One size fits all? Not in health care research

Editor’s note: Sheryl Bronkesh is president and Dawn Hunter is a senior project manager of The HSM Group, a Scottsdale, Ariz., marketing research and consulting firm.

Health care marketing executives, like many other business decision makers, are often faced with the question how to best accomplish their research objectives within the constraints of tight timeframes and budgets. Many have found that qualitative research plays an important role in effectively and efficiently gathering information. Executives with a proven track record in getting timely data to make informed decisions say that knowing why and when to take a qualitative approach is a critical learning.

Quantitative vs. qualitative

Both quantitative and qualitative approaches have been successfully employed to address almost any research topic. Quantitative research involves larger-scale data gathering, requiring contact with a greater number of respondents than qualitative research. The most commonly accepted benefit of quantitative research is that it carries a great deal of power, since the findings are tested using proven statistical methods. Results can be reliably projected from study participants to the larger population. This is critical when anticipating future purchase behavior and for longitudinal studies - tracking patient satisfaction or HMO disenrollment over time, for example.

In contrast, qualitative studies delve deeper with a smaller number of participants. The goal is to discover how and why people feel the way they do, and draw out a rich level of detail about underlying assumptions and attitudes. A clear understanding of the complexity and nuances in the perspectives of a target audience can mean the difference between a product or initiative that’s almost on target and one that exceeds expectations.

Getting the most value from research dollars

We recently talked with market research experts at three prominent health plans. All said that expenditures for qualitative research are currently a small part of their entire research budgets - from 10 percent to just under a third. Yet qualitative approaches can be extremely effective in extending the dollars invested in quantitative research. Frequently, an initial qualitative exploration can ensure that the right questions get asked in a later quantitative phase. In other cases, qualitative results may allow researchers to scale back or even eliminate quantitative research. “The marginal cost for not doing qualitative research and just quantitative studies is way too high,” says Joe Wilds, director of market research and assessment for The Regence Group in Portland, Ore. “Qualitative will steer you in the right direction, or in some cases even solve your problem.”

Quantitative studies are almost always more expensive than qualitative research. The scope of the research, target population and number of completes required for statistical analysis dictate the study design. Many of the variables in the quantitative cost equation, such as response rates and incentives needed, can be difficult to predict at the outset. The costs of qualitative research, in contrast, are easier to anticipate and manage.

Wilds believes that qualitative research can help health plans control research costs while at the same time obtain the most useful information. “In some cases it may be better to spend $20,000 on focus groups, rather than $100,000 on a quantitative study that might be too narrow in focus and not deliver all the results you need or expected. Qualitative research costs are predictable and more modest, and in some cases give you all the information you need.”

Why choose qualitative? The big three

Our experience conducting both quantitative and qualitative research suggests that focus groups or in-depth interviews may be the best choice when the research objectives touch on three key areas of human behavior: why people do things, what they want, and how they respond to marketing messages.

Exploring why people act
Qualitative research is a powerful tool to go beyond a quantification of what people do and gain an understanding of why they do it. What drives some patients to comply with medical advice, while others toss prescriptions in the trash? What makes doctors shift from the tried-and-true approach they learned in medical school to a new treatment option? Because health care is a complex and evolving arena, qualitative research is particularly appropriate methodology and can be used among audiences such as consumers, physicians and insurance brokers. A focus group or in-depth interview gives researchers the ability to probe and get beyond quick-answer, top-of-mind responses.

Discovering what people want
Another area particularly well-suited to qualitative research is insurance product design. After reviewing published studies about various plan options, Wilds uses qualitative research to test new health insurance product concepts, proposed product changes and new plan designs. Liz Clark, director of market analytics for Blue Shield of California (BSC), agrees that complex and innovative products — consumer-driven health plans, for example — would be too confusing to explain in a quantitative survey. Focus groups or one-on-one interviews with consumers and employers allow researchers to present a range of options without overwhelming participants. Such efforts often prove sufficient to move forward, while in some instances, according to both Wilds and Clark, a quantitative study may be employed when additional “drill down” is needed after the qualitative phase.

Testing communication messages
Qualitative techniques have long been used in health care and other industries to test advertising and communication messages. In health care, there is an added need to educate consumers and determine if the messages, often technical and confusing, are understood.

Managed care organizations, for example, face the challenge of conveying complicated benefit information such as formulary structures, provider networks, co-pays, co-insurance, deductibles and premiums as well as ways individuals can be involved in disease prevention and management. Health care is a very personal and often emotional subject, which colors how an individual looks at the financial and procedural aspects of their coverage. “A health care organization needs to convey an enormous amount of information to its members about how the plan works. If we put together information covering everything a member needed to know, it would be overwhelming,” says Linda Lynch, director of market research for Blue Cross Blue Shield of Massachusetts (BCBSMA).

Recently BCBSMA held consumer focus groups to review a wellness and preventive health information package that would cover various programs available from the plan, including disease management, wellness programs, a nurse call line and discounts on safety items such as infant car seats. One of the objectives of the research was to learn why members valued certain programs over others, along with the best way to package the information to be most appealing to members. The plan not only learned about its members’ priorities, but the research uncovered a need to split information into several separate brochures in response to the way certain programs and discounts were viewed and grouped by members.

Engaging the internal partner

Before health care marketers launch a new product or make a change to existing materials, for example, they look not only for buy-in from members or providers (the external clients) but also for commitment from others within their organization to ensure a successful outcome. An added benefit of qualitative research is that it generates considerable interest from internal clients or partners. Some health care researchers say that having managers and executives observe research sessions can be just as valuable as the findings. The qualitative process can result in new ideas and discussions or simply build consensus for the initiative under consideration.

Focus group sessions and some one-on-one interviews can be viewed real-time or after the group has been conducted. “Sometimes we edit the research and produce a 10- to 15-minute segment for senior managers so they can see what went on, and not just hear or read about it. A video is compelling. It tells results in a way that nothing else can,” Lynch says. She admits that it can take a long time to produce a 10-minute summary, but “sometimes that 10 minutes can make all the difference.”

The expectations and preferences of internal partners often need to be managed to obtain the best research results. Some organizations lean toward focus groups because they don’t want to wait for the results of a quantitative study. In other cases, risk-averse executives may lobby for a complete census, when a couple of focus groups might provide compelling information that indicates a quantitative study is not needed. It is important to educate internal partners and ensure that the appropriate methodology is employed given the specific research objectives.

Selecting a research partner

Businesses frequently contract with third-party research companies or consultants to conduct qualitative research. Benefits of using outside consultants include: freeing up internal resources, drawing from the experience of the moderator or research firm, obtaining additional perspectives, protecting anonymity and enhancing objectivity.

Choosing the appropriate individual or group to conduct outstanding qualitative research can be difficult no matter what the topic. Health care topics present unique challenges. Finding a firm that is well versed in the nuances of health care delivery and the constantly changing environment can be difficult. The health care executives we talked with typically make prior health care experience one of their first criteria when selecting moderators. Lynch says, “A moderator needs insights and expertise that comes from substantial health care experience.”

Regence Group’s Wilds agrees and adds that if you get “the right firm to do qualitative research, that in itself is half the battle. So much of the work has to get done up front in understanding the product or disease management program so that you can ask the right questions and nail down the objectives.” He speculates, “If your qualitative data doesn’t give you data you can use, the wrong firm did it, or you didn’t do enough of it.”

Following are some assessments to make when choosing a focus group moderator or in-depth interviewer. Do they:

  • have the ability to put respondents at ease quickly?
  • pay close attention to speakers and use active listening skills?
  • probe to pursue an understanding of intentions and meanings?
  • redirect when appropriate?
  • link trains of thought and divergent comments into a cohesive whole?
  • think quickly and demonstrate flexibility and the willingness to vary their approach?
  • stay focused on the project purpose and direction?
  • demonstrate knowledge about the research topic?

Qualitative can supplant a quantitative study

The results of qualitative research efforts sometimes prompt a change in direction. In the past two years, Wilds reports, 60 to 70 percent of product studies have not gone to the quantitative stage because the focus group or one-on-one interviews provided “a sufficiently sensitive barometer” of the market needs. For example, The Regence Group held consumer and employer focus groups to test a new consumer-centric product that featured flexible spending accounts. There had been plans to conduct a quantitative study after the focus groups. But, Wilds says, they got such consistent information from focus group participants that the executive staff felt they had sufficient information and no additional research was necessary at that stage.

Another example was an effort to test redesigned provider vouchers and evidence of benefits forms (EOBs) with physician office staff. While the initial plan was to use focus groups for direction only, the input gathered and the overwhelmingly positive response from participants allowed Regence to move directly into the next stage of design. “Participants said to us, ‘Why didn’t you do this sooner?’ Anything we would have come up with in a quantitative study would have been good, but we had plenty to go on and could fast-track the changes after the qualitative stage,” Wilds says.

An important finding from one set of focus groups was that a more extensive quantitative study was not necessary. BSC’s Clark tells of the situation when her plan wanted to better understand the decision process of selecting health care coverage when an individual approaches Medicare eligibility. After conducting three focus groups with 60-to-63-year-old consumers, BSC found that this age cohort was not yet thinking about what they were going to do about health insurance when they turned 65. “It didn’t make sense to talk to 100 or 200 more 60-to-63-year-olds. It wasn’t worth the time or money because the vast majority weren’t yet thinking about it.”

One size does not fit all

There is no doubt that both qualitative and quantitative research have their rightful place in the vast health care research arena. Clark observes, “Health care is a complex product and service industry with lots of factors involved. Health care decisions are not as cut-and-dried as other choices, like what toothpaste to buy or where to drink your morning coffee.” She suggests that health care organizations should think broadly when considering which methods might most effectively achieve research objectives.

As health care marketers seek ways to increase the value of research to their organizations, flexibility will be essential. Which methods to employ should be based on the questions that need to be answered, the complexity of the topic, how many issues will be explored, what decisions are needed based on this research, budget considerations, timeline, and the target audience.

Given the ever-changing environment that health care organizations find themselves functioning under, it would not be surprising to see a trend toward increased use of qualitative methods and multi-method approaches — strategically combining both qualitative and quantitative methods. Capitalizing on the strengths of both quantitative and qualitative methods, whether used independently or together, will help ensure that organizations obtain the most appropriate, highest-quality data.


ARTICLE SIDEBAR

Physicians: A challenging and critical research segment

Health care is the largest sector of the U.S. economy, and executives throughout the industry are keenly interested in the thoughts and behaviors of physicians. Qualitative research works particularly well with this audience because a seasoned researcher can get beyond a doctor's top-line thoughts. The best results are obtained when moderators or interviewers are fully conversant with the topic under study and experienced in dealing with physicians and other care providers. Based on our experience, we have developed a number of strategies to help uncover candid information from doctors.

The fundamentals: Do your homework and understand the subject matter. While it is not necessary to know all the intricacies of a disease or a drug's mechanism of action, it is imperative to know the basics of the disease, treatment options and impacts. If something is brought up that you are not familiar with, follow up with "That's a point I hadn't heard before; please tell me more." Or, "That is a side effect I'm not familiar with; what are its manifestations?"

Depending on the topic, a participant may want to use the focus group as a soapbox. Recently, I conducted a physician focus group for a health plan on how to improve compliance with nationally accepted clinical guidelines. One participant refused to talk about the topic at hand, and instead wanted airtime for her beliefs about the negative impact of HMOs on physician practice. After several opinionated outbursts unrelated to the question at hand, I asked the doctor if she could —just for the next 45 minutes, just for the sake of research - operate under the assumption that the managed care organization was providing these clinical guidelines to ensure that members received a high level of care. Since none of the physician participants had any quarrels with the selected guidelines, the other focus group participants helped keep this outspoken critic on topic.

Another recent experience conducting in-depth telephone interviews with specialist physicians reinforced the importance of knowing the subject matter. After a long and complicated series of questions and probes, I asked the doctor if he realized that the response he had just given contradicted something he had said earlier about the properties of a specific drug. He expressed amazement that I understood the subject matter well enough to have caught the misstatement. For the rest of our time on the phone he gave the interview his complete attention. When we finished, he thanked me for the stimulating hour-long exchange and commented that this wasn't like most interviews when he just rushes through answers because he knows the interviewer doesn't have a clue about what he says.