Department  of Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
Medicare  Beneficiary  Satisfaction:  1997 
JUNE  GIBBS  BROWIf 
Inspector  General 
JUNE  1998 
OEI-04-97-00030  OFFICE  OF INSPECTOR  GENERAL 
The mission of the Office of Inspector  General (OIG),  as mandated by Public Law  95452,  is to 
protect  the integrity  of the Department  of Health  and Human  Services programs  as well  as the 
health and welfare  of beneficiaries  served by them.  This statutory  mission is carried out through  a 
nationwide  program  of audits, investigations,  inspections,  sanctions, and fraud alerts.  The 
Inspector  General informs the Secretary of program  and management problems and recommends 
legislative,  regulatory,  and operational  approaches to correct  them. 
Office  of Evaluation  and Inspections 
The Office of Evaluation  and Inspections  (OEI)  is one of several components  of the Office of 
Inspector  General.  It conducts  short-term  management and program  evaluations (called 
inspections)  that focus on issues of concern to the Department,  the Congress, and the public.  The 
inspection  reports  provide  findings  and recommendations  on the efficiency,  vulnerability,  and 
effectiveness of departmental  programs. 
OEIs Atlanta  Regional  Office prepared this report  under the direction  of Jesse J. Flowers, 
Regional  Inspector  General, and Christopher  Koehler,  Deputy  Regional  Inspector  General. 
Principal  OEI  staff included: 
REGION  HEADQUARTERS 
Betty  Apt,  TeamLeader 
 Wynethea Walker, Program Specialist 
Jason Stanfield, Contractor 
 Linda Moscoe, Technical Support 
Jackie Watkins,  Program Analyst 
 Brian Ritchie,  Technical Support 
Joe Townsel,  Program Analyst 
 Barbara Tedesco,  Technical Support 
Paula Bowker,  Program Analyst 

Janet Miller,  Program Analyst 

To obtain copies of this report, pleasecall the Atlanta Regional Office at (404) 562-7743. 
Reports  are also available on the World  Wide Web at our home page address: 
http://www.dhhs.gov/progorg/oei  PURPOSE 
To determine the experience with  and satisfaction  of fee-for-service  beneficiaries with  Medicare 
services. 
BACKGROUND 
This is the sixth survey the Office of Inspector  General (OIG),  Department  of Health  and Human 
Services (I-II%),  has conducted  to determine beneficiary  experience and satisfaction with 
Medicare  services.  In July 1997, we surveyed 1269 randomly  selected beneficiaries  for whom 
Medicare  Part B claims were  submitted in Calendar Year  1996.  Participation  in the survey was 
voluntary  and yielded a response rate of 77 percent--977  beneficiaries.  Prior  to the 1997 survey, 
the most recent one had been conducted  in 1995. 
FINDINGS 
As in 1995, beneficiaries  report  positive  experience  with  the Medicare  program. 
0 	 Beneficiary  Understanding--Eighty-one  percent of the beneficiaries responding  to our 
survey said the Medicare  program  was understandable. 
0 	 Getting  Information--Seventy-five  percent of the beneficiaries  said they could get 
information  about Medicare  when they needed it.  Most  beneficiaries  said they would 
consult their physician (68 percent)  or their Medicare  Handbook  (55 percent)  to get 
specific information. 
0 	 Participating  Physicians--Seventy-seven  percent of the beneficiaries that replied to our 
survey said that they were aware of participating  physicians. 
0 	 Claims  Processing--Eighty-nine  percent of the beneficiaries  said they were satisfied with 
the way Medicare  carriers processed their claims. 
Beneficiary  awareness  of one service improved  from  1995 to 1997. 
0 	 Flu  Shots--Eighty-three  percent of beneficiaries were aware that Medicare  will  pay for flu 
immunizations.  In 1995, only 76 percent knew. 
Beneficiary  awareness  of some services declined. 
0 	 Second  Surgical  Opinions--In  1997, 66 percent of beneficiaries were not aware 
Medicare  would  pay for a second opinion  concerning  the need for surgery.  This is an 
i  increase from  1995 when 60 percent did not know  about Medicares  second surgical 
opinion  coverage. 
Physician  Fees--Thirty-three  percent of the beneficiaries  surveyed did not know  Medicare 
limits physicians fees for specific services.  This is an increase from  1995 when 26 percent 
did not know  about the limits. 
Medicare  Claims--Ten  percent of responding  beneficiaries did not know  that their 
doctors  were supposed to file their Medicare  claims for them.  This is an increase from 
1995, when only 7 percent did not know. 
Some services needed  improvement  in 1995, and  still  do in 1997. 
Claims  Processing--Twenty-two  percent of beneficiaries experienced at least one 
problem with  their last Medicare  claim. 
Telephone  Service--Fifty-seven  percent of beneficiaries who  had called their carriers 
experienced at least one problem when calling.  Twenty-seven  percent who  had tried to 
call had to call three or more times to get through. 
Appeal  Rights--Thirty-two  percent of the beneficiaries surveyed did not know  they could 
appeal or request a review  of decisions made by Medicare  carriers concerning  their claims. 
Mammograms--Twenty-three  percent of the female beneficiaries  surveyed did not know 
that Medicare  pays for mammograms. 
Hospital  Care--Of  those beneficiaries who  had been a patient in a hospital for at least one 
night,  18 percent said it was not clear what Medicare  had paid for.  In addition,  29 percent 
said they had not received written  information  concerning  their rights as a Medicare 
patient. 
Beneficiary  awareness  of some services not  reported  on in 1995 was found  to be lacking  in 
1997. 
0 	 Pneumonia  Shots--Forty-two  percent of the beneficiaries were not aware that Medicare 
pays for pneumonia  immunizations. 
0 	 Home  Health  Hot  Line--Eighty  percent of all responding  beneficiaries,  and 73 percent of 
those who  had received home health, did not know  that States provide  a hot  line to 
register  complaints  about home health care. 
ii  RECOMMENDATION 
We recommend  that the Health  Care Financing  Administration  develop a plan for improving 
beneficiary  satisfaction  and understanding  in the problem  areas mentioned  above.  Several of the 
problem  areas cited have been identified  as problems in previous  OIG reports.  For example, 
problems with  carrier telephone  service have been noted in each of the six reports  on beneficiary 
satisfaction.  In the past, HCFA  has agreed these are problem  areas, and planned corrective 
actions.  Nevertheless,  some of the same problems continue  to exist.  We suggest that in planning 
corrective  actions, HCFA  set numerical  goals that can be tracked  for program  improvement.  We 
believe this activity  can be useful to HCFA  in correcting  the problems and fulfilling  requirements 
of the Government  Performance  and Results Act. 
AGENCY  COMMENTS 
The HCFA  Administrator  reviewed  our draft report  and concurred  that HCFA  should develop a 
plan to improve  beneficiary  satisfaction  and understanding  in the troubled  areas identified  by the 
survey.  HCFA  has initiated  a National  Medicare  Education  Program  that will  use 
multidimensional  strategies to assist beneficiaries make informed  health care decisions.  Further, 
HCFA  will  provide  access to program  information  via the Internet  and an updated Medicare 
Handbook.  HCFA  is also evaluating  additional  performance  measures for carrier telephone 
service.  We continue  to believe that it would  be useful for HCFA  to set numerical  goals that can 
be tracked  to determine if new initiatives  improve  program  performance. 
HCFA  also suggested changes for our  1998 survey of Medicare  beneficiaries.  We appreciate 
HCFAs  input  on our survey instrument.  As in the past, we plan to continue  working  with  HCFA 
to refocus certain parts of the survey to provide  more useful information  to HCFA  policy  makers. 
... 
111  PAGE 
EXECUTIVE  SUMMARY 
INTRODUCTION  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 

FINDINGS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...3 

Beneficiaries  Report  Positive Experience  with  Medicare  Program  ......................  3 

Generally Understand  Program  ............................................  3 

Can Get Needed Information  ............................................  .4 

Knew  About  and Used Participating  Physicians  ...............................  5 

Are  Satisfied with  Claims Processing  .......................................  6 

Claims are Paid Quickly  Enough  .........................................  .7 

Are  Satisfied with  Carrier  Telephone  Service  .................................  8 

Awareness  of Flu Shots Improved  . . . . . . . .  . . . . . . . . . . . . . . . . . .  . . . .  . . . . . . . .  . .9 

Awareness  of Some Services Improved  ......  ..................................  9 

Second Surgical Opinions  ............  ..................................  9 

Limits  on Physician Fees  .............  ..................................  9 

Physicians Filing Medicare  Claims  ......  .................................  10 

Some Services Continue  to Need Improvement  . . . . .  . . . .  . .  ..........  10 

Claims Processing Problems  ...........  . . . .  . .  ..........  10 

Calling  Carriers  ....................  . . . . .  . . . . . .  . .  ..........  12 

Appeal Rights  .....................  . . . . .  . .  ..........  14 

Hospital  Reimbursement  .............  . . . . .  . .  ..........  15 

Mammograms  .....................  . . . . .  . . . . . .  . .  15 

Some New  Problems Observed  ...............................................  15 

PneumoniaShots  ...................................................  ..15 

Home Health Hot  Line  .................................................  15 

RECOMMENDATIONS.....................................................  16 

AGENCYCOMMENTS.....................................................19 

APPENDICES 
Responses to  1997 Survey of Beneficiary  Satisfaction  ........................  A-l 
Analysis of Respondents  vs. Non-Respondents  ..............................  B-l 
Related OIG  Surveys  .................................................  C-l 
HCFA  Comments  ....................................................  D- 1 
 INTRODUCTION 

PURPOSE 
To determine the experience with  and satisfaction of fee-for-service  beneficiaries with  Medicare 
services. 
BACKGROUND 
Medicare  is a Federal health insurance program  for individuals  age 65 and older, and for certain 
categories of disabled people.  Medicare  was authorized  in 1965 by title XVIII  of the Social 
Security  Act.  In Calendar Year  1997, Medicare  served over 38 million  people, known  as 
beneficiaries,  and paid benefits totaling  over $211 billion. 
The Health  Care Financing  Administration  (HCFA),  Department  of Health  and Human  Services 
(HI%),  has responsibility  for the Medicare  program.  However,  other organizations  share 
program  administration.  The Social Security Administration  establishes eligibility,  enrolls 
beneficiaries in the program,  and collects Medicare  premiums.  Private health insurance companies 
contract  with  the Federal Government  to service claims for Medicare  payment.  Insurance 
companies that handle hospital  claims are called intermediaries.  Those handling  physician claims 
are called carriers. 
METHODS 
In July 1997, we surveyed  1269 randomly  selected Medicare  beneficiaries.  We initially  selected 
1284 beneficiaries for whom  Medicare  Part B claims had been filed in Calendar Year  1996. 
However,  we dropped  15 beneficiaries from our sample because 12 questionnaires  were 
undeliverable  and 3 beneficiaries were deceased.  This reduced the sample size from  1284 to 
1269.  Appendix  A contains our questionnaire  and beneficiaries responses to the questions. 
Based upon previous  experience with  similar client and beneficiary  surveys, the sample size of 
1284 beneficiaries was calculated to produce  an estimate within  3.5 percent of the true value at 
the 95 percent confidence  level.  We used standard equations for estimating  sample size with  a 
binary response variable. 
Beneficiary  participation  in the survey was voluntary.  A total  of 977 beneficiaries  returned 
completed  questionnaires,  for a response rate of 77 percent.  Another  26 beneficiaries  sent in 
completed  questionnaires,  but we received them too late to include their responses in our analysis. 
Given the size of our sample and response rate, results of our survey are projectable  to the 
universe of 38 million  Medicare  beneficiaries. 
Health Care Financing Administration, United StatesDepartment of Health and Human Services,HCFA 
Statistics,October1997.  Percentages in the report  are based on the number of beneficiaries answering  each question. 
Appendix  B presents an analysis of respondents and non-respondents. 
Comparison  to Previous  Surveys 
In 1989, 1991, 1993, 1994, and 1995, we conducted  similar national  surveys of Medicare 
beneficiaries to assesstheir awareness of and satisfaction with  various aspects of the Medicare 
program.  (Appendix  C lists our previous reports  on beneficiary  satisfaction.) 
The majority  of questions used in the 1997 survey were used in our  1993, 1994, and 1995 
surveys.  Therefore,  Medicare  beneficiary  responses in those years are comparable to our  1997 
survey results. 
The 1993, 1994,. 1995, and 1997 surveys were also similar to the 1989 and 1991 surveys. 
However,  some questions were worded  and sequenced slightly  different.  Additionally,  we 
provided  more response options  to questions in the 1993, 1994, 1995, and 1997 surveys than we 
did in the 1989 and 199 1 surveys.  Therefore,  we cannot compare beneficiary  responses in each of 
the six survey years for all questions.  However,  we did make comparisons  whenever  possible, 
and determined  significant  differences in responses through  use of a t-test.  If there was a 
statistical difference between the responses to the 1995 and 1997 surveys, we stated in the report 
that a percent increased or decreased, depending on the finding.  If there was not a statistical 
difference, we stated in the report  that the percent stayed about the same. 
We conducted  this inspection  in accordance with  the Quality Standuds for Inspections issued by 
the Presidents Council  on Integrity  and Efficiency. 
2 
 FINDINGS 

BENEFICIARIES  REPORTED  POSITIVE  EXPERIENCE  WITH  THE  MEDICARE 
PROGRAM 
In 1997, beneficiaries were positive about several aspects of the Medicare  program.  In the 
following  areas, beneficiaries responded  similarly to those in our  1995 survey. 
0  They said they understood  the program  and could get information  when they needed it. 
0  They were aware of and used participating  physicians. 
0 	 Most  who  had called their carriers were at least generally  satisfied with  the service they 
received. 
0  Over three-quarters  said that their Medicare  claims were paid quickly  enough. 
Beneficiaries  Generally  Understand  the Program 
Eighty-one  percent of the beneficiaries  said that the Medicare  program  is understandable.  This is 
about the same as in 1994 and 1995, when 79 and 80 percent respectively  said the program  was 
understandable.  Figure  1 shows the level of understanding  over the 6 years we have surveyed 
Medicare  beneficiaries. 
Figure  1 
BENEFICIARIES  UNDERSTAND 
THE  MEDICARE  PROGRAM 
PERCENT 
100 
1989  1901  1893  1894  1096 
YEAR 
3 
 Beneficiaries  Can Get Needed Information 
Getting  General  Information:  Seventy-five percent of the beneficiaries  said they could get 
general information  about Medicare  when they needed it.  This is not significantly  different  from 
the percent of beneficiaries who  believed they could do so in 1995.  Table 1 shows the percent of 
beneficiaries who  said they can get general information  over the last 4 years. 
Table  1 
PERCENT  OF BENEFICIARIES  WHO  CAN  GET  GENERAL  INFORMATION 
1993  1994  1995  1997 
Yes  72%  75%  78%  75% 
No  7%  5%  5%  5% 
. 
Dont  Know  21%  20%  17%  20% 
Getting  Specific  Information:  Seventy-one percent of the beneficiaries who  have needed 
specific information  about their Medicare  coverage said they have been able to obtain it most of 
the time.  Table 2 shows that this percentage is the same as in 1995. 
Table  2 
PERCENT  OF BENEFICIARIES  WHO  CAN  GET  SPECIFIC  INFORMATION 
Sources  of Information:  Beneficiaries  were asked to indicate which  places they might go to 
obtain answers to questions about what Medicare  pays for.  They could identify  more than one 
source. 
Most  beneficiaries  said they get Medicare  information  from their physicians offkes  and the 
Medicare Handbook.  Sixty-eight  percent of all beneficiaries said they would  go to their 
physicians offices.  Fifty-five  percent of the beneficiaries surveyed said they would  refer to the 
Medicare Handbook.  Other sources that were acknowledged  as good  sources by more than a 
quarter  of those surveyed were carriers (38%)  and Social Security Ofices  (28%).  Most  Beneficiaries  Knew  About  Participating  Physicians 
Medicare  has participating  physicians  who  agree to charge no more than the Medicare  approved 
amount.  Medicare  pays 80 percent of the approved amount.  A beneficiary  is responsible for 
paying a deductible  and a 20 percent coinsurance.  Figure 2 shows that the number of 
beneficiaries who  were aware of participating  physicians in 1997 has remained about the same as 
past years findings. 
Figure  2 
BENEFICIARY  AWARENESS  OF PARTICIPATING  PHYSICIANS 
PIERCENT 
100 I
DOI - ................................................................................................................................... 
80 I - ......n..  ................T6.. ..........  83  ......  82  ............8..0.. ..  3.7.. ..... 
70 , -  ......  ......  ......  ......  ...... 
60 I -  ......  ......  ......  ......  ...... 
60 I -  ......  ......  ......  ......  ...... 
40 I -.  ......  ......  ......  ......  ...... 
30 I -.  ......  ......  ......  ......  ...... 
20 , -.  ......  ......  ......  ......  ...... 
10 I -.  ......  ......  ......  ...... 
0I-
1989  1091  1003  1094  IQ06  1997 
YEAR 
Figure  3 shows that beneficiaries use of participating  physicians  is about the same as in 1995. 
Figure  3 
BENEFICIARY  USE  OF PARTICIPATING  PHYSICIANS 
PERCENT 
100 
90 
80  _ ...........................................................................  ll..  ................  71..  ............................ 
,o  -.......  86.  ..................  ...............  *6..  ..........................  .6.8..... 
......  ......  ......  ......  ...... 
......  ......  ......  ......  ...... 
......  ......  ......  ...... 
......  ......  ......  ......  ...... 
1989  1991  1993  1004  1996  1997 
YEAR 
Twenty-seven  percent of beneficiaries we surveyed said they did not know  if their physicians were 
participating. 
5 
 Beneficiaries  are Satisfied  with  Claims  Processing 
Eighty-nine  percent of the beneficiaries said they are at least generally  satisfied with  the way 
Medicare  carriers processed their most recent claim for a doctors visit.  As Figure 4 illustrates, 
few beneficiaries  said they were dissatisfied. 
Figure  4 
SATISFACTION  WITH  CLAIMS  PROCESSING 
Wry  Satirfiod  48% 
Claim  Not  Paid  bt  2% 
Vary  Olrs~tlsflod  1% 
Qonorally  Olss~tlsfl~d  1% 
Qonrrally  8atlrflad  41% 
Figure  5 shows the number of beneficiaries expressing satisfaction remains high.  However, 
interpretation  of trends for the past 6 years should be done with  the understanding  that we 
changed our survey instrument  in 1993.  This change could slightly  affect the trend.  The 1993, 
1994, 1995, and 1997 surveys had a response option  that was not offered in 1989 and 199 1. 
Also,  in 1989, when beneficiaries  could file their own claims, we asked only those beneficiaries 
who  submitted their own  claims about their satisfaction. 
6 
 Figure  5 
TRENDS  IN  BENEFICIARY  SATISFACTION  WITH  CLAIMS  PROCESSING 
PERCENT 
100 
.....  .  a6  ... 
90 
80 
70 
00 
60 
40 
30 
20 
10 
0 
1988  1881  1893  1994  1996  1997 
YEAR 
- SATISFIED  m  DISSATISFIED  m  NEITHER/UNPAID  CLAIM 
Beneficiary  Claim  are Paid  Quicky  Enough 
Seventy-seven percent of the beneficiaries agree that their Medicare  claims are paid quickly 
enough.  This is approximately  the same as 1995s finding.  Fourteen  percent of those answering 
the survey did not know  if their claims were paid quickly  enough. 
Figure  6 
MEDICARE  PAYS  CLAIMS  QUICKLY  ENOUGH 
Dont  Know 
14% 
7 
 Most  Beneficiaries  are Satisfied  with  Carrier  Telephone  Service 
About  14 percent of the beneficiaries we surveyed said they had tried to call their carriers.  Figure 
7 shows that 79 percent of those beneficiaries who  had called their carriers said they were at least 
generally satisfied with  the service they received the last time they called. 
Figure  7 
SATISFACTION  WITH  CARRIER  PHONE  SERVICE 
Very  Satislied  40% 
v  Neither  11% 
Figure  8 shows that the percent of beneficiaries who  were satisfied with  carrier telephone  service 
in 1997 is about the same as in 1995, which  means satisfaction is still high. 
Figure  8 
TRENDS  IN  BENEFICIARY  SATISFACTION  WHEN  CALLING  CARRIERS 
PERCENT 
-
lQ89  1991  1993  1994  1996  1997 
YEAR 
m  SATISFIED  m  DISSATISFIED  m  NEITHER 
8 
 AWARENESS  OF FLU  SHOTS  IMPROVED  FROM  1995 TO  1997 
The only area to show improvement  from  1995 was beneficiary  awareness of flu shots.  Eight-
three percent of the respondents were aware that Medicare  will  pay for immunizations  as 
compared to 76 percent in 1995.  This is determined to be a statistically  significant  difference. 
AWARENESS  OF SOME  SERVICES  DECLINED  IN  1997 
Some areas that we identified  as problems in 1995 were greater problems in the 1997 survey. 
More  beneficiaries were unaware  of Medicares  coverage of second surgical opinions,  limits on 
physicians fees, and the requirement  that physicians file claims. 
About  Two-Thirds  of Medicare  Beneficiaries  Were Not Aware  that Medicare  Provides for 
Second Surgical  Opinions 
In  1997, 66 percent of all beneficiaries  surveyed were not aware that Medicare  pays for a second 
opinion  on the need for surgery.  Table 3 shows that this is a significant  increase from  1995, when 
60 percent did not know  Medicare  paid for second opinions. 
Table  3 
SECOND  SURGICAL  OPINIONS 
1989  1991  1993  1994  1995  1997 
I 
Unaware  of Second  57%  59%  61%  64%  60%  66% 
Surgical Opinions 
About  One-Third  of Beneficiaries  Were Not Aware  that Medicare  Limits  Physician  Fees 
In our  1997 survey, we asked beneficiaries if they knew Medicare  limits the fees that physicians 
can charge for specific services.  Thirty-three  percent of the beneficiaries did not know  about the 
limits.  This is a seven percent increase from the previous two  survey findings,  1994 and 1995. 
Table 4 shows the decrease of knowledge  about Medicare  regulating  physician rates. 
Table  4 

MEDICARE  LIMITS  PHYSICIAN  FEES 

I  1994  1995  1997 
Unaware  That Medicare  26%  26%  33% 
, Limits  Phvsician Fees 
9 
 About  10 Percent  of Beneficiaries  Were Unaware  that Physicians  Should  File  Medicare 
Claims 
In 1997, 10 percent of the responding  beneficiaries  said they were unaware that their doctors 
were supposed to file their Medicare  claims for them.  This is a significant  increase from  1995, 
when only seven percent did not know. 
SOME  SERVICES  NEEDED  IMPROVEMENT  IN  1995, AND  STILL  DO  IN  1997 
Overall, beneficiary  understanding  of and satisfaction with  Medicare  program  services was 
positive.  However,  some trouble  spots remain.  Several problem  areas identified  in our  1995 
survey failed to improve  in 1997. 
0  Some beneficiaries  had problems with  claims processing and carrier telephone  services. 
a 	 Some beneficiaries were not aware of their appeal rights and almost a fourth  of the female 
beneficiaries were not aware that Medicare  paid for mammograms. 
About  One-Fifth  of Medicare  Beneficiaries  Identi$ed  Problems  with  Claims  Processing 
Although  89 percent of beneficiaries  are at least generally satisfied with  claims processing,  22 
percent identified  one or more problems with  their last Medicare  claim.  More  beneficiaries cited 
problems in 1997 than in 1995, when  19 percent cited one or more problems;  however,  this is not 
a statistically  significantly  difference. 
Figure 9 shows claim processing problems beneficiaries experienced before their claims were paid. 
Numbers  in the figure  represent the percent of all beneficiaries surveyed. 
10 
 Figure  9 
BENEFICIARY  PROBLEMS  PRIOR  TO  PAYMENT  OF CLAIMS 

Probkm  Getting  Claim  Stalum  Claim  Paymont  Taking  Too  Low 
m  1981  ~1903  @#id1994  ml996  m  1997 
Figure  10 shows claims processing problems beneficiaries experienced after their claims had been 
paid.  Numbers  in Figure  10 represent the percent of all beneficiaries  surveyed. 
Figure  10 
BENEFICIARY  PROBLEMS  AFTER  PAYMENT  OF CLAIMS 
PERCENT 
60 
40  r...3a  ,,,,,..._._.,,,,,,,,,,,,,,,.,...............,,,,,,,,,,,,...................,,,,,,,,,,.................................................... 
30 
20  .  . .......... .  . .......08 .__.................,,,,,.............................................................. 
10 
11 
 Over Half  of Medicare  Beneficiaries  who  Had  Called  Their  Carriers  Experienced  Difficulty 
Calling 
While beneficiaries who  called their carriers generally expressed satisfaction,  over half, 58 
percent, said they experienced problems.  They had difficulty  getting  access to their carriers, using 
carriers automated voice systems, and getting  answers once they got through  to the carriers. 
Table 5 shows this is the same percent of beneficiaries who  experienced problems in 1995. 
Table  5 
BENEFICIARIES  WITH  PROBLEMS  CALLING  CARRIERS 
Getting  Telephone  Access with  Carriers  is Diffkult  for  Beneficiaries:  About  14 percent of 
the beneficiaries  surveyed had tried to call their carriers.  However,  6 percent of the beneficiaries 
answering  our question  said they had wanted  to call, but did not have their carriers phone 
number. 
In 1997,27  percent said they had to try three or more times to get through  to their carriers. 
Further,  3 percent were unable to get through  at all.  Table 6 shows that getting  access to a 
Medicare  carrier is a continuing  problem. 
Table  6 
CALLING  CARRIERS 
Number  of Tries 
The beneficiaries who  had called their carriers were given a list of possible reasons why they 
might have been dissatisfied the last time they called.  They could cite as many problems as they 
experienced. 
12 
 Figure  11 shows that 60 percent of beneficiaries either encountered  a busy signal or thought  they 
were put on hold too long when they called their carriers to get questions answered.  Numbers 
shown in the chart represent the percent of beneficiaries who  had called their carriers. 
Figure  11 
BENEFICIARY  PROBLEMS  GETTING  THROUGH  TO  CARRIERS 
PERCENT 
90 .................................................................................................................................................. 
60 ...7..1........................................................................................................................................ 
I 
,,,..,..........,,..,,,.,,.......,..........,.....................,,,,,,,,..,............................................... 
70 
................ ....  .......  ........
60 
,,,,,..._.......................... 
60 
,,,,,....._,.,.............................. 
40 
30 
20 
10 
0 
LINE  BUSY  PUT  ON HOLD 
-1980  ml001  ml008  ml804  ~1008  tjlQ97 
Beneficiaries  Experienced  Other  Problems  After  Getting  Access to Carriers:  Figure  12 
shows that in 1997, some beneficiaries experienced other problems after they got a telephone 
connection  with  their carriers. 
13 
 Figure  12 
BENEFICIARY  PROBLEMS  AFTER  GETTING  THROUGH  TO  CARRIERS 
PERCENT 
60 
40 
30 
20 
10 
0 
D~~FgEwREl  UNCOURfEOU8  ANSWERS  NOT  QUESTION
UNDERSTOOD  UNANSWERED 
-1980  mlQQ1  mlQQQ  mlQQ4  mlQQ5  a1987 
Almost  One-Third  of Beneficiaries  Were Not Aware  of  Their  Appeal  Rights 
In 1997, 32 percent of the beneficiaries  surveyed were unaware that they could appeal or request 
a review  of decisions Medicare  carriers made about their claims.  Although  this in no worse than 
in 1995 when 34 percent lacked such knowledge,  it indicates needed improvement.  Table 7 
shows the percentages of beneficiaries who  did not know  they could appeal or request a review  of 
their Medicare  claims. 
Table  7 
AWARENESS  OF APPEAL  RIGHTS 
Year  1989  1991  1993  1994  1995  1997 
Beneficiaries  24%  22%  25%  31%  34%  a  32% 
Not  Aware 
In  1997, 4 percent of the beneficiaries said they had appealed a Medicare  decision on their claims. 
This response was exactly the same as the response in 1995. 
14 
 Almost  One-Fift  of Hospitalized  Beneficiaries  Did Not Know  what  Medicare  Paid 
Eighteen  percent of the beneficiaries  surveyed who  had been a patient in a hospital for at least one 
night said that it was not clear what Medicare  had paid for.  This is about the same as in 1995, 
when 23 percent did not understand what Medicare  had paid for. 
Of those beneficiaries who  had been a patient for at least one night in a hospital,  29 percent said 
they had not received written  information  entitled  An Important MessageFrom Medicare.  The 
information  provides beneficiaries with  knowledge  about their rights to ask for a review  if they 
believe they are being discharged from hospitals too early. 
Almost  One-Foutih  of  Women  Were Unaware  that Medicare  Paidfor  Mammograms 
Twenty-three  percent of the female beneficiaries  surveyed did not know  that Medicare  pays for 
mammograms.  This is about the same as in 1995, when twenty-four  percent of the female 
respondents  did not know  about Medicares  mammogram policy. 
BENEFICIARY  AWARENESS  OF SOME  SERVICES  NOT  INCLUDED  IN  OUR  1995 
REPORT  WAS  FOUND  LACKING  IN  1997 
Beneficiary  knowledge  about other aspects of the Medicare  Program  also need improvement. 
These were not mentioned  in our  1995 report. 
Pneumonia  Shots:  Forty-two  percent of the beneficiaries did not know  Medicare  pays for 
pneumonia  shots. 
Home  Health  Hot  Line:  Eighty  percent of all the beneficiaries surveyed, and 73 percent of those 
who  had received home health services, did not know  that each State has a hot line to register 
complaints  about home health care. 
15 
 RECOMMENDATIONS 
We recommend  that  HCFA  develop  a plan  for  improving  beneficiary  satisfaction  and 
understanding  in the trouble  areas mentioned  in this  report. 
Several of the problem  areas cited have been identified  as problems in previous  OIG reports.  For 
example, problems with  carrier telephone  service have been noted in each of the six reports  on 
beneficiary  satisfaction.  In the past, HCFA  has agreed these are problem  areas, and planned 
corrective  actions.  Nevertheless,  some of the same problems continue  to exist.  We suggest that 
in planning  corrective  actions, HCFA  set numerical goals that can be tracked  for program 
improvement.  We believe this activity  can be useful to HCFA  in correcting  the problem  areas and 
fulfilling  requirements  of the Government  Performance  and Results Act. 
Problems identified  in this survey and in previous years that still need attention  are highlighted 
below 
0 	 Claims  Processing:  Almost  one quarter (22 percent)  of the beneficiaries experienced a 
problem  with  their last Medicare  claim. 
Telephone  Service:  The number of beneficiaries experiencing  problems when calling 
remains high (57 percent).  Further,  over one-fourth  (27 percent)  of the beneficiaries had 
to call three or more times to reach their carriers. 
ADDeal Riphts:  Almost  one-third  (32 percent)  of the beneficiaries  surveyed said they did 
not know  they could appeal Medicare  decisions about their claims. 
Mammowams:  Almost  one-fourth  (23 percent)  of the female beneficiaries  surveyed did 
not know  Medicare  paid for mammograms. 
Hospital  Reimbursement:  Eighteen  percent of the beneficiaries who  had been a patient 
in a hospital  for at least one night said it was unclear what Medicare  would  pay for.  Also, 
only 30 percent said they received information  that provides beneficiaries with  knowledge 
about their rights to ask for a review if they believe they are being discharged from 
hospitals too early. 
By  1997, the extent of some problems identified  in 1995 had gotten worse. 
0 	 Second  Surgical  ODinions:  In  1997, 66 percent of the beneficiaries  surveyed did not 
know  that Medicare  will  pay for a second opinion  on the need for surgery.  In 1995, only 
60 percent were unaware. 
16 
 0 	 Physician  Fees:  In  1997 one-third  (33 percent)  of the beneficiaries  surveyed did not 
know  Medicare  limits physicians fees for specific services.  This is an increase from  1995 
(26 percent). 
0 	 FilinP  Claims:  In  1997, a tenth of the responding  beneficiaries were not aware that their 
physicians should file their Medicare  claims for them.  In 1995, only 7 percent did not 
know. 
Finally,  some new problems identified  in our  1997 survey need attention. 
0 	 Pneumonia  Shots:  Forty-two  percent of the beneficiaries  surveyed did not know 
Medicare  paid for pneumonia immunizations. 
0 	 Home  Health  Hot  Line:  Eighty  percent of all beneficiaries,  and 73 percent of those who 
had received home health services, did not know  a State hot line to register home health 
complaints  existed. 
17 
 The HCFA  Administrator  reviewed  our draft report  and concurred  that HCFA  should develop a 
plan to improve  beneficiary  satisfaction  and understanding  in the troubled  areas identified  by the 
survey.  HCFA  has initiated  a National  Medicare  Education  Program  that will  use 
multidimensional  strategies to assist beneficiaries make informed  health care decisions.  Further, 
HCFA  will  provide  access to program  information  via the Internet  and an updated Medicare 
Handbook.  HCFA  is also evaluating  additional  performance  measures for carrier telephone 
service.  We continue  to believe that it would  be useful for HCFA  to set numerical  goals that can 
be tracked  to determine if new initiatives  improve  program  performance. 
HCFA  also suggested changes for our  1998 survey of Medicare  beneficiaries.  We appreciate 
HCFAs  input  on our survey instrument.  As in the past, we plan to continue  working  with  HCFA 
to refocus certain parts of the survey to provide  more useful information  to HCFA  policy  makers. 
The full text of HCFAs  comments can be found in appendix D. 
18 
 RESPONSES  TO  1997 SURVEY  OF MEDICARE  BENEFICIARY 
SATISFACTION 
0  Not  every respondent  answered every question. 

0  For Questions  12, 13, 21,25,  and 26, respondents could check more than one choice. 

Question  Responses 

PART  1:  MEDICARE  COVERAGE 

1.  In  general,  do you  think... 
a.  The Medicare  program  is understandable? 
Yes  759 
No  179 
Not  Answering:  39 
b.  You  can get information  about Medicare  when you need it? 
Yes  711 
No  50 
Dont  Know  194 
Not  Answering:  22 
Medicare  pays your  claims quickly  enough? 
C. 
Yes  735 
No  88 
Dont  Know  130 
Not  Answering:  24 
A-l  Question  Responses 
2. 	 Thinking  about  the last time  you were  a patient  in a hosnital  for  at least one night, 
was it clear  to you what  Medicare  paid  for? 
(Check  one answer.) 
I have not been in the 
hospital  for at least 
one night  since I have 
had Medicare.  303 
Yes, it was clear what 
Medicare  paid for.  402 
No,  it was not clear what 
Medicare  paid for.  115 
I do not remember if it 
was clear what Medicare 
paid for.  125 
Medicare  has not yet paid 
the hospital.  12 
Not  Answering:  20 
3.  Think  about  the last time  you were  a patient  in a hosnital  for  at least one night. 
Were  you  given  written  information  entitled  An  Important  Message  From 
Medicare,  that  said you  have a right  to request  a review  if you  think  the hospital  is 
forcing  you  to leave before  you  are well  enough? 
(Check  one answer.) 
I have not been in the 
hospital for at least 
one night since I have 
had Medicare  coverage.  298 
Yes, I was given written 
information  about my 
right  to request a review.  195 
No,  I was not given written 
information  about my 
right to request a review.  186 
I dont remember.  271 
Not  Answering:  27 
A-2 
 Question  Responses 
4. 	 Think  about  the last time  you  received  services in vour  home from  a  home  health 
agencv. 
Was it clear  to you what  Medicare  paid  for? 
(Check  one answer.) 
I have not received services 
in my home from a home health 
agency since I have been on 
Medicare.  670 
Yes, it was clear what Medicare 
paid for.  191 
No,  it was not clear what Medicare 
paid for.  38 
I do not remember if it was clear 
what  Medicare  paid for.  40 
Medicare  has not yet paid for the 
home health services.  11 
Not  Answering:  27 
5. 	 Before  today,  were  you  aware  that  your  State has a hot  line  to register 
complaints  about  home health  care? 
Yes  186 
No  764 
Not  Answering:  27 
__---------------_------------------------------------------------ _____________-----------------------------------
6. 	 If your  doctor  recommends  that  you  have surgery  Medicare  will  help you  pay to get 
the opinion  of another  doctor. 
Were  you  aware  before  todav  that  Medicare  would  help  pay for  a second 
doctors  opinion  before  having  surgery? 
Yes  325 
No  635 
Not  Answering:  17 
A-3 
 Question  Responses 
7.  Before  today,  did  you  know  that  Medicare  pays for  flu  shots (immunizations)? 
Yes  809 
No  160 
Not  Answering:  8 
-------____---______----------------------------------------------------------------------------------------------
8.  Before  todav,  did  you  know  that  Medicare  pays for  mammograms  (breast 
x-rays  to detect  cancer)? 
All  Females 
Yes  674  433 
No  270  126 
Total Not  Answering:  33 
Females Not  Answering:  8 
9.  Before  today,  did  you  know  that  Medicare  pays for  pneumonia  shots? 
Yes  557 
No  403 
Not  Answering:  17 
_________-_--_______-------------------------------------------------------- ___________--------_------------------
10. 	 Medicare  has participating  doctors  who  agree to charge  no more  than 
Medicares  approved  amount.  Medicare  pays 80%  of the approved  amount.  You 
are only  responsible  for  paying  the deductible  and  20%  coinsurance  of the 
Medicare  approved  amount.  Before  todav,  had you  ever heard  about  Medicare 
participating  doctors? 
Yes  743 
No  216 
Not  Answering:  18 
__---------___------------------------------------------------------ ____________________--------------------------
11.  Are  any  of your  doctors  participating  doctors? 
Yes  655 
No  46 
Dont  Know  259 
Not  Answering:  17 
A-4 
 Question  Responses 
12. 	 In  the past,  if you  had  a concern  about  the quality  of your  medical  care, whom  did 
you  call? 
(Check  all that  apply.) 
(N = 928 - Number  Responding 
 to Question) 
I did not have a concern about 

the quality  of my medical care. 
 540 
I did not know  who  to call. 
 167 
The insurance company that pays 

my Medicare  claims 
 87 
Social Security Office 
 76 
The Medicare  Peer Review 

Organization(PR0) 
 9 
The Health  Care Financing 

Administration  (HCFA)  - Federal 

Government 
 9 
State Department  of Health 
 11 
State Board  of Medical  Licensure 
 7 
My  states insurance commission 
 6 
My  local Medical  Society 
 16 
The hospital  or health care 

organization  that provided  the 

care. 
 116 
The doctor  that provided  the care 
 205 
Other 
 24 
Not  Answering:  49 

A-5  Question  Responses 
PART  2:  GETTING  INFORMATION  ABOUT  MEDICARE 
13.  Where  would  you  go to get information  about  what  Medicare  pays for? 
The following  are some of the places people  might  go to get answers  if they  have 

questions  about  what  Medicare  pays for.  Please check  all the places you  would  go 

to find  out what  Medicare  pays for. 

(N = 952 - Number  Responding  to Question) 

My  doctors  office 
 644 
A friend or relative 
 95 
AARP  or other membership 

organization 
 133 
Insurance  company that 

processes my Medicare  claims 
 364 
Insurance  company that issues 

my supplemental  (Medigap) 

policy 
 221 
Social Security  Office 
 268 
A local Senior Citizens 

group 
 73 
The Health  Care Financing 

Administration  (HCFA)  -

Federal Government 
 22 
An insurance salesperson 
 18 
The Medicare  Handbook 
 523 
The Medicare  Peer Review 

Organization  (PRO) 
 25 
My  States Information, 

Counseling,  and Assistance 

(ICA)  ofice 
 30 
Other 
 27 
Not  Answering:  25 

____________________------------------------------------------------------------------------------------ ---------- 
14. 	 Think  of when  you  needed  specific  information  about  what  Medicare  pays for, 
how  often  were  you  able to get the information  you  needed? 
Most  of the time  367 
Some of the time  98 
Seldom or never  55 
I have never needed information  414 
Not  Answering:  43 
A-6 
 Question  Responses 
PART  3:  MEDICARE  CLAIMS 
15. 	 Did  you  know  before  todav  that  Medicare  limits  how  much  doctors  can charge  you 
for  specific. services? 
Yes  641 
No  316 
Not  Answering:  20 
___---__---___----------------------------- ---------------_--______________________------------------------------- 
16. 	 Did  you  know  before  todav  that  your  doctors  are supposed  to file your 
Medicare  claims  for you? 
Yes  869 
No  98 
Not  Answering:  10 
--------__-__---____--------------------------- -------___---_______-----------------------------------------------
17. 	 How  satisfied  are you  with  the way  Medicare  processed  your  most recent  claim  for 
a doctors  visit? 
(Check  w.) 

Very  Satisfied  454 

Generally  Satisfied  390 

Neither  Satisfied nor Dissatisfied  58 

Generally Dissatisfied  11 

Very  Dissatisfied  10 

Medicare  has not yet paid the claim  19 

Not  Answering:  35 

_________-_______--_____________________--------------------------------------------------------------------------
18. 	 Sometimes  people  disagree  with  the decisions  made on their  Medicare  claims. 
When  this  happens,  you  may appeal  or request  a review  of those decisions.  Did 
you  know  before  today  that  you  could  appeal  or request  a review? 
Yes  650 
No  299 
Not  Answering:  28 
A-7 
 Question  Responses 
19.  Have  you  ever appealed  a decision  made by Medicare  on one of your  claims? 
Yes  34 
No  915 
Not  Answering:  28 
-__------------------------------------------------------------------ --------------------------------------------- 
20.  Do you  think  your  appeal  was handled  fairly? 
Yes  25 
No  7 
I have never appealed a 
decision made by Medicare 
on one of my claims.  710 
Not  Answering:  235 
_______-_--__------------------------------------------------- ______________--------------------------------------
21. 	 Did  you  have any  of the following  problems  the last time  you  had  a Medicare 
claim  for  a doctors  visit? 
(Check  as many  as apply.) 
(N = 900 - Number  Responding  to Question) 
I had difficulty  getting 
information  from Medicare  on 
the status of my claim.  18 
I did not understand  what part 
of my claim Medicare  paid and why.  83 
I did not understand  why Medicare 
denied the claim.  57 
Medicare  took  too long to pay my 
claim.  47 
I did not understand  the notice 
Medicare  sent after processing my 
claim.  (The notice is called 
Explanation  of Your  Medicare 
Part  B Benefits  or Medicare 
Summary  Notice.)  100 
Other  2 
I did not have a problem with 
my last Medicare  claim.  699 
Not  Answering:  77 
A-8 
 Question  Responses 
PART  4:  CALLING  MEDICARE 
22. 	 Have  you  ever tried  to call the insurance  company  that  processes your 
Medicare  claims? 
(Check  one.) 
Yes  .  126 
No,  I have not needed to call.  752 
(Skip  to Question  33.) 
No,  I wanted  to call, but do 
not have the telephone number.  54 
(Skip  to Question  33.) 
Not  Answering:  45 
___-_-------_____----------------------------- ____________________------------------------------------------------
23. 	 Thinking  about  the last time  you  tried  to call, how  many  tries  did  it take  you  to 
reach  the insurance  company  that  processes your  Medicare  claims? 
(N = 126 - Number  Who  Had  Called) 
First Try  59 
Second Try  23 
Three or More  Tries  32 
Never  Got Through  3 
Not  Answering  Who Have Called:  9 
--------------------------------------------------  -----------__---------------------------------------------------
24. 	 How  satisfied  were  you  with  the service you  received  the last time  you  called  the 
insurance  company  that  processes your  Medicare  claims? 
(N = 126 - Number  Who  Had  Called) 
Very  Satisfied  47 
Generally  Satisfied  46 
Neither  Satisfied nor Dissatisfied  13 
Generally Dissatisfied  7 
Very  Dissatisfied  4 
Not  Answering:  9 
A-9 
 Question  Responses 
25.  Listed  below  are possible  problems  someone might  have when  calling  the 
insurance  company  that  processes your  Medicare  claims. 
From  the list  below,  identify  problems  you  had  the last time  you  called  the 
Medicare  insurance  company. 
(Check  as many  as apply.) 
(N = 126 - Number  Who  Had  Called) 
The line was busy.  42 
I had problems with  the automated 
voice system.  25 
The person answering  the call was 
not courteous.  5 
I was put on HOLD  too long.  30 
I was not able to get my question 
answered.  4 
I could not understand  the answer 
they gave me.  10 
I got different  answers from 
different  people.  7 
Other  5 
I did not have a problem with  the 
service I received.  51 
Not  Answering:  6 
A- 10 
 Question  Responses 
PART  6:  OTHER  INSURANCE 
26.  What  types  of medical  insurance  do you  or your  spouse have in addition  to 
Medicare? 
(Check  all that  apply.) 
(N = 907 - Number  Responding  to Question) 
I do not have additional 
insurance coverage  128 
Medicaid  (or other  State or 
county  medical assistance 
program)  86 
Health  insurance through  you or 
your  spouses current  employer  59 
Health  insurance through  you or 
your  spouses former  employer  313 
Private Medicare  supplement 
W&zap)  244 
Other  146 
Not  Answering:  70 
27.  How  satisfied  are you with  your  private  Medicare  supplemental  (Medigap) 
insurance? 
(Check  one.) 
I do not have supplemental (Medigap) 
insurance.  282 
Very  Satisfied  305 
Generally  Satisfied  189 
Neither  Satisfied nor Dissatisfied  38 
Generally Dissatisfied  20 
Very  Dissatisfied  10 
Not  Answering:  133 
A- 11 
 ANALYSIS  OF RESPONDENTS  VS. NON-RESPONDENTS 
A consideration  in surveys of this type is that the results may be biased if non-respondents  are 
significantly  different  from respondents.  To determine whether  significant  differences exist in this 
survey, we analyzed age, gender, and time of response for the 997 respondents and the 272 non-
respondents.  Age is a continuous  variable which  was tested using the t-test for a difference 
between means.  Gender and time of response are categorical  variables which  were tested using 
the (X-square  with  the appropriate  degrees of freedom.  The analyses suggests that our survey 
results were not biased with  regard to these factors. 
ANALYSIS  BY  AGE 
The average age for respondents was 73, compared to age 72 for non-respondents.  A 
comparison  of means with  the t-test revealed that the difference in average ages for the two 
groups was not statistically  significant. 
Sample  Respondents  Non-Respondents 
N=  1269  N=977  N=292 
t = -0.7963 
DF = 1267 
ANALYSIS  BY  GENDER 
An analysis by gender showed that the distribution  of male and female respondents was not 
comparable to the distribution  of non-respondents.  The Chi-square  test statistic was significant 
for the gender variable because it was greater than 3.84 at the 95 percent confidence  level.  This 
indicates a potential  for bias in the results, 
Ll 
Sample  Respondents  Non-Respondents 
,ElN = 1269 N=  977  N=292 
H
FFMMeemmaallaaeell  ee   7755N5511S6633a=   m((((46461p00002le%%%%6 9))))      R44e5511Ns66p0077=o     ((((n4455d92288e7%%%%n7t))))s     Non-1111RN0088e33=99s    2p((((93366o25555n%%%%de))))n    ts
(X-square  = 4.179 
DF=l 
B-l  To determine the effect of the relationship  between response rate and gender, we undertook  an 

analysis of the non-respondents.  Assuming that non-respondents  would  have responded the same 

by gender as the respondents,  we calculated  a hypothetical  global response to Questions  la,  lb, 

and lc  on the questionnaire.  Those three questions, posed to all respondents,  relate to program 

understandability,  availability  of information,  and claims processing promptness.  Calculations 

found that the responses were within  the confidence intervals for the original  estimates. 

Therefore,  no statistical evidence of gender bias was shown. 

ANALYSIS  BY  TIME  OF RESPONSE 

As an additional  guard against obtaining  biased results, some surveys similar to this one are 

reviewed  for differences which  may exist between early and late responses.  The rationale  is that 

late respondents  and non-respondents  may share certain tendencies.  For example, when 

compared to early respondents,  late respondents could hold more negative (or, at least, less 

enthusiastic)  opinions. 

To analyze for potential  bias related to time of response, we compared the responses of the first 

728 respondents  (75 percent) to the last 249 respondents.  We performed  a test using the Chi-

square test on each groups responses to Questions  la,  lb,  and lc.  Based on the test, there was 

no statistically  significant  difference between the early and late responses. 

B-2 
 RELATED  OIG  MEDICARE  BENEFICIARY  SURVEYS 
1.  A Survey  of Medicare  Beneficiary  Satisfaction  (OAI-04-89-89040),  November  1989 
2.  Medicare  Beneficiary  Satisfaction:  1991 (OEI-04-90-89030),  October  199 1 
3.  Medicare  Beneficiary  Satisfaction:  1993 (OEI-04-92-00480),  August  1993 
4.  Medicare  Beneficiary  Satisfaction:  1994 (OEI-04-93-00  140), June 1995 
5.  Medicare  Beneficiary  Satisfaction:  1995 (OEI-04-93-00  150), December  1996 
6.  Medicare  Beneficiaries  Plans for  Financing  Nursing  Home  (OAT-04-90-8903  l), 
November  199 1 
7.  Medicare  Beneficiaries  Plans for  Financing  Nursing  Homes  (Management  Advisory 
Report),  (OEI-04-92-00482),  April  1994 
8.  Use of Nursing  Home  and Medigap  Guides, (OEI-04-92-0048  l),  May  1994 
9.  Beneficiary  Awareness  of HCFA  Publications,  (OEI-04-93-00  14l),  June 1995 
10.  Beneficiary  Awareness  of HCFA  Publications:  1995, (OEI-04-93-00152),  April  1997 
11.  Beneficiary  Satisfaction  with  the 1996 Medicare  Handbook,  (OEI-04-96-00280), 
February  1997 
12.  Medicare  Beneficiary  Interest  in HMOs,  (OEI-04-93-00  142), October  1995 
13.  Beneficiary  Interest  in Medicare  HMOs  in 1995, (OEI-04-93-00151),  February  1997 
14.  Medicare  Beneficiary  Satisfaction  with  and  Understanding  of Home  Health  Services, 
(OEI-04-93-00143),  November  1995 
15.  Beneficiary  Satisfaction  with  and  Understanding  of Home  Health  Services in 1995, 
(OEI-04-93-00  153), April  1997 
16.  Beneficiary  Satisfaction  with  Supplemental  Insurance,  (OEI-04-93-00  154), January 
1997 
C-l  APPENDIX  D 

HCFA  COMMENTS 

D-l  b 
DEPART MENT  OF HEALTH  & HUMAN  SERVICES  Health  Car0  FinanCing  klministtatjo,, 
The Administrator 
DATE:  APR21  I990 
TO:  June Gibbs Brown 
Inspector General 
FROM:  Nancy-Ann Min DeParle  (3w  13 
Administrator 
SUBJECT: 	 Wee  of Inspector General (OIG) Draft Report: Medicare Beneficiary 
Satisfaction: 1997, (OEI-O4-97-00030) 
In July  1997, OIG surveyed 1,269randomly selectedMedicare beneficiaries to assess 

their  awarenessof and satisfaction with various aspectsof the Medicare program  Based 

on that survey, OIG recommendsthat the Health Care Financing Administration (HCFA) 

develop a plan for improving beneficiary satisfaction and understanding in specific 

trouble  areas. We concur with the OIG recommendation and our detailed commentsare 

as follows: 

OIG  Recommendation: 

We recommend that HCFA develop a plan for improving beneficiary satisfaction and 

understanding in the trouble areasmentioned in this report 

HCFA  Response: 

We concur.  HCFA is embarking on a National Medicare Education Programto ensure 

that consumersreceive accurate,easily understandableinformation about their benefits, 

rights, and health plan options to assistthem in becoming more active participants in their 

health care decisions. 

The National M-edicareEducation Programwill  employ multidimensional strategiesfor 

educating beneficiaries in making informed decisions concerning: 

program benefits and choice of health plan 

l 
health care choices 

l 
program protections and rights (i.e., appeals),and beneficiary responsibilities 

l 
health behaviors and health promotion 

l 
As part of this program, HCFA will  provide acgessto program information via the  _  :y   
Internet and in printed materials, suchas the Medicare Handbook.  This is a phased,: .<  g 
approach that we began in February 1998 and will  continue through 1999 and beyo@  T:y  :
r

--_  -3  -: 

.
-. 
-_ Y  .. 

u  ;
:  -T  - 
---  Page2 - June Gibbs Brown 
Addressing  Specific Trouble  Areas for Improvement 
Telenhone Service: The number of beneficiaries experiencingproblems when calling 
remains high (57 percent). Further, over one-fourth (27 percent) of the beneficiaries had 
to call three or more times to reach their carriers. 
HCFA Resnonse: 
We agree that further improvements need to be madein order to improve the current level 
of telephone service to our beneficiaries. While HCFA is currently pilot testing several 
approachesto improving telephone sticc  in the long term, we must contiue  to also 
concentrate on improving the current level of serviceby Medicare carriers in the short 
term.  HCFA is currently analyzing additional performancemetrics for canier telephone 
senice that would be included in the fiscal year (FY) 1999canier budget and 
performance requirements. Examples of new potential metrics include: establishing a 
threshold for phone calls being answeredin the first 30 seconds;handling a high 
percentage of calls during the initial  call, thereby minimi&g  transferralsand referrals to 
other entities; and measuring the quality of customerservicecontinuously, ensuring that 
all telephone agentsare closely monitored for quality call handling and order processing 
for accuracy, knowledge, responsiveness,clarity, tone, etc. In the upcoming months 
HCFA will  be discussing and costing out theseproposedmetrics with regional offices and 
Medicare contractor staffs in order to reach final agreementfor performancemeasuresin 
FY  1999. While clearly theseadditional resourceswould significantly improve customer 
service, HCFA must move forward within  its currentbudget. This meansthere may be 
incremental improvements in the contractor telephoneserviceto beneficiaries given the 
current funding levels. 
We believe that the development of theseadditional performancemetrics will  result in 
improvements in telephone service to our Medicare beneficiaries. 
ADDS  RiPhts:  Almost one-third of beneficiaries smveyeddid not know they could 
appeal Medicare decisions about their claims. 
HCFA  Resnonse: 

Appeal rights will  be addressedin the Medicare Handbookand on our Internet site. 

Pending availability  of funds, we plan to do a major outreacheffort to inform 

beneficiaries of their rights and protections. 

Mammograms:  Almost one-fourth  (23 percent)of  the female beneficiaries surveyed 
did not know Medicare paid for mammograms.  Page 3 - June Gibbs Brown 

HCFA  Resoonse: 

Over the past few years, HCFA has conducted national campaigns  to educate 

beneficiaries about the mammographybenefit and will  continue to carry out campaigns. 

We are working in partnership with the Public Health Seth  and severalnational 

organizations. 

The National Mammography 2000 Campaign is linked to the Healthy People 2ooOgoal 

of increasing the rate of screeningmammogramsin Medicare eligible women to 60 

percent.  The campaignincludes a national distribution of posters,postcards,bookmarks, 

and stickers to support community-basedefforts to promote increased.nseof screening 

mammograms in the Medicare population 

The Multi-City  Mammography Project is a part of the national  campaign  and targets 

Miican-American  and Hispanic Medicare beneficiaries in six major metropolitan areas. 

We also are conducting a campaign on new Medicare prevention benefits. The campaign 

provides  information about annual mammograms,which is a new Balanced Budget Act 

of 1997 provision. 

HCFAs  consumer Internet site has a Wellness Pagethat provides information on 

mammography coverageand other information on mammograms. 

Second Sureical  ODinions:  In 1997,66 percent of the beneficiaries surveyeddid not 

know that Medicare will  pay for a secondopinion on the need for surgery. In 1995, only 

60 percent were unaware. 

HCFA  Rewonse: 

This problem areawill  be addressedthrough the consumerInternet site we recently 

established. 

Phvsician  Fees:  In 1997,one-third (33 percent) of the beneficiaries surveyeddid not 

know  Medicare limits physicians fees for specific services. 

HCFA  Resuonse: 

We will  addresslimiting  chargesin the Medicare Handbook and on our Internet site. 

Filine  Claims:  One-tenth of surveyedbeneficiaries were not awarethat their physicians 

should file their Medicare claims for them. 
 Page 4 - June Gibbs Brown 

HCFA Response: 

We will  addressthe filing  of claims by physicians in the Medicare Handbook and on our 

lntemet site. 

Pneumonia  Shots: Forty-two percent of the beneficiaries did not lmow Medicare pays for 

pneumonia shots. 

HCFA  Resnonse: 

HCFA  conducts au annual flu campaign between October and February. We believe the 

campaign has contributed to the increase in awarenessthat Medicare pays for flu shots. 

This year we are working with our national prt~ers,  CDC and the National Coalition for 

Adult  Immunization,  to promote both flu and pneumoniashots. During the campaigns, 

we distribute posters,postcards, stickers, and bookmarks. 

We also are conducting a campaign on Medicare prevention benefits. The campaign 

provides information  about pneumonia shots. In addition, the Wellness Pageon the 

consumer Internet site provides information on the Flu/Pneumonia2000 campaign, 

coverage of the pneumonia shot, and questionsand answersabout pneumococcal 

pneumonia. 

Technical  Comments 

1. 	 As a general response,the survey Medicare Beneficiary Satisfaction is not really 
a beneficiary satisfaction survey.  Rather, for the most part, it focusseson 
awarenessissues. Even so, the report paints a generally positive picture of the 
beneficiary satisfaction with fee-for-service and points out someof the areas 
HCFA needsto look at for improvement. 
2. 	 The survey instrument would better assistour abilities to servebeneficiaries if it 
were expandedfrom its awareness of a right focus to include a focus on the 
ability  of the beneficiary to assertthe right and the results of suchan assertion.. 
For example, (Question 3) from amongthosesurveyedwho were aware of their 
right to appeal a hospital discharge decision,how many exercisedthe right?  What 
was the outcome?  Of those who didnt know, would they have exercisedthe right 
had they known?  Parallel argumentscan be raisedin other areas,suchashome 
health care and appeals. Such an expansionappearsto be consistentwith the  . 
Purpose of the survey as set out on page 1 and would better support a discussion 
of satisfaction. 
3. 	 The numbers and percentagesin the text needto be cross-checkedwith the figures 
in the survey instrument appendix. For example,pagesii and 15 of the report state 
that 29 percent of the beneficiaries who had beena patient for at least one night in  Page 5 - June Gibbs Brown 
a hospital statedthat they had not received written information entitled, An 
Important Messagefrom Medicare.  The sumy  instrument cites 20 percent at 
A-2, with the 29 percent figure representing those who did not remember. 
4.  The options for Question 21 could be expandedto include other areas,such as 
understandingappeal rights as provided on the Explanation of Your Medicare 
Part B Benefits or Medicare Summary Notice. 
5.  OIG should work with HCFAs Center for Beneficiary Servicesto develop a 
survey instrument that would provide us with a better measureof satisfaction and a 
more useful tool for serving our beneficiaries. 
6.  It is not clear which differences in fkxlings from prior surveyswere statistically 
significant, and which were not.  It may be useful to group the klings  as either 
statistically significant or trends to follow. 
7.  The question on claims processingproblems (item 25) would be more helpful if 
it was differentiated between problems with finding out the statusof a claim and 
problems understandingthe explanation of benefit payment. 
8.  It would be useful to seean analy@sof responsesby race, socioeconomiclevel, 
and age for certain questions,e.g., knowledge of whether Medicare pays for 
mammograms(item 8). 
we  believe that the coordination efforts mentioned aboveshould go a long way towards 
improving  beneficiary satisfaction and understanding of the Medkare program. 
-m-s  s----- -s-v- ---  --s- B--s--
OIG  COMMENT:  In  reference  to HCFAs  comment  number  3 above, we rechecked  our 
figures  to ensure  their  accuracy.  The  percentages  were  correct,  but  different  because  we 
calculated  percentages  for  the report  and  appendix  A from  different  bases.  In  the  report 
we show  the  percent  of the 652 beneficiaries  who  answered  the question  and  had  been in 
the  hospital.  In  appendix  A, the percent  was based  on the 950 beneficiaries  who  answered 
the  question.  The 950 beneliciaries  included  the  652 who  had been in the hospital.  The 
950 beneficiaries  also included  the 298 who  had  not  been in the hospital.  Therefore,  the 
percent  shown  in  appendix  A was lower  (20 percent)  that  than  shown  in the report  (29 
percent). 
To  eliminate  confusion,  we deleted  the percentages  from  appendix  A and  show  only  the raw 
number  of responses to each question.