People enrolled in Medicare often turn to family members and friends for help in making health decisions, including Medicare health plan choices. To learn how family members and friends participate in decisionmaking, what information they currently use, and what information they would like, we held eight focus groups in San Diego and Baltimore. Although responses were different in the two markets, participants in both cities reported receiving inadequate information and indicated they were largely unaware of available CMS-supported information. Beneficiaries want easy-to-use print materials targeted to their needs and opportunities to participate in seminars and receive personal counseling.

OBJECTIVETo provide an overview of reasons why qualitative methods have been used and can be used in health services and health policy research, to describe a range of specific methods, and to give examples of their application.DATA SOURCESClassic and contemporary descriptions of the underpinnings and applications of qualitative research methods and studies that have used such methods to examine important health services and health policy issues.PRINCIPAL FINDINGSQualitative research methods are valuable in providing rich descriptions of complex phenomena; tracking unique or unexpected events; illuminating the experience and interpretation of events by actors with widely differing stakes and roles; giving voice to those whose views are rarely heard; conducting initial explorations to develop theories and to generate and even test hypotheses; and moving toward explanations. Qualitative and quantitative methods can be complementary, used in sequence or in tandem. The best qualitative research is systematic and rigorous, and it seeks to reduce bias and error and to identify evidence that disconfirms initial or emergent hypotheses.CONCLUSIONSQualitative methods have much to contribute to health services and health policy research, especially as such research deals with rapid change and develops a more fully integrated theory base and research agenda. However, the field must build on the best traditions and techniques of qualitative methods and must recognize that special training and experience are essential to the application of these methods.

An overview of (1) key trends shaping the healthcare environment and market; (2) ways in which these environmental trends are reflected in changes in the organization and delivery of healthcare; (3) the implications of environmental and organizational changes for older Americans; and (4) the research issues that can be addressed using organizational and behavioral theories. This introductory article sets the healthcare scene for the articles that follow.

Background: Initiatives on the part of many groups to provide American consumers with information about the quality of health care may have several goals. Symbolic aims include recognizing consumers, increasing the sense of accountability, providing reassurance about health care quality, and emphasizing quality. Instrumental aims include improving system performance, increasing satisfaction with care and/or plans, and reducing random plan switching. These efforts may have both good effects and bad effects.Benefits and risks: The possible positive byproducts of consumer information initiatives are learning about consumer preferences and variations, learning how to help consumers use health plans and providers, changing consumer-provider relationships, and building an infrastructure of consumer-centered intermediaries. Possible bad effects are generating demands that cannot be met, skewing the system to certain consumers' preferences, discouraging consumers from using information, adding another new program that will die, contributing to biased plan selection, and decreasing trust in providers.Discussion: Before health care professionals can gather evidence about outcomes signaling success, they must address several major issues. How should high-quality performance be defined and by whom? Whose vision will be embedded in these definitions? Will it be the consumer's vision or the patient's vision that will be maximized? How long will it take before expected consequences occur? A strategy to measure success calls for beginning immediately to develop consensus on outcomes and a ''theory of action'' specifying the pathways and timing for different players.

A system of analysis addressing predictors of management outcomes in Cranial Base Surgery has yet to be published. We therefore report data on seventy-nine consecutive patients undergoing surgery for tumors involving the cranial base, excluding patients with the diagnosis of pituitary microadenoma. Outcomes were defined prospectively in terms of completeness of tumor resection, complications of treatment with emphasis on neurological morbidity, and return to work or independent living. Also, preoperative features are analyzed as influencing cost of treatment, estimated in terms of the number of surgical procedures required, duration of hospital and Intensive Care Unit stay, and time taken to return to work. Preliminary analysis of data reveals that severe brainstem compression, large tumor size (average diameter > 3 cm), high cavernous sinus grade, and tumor encasement of major cerebral arteries are associated with incomplete tumor resection (p < 0.05). Patient age greater than 65, preoperative Karnofsky Performance Score (KPS) less than 80, and severe brainstem compression are associated with increased risk of stroke (p < 0.05). Age greater than 65 and preoperative KPS less than 80 are associated with an increased length of stay (p < 0.05). Other untoward events did not occur with sufficient frequency to reach statistical significance. A model of outcomes analysis in Cranial Base Surgery is proposed utilizing a database to incorporate a group of non-operated patients and include quality of life measurements in long-term patient follow-up.

BACKGROUND:A variety of financing mechanisms and managerial innovations have been developed in the past decade to control hospital costs. Some evidence suggests that those changes have not produced substantial improvements in labor efficiency among employees in the hospital's technical level, such as in the blood bank laboratories. STUDY DESIGN AND METHODS:This study measured labor efficiency in 40 hospital-based blood bank laboratories in Southern California during the year from July 1989 to June 1990 and explored the impact of financial, managerial, and operational factors on labor efficiency. RESULTS:With standardized output measures used in all blood bank laboratories, a wide variation of labor efficiency was found. Multivariate analyses indicate that the labor efficiency of blood bank employees was not influenced by organizational financial incentives, but was affected by the managerial styles of blood bank managers. CONCLUSION:Interpretation of the findings suggests that labor efficiency is affected by operational designs intended to improve responses to variable workloads and reduce slack time.

Under a reformed health care system, what information will help consumers evaluate health care providers and plans? A member of the White House health care task force provides her perspective.

Medicare beneficiaries who enroll in ''risk contract'' Health Maintenance Organizations (HMOs) are covered for services only if they are provided or approved by the HMO. Thus, their enrollment decisions involve selecting a health care delivery system and may be influenced by whether the HMO has contracts with particular providers. Disenrollment decisions, in turn, may be influenced by breaks in contracts between the HMO and its medical groups. This study examines decisions made by Medicare HMO enrollees when their HMO terminated its relationship with a major medical group; the group then signed a contract with a competing HMO. Beneficiaries were forced to choose between remaining with their HMO and switching to another provider, and switching to the competing HMO where they could keep their provider. Beneficiaries demonstrated considerable loyalty to their providers; nearly 60% switched to the competing HMO. Previous research on health care coverage decisions has been based on models which did not address consumers' knowledge, options, and information sources. In this decision context, we found that knowledge and information sources were the most important determinants of beneficiary decisions.

Efforts are currently underway to develop a prospective payment system for inpatient medical rehabilitation. In this study, a clinically based, condition-specific patient classification scheme was developed that includes 33 patient groupings, referred to as Functional Related Groups (FRGs). Each FRG is comprised of patients with similar clinical characteristics and resource use, as measured by length of stay. From a policy perspective, the FRGs minimize the adverse incentives that may develop in the selection of patients for admission to the rehabilitation facility. The FRGs, therefore, may be used as a basis in the development of a prospective reimbursement system for rehabilitation services.

Previous studies have demonstrated that functional status is a significant predictor of resource utilization for rehabilitation patients. Before implementing a prospective payment system (PPS) for rehabilitation, it is important to first: 1) develop an underlying conceptual framework of rehabilitation resource use; and 2) understand how the role of functional status may vary by rehabilitation condition. In this study, a theoretical model of rehabilitation is presented that proposes relationships between patient and provider characteristics, rehabilitation treatment, costs, and clinical outcomes of rehabilitation. Also presented are regression analyses based on this model for a key outcome of rehabilitation, change in functional status, for nine rehabilitation conditions using variables that minimize adverse incentives by providers in selecting patients for admission to rehabilitation. The change-in-functional-status model explained the most variance for back injury, cardiopulmonary, and arthritis, and less variance for stroke, spinal cord injury, and neurologic impairment. The significant predictors of change in functional status varied by condition. Results support the use of functional status measurements in a PPS for rehabilitation services, the need to refine the measurement of functional status, and the use of condition-specific activities of daily living (ADL) items to include in summary indices.

Research Article Health AffairsVol. 12, No. suppl 1: Health Reform Informing And Protecting Consumers Under Managed CompetitionShoshanna Sofaer AffiliationsHealth care services at the George Washington University Medical Center in Washington, D.C.PUBLISHED:1993No Accesshttps://doi.org/10.1377/hlthaff.12.suppl_1.76AboutSectionsView articleView Full TextView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions View articleTOPICSQuality of careAccess to careManaged competitionHealth care providersPremiumsPrimary care providersOrganization of careHospital qualityOut-of-pocket expensesMarkets Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 16 History Published online 1 January 1993 InformationCopyright © by Project HOPE: The People-to-People Health Foundation, Inc.PDF downloadCited byConsumerism: OverviewNavigating Poorly Charted Territory16 November 2016 | Medical Care Research and Review, Vol. 66, No. 1_supplConsumerism: OverviewDeveloping a Spanish-language Consumer Report for CAHPS® Health Plan SurveysThe Joint Commission Journal on Quality and Patient Safety, Vol. 33, No. 11Consumers of Health Information and Health Care: Challenging Assumptions and Defining Alternatives26 August 2016 | American Journal of Health Promotion, Vol. 18, No. 2Establishing geriatric health centers: can the aging network successfully navigate the changing healthcare system?Journal of Aging Studies, Vol. 17, No. 2Not Afraid to Blame: The Neglected Role of Blame Attribution in Medical Consumerism and Some Implications for Health PolicyThe Milbank Quarterly, Vol. 80, No. 1The Theory and Practice of Disclosing HMO Physician IncentivesSSRN Electronic JournalManaging Medical Technology: Lessons for the United States from Quebec and France22 June 2016 | International Journal of Health Services, Vol. 30, No. 3Consumer Responses to Health Plan Report Cards in Two MarketsMedical Care, Vol. 38, No. 5Challenges for the public in negotiating the health system in the 21st centuryJournal of Urban Health, Vol. 76, No. 2Will Quality Report Cards Help Consumers?Judith H. Hibbard and jacquelyn J. Jewett24 July 2017 | Health Affairs, Vol. 16, No. 3Managed care in the public mental health systemCommunity Mental Health Journal, Vol. 32, No. 2What Type of Quality Information do Consumers Want in a Health Care Report Card?18 August 2016 | Medical Care Research and Review, Vol. 53, No. 1The FEHBP as a Model for a New Medicare ProgramStuart M. Butler and Robert E. Moffit24 July 2017 | Health Affairs, Vol. 14, No. 4Cascade or Facade: Focusing or Obfuscating the Pathogenesis of latrogenesis?QRB - Quality Review Bulletin, Vol. 19, No. 6

This article reports on a quasi-experimental test of the Illness Episode Approach (IEA), a new approach to providing Medicare beneficiaries with information about the financial consequences of alternative health care coverage decisions. Beneficiaries were randomly assigned to free, three-hour workshops, half using materials developed through application of the IEA, half using traditional comparative information on insurance options. Analysis of data collected before and after the workshops indicates that participants in the Illness Episode sessions were more likely to drop duplicative coverage, to spend less on premiums, and to report that their decisions to change coverage had met their expectations. The entire sample of workshop participants showed significant increases in knowledge of Medicare and their own insurance, as well as improved satisfaction with the cost of their health care coverage.

Lacking objective, comprehensible information about health care coverage options, Medicare beneficiaries rarely understand the consequences of alternative purchasing decisions. We describe the Illness Episode Approach, a method providing information on Medicare itself, Medigap policies, and HMOs. The method presents calculations of seniors' out-of-pocket costs under different insurance options for 13 common illnesses.

Over two-thirds of Medicare beneficiaries have private supplementary coverage, but few know enough about Medicare, their own supplements, or available alternatives to make intelligent comparisons and informed purchasing decisions. The illness-episode approach, a new way to provide insurance information to Medicare beneficiaries, calculates out-of-pocket costs likely to be faced by beneficiaries experiencing 13 illnesses, under Medicare alone and under different medigap policies. Applying the approach to six policies marketed in Los Angeles in 1986 revealed that plans varied widely in their ability to reduce financial vulnerability; many still leave the elderly with substantial out-of-pocket costs.

To examine the effect of restrictive state, federal, and private hospital reimbursement policies in California, we examined trends in uncompensated care and other deductions from hospital revenues from 1981 to 1986. During a period when the number of uninsured in California increased substantially, uncompensated care grew, but not as rapidly as other deductions from revenue, especially Medi-Cal and private-sector contractual allowances. A trend toward redistribution of uncompensated care from public to private hospitals reversed. Voluntary teaching hospitals, whose Medi-Cal and private-sector contractual allowances grew rapidly, recently reported a decline in uncompensated care. As reimbursement pressures increase, private hospitals may resist pressures to provide uncompensated care, increasing the burden on public institutions and perhaps limiting the access of indigents to quality care.

Elderly women and men have different patterns of disease and utilize health services differently. This essay examines the extent to which Medicare covers the specific conditions and services associated with women and men. Elderly women experience higher rates of poverty than elderly men; consequently, elderly women are especially likely to be unable to pay high out-of-pocket costs for health care. Using a new method for simulating out-of-pocket costs, the Illness Episode Approach, the essay shows that Medicare provides better coverage for illnesses which predominate among men than for those which predominate among women. In addition, women on Medicare who supplement their basic coverage by purchasing a typical private insurance "Medigap" policy do not receive as much of an advantage from their purchases as do men. The calculations also show that the Medicare Catastrophic Coverage Act would have had little impact on the gender gap in financial vulnerability.

To reduce Medicare costs, Medicare beneficiaries are being encouraged to enroll in "risk contract" HMOs. This paper explores the financial consequences to the elderly of joining a Medicare risk HMO. Using a new method for estimating consumer financial vulnerability called the illness episode approach, we modeled the out-of-pocket costs associated with thirteen illnesses of varying severity for beneficiaries with traditional Medicare coverage only and for beneficiaries who join one of two Los Angeles HMOs which charge no additional premium. The typical total charges for a year's treatment of these thirteen illnesses in Los Angeles in 1986 ranged from a low of $856 for moderate hypertension to a high of $28,411 for care of a severe stroke. For beneficiaries with traditional Medicare whose providers did not accept assignment, out-of-pocket costs ranged from $539 to $14,676 and from a low of 7.7 percent to a high of 84.1 percent of total charges. Out-of-pocket costs are considerably reduced in the two Medicare HMOs in this high-cost market; beneficiaries had modeled out-of-pocket costs ranging from $11 to $7,478 and from less than 0.1 percent of total charges to 60 percent of charges. Reductions in financial vulnerability ranged from over 20 percent to 99.3 percent. The relation of these reductions to altered benefit structures and the policy implications of the results are discussed.