Types Used by CHCD

Different deliberative techniques or tools can be used to explore how groups make decisions when faced with various options. Approaches vary depending on the topic of the deliberation, the types and number of individuals that will participate, and the time and resources available. CHCD uses a variety of approaches:

CHAT: a computer-based process

CHAT® (Choosing All Together) is a computerized process for individual and group decisions. Licensed through the University of Michigan, CHAT is an effective tool for considering coverage priorities and other types of priority-setting when multiple options are available. Since 2002, CHCD has designed more than a dozen versions for use in California and other states, facilitating more than 300 sessions with various demographic populations.

Articles about CHAT have been published in professional journals:

Case Scenarios

Many of the challenging issues in healthcare policy or practice relate to health care quality, cost containment, physician or patient authority, and the results and use of medical research. Both the lay public and healthcare professionals can best respond to complex trade-offs when they are described using scenarios that illustrate the issue through a common medical situation. Case scenarios are used as examples of the issue at stake; from these examples – and by introducing variations of the scenarios – facilitators draw out the underlying principles that are foundational for individual/group choices.

Surveys

As noted in What is Public Deliberation?, phone or internet surveys are not considered deliberative. Yet CHCD has occasionally used surveys to lay a foundation for a deliberative process. For example, identifying how the public responds to an uncomplicated healthcare policy issue could form the basis for a more detailed exploration that involves trade-offs. In other instances, a survey can be used to validate qualitative conclusions.

Educating Others on Social Decision-Making

While our work is primarily to inform healthcare policy and practice, deliberative discussions are also educational for participants. Regardless of the healthcare topic, the process itself exposes individuals to insights about themselves and others and fosters understanding of “social decision-making” – when the needs of many people are taken into account. This is especially important in health care whose structure, financing and delivery are based on models that must serve diverse populations.

CHAT: A Computer-based Tool for Public Deliberation

CHAT® (Choosing All Together) is a simulation exercise, allowing participants to use their own experiences, beliefs and values to create the best possible coverage for themselves and others.

CHAT was created by bioethicists at the University of Michigan and the National Institutes of Health who understood that the public needed more information and opportunities to participate in policy discussions that impact them and their communities. CHCD has customized the CHAT process and utilized it with four unique projects in California. CHCD has also worked with four other states to help them design their own CHAT board and engage their state residents in this social decision-making exercise.

How CHAT Works

  • On individual computers, participants consider 12-15 categories of coverage displayed on a pie chart. Each category offers one or more benefit levels.
  • Participants have more coverage options than they have resources to spend.
  • Participants make coverage decisions for a whole population, not just themselves, moving from “What do I want?” to “What makes sense for all of us?”
  • A skilled facilitator encourages participants to explore their views and values in an engaging, interactive environment.

This is both a qualitative and quantitative process. The goal is to better understand what participants most value and why. Data from all sessions are collected and analyzed, along with pre- and post-session survey questions.

CHAT Projects in California

    • Just Coverage (2006-07). To define ‘basic’ coverage, more than 900 insured and uninsured Californians identified the core components of an essential health plan.
    • Medi-Cal CHAT (2004). Adults with disabilities identified the trade-offs they regarded as most acceptable if budget cuts are necessary in California. Results were shared with leaders at the Department of Health Care Services.
    • Capitol Region CHAT (2003). Seventy-one (71) local companies learned their employees’ priorities regarding trade-offs in health plan benefit design. Employers sought this information as they faced increased costs of coverage.

Just Coverage (2006-07)

Citizens define the limits of "basic" health care

Project Summary

Responding to growing interest in universal health care (pre-ACA), more than 900 insured and uninsured Californians defined the core components of an essential health plan. Project results showed:

  • What healthcare needs should be met by insurance coverage and why
  • How essential coverage was distinguished from non-essential
  • How groups balanced cost-sharing, provider restrictions and coverage limitations
  • That an informed public could develop an acceptable basic plan

Project Reports

Publication

Medi-Cal CHAT (2004)

Adults with Disabilities Prioritize Their Medi-Cal Coverage Options

Project Summary

In response to anticipated cuts in the state’s Medi-Cal budget, adults with disabilities identified the most acceptable trade-offs if funding was to be reduced by 15%. Independent Living Centers recruited 131 non-institutionalized adults with disabilities to participate in 12 discussion groups statewide. Results were shared with leaders at the CA Department of Health Care Services.

Project Report

Publication

Capitol Region CHAT (2003)

Health plan coverage preferences when resources are finite

Project Summary

Facing increased coverage costs, employers sought guidance in addressing the tensions between what consumers want and what companies are able to purchase. Seventy-one public and private sector companies in the Sacramento region learned the coverage priorities of their 750 employees.

Project Report

Sharing in the Cost of Care (2012)

Perspectives from Potential Health Plan Users of the California Health Benefit Exchange

Project Summary

During its planning phase, Covered California (the state’s health benefit exchange) asked CHCD to learn how future beneficiaries would structure health plan cost-sharing in the fairest way possible to meet the needs of new enrollees. CHCD held ten deliberative discussion groups throughout the state, meeting with 113 uninsured Californians. Participants reviewed and prioritized multiple case studies that illustrated how different cost-sharing models would affect patients with different needs: chronic illness, episodic care, catastrophic care and preventive care.

Project Report

What Matters Most (2009)

Californians' Priorities for Healthcare Coverage

Project Summary

What Matters Most tackled a key aspect of healthcare reform efforts: at a time of rising healthcare costs, what medical situations are most essential for coverage and which are less essential? The project included a random sample telephone survey of 1019 Californians. Each ranked 10 (of 80) short medical vignettes on a scale of coverage importance. This was followed by 15 group discussions with 176 community members who reviewed the results of the phone survey and provided their reasoning for differentiating higher and lower priorities. Findings were reported in Congressional Quarterly, Talk of the Nation and other national media outlets.

Project Report

Value-based Insurance Design (V-BID)?

June 2012 – CHCD completed a pilot project, Probing the public's views on V-BID, with partners in Michigan to see how average employees considered the pros and cons of using value-based insurance design as a tool for encouraging high-value health care and discouraging low-value health care.

Hospital Quality (2010)

How and why the public cares about certain quality domains

Project Summary

In an effort to help leaders of the California Hospital Assessment and Reporting Taskforce (CHART) evaluate the usefulness of its work to consumers, CHCD asked diverse groups of consumers throughout California to consider four quality domains: clinical effectiveness, patient safety, responsiveness to patients and efficiency. Using an Audience Response System (keypad voting) and a series of case scenarios, project participants were asked to prioritize the relative importance of these domains and discuss the rationale for their decisions. This CHCD report has been distributed nationally to organizations sponsoring hospital public-reporting websites.

Project Report

What Matters Most (2009)

Californians' Priorities for Healthcare Coverage

Project Summary

What Matters Most tackled a key aspect of healthcare reform efforts: at a time of rising healthcare costs, what medical situations are most essential for coverage and which are less essential? The project included a random sample telephone survey of 1019 Californians. Each ranked 10 (of 80) short medical vignettes on a scale of coverage importance. This was followed by 15 group discussions with 176 community members who reviewed the results of the phone survey and provided their reasoning for differentiating higher and lower priorities. Findings were reported in Congressional Quarterly, Talk of the Nation and other national media outlets.

Project Report

Visible Fairness (2002)

Cost-Effectiveness as a Criterion for Medical and Coverage Decisions

Project Summary

This regional project was a community-wide dialogue on the role that cost plays in healthcare treatment and coverage decisions. Designed to gauge the public’s notion of cost-effectiveness as a component of medically necessary care, this was an extension of Stanford University’s earlier report on Defining Medical Necessity. Consumers weighed in on one of society's most difficult dilemmas: how to balance the medical needs of individuals with those of the larger community. CHCD conducted a written survey of 500+ physicians, held 25 discussion groups with 263 consumers and commissioned a 500-person random phone survey of the general public. Results were presented in CA and nationally. To see how average consumers debate a controversial health policy issue, see this 8½ minute video.

Project Report

Publications

Healthcare Matters (2002 – current)

Lectures about health insurance are exceedingly complicated and inherently boring. But when you ask groups to negotiate and collaborate on policy decisions, this activity improves their understanding of healthcare and appreciation for the collective wisdom that emerges. This is not boring; it is stimulating in ways that surprise people and helps to connect them to real world situations.

CHCD has been using CHAT® for interactive group discussions since 2002. While most of this work has been project-specific – to help address current healthcare policy dilemmas on what health plans should cover – we learned quickly that this process does more than answer research questions. It helps individuals think about healthcare policy from a different perspective – as citizens grappling with competing priorities and disparate values.

For that reason, we have been using CHAT for three distinct purposes:

1. Educating healthcare and community leaders.
In academic settings, CHAT is an effective process for understanding the dilemmas of allocating communal resources; learning the relative costs of coverage components; and appreciating how societal values influence individuals’ judgments of what is essential and what is not.

2. Creating the next generation health plan.
Businesses, public sector entities and communities may be seeking new models of healthcare coverage in an environment of diminishing resources and the need to deliver value-based, high-quality care. Leaders should start by learning from their constituents. CHCD can create a customized version of CHAT, responding to the interests and circumstances of sponsoring organizations.

3. Team-building.
Leadership trainings, conferences, and board retreats seek activities that are engaging, highly interactive and educational. For health and non-health organizations alike, this two-hour group session will have participants responding as one Society of Actuaries member did, "Easily the best session I have ever attended at an SOA meeting." Click here to see the types of groups that have benefited from CHAT as a team-building exercise.

Contact CHCD for more information on bringing Healthcare Matters to your organization.