SECRETARY'S ADVISORY COMMITTEE ON REGULATORY REFORM

MONDAY, FEBRUARY 25, 2002

HYATT REGENCY HOTEL, MIAMI, FLORIDA
9:05 a.m. - 5:15 p.m.

VOLUME II

(Whereupon, the proceedings continued after the lunch break at 1:30 p.m.)

CHAIRMAN WOOD: I would like to invite the Committee members to return to the table so we can begin our afternoon. I apologize for the delay in the serving of lunch. We've lost some time that we'll unfortunately have to try to make up as much as we can.

I'm particularly pleased to be able to welcome today Bobby Jindal, who's talked with us more about the work that we have in front of us and how we can help him and his colleagues and the persons of the Steering Committee. We've made this reference to the Steering Committee from time to time.

At our first meeting in Washington we were anticipating we might have some time at the end to be able to share some specific recommendations with Bobby, but we know that he was called for some more important things, and we -- I know individually, as well as collectively, offer him our great congratulations, and we're very happy that you're with us now, and I would invite you to share a few of your thoughts with us before we start the afternoon.

MR. JINDAL: Thank you, and I will keep my remarks brief to get us back on schedule. I've seen several of you already, and already the most important question I've gotten is was it a boy or a girl.

I'm pleased to report -- I apologize having to leave you so abruptly last time. I'm pleased to report we had a baby girl, our first child, and she did me the honor of waiting at least 36 hours to be born. So I had plenty of time to get back to the delivery room. Her mother wasn't so pleased with her patience, but she's a healthy baby girl. She is going to be -- I guess she just turned seven weeks and is doing very well.

I really wanted to bring you greetings on behalf of the Secretary. I know he personally wanted to be here and will be coming to some of the field hearings. This week and next week he'll be testifying in front of the various budget committees in Washington with the Congress coming back from the recess, and there's also significant welfare reform announcements and events and developments, so he's meeting with the governors in Washington, so he did want to send his regrets.

I've already heard from several of you that the morning has gone well, and one question that I've gotten from so many of you, because you do have so many good and specific ideas, is about the outcomes of this Committee and what is the Secretary's intention, and so I'll remind you of where he started as to start off our afternoon session, which is the Secretary absolutely is looking for concrete tangible solutions and recommendations on ways that we can make the rules and regulations less onerous, less burdensome, to providers and beneficiaries across the country.

His mandate is very clear. His willingness to follow through is very clear. He wants to be able to implement specific changes to reduce the paperwork, reduce the burden, make our healthcare system much more responsive, more efficient and to emphasize high quality.

Now, it may not surprise any of you, now that we're getting into the details of the work, that you're never going to find a rule where everybody simply jumps up and says absolutely that rule needs to go, that form needs to go, that paperwork is absolutely redundant, and the reason being that there will always, behind any rule or paperwork or form, form some rationale or some reasoning, and so I hope nobody was astonished that all of the wonderful examples that you brought to this Committee, you haven't met with some explanation from somebody.

The Secretary certainly doesn't want you to back away from the challenge. That doesn't mean the first time somebody says yes, but or oh, we've thought about that, or oh, we're going to do that one day, he certainly doesn't expect you to back away.

He is aggressive. He is impatient, and he wants to make changes as quickly as he possibly can, and so what he has charged us with doing, what he's charged you with doing is to sift through those, and when they're reasonable, certainly accommodate those explanations, answers and other justifications you'll get, but to persist. You bring a valuable experience to this table, you bring valuable experience, each of you, from your different backgrounds to this process, so what he's looking for you to do is to use your experience collectively as a group to say we understand the obstacles, we understand the rationalizations, we understand the reasons, but we think there's a better way to do it, and here is the way that we think we need to go.

So with that, I'll stop there. I do have, as any proud father would, a baby picture, and so I'm happy to share with you afterwards in a private moment, and I'm happy to bore you to tears with details about my baby girl.

I will leave you with this final thought. Last night -- my daughter has a wonderful ability to know when her father's leaving, and so she chooses not to sleep those nights so we can enjoy late night TV together, and so I had the wonderful experience of watching the Home Shopping Network last night, showed up at the airport to find out from the airline representative, who looked at me and said, AYou don't think that you're traveling today, do you,@ and so I'm happy to say that I'm here despite those challenges and obstacles.

I thank you for letting me join you this afternoon and tomorrow.

CHAIRMAN WOOD: I'm anxious to know what you bought. That's when I know you've got -- when she's got you truly wrapped around her finger.

I'm particularly pleased to begin the afternoon by welcoming Michael McMullan to share with us what CMS is doing for beneficiary communications and education. It's been a privilege of mine actually to work on a project -- I won't say how long ago -- with Michael, which I do think has had a measurable and significant impact on the outcome of care for Medicare beneficiaries.

I'm particularly anxious to hear from her about what she and her colleagues are doing at CMS to communicate and educate our elderly and other beneficiaries in the use of these services.

So Michael.

MS. McMULLAN: Good afternoon. I'm going to -- at the risk of having slides after lunch, we're going to go through these slides, and I will try to do it as quickly as possible.

This overview slide -- I'm going to be talking about all of this, but the significant components of the National Medicare Education Program include the 1/800-Medicare, which is a toll free help line; Medicare and You handbook and other publications, and there's a whole table full of the publications that we develop, and I put at each place the order form so you can see the array of things that we do, the Website, www.medicare.gov, and I commend that Website to you, it is really quite comprehensive, and REACH and SHIPS, and those are the only acronyms.

REACH is the Regional Education and Bad Choices in health, and that's an activity that we do through our 10 regional offices to reach out at the community level, and I'll be talking a little bit more about that later, and SHIPS are the State Health Insurance Assistance Programs, and they go by many different names in different states, but they're run out of either the Office on Aging or the State Health Insurance Commissioner's Office, and their principal purpose is to be -- to provide advice to people with Medicare about Medicare and other insurance products, including supplemental insurance and Medicaid.

I also wanted -- this is not talk about customer service, but I wanted to just share this sort of pretty picture with you to tell you that we hold ourselves responsible for certain performance metrics, and it's very hard to read and I apologize for that, but in developing our materials our outcomes that we're seeking, and I'll only go through those, is that we want to be responsive to diverse groups, and I'll talk a little bit about what we do to meet that outcome.

We want to be convenient and accessible and a trusted source of accurate information, which is an interesting issue for us, and I'll talk a little bit about that as well, and we want to be perceived as courteous and professional.

The National Medicare Education Program began after the Balanced Budget Act of 1997 was very explicit in its expectation of what we are to do for Medicare beneficiaries, and that Act requires that we provide general information about benefits, how people elect different health plan options, rights and protections, including appeal protections and information about supplemental insurance, also known as Medigap.

They -- it also required that we provide comparative information about health plans, including their supplemental benefits, satisfaction information, quality information when it becomes available, cost sharing information, service areas and other pertinent decision factors for our consumers.

The law also instructed us to use direct mail, a toll free telephone service, the Internet and a national publicity campaign. So the Congress was very explicit in its direction on how we were to go about this.

And the purpose of the education campaign was to provide people with Medicare with the information that they need to make the best decision for them about their health plan options, and the target is both the beneficiaries themselves and the people who care for them, and we refer to that group of people as caregivers, although it's interesting that that's not a way that people see themselves as caregivers. That's our shorthand for that. And we also are in the business of making sure people get accurate information and protect them from misleading information.

One of the most important things about this next slide is that we want to be able to speak with one voice so people get reliable, consistent messages about what their opportunities are, and that's difficult when you are talking about reaching 40 million people through many different avenues. We have contractors that process our claims. We have the State Health Insurance Assistance Programs. We have the telephone customer service representatives. So we have literally thousands of people that we have to equip with information so that they can give the same answer each time someone asks the question, and we, I think, are doing a good job of providing that kind of consistency, but it is a challenge.

And, finally, we want to provide consumers with information about the quality of care so that they can make decisions and incent the system to improve the outcomes of care. It's an important consumer-driven quality aspect of all of this.

We have four main objectives, and these have not changed from the beginning. We want people to receive accurate, reliable and relevant information. Accurate, meaning that it's factual; reliable, meaning that each time they ask they get the same answer; and relevant, meaning that it's important to them.

We use a lot of consumer research approaches to determine what people want to know. We also work with them on what they need to know so the relevant factor is very important, particularly with the current population of people with Medicare.

They're a relatively passive group of information seekers, different than some of the younger populations, and so it needs to be relevant to them at the moment that they need it, at the moment that their lives have changed and they need information about healthcare. We want to give them the opportunity to access information when they need it, and we want them to understand the information when they get it. And so we've gone through an extraordinary effort to simplify the way we explain information to people with Medicare.

There are some examples of our publications on the back table for people to look through, and they're on this table in the front here for the panel members, and it's been a very interesting process. I've learned a great deal about how to explain things simply to people, and we have a lot more to learn.

We also want people to trust the materials that we give them. The principal direct mail is Medicare and You. That's the name of our handbook. We want them to trust the 1/800 number, and we want them to understand that these are authentic documents for them, and that they were -- include the correct information.

A little bit about our population is 87 percent of people with Medicare are eligible because of age, 65 and older; 13 percent are eligible because of disability. If you're disabled for 24 months, on the 25^th month you become eligible for Medicare. Included in the disabled category are people with end stage renal disease, which is kidney failure, and people with kidney failure, the majority of them are eligible for Medicare benefits; the majority of people eligible are in the 65 to 74-year old age group.

The fastest growing sector of the Medicare population is 85 and older, which brings with it other challenges in communicating.

Eighty-five percent of the Medicare population are white non-Hispanic, nine percent are African-American non-Hispanic, and seven percent are Hispanic. These are self-identified categories.

Sixty-one percent of Medicare beneficiaries have incomes below $25,000.

The next statement is where the majority of the population is. Those are high population states. Proportionally it looks different than that. If you looked at the proportion of aged people in sun states, they're proportionately higher, and I think the highest proportion of elderly per capita live in North Dakota, as an example, not a high population state.

Thirty-three percent do not have high school diplomas. Thirty-five percent are graduates or have certificates, and 70 percent have no college, and this is significantly different for the minority populations. They are less well educated.

Now, when it gets to what do people know about Medicare; they love it. I should tell you that all people that we survey love Medicare. They don't know much about it, however.

Medicare and Social Security are probably the two most well-liked social programs, but they don't know much about it. Very few people, 37 percent of the population, don't know about Medigap, or supplemental insurance, and Medicare does not pay for everything, so for those people who do not have an employer-sponsored retirement, health benefit or don't have other supplemental insurance, such as Medicaid, then they -- all of the cost would be out of pocket, so Medigap becomes a very important part of what they need to know.

And 56 percent of the people know little or nothing about managed care, and if you remember, the origin of the -- of the educational benefit came out of the Balanced Budget Act where they were trying to encourage people to look at their other health plan options, other than the fee per service part of Medicare.

The way people want to receive information -- 38 percent of beneficiaries prefer to talk to people face to face. Now, again, 40 million people, face to face is not a reasonable option to be able to think about how we would provide that, and though people say this, they are as apt to want to do it person to person. So doing it over the phone, even with the State Health Insurance Assistance Programs, often they contact that -- which is a community-based program, they contact people over the phone.

Twenty-five percent like to read, want to see the material in front of them and read it. Nine percent learn through TV, and three percent use the Internet. Now, that number of the Internet is growing. A larger proportion of our population, each time we do a survey, show that they have access to the Internet, and we certainly do see that among the caregiver population using the Internet to get information.

I think I'll -- just for the sake of getting back on schedule -- the other ways that we can reach this population are through media and our advertising campaign. This last year we did a lot of television advertising to increase people's awareness of 1/800-Medicare, and the other information outlets. We also have used radio.

Print, it's interesting, this -- mostly the aged population are very big newspaper readers, but they don't notice print ads as much as they notice news stories, and so it's understanding how to effectively use print media to reach this population.

Now, just to go through the components of the educational program, and I'll talk about each of these in turn so I won't read through all of the -- this list. I'll just talk about each of them.

As I mentioned, the Balanced Budget Act of 1997 mandated that we provide an annual mailing and told us that it would -- all of the mailings were to go into the -- be mailed by October 15^th, and so each year we mail out the Medicare and You Handbook, and there are copies on the table.

We have the handbook available in English and Spanish, audio tape, video -- there's a video production and Braille so that it is available to all of those audiences. We mail out 34 million handbooks, and the 34 million instead of 40 million is that we mail one handbook in a household of four or fewer people.

We have 26 different versions of the handbook because we include in those handbooks information about the health plan options available in the area so they're specific to the area.

Each month we mail out about 200,000 handbooks to new Medicare enrollees, and we send out copies to health plans and congressional offices, and we have two other versions of the handbook.

We send the handbook to the libraries, the public libraries, and in this library version we have other publications that we have written that complement the handbook, and when the -- we refer people to the libraries to use the Internet, so from the beginning we've done this library edition, and we worked with the libraries to make sure that it could be shelved. So this handbook is available in most public libraries.

And we also have a physician's version of the handbook, and in the physician's edition there's additional information in the front about new benefits and payment information for physicians. So this is made available to physician offices.

We have a long list, and I put one at each table, of other publications that we do that are targeted to particular needs of the Medicare beneficiary. For example, when we did -- when we do new payment systems, we will explain the new payment system and its effect on the -- on people with Medicare, or if there's a new health benefit or particular focus of health benefits, we'll write a little flyer or brochure on that so that it can be used for people who have a specific interest.

We do all of our publications in Spanish. We do some publications in other languages. The issue in other than Spanish is that we don't have the quality assurance mechanism to develop multiple language versions. What we rely through the REACH that I mentioned earlier, we ask our regional offices if they have the ability to do other language versions.

They will often develop them, but we need to have a quality assurance mechanism, and if they have other -- people who speak other languages in the community or can arrange that with community-based organizations, then other language versions are done.

We've done some in Chinese. It's very challenging because culturally some of the Chinese concepts are not easily trans- -- it's not even translated, easily explained. The insurance process is not easily explained in Chinese. It's not -- oh, nor in English, someone said.

We -- for those people who are Internet-savvy, we had in December 3.9 million page views. That means visitors looked at that many pages on the site, and in calendar 2001 it was nearly 40 million page views.

The toll free help line. We started the toll free help line in 1998 with five states, 1/800-Medicare. What we do, and this is really a very interesting approach for us, the customer service representatives use what is called a desktop, and on their desktop they have scripted answers to questions, and they navigate through the desktop to answer the questions of people calling in, and this is the way -- I said earlier our biggest challenge is getting reliable -- accurate reliable answers, and so this is the way that we use this, and we've been very successful doing this.

We started out in a much more structured process. Now it's much more conversational, but it's been a very successful approach in getting people the answers that they need.

We went 24 hours a day, seven days a week this year, in 2001, and we added another level of training to our customer service representatives so that they can answer more questions, meaning that people did not have to leave 1/800-Medicare to get the answers to some of their questions.

We -- in 1999 when we started, we got one million calls. In 2001 we had five million calls, and we estimate the calls this year to go up to six million calls.

The average call time is seven minutes, which is long for a call center, but not long for this kind of a call center. I think Social Security is about -- in their call center runs about five and a half to six and a half minutes.

The majority of information that they ask for is information about their Medicare Plus Choice options because we will run them through the options in their area and send them out information that's pertinent just to the area that they're interested in, interested in what Medicare benefits are, enrollment, replacement cards, and the -- one of the most interesting part of this is that in 2001 we increased the volume of Spanish-speaking calls significantly.

Spanish speakers were not calling the number, despite the fact that we had Spanish-speaking customer service representatives. We did the ad campaign that I mentioned, and we had the significant increase in Spanish speakers calling 1/800-Medicare. It still, though, is not representative of the proportion of the population that are Spanish-dependent.

The most frequent -- the two most frequent issues that we deal with are issues of eligibility to Medicare and replacement cards. Both of those are activities that we coordinate with the Social Security Administration so we're looking at ways to facilitate to prevent those calls by making sure people get those answers up front and can easily access that information.

After that for the non -- for English speakers Medicare Plus Choice is the next question. For Spanish speakers Medicaid is the next question.

I think that -- oh. One of the interesting aspects of the call center is that we handle a lot of the calls through the automated voice response unit, and if you look at the handbook, we give people what the voice response unit will sound like when they call and what they need to do to get to a customer service representative.

The reason that many calls are handled here is that people sometimes just want a publication or they can listen to frequently asked questions and answers on the voice response unit, and we handle about 40 percent of the calls through that and the remainder through customer service representatives.

This is what our call center, just schematic, looks like, and it's interesting. I've learned a great deal of things that I never knew before, but the -- what we -- we handle the distribution of the calls through the network level and so we can direct the calls to the next available operator so that it's very efficient.

The most important thing, though, is the square box on the right is the desktop that we use to make sure that people get the answers to the questions that are accurate and relevant to what they want to know, and we spent a lot of time thinking about how to make that knowledge in that desktop appropriate to this population and how to train the customer service representatives.

Another element of what we do on the National Medicare Education Program is building partnerships, both at the local and national level. The regional Education by Choices In Health, one of their main responsibilities at the regional office level is to find partners in the community so that we can leverage one relationship to reach many people in the community.

We look for employers to get information out through their employer -- employee benefit managers. We look for the Triple As. We look for AARP or any natural organization that touches the population that we serve to try to leverage, as I said, one relationship to meet many people.

We have a National Partners Alliance Network. We meet quarterly. This alliance network is made up of advocates, organized medicine, organized law, employee benefits administrators, other federal agencies, and we share with them what's happening in the education program and other aspects of things that are going on within Medicare so that everyone has the opportunity to have that information, and then they will share among themselves things that are important.

In the last meeting we heard about Tri-Care, which is a benefit for military dependents, interesting coordination of benefits issues for many people.

We also have a federal advisory committee called the Advisory Panel on Medicare Education, and Heidi Margulis was a part of that committee until -- and they have provided us with recommendations on what we need to do in the educational program and also are another way for us to make sure that the external community knows what we're doing, and then we also have a very large Train the Trainer Program, which I'm going to talk about later.

I think I talked about this.

The Train the Trainer. Our point of developing a Train the Trainer program is we have a lot of resources in the federal program that we put to making sure that we explain the Medicare benefits and opportunities as clearly as possible, and we want to be able to share this as broadly as possible.

And one approach that we have used is to train others who then have outlets into the community about this, and for the last three years we've done national Train the Trainer programs in each of our 10 regional offices and train people in the community about Medicare basics; benefits, enrollment, eligibility, rights and protections, Medicare choices, coordination of benefits, a whole array of activity so that we can get the information into the community.

One of the things that we are doing that I think is going to be very useful is that we're going to turn this training into web-based training, and the reason that we want to do this is, is again, as I mentioned earlier that the Internet is just an enormously useful tool in reaching many people, is that if we can create a web-based training tool, we can make it available to virtually everyone, and so hospital discharge planners or hospital admission staff can learn information that we would never have the opportunity to reach them with if we didn't use a vehicle such as the web. So we're very anxious for this product. So, again, we can reach the maximum achievable audience.

National publicity campaign. This, again, was part of the instructions we received in the Balanced Budget Act that they wanted us to do an annual national publicity campaign for the purpose of people understanding their open enrollment options and other aspects of Medicare, and one of the things that we use that advertising campaign to do is build people's awareness of the information channels and their trust in those channels because when we sat down and talked to the marketing and advertising professionals, they said you can advertise something, but you have to be willing to deliver on your promise. So don't advertise something that you don't have to give.

So it's very important that the 1/800-Medicare number and the Website and the other aspects of the program work effectively, and they realize the promise of the advertising.

The -- meeting the needs of the individual beneficiaries, the State Health Insurance Assistance programs. These I mentioned are part of the State departments of insurance or State Department on Aging. They often work through community-based organizations like Triple As, and they provide individual counseling, either on the phone or face to face.

The other thing I wanted to mention to you is that our agency -- this is -- doesn't have our new name yet, but this is called the Health Care Financing Review. It has research findings that it publishes quarterly, and in the fall 2001 review is on consumer research, most of it funded by CMS for the purpose of understanding how to communicate effectively with our beneficiary population, and this is available through the CMS dot -- CMS.HHS.GOV Website.

Consumer research I talked about.

Just an aspect of what we do in the consumer research, we want to understand who the target audience is that we're trying to serve. We want to understand what we're trying to get them to do, whether it's awareness or action. We want to present the information in a way that people perceive that there's something in it for them or else they wouldn't pay any attention to it. We want to understand how to convey it to them in a way that they can see themselves in it. That's the image.

We want to plan around an activity supporting actions to make sure that people have the resources that they need, and that in a local level is the REACH and SHIP activities, and we want to be able to understand when people are ready to receive the messages, and this is perhaps the most difficult part of what we have to do, is that most people on insurance and health care want the information when they are at the moment, the event in their life.

And to make sure that it is accessible to people when they need it and helping people know that there's something there for them to access information is very important, and we're still learning how to do that aspect of it.

So with that, that ends my prepared remarks. I can take questions now or wait until the panel, whatever you like.

CHAIRMAN WOOD: We will actually ask for them now, Michael, so, Heidi.

MS. MARGULIS: Thank you very much, and I'd like to say that Michael and her colleagues have worked on about $1.95's worth of funding to do all that they've done, and at least from one industry perspective have really done a yeoman's job of getting the word out, and I commend you for that.

MS. McMULLAN: Thank you.

MS. MARGULIS: As Michael mentioned, I served on the Advisory Panel for Medicare Education. There is an annual report, Michael, that if you can, I'd like to see that every member of the panel gets a copy, and I will turn my copy over to Erik for the Communications Committee because there are a number of very good solid recommendations in the area of how to reach minority populations and most vulnerable of the senior population.

I might also add that some of the recommendations made by the Committee which probably don't appear in here are some that we chatted at our very last meeting about, things as easy as if one looks at the Medicare and You handbook, it has 27 pages, I believe, of telephone numbers of where to call.

We suggested that similar to my ID card, that there be a 1/800 number, no matter what, and that perhaps that number be printed on the Medicare beneficiaries' ID card, just like ours, so that it's very easy, and one doesn't have to search through many, many pages.

But I believe that funding has probably been one of the primary reasons that a lot more hasn't been done, and also working with some community-based organizations to get the word out are among a number of the recommendations.

MS. McMULLAN: We are doing a pilot in the State of Pennsylvania where people can reach any of the Medicare contractors through 1/800-Medicare. There are a lot of technology issues behind that, and we're working through them in Pennsylvania.

What we do plan to do for the plan year 2003 handbook is to use 1/800-Medicare as a place people can get the right telephone number by calling, and we would refer them and give them the right telephone number, doing the network solution so people only need to call one number, and then they're directed to the right place will take more time.

DR. CROSBY: I'd like to ask if you could do this for physicians in an education project, as well, because patients often bring their confusing communications to their family doctor for interpretation, and often the doctors are not any better equipped than the patient to answer the question.

And last week speaking with one of my physician colleagues about my responsibilities on this Committee, he told me that it was his office practice that they would call repeatedly to the regional office or CMS until they got the same answer twice in a row, and then they would go with that.

MS. McMULLAN: The physician education part of it is handled by a different group than mine, but I'll tell you what I know about what they're doing, and as far as the beneficiary materials, things that could be made available to a beneficiary through a physician, we're happy to look at ways that that can be done effectively so that the right information gets to them.

As far as physician education, there is an entire group of people whose mission it is to improve our communication with healthcare professional physicians and other healthcare professionals, and they have -- also have a Website called Med Learn on CMS.HHS.GOV.

They have part of that activity are -- is represented in some of the open door activities that are going on, and they're looking at improving the way that the -- improving the information base that we make available through our Medicare contractors to respond to physician questions on coverage and local medical review policy, which you've heard about earlier, and we're actually looking at putting local medical review policy in a navigable database on the Website, and that's -- that'll be coming this year. I don't know exactly when.

CHAIRMAN WOOD: Patricia Shafer, then Dr. Nielsen.

MS. SHAFER: Thank you. I had a couple questions, but one was -- I think you alluded to in the beginning that it's sometimes difficult. There's lots of different people that will give answers, you know, when a beneficiary calls and has questions. Yet you have outlined a lot of good steps in really trying to get a handle on the educational needs.

From your perspective, what are some best ways to try to get some consistent, clear, understandable answers? I mean it sounds like in some ways the way you describe this that there is a central repository of information, yet outside of here, you know, I don't hear that that's the case. They have people calling different places and they get different answers.

So maybe you could comment on that.

MS. McMULLAN: Uh-huh. The -- we are building a central repository of information for the Website and for the telephone, and one of the things that we are looking for is how do we make that available more broadly. The telephone desktop is built to make it efficient, you know, the least wasted time for the customer service representative, but there's an enormous amount of information there that other people could use to answer the questions if they got them directly.

So we're looking at ways to build a database that allows people to get the same -- have the same opportunity to access that information.

So the -- there are lots of different steps. Simplifying the language that we use. I had a video that I was going to show and decided that it would take too long, but one of the issues that came up has been in a Spanish-dependent individual. They said, AI have this wonderful book. It tells me about physician assignment, but I don't get -- what is assignment, you know, even though you've explained it to me, I don't get it.@ Explaining things simply, we can learn how to do that.

Some concept, some insurance concepts are not intuitive, and physician assignment may be one of them for people who don't have experience in the -- in the native American insurance system where assignment is just part of what we have come to expect under different terms.

Simplifying the rules, but that's something that often Congress needs to do, would be one aspect of it, and I -- we deal with another group within the agency on trying to explain the juxtaposition of Medigap rules, supplemental insurance rules, with Medicare + Choice activities, especially if there's an issue with non-renewing plans. It's very complicated, and explaining that simply to people is -- is quite challenging.

So some of it is the complexity of the system, and insurance products are complex, and that's what we're dealing with. There are a lot of rights that are afforded to people with Medicare to protect them, and that makes layers of complexity and to navigating to help people find the information that they need among all of those things, you know, finding out which election period you're in, of which there are many, trying to get them right where they need to go without having to sort through all of that. So coming up with the navigation tools are important, and storing it -- and having one place.

The knowledge-base concept, which is gaining popularity in a lot of different aspects of what we do is really important here so that we only have one answer to the question.

MS. SHAFER: Along those lines, what readability level do you target most of your materials to, or do you have -- like Your Medicare and You that is comprehensive, and then do you -- do you do fact sheets are more, you know, more simplified versions --

MS. McMULLAN: We work with low literacy and plain language experts, and we target the sixth to eighth grade level. Having said that, some of the concepts that we need to explain are not at that level.

The -- we have commissioned Jean McGee (ph), who wrote a book that's available for writing for people with Medicaid to -- in plain language, in cultural -- culturally appropriate ways to relook at her work and look both at Medicare/Medicaid and Medigap so that we can learn from people who have studied this for a long time how better to do it, but sixth to eighth grade.

Now, another thing that I don't believe I mentioned, in our regional activities we've asked the regions to focus both on partnerships and the vulnerable populations and vulnerable in our context means people who have access barriers, either because of language, location or literacy, and so often the population who have low literacy or language barriers need to have more face-to-face simple explanations.

CHAIRMAN WOOD: Nancy.

DR. NIELSEN: You talked about the average length of time of the phone calls to the 800 number. Does that include being on hold and -- I mean I'm just curious. I don't know. I've never called it.

And, also, what is the abandon rate for people left on hold? And then I have just one other question.

MS. McMULLAN: Okay. We pick the phone up within three seconds. We have a very high almost instant call answering, and I don't believe -- I don't know the abandoned statistic because we don't have many. Usually if there are any abandoned calls, it's because we're having a problem in the network where the call -- there's just some blip. We really are very quick in answering the calls.

DR. NIELSEN: That's wonderful.

MS. McMULLAN: I invite you to call. I really do. It's a wonderful service.

DR. NIELSEN: This was actually a very impressive presentation. I have a question.

How much of this was being done before the Balanced Budget Act of 1997?

MS. McMULLAN: Before the Balanced Budget Act of 1997 we sent the handbook out to all new enrollees, and in, I believe it was 19- -- I should know this. We had occasional mailings to many people -- to everyone, but we only sent it out regularly to new enrollees, and we wrote -- we wrote things like the Guide to Health Insurance.

In the Guide to Health Insurance, there's a copy on the table, we do with the National Association of Insurance Commissioners and explains lots of different health insurance products that complement Medicare, and the -- when we assumed the responsibility for that, I couldn't understand it, and I have a master's degree, and I do this. This is my living.

So I couldn't understand it, and we now -- it's not -- I don't believe it's at sixth or eighth grade level, but it now is an understandable document. So we did -- we were -- I think we put a lot more burden on our contractors to answer questions, and we relied on them in understanding the program fully, and so there wasn't the -- necessarily the consistency. A lot more was forced into the contractor community. We did very little centrally.

CHAIRMAN WOOD: We'll have time for just two last questions so we can try to get back to schedule. I'll have Mr. Bloom and then Mr. Toby has a question.

MR. BLOOM: Thank you. Just have a quick question. I realize this is a very difficult thing since Medicaid is different in every state, obviously, but in looking over and doing some research prior to this meeting, it seems that there's a -- a lack of information for dual eligibles to find out exactly what they're eligible for, if they're eligible for Medicare or Medicaid.

What efforts are being made to provide the materials for people that are dual eligible, and, obviously, it's a great challenge, and perhaps this will be something that'll be taken up at a future date, but I was wondering if you looked into doing some more things in that regard, >cause in this list of materials there's nothing that indicates anything for dual eligibles.

MS. McMULLAN: Right. The issue on Medicaid is that they are state-specific and sometimes sub-state-specific programs, and we did one pilot of a state level book, and it's on the table. It's the guide for people with disabilities in the State of Colorado where we worked with the Social Security Administration, the State Medicaid Administration to develop a book for people with disabilities because there are more programs at the State level.

It's very difficult keeping that current because State programs change much more frequently than federally managed programs. Medicare is a federally managed program, and the rules -- people may feel they change frequently, don't change as frequently as something that's managed on a local level.

We do rely on the states with help from the federal system to develop the Medicaid materials, and you're right, people with -- who are dually enrolled in Medicare and Medicaid have two sets of programs to coordinate.

We are doing some demonstration projects and figuring -- figure out how to better coordinate both the programs, the benefits themselves and the explanation of how to take advantage of those benefits.

MR. BLOOM: Thank you.

MS. McMULLAN: Okay.

MR. TOBY: Thank you, Mr. Chairman.

Michael, my -- my question goes to I guess what Dr. Nielsen said, her last question, and it has to do with the long-term effect of beneficiary confidence. I worked in the Medicare program, I guess, for 30 years. I remember doing this before and nothing as good as this. This is as good as it gets. I have never seen such a massive education program.

And so I'm -- I just have two questions. One is how is the program currently being funded, and, two, what is the outlook of getting this program funded under the Medicare Trust Fund? If it's not funded under the Medicare Trust Fund, it eventually will fall away.

MS. McMULLAN: The -- this gets into inside budget knowledge here, but we are -- we rely on appropriated funds and user fees. That's the way that we are funded, and what Mr. Toby's talking about is some programs are allowed to be apportioned from the trust fund, and so it doesn't rely on an appropriation, and this is -- it is -- the predictability of funding is greater with an apportioned program just because there are lots of different demands on appropriated dollars.

We are funded by user fees. It's the proportion of people in Medicare Plus Choice plans to the total of our total budget. It is constituted with user fees. The original program was funded exclusively with user fees, and now it's funded proportionately with user fees, and the rest of the money -- largely the rest of the money comes out of appropriated funds, and then some of the activities that we do, the -- some of the surveys that we do serve multiple purposes, and one of the purposes is quality improvement and so some of the funds comes out of the account that goes to the quality improvement, which is the pro account, which is an apportioned account.

This is very inside the beltway, and I apologize, but we have multiple funding sources. Some of it -- this year we also had a directed appropriation for the State Health Insurance Assistance Program. So the Congress told us of the money you get, you are to give 122 million to the State Health Insurance Assistance Program.

So there are different aspects of the way we're funded that is -- and the way that we're funded, that is the nature of a federal program.

MR. TOBY: Excuse me, but my question was is there -- in the future do you think it will be funded out of the trust fund, because, if so, it'd be permanent, and we can all be very happy.

MS. McMULLAN: I think -- I don't -- I can't predict that. That's really an OMB philosophical view.

MR. TOBY: Well, what's your judgment?

MS. McMULLAN: It's not a popular way of funding programs, and the reason that it's not a popular way is that Congress reviews appropriations, and they -- they make decisions on what should be funded and what shouldn't. When it's apportioned, it becomes a fully executive office activity, and it's not subject to the same scrutiny.

So it's not a -- it's not popular to do that, and so I don't know whether or not Congress would choose to or not.

CHAIRMAN WOOD: We have the field perspective this afternoon offered by several individuals, and I'm very pleased to be able to introduce them to you.

Beginning to my left and going down the table is Leslie Powell from Legal Services of Greater Miami, and next is Barbara Weese, who is an AARP volunteer. She's from Leesburg.

Mr. Hugo Huapaya from the First Coach Service Options in Fort Lauderdale, and then next is Jane Rauer. She is from SHINE, which is the SHIP in Florida. She's from Hillsborough County.

And then last is Mr. Ramon Perez-Dorrbecker from the Little Havana Activity Center here in Miami. And we're particularly pleased to have all of you with us today, and I'll ask Ms. Powell to lead.

MS. POWELL: Thank you, Dr. Wood.

Good afternoon. As was stated my name is Leslie Powell. I'm an attorney with Legal Services of Greater Miami. I work on a number of issues relating to the Department and community here, including issues related to Medicaid and Medicare. I'm happy to hear the presentation, as many of you are, about the educational efforts in Medicare and hope that similar efforts are being made in Medicaid.

In my experience, although I have no statistics, the Medicaid population is probably lower educated, and with the institution of Medicaid Managed Care we certainly have some concerns that they will have difficulties making choices and understanding covered services. In fact, we have seen many of those problems already, and I hope to talk about those and some other things today.

Specifically I was asked to talk about language access and cultural competency issues, and I will also be discussing the simplification of application and eligibility processing and then the standardization of notices.

As a preface you're going to hear a lot today about burdens to providers and agencies, as well as burdens to the beneficiaries in accessing services, and I just want to be clear that in my experience the needs of beneficiaries and providers are not mutually exclusive. Those regulations which ease the process for providers can still maintain protections for beneficiaries. Beneficiaries obviously benefit if more providers participate in the Medicaid and Medicare programs in a way that allows them to focus on care and not the administrative hoops.

And on the other side providers benefit when their recipients can approach their medical care with knowledge of what their choices are, what services are available to them and including what rights they have to request a review of decisions that are made in relation to their medical care. Such solutions only allow for a more trusting relationship between the provider and the beneficiary, and I think that that really should be the goal of regulatory reform is making sure that that communication between the provider, the beneficiary and the administrating agencies is made easier and helps in that development of the relationship.

To begin with the focus on language access and cultural competency issues, as might be suggested, Miami is definitely a place where this comes up. I could share many, many stories with you of difficulties that beneficiaries have had in accessing services due to the language barriers that are there.

Clients often receive notices in English when they speak Spanish only, and we've actually had a number of cases where individuals with names of Spanish origin received notices in Spanish and don't speak any Spanish. So it's sort of -- it works both ways. There are some difficulties there.

On a more personal level we have clients who tell us they go to doctors' appointments where they can't find a Creole speaker, for example, who can translate for their doctor so their child is asked to translate very personal medical details to the doctor, and that obviously is a difficult position.

So these issues are important to the community here, just basically the ability to communicate clearly, effectively and accurately about healthcare decisions.

In response to Executive Order 13166, the Department of Health and Human Services has recently issued detailed guidance on language access issues. Prior to that, also as a response to that Executive Order, in August of 2000, CMS sent a letter to state Medicaid directors encouraging them to incorporate the Executive Order guidance and reminding states of available funding to pay for interpretation and other language access services.

To date, only five states have agreed to accept that matching funding. States should be encouraged by CMS to accept this additional funding in order to provide interpreters and written translated notices and educational material. This could clearly bridge the gap allowing beneficiaries to better understand the services that are available to them and also to improve their medical care.

Formal regulations enforcing the steps detailed in the Executive Order are also necessary, and failure to enforce would not only be fiscally responsible, but enforcement allows this guidance to let beneficiaries fully receive the benefits available within Medicaid and Medicare.

In addition, data collection, which details each individual's primary language, is essential to ensure that each person gets a notice in their primary language and also to compile statistics to ensure that proper written translation and provision of services is made in prevalent languages.

There was some discussion of the dual eligible issue, and that in particular does affect the population in South Florida. There are a lot of dual eligibles down here, including with the buy-in programs, and it -- to have those explained in the prevalent languages would also be a useful requirement.

Moving on a little bit to managed care issues, many of these issues about language access are prevalent in the new managed care regulations, the Medicaid managed care regulations, which are in the pipeline and I understand may be coming out within the next -- or the final regulations may be coming out within the next few months.

We regularly see clients who are enrolled in an HMO without their knowledge. They don't know how they were enrolled in that HMO and not the one that they had already been participating in. When they attempt to disenroll, they can't find an operator through the enrollment hotline who speaks their language.

I have had reports, although I don't do much Medicare work myself, that similar problems have happened with disenrollment and informational seeking done through the 1/800-Medicare hotline, that they've asked to be transferred to a Spanish operator and have not been -- that has not happened. Either they've been disconnected, or there wasn't one available.

These new Medicaid/Medicare -- Medicaid managed care regulations need to make clear that providers and administering agencies communicate with individuals in their primary language so that continuity of care and services are not affected.

Multi-lingual outreach and education is also important. It's not easy for anyone to deal with HMOs, especially disabled and elderly recipients of the programs; therefore, CMS must mandate and fund well-developed outreach and educational efforts. Detailed plan descriptions should be made readily available for each recipient.

A few years ago in our office we had a training by the -- the agency that runs the hotline, the Medicaid managed care hotline in Florida. They came to our office and discussed the plan descriptions and the process for clients enrolling in managed care, and when we asked for a copy of the plan descriptions, we were told it wasn't public and it wasn't available to us.

The following year we requested an updated training, and we were told that funding for such outreach was no longer available, either, and my thoughts are that if the advocates for the clients can't get this information, then how are the recipients supposed to get it, and there really needs to be a focus on making sure those plans are made available in -- at a level, at a literacy level that the individuals can understand. For beneficiaries to have actual choice they must have an opportunity to review the plan in their own language.

Sort of as an aside to the language issue, I do have some concerns about the direction taken and the proposed regulations for Medicaid managed care. The most recent proposed regulations seem to have removed some of the protections that were available under general Medicaid regulations and under the Medicare Plus Choice regulations for managed care.

For example, the proposed regulations fail to define that a failure to act on a request for services in a timely manner is an appealable action. This means that someone requests a service, they don't hear anything from the HMO. They are actually given appeal rights to determine why they weren't responded to, whether that was an actual denial of service, and that is something that should be addressed in those regulations.

I am hopeful that this process of regulatory reform will not attempt to further limit the individual rights under Medicaid and Medicare as it appears that those proposed regulations have done.

CHAIRMAN WOOD: Could you please wrap up for us.

MS. POWELL: Sure. The other two issues, just to sum, is that there -- I would like to congratulate the Department and CMS on its implementation of the children's health insurance program and the eligibility processing for Medicaid of pregnant women.

They have minimalized and simplified and streamlined the process from what were very lengthy applications to a one to two-page application by removing the asset test and the asset verification. It's reduced the administrative burden. It's reduced the administrative cost, and it's also reduced the burden on the recipients of the benefit.

And I would also like to congratulate the use of standardized notices and the beneficiary notices initiative through the Medicare program which is -- really, they're excellent steps toward simplifying the understanding that's necessary for the beneficiaries in their ability to access the services.

And to hit a little bit on what Dr. Crosby has -- had stated in her questions to Ms. McMullan, provider education and beneficiary education are really the keys. When those two things work together, when all sort of interested parties can communicate, I think that that's really the -- should be the focus of the regulatory reform effort.

CHAIRMAN WOOD: Thank you.

Ms. Weese.

MS. WEESE: Thank you. First of all, I'd like to say how glad I am to be here today, and I'm a little bit shaky after seeing that 65-year old woman this morning. I wasn't quite sure I was going to get unconfused enough to come back this afternoon.

I have a number of many of the same statistics that were just given by Ms. McMullan, so I'm going to skip down to a few other things. Let me just sum that up by saying number one, education; number two, education; number three, education is what we need in all of these things, and, yes, there are an awful lot of people out there who are not well educated enough to take advantage of what's going on.

There is another large group of people out there who were very well educated, were very, very coherent, but especially in Florida have passed the age of 80, and many of those people find themselves now needing help from someone to interpret their rights and their -- and their use of Medicare.

As a former middle school teacher I want to tell you half the eighth graders can't read on the eighth grade level, and I -- I don't want to disparage high school teachers, but I don't think they learn it before they leave there. I think that level is very high to expect as a literacy level for the average American. I could say I'm a snob from New York and our standards are a lot higher than Florida, but that's okay.

One of the top challenges these beneficiaries who've all been told their statistics is to get the information that they need, and I'm going to give you some of my experiences with this. It was mentioned that many of them are in a crisis situation when they want the information because their health plan pulled out, and, boy, do we see that in Florida, or they need a nursing home right away for themselves or for a relative. If you ask them to locate their Medicare handbook, they tend to get a bit testy. Yes, they remember having one; no, they can't locate it, and what are you going to do for them.

We in AARP in Florida get a lot of calls from seniors of -- I think they think we're kind of an oracle, that we know all these things and at our fingertips, have all this information, so usually we suggest, you know, get their handbook out and we'll help them with that.

This is a special concern here in Florida where nursing home problems have been so pervasive, disgustingly pervasive. I went on the Website before I came here to check out the homes, nursing homes in my county and found the information helpful, and I found it easy to read, but then I have a master's degree, too, but in many cases the last inspection of that nursing home was a year old or close to that, and I understand they're done annually.

In my county, Lake, I found out that there are 17 nursing home beds per 1,000 persons over the age of 60, and those figures, of course, do not include the younger disabled people.

I can also tell you in Lake County that a great many of those people over 60 are a lot over 60. We have many more seniors than we have children in Lake. It's a big retirement area. All those northerners came down, and they don't want to go home, including me.

AARP in Florida has made nursing home a top priority. We certainly did last year, put almost all of our efforts into a nursing home reform bill. We need to know about all problems, both those found in the annual surveys and those found when surveys -- surveyors investigate specific complaints.

Complaint investigations can reveal problems just as serious as those found in the annual surveys, and I'm going to tell you right here last year, although it was denied all over the place, we had person after person tell us they had overheard in a nursing home someone being called, saying that an inspector would be arriving within a week. I don't know what that means to you, but I know what it means to me.

Now, here's another thing. I have two people I'll tell you about, and I hope your stomachs are strong. Both of them felt that their loved ones, one a husband, one a father, were in great nursing homes. They touted them. They told wonderful service they were getting. They were both going to the nursing home every day.

One of the women became ill herself and now can only go visit her father two, maybe three times a week. I happened to encounter her at a meeting after she had just returned from the nursing home, and to say that she was near hysteria would be putting it mildly.

She went in and found her father at noontime sitting in a urine, feces-soaked wheelchair and obviously had been there for quite awhile. She immediately got a CNA and demanded attention. She got the attention and her father was cleaned up.

She was complaining bitterly about this, wanted to know how this could possibly have happened, and she was told by the staffer that if she wanted to make sure her father -- he did have sores when it finally came out -- didn't have sores, then she should check him when she came in, to which she replied, AI have never seen my father in his underwear, and if I walked in this building and started checking my father personally, he would be devastated.@ So she went home and called the Ombudsman. Now we hope something will come out of that.

The other woman who thought her husband was getting great care was so impressed because every day when she went there at the same time he was dressed, and she thought now, boy, talk about a level of care. He's dressed. He's sitting in a chair. This is wonderful. That was until the day that she was called by the nursing home that he'd been hospitalized, and she arrived there to find out that he had very, very severe sores from neglect and concluded that one of the reasons he was probably dressed every day and sat up -- now, obviously, these men were not communicating, but not an awful lot of people in nursing homes communicate well, even if they can communicate. They depend totally on others.

So I don't know, but something's got to be done about that. We felt staffing -- staffing education, more staffing. Then there's the problem if you are -- do not speak English and the staff only speaks English, and then there's the other problem, if you don't hear well and you only speak English and the staff members have a strong accent, you can't understand them, either, and that could be any kind of an accent, including the New York accent.

These are things that we know are extremely difficult and extremely difficult to fix, but that doesn't mean that we don't have to keep looking at them and fix them.

We have to keep going on with all of this and trying harder to make our nursing home and community-based services, which we heard about this morning and I was gratified to hear, about these programs this morning because all of us know that that is another avenue that has to be fully researched and fully implemented.

Many of our people don't need a nursing home, but they go simply because there is not available service for them, and we have a lot of -- believe it or not, it's hard to realize in Miami, but Florida has a great deal of rural country, and the services, as in every other state with rural country, whether it's doctors or hospitals or nursing or staffing or anything else, are very limited, compared to more metropolitan areas.

CHAIRMAN WOOD: Could I ask you to wrap up.

MS. WEESE: Yes. So we tell everybody to call SHINE, actually, if they have problems that sound like they're easily solvable.

I did hear about the Medicare 1/800 number and some other people alluded to that. I had several people, when I asked them to call that, tell me, AI called, but they're always busy.@

I think we have to understand, too, that a lot of our older people are really older people, are short-tempered because they're frustrated. They know that they're not receiving and comprehending information the way they did 10 years ago, sometimes five years ago. They know they depend on other people, and so anything that we can do to bring this more down to a more personal one-to-one level, whether it's going out and talking to people, having resources available at our agency, a person to answer the phone maybe who specializes in this type of a client, is something that is extremely needed, and we're very aware of that here in Florida.

Thank you.

CHAIRMAN WOOD: Thank you.

Mr. Huapaya.

MR. HUAPAYA: Good afternoon, Mr. Chairman, and thank you for the opportunity to address the Secretary's Advisory Committee on Regulatory Reform with my observations from the beneficiary communication and education perspective to improve Medicare.

I will address these observations on four points. First I will describe how regulatory and legislative complexities can create and cause obstacles or may further some beneficiary interaction with Medicare. Secondly, I will give you some examples of regulations and procedures that are complex, lengthy or burdensome for beneficiaries. Thirdly, some of the challenges we have in educating and informing beneficiaries about Medicare and its complexities. And fourth, practical and specific solutions.

Number one, regulatory legislative complexities are received from beneficiary feedback. This is in personal comments that I get when I address the media, the public, beneficiaries in person through the media and the press. My personal observations are as follows. The examples for regulations are detailed under the coverage, specifically, eligibility issues, payment issues and beneficiary and provider interactions.

For example, on the eligibility there's a seven-month enrollment period that can be daunting for some people to understand that they can't wait a year and five months before they can enroll in Medicare Part B if they choose not to take it initially.

Secondly, for disabled people they may have to wait 30 months to be in Medicare because Social Security has a five-month waiting period that's mandatory before they receive the first check. In addition, they will have to wait the 24 months of receiving disability benefits before they're in Medicare, and it becomes effective the following month. So we're looking at 30 months before someone with disabilities can be on Medicare. I understand from our Social Security partners that some of the people actually expire before they become entitled to Medicare.

Lock-in periods that became available or in effect this year can add to some of the confusion because there's a particular procedure to follow if someone wants to change an HMO. They most enroll in the second one so that that will automatically disenroll them from the first. If they don't follow that procedure, they can be left in a position where they cannot enroll in another HMO, and they will have to be in original Medicare. They need to be well informed of this particular detail.

Payment issues. I was just talking previously about getting into Medicare, the pre-Medicare section. This is during Medicare. To getting services, for example, a beneficiary may be asked to sign an advance beneficiary notice, or ABN. This notice might be technically and legally correct, but it doesn't get the message across. Some people are confused about you may -- this may or may not be covered, and there is no set amount of what you may or may not have to pay.

After the Medicare services they may receive a Medicare Summary Notice, and the language might be, again, technically correct and legally correct, but the message doesn't get across. Many people don't understand when they hear you have met the $100 deductible, they really don't know what that means.

So compound that with fragmentation of services, that is, receiving services and calling different agencies, organizations for these services, on questions they may have about bills, for example, supplemental insurance policies or who they go to for what.

We talk about the third item, and that's a challenge of educating and informing beneficiaries about their Medicare benefits and rights. The way I separate the audience is that first let you know that beneficiaries are not one audience. They're a diverse group of people that are English or non-English speaking with limited English proficiency.

Also, there might be active or passive learners. This, in addition to other sub-populations that are just physically hard to reach, they might be disabled and also in rural areas. And another part of the audience, caregivers or healthcare professionals. For the English and non-English we try to reach the French Creole speaking, the Chinese, Russian and Spanish in South Florida.

For the active learners and passive learners that are culturally diverse it is imperative to know how to address the information so that they would understand it. Basically want to give them the information in the format that they need, in the language that they understand and prefer. Some of the disabled are patients with mental deficiencies that rely on caregivers, and some of them have literacy issues. That's why it's important to address the caregiver in education, the information outreach.

Now, some of the proposed solutions I believe are practical and specific. First, make regulations easier for -- and simplify things for Medicare. Make it easier for beneficiaries to enroll. Make MSN, the Medicare Summary Notice, and the Advanced Beneficiary Notice easier to understand and use more plain language.

As an example, to say a service is 24/7 doesn't really translate well, whereas, if we say any time every day, this is better understood.

Increase outreach to caregivers. We partner with the Social Security Administration, Florida Medical Quality Assurance and the with Department of Elder Affairs SHINE program. We address several groups of people that we can -- by partner with the shared resources, and they can receive official Medicare information before they need it.

These are the pre-retirees, these are people that are not in Medicare yet. They need to know about the enrollment periods. This is also the next wave or large well-informed demanding beneficiaries, the need to have the information, again, before they need it.

I'd like to address the under served population need face-to-face communications. We propose to have expanded partners and advocacy groups to reach people, and some of these groups are the Centers for Independent Living, Goodwill, National Federation of the Blind to address specific targeted disabled groups.

And two more items, innovative communication vehicles, such as partner with national public radio, Public Broadcasting Service. This will use radio, TV, close-captioned and Webcast to a large number of people. This will be, of course, the English-speaking active learner beneficiaries.

Look at what MPR and PBS have done for helping kids understand just basic information. We can do this for the adults. New partnerships that can help Medicare beneficiaries and caregivers is the target with MPR.

For disabled, specifically nationwide radio reading service. This will reach not only the blind or low vision, but the print-impaired, dyslexic, homebound and people with mobility impairments.

First Coach partners with 10 radio reading stations in Florida. We reach thousands of peoples with CMS-produced public service announcements that they broadcast on test stations in Florida. They reach a specific targeted group.

For example, WLRN in Miami has almost 10,000 radios, and this is broadcast on a subchannel so that information is reached to a very targeted group.

Lastly, one thing that would help beneficiaries that are non-English-speaking is to have concurrent translations of beneficiary publications. This would help with timely delivery of the information, and instead of having sequential preparation from English to Chinese or Spanish, we will have current -- concurrent translations that will offer timely information.

Want to thank the Advisory Committee for the opportunity to address these issues. Thank you.

Ms. Rauer.

MS. RAUER: Good afternoon. I'm the State of Florida's volunteer coordinator for SHINE, serving the health information needs of elders, one of the 53 SHIP programs throughout the United States.

I'd like to first express my thanks to CMS for the wonderful relationship that we have with our regional office in Atlanta and with Baltimore. They have provided the SHIP program with wonderful technical support and on a timely basis.

As SHINE team members we face some very challenging problems on a daily basis as we work with the elders in Florida, and particularly here in the Miami-Dade County area. We were able to serve approximately 100,000 reported clients last year. Most likely that number was even greater. We expect that we'll be able to capture that this year as we have been introducing the new national client intake form that helps us capture the information.

One of our greatest challenges in the area of our counseling is in the prescription drug problems. Well over 50 percent of our clients' inquiries deal with elders asking us for help with this most pressing issue. They cannot afford the high cost of drugs. Counselors deal with client frustrations as they try to help the elder clients resolve this most compelling problem.

Florida has faced HMO terminations for the past four years that have affected 250,00 elders in this State, leaving many elders with no available HMO coverage in many of the state's 67 counties. Elders here in Miami-Dade have been somewhat more fortunate than their rural counterparts, but they, too, have experienced change in their benefits that their plans cover and in what they must provide for themselves out-of-pocket.

Marketplace changes have made healthcare difficult for our elders as they cope with providers leaving plans for business reasons which forces our elders to secure new physicians and medical facilities that not only present a transportation challenge for them, but one of a personal nature as these elders now have to establish new relationships with new providers.

In the rural areas there's no available public transportation, and in the urban areas elders sometimes face the problem of public transportation being inaccessible or unreliable, causing frustrations and stress for the frail and sick. Even though that is not a problem that SHINE can assist with, we are able to usually forward that elder on to another agency that might be able to help them with transportation.

SHINE works diligently with limited resources to continuously educate our SHINE counselors. These individuals work on a one-to-one basis with elder clients in solving or reaching an agreeable compromise on a health insurance problem.

In addition, SHINE counselors make presentations to elder groups apprising them of their Medicare benefits, as well as the rural community health clinics and the service that they provide to seniors and the communities they serve. In the urban areas we educate them on the availability of community health clinics and their types of services.

We educate the elder veteran on services available in their veterans affairs clinics and hospitals. Educating elders on QMB/SLMB, or the Medicare buy-in programs, make them aware of the benefits available that can help them if they meet the eligibility criteria. This program, folks, is one of the best kept secrets.

We have to dispel the myth of being on the dole if you apply for QMB/SLMB. Accepting assistance of this nature is of the hard sell. Pride is everything with these elders. They are the product of the Depression era, and they maintain strong views on being independent. Perhaps a new method of enrollment would capture more of the eligible individuals. Publicity of the program's value done on a national level may also increase awareness of its value and take away the handout taboo.

Within each area of this great State we have cultural diversity issues, and Miami is representative of the melting of many nationalities and cultures. SHINE has had to find ways to make sure that the elders are made aware of the services that we have available to them.

SHINE has tackled the problem of culture diversity by educating and certifying SHINE volunteer counselors who are bilingual, as well as being a member of a specific cultural group. Peers working with peers. We have recruited volunteer counselors from the Hispanic communities, the African-American communities, the Asian-Pacific Rim communities and the Creole communities here in Miami-Dade.

SHINE has 19 counseling sites available in Miami-Dade to help the elders with their health insurance issues. We continue to pursue the Native American communities to avail themselves of our service.

We continue also in our effort to educate the blind, deaf and physically challenged individuals, both those over 65 and those under 65 eligible for Medicare about their Medicare benefits, as well as what other programs and services are available to them.

Other areas of the State have the same kind of challenges as they have here in Miami-Dade, as well as different ones.

SHINE must address the issue of