Recently a woman in her 80s called the customer service line at Sentara Medicare Choice in a panic.
She was newly enrolled in the Virginia HMO and couldn't understand why she had been billed about $5,000 for oxygen delivered to her home.
It turned out that the woman had used her old Medicare card for the oxygen, and Medicare rejected the bill.
In response, a Sentara employee promptly called the company that sent the bill and negotiated a payment, eliminating the woman's debt. A case manager then arranged for her to be served by the HMO's home-health network.
To Kathi Saunders, customer operations manager at the 3,000-enrollee plan, the incident illustrates keys to a successful Medicare HMO: Educate enrollees, and be a strong patient advocate.
The growing business of marketing managed care to seniors-and keeping them enrolled-is a highly competitive one that stresses personal contact, physician relationships and real case management.
Doctors are playing a pivotal role in capturing and retaining enrollees. Seniors visit the doctor four times as often as younger people and, for them, leaving a trusted physician to join an HMO is the biggest hurdle.
"That (physician) relationship is even more critical to seniors than the hospital relationship," Saunders said. Easing the transition to an HMO.
HMOs are finding ways to include more physicians and to ease the transition to a new doctor.
For instance, when Sentara, a staff-model plan based in Virginia Beach, wanted to expand its territory last year, it contracted with an extra 25 independent primary-care physicians with geriatric expertise. That added to its network of nearly 100 primary-care physicians. Plan representatives help enrollees select a suitable primary-care physician during a face-to-face visit.
In California, Medicare beneficiaries usually can keep their doctors because so many physicians participate in HMOs. But Fountain Valley-based FHP Health Care, with 211,000 Medicare enrollees in the state, keeps large books with resumes and photos of its physicians at all facilities. Seniors also can call FHP for information about doctors.
Doctors make good marketers.
Medicare HMOs find physicians to be valuable liaisons for the sales force.
In Northeastern Pennsylvania, Danville-based Geisinger Health Plan used personalized letters from its physicians to encourage their patients to enroll in the HMO. The plan has grown to 3,000 enrollees since starting in April 1994, and already a competitor has joined the market.
The sales staff at Woodland Hills, Calif.-based CareAmerica 65 Plus makes regular visits to doctors' offices to explain procedures. The plan, which contracts with independent practice associations and medical groups, pays bonuses to doctors who retain a high percentage of patients.
"That encourages them to take a little more time with the seniors to explain how things work, such as why there sometimes is a time lag for an appointment. The physicians' offices, whether it's the doctor or staff, are in a pivotal position with us for retaining patient load," said Katie Conley, CareAmerica's vice president for sales.
Retention is critical in Southern California, where 14 Medicare HMOs compete. Disenrollment is about 18% to 22% a year, compared with about 12% for commercial plans in the market, Conley said. Unlike commercial enrollees, Medicare beneficiaries can disenroll with just 30 days' notice, and their choice of plans isn't limited by an employer.
Almost all Medicare HMOs in California have zero premiums and similar benefits, such as up to $1,500 a year for prescriptions.
With such competition, selling a plan becomes a job of aggressive marketing and customer service-everything from answering the phone promptly to reporting clinical outcomes.
CareAmerica, for instance, staffs its customer service and sales departments for Medicare at 2.7 times the rate of its commercial plan. Sales representatives place monthly follow-up calls after an enrollment to make sure seniors are satisfied, and they put their pictures on business cards for easy recall.
"Since there isn't a whole lot of plan loyalty.........it goes back to relationship-building," Conley said.
Competition adds benefits.
With competition comes more and more benefits. In California, PacifiCare Health Systems is pioneering free use of private health clubs for its senior enrollees during off-peak hours. And HMOs in competitive markets offer prescription drug benefits that HMOs elsewhere are only starting to explore.
FHP started in Medicare risk when the concept was launched in 1982. It offered unlimited free drugs until around 1991, when a $1,500 cap was established to control costs.
Drugs are not only a big selling point, but their managed use can be a major cost saver, FHP spokeswoman Ria Marie Carlson said. Often seniors arrive at their first visit to an HMO doctor carrying a grocery bag of drugs, some of them countereffective, she said. Some seniors without drug benefits have been known to take half-doses to stretch out supplies, Carlson said.
Changes could speed growth.
Medicare HMOs have about 7% of the Medicare market, but they are growing rapidly. Several changes in the works could foster their growth.
HCFA is considering abolishing the 50-50 rule, which says HMOs must have at least as many commercial enrollees in a market as Medicare beneficiaries. That can be a problem in areas with many retirees, such as Arizona, where FHP has had to throttle its Medicare growth.
Also, HCFA has authorized pilot point-of-service plans, which if approved nationwide could attract seniors who want the option of using providers outside an HMO network.
And HMOs are looking for ways to make benefits portable for seniors who travel or have two homes. Now, seniors must disenroll if they leave the service area for more than three months.
The country's largest Medicare HMO, Cypress-based PacifiCare, is discussing reciprocity arrangements among its plans, which cover five Western states. Also, the Blue Cross Blue Shield Association is planning a national managed-care strategic alliance, which would make benefits transferable among its plans. Fourteen of the 67 Blues plans offer Medicare managed care, and many more plan to add such products.