Examining health care, what's the public's prescription?

Results from Citizen Forums

Examining Health CareWhat’s the Public’s Prescription?

A Kettering Foundation Report September 2004

prepared by Paul Werth Associates

Copyright © 2004 by the Kettering Foundation

The Kettering Foundation, chartered in 1927, is an operating foundation —not a grant-giving foundation — rooted in the American tradition of inventive research. Its founder, Charles F. Kettering, holder of more than 200 patents, is best known for his invention of the automobile self-starter. He was interested, above all, in seeking practical answers to “the problemsbehind the problems.”

The foundation today continues that tradition. The objective of the research now — the study of what helps democracy work as it should. Sixmajor Kettering programs are designed to shed light on what is required for strengthening public life. Kettering is a nonprofit 501(c)(3) research corporation supported by a $260 million endowment. For information about the Kettering Foundation, contact the foundation at 200 Commons Road,Dayton, Ohio 45459-2799. Phone: 800-221-3657.

The Kettering Foundation does not make grants but welcomes partnershipswith other institutions (or groups of institutions) and individuals who areactively working on problems of communities, politics, and education. The interpretations and conclusions contained in this publication, unlessexpressly stated to the contrary, represent the views of the author or authorsand not necessarily those of the foundation, its trustees, or officers.

www.kettering.org

A Public Prescription for Health Care 1

Introduction: Overview of Approaches 3

Executive Summary 4

An Overview of Americans’ Discussions about Health Care and the Tradeoffs They Are Considering 6

Tradeoffs Involving Cost, Quality, and Access 6

• Coordination of Care vs. Cost of Care

• Quality of Care vs. Increase in Number of Covered Lives

• Quality of Care vs. Cost of Care

• Access to Care vs. Increase in Number of Covered Lives

• Patient Privacy vs. Coordination of Care

• Quality of Care vs. Medical Lawsuits

• Physician Autonomy vs. Cost of Care

• Increase in Taxes vs. Increase in Covered Lives

• Competition vs. Collaboration

Shifts in Citizen Thinking 10

Specific Findings 11

Citizens Are Frustrated by the Lack of Action to Improve the Health Care System 11

• Passionate Interest in Improving Health Care

• Industry Should Be Working Together

• Personal Sacrifice for Improved Care for Others

• Unknown Effects of Changing the System

• Personal Accountability and Responsibility, Along with Government Interaction

Contents

(Continued on next page)

Citizens Want an Ombudsman to Help Them Navigate the System 14

• Absence of a Global Perspective

• Defining Industry Terms

• Abusing the System

• Unqualified for Personal Accountability

• Physician Impact on Citizen Opinion

• Better Communication and Collaboration Needed throughout All Health Care Entities

• Physician and Patient Partnerships

• Supporting Physicians with Other Health Care Professionals

• Insurance Company and Pharmaceutical Company Partnerships

• Ombudsman or Advocate Organization Needed

Citizens Suggest Rewarding Healthy Behavior and Penalizing Unhealthy Behavior 19

• Preventive Care Should Be Encouraged by Insurance Providers

• Skepticism about Health Care Education

• Rewarding Healthy Behavior and Penalizing Unhealthy Behavior

• Struggling with “Appropriate Care” for Everyone

• Appropriate Use of Resources

• Universal Health Care System

Common Ground for Action 24

Several Action Steps Are Considered 25

Appendix 26

Methodology 26

Questionnaire Results: Demographics 28

Other Notables 30

Analysis of Post-Forum Questionnaires 31

About National Issues Forums 33

About Paul Werth Associates 34

Contents (continued)

Examining Health Care 1

Health care policy in America is a maze of contradictions. Our system offers some ofthe most advanced medical treatments andtechnologies in the world, yet more than 43million Americans have no health insuranceof any kind. Each year, as a nation, we spend more than twice as much per personon health care as most other industrializedcountries yet rank below them not just in key health indicators such as infant mortality, but also in access to services —with lower numbers per capita of everythingfrom doctors and nurses to machines forMagnetic Resonance Imaging.

The sense of frustration is growing. Wary of misunderstanding the public’s wishes, policymakers propose little more than piecemeal programs — lower drug costs for senior citizens and expanded healthinsurance coverage for low-income children —that fail to address the problem in its entire-ty. Weary of working in an increasinglyunworkable system, a small, but growingnumber of physicians across the country are simply closing their clinics and walkingaway. The demands on the health care system, meanwhile, are steadily growing.

While layoffs and the soaring costs of coverage steadily add to the ranks of theuninsured, our aging population creates anever-increasing demand for care. In 2003, the U.S. spent nearly $1.5 trillion on healthcare, roughly 14 percent of the gross domestic product. By 2013, that figure isexpected to more than double. Without public action, the only sure thing about thehealth care crisis is that it will surely only get worse. What should we as a nation do?

For politicians and government officials,health care reform is a seemingly thanklesstask. The public, or so conventional wisdomgoes, has no useful input to offer: it simplywants the best care possible with no additional taxes or cost. It is unable to trulyengage the issue or make tough tradeoffs.This report, however, presents a radically different view.

What follows is not a product of traditionalopinion polls or the finding of a blue-ribbonstudy panel. It is the result of something farmore powerful: public deliberation — the collective judgment and insights of citizens as expressed in dozens of locally organized,nonpartisan National Issues Forums.

Forum participants care passionately about health care. Not only are they ready to come to the table to think about tough

tradeoffs and consider new approaches, they are also increasingly angry that others — health care providers, insurance and pharmaceutical companies, and policymakers — seem unwilling to join them.Solving the health care crisis, they believe, will require the input of everyone, citizensincluded. Rather than the specific details ofplans, they are more interested in process.They want to make themselves heard as wellas hear what others have to say. What ismissing, they suggest, is a process that actually engages the public — one that notonly respects their values, but also demandsthat they take responsibility. Forum partici-pants, as Kettering Foundation PresidentDavid Mathews has noted, recognize “thatgood health begins with personal decisions”and that they “could do something about costsby changing lifestyles.” That notion of publicresponsibility, in turn, has important policyimplications when it comes to health care.

A Search for Common GroundThis report is an attempt to bring those

kinds of public ideas to the forefront. Prepared by Paul Werth Associates, it brings a uniquely public perspective to the healthcare debate. Health care is an issue thattouches all Americans. And as we, as a nation, attempt to fix its problems, the ideas,insights, and beliefs of everyday Americans are all-important.

Involving more than 1,000 citizens in 44 different states, the forums covered a widerange. They included physicians and highschool students, as well as retirees and public officials. Some participants had comprehensive medical coverage. Others hadnone at all. But regardless of background, all came with personal stories: the struggles of a loved one with a life-threatening illness,worries about limited care in the future, or the frustrations of dealing with an increas-ingly complex and costly system. From personal insights, however, forum participantsquickly shifted their conversation to the needfor finding common ground as they wrestledwith the tradeoffs involved in balancing theproblems of quality, access, and cost. How can we make health care more affordable?How can we make it more accessible? Howcan we make it more effective?

Building RelationshipsAlthough forum participants often started

their discussions by sharing personal experiences and frustrations, their discussions

A Public Prescription for Health CareKenneth A. Brown

2 Kettering Foundation

soon switched to the need for developing relationships: not just between doctors andpatients, but within the health care system as a whole — insurance companies and policymakers as well as the pharmaceuticalindustry. Whether the problem was finding a doctor or filing an insurance claim, participants found the system so complicatedand confusing that they wished for a personal guide, or ombudsman, to help them.

Taking ResponsibilityWhile participants initially blamed a

specific part of the system — HMOs, insurancecompanies, doctors, or overly demandingpatients — as they began to talk, they quicklychanged their view. Rather than finding fault, they began to see the problem as one that stretched across the health care system as a whole. While forum participantswanted government agencies and insurance companies to do more, they also suggestedthat private citizens needed to take moreresponsibility for their health. They felt that all citizens should be more informed about both their own health problems and those of the health care system at large. Forum participants favored both private and publicinsurance programs that encouraged healthybehavior. They saw the need for a system that focused as much on preventing disease as it did on treating it.

Making Change PossibleWhen it came to making health care more

available, most expressed a willingness tomake sacrifices. Some forum participants, forexample, suggested that they would be willingto sacrifice a portion of their health care benefits for others if they believed the helpwould really arrive where it was needed. Butthey saw little evidence that professionals and businesses in the field were willing tomake similar sacrifices.

Above all, forum participants believed that the process of developing a real solutionto the health care crisis could begin only if everyone made his or her way to the table.While the proper level of government controlwas a topic they were still “working through,”almost all of those in the forums believed thatthe government would have to play a leadingrole in starting the conversation. Frustratedwith nearly a decade of inactivity, they wereclearly ready for action. All were interested in changing the current health care system.None was interested in seeing it stay the wayit is. Real change, however, was seen by forumparticipants as something that would have tooccur from the bottom up — beginning withpeople at the local level.

Bringing People TogetherIn an era of rising civic detachment and

declining voter participation, public deliberation helps bring citizens together tosearch for solutions to common problems.National Issues Forums have helped isolatedrural communities come together to buildhealth clinics and inspired troubled inner-cityneighborhoods to address the problem ofcrime in their schools and streets. For manygroups, however, a forum’s most importantproduct is simply the sense of community itengenders — the way it brings people together.

Putting the Public into Public PolicyThese kinds of deeply felt public judgments

need to be part of our current debate onhealth care. Most important public policy decisions are really questions of value — whatwe as citizens hold most dear. And revealingcommon values is what forums are all about.

The findings detailed in the following pagesare important because they represent far more than just a collection of competing views and opinions. Forums are not popularity contests. Participants do not merely argue orvote. Instead, they work together, carefullyweighing the costs and benefits of differentapproaches, struggling to define a collectivecourse for action.

For both the press and political leadersalike, these conversations offer a glimpse into our nation’s most deeply held publicbeliefs and desires — invaluable informationwhether one’s goal is covering the news ordeveloping policy.

Making Democracy Work as It ShouldA healthy democracy depends on public

participation, not just in regularly scheduledelections, but in the ongoing and much harder business of finding solutions to difficult public problems. For far too long,developing public policy has been seen as ajob solely for professionals and political leaders. The public need not apply.

By offering a framework for public delibera-tion, the NIF network helps citizens find solutions to common problems that concernthem. It helps connect them both with othersin their community and with their elected officials. People cannot act together until theydecide together. Deliberation is not just abouttalking over issues, but about deciding whatto do — bringing divided interests together tofind common ground for action.

Kenneth A. Brown is a program officer with theKettering Foundation. He works regularly with theNIF Network on outreach and research.


INTRODUCTION: Overview of Approaches

Approach 3: Care for All, Not Just for Some

This approach holds that we need toset new priorities aimed at providingAmericans the health care they needwhen they need it. We need to seal upthe cracks in the system so that peopledon’t fall through. We need an unflaggingcommitment to providing the medicaltreatment that each person needs. Thisis the best way to improve individualhealth and prevent illnesses that aremore difficult and expensive to treat.

The participants in this year’sforums deliberated using the NIFIssue book Examining Health Care:What’s the Public’s Prescription?This book provides participants witha framework for dealing with theissue of health care, outlines theissue in a nonpartisan way, andthen presents for public deliberationthree approaches for addressing it.The approaches are not mutuallyexclusive. Instead, each presents a variety of ideas and options for participants to consider anddeliberate about so that they mayconstruct their own approach to the issue.

Approach 1: ConnectedParts, Not Fragmented Pieces

This approach says the most effectiveway to improve health care in America is to take firm hold of it and make it run like a true, well-coordinated system.We need to take the existing, unwieldycollection of health care fragments andfashion them into a connected web ofhealth care services, within which information flows readily between thepieces and they work in concert.Coordination is the best way to curbcosts and provide health care in a timely way.

Approach 2: Partners, Not Just Patients

This approach states that we need to create new relationships in health care within which consumers and professionals work hand-in-hand so that people become partners in their own health care. We must take time tocommunicate, to help people makeinformed decisions, and to educate forhealthy lifestyles. This is the best way to improve the health of Americans andlay a firm foundation for personalresponsibility and prevention that willresult in long-term savings.


Executive Summary

OverviewOver the past 12 months, more than

1,000 citizens from across 44 states have participated in 2-hour discussionforums on the topic of health care. Theseforums took place in small and largecities throughout the nation. Citizens discussed what ails the health care system and what they are willing to do to fix it.

In the forums, participants sharedtheir opinions, their concerns, their experiences, and their knowledge ofhealth care. With the help of moderatorsand issue books, participants weighedseveral possible ways for society toaddress the health care system’s problems. They analyzed each choice, the arguments for and against it, and the tradeoffs and other implications oftheir choices. Moderators encouragedparticipants, as they gravitated to oneoption or another, to examine their basic values as individuals and as community members.

Report MethodologyThis report is based on an analysis

of what happened in 40 of the hundreds of forums that have taken place, and continue to take place, across the United

States. The report describes what happened as diverse groups of peoplecame together and deliberated aboutissues related to health care.

Participants were recruited to take part in the discussion through a variety of media, including direct mail, newspaperarticles, newspaper advertisements, Website postings and word-of-mouth. Everyperson who was interested was allowed to participate in the forums.

To complete the report, Paul WerthAssociates used five research methods.The process consisted of 5 interviews with the committee members whodesigned the issue book (a nonpartisanoverview of the issue), 29 in-depth interviews with moderators who leadforums, observing 5 live forums, interviewing dozens of forum participants,reviewing reports from 17 completedforums, and analyzing survey results from 1,027 participants. The researchtook place from January 2003 throughMarch 2004. To ensure consistency, all aspects of the research process were completed by the same individual at Paul Werth Associates.

The research process and report weresponsored by the National Issues ForumsInstitute and the Kettering Foundation.


Executive Summary

Key Findings: Three Themes

Three key themes resonated through-out the forums. These themes, describedbelow, are organized according to theorder in which they were discussed.

1. Citizens Are Frustrated by the Lackof Action to Improve the Health CareSystem

Citizens in the forums recognize there are problems with the health care system, and many are frustrated over the unrecognizable improvements under way. Many participants want representatives from specific health care constituent groups (for example,insurers, providers, and policymakers) to be part of further discussions toensure action is taken.

Citizens who participated in the discussions also recognize the need tochange the current health care system,and many would consider making personal changes to help in the process.They are disappointed other entities in the system do not share the same passion and are not making a concertedeffort to better the system as a whole.

Participating citizens believe thatthough personal accountability andresponsibility are critical for change tooccur, the government must take anactive role in the process of changing the health care system.

Forum participants comprehend thatby changing the health care system,patient access, privacy, quality of care,and overall health care costs may be at risk. They understand that makingchanges will require considering sometradeoffs. However, all still believechange must occur.

2. Citizens Want an Ombudsman toHelp Them Navigate the System

Citizens in the forums acknowledgethat multiple organizations and components are part of the health caresystem and that each deserves bothcredit and blame for the current statusof health care in America. Participants donot, however, understand the health care

system as a whole. Many want an entity or individual to personally help guide them through the complete process fromfirst accessing care through payment for services.

Citizens who participated in the discussions suggested several actions toimprove communication and collaborationwithin the health care system. The actionsare aimed at improving the patient experience. Participants recognize theseactions may lead to an increase in cost.Steps such as increasingthe number of midwives, dieticians, and nutrition-ists to support patient care were suggested. Also,encouraging patients andphysicians to form strongerpartnerships, founded ineducation, was thought tolead to better health careand a healthier population.

3. Citizens SuggestRewarding HealthyBehavior and PenalizingUnhealthy Behavior

Citizens in the forumsbelieve preventive careshould be acknowledgedand rewarded since itshould lead to a reductionin health care costs. They perceive the current health care environment asfocused on reacting to existing health problems instead of rewarding those whotake a proactive approach to anticipatepotential health problems. Many suggested initiating a system that rewardspeople who take precautionary health care measures and behave in a healthymanner. Many also suggested a financialpenalty for those citizens who knowinglybehave in an unhealthy manner.

Most citizens who participated in thediscussions believe every person shouldhave access to some level of quality health care but believe employers and taxpayers should not be additionally burdened with paying for this care. A common definition of a minimum, or anacceptable, amount of health care stillneeds to be “worked through.”

Key Findings:

1. Citizens Are Frustrated by the Lack of Action to Improve the Health Care System

2. Citizens Want an Ombudsman to Help Them Navigate the System

3. Citizens Suggest Rewarding Healthy Behavior and Penalizing Unhealthy Behavior


An Overview of Americans’ Discussions about Health Care and the Tradeoffs They Are Considering

Interest in changing the health care system is at an all-time high. Many citizens believe the health care system is near catastrophe and are waiting for it to crumble. They are frustrated withincreasing costs, increasing restrictions on care, longer waits for care, the unpredictability of their coverage, and most of all, the perceived lack of actionunder way to fix the problems.

Throughout the discussion, citizensrevealed an impressive understanding of several aspects of the health care system. They considered numerous tradeoffs during deliberation. Most tradeoffs included some combination ofcost, quality, and access to health care.

Tradeoffs Involving Cost,Quality, and Access

Citizens comprehend that by changingthe health care system, patient access,privacy, quality of care, and overall health care costs may be at risk. Theyunderstand that making changes willrequire considering some tradeoffs.However, all still believe that change must occur.

Throughout the forum, citizens weighed numerous points of view on avariety of health care issues. They grappled with the consequences each

action could produce.The following is a summary of the tradeoffs citizens considered.

Coordination of Carevs. Cost of Care

While participantsagreed that more coordination among allstakeholders (patients,families, physicians,and insuranceproviders) is essential,

they questioned what would happen tothe cost of care if this occurred. Somebelieved a more integrated health caresystem would lead to more efficiency andultimately drive down the cost. Othersbelieved that there would need to be a

“Full access to marginal health care is common in other countries.…”

significant investment in infrastructureto help the health care system becomemore integrated. Those participantsthought the investment would be passedon to the consumer, resulting in higherhealth care bills.

Quality of Care vs. Increase inNumber of Covered Lives

Participants questioned whetherenabling everyone access to health carewould sacrifice or improve the quality ofcare. Some reasoned that health careproviders would master their skillsbecause they are exercising them morefrequently. This would increase the quality of care they provide. On the otherhand, some thought extending access tohealth care could overburden the system.This would force physicians to spend lesstime with each patient, and the quality ofcare would decline. Some also suggestedthat an increase in demand, given thesame number of physicians, would causeexisting physicians to perform services for which they were less qualified. Thiswould negatively affect quality of care.

“If a system [were] in place to connect allthe health care parts, the quality of carecould decline. Caregivers would not havean incentive to treat anyone better, differently, or uniquely. Everyone wouldmeet the minimum standards.”

Charleston, SC

“Full access to marginal health care iscommon in other countries. If everyonehere had full access, what would thequality of health care look like?”

College Park, MD

A brief discussion between participantsreveals that they understand a complexrelationship exists between quality ofcare and the number of people withaccess to care.

“If everyone can get care, then demandwill increase. An increase in demand will lead to lower reimbursement rates.Lower reimbursement rates will keepphysicians from investing in their practices. Long term, this will reducequality of care.”



“And, physicians will not have an incentive to see as many patients. Thismay jeopardize the quality of care too.”

Dell Rapids, SD

Quality of Care vs. Cost of CareThere is a belief that while the quality

of care is very good in the United States,citizens who want higher quality mayneed to pay more for their care. Also,with the continuing reduction in reimbursement, physicians will need to push more patients through theirpractices to maintain their standard ofliving. This action could negatively affect quality of care. Reimbursementreduction trends could also lead to fewerpeople pursuing degrees in medicine.This would affect the supply of quality physicians and ultimately the quality ofpatient care. Ultimately, if costs continueto rise while reimbursement remainsstagnant or declines, citizens believehealth care quality is at risk.

“I’m willing to pay more for better quality.”

College Park, MD

“Hospitals and doctors cannot afford toprovide high quality of care with lowreimbursement. It is easy to realize thisbusiness model won’t last long.”

Estherville, IA

“How will people receive quality of carewith a shortage of physicians and nurs-es? The idea of a nationwide reimburse-ment system and/or further reductions inreimbursement could scare physiciansaway.”

Columbus, OH

Access to Care vs. Increase inNumber of Covered Lives

Participants contemplated whetherexpanding citizen access to health carewould increase the waiting time to see a health care provider. Some thoughtenabling more people to receive healthcare would raise the demand and wouldultimately increase the time people hadto wait to see a health care provider.

Alternately, others thought that ifpatients knew they could receive healthcare any time they need it, they would be less likely to abuse the system andwould seek health care only when it wasneeded, thus making the overall demandmore consistent and predictable.

“I would expect to have less say andparticipation in my care if everyone hadequal access.”

Charleston, SC

Patient Privacy vs. Coordination of Care

Participants exploredwhether their privacywould be compromisedby a more integratedhealth care system. Themajority was willing to sacrifice some level of privacy for a moreintegrated system. Theconcept of a personal IDor health care card wasdiscussed as a way toimprove coordination ofcare, and it met withmuch interest. This wasseen as one tool tostreamline the process of receiving health care.Some citizens were concerned that an IDcard could lead to lesspersonal service fromproviders and an increase in patient costswhile providers paid for their card-readingsystems. Others cautioned that insurancecompanies could use theinformation to penalizepatients and increasecosts. Overall, citizenswere in favor of a healthcare card.

Tradeoffs InvolvingCost, Quality, andAccess

1. Coordination of Care vs. Cost of Care

2. Quality of Care vs. Increase in Number of Covered Lives

3. Quality of Care vs. Cost of Care

4. Access to Care vs. Increase in Number of Covered Lives

5. Patient Privacy vs. Coordination of Care

6. Quality of Care vs. Medical Lawsuits

7. Physician Autonomy vs. Cost of Care

8. Increase in Taxes vs. Increase in Covered Lives

9. Competition vs. Collaboration



“Malpracticesuits arejust gettingridiculous.”

“The health care passport idea is good. It will encourage a better use of the system.”

Sioux Falls, SD

“I’ve moved several times, and there is a tremendous advantage to having myfamily’s medical records in one place.This outweighs my fear of other peopleaccessing my information.”

Sussex, DE

A few comments and a brief dialoguebetween citizens shows the connectionand importance of security and personalservice associated with health care.

“It would be wonderful if physicians and hospitals could share information.However, every office has different technology and systems. It would be veryexpensive to get everyone on the samesystem and keep it up to date. Whowould pay for this?”

Dell Rapids, SD

“If a health care card is adopted, the primary care provider or a statewideorganization should be responsible fordeveloping and maintaining a databaseof your health care history. Insurance companies should not be involved.”

Harding, AR

”The health care passport sounds convenient and could be a lifesaver, aslong as I carry the card and no one elsehas access to it.”

“However, I don’t just want to be seen as a number. The more impersonal thecare is, the more likely they are to misssomething.”

Minneapolis, MN

Quality of Care vs. Medical Lawsuits

Citizens struggled to determinewhether medical malpractice suits contributed to the rise of health carecosts or whether they were necessary toensure that patients received qualityhealth care. Many were disgusted withthe number of malpractice suits becausethey believed that medical lawsuits contributed to the rise in health carecosts. However, most realized that whilethey are costly and burdensome, they arenecessary to ensure the quality of care.Ultimately, citizens understand thatpatient care, patient access, and costsare affected by lawsuits.

“Medical lawsuits are necessary to makea point, but they drive costs way up.Common sense needs to intervene.”

Sioux Falls, SD

“Malpractice suits are just getting ridiculous. If you are going to do punitive damages, give some of the money back to the system in general. This would really improve the health care of many by the mistakes of a few.”

Santa Fe, NM



“I’m willing to give somethings up or pay more to help change the system.…”

“There should be a cap on malpracticesuits. Physicians are leaving their practices and this impacts my ability to receive care when I need it.”

Minneapolis, MN

“Physicians are ordering more tests than what may be necessary to protectthemselves legally. Now our health carecosts are higher than necessary.”

Madison, WI

“Physicians are being placed in a position where patient care and access is being impacted by rising insurancecosts.”

Carbondale, IL

Physician Autonomy vs. Cost of Care

Participants grappled with who shoulddetermine what kind of health carepatients receive. Many thought healthcare decisions should be left to the physicians who are providing the care.They did not like insurers controlling apatient’s coverage. On the other hand,participants thought that giving all thecontrol to physicians could drive up thecost of health care. They cited examplesof physicians who took advantage of their patients’ health care coverage byperforming expensive tests.

“I want the physician to determine howlong the hospital stay should be, not the insurance company. We will justneed to make sure all physicians haveguidelines to work within so that costsdo not spiral out of control with unnecessary procedures.”

Dell Rapids, SD

Increase in Taxes vs. Increase in Covered Lives

Participants questioned whether paying more taxes would improve qualityand access to care. Some were willing to pay more taxes to increase the qualityand availability of health care. However,they wondered whether it would work.Others speculated that, in theory, moremoney could make health care availableto more people without sacrificing quality, but if nothing were done tochange the health care system, it mightnot be effective. Instead, they would be contributing more dollars to an ineffective cause.

“I’m willing to give some things up or pay more to help change the system, Ijust don’t know how much and if it isworth it. How much will it cost? Will itreally make a difference? We need moreinformation on this idea.”

Charleston, SC

Competition vs. CollaborationSeveral citizens weighed their opinions

to determine whether a more competitivehealth care system would lead to lowercosts. Some favored a more competitivehealth care system to increase the quality and drive down the cost. Theycompared this theory to the capitalisticapproach used in other industries.However, other participants noted thathealth care is the only industry in whichcosts have risen, not declined, because of competition. Instead, they believedthere should be more collaborationacross the health care system.

“In the past we approached health careby introducing more competition. It hasnot worked. Costs continue to rise. Why not try collaboration? Why not work together?”

Minneapolis, MN


Three shifts in thinking occurred over thecourse of the forums. The shifts did notalways occur at the same time, and notall participants demonstrated a shift inthinking. Some participants dramaticallychanged their perception, while othersshifted their thinking only slightly, andsome did not change their perception atall. Regardless, the areas in which a shiftoccurred are listed below.

1. Physician-patienttransaction •Developing physicianrelationships •Developing relation-ships with otheraspects of the healthcare delivery system.

When participants first explored the topic of health care, many considered it transactionbased. They believed theirrole in the health caresystem was to visit thedoctor only when theywere sick. Over thecourse of the discussion,many citizens recognizedthe value of developing a relationship with theirdoctor. They began torealize the benefits of taking a more proactiveapproach to care.

Some citizens applied this approach to the entire health care system and concluded that patients should developrelationships with other stakeholders in the system, such as their healthinsurance providers.

Shifts in Citizen Thinking

Three Shifts in Thinking:

1. Physician-patient transaction • Developing physician relationships • Developing relationships with other aspectsof the health care delivery system.

2. General complaints and blame about the system • Government responsibility • Personal responsibility

3. Unwieldy national crises • Localized issue • Citizens can make a difference.

2. General complaints and blame about the system •Government responsibility •Personal responsibility

The forum began with intense passion and emotional stories about how the health care system had failedparticipants. Many shared personaltragedies and complaints and pointed fingers about who was responsible for the demise of the health care system. Asthe conversations evolved, participantsbegan to realize that problems in thehealth care system couldn’t be attributedto any one individual or single entity.They recognized that health care problems are not always someone’s fault,but instead, the problems cross the entiresystem. As the discussions progressed,participants began to acknowledge theywere personally responsible for stayinghealthy and receiving quality health care.

3. Unwieldy national crises •Localized issue • Citizens can make a difference.

At the beginning of the discussions,many participants felt a sense of doom.They thought the health care systemcould not be improved because the problem was too big and too complex.However, as they discussed the issue further, they began to explore how providers could improve health care at a local level. They began offering ways the health care system could be improvedlocally. The conversation, in some cases,evolved even further to identify ways individuals could improve the health care system.


Citizens AreFrustrated by theLack of Action toImprove the HealthCare System

Citizens recognize there are problems with the health care system, and manyare frustrated over the unrecognizableimprovements under way. They are disappointed that other entities in the system are not making a concerted effortto better the system as a whole. Manyparticipants want representatives fromspecific health care constituent groups (for example, insurers, providers, and policymakers) to be part of further discussions to ensure action is taken.

Passionate Interest in ImprovingHealth Care

Citizens were very aware of the issues facing the health care industry.Many cited national news stories abouthealth care in America, demonstrating ageneral awareness of the issue. However,participants were most often able torelate to the local news and stories abouthow community employers were affectedby issues addressed nationally. Manytook the issue one step further by applying local stories to personalaccounts about themselves or peopleclose to them who were affected by thehealth care system.

Most discussions began with tremendous emotional and personalinterest and gradually evolved into more holistic conversations about better health care and how the healthcare industry could be improved to better society as a whole. Participantsbegan thinking beyond their personalexperiences and started recognizing thedifferent components that make up thehealth care system. Furthermore, in

Specific Findings

“I would like to have a discussion like this andinclude a medical doctorand insurer in the room.”

their discussions, many considered thepoints of view of the following health caresystem stakeholders:

• Accountants

• Attorneys

• Families

• Government

• Insurance Providers

• Patients

• Physicians

• Schools

After considering other points of view, numerous participants recognizedthe significance of each stakeholder’s contributions to the health care system.Many citizens wanted to hear and learndirectly from other stakeholders to makethe deliberative process more meaningful.

“I would like to have a discussion likethis and include a medical doctor andinsurer in the room. I’m sure they have apoint of view I’m not considering.”

Sumter, SC

Overall, the discussions seemed toforge a greater understanding of thescope of the problem with the health care system. Citizens appreciated beingpart of the discussions.

Industry Should Be WorkingTogether

When participants began to identifythe problems in the health care system,they soon realized the need for change.Furthermore, they acknowledged that themultiple stakeholders (patients, families,physicians, insurance providers, and others) who comprise the system alsorecognize the need for change. Thiscaused them to feel angry because theybelieved no true efforts had been made to change a system everyone recognizesis not working properly.

“Our health care system is not set up to place blame or identify who is responsible for making changes. Wheredoes the responsibility to improve it lie?”

Dell Rapids, SD


Specific Findings

Participantsrealized thatregardless of howinvolved thegovernmentis, they asindividualsare alsoresponsiblefor changinghealth care at a locallevel.

From a national perspective, citizensnoted the failure of the health carereform legislation sponsored by Senator

Hillary Clinton while serving asFirst Lady. From a local perspective, they shared storiesabout their insurance providers,physicians, and community hospitals complaining about losing money because of thehealth care system, but none of them had attempted to worktogether to fix the problem. They noted that while the stakeholders, legislators in particular, were looking out forthemselves no one appeared to be working together for thebetterment of the system.

A brief dialogue between two participants reveals the frustrationwith how health care organizations are not working together to address a known issue:

“We are all in this together. Health careprofessionals, providers, and residentsall want the same thing — better health care.”

“You are right.… As a country, we are not willing to have a serious discussionon this subject. Hillary’s plan wassquashed. It was not even considered.”

Sioux Falls, SD

Other discussions highlighted citizens’concerns about relying on legislators tochange the system.

“Federal employees have wonderfulhealth care benefits. How can they relateto us? Why do we expect them to makechanges to the system?”

“I believe there is too much reliance onthe legislation in our country to make adifference. Medical providers, insurers,and pharmaceutical companies are the biggest founders of legislation. Dothey really act in the best interest of the system as a whole? Can we really count on them to work together for ourbenefit?”

Estherville, IA

“Our legislators and policymakers gettheir health care taken care of. Why dothey get to decide what kind of care Ireceive? This seems inappropriate.Everyone should have a health care plan as good as their representatives.”

Minneapolis, MN

Personal Sacrifice for ImprovedCare for Others

Citizens struggled to determinewhether making a personal sacrificewould help improve the health care system. Several participants weighed thepros and cons of limiting their care orgiving unused portions of their insuranceto help the uninsured. However, most were unwilling to make a commitmentbecause they did not believe it wouldmake a difference, given the currenthealth care environment.

“I would opt out of some insurance company benefits to give my neighbormore health care if I knew [he or she]would receive it.” Minneapolis, MN

“If I give something up, how do I know it will actually benefit anyone else?”

Washington, DC

Some citizens were very protective oftheir health care benefits, and the idea of sacrificing their options was new tomany. Even if they did not currently useall their health care, the concept of givingup their prized possession made severalcitizens uncomfortable.

Two participants had a brief dialoguethat summarized this opinion.

“It is not right for some people to nothave health care and others to have toomuch. However, this is such a covetedbenefit, it is difficult for me to give anypart of mine up.”

“As citizens we have not really thoughtabout what we could and would let go ofin order to have quality of care for morepeople. The idea seems so foreign andvery scary.”

Norman, OK


Specific Findings

“The system is so complicated, if we make a change, we really don’t know what will happen long term.”

Unknown Effects of Changing the System

The conversation among participantsoften evolved into questioning how anychange, such as giving up portions oftheir health care, would affect the overallhealth care system. Participants thoughtthe system was so complex that it would be difficult to understand the long-term effects brought about by any modification. Even if change were madewith good intentions, participantsthought the system was so convolutedthat it would be difficult to understandhow any change affected it. This does not mean participants did not wantchange, just that they were unsure whatwould happen if changes occurred.

“The system is so complicated, if wemake a change, we really don’t knowwhat will happen long term. What elsewill occur that we cannot predict?”

Washington, DC

“A small change in one part of the system will have unknown ripple effects.Any changes that are made will likelyhave larger consequences we cannot predict. We need to proceed but proceedwith caution.”

Carbondale, IL

Personal Accountability andResponsibility, Along withGovernment Interaction

Citizens believe that though personalaccountability and responsibility are critical for change to occur, the government must take an active role inthe process of changing the health care system because of the size of the issueand because the government regulatesMedicare and Medicaid. However, opinions varied as to the degree of government involvement. Some wantedthe federal government to have total control of the health care system, whileothers wanted only minimal control evenat the local level. In addition, participantsalso realized that regardless of how

involved the government is, they as individuals are also responsible forchanging health care at a local level.

“We are all responsible for making the health care system better. The government will need to be involvedbecause they have control at a statelevel. However, we (the people) are the government, and we can make a difference if we try.”

Minneapolis, MN

“Local government needs to solve issuesourselves because we don’t believe people at the federal level will ever cometogether to solve this real issue. We cannot hold our breath and wait for others to change things.”

Estherville, IA

“We need a local champion, not the government, to keep the momentum. If no one leads the charge locally, this will go nowhere.”

Norman, OK

“Having the government change the system will be like waiting for a glacier to melt. It will eventually happen, we justdon’t know when and we may not bearound when it happens.”

Charleston, SC

In addition to citizens being personallyresponsible for making changes to the health care system at a local level,many participants commented that they as individuals needed to be moreaccountable for their own health care.The belief is that the more control peopletake over their health care, the moreresponsible they will be with their healthcare resources.

“People just need to take responsibilityfor themselves.”

Santa Fe, NM

“Each person should ultimately be responsible for deciding what care [heor she] need[s]. People need to takegreater responsibility for their health.”

Ellensburg, WA


Specific Findings

Citizensacknowledgethat multiple organizationsand components are part of the healthcare system.

The following dialogue between twoparticipants reveals citizens’ interest inbeing more responsible for their health.

“People go to the doctor too soon. Weovermedicate. This creates unnecessaryexpense and immunity to diseases. Longterm this will put more stress on thehealth care system.”

“If we just did the simple things ourselves, it could improve the entire system. If everyone drank a big glass of water every day, who knows howhealthy we would be!”

Youth Development Center, SD

Citizens Want anOmbudsman to Help Them Navigate the Health Care System

Citizens acknowledge that multiple organizations and components are part of the health care system and eachdeserves both credit and blame for thecurrent status of health care in America.Citizens do not, however, understand thehealth care system as a whole. Manywant an entity or individual to personallyhelp guide them through the completeprocess from first accessing care throughpayment for services.

Absence of a Global PerspectiveThough participants attempted to

understand the health care systemthrough deliberation and by examiningother points of view, the process stillraised numerous questions and concerns. It appeared as though the more participants discussed the topic,the more they realized they did notunderstand the health care system wellat all. Some believe the United Statesdoes not have a health care system, justcomponents they access when they needthem. Others believe there is a system

but that no one knows how to navigate it because they are missing a global perspective.

During this portion of the deliberativeprocess, the interaction often moved from between the participants and themoderator to an interactive discussionamong participants.

“We always look at health care in tunnels. We never look at it as an entiresystem for the holistic needs of the people.”

Estherville, IA

“I think there is a health care system in the United States. It’s complex, inefficient, and in places broken, butthere is a system.”

Norman, OK

“I don’t see it as a health care system.Health care is a service I access throughmy employer.”

Oklahoma City, OK

A brief dialogue between participantsrevealed different opinions about thesame frustrations.

“There is an assumption that there is a health care system in place already. If this is true, it’s up to each person to figure it out.”

“I believe all the components of thehealth care system are there; they haveto be for how much health care costs. It’s figuring out how to access them andmove between the components that is the challenge.”

Minneapolis, MN

Defining Industry TermsPart of the confusion is a result of

inconsistent definitions for many industry terms. While attempting toexamine health care, participants notedthat the industry uses terms that evokedifferent meanings among people, whichcaused them to become confused. Forexample, they questioned the word“access” and determined that “access” tohealth care could have several meanings.One person might think “access” means


Specific Findings

Common termsthat confuse citizens:

• “Access”

• “Necessary care”

• “Provider”

“I work the system by going to the emergency department. If I took the proper route, it takes me all day to get an appointment. However, if I go to theemergency room, it is more expensive,but someone will see me.”

Sioux Falls, SD

“I’m constantly trying to navigate the system and work it in my favor. It seemslike a big game, but I am gambling withmy health.”

Minneapolis, MN

“Emergency rooms eliminate the need tounderstand the health care system. Youdon’t have to find a doctor, worry aboutinsurance, or even make an appointment.Sure it is expensive, but the convenienceis hard to beat.”

Dell Rapids, SD

“I go to Canada for drugs. I feel like I’mdoing something illegal and could go tojail. This does not seem right. I don’twant to feel guilty about making sure myfamily and I are healthy.”

Minneapolis, MN

Unqualified for PersonalAccountability

Citizens became increasingly frustrated when discussing their personal role in the health care system.They think patients have to take anactive role in a process they do notunderstand to ensure they get the carethey need and are not overcharged. They believe patients are held personallyaccountable (since they receive a bill) for identifying and fixing problems theyencounter, even though they are notresponsible for the problem. For example, if patients experience a denialof an insurance claim, they have to fix the problem themselves, even if they do not understand the system or did not cause the problem.

affordability. Another person could apply “access” to being insured. Someone else might think it means to be geographically accessible to care.

Other questionable terms were “emergency,” “necessary care,” and“provider.” Citizens noted that the definition of “emergency” is relative,based on an individual’s perception. They examined the word “provider,”which could refer to nurses, physicians,or insurers. Citizens concluded that having terms with multiple meanings is a significant problem the health care industry should address beforeundertaking any change.

“The definition of necessary care andemergency care is completely dependenton the individual.”

Santa Fe, NM

“Everyone needs to agree on the samevocabulary. Otherwise, who will knowwhat everyone is talking about?”

Dell Rapids, SD

Abusing the SystemWhile participants wanted to follow

the appropriate processes when seekingcare, several admitted to manipulatingthe system to receive their care in a timely fashion. Participants admitted tolearning and using phrases to get anappointment more quickly. For example,they would learn and use a buzzwordsuch as “chest pain” that is used todescribe a life-threatening emergency. As a result, they would be given a higherpriority and reduced waiting time for thedoctor. They also admitted to going to the Emergency Room for care, eventhough it was not necessary becausethey wanted their problem addressedmore quickly. Others revealed their tripsto Canada and Mexico to purchase prescriptions. Citizens acknowledgedtheir behavior was not ideal (some wereeven embarrassed), but they did notappear willing to change until the rulesand regulations of the health care systemmade sense for their family.


Specific Findings

“The billing system puts the burden on the patient to create efficiency. It’s up to me to straightenthings out.”

Physician Impact on Citizen Opinion

Adding to participants’ confusion, several noted, was the direct impact oftheir physician’s opinion of the healthcare system. Many participants placetrust in their doctors and rely on them as their sole advocate in navigating thehealth care system. When a doctorshares his or her lack of confidence inthe system or process with a patient,then the patient’s confidence erodes. This creates even more bewilderment.

“I don’t believe anyone is acting in my interest except my primary carephysician. However, even they are havingdifficulty with the system.”

Oklahoma City, OK

“Many health care providers don’t know their way around the system. Their frustration rubs off on me.”

Minneapolis, MN

Better Communication andCollaboration Needed throughoutAll Health Care Entities

Citizens suggested several actions to improve communication and collaboration within the health care system. The actions are aimed at improving the patient experience, andparticipants recognize these actions maylead to an increase in cost. Steps such as increasing the number of midwives,dieticians, and nutritionists to supportpatient care were suggested. Also,encouraging patients and physicians to form stronger partnerships, founded in education, was thought to lead to better health care and a healthier population.

Participants were frustrated becausethere is no entity that fully understandsthe system and can advocate on theirbehalf. This frustration has led some citizens to take a more active, and morerisky, role in their health care.

“Billing issues are one of the greatestsources of confusion. They are also themost stressful. The billing system putsthe burden on the patient to create efficiency. It’s up to me to straightenthings out. I’m the least qualified to navigate the billing system.”

Sioux Falls, SD

“It takes a lot of time to take care of payments. I feel I am on the edge ofbeing taken advantage of. I don’t want to overpay or not pay enough. This is a very stressful situation.”

Norman, OK

“I want to be a partner (in the health careprocess), but I am uncomfortable thatdoctors and insurers will always act inmy best interest. I don’t trust the systemto take care of me.”

Oklahoma City, OK

“Complementary payments, referrals forcare, limited stays in hospitals, limitedbenefits … it is a full-time job for peopleto sort out care for themselves and theirfamily. One minute you understandwhom to call. The next it changes. Itkeeps you off balance as you sortthrough the health care maze.”

Ellensburg, WA

“The system has created so many obstacles and barriers, people are starting to organize their own care tomake sure they get what they believe isbest for them. Many are willing to risknot knowing what they really need inorder to have some sense of control.”

Philadelphia, PA


Specific Findings

Given the restrictions onphysician time, numerousparticipants suggested usingother health care experts (nurses, dieticians, nutritionists, and others) to help with education, communication, and collaboration.

Supporting Physicians with Other Health Care Professionals

The topic of physician/patient partnerships often led to deliberationabout the role of other health care professionals in the health care system.Given the restrictions on physician time, numerous participants suggestedusing other health care experts (nurses,dieticians, nutritionists, and others) to help with education, communication, and collaboration. These other professionals are thought to be experts at navigating the system, and they have the added benefit of providing quality patient care.

“Dieticians, nutritionists, and physicianassistants need to be in place to increaseeducation. We do not have enough doctors to begin with, so let’s use otherresources to help educate patients.”

Carbondale, IL

“Nurses and midwives could be used to educate and care for people in thecommunity.”

Ellensburg, WA

“Professional nurses should be includedin the process of increasing preventiveservices.”

Sioux Falls, SD

“If physicians do not have time, carecould be provided through schools if localclinics partner with school nurses.”

Norman, OK

Physician and Patient PartnershipsMost participants understood the

value and would appreciate having agood relationship with their physician.However, they also acknowledged howphysician time and payment limitationshinder this opportunity. They fear thatwith a true physician/patient partner-ship, authority and accountability are atrisk. Also, several citizens commentedthat patients would need to be moreactive in the health care process if apartnership were developed.

“Having a partnership with my physicianis easier said than done. The currenthealth care environment restricts whom Ican see and how long they can spendwith me. There are too many demands on my doctor’s time to develop a truerelationship with me.”

Santa Fe, NM

“This will never truly be a balanced partnership. Some people won’t participate. Others will ignore advice.When the physician has all the knowledge, there really is no balance.”

Harding, AR

“The patient must be capable of helpingor participating in decisions about theirhealth. Education levels will need to beincreased for this to occur.”

Carbondale, IL

“Having a partnership is a great idea.But who is the final expert? Who has thefinal decision? Out of everyone in thehealth care system, who is the most qualified to provide the best advice?”

Ellensburg, WA

“If the patient and physician have theopportunity to develop a relationship, itwill result in better care. However, thisrelationship takes time to develop. Whycan’t we afford something like this thatseems like a no-brainer? We know it’sright. The physician knows it’s right.Even the insurance company knows it’sright. Why don’t we work together anddo it then?”

Minneapolis, MN

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Specific Findings

“Doctors should not be told what types of care they should provide. Insurancecompanies are dictating the types of carepeople receive. People don’t feel you canpartner with an insurance company.”

Santa Fe, NM

A brief dialogue between participantsreveals that citizens believe insurancecompanies have too much authority in health care decisions. Citizens alsobelieve that if insurance companies really wanted to improve the system, they have the resources to do so.

“Insurers should get out of the way and let the doctors decide what care isneeded.”

“If they want to make a difference in the system, what if they did not send me ten pieces of paper each month, butinstead, had a nurse call me each quarter to make sure I was followinginstructions and staying healthy? I think the call is much more helpful than a newsletter.”

Minneapolis, MN

Another short discussion reveals thatcitizens link medical lawsuits to higherinsurance company premiums. There is a desire to control lawsuits and stabilizeinsurance premiums.

“As an employer, it is difficult to affordoffering insurance to my employees. It’s too expensive. However, I lie awakeat night thinking of the consequences ofnot offering them some sort of coverage.”

“What if there [were] a cap on medicallawsuits? Would this not allow physicians to offer services at lowerrates? I’m not sure they would alwayspass along these savings, but in theory it makes sense.”

Dell Rapids, SD

A brief dialogue between participantsrevealed that participants do not believeeducation has to come solely from theirphysicians.

“Physicians could serve as the information conduit for the system.However, this increase in responsibilitywould reduce the number of patientsthey can see.”

“What if interns were placed in physicianoffices to help with education and communication?”

Sumter, SC

Insurance Company andPharmaceutical CompanyPartnerships

As in previous research, insurancecompanies and pharmaceutical companies are criticized for restrictingpatient access and increasing the cost of care, respectively. Citizens do notbelieve these companies are interested in a partnership. However, they believethey are an important part of the partnership concept and could use theirresources more effectively to improvehealth care if they so desired.

“For a partnership to work within thehealth care system, all parties need tohave a mutually beneficial relationship.We already have patients developingrelationships with physicians and physicians with hospital relationships,but no one seems to have a good relationship with insurers. This is wherethe idea of partnership will have trouble.”

Charleston, SC

“Who is in control of our health care system? It’s not the doctors. It’s the pharmaceutical companies and insurancecompanies. One is making medical decisions for us and one is increasingdemand for care. They do not seem towant to be a partner with anyone.”

Harding, AR


Specific Findings

Citizens SuggestRewarding HealthyBehavior andPenalizing UnhealthyBehavior

Citizens believe preventive care shouldbe acknowledged and rewarded since itshould lead to a reduction in health carecosts. They believe the current healthcare environment is focused on reactingto existing health problems instead ofrewarding those who take a proactiveapproach to anticipate personal healthproblems. Many suggested incorporatinga system that rewards people who takeprecautionary health care measures andbehave in a healthy manner. Many alsosuggested enacting a financial penalty forthose citizens who knowingly behave inan unhealthy manner.

Preventive Care Should BeEncouraged by Insurance Providers

Citizens believe preventive care shouldbe acknowledged and rewarded since itshould lead to a reduction in health carecosts. Many citizens believe the industryis too fixated on the treatment of illness.They would like more focus on preventionand education. Specifically, they wouldlike preventive care to be covered by theirinsurance. There is a widely held beliefthat proper education and preventioncould lessen the demand on the healthcare system. Citizens also discussedaltering the reimbursement process sothat physicians were paid for havinghealthy patients.

“If they wantto make a difference in the system,what if theydid not send me ten piecesof paper eachmonth, butinstead, had a nurse call me each quarter.…”

Ombudsman or AdvocateOrganization Needed

Numerous citizens suggested the needfor one entity that could be responsiblefor the entire health care system and bean advocate on behalf of patients. Theybelieved that each stakeholder in thehealth care system looked out for itselfand that no single entity looked at the big picture. Citizens discussed the creation of an oversight organization toserve as an ombudsman among all thestakeholders, especially patients. Theadvocacy organization would be chargedwith understanding all the componentsthat comprise the health care system.The organization could help all the stakeholders navigate the health caresystem.

“There will always be someone who willabuse the system. We need someone orsome organization to oversee people’shealth care.”

Minneapolis, MN

“People need health care advocates,someone to chaperone them through the health care process. This will beexpensive at first. But long term it couldimprove health care, increase access, and save money.”

Estherville, IA

“The system is so fragmented now that it is too intense to navigate. No one evertries to coordinate what is in the bestinterest of patients. People are too busydoing what is mandated or regulated todo what makes common sense. A patientadvocate could help people receive bettercare.”

Dell Rapids, SD

“Ombudsmen should be built into thehealth care system to review all aspectsof individual patient cases and identifywhere the system may be breakingdown.”

Carbondale, IL


Specific Findings

Many believeeducation will not be enough tochange behaviorbecause thereare no financial consequencesfor beingunhealthy.

“People need information about theimpact their lifestyle has on their health.It should be infused into their curriculumat grade school. Well-educated childrencan be healthier.”

College Park, MD

“Many people think that education is the key to healthier people. Do we reallythink we are smart enough to educatepeople and change their behavior to eatbetter and exercise more? It’s no mysterythat smoking kills, yet we have more people smoking now than ever before.Instead of educating the abusers, let’s reward those who act healthy.”

Estherville, IA

“Education does not always changebehavior. We have seen many attemptsand lots of money spent on educationthat results only in minimal change.”

Dell Rapids, SD

“People have the right to behave anywaythey want. They can disagree with recommendations from their doctor anddo their own thing. Our ability to choose ultimately impacts the success of anyhealth care programs.”

Dell Rapids, SD

Rewarding Healthy Behavior andPenalizing Unhealthy Behavior

A complement to the point of view thatprevention is critical is that participantsfeel passionately that people who engage in unhealthy behavior should bepenalized. In general, individuals whoknowingly act in an unhealthy fashionshould be held accountable by payingmore for their health care. While additional discussion is needed to reachconsensus on determining specificactions for which people could be heldaccountable (for example, being overweight and smoking), many believeindividuals should pay for care based on a tiered approach. Those who participate in unhealthy behavior shouldbe responsible for paying for care

“Why won’t insurance companies pay forpreventive care? Why do I have to besick to get anyone to care about myhealth?”

Oklahoma City, OK

“Preventive medicine is not covered orreimbursed. I am sure doctors wouldrather get paid to keep people healthythan to treat them when they are ill.”

Estherville, IA

“The current health care system pays hospitals and doctors when you are sick,not when you are well. Health care professionals need to be paid for keepingpeople healthy.”

Dell Rapids, SD

“A true health care system includes morethan just receiving care when you needit. It needs to promote a healthy lifestyle, education, and prevention.”

Madison, WI

A conversation between two participants illustrates the desire formore education and preventive healthcare programs.

“We don’t have a health care system forthose who are educated and healthy.”

“I agree; the current system is for sick people. The ideal health care system is acombination of prevention, education,insurance, and hospital care.”

Ellensburg, WA

Skepticism about Health CareEducation

Despite an interest in following an educational approach to lessen the burden on the health care system, forumparticipants demonstrated significantskepticism about the potential effectiveness of current educational practices. Many believe education will not be enough to change behavior because there are no financial consequences for being unhealthy.


Specific Findings

Individuals who knowinglyact in anunhealthy fashion should be held accountable by paying more for theirhealth care.

Struggling with “Appropriate Care”for Everyone

Most citizens believe every personshould have access to some level of quality health care but believe employersand taxpayers should not be additionallyburdened with paying for this care. Acommon definition of a minimum, or anacceptable, amount of health care stillneeds to be “worked through.”

While almost every participant agreedit would be nice for everyone to haveaccess to some level of quality healthcare, there were mixed reactions towhether or not health care was a right of every citizen. Several participants commented that “just because we havesuch good health care resources, it doesnot mean everyone can and should usethem.” Setting expectations about whattype and quantity of health care peoplecan have access to was important to participants.

Everyone was concerned over how topay for health care for more citizens.Many were not willing to bankrupt thecurrent system to extend care to morepeople. And others commented that raising taxes or asking employers to paymore was not appropriate since they areburdened enough. There was also a beliefthat unless the health care system waschanged dramatically, applying moremoney to the same system would notlead to better care.

beyond a “normal amount.” And, thosewho participate in healthy activitiesshould be rewarded for their efforts. They noted the current health care system does not acknowledge or rewardthose who live a healthy lifestyle.

“Insurance companies try to encouragehealthy behavior with lower premiums.What if the state or my employer did thesame?”

Oskaloosa, IA

“I resent paying more and paying for people who smoke and have unhealthylifestyles.”

Minneapolis, MN

“People with addictions use a lot ofhealth care. Who should pay for thosewho do not take care of themselves?”

Santa Fe, NM

“Some people drink, smoke, and dodrugs. They will never be partners in thesystem. They will only abuse it. Theyshould pay more.”

Dell Rapids, SD

“There are many people who make badchoices in life and have more health carecosts because of this. Why should I haveto pay more if I am healthy and take careof myself?”

Madison, WI

“Citizens should pay for care based on a graduated payment plan.”

Sumter, SC

“Everyone should understand the importance of making responsible decisions. Paying more for irresponsibilitywould help in the learning process.”

Madison, WI

“There needs to be some sort of consequence for those who choose toengage in unhealthy behavior, possiblycharging higher insurance rates.”

Dell Rapids, SD


Specific Findings

“We expect the best carepossible. As a country, wecannot affordthe best carefor everyone.”

A dialogue between two participantsreveals deep concern over both the allocation of health care resources andthe financial burden associated withoffering care for more people.

“How much care can you give and still befinancially viable? Where do you drawthe line? What are the criteria you use todetermine who gets what care?”

“We can’t go broke saving lives. Thecountry should not be willing to acceptfinancial crises to give more people care.”

Santa Fe, NM

“How do you determine how much tospend on each person? Who determineswhat is necessary and what is vital?These are questions that need to beaddressed, but many are not qualified to answer.”

Youth Development Center, SD

Discussion among multiple partici-pants shows the difficult dilemma citizens struggle with when discussingwho can receive care and how much care they should have access to. No consensus was reached on this topic.

“We expect the best care possible. As a country, we cannot afford the bestcare for everyone.”

“Half a person’s health care costs occurin their last 30 days of life. How do you decide when and when not to provide care?”

“But should we put people lower on thelist [to receive care] because they chooseunhealthy lifestyles? Somehow we haveto prioritize.”

Estherville, IA

“We need to rethink costly proceduresthat prolong life for short periods of time.Heroic procedures for those who will not benefit long term are a source ofgreat controversy.”

Norman, OK

The deliberation surrounding responsibly allocating health care oftenled to a discussion about whether denying care is appropriate, and if so,

“The United States has enough healthcare capacity to care for every citizenalready. The resources are already inplace. We just need to manage it better.”

Carbondale, IL

“Health care should be considered anational right. Without health, you cannotpursue happiness, and this is in ourConstitution.”

Minneapolis, MN

“Health care is not a right. We are a fee-for-service economy. Those who wantsomething realize they have to pay for it.”

College Park, MD

“We need to examine our expectations ofhealth care and the health care system inAmerica. Are they realistic?”

Harding, AR

A brief dialogue between two citizensreveals how a definition of basic care orcoverage is necessary before an in-depthdiscussion of a national health plan can occur.

“We don’t need socialized medicine.Medicaid is already available. I wouldlike to see more universal care.”

“Before we do this, we really need todecide what the definition of coverage is.We could all have basic coverage. Butwhat constitutes “basic”?

Charleston, SC

Appropriate Use of ResourcesParticipants questioned whether

everyone should receive all the healthcare he or she needs. They recognizedthat the United States has the besthealth care in the world but debatedwhether that meant all care should bemade available to everyone in the country. No solution was reached.However, there was universal concernover how to pay for care for more citizens, and many participants werenervous about how to responsibly allocate available health care to thosewho need it.


when care should be denied. Citizens discussed the moral and ethical dilemmas health care stakeholders face.They questioned whether health careshould be denied to someone because of age or health status. They also confronted whether a price tag should be put on human life. In the end, no citizen was willing to take a stand or offer a solution to this highly controversial topic.

Tension exists and citizens strugglewith how to approach individuals withpreexisting conditions and conditionsthey cannot control. Some believe thatsince these individuals will require more resources than others they should pay more for their care. However, most recognized that these issues were beyond people’s control and they shouldnot be held financially accountable for something they cannot control. Most believe this point deserves more discussion by all health care professionals.

Citizens also grappled with whetherpeople predisposed to health problemsshould be penalized and asked to paymore because they will have more healthcare needs. While many thought this wasan unfair practice, most participantswere not willing to personally financiallysupplement the additional costs to coverthose predisposed to health problems.

Specific Findings

“I would liketo have carefor everyone,but I am tiredof payingmore eachyear for thesame care Icurrentlyreceive.”

Universal Health Care SystemOverall, participants agreed that they

would like everyone in the UnitedStates to have health care and that auniversal health care system was oneoption to consider. However, mostbelieved employers and the generalpublic should not have to pay for it.They believe these groups are alreadypaying for health care for many andshould not be penalized by payingmore to ensure everyone else hashealth care coverage. Due to thelength of most forums, this section ofthe issue book did not receive asmuch time for discussion as others.

“I would like to have care for everyone,but I am tired of paying more each yearfor the same care I currently receive.”

Oklahoma City, OK

“How would you pay for universal healthcare? There is no universal health caresystem that runs in the black.”

Santa Fe, NM

“I like the concept, but offering care toeveryone will make the working adultspay more for others without jobs.”

Dell Rapids, SD


Common Ground for Action

Though various points of view, ideas,and topics were discussed, citizensreached consensus on several issuesregarding the health care system in theUnited States. In general, citizensbelieved that since a big change to thesystem may not occur, many littlechanges might create incrementalimprovement.

• Regardless of each person’s approach to solving problemsacross the health care system, everyone agreed that health care will not improve unless everyone and every organization involved is held individually accountable.

• All participants agreed that government would need to play some kind of role in improving thehealth care system.

• Everyone believes that the systemwould take too long to change if thechange occurred from the top. Theyagreed that change needs to happenfrom the bottom up. In other words,change needs to occur at the locallevel.

• All participants had an interest inimproving the health care system. None wanted it to remain the same.

• Health care will not improve unless everyone and every organization involved is held individually accountable.

• Government would need to play some kind of role in improving the health care system.

• The system would take too long to change if the change occurred from the top.… Change needs to occur at the local level.

• All participants had an interest in improving the health care system.

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Several Action Steps Are Considered

Deliberation seems to have created aconnection among a number of healthcare issues. For many participants, thediscussions appeared to support theirperspective that the health care system is reaching a crisis point.

During the deliberation process, participants offered ideas and potentialactions to address parts of the issue.These suggestions usually did not evolveinto significant conversations but were of interest to the group in which the topics were raised. The ideas for potential action included:

Public Policy at the State or Federal Level

• Share personal concerns with legislators/representatives.

• Draft petitions that explain frustrations with insurance companies.

• Send local representatives to Capitol Hill to promote changes to the system.

• Develop fact sheets that show health care’s impact on and importance to each local community.

• Research “socialized medicine” health care systems to find best practices and suggest a pilot program within the United States.

Local or Personal Actions

• Hold and attend more forums on the subject, and involve community leaders and health careprofessionals in the discussions.

• Pay more attention to national andlocal health care issues and how theymay have a personal impact on areafamilies.

• Promote local health care successesso others can learn from good fortuneand best practices.

• Develop a “new resident to the community” program to educate newcomers about the local healthcare system and how to access it.

• Respond to community health needsfaster.

• Learn more about the health caresystem and environment in general.Additional education was thought tolead to more ideas.

• Begin an initiative to improve health care education in local school systems. The program could encourage children to be healthier.

• Suggest local schools make theirlunches healthier. Partnering witharea hospitals to provide more nutritious meal ideas to schoolscould be helpful.

• Train local doctors to be well versedon prevention and education, in addition to their training on treatingthe ill.


Methodology

The following five research methods were used:

Issue Book Framing CommitteeInterviews• Barb Brown• Patty Dineen• Betty Knighton• Renate Pore• Taylor L. Willingham• Ruth Yellow Hawk

Moderator and Convenor Interviews• American Association of Family and

Consumer Sciences (AAFCS),Alexandria, VA

• Avera Hospital, Dell Rapids, SD• Center for Community Leadership

Development and Public Policy,Montgomery College, Montgomery, MD

• Central Washington University, Ellensburg, WA

This report is based on an analysis of what happened in 40 of the hundreds ofNational Issue Forums that have taken place, and continue to take place, on this issueacross the United States. It describes what happened as diverse groups of people cametogether and deliberated about issues related to health care. Forum participants represented in this report came from the states indicated on the map.

• ChangeWorks of the Heartland, Columbus, OH

• Custer Youth Development Center,Pierre, SD

• East End Listening Project, East EndFamily Resource Center, Charleston,WV

• Estherville Community Center,Estherville, IA

• Florence County Library, Florence, SC• Harding University, Searcy, AR• Iowa State University Extension,

Ames, IA• Learn and Serve America, Project 540,

Oklahoma State Department ofEducation, Oklahoma City, OK

• Mahaska County Extension,Oskaloosa, IA

• Mahaska County ISU ExtensionAuditorium, Des Moines, IA

Appendix


Moderator and Convenor Interviews(continued)• Minnesota Humanities Commission,

St. Paul, MN• Norman Planning Committee, Norman

Public Library, Norman, OK• Root Cause, Austin, TX• Santa Fe Community College,

Santa Fe, NM• Skyway Senior Center, Minneapolis, MN• Sumter County Library, Sumter, SC• Sussex County Librarians, Sussex, DE• The Columbus Council for Public

Deliberation, Columbus, OH• The South Dakota Issues Forums,

Sioux Falls, SD• Tri-County Rural Health Network’s

Community Connectors, MO• University of Hawaii, Manoa, HI• University of Maryland Extension

Program, College Park, MD• University of Maryland,

College Park, MD• Washington Affiliation of Family

Community Service (WAFCS)• West Virginia Center for Civic Life,

Charleston, WV

Forum Observation• Avera Hospital, Dell Rapids, SD• Avera Hospital, Sioux Falls, SD• Iowa Community Center, Estherville, IA• Skyway Senior Center, Minneapolis, MN• Worthington Public Library,

Worthington, OH

Questionnaire ResultsAfter the forum, participants were askedto complete a questionnaire that framesthe issue and identifies key tradeoffs fordifferent choices. In preparing this report,Paul Werth Associates analyzed the 1,027surveys received by May 12, 2004.

Moderator Reports• Avera Health, Health Care Report, Dell

Rapids, SD• Class IX of the Randolph County

EXCEL, Inc., MO• Democratic Deliberation: Our Delta

Experience, The Tri-County RuralHealth Network’s CommunityConnectors, MO

• Examining Health Care, MahaskaCounty Health Care Forum, IA

• Examining Health Care, NormanPlanning Committee, Norman PublicLibrary, Norman, OK

• Examining Health Care, NorthwestLibrary, Columbus, OH

• Examining Health Care, State College, PA

• Examining Health Care, Sussex CountyLibrarians, August 21, 2003,Georgetown, DE

• Examining Health Care, The ColumbusCouncil for Public Deliberation,Columbus, OH

• Examining Health Care, University ofHawaii, College of Social Sciences,Manoa, HI

• Iowans Talk About Examining HealthCare: What’s the Public’s Prescription?Iowa Partners in Learning, Des Moines, IA

• Report for Council on Public PolicyEducation Cooperative Agreement (Ref.25.30.05), University Extension,Missouri Community Development,Columbia, MO

• Report on Health Care Forums inTexas, Austin, TX

• South Dakota Issues Forum Report,Aberdeen, SD

• The American Association of Familyand Consumer Sciences (AAFCS) PublicPolicy Committee, Alexandria, VA

• West Virginia Center for Civic Life,Charleston, WV

Special Thanks to:Sue Adams, Kellen Barnhart, PriscillaBondhus, Don Bower, Bonnie Braun,Judy Breiland, Barb Brown, JaneCunningham, Dave Dillon, Patty Dineen,Lloyd Eisenberg, Karen Felton, SadieFlucas, Steve Herminghausen, SandraHodge, Helen Jenkins, Janelle Jones,Chris Kloth, Betty Knighton, Sue Miles,Patty Miley, Amy H. Nossaman, Dave Patton, Renate Pore, Julie Pratt, Lisa Pryor, Bruce Robb, Mary EllenSaunders, Michelle Scott, DouglasScutchfield, M.D., Harris Sokoloff,Meredith Southerd, Roxanne Trees, Kristi Wagner, David Wilkinson, Sue E. Williams, Taylor L. Willingham,Beth Wilson, Ruth Yellow Hawk

Appendix


Appendix

Questionnaire Results: Demographics

Below are summary statistics that describe the participants. Percentages may not total 100 due to rounding.

Table 1

Percent of Total

Your employer 54%

Medicare 18%

Medicaid 2%

You/Self-pay 35%

Other 1%

I have no health insurance 5%

No answer 6%

* Participants can select more than one option. Therefore, the total is greater than 100 percent.

Table 3

Table 2

Percent of Total

Rural 16%

Small town 41%

Large city 19%

Suburban 19%

No answer 6%

Percent of Total

17 or younger 3%

18-30 17%

31-45 16%

46-64 39%

65 or older 22%

No answer 4%

How old are you?

Where do you live?

Who pays for your health insurance?*


Appendix

Table 8

Are you thinking differently about this issue Percent now that you have participated in the forum? of Total

Yes 41%

No 48%

No answer 11%

Table 7

In your forum, did you talk about aspects of Percent the issue you had not considered before? of Total

Yes 67%

No 24%

No answer 9%

Table 6

Percent of Total

1-3 82%

4-6 6%

7 or more 3%

Not sure 4%

No answer 6%

Table 4

Percent of Total

African American 4%

Asian American 2%

Hispanic 2%

Native American 3%

White/Caucasian 81%

Other 3%

No answer 6%

Table 5

Percent of Total

Male 30%

Female 65%

No answer 5%

How many forums have you attended?

Are you male or female?

Race


Appendix

Movement between Issues Was Primarily ComplementaryThroughout the course of the forum, participants engaged in fluid discussion

with minimal disagreement. For example, the options offered in the issue book werediscussed with no significant controversy. Because all the options presented werethought to be complementary, participants did not need to debate over which one tochoose.

The Issue of Health Care Was Too Large for a 90-Minute DiscussionBecause of the complexity and the magnitude of issues surrounding the health care

industry, participants were not able to thoroughly address the issue in a 90-minuteforum. Because the first third of many forums was spent bringing everyone up tospeed with the industry and its issues, the forum primed participants for further discussion. Some participants suggested a series of three forums on the topic. Eachforum would tackle one approach.

Localized Stories Have More Impact Than National StatisticsNational stories about issues in health care made little or no impact on participants.

Instead, local and personal stories piqued their interest and created very emotionalresponses.

Much Interest in Opinions from Different PerspectivesParticipants and moderators were interested in learning the opinions of those

in areas with unique health care needs. For example, they would like to seek the opinions of those affected by health care in Florida, Texas, and the West Coast — all of which have unique health care environments. In addition, participants were curious about the views of African Americans, Hispanics, and people from otherdiverse ethnic backgrounds who were not equally represented in the forums.

Almost everyone who participated had access to health care. Very few admitted tonot having access to care when they needed it. Citizens would like to involve in futurediscussions those who do not have health care.

Other Notables


Appendix

The issue book contained a single questionnaire that participants were asked tocomplete at the end of each forum. In the following tables, we provide the tabulationsfrom the 1,027 questionnaires completed as of May 12, 2004.

Please note that those who filled out a questionnaire were a self-selected group and thus the findings should not be construed as polling data. These results should be interpreted in the context of the qualitative analysis presented in this report tounderstand better how a particular diverse set of Americans felt about health careafter deliberating the issue.

Analysis of Post-Forum Questionnaires

Overall, participants in the forums believe that citizens should have access to somekind of health care insurance or coverage and that doctors should treat their patientsas partners in their health care. This is directly supported by discussions occurringthroughout the forums. Of note is that while citizens believe Americans should havesome kind of health insurance, there are mixed opinions on the need for universalcare and how this coverage should be paid for.

A little more than half of the participants believe minorities do not receive the same quality of care as whites. Primarily African Americans and Hispanics believethere is inequality in care. Also, African Americans, more so than other races, believepatients often have no one to oversee their entire health care experience. Nonwhiteparticipants more strongly favor the public having access to information about doctors’ mistakes.

Percent Percent Total“Somewhat “Strongly Percent

Agree” Agree” “Agree”

23% 69% 92%

30% 61% 91%

38% 50% 88%

30% 53% 83%

41% 37% 78%

32% 25% 57%

Do you agree or disagree with the statements below?

All Americans should have some kind of health insurance.

Doctors should treat patients as full partners in their own health care.

Patients dealing with many parts of the health care system often have no one to oversee the whole picture.

Huge malpractice awards are driving up the cost of health care.

The public should have easier access to information about doctors’ mistakes.

Regardless of income, minorities do not receive the same quality of health care as whites do.

Table 1

Level of agreement on key issues facing the health care industry


Appendix

Percent Percent Total“Somewhat “Strongly Percent

Favor” Favor” “Favor”

33% 52% 85%

40% 43% 83%

47% 34% 81%

37% 39% 76%

29% 46% 75%

51% 20% 71%

42% 28% 70%

47% 14% 61%

32% 35% 67%

Do you favor or oppose each of these actions?

Expand Medicare to include prescription drugs.

Require doctors to be retested periodically to ensure that they are still competent.

Create local and regional health care systems to make doctors and hospitals share services and equipment.

Make people whose choice of behavior threatens their ownhealth pay more for insurance.

Set caps on awards for medical lawsuits.

Doctors should spend more time with their patients, EVEN IF this raises the cost of health care.

All Americans should have access to basic health care services,EVEN IF this means cutting coverage of some costly treatments.

Health care providers should coordinate and share facilities andresources, EVEN IF patients would have to wait longer for someservices.

Provide health care to all Americans through a government-funded system.

Table 2

Reactions to Proposed Health Care Solutions

Analysis of Post-Forum Questionnaires

Of the proposed actions, forum participants are most in favor of expanding Medicareto include prescription drugs, requiring doctors to be retested, and making doctorsand hospitals share services and equipment. Two thirds of the participants, mainlyAfrican American and Hispanic, are in favor of a government-funded system.

More than three-fourths of the participants believe that citizens who act inunhealthy manners should pay more for their insurance. This is consistent withnumerous comments made throughout the forum.


Appendix

National Issues Forums bring togethercitizens around the nation to discuss challenging social and political issues ofthe day. They have addressed issues suchas the economy, education, health care,foreign affairs, poverty, and crime.

Thousands of civic, service, and religious organizations, as well as libraries,high schools, and colleges, have sponsoredforums. The sponsoring organizationsselect topics from among each year’s most pressing public concerns and thendesign and coordinate their own forumprograms, which are held through the fall, winter, and spring.

A different kind of talkNo two forums are alike. They range

from small study circles to large gatherings modeled after town meetings,but all are different from everyday conversations and adversarial debates.

Since forums seek to increase understanding of complicated issues, participants need not start out withdetailed knowledge of an issue. Forumorganizers distribute issue books such as this one, featuring a nonpartisanoverview of an issue and a choice of several public responses. By presentingeach issue in a nonpartisan way, forums encourage participants to take afresh look at the issues and at their own convictions.

In the forums, participants share their opinions, their concerns, and their knowledge. With the help of moderatorsand the issue books, participants weighseveral possible ways for society to address a problem. They analyze eachchoice, the arguments for and against it,and the tradeoffs and other implications of the choice. Moderators encourage participants, as they gravitate to oneoption or another, to examine their basicvalues as individuals and as communitymembers.

The search for common groundForums enrich participants’ thinking on

public issues. Participants confront eachissue head-on, make an informed decisionabout how to address it, and come toterms with the likely consequences of their choices. In this deliberative process,

participants often accept choices that are not entirely consistent with their individual wishes and that impose coststhey had not initially considered. This happens because the forum process helps people see issues from differentpoints of view; participants use discussionto discover, not persuade or advocate. The best deliberative forums can help participants move toward shared, stable,well-informed public judgments aboutimportant issues.

Participants may hold sharply differentopinions and beliefs, but in the forumsthey discuss their attitudes, concerns, and convictions about each issue and, as a group, seek to resolve their conflictingpriorities and principles. In this way, participants move from making individualchoices to making choices as members of a community — the kinds of choicesfrom which public action may result.

Building community through public deliberation

In a democracy, citizens must cometogether to find answers they can all live with — while acknowledging that individuals have differing opinions. Forums help people find the areas wheretheir interests and goals overlap. Thisallows the emergence of a public voice that can give direction to public policy.

The forums are nonpartisan and do not advocate a particular solution to anypublic issue, nor should they be confusedwith referenda or public opinion polls.Rather, the forums enable diverse groupsof Americans to determine together what direction they want policy to take,what kinds of action and legislation theyfavor and what, for their common good,they oppose.

Moving to actionForums can lead to several kinds of

public action. Generally, the public voicethat emerges helps set the government’scompass, since forum results are sharedwith elected officials each year. Also, as a result of attending forums, individualsand groups may decide individually or with others to help remedy a public problem through citizen actions outside of government.

About National Issues Forums


Appendix

About Paul Werth Associates

Paul Werth Associates is a full-service public relations, public affairs, and marketing communications firm that provides research, strategic counsel, and implementation of results-driven communications programs to help clients build successful relationships with their constituents. The firm hasattained a national reputation for its high-quality, pragmatic approaches to communications challenges.

As a result, the firm has won numerous awards from professional associationsfor campaigns carried out on behalf of clients. Paul Werth Associates is the onlypublic relations firm with headquarters in Ohio to have won the prestigious SilverAnvil Award — the highest national honor of the Public Relations Society ofAmerica — nine times.

Founded in 1963, Paul Werth Associates is a founding member of the Council ofPublic Relations Firms, and the firm’s president sits on the executive committee.

Research ServicesWerth’s in-house Research Services division provides clients with integrated

solutions in support of their communication efforts. The group specializes in themanagement and execution of complex research challenges in areas ranging frompublic opinion sampling and marketing image studies to employee and customersatisfaction assessments. Services include research, survey design, interview execution, data analysis and interpretation, presentation of research findings, and action planning.

Research LeadScott Zunic is vice president of Research Services for Paul Werth Associates.

Zunic has successfully managed more than 250 marketing research projects for both professional and consumer audiences throughout the country. Typicalresearch projects include brand development (for product launches), company and product positioning, brand character/personality creation and measurement,message and concept testing, registry and e-commerce development, customersegmentation, customer satisfaction, ROI measurement, and others.

In Zunic’s 12 years of health care marketing research experience, he has consulted with, planned, and implemented marketing research with numerous companies including Abbott Labs, AstraZeneca, Cardinal Health, Children’sHospital, CINGA, Eli Lilly, Duke University Medical Center, Genentech, Johnson & Johnson (EES), Medicis, Merck, Pharmacia, Procter & Gamble, Roche, RossLaboratories, OhioHealth System, Ohio Department of Insurance, Ohio StateMedical Association, The Cleveland Clinic Health System, The Ohio StateUniversity Medical Center, United HealthCare, and University Hospitals HealthSystem. Zunic has also performed advanced marketing research with one-third of the health plans in the United States.

He completed his B.S. in Marketing from The Ohio State University and his M.B.A. from Franklin University. He has 148 hours of additional marketingresearch education at the A.C. Nielson/Burke Institute. Topics of study included Market Research, Market Analysis, Advertising Research, Focus Group Facilitation, and Introductory and Advanced Questionnaire Design.

Zunic teaches undergraduate and graduate Marketing Research courses at Franklin University and serves on the advisory board for their MarketingDepartment.

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Examining health care, what's the public's prescription?

Healthcare

Transcript of Examining health care, what's the public's prescription?