FOCUS GROUP OR INTERVENTION?
PUBLIC RESPONSES TO COST
EFFECTIVENESS INFORMATION
Shoshanna Sofaer, Dr.P.H.
School of Public Affairs
Baruch College
OVERVIEW
Background
Research Questions
Design for study public responses
Methodological issues
June 3, 2007
Shoshanna Sofaer, Dr.P.H.
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BACKGROUND
Other members of the Research Team:
Marthe R. Gold, M.D., M.P.H., Sophie Davis
Medical College, City University of New York
Taryn Siegelberg, M.P.A., Sophie Davis
Medical College, City University of New York
Peter Franks, Ph.D., UC Davis (statistical
analysis)
June 3, 2007
Shoshanna Sofaer, Dr.P.H.
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BACKGROUND
Cost effectiveness analysis is used in other
developed countries as an input to coverage
decisions, particularly for new technologies.
In the US, it has been assumed that it will
be unacceptable to the public and many
senior officials have made it clear that it
will not be used, for example, in making
decisions for the Medicare program.
June 3, 2007
Shoshanna Sofaer, Dr.P.H.
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BACKGROUND
Concerns about the use of cost effectiveness
analysis (CEA) seem to be related to three kinds
of concerns:
The sense that it will be viewed as a form of rationing,
and therefore unacceptable on its face
The backlash against managed care plans which were
perceived as making individual decisions about
“medical necessity” on the basis of the cost of the
treatments and tests in question
The real ethical and normative issues that inevitably
arise when using CEA
June 3, 2007
Shoshanna Sofaer, Dr.P.H.
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BACKGROUND
However, there has been virtually no
empirical research conducted to confirm the
existence and nature of concerns about CEA
The purpose of this studies, therefore, was
to conduct exploratory empirical research to
examine these issues
June 3, 2007
Shoshanna Sofaer, Dr.P.H.
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RESEARCH QUESTIONS
Our first study conducted (with support from
AHRQ) focused on the responses of members of
the public. We will discuss this study today.
A second study conducted (with direct support
from the California Health Care Foundation and
indirect support from The Commonwealth Fund’s
Harkness Fellowship Program) focused on the
responses of key decision makers in the public and
private sectors in California.
We are presenting findings of that study on Tuesday
morning.
June 3, 2007
Shoshanna Sofaer, Dr.P.H.
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RESEARCH QUESTIONS
With respect to the public, questions were:
Can members of the public gain a basic understanding
of CEA?
Do members of the public recognize, and how do they
respond to, ethical and normative issues related to
CEA?
Are members of the public willing and able to take on a
“social decision maker” role and set hypothetical
priorities for coverage of particular treatments by the
Medicare program?
June 3, 2007
Shoshanna Sofaer, Dr.P.H.
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RESEARCH QUESTIONS
More questions for the public:
When presented with cost effectiveness information
about a range of treatments for particular conditions,
are people willing and able to set priorities such that
some are not covered?
Do their priorities change when they receive
information not only about treatment effectiveness, but
about treatment costs, cost effectiveness, and impact on
the Medicare budget?
How do they respond to the opportunity to be involved
in this kind of deliberation on priorities for coverage?
June 3, 2007
Shoshanna Sofaer, Dr.P.H.
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DESIGN & DATA COLLECTION
Participants: members of the public chosen
from the jury pool in Manhattan;
demographically diverse; had to have very
basic math skills
Pair of focus groups/workshops, two weeks
apart: six pairs, two with people whose
education level was high school or less
June 3, 2007
Shoshanna Sofaer, Dr.P.H.
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DESIGN & DATA COLLECTION
First session:
Presentation of information on health care costs
in the US
Discussion of possible drivers of health care
costs -- ideas generated first from the group
with additional ideas presented by researchers
Presentation and discussion of what CEA is,
with a focus on the calculation of Quality
Adjusted Life Years (QALYs) and CE ratio
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Shoshanna Sofaer, Dr.P.H.
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DESIGN & DATA COLLECTION
First session, continued:
Presentation of hypothetical “choices” among different
treatments or treatments for different groups of people
designed to elicit ethnical and normative concerns that
arise in the context of CEA, including
The rule of rescue
The concept of ‘fair innings”
The issue of personal responsibility
The potential for discrimination against those already quite ill
or with disabilities
The relative value of improvements in quality of life v.
extension of life
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Shoshanna Sofaer, Dr.P.H.
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DESIGN & DATA COLLECTION
At the end of the first session, participants given a
list of 14 treatment/condition pairs, which were
described in lay terms
Descriptions incorporated available information
about the effectiveness of each treatment with
respect to the Medicare population
Participants asked to put on a “social decision
maker” hat and, as a homework assignment,
identify 5 treatments they would definitely fund, 5
they would probably fund, and 4 they would not
fund
June 3, 2007
Shoshanna Sofaer, Dr.P.H.
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DESIGN & DATA COLLECTION
Second session:
Review of CEA
Presentation of aggregate responses to the 14
treatment/condition pairs
Discussion of areas of consensus and dissensus
in the responses
June 3, 2007
Shoshanna Sofaer, Dr.P.H.
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DESIGN & DATA COLLECTION
Second session, continued:
Distribution of information about the CE ratios
associated with each of the 14
Second round of priority setting (individually)
Elicitation of new priorities
Discussion of reasons why people did and did
not change their priorities in response to the
information
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Shoshanna Sofaer, Dr.P.H.
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DESIGN & DATA COLLECTION
Second session, continued:
Distribution of information about the impact coverage
of each treatment would have on the Medicare budget
Charge to group to presume a constrained budget that
would require that at least some treatments not be
funded
Identification of a member of the group as a facilitator
for next segment, which was
Attempt of group (with no participation from
researchers) to build consensus on what to fund and not
fund
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Shoshanna Sofaer, Dr.P.H.
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DESIGN & DATA COLLECTION
Second session, continued:
Final discussion, questions, etc.
Quantitative component:
Pre-group survey, with questions about attitudes drawn
in part from existing public opinion polls on health care
issues
Post-group survey, with same questions, more questions
about the use of CEA, plus questions about the group
and the idea of having members of the public
participate in setting coverage decisions in Medicare
June 3, 2007
Shoshanna Sofaer, Dr.P.H.
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DESIGN & DATA COLLECTION
Analysis:
Groups videotaped, transcribed, and key
sections coded using NVivo
Surveys analyzed using traditional descriptive
and inferential statistics (not n was not large)
Calculation of the cost implications of priority
setting decisions and changes in those decisions
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Shoshanna Sofaer, Dr.P.H.
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METHODOLOGICAL ISSUES
In many ways, this looks like a focus group
study, with these features:
A more extensive pre-group survey
Exercises using “stimulus materials” and that
generated data that could be quantified
A much more extensive post-group survey
Thus, the process of data collection was
HIGHLY integrated
June 3, 2007
Shoshanna Sofaer, Dr.P.H.
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METHODOLOGICAL ISSUES
However, a lot of “education” was done in
these groups
The education could be considered an
“intervention”
Even the discussions and the exercises
could be considered an “intervention”
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Shoshanna Sofaer, Dr.P.H.
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METHODOLOGICAL ISSUES
So in what ways is this a focus group study, and in
what ways is this a study that uses key elements of
focus group methodology as the basis for carrying
out an intervention and measuring its impact?
Note, however, that the impact is discerned not
just through quantifiable results of surveys and
exercises, but through classic qualitative analysis
of discussions (both moderated and unmoderated)
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Shoshanna Sofaer, Dr.P.H.
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METHODOLOGICAL ISSUES
Questions for the audience:
Is this a qualitative or mixed method study?
What is the potential of this kind of method
within health services and policy research,
especially vis a vis exploring the views of
members of the public on key issues?
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