We studied the views of adults in families with at least one child aged ≤17 years who had an HDHP, defined as a health plan with a deductible of $1,000 or more per individual and $2,000 or more per family. Families were drawn from the population of Harvard Pilgrim Health Care, a New England-based non-profit health insurer. In Harvard Pilgrim Health Care's HDHPs, most preventive services including routine check-ups, immunizations, and selected screening tests were exempt from the deductible, i.e., enrollees paid either a co-payment or nothing, whether or not they had met the deductible amount. In contrast, most diagnostic laboratory tests were not covered until the deductible had been met.12
We selected families who had been enrolled in an employer-sponsored HDHP for at least 12 months and who had experienced high or unexpected out-of-pocket costs.13
Each focus group was composed entirely of patients selected from 806 families with one of the following characteristics during the previous 12 months based on the health plan's computerized data: (1) made an emergency department visit (n
553); (2) had out-of-pocket health care costs of $1,000 or more (n
259); (3) had out-of-pocket health care costs of $500 to 999 (n
320); or (4) had an adult family member with a cardiac condition, and the same adult family member was hospitalized or the family had out-of-pocket health care costs of $1,000 or more (n
132). Some families qualified for more than one subgroup. We selected a random sample from each subgroup, sent invitation letters, and made telephone calls to invite participation of the adult in the household most responsible for health care decisions. Of the 244 eligible families contacted by telephone, 30 (12%) initially agreed to participate, and 21 (9%) actually participated.
Data collection We conducted four focus groups, each of which included four to six participants, in a conference room housed in a clinical center. Immediately prior to each group, participants were asked to complete a seven-item questionnaire on demographic characteristics. Each focus group lasted approximately two hours and was facilitated by a lead moderator (JS). Audio recordings were transcribed verbatim. A gift card incentive of $100 per participant was provided. The protocol was approved by the Institutional Review Board of Harvard Pilgrim Health Care.The focus group interview protocol, which was developed by our multidisciplinary study team, included seven topic domains: (1) knowledge of how the HDHP worked; (2) strategies to reduce health care use; (3) other strategies to manage costs; (4) financial burden; (5) sense of control over health care use and costs; (6) health savings or other accounts; and (7) satisfaction with the HDHP.
Data analysis Qualitative methods were used to code and analyze the data from focus group transcripts. The seven topic domains guided the reviews of transcripts, however the approach was inductive in that salient themes regarding the domains became apparent—or emerged—only upon a complete and close reading of all the data. In the first phase of analysis, five investigators independently read the transcripts, adapting principles from “grounded theory” (known as an “open coding” process) to identify general level salient themes.Subsequently, a sub-group of three investigators examined the transcripts in greater detail to either flesh out or refine the initial salient themes and identify various sub-themes pertaining to the broader general themes. The three investigators first independently coded each of the four focus group transcripts and then met to discuss the themes and achieve consensus about them. Finally, these themes were reported back to the entire research team for further discussion, during which consensus was achieved.