Resource Center
Planning Health Care Focus Groups? Pack Your Scuba Gear.
By Ariella LaBell
Have you ever noticed the way backroom viewers' eyes light up when they learn something significant or unexpected from their customers? Clients' fascination with participants' colorful and uninhibited expressions often reminds me of curious children admiring tropical fish during a visit to an aquarium.
Like aquariums, focus groups give us a chance to view a hidden world. But these days, we can't count on easily snaring respondent insights. Particularly in health care, we're seeing more and more that consumers, besieged with verbal, print and television advertising on the state of health care, are telling us what they hear rather than what they really think.
To reach the depths of discovery often required in health care research, it takes more than snorkeling fins. You have to use your scuba gear.
Getting to the Truth
In research we often refer to the qualitative questioning technique of asking The Five Whys. In its literal sense, the expression suggests an interviewer should ask a question and then follow-up the participant's response with "Why?" and "Why?" again a total of five times to get to the root cause of a concern or behavior. In practice, The Five Whys is a reminder that you can't always take the first answer as the answer. It is important to confirm understanding of participants' responses with more open-ended probes.
Particularly in patient satisfaction and health plan disenrollment research, moderators must have a firm understanding of the common "untruths." For example, having conducted research with both Medicare HMO disenrollees as well the marketing directors trying to retain them, we have learned members frequently cite cost as the primary reason for disenrolling from their current health plan and switching to another. However, we learned that if you follow up with disenrollees to find out where they went, somewhere close to 50 percent actually move to more expensive plans.
What this shows is that while a member might initially associate the reason with cost, it may have actually been perceived lack of value, service issues, or physician selection that truly caused the member to switch. The appropriate approach would then be to solicit more details about the participant's experience to better understand the true issues leading to disenrollment. The immediate answer, and often the simplest, is not always the right answer.
Cut Through the Bias
After conducting focus groups with the entire spectrum of players in the health care industry - suppliers, providers, payers, employers and consumers - you get a very clear picture of some the current and future patterns in the delivery of health care. One common characteristic in particular adds to the complexity of conducting focus groups: frustration with managed care and reductions in reimbursement.
No segment of the health care delivery chain is unaffected by the whirlwind changes in the industry. For example, frontliners of the industry like hospital clinical managers and physicians have over the last few years been learning to juggle cost and quality. The complexity of seemingly commonplace discussions such as medical product selection and purchasing is magnified by the fact that empowerment to choose preferred products and suppliers has been rapidly slipping through the hands of the traditional customer and into those of the economic customer, like purchasing managers.
So, as a moderator, anticipate that topics like managed care or government cutbacks will tend to elicit a negative knee-jerk reaction. For example, not all physicians feel prepared for the changes in health care that require them to recalibrate their habits, practices and attitudes. It then makes sense that the physicians who are reluctantly confronting this reality tend to come into a related discussion with negative sentiments. You can sidestep this hurdle first by thinking through your line of questioning to ease participants into a potentially controversial discussion. Second, acknowledge and empathize with the challenges participants face. Consider using your warm-up questions to allow participants to vent their concerns, thus enabling you to later shift the discussion to the critical client objectives.
Not surprisingly, much consumer sentiment mirrors what we hear from the provider side. Over the last few years, consumer focus groups have revealed an increased level of concern about the direction in which people perceive our health care system is headed. In fact, a recent American Hospital Association focus group study1 highlighted the U.S. consumer's growing skepticism of the "corporatization of health care." The lay press has further spread cause for distress by featuring articles on anecdotal "drive-through deliveries" and surgical horror stories.
This means that we moderators have a tough crowd with whom to discuss health care issues. How do you talk with seniors not currently in an HMO about a new HMO product when much of what they read about managed care is negative? What about talking to local residents about an impending merger of two hospitals, when fumbled mergers in the banking industry have bred consumer pessimism?
This is not to say all focus groups about health care will take a negative slant. We have heard very positive comments from extremely satisfied HMO members. Still, the first step is carefully considering the flow of the discussion guide to prepare for potentially controversial topics. Make your way through the thicket by approaching the same critical questions or issues from a couple different angles throughout the discussion. This can help discern the difference between biased initial resistance and true product or concept shortfalls. Take note of how respondents open up or change their minds during the discussion, because this can help your client overcome the same issues in the marketplace.
Facilitate to Articulate
There are times when moderators are challenged with discussing a topic to which participants do not normally give much consideration. For example, testing advertising concepts with a group of internal medicine sub-specialists. As physicians, these types of participants tend to be very focused, left-brained thinkers who rarely are engaged by advertising. When asked point blank to compare two advertisements, physicians might give responses like, "It's okay," or "Good." These answers won't help your client or agency creative director eagerly watching behind the glass.
When charged with this task recently, our firm designed a progression of questions to facilitate a more enlightened discussion on medical product advertising. First, we showed concept boards for the client's new campaign (without revealing the client's identity) to gain initial reactions. It was clear that the group was having a difficult time articulating what they liked about the ads and how the ads compared to others currently running. Then we asked participants to imagine the sponsor of these ads was an automobile manufacturer and identify which manufacturer that would be. This enabled us to get down to participants' real feelings and move beyond strictly literal comments we might traditionally hear.
Free association (such as asking participants to compare the image of the client's product to something commonplace like cars), written exercises and other creative techniques can really make the difference in the way your participants articulate their thoughts. Also, factoring down these types of topics into incremental discussion steps frequently yields more insightful and articulate comments than head-on questioning.
In talking with consumers, the difficulty lies in the fact that participants sometimes are misinformed or don't understand how health care really works. This gives us a challenging balance to maintain; we must help respondents articulate intricate ideas without biasing their opinions or putting words into their mouths. For instance, when consumers say they are looking for quality health care, ask them how they define quality. What is quality? I have heard everything from industry accreditation, to a doctor with good listening skills, to a full waiting room (if this many people go to him, why shouldn't I?) The point is, there is a lot of confusion we need to sift through to better understand what our participants really mean in their response.
Exploration or True Discovery
Some focus groups are nothing more than straightforward concept testing or brainstorming sessions. Group discussions are often a great intermediate checkpoint with customers for member retention or to stay ahead of the industry curve. However, when taking on anything that requires a more refined level of detail, remember to pack your scuba gear. It can make the difference between mere exploration and true discovery.
1 "Eye on Patients: A Report to the American Public." American Hospital Association and The Picker Institute. (January 27, 1997). Obtained from an AHA report press release.