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Topics: Health

Community Meetings Shape Oregon Health Plan, continued

Index

Story: Citizens Create Dialogue on Values in the Oregon Health Plan

Case Study Plus: Common Purpose in Health Policy. Report of Focus Group Meetings, March 1994: a 33-page report by OHD that includes an account of focus groups conducted by OHD to aid the Health Services Commision in determining how citizens feel about 2 issues: a) whether practice guidelines will be useful within the priorities list established by the Oregon Plan; and b) whether availability and access to some medical technologies should be regulated and managed in a way that reduces cost and redundancy, or for other reasons.

Case Study Plus: A 10-page overview of Oregon Health Decisions from its origins in the early 1980s through the community meetings in 1990.

Contents

Case Study Plus: Common Purpose in Health Polic

Acknowledgments
Part One: Executive Summary
Part Two: Categories of Values
Part Three: Demographics
Part Four: Meeting Structure
Part Five: Method

Common Purpose in Health Policy

by Oregon Health Decisions

Conducted for The Oregon Health Services Commission, and The Oregon Health Resources Commission Report written by Michael J. Garland, Barry F. Anderson, Paula A. McNeil March 1994

Acknowledgments

Oregon Health Decisions is profoundly grateful to the forty-seven Oregon citizens who contributed their time and ideas to make this report possible. Carl Sandburg wrote in one of his poems, "The people is a polychrome, a spectrum and a prism." Our program participants were just that. Through thoughtful discussions, they made visible the many shades and colors hidden in the seemingly simple light of community values.

We give special thanks to the "people finders" who helped us locate, contact, and convince our participants that these meetings were worth the inconvenience required to be there. Amy Aycrigg, Cam Camburn, Cindy Scoggins and Sally Timm spent countless hours on the phone getting names, making contacts, explaining, making arrangements, and answering questions. They were helped in this work by a statewide team of guides who identified possible participants: Gay Abdon, Frances Alvarado, Amy Backman, Omar Barbarosa, Rick Bardway, Holly Berry, Don Bowler, Tom Brawley, Gary Capps, Tanya Collier, Michelle Dahl, John Duke, Kevin Fitz, Gregory Fowler, Nellie Fox, Kathy Garland, Thelma Golden, Jan Hare, Candyce Hayes, Heidi Hobby, Juanita Hodges, Louann Houda, Mary Jaeger, Denise Johnson, Ruth Johnson, Cheryl Kennedy, Sharon Laws, Nan Lenhart, Mimi Luther, Don McClave, Laurie McFarland, Danielle McNack, Patrick McNeil, Sandra Millius, Chris Neilson, Noi Nguyen, Al Nunez, Billie Odegaard, Pat Oliver, Ed Parrot, Ellen Pinney, Liesell Schaedig, Loretta Slaughter, Babs Smith, Ann Sola, Bev Stein, Willis Steinberg, Stephanie Thomas, Lori and Don Vinson, Zonya Watts, Betty Duffy Wetzel, Laurie Wilcox and Elaine Yang. The Office of Research Development and Utilization, Oregon Health Sciences University School of Nursing, was generous in its assistance with the computerization of demographic data for this project.

A very special thanks is owed to the Health Services Commissioners, the Health Resources Commissioners, and their respective Executive Directors, Paige Sipes-Metzler and Daniel Harris. Their commitment to democratic process brought this project to life, gave it focus, and will ultimately make it meaningful by integrating the results into their public policy work.

Oregon Health Decisions is particularly delighted to continue its working relationship with the Health Services Commission which began in 1989 when the Commission took on the perplexing task of creating a prioritized list of health services. The model of public involvement in health policy developed then continues to attract inquiries from health policy leaders worldwide. We believe new opportunities abound for applying this model to the work of health care reform now challenging the nation. By continuing the partnership between state commissions and the citizenry, Oregon further demonstrates practical ways for the public to help shape policies that so fundamentally affect the life of society. We know health care reform can grow out of common purpose and be much more than the surviving ideas left standing after warring special interests have exhausted their forces. By collaborating with these two commissions, Oregon Health Decisions shows again how common purpose can be identified and made relevant to public policy decisions. We take grateful pride in being part of the process.

Part One: Executive Summary

The Meetings. Oregon Health Decisions conducted five focus group meetings between February 15 and March 3 in Portland (2) Salem, Bend and Ashland. The focus group method consists of a structured group interview in which participants provide answers to a prearranged set of questions designed to develop information desired by the client, in this case the Health Services Commission and the Health Resources Commission. Forty-seven citizens participated in the meetings. Michael Garland and Barry Anderson facilitated the sessions and, together with Paula McNeil, reviewed the results of each meeting and analyzed all the data.

The Issues. The Commissions wanted to have the following questions addressed by a selected sample of Oregon citizens. (In italics following each question, we provide brief summary answers drawn from the focus groups.)

1. The Health Services Commission (HSC) will use the information in reporting to the legislature on whether practice guidelines will be useful within the context of the priorities list. To this end the HSC wants information about the following:

Whether people will object to the use of practice guidelines?

No, but participants emphasized their concern that special attention should be paid to basic human values of respect and equity in the way guidelines are developed and implemented.

Whether people will see practice guidelines as improving the quality of their care?

Yes, this is a clear hope of participants who believe that carefully constructed and administered guidelines might contribute to the sense of security patients have in the health care system.

Whether people will see practice guidelines as interfering in their relationships with their physicians, nurse practitioners, mental health professionals, and other health professionals?

Participants see this as a potential problem to be addressed up front and built into the process of selecting, promulgating, and evaluating guidelines. Participants particularly feared that guidelines might create an assembly line mentality in health professionals or a restriction of professional judgment and innovation.

2. The Health Resources Commission (HRC) will use the results in designing and developing a technology assessment program to address the introduction, diffusion and utilization of medical technology. Within the context of values concerning health care technology, specifically its costs, availability of, and access to it, its clinical and cost effectiveness (quality and effectiveness dimensions) and the relative importance/significance of each of them (the values associated with each of these dimensions in relation to/relative to each other), the HRC wants information about:

Whether people believe that availability of or access to some medical technologies should ever to be controlled/regulated/managed by public or private efforts because of cost, duplication/ over supply/ redundancy, questionable or uncertain effectiveness, availability of less costly alternatives, or any other reason?

Yes. This belief was strong and consistent throughout the meetings and participants appealed to all of the above reasons to justify controlling availability of and access to medical technologies.

Whether people will like or object to having their access to medical (and/or the medical technology available to them) technology regulated/ influenced, affected by public policy that favors:

technology of known effectiveness (proven technology) over new and possibly more effective but not yet fully proven technology?

Yes. Participants favor controls driven by effectiveness, but also value a reasonable capacity for technical innovation.

cost effective technologies over less cost effective technologies (or less costly technologies that are as effective or almost as effective as more costly technology)?

Yes. There is a strong value for efficiency in technological and program development and distribution.

What values do people want policy makers, including public and private sectors, to consider (balance, take into account) when deciding about:

The supply (how much? what kind?)

Values focus on pursuit of health for individuals and the community as a whole, realistic assessment of health needs, and foresight in meeting evolving needs.

and distribution (where?) of medical technology

clinical site—e.g., academic research center, regional referral center hospital, smaller hospital, clinic, doctor's office.

Participants value well-honed skills and believe that high technology tools in inexperienced hands can be of little use or even dangerous.

community setting—e.g., major population center, regional population center, "close to where people live", every community, communities that have the necessary clinical infrastructure, etc.

Participants value the efficiency and effectiveness gained by concentrating high technology services and programs and felt that explicit attention to the transportation consequences of distribution decisions could provide for equity for persons living in remote sites.

3. Both Commissions want to know in reference to both practice guidelines development and medical technology supply and distribution decisions, whether people prefer public entities (state agencies, commissions, legislators), technical experts from relevant fields, providers (e.g., health systems and integrated networks, physicians, and hospitals), or payers (e.g., insurers or health plans) to make and practice guidelines?

Participants showed no doubt in the need for commissions to call on relevant experts in developing policies in these complex issues. They felt it is important for commissions to recognize that experts can bring biases or narrow focus and that the commissions should carefully seek out a variety of experts so input will be appropriately balanced.

Whether people will want to play a role/have a voice in the development of practice guidelines, and in making availability, access, supply and distribution decisions and policies (regardless of who else is involved)?

Yes. Participants believe there is an important role for the public to play that can enhance the political legitimacy and effectiveness of this process. They emphasized the importance of the experience of health problems that the public brings to the consideration of these issues.

Whether people will applaud the intent of using health resources judiciously and how they define "using resources judiciously"?

Yes. It is a strongly held hope and desire of participants that this intention can succeed. "Judicious use of resources" means decisions aimed at producing efficiency in the system, improving equity, and contributing to the health status of the community.

The Values

The following table summarizes the categories of values found in the participants' discussions across all the meetings.

Basic Human Values

Personal and Community Health Values

Economic Values: Spending Wisely

Political Values: Common Purpose

The Application

How can values expressed by the participants be used by the commissions to accomplish their work? We recommend that the commissions use the device of checklists to connect these public values to their specific policy tasks. We offer two sample checklists here that can be used and modified by the commissions.

Purpose and Use of the Checklists. The purpose of the checklists is to make it easier for the commissions to apply public values to decision making. Each of the checklists is considerably shorter than the full list of values, and each focuses directly on a particular category of decision the commissions have to make.

The checklists are qualitative aids to decision making, not quantitative ones. They can be used to bring to mind, and ensure consideration of, values that were brought up at the focus group meetings. However it would be inappropriate to regard them as quantitative judgments regarding tradeoffs, that is, judgments as to whether a benefit on one value is sufficiently great to justify a cost on another. Quantitative judgments as to whether a given impact is significant and how it trades off against other impacts must be made by the Commission.

The checklists should be used as follows:

1. Early in the discussion of any commission decision the relevant portion of the checklist should be consulted.
2. Each Commissioner should consider, for each value, whether the decision could have a significant impact on that value. When asking this question, it is important to think about the entire public and to think well ahead into the future.
3. If the decision could have a significant impact on a value, that value should be included in the Commission's deliberations, and the final justification of the Commission's decision should make explicit reference to that value.

Refinement of the Checklists. What we have provided are sample checklists to get the commissions started. We are neither the public nor commission members. Our role is to link the commissions with the participants in the focus group meetings. It is important that each commission member look behind our efforts and become directly familiar with the expressions of values on which the checklists are built.

To this end, the two appendices that give detailed lists of ideas expressed at the meetings should be read through, annotated, questioned, thought about, and interpreted. These lists retain, nearly verbatim, the words used by the participants to put their ideas before one another and before the commissioners. The commissioners, by immersing themselves in the lists and interacting with them, can deepen their grasp of what the participants were getting at and refine the checklists in ways that will make them both truer to the public's values and more useful in making policy decisions. These refined checklists will serve as systemic reminders of the values identified by the focus groups and will link directly to the way each commission approaches its decisions.

Sample Checklist A—Deciding about the Usefulness of Practice Guidelines

Would practice guidelines add any benefit to the prioritized list?
Are there specific lines on the list for which guidelines could add benefit?

1. Could guidelines enhance the respectful treatment of patients?
2. Could guidelines improve patient security?
3. Could guidelines enhance equity among persons with various health conditions?
4. Might guidelines lead to improved health of the community?
5. Could guidelines reduce medical waste?
6. Are we minimizing bureaucratic waste?

B. Decisions/Values to Bear in Mind

What sources of practice guidelines are most appropriate?

7. Are we consulting appropriate experts?
8. Are we preparing to give these guidelines maximal legitimacy and political effectiveness?

C. Decisions/Values to Bear in Mind

How can we measure the benefits of practice guidelines?

9. Can we determine their potential impact on the health of the community?
10. Can we measure the impact of guidelines on equity among persons with different health problems?
11. Can we determine whether guidelines affect the depth and focus of skills of practitioners?

Sample Checklist B—Deciding about Technology Allocation

Whether to Evaluate

1. Consider chronic, as well as acute, conditions.
2. Focus on real needs.
3. Consider preventive programs as well as treatments.
4. Consider costs of non-treatment.

B. Decisions/Values to Bear in Mind

Whether to Introduce

5. Consider alternative ways to address the same condition, including nontraditional ones.
6. Consider the effect on access.
7. Consider the use of outreach programs.
8. Consider the effects on those with special communication needs (language, sensory loss).
9. Consider effects on safety.
10. Make sure that the care is appropriate to the condition (e.g., misuse of Emergency Rooms).
11. Consider the integration of tools, programs, and guidelines.
12. Consider the fairness of the process.

C. Decisions/Values to Bear in Mind

When to Introduce

13. Consider effects on existing programs.

D. Decisions/Values to Bear in Mind

Where to Locate

14. Consider transportation needs.
15. Consider the availability of qualified providers.
16. Consider the opportunity for providers to maintain their skills throughout frequent use.
17. Consider the effects of market forces on distribution and pricing.
18. Consider equity.
19. Consider local autonomy.

E. Decisions/Values to Bear in Mind

How to Use

20. Consider coordination with in-home services and educational programs.
21. Consider communication needs.
22. Consider involving a wide range or professionals.
23. Consider the coordination of those professionals involved.

Part Two: Categories of Values

The meetings produced a rich array of ideas. Some of them were clearly expressed as values the participants believe the Commissions should bring to bear on their decisions about planning, implementing and evaluating their policies. Other ideas are beliefs held by participants about how the health care system works. We have arranged the themes into four groups to make it easier to follow the thought of the participants. Some ideas were expressed by several of the groups, others came up in only one or two meetings. We have built the list out of responses to the whole range of five questions that structured the meeting process. This list speaks to the concerns expressed by the public about the work of both Commissions.

Basic Human Values—Respect and Fairness

In this group we bring together those hopes and concerns that touch on the fundamental sense of human worth and dignity that participants voiced when thinking about the tasks of the two commissions. It is clear that the participants think that policies can and should be judged by the way in which they contribute to or harm these dimensions of human life in community.

[1] Respect for personal worth, values, and knowledge

Participants quite consistently raised concerns about the ways in which the experience of seeking and getting health care can give evidence of respecting their basic human worth and dignity. This came up in various ways in most of the meetings and focused on the importance of feeling empowered by the transfer of information, by the communication skills of providers, by provider's attention to them as members of a cultural or linguistic group, a religious tradition, a person with special needs, as persons or families with distinct values and preferences, as persons whose life experiences gave them an important knowledge base. This value would be served by attending to the capacity of guidelines to promote providers' efforts to enter into collaborative relationships with patients. It would be hurt by guidelines that created greater time pressures on providers.

[2] Equality and fairness in access to health care

[2a] basic equity

Participants identified a wide range of equity problems that might arise in the course of devising guidelines and distributing resources around the state. They are aware of the risks and benefits of inputs from both experts and the public. It will be important to attend to the process by which these decisions are made so that they can be seen and defended as fair to all the subgroups that make up our state community.

[2b] ability to pay

One of the most obvious concerns of the participants was the way in which efforts to control health care expenditures can intensify inequities that are based on the unequal distribution of wealth among our fellow citizens. The value of equity, they observed, will be served by respecting the freedom of the well off to get services they want while not making things worse for persons who cannot easily find the resources needed to secure basic care.

[2c] language and culture

Problems involving language, culture, and a broad range of communication difficulties were identified as potential barriers that may be helped by guidelines and distribution policies that take them into account, and exacerbated by failure to attend to them. The example was given of a program aimed at increasing access to primary care for women in migrant labor families by providing van transportation to the clinic. Many women stopped using the van and going to appointments when they realized that they might be alone in the van with a male driver—a culturally unacceptable occurrence.

[2d] geography

Distribution of technology and programs around the state could improve equity for people in rural areas if transportation and regional program integration were factored into the policy. It would be made worse if policy fails to factor these in and attends only to population factors in deciding how and where to distribute costly technologies and programs.

[2e] freedom of choice

Participants felt that these approaches could lead to a restriction in the freedom of patients to get care from the providers of their choice including alternative and unorthodox providers. On the other hand policies could enhance freedom by allowing for a wide range of providers based on licensed scope of practice.

[2f] equity among health conditions

The commissions could enhance equity by attending to chronic as well as acute conditions and to those forms of health care that seem to have "second class" status in the system, e.g., mental health, dental health, vision care.

Personal and Community Health Values

[3] Pursuit of Health

Participants expressed many values that associate directly with health status, both of individuals and of the population as a whole. Keeping access to services and technologies that prevent disease, contribute to the health status of the population, and meet real health needs should be primary. The danger of rationing health services should be frankly acknowledged and policies should seek to minimize this risk. The health status of the population as a whole was felt to be an important outcome by which to evaluate policy decisions regarding the use of guidelines and the rational distribution of resources.

[4] Using good data

Participants value the contributions of technical experts to the acquisition of data about the health care system, effectiveness of services, financing, social organization, and the like. Similarly the experiential data and values information available through public participation were seen as important sources to include in the development of health policy. Both of these sources were also seen as capable of bias and therefore ought to be thoughtfully and critically consulted.

[5] Focusing on real needs

The importance of thoughtfully targeting real health needs of the community in policy choices was a consistent concern of the meeting participants. This concern pointed to the belief that both experts and the public have critically important perspectives to help maintain this focus.

[6] Keeping what works

Throughout the series there was a clear sense that guidelines and distribution policies need to be careful to not interfere with those parts of the health care system where effective and efficient work is now being done.

[7] Community preparedness to meet needs

[7a] breadth of tools and programs available

A clear value was evident in many discussions: people believe that the health care system should have a varied array of "tools in the toolbox" in order to take care of the array of problems and tasks that arise. This sense of equipping the system to be a flexible and effective responder to health problems was seen to be a primary challenge of health policy.

[7b] depth and focus of professional skills

A companion value to the concept of a "good set of tools" was the value of professionals appropriately skilled in using the tools. Participants felt that this value works itself out in policy decisions that aim at integrating programs through regionalization and layering of professional skills.

[7c] foresight

Participants emphasized the value of rationally attending to long range benefits of programs and services by using a wide array of values and costs to judge the utility of policy decisions.

[7d] integration

Focus group discussants felt that the work of both commissions would gain by seizing opportunities to coordinate efforts, making distribution decisions more equitable and efficient by also developing guidelines relating to the use of costly technologies and the more ordinary care levels that precede utilization of "high tech" interventions.

Economic Values—Spending Wisely

[8] Paying for Real Benefits

Participants felt that the work of the commissions can contribute to greater rationalization of the health care system leading to appropriate levels of care in appropriate settings, making greater efforts to secure health dividends in return for investments in equipment and programs, and reaping the benefits of effective primary and preventive services.

[9] Efficiency

Members of the focus groups believe that greater accountability in health care professions and institutions, greater rationality in resource allocation, and delivery reform (managed care) can reduce system costs, rather than merely shifting them around.

[10] Avoiding Bureaucratic Waste

Participants were consistently concerned that the commissions' work might be diverted and nullified by mistaking wasteful bureaucracy for organizational accountability.

[11] Avoiding Medical Waste

Participants felt that significant waste is found throughout the health care system and that the work of the commissions can reduce its impact. Drug pricing, overuse of certain procedures, requirements for the latest technologies (without evidence of need or effectiveness), and the "free lunch" mentality of well-insured consumers were all identified as appropriate objects of attention.

[12] Fair Pricing

Participants consistently expressed hope that the commissions' work would control health care inflation but expressed considerable ambivalence about how to succeed, some favoring regulation, others favoring market discipline through competition.

Political Values—Common Purpose

[13] Legitimacy and Political Effectiveness

Participants felt strongly about the value of bringing many people into the policy process to increase the legitimacy of the policy, the breadth and depth of considerations on which it is based, and the possibility of mobilizing local insights, commitment, and resources for dealing with the challenges which the commissions face.

Part Three: Demographics

The Commissions requested that Oregon Health Decisions attend to certain demographic interests in recruiting participants for the meetings. In response to the Commissions' categories, OHD recruited focus group participants representing: a mix of rural and urban citizens; the major geographic sections of the state; multiple ethnic groups; a spread of socioeconomic strata, including homeless citizens; people with and without insurance and Medicaid clients; persons with physical and mental disabilities; persons who have little as well as great needs for health care; a full spectrum of age groups; and as close to a 50-50 balance of men and women as possible. A total of 47 citizens participated in the meetings. Demographic data from the focus groups are summarized in the tables below.

Participants' Counties

Clackamas 2
Deschutes 10
Jackson 5
Josephine 1
Linn 1
Marion 6
Multnomah 13
Polk 2
Washington 7

Participants' Cities

Bend 10
Hubbard 1
Jacksonville 1
Keizer 1
Grants Pass 1
Colton 1
Albany 1
Gaston 1
Ashland 3
Lake Oswego 1
MKedford 1
Portland 17
Salem 5
St. Paul 1
Tigard 2

Ethnic group

Afro-American 3
Asian 8
Caucausian 30
Hispanic 5
Native American 1

Age Distribution

17-19 3
20-29 7
30-39 11
40-49 10
50-59 7
60-69 2
70-79 4
80-89 2
no info 1

Income Distribution ($ in thousands)

0 3
10-19 8
20-29 5
30-39 5
40-49 9
50-75 8
> 90 2

Gender Distribution

Male 25
Female 22

Third Party Coverage

                        Yes     No Medicaid             	9	36 Health Insurance	39	7 

Part Four: Meeting Structure

Barry Anderson and Michael Garland facilitated all the meetings. Paula McNeil coordinated arrangements for all the meetings and attended all sessions as an independent observer.

Introduction. Participants filled out demographic questionnaires as they settled around the table prior to discussion. They then introduced themselves giving some "bit of information that would help other participants understand who is here." After the introductions, Garland described the context of the program and plan for the meeting, using the flow chart below to explain the purpose and elements of the focus group project.

The chart indicates that the discussions from the five focus groups will be the basis for the report to be prepared by Oregon Health Decisions for the two commissions which will combine this data with information solicited from various technical experts to produce their reports for the Legislature and the Governor. The image at the bottom of the chart symbolizes the links which connect members of the public with the development of health policy.

[insert chart here]

Questions and Discussion. After the introduction, Anderson and Garland facilitated the group's responses to the questions derived from the Commissions' identification of issues. For each of the questions a flip chart page was displayed on the wall in front of the participants so everyone could see where the discussion was headed and where it had been. The pages had two columns, one for "positive" thoughts, the other for "negative" thoughts responding to the question. Pages were labeled (1) TREATMENTS, (2) TOOLS AND PROGRAMS, (3) CONTROL HEALTH $, (4) ASK EXPERTS, (5) ASK THE PUBLIC. Off to the side of these pages was a blank sheet for "Hold that thought" ideas that didn't seem to fit categories under discussion although their relevance might become clearer through discussion later in the meeting.

Participants' ideas were recorded on the note sheets after checking to be sure that the wording accurately captured the thinking of the participant who proposed the idea. The questions were read to the group in sequence as worded below. Discussion of about fifteen minutes followed the reading of each question. Probes were introduced as the discussion proceeded.

Question 1

The Health Services Commission has already created a list that puts health services in priority order. Now the Commission is looking at what physicians, nurses, psychologists, physical therapists and other professionals actually do when they treat patients for their problems or try to help people stay healthy or prevent more serious problems by treating them early.

When you think about a government Commission proposing guidelines that might affect what these professionals do in patient care or preventive measures, what positive and negative thoughts come to mind?

• Probe for hopes that guidelines might improve quality of care
• Probe for fears about intrusion into relationships between patients and health professionals
  • autonomy
  • innovation, creativity
  • new treatments
  • "unorthodox" treatments

Question 2

The Health Resources Commission will come up with a plan for the Legislature to follow in creating a way to control the tools professionals have available to them and the very complicated service programs they can refer patients to when they treat them. The Legislature is particularly concerned about being able to spend health care dollars carefully when it comes to distributing new and very costly tools and programs around the state.

When you think about a government Commission helping the Legislature control health care spending in this way, what positive and negative ideas come to your mind?

• Probe for meaning of "spending carefully"
• Probe for values, hopes and fears associated with the fact that different communities in the state might experience different levels of
  • availability
  • access
  • inconvenience
  • cost

• Probe for values about community settings
  • major population center
  • sparsely populated areas
  • equality among different communities

• Probe for values regarding special clinical sites
  • academic research centers
  • regional referral hospitals
  • clinics and physicians' offices

• Probe for whether participants think differently about commissions' decisions affecting government decisions versus private corporations.

Question 3

Both commissions have been asked by the Oregon Legislature to help design ways to use dollars spent on medical care more carefully.

When you think about money you might spend on health care, your own, your insurance company's, the government's, what positive or negative reactions do you have to this effort by Oregon government?

• Probe for values people have in mind when they hear "spend more carefully".

Question 4

In accomplishing their tasks, each of the commissions will have to decide how to go about making their decisions. The commissions will call on experts, e.g., adopt policies developed by others, seek technical consultants, hold hearings, conduct polls, or use other approaches. When you think about how such decisions might be made, what positive and negative thoughts come to mind?

• Probe for "government agencies" making decisions, e.g.,
  • commissions
  • legislators
  • administrators ("bureaucrats")

• Probe for providers making these decisions,
  • physicians
  • hospitals
  • health systems and integrated networks

• Probe for payers making decisions, e.g.,
  • insurers
  • health plans
  • integrated health systems
  • government programs (like Medicaid)

Question 5

Both commissions will look for ways to get members of the public to participate in their decision making process. When you think of people like yourselves participating in these decisions, what positive and negative thoughts come to mind?

• Probe for different ideas about guidelines versus technology assessment.
• Probe for ideas about "having a voice", "participating".

The Dot Exercise

Toward the end of the meeting, participants were asked to look over the five sheets and place a dot next to any item in the "positive" or "negative" columns. Each participant received ten dots and were told to use the dots to send a message to the commissioners that says, "As you do your work, try hard to make sure this (positive idea) happens, and that this (negative idea) doesn't happen." As participants placed their dots, any new ideas that came up were noted on the sheets. After the exercise was complete, further discussion explored new ideas and final thoughts of the participants.

Finally the meeting concluded with the assurance that the two commissions were eager to hear the participants' responses to their questions. Participants were invited to sign up to receive a copy of the project report.

Part Five: Method

Discussion. Focus Group discussion was the central method of this program. In this method, the client identifies several key issues that are to be discussed with selected members of the public. The client also identifies the segments of society that are to be invited to participate in the group interviews.

The dynamic element in the focus group process is small group discussion of specific questions. (We limited our groups to ten persons.) The process seeks to get ideas clear and relevant to a specific question. We attended particularly to the values involved in answers to questions the commissions wanted to have addressed. The process pays very close attention to helping participants find words that best convey what they have in mind. Often, other members of the group assist the process by asking for clarification, or offering variations in wording, or questioning whether the facilitators have accurately captured an idea. Participants often find that they are able to better express thoughts which did not come out clearly at first. The facilitators contribute to this clarification since expressions are checked with participants as they are recorded on the note sheets. Keeping all note sheets visible to the participants throughout the meeting allows them to review and refine ideas, particularly as they consider related issues while answering each of the succeeding questions. This work creates a strong sense of joint effort and shared vision among participants.

Accumulation. After each meeting, Garland transferred the meeting notes from flip chart sheets to computer files. Notes were recorded mostly verbatim with occasional explanatory additions. Copies were distributed to McNeil and Anderson for review within a week of each meeting. Their review allowed them to keep previous meetings fresh in mind as they prepared for subsequent meetings and determined whether one or other question needed special attention.

Analysis. On the basis of the content of ideas coming from the early meetings, Anderson and Garland developed several categories of underlying values into which items from the meetings could be sorted. Using a consensus method, Garland, McNeil, and Anderson sorted all items from all meetings immediately after the last meeting in Ashland. Further sorting and refinement of the categories was accomplished by Anderson with review and revision by consensus between Anderson and Garland. This work led finally to the four main groupings into which the thirteen value categories are divided in this report.

Synthesis. The last step of the process was the creation of the checklists presented in the executive summary of this report. Anderson, McNeil and Garland analyzed the entire list in detail to identify specific issues that relate to several questions the commissions have to answer to complete their tasks. Anderson and Garland further revised these after discussions with Daniel Harris and Paige Sipes-Metzler, executive directors of the two commissions.

Caveat. Focus group method is very effective for extracting information about values from members of the community. Because of the relatively small numbers involved, however, the method does not contribute much to the public policy task of building community around the issues. Policy questions affecting common resources, such as health care, raise important challenges for political will in the community at large. Oregon Health Decisions hopes and recommends that both commissions will continue to reach out to the general community seeking both to extract needed information and to stimulate political will and commitment needed to make well designed policy achieve its optimum effect.

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