National Medicare & You Education Program (NMEP) Case Study Sites Assessment

1. National Medicare & You Education Program (NMEP) Case Study Sites Assessment Authors: Margaret Gerteis (BearingPoint) Vasudha Narayanan (Westat) Kimberly Derwinski (Ketchum Public Relations) Elizabeth Goldstein (CMS) Suzanne Rotwein (CMS)

2. Scope & Purpose of NMEP • The National Medicare & You Education Program (NMEP) grew out of the recognized need to better inform the public about Medicare policies, procedures, and changes to the program mandated by the Balanced Budget Act of 1997. • Objectives of the NMEP are to ensure that people with Medicare • receive accurate and reliable information, • can access information when they need it, • understand the information needed to make informed choices, and • perceive the NMEP, the Federal Government and its private sector partners as a trusted and credible source of information.

3. Scope & Purpose of NMEP • Major vehicles of communication for the NMEP include • Medicare & You Handbook • Toll-free Medicare telephone line (1-800-MEDICARE) • www.medicare.gov public Web site • Community outreach and senior counseling • National mass communication campaign based on paid advertising in the print and broadcast media

4. Purpose of Case Study Sites Assessment • From 1998 until 2003, CMS tracked the NMEP in six communities across the United States • The overall purpose of the case study sites assessment was • to understand how various components of the NMEP work together at the local level, • to chronicle relevant changes and events within each community as they impact the NMEP, and • to probe the reactions of beneficiaries and information intermediaries to the information that the NMEP provides. • From 2001 to 2003, Ketchum Public Relations and its subcontractors, BearingPoint, Westat,Market Resources International (MRI) and Magna Systems, Inc., contracted with CMS to continue and expand this tracking and assessment activity.

5. Case Study Sites Olympia, WA Eugene, OR Dayton, OH Springfield, MA Tucson, AZ Sarasota, FL

6. Dayton, OH Population over age 65 – 12% Non-white population – 45% Medicare Managed Care enrollees - 16% Physicians per 1,000 – 1.48 Eugene, OR Population over age 65 – 12% Non-white population – 8.5% Medicare Managed Care enrollees – 38% Physicians per 1,000 – 1.79 Olympia, WA Population over age 65 – 13% Non-white population – 11% Medicare Managed Care enrollees – 31% Physicians per 1,000 – 1.71 Sarasota, FL Population over age 65 – 28.5% Non-white population – 22% Medicare Managed Care enrollees – negligible Physicians per 1,000 – 2.05 Springfield, MA Population over age 65 – 12% Non-white population – 41% Medicare Managed Care enrollees – 20% Physicians per 1,000 – 2.02 Tucson, AZ Population over age 65 – 14% Non-white population – 27% Medicare managed care enrollees – 36.5% Physicians per 1,000 – 1.80 Case Study Site Characteristics

7. Research Questions • What effect does the diversity of each of the sites have on information dissemination and perceptions of Medicare? • What key local or market factors affected Medicare communication in each of the case study sites? • Do beneficiaries recognize the different ways in which they can access information to help answer their questions? • What parts of the NMEP campaign did beneficiaries find useful? • What evidence is there that the NMEP campaign changed awareness, knowledge and or beneficiary behavior? • What gaps exist between official channels of communication and beneficiaries’ subjective behaviors and experiences?

8. Methodology:Media Monitoring • Ketchum Public Relations monitored and evaluated thecontent and impact of media messages • conducted daily monitoring of television stations and newspapers within each of the six markets • search terms covered all health issues relating to seniors, not just “Medicare” • print and broadcast information channels targeted were selected according to levels of readership, viewership or listenership • media messages categorized in comprehensive database

9. Methodology:NMEP Community Survey • Westat administered the NMEP Community Survey in 2002 and 2003. • Abt Associates administered Survey from 1998 to 2001 • Administered by telephone once a year from 1998 through 2003 with selected Medicare beneficiaries in each study site. • Survey instrument probed respondents’ information-seeking behavior over previous 12 months and knowledge of specific Medicare programs. • Topics surveyed included understanding and satisfaction with • Medicare programs and initiatives • Channels of communication • Access to Medicare information • Use of Medicare information for decision-making

10. Methodology: Site Visits • BearingPoint, in collaboration with MRI and Magna Systems, conducted three site visits to each of the case study communities in 2002 and 2003 • Site visit team used five principal methods of data collection: • Medicare beneficiary diaries (n=36); • in-depth-interviews (IDIs) with Medicare beneficiaries (n=145) ; • participant observation (n=15); • focus groups with beneficiaries and information intermediaries (n=21); and • key informant interviews (n=24). • Medicare diaries, kept by beneficiaries over 17-week period, probed their exposure to Medicare information, their perceptions, and their interactions with Medicare • In-depth-interviews (IDIs) were conducted with low-income beneficiaries; non-English speaking Hispanics and Asians; African Americans; frail elders and the disabled; and residents of isolated, rural areas.

11. Summary of Findings:Effectiveness of Components of NMEP • Medicare & You Handbook • Among all components of the NMEP campaign, the Handbook was the most recognized source of official Medicare information • The proportion of community survey respondents who reported having used the Handbook rose from slightly under 7% in 1998 to between 22% and 25% in 2003. • 86% of respondents in 2002 thought the Handbook was very easy or fairly easy to understand . • Beneficiaries interviewed during site visits often brought their Handbooks with them and mentioned keeping them as a reference.

12. Summary of Findings:Effectiveness of Components of NMEP • Toll-free 1-800 number • In 2003, 14% of survey respondents in the 6 study sites had called an 800 number for information about Medicare • Of these, 35% had called 1-800-Medicare • www.medicare.gov Web site • The proportion of survey respondents reporting that they use the Internet rose steadily between 1998 and 2003, to about 6%. • However, a smaller percentage of survey respondents reported having consulted the www.medicare.gov Web site, making it less used than either the Handbook or the 1-800 number. • CMS continues to encourage active use of the Internet and its consumer Web site, www.medicare.gov

13. Summary of Findings:Effectiveness of Components of NMEP • Senior health insurance (SHIP) counselors • SHIP counselors, trained to advise Medicare beneficiaries about their health insurance options, were regarded as a valuable resource among information intermediaries at most of the study sites. • However, in-depth interviews and focus groups with beneficiaries at the study sites suggest that beneficiaries’ awareness of their services is limited • Community survey data show that the use of senior counselors remained small (about 2% of survey respondents in 2003), and declined slightly (from about 3%) after the early years of the survey.

14. Summary of Findings:Effectiveness of Components of NMEP • Media Campaign • The proportion of community survey respondents who recalled noticing publicity relating to Medicare increased from 21% in 2002 to about 33% in 2003. • However, Medicare diaries and in-depth interviews suggest that campaign messages were not particularly memorable. • Respondents reported that television commercials went by too quickly for them to catch the message and that they found it difficult to distinguish Medicare-sponsored advertisements from commercials that invoked the Medicare name to sell products. • Media monitoring further suggests that most Medicare-related coverage in the study communities was situational, driven by local issues or political concerns, which shaped the positive or negative slant of the story

15. Survey Trends, 1998 – 2003:Information-Seeking Behavior • Factors affecting information-seeking behavior • Experiencing new financial difficultyincreased both the propensity to look for Medicare information and satisfaction with Medicare information • survey respondents reporting new financial difficulty were 44% more likely to look for information about Medicare than those who did not report such difficulty. • beneficiaries who reported new financial difficulty were also 124% more likely to report satisfaction with Medicare information than those who did not experience any such difficulty. • Worsening health status also affected the propensity to look for Medicare information, as well as satisfaction with that information.

16. Survey Trends, 1998 – 2003:Information-Seeking Behavior • Type of information sought • Most beneficiaries looked for information about paying for prescription drugs • often associated with new financial difficulties. • Worsening health and new financial difficulties also prompted beneficiaries to look for information about nursing homes, doctors, or health plans. • Satisfaction with information • 84% of survey respondents reported having their questions answered. • More than 80% reported being able to find useful information about nursing homes, locating doctors, and choosing or comparing health plans. • 72% reported finding useful information about paying for prescription drugs.

17. Qualitative Findings Across Sites:Effects of diversity • Language • In-depth interviews with non-English speaking beneficiaries in Tucson, Springfield, Eugene, and Olympia suggest that they have limited understanding of the Medicare program and often confuse it with Medicaid. • They were unaware of official Medicare sources of information, including Spanish-language publications or Spanish-speaking customer services representatives. • They often did not follow the mainstream media (print and broadcast) through which NMEP messages were disseminated. • Non-English speaking beneficiaries preferred talking to someone in person to get information, rather than reading published materials or talking on the telephone. • Most were acquainted with one or more informal local resources, which they relied on for information and help.

18. Qualitative Findings Across Sites:Effects of diversity • Geography and income • In Springfield and Dayton, community resources serving as a conduit for Medicare information were better staffed and funded in more affluent suburban areas • However, poorer and frailer elders were concentrated in the inner city. • In the Eugene and Olympia, hard-to-reach populations included the poor in isolated rural areas. • Age • Elders in Sarasota, a retirement destination, play a key part in shaping the life of the community. • have traditionally enjoyed an abundance of health care resources and social services geared towards the elderly • appear more knowledgeable about Medicare than beneficiaries at other sites • By contrast, elders at other study sites were a less identifiable political or social force in the community.

19. Qualitative Findings Across Sites:Effects of diversity • Wealth and Income • Health insurance or third-party coverage appeared to be a more important factor than wealth in shaping beneficiaries’ perceptions and experiences with Medicare • Wealthier respondents could purchase coverage through supplemental health plans • However, those of more modest means sometimes enjoyed generous employer-based retirement benefits, and those in low-income brackets were often eligible for Medicaid or state supplemental benefits. • Regardless of the source, those with more comprehensive coverage tended to have more positive impressions and experiences, while those who lacked supplemental coverage had the most negative impressions and experiences.

20. Qualitative Findings Across Sites:Local Market Factors • State budget cuts • Olympia and Eugene were especially hard hit by budget cuts in 2003, leading to cuts in health and welfare programs • State budget cuts exacerbated beneficiaries’ concerns about the stability and sustainability of Medicare coverage and benefits. • Influence of large employers or unions • The influence of large employers or unions was most noteworthy in Tucson, Olympia, and Dayton, less so in Sarasota, Springfield, and Eugene. • Beneficiaries with retirement benefits from large employers and/or unions were better informed about Medicare issues and insurance options and had better overall coverage. • However, retirement benefits were subject to change at the employer’s discretion, or as a result of labor contract negotiations – changes for which retirees were often ill prepared.

21. Qualitative Findings Across Sites:Local Market Factors • Managed care enrollment • Beneficiaries enrolled in Medicare managed care recognized the plan customer service representative as an informational resource, while those in traditional fee-for-service Medicare were less likely to have an identifiable source of Medicare information. • Recruitment and retention of physicians • Retention of physicians was a continuing issue of concern in Dayton and Olympia, framing messages about and perceptions of Medicare • The supply of physicians willing to accept Medicare was limited and reportedly dwindling in both of these sites. • Shortages were widely attributed, both in the media and within the provider community, to low rates of reimbursement for Medicare, which contributed to local coverage of Medicare issues

22. Conclusions • Medicare & You Handbook has become a recognized and appreciated source of Medicare information. • Medicare’s image and identity are shaped by factors outside of its control, including commercial sources that invoke the Medicare name to promote their products and services. Beneficiaries find it difficult to distinguish the official from the unofficial. • Media coverage of Medicare is largely shaped by local issues. • Confusion about basic features of the Medicare program is common. • Newsworthy Medicare initiatives create an opportunity for positive media coverage and dissemination of CMS messages. • Medicare beneficiaries rely on recognized local information intermediaries, including health plan customer service representatives, for answers to specific questions. • Most beneficiaries seek information only when they need it, often as a result of changing life circumstances, such as financial difficulties, death of a spouse, or change in health.