Focus group, dog and pony show, or both? Early Results from Health Connector FOIA
If government agencies had nothing to hide, perhaps they would follow public records laws.
I’ve written before about how non-responsive state agencies can be to public record requests, and in particular to requests dealing with Evergreen Solar, and it now appears somebody has been listening. Eight days after my blog post on the delayed Evergreen Solar request, and just 175 days after it was originally filed, I finally received 66 pages of responsive documents. The Executive Office of Housing and Economic Development kindly waived potential fees.
Shortly before that I received the results of another overdue request, this one to the Commonwealth Health Insurance Connector for the results of early focus groups the state used to shape the simple Gold/Silver/Bronze selection now enshrined in law. As Pioneer’s Interim Report Card noted (PDF, see pages 9-10) , this effectively reduced consumer health care options in 2010:
The Connector conducted focus groups with consumers purchasing in the non-group market and found that consumers generally wanted fewer, more meaningful product choices. That, in combination with the Board members’ overall belief that standardization is important in a managed-competition environment, prompted the Connector to reduce the number of options available to consumers through the Connector this year.
If these focus groups were so important in drafting how health reform was implemented, the hope would be that they were professionally handled to achieve the most honest – and useful – possible outcome. I have not yet had a chance to go through more than a fraction of the responsive documents, but already there is enough to give an outside observer pause. For example let’s take a look at the input of Jon Kingsdale, former executive director of the Commonwealth Health insurance Connector Authority and reportedly now advising the Department of Health and Human Services on a federal exchange, and a number of other states on implementation.
Here is the e-mail he sent in advance of one of the employee focus groups, with my own emphasis added, some staff names retracted, and edited for language:
I just looked at K–‘s guide and it sucks. I presume you did not look thru it before handing me a copy. As far as I can tell, it is the employer focus group guide and it is entirely inappropriate for employees and for what we want to test.
I don’t think there is anything you will be doing over the next month that is higher risk than the focus groups on November 7th. We will only get this one crack at them and if K– f***s up, we’re f***ed. You need to spend some serious time with K– this week, getting him to understand what we need. This cannot be done hands-off.
Now then, what we need to do this night is to test the status quo (“Employer’s Plan”), where typically a small employer who offers insurance—and some 25% of small employers do not even offer their employees any insurance—picks one health benefits plan from an insurance company and offers to pay for part of that plan e.g., HPHC Bronze with Rx. Depending on whether they’re buying single, two-person, or 3+ family coverage, the employee of a small business that does offer insurance typically is asked to pay somewhere between about 20% and 50% of premium. For example: give names and household size to the 4 employees; vary contribution percentage by family size, and show employee contribution for Bob (young, single), Mary (youngish childless couple), Henry (middle-aged and family of 3+) and Jane (spinster). Employer pays 80% (single) and 60% (family). Use round premium numbers e.g., single=$300, 2- person=$600, 3+family = $900 per month. So:
Bob (25) pays $60
Mary (33) pays $240
Henry (45) pays $360
Jane (60) pays $60
Ask what they like or don’t like about this; in particular, how do they feel about Mary and Henry paying different amounts than Bob and Jane for the same plan, but Bob and Jane pay the same amount for this plan, even tho Jane is likely to use services a lot more than Bob (given their ages).
Now explain alternative to be tested: “Employer’s Plan + Choice”
Show Bronze tier and highlight HPHC w/Rx.
Show employee share at same contribution formula, if everyone picks HPHC:
$60, $240, $360, and $60
Now show employee contributions separately for Bob—one slide—if he picks NHP, Fallon, THP, HPHC, or BCBS; separately for Mary, separately for Henry, and separate slide for Jane.
Now put all 5 choices for all 4 employees together on one slide.
Then ask, which they prefer—(1) Employer’s Plan, or (2) Employer’s Plan + Choice
Then go into a bunch of questions about why? How they would go about choosing? What support would they need to shop? How do they feel about Bob and Jane paying very different amounts if one stays with HPHC and the other picks Fallon or BCBS. How would they feel if each of the 4 picks a different plan e.g., NHP, Fallon, HPHC & BCBS, and pays a very different amount than the others?
This is going to take a lot of your time and K–‘s full attention. I would suggest that you have K– do a complete dry-run of the focus group, using a few of us a participants, before Wednesday night. Please see that he does this really well the first time in front of Rick, Nancy and Celia. Thank you –Jon
Later on, writing directly to “K–“, Jon continues:
I know K—- will be talking to you soon about the discussion guide and preparation for the employee focus groups on November 7th.
I just want to emphasize how high risk these focus groups are for us. A few of our board members, who would dearly love to kill this idea on the basis that it is too confusing, will be observing. This is live-or-die for us. Please make this go very, very smoothly.
First, we are only testing Option 3 against the status quo; second, we need to “dumb” the info down to what the employee needs to know—not all the age-rating, employer contribution, etc. k—- can guide you here, but we want to see a revised guide that is thought thru for this audience ASAP.
I think that you should completely re-think and simplify the presentation. I have already shared with K—- and R—some thoughts for how to do this, and K— will be talking to you about it. Beyond re-doing the guide, please plan to do a dry-run with several of our staff “playing” employees before you get into the room Wednesday night. THIS HASD TO GO RIGHT THE FIRST TIME!
Avoiding complexity and unexpected outcomes is a noble goal, but perhaps not at the expense of actually honest focus groups. One has to wonder, if these focus groups were so important, why they were managed so closely by the Connector instead of by an unbiased third party.
Asking repeatedly how focus group members feel about others paying different amounts for insurance, would seem to lend credence that the Connector had a policy outcome in mind before they even started.
Again, this is a sample selected from what I have read so far: I’ll be taking a more comprehensive look at the focus groups and their results in the weeks to come, and welcome any questions you think warrant further investigation.