                          ries prefer and current efforts to dissemination
understand that insurance decisions are                                      (Gold and Justh, 2001). In the 2000 open                              Medicare information. This mismatch is par-
important for their health, and the mismatch                                 enrollment period, only 14 percent of benefi-                         ticularly distinct for vulnerable populations.

    Table 2

Sources of Information Used in Making Choices for Beneficiaries for Whom Choices Are Salient,* Selected Vulnerable
Subgroups, 2000 (in percentage)
                                                                        Any Use of Source                                                                    Most Important Source

                                  All** Disabled           85+ Fair/Poor          Less African Other Hispanic    All** Disabled                      85+ Fair/Poor    Less African Other Hispanic
                              Beneficiaries under               Health            than American Races         Beneficiaries under                         Health      than American Races
                                            age 65                                High                                      age 65                                    High
                                                                                 School                                                                              School

Current health plan                 49           49         51          59          64        52          51         43           12          19       4      15      14        8      7      12
Medicare/Social Security            47           62         52          51          54        51          49         51           14          13      23      16      22       46     12      28
Former employer/union               21           16         16          22           7        41          33         14            5          11       4       2       1        0      5       8
Local hospital/clinic               21           35         23          25          29        30          29         20            5           1       0       7       1        3      1       1
Doctor/other medical                47           51         40          45          61        53          37         37           38          38      27      43      42       17     15      13
AARP/senior group                   10           14         26           8          11         9          12          8            2           4       1       2       2        1      2       0
Spouse                              24           17         11          28          29        10          59         35           15           3       5       5       2        5     35      27
Other family                        26           25         38          25          33        19          33         30                        6      22       4       8       16     10       5
Friends                             22           35         27          27          19        12          23         19             3          1       8       2       3        2      4       3
Library/newspaper                   20           29         26          22          16        10          28         16             1          0       0       0        1       0      2        1
Television/radio                    21           32         28          22          11        17          21         14             2          1       4       1        1       3      1        1
Internet                             2            5          3           3           3         3           8          3             1          3       0       2        3       0      5        0
Attended in-person meeting 11                     9         11           6           3        34          10          6           NA         NA      NA       NA      NA       NA     NA      NA
Used Medicare handbook 33                        31         20          43          29        14          20         15           NA         NA      NA       NA      NA       NA     NA      NA

SOURCE: MPR Survey of Medicare Beneficiaries, 2000
NA: Not applicable; not included in the list used for most important source.
*Includes new beneficiaries; those switching to, from, or among HMOs; and other beneficiaries who say they seriously considered making a change.
**Figures shown include entire sample, not just vulnerable subgroups.
     Medicare’s National Medicare Education
Program (NMEP) is designed to reach large
audiences through: (1) distribution of a writ-       Policymakers should be cognizant of the diversity
ten handbook, Medicare & You; (2) a toll-free
                                                 among Medicare beneficiaries and the need for transitional
telephone service for general questions about
Medicare; (3) a website (          and targeted educational strategies to reach them,
that provides comparative information on           particularly when there are major program changes.
health plans, benefits, and costs; (4) health
fairs in local communities; (5) mass media       The disabled, those in fair or poor health, and        more likely to use independent counseling
messages in public service announcements         those with less than a high school education           than are other subgroups.
and newspaper features; and (6) insurance        were particularly likely to name physicians          • To better reach those age 85 and older,
counseling offered by SHIPs.                     as their most important source of informa-             Medicare educators need to reach out to
     However, most beneficiaries—particu-        tion in considering choice (38 percent, 43             educate their families because many in
larly those in vulnerable subgroups—tend to      percent, and 42 percent, respectively).                this subgroup require family to help them
favor personal and locally focused sources.          Clearly, beneficiaries use their physi-            make insurance choices. This task can be
According to the MPR survey, the most pop-       cians, families, and friends with greater fre-         demanding. On average, surveyed care-
ular sources of information were the benefi-     quency than NMEP takes into account.                   givers who assisted beneficiaries in mak-
ciary’s current health plan (49 percent); the    Addressing this gap will not be not easy;              ing insurance decisions spent seven hours
beneficiary’s own physician or other medical     physicians are often overwhelmed by                    in person or on the phone with the benefi-
professionals (47 percent); and spouse,          requirements of managed care and are likely            ciary to discuss choices and 12 hours
other family, and friends (54 percent) (see      to need help to better respond to beneficia-           reading about and considering the options.
Table 2). While 47 percent made some use of      ries’ questions about health plan choice.              To do this, 44 percent said they had to
information from Medicare/Social Security,       Family members have other demands on                   drop or ignore other matters. Many proxies
only 14 percent said it was the most impor-      their time and may find the task of seeking            felt their stress would be eased if they had
tant source of information. In contrast, 38      out Medicare information challenging, espe-            more easy-to-understand information on
percent of Medicare beneficiaries were most      cially when they do not live in the area and,          choices and could talk with Medicare
likely to name their physician. In comparison    thus, are less familiar with the choices and           workers, social workers, and other family
to other channels, fewer beneficiaries used      providers in the beneficiary’s community.              members about plan options.
the mass media as a major source of infor-           With resources limited, there may be a           • New ways to reach beneficiaries with limit-
mation about Medicare. Twenty-one percent        tendency to prefer methods that reach the              ed education and less income are needed
used television or radio to get information,     largest number of people. This strategy, how-          (Gold et al., 2001). Only 32 percent of ben-
and 2 percent used the Internet (as of early     ever, may be least successful in getting infor-        eficiaries without a high school education
2000, when the survey was conducted).            mation to those beneficiaries who are hard-            who were seriously considering choice said
     Information preferences vary across sub-    est to reach and most vulnerable.                      they would be very likely to use a source of
groups of beneficiaries. Hispanics and bene-                                                            unbiased counseling if they knew about it,
ficiaries from other races were more likely      Priorities for Improvement                             compared with 53 percent of high school
than the general beneficiary population to       Vulnerable Medicare beneficiaries are in great         graduates. As a result, those with less edu-
use personal contacts—spouse, other fami-        need of usable information about the choices           cation are likely not to articulate needs or
ly members, and friends—to get information       they face under Medicare. Following are some           be as aggressive about seeking answers to
about Medicare. In contrast, African             ways to reach some subgroups:                          questions as are better-educated benefi-
Americans were less likely to rely on family     • Campaigns focused on the under-age-65                ciaries. Less-educated beneficiaries also
and friends and tended to rely more heavily         disabled should involve physicians and hos-         were less likely to use mass and print
on Medicare for information. The under-age-         pitals more to reach their patients. According      media or the Internet for accessing
65 disabled and the oldest-old used televi-         to the National Association of Protection and       Medicare information, or to attend meetings
sion and radio more than the general                Advocacy Systems, the disabled are increas-         about Medicare. They seem to be best
Medicare population, probably in part               ingly turning to listserves on the Internet for     reached through their health plans, physi-
because they have less physical mobility.           information on health issues. They are also         cians, and family and friends.
• Racial and ethnic minorities pose specific           easy. Some of the most critical groups to               Policymakers should be cognizant of the
  challenges for information dissemination.            reach require targeted strategies and one-          diversity among Medicare beneficiaries and
  African American beneficiaries are less              on-one interventions. Mounting this kind of         the need for transitional and targeted educa-
  likely than average to consult their physi-          effort requires resources—probably sub-             tional strategies to reach them, particularly
  cians, hospitals, or former employers for            stantially more than are available. Even with       when there are major program changes. s
  Medicare information. They, like the dis-            such resources, it may be difficult to make
  abled but unlike other minorities, are               choice salient to many beneficiaries.
  much more willing to turn to independent                 Those age 85 and over are a case in
  counselors for help in making Medicare               point. In 2000, only 10 percent of these ben-       About the Data
  decisions (59 percent versus 47 percent              eficiaries either switched plans or seriously       The data presented are from a national
  for the general Medicare population).                considered making a change. Despite only            survey of Medicare beneficiaries age 18 and
  Hispanic beneficiaries rely on family and            average rates of supplemental coverage, the         older conducted by MPR between March and
  friends more extensively than any other              oldest-old tend to rate their current coverage      June 2000. Nationally, 6,620 responded,
  subgroup, but are less likely to use med-            experience relatively favorably. Getting them       a 64 percent response rate. The results are
  ical providers, print, or mass media for             to focus on Medicare health care choices            weighted to provide unbiased estimates
  information about Medicare choices. One              may take a considerable investment of time          for Medicare beneficiaries nationally and
  way to reach Hispanics and other ethnic              to reach family and friends first and then,         for selected subgroups. Information on
  minorities is through community-based                through them, to reach the beneficiaries,           current practice is based on site visits
  religious and neighborhood institutions.             many of whom are averse to change and/or            to Albuquerque, Baltimore, Detroit, New
    Educating Medicare beneficiaries is not            are unfamiliar with making choices.                 Orleans, Orange County (CA), and Orlando.


     Baker, David W., et al. “The Health Care Experience of Patients with Low Literacy.” Archives of Family Medicine 5:329-334, June 1996.
     Gold, Marsha, et al. Medicare Beneficiaries and Health Plan Choice, 2000. Washington, DC: Mathematica Policy Research, Inc.,
     January 2001.
     Gold, Marsha and Natalie Justh. “How Salient Is Choice to Medicare Beneficiaries?” Fast Facts No. 5. Mathematica Policy Research,
     Inc., January 2001.
     Gold, Marsha, and Beth Stevens.“Medicare’s Less Visible Population: Disabled Beneficiaries under Age 65.” Operational Insights No. 2.
     Mathematica Policy Research, Inc., May 2001.
     Kirsch, Irwin, et al. A First Look at the Findings of the National Adult Literacy Survey. Washington, DC: National Center for Education
     Statistics, 1993.
     Lubitz, James, et al. “Three Decades of Health Care Use by the Elderly, 1965-1998.” Health Affairs 20(2): 19-32, March-April 2001.
     Stevens, Beth, and Jessica Mittler. Making Medicare+Choice Real: Understanding and Meeting the Information Needs of
     Beneficiaries at the Local Level. Washington, DC: Mathematica Policy Research, Inc., November 2000.
     Stevens, Beth, Donna Yee, and Jose Ortiz. “Developing Culturally Appropriate Medicare Education Materials.” Center for Medicare
     Education, Issue Brief 12(4), June 2001.

     Operational Insights is published by the Washington office of Mathematica Policy Research, Inc.       Visit our Web site at
     Princeton Office                        Washington Office                       Cambridge Office                    Marsha Gold: Project Director,
     P.O. Box 2393                           600 Maryland Ave., S.W., Suite 550      50 Church St., 4th Floor            Monitoring Medicare+Choice
     Princeton, NJ 08543-2393                Washington, DC 20024-2512               Cambridge, MA 02138-3726
                                                                                                                         The Stein Group: Editor
     Phone: (609) 799-3535                   Phone: (202) 484-9220                   Phone: (617) 491-7900
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