These are the original eight variables and the questions that I attached to them. It needs to be stated, however, that Grounded Theory requires iterating and altering the theory as new information comes in. In this section, therefore, I will explain the original variables, the questions based on them, and how they changed as the research went on.
Variable I: Expert Training – One of the goals of this research was to examine how perceptions differ between policy experts and laypeople, which required some assessment of what separates the two groups. For the purposes of this study, people who work professionally in healthcare policy such as professors or government officials are said to possess “expert training.” This is knowledge of how their own country's system works and how healthcare systems work generally. This is the main factor delineating groups A and B from group C. Questions for this variable were open-ended as it was important to see what experts emphasized vs. what laypeople did.
How familiar are you with Taiwan's National Health insurance system on a 5-point scale with 1 being not at all familiar and 5 being very familiar?
◦ Why did you choose that rating?
This question pair was one of the most important for this thesis, and it was asked of everyone, whether or not they were a designated “healthcare expert”. It was important to identify people who might know more about the health system through their job or previous life experience. Subject B3, when asked why she gave herself a 5, responded with, “because I used to work in a (expletive deleted) hospital in Taiwan.”
81 (Kahneman et al. 2000 p. 226)
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Can you describe how Taiwan's National Health Insurance is structured?
This question was originally supposed to elicit a large detailed response from policy experts. However, it very quickly became apparent that this question was far too open-ended. In addition, the responses elicited would be essentially reference material, and it was a waste of the experts'
valuable time to ask them a question which was better served by reading from a book. The level of detail needed and the length of responses I received the first few times I asked this question proved that it was going to be too long and useful enough to use in the study. This question was eventually removed.
How do you use cross-national comparisons in your professional work?
The goal of this question was twofold. The first purpose was to show that policy experts use cross-national comparisons in their professional work.
The second goal was to see how it was integrated with the work they were already doing.
What kind of sources do you use to get information about a health system?
This question served to illustrate the source of expert knowledge.
Variable II: Previous Experience – This variable assessed the role of previous experience with healthcare in creating expectations. Partially, that entails assessing what someone's previous experiences were but it was also trying to illuminate how those experiences generated expectations. In the end, this variable was functionally identical to Variable V: Direct Experience. So I folded them together in the final analysis. .
How often do you go to the doctor? (1-5 almost never - very often )
◦ What does that mean in times per year?
◦ This question pair was to measure both the actual experience of seeing the doctor and investigate what the subject's ideals about going to the doctor were.
According to C2, Taiwanese people go to the doctor an average of fifteen times per year while Americans only go 4.1 times per year.82 It follows that what might seem “occasional” to someone in Taiwan might seem “often” to
82 (McCarthy, 2014 web)
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someone who has been living in America.
Where do you go? (private clinics, hospitals, etc.)
◦ This was important for the study in case there was a significant difference between people who went to the clinic vs, going to the hospital. One of the things that did come up was that some subjects in Group A didn't seem to consider times they went to a clinic, as “going to a doctor.”
Have you ever been covered by the health system of another nation besides the US or Taiwan?
◦ This question was to make sure that no one had been covered in a country that wasn't the US or Taiwan.
Have you been covered under Taiwan's NHI?
What kind of healthcare coverage do (did) you have in the United States?
◦ Both of these questions were to establish what the subject was covered by in the US and Taiwan. Someone with very expansive employer-provided care might perceive the US system differently than someone who lacks insurance.
Have you ever used the health system in the United States?
Have you ever used the health system in Taiwan?
How did you choose your doctor?
Did you use it for urgent or routine care?
◦ These questions were to see the extent of their experience. There were a handful of subjects who had lived in the United States but had never used the medical system there. Their answers were different from those who had had direct experience.
When did you first get health coverage?
How did you first get health coverage?
Describe your first experience with the healthcare system as an adult.
◦ These three questions were removed from the study because the first few times I asked, subjects were unable to remember.
Variable III: Knowledge of What to Expect – This was supposed to illicit how much a person knows about healthcare, but not from direct experience. The goal behind
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looking at this variable was examining how much people form their expectations based on external sources, schools, newspapers, media, family members etc. as opposed to direct experience.
Unfortunately, this variable was similar to “Expectations” and ran into the problem of subjects being unable to recall accurately. Most of the subjects were old enough that the first time they would have learned about the system as a responsible adult was over a decade in the past. They were not able to remember when they first heard about the system vs. experiencing it directly. It quickly became apparent that separating out the external sources of expectations as separate from direct experiences would have required an entirely new study.
How did you learn about the healthcare system?
Do you feel like you were adequately informed about the healthcare system before you used it directly? (1-5 not informed – extremely well informed)
What did you already know and what was new after your first encounter?
Where would you go to learn more about the healthcare system?
◦ None of these questions were used in the final study and this category was eliminated entirely. In retrospect, it might have been useful to ask about preparing to go to America. Alternatively, I could have checked for familiarity with certain sources.
Variable IV: Expectations – This was looking at a person's current expectations for their healthcare system. Current expectations were used because trying to assess expectations prior to direct experiences that were already in the past was likely to produce unreliable results with people unable to recall what they expected at a given time.
If you broke a bone and had to go to the hospital, describe what you think would happen.
◦ What kind of treatment would you receive?
◦ Would it be expensive to treat? (1-5 scale)
▪ How much is that in monetary terms?
◦ How long would it take to get treatment? (1-5 scale very quick – very long
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time)
▪ How much time would that be?
▪ This set of hypothetical questions was given to subjects in Group A for the Taiwan system while subjects in Group B received questions about both the Taiwan and US system. As the study proceeded, the question was changed to “broken arm” rather than “broken bone”. The reason for using a broken arm instead was to give the subjects a common and concrete frame of reference. A broken arm is an injury that most people can think about, and it was a way to see how they would react to a similar
experience. One of the unintended side effects of this question was that it tended to elicit any similar experience that the subject might have had.
Variable V: Direct Experience Seeking Healthcare in Taiwan or the US – These questions asked people to describe the extent of their direct experience with the health system. For example, someone with a chronic illness will use the system more than someone who is healthy and their usage of the system will be different. In practice, this variable was unable to be separated from “Previous Experience”.
If you're comfortable, describe your most recent experience going to the doctor in Taiwan.
If you're comfortable, describe your most recent experience going to the doctor in the US
◦ These two questions elicited a wealth of information and experience. They also were invaluable to characterizing the depth of their experience.
Variable VI: Perceptions of the Experience with the Healthcare System – These questions asked for thoughts about the direct experience that they had. Earlier, the survey asked similar questions about a hypothetical scenario, but here, they were asking about an instance that had actually happened. Here the study was less concerned with how much someone paid objectively or how much time it took to get treatment, and was instead interested to know what the patient thought about the details of the experience, such as expense or how long it took.
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How would you describe the cost of your care? (1-5 cheap - expensive)
◦ How much was that roughly?
Did it take a long time to get treatment?(1-5 scale very quick – very long time)
▪ How much time would you estimate that to be?
▪ These two questions are very much like the questions in Variable IV:
“Expectations”, but those questions asked about a hypothetical and these ones ask about something that actually happened. The first set elicited expectations while this set elicited reactions to an actual experience.
Describe your most recent doctor.
◦ How would you describe his/her professional knowledge?
◦ How would you describe his/her bedside manner?
▪ These questions were removed from the survey because they were related to a different research question. These questions would illuminate
differences between the way patients perceived their doctors but perception of the doctor is not the same thing as perceptions about the system. Furthermore, these questions would have asked laypeople to evaluate a doctor's professional knowledge which, by definition, laypeople are unable to do.
Variable VII: - Ideals for Quality and Value – After measuring perceptions, it was important to ask the subjects why they had those perceptions. What were the
personal metrics that someone was using to form these perceptions? Were they measuring their experiences against some sort of ideal?
Do you feel like your care took a reasonable amount of time? (1-5 agree disagree)
◦ What would be a reasonable amount of time?
▪ These two questions were asked after the direct experience questions but they were really about ideals. At this point, the subject had just said how long an experience with a doctor had taken, and this question asked them if that's how long they felt it should have taken. Did the actual amount of time match their ideal amount of time?
How much do you think it should cost to go to the doctor for a routine checkup?
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◦ What should be included in that checkup?
▪ These two questions were one of the most problematic in the survey, and they illuminated the researcher's preexisting bias. The question was asked based on the researcher’s own American experience where people go see the doctor once a year even if they are not sick for an “annual physical check-up”. From the interviews, it quickly became apparent that this practice was not common in Taiwan. Subjects often didn't understand the variable and had to have it explained or they interpreted it to mean a very complex and costly physical. Two reasons for this seemed apparent. First, Taiwanese people go to the doctor often enough for other reasons that there is no perceived need to go to the doctor when one is not feeling sick.
Second, large expensive physicals are not uncommon. I had known from Hsiou and Pylypchuk that Taiwanese people use preventive care less than the US, but I was surprised by the difficulty. I didn't know it at the time, but this probably represents a good thing for the Taiwan system as a whole. In the past two to three years, there has been compelling research that American style physicals don't do anything to improve outcomes83.
How much should someone pay every month for health insurance?
▪ This was an important question for several reasons. It was designed not only to elucidate a monetary amount, but also to impel the subject to think about the responsibility for paying. It was also revealing for knowing how much money someone thought the system needed to function.
Who should pay for the rest of the cost?
▪ This was an important question, because often the answers given by the subjects to the above question would have resulted in the NHI being insolvent. I wanted to see who the subjects thought should be responsible for compensating for cost overruns.
Would you be willing to raise the monthly premium in order to keep the health insurance system solvent?
▪ This was related to the above two questions. I wanted to see whether a
83 (Emanuel, 2015)
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subject was willing to personally pay more to cover the cost of the NHI.
Unfortunately, I didn't think to add this question until I was halfway through the interviews, so many subjects were never asked.
What kinds of services should be provided by the national health system?
▪ This question aimed to elicit the subject's idea about the obligations of the National health system. In practice, most subjects favored a broad scope of responsibilities such that it became more expedient to change this question to be the services that shouldn't be provided by the NHI.
How long should a doctor spend with a patient?
▪ This question was to address a complaint about Taiwan's system that came up in the literature review and that was echoed by many people during the study. Namely, that Taiwanese doctors spend too little time with their patients. However, if doctors are apparently spending “too little” time, it becomes important to ask how much time would be deemed sufficient.
What do you want from your healthcare?
What do you think is important for a national health system?
▪ Both of these questions were deemed too broad to be useful and removed from the study.
Variable VIII: Perception of the System as a Whole – This variable was to determine a person's perceptions about the healthcare system as a whole either in Taiwan alone or both Taiwan and the United States.
Describe the most important problem with the Taiwan (American) system? How do you think it could be fixed?
▪ This was probably the most illuminating question on the survey. It was one of the areas where there was the most variation between groups A, B and C, as well as revealing how people saw the system. Many people agreed on the problems and solutions and living in America seemed to have a large effect on the responses to this question.
What is the best aspect of the Taiwan (American) system? Why?
▪ This was the reverse of the above question. It was important to see what
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people appreciated in addition to what they disliked. Often times, what someone listed as the biggest problem, like the system being “too convenient,“ for example, would be listed here, by the same subject, as one of the best things about the system.
Is the Taiwan (American) system as a whole expensive? (1-5 scale) Why?
▪ This is a question I didn't put in because I initially thought it was
sufficiently answered by the questions about the hypothetical experience and the direct experiences. In retrospect, this question might have revealed more information.
How do you feel about the quality of care in the Taiwan (American) system? (1-5 scale)
▪ This question was about how the subject saw the system as a whole. I also wanted to see if living in the US or being an expert would change how someone perceived the quality of Taiwan's system.
How convenient is it to go the doctor in Taiwan (America)? (1-5 least to most convenient)
▪ This question was expected to elicit a clear variation between groups A, B, and C. I expected that living in the US would make Group B perceive Taiwan's system as more convenient, but the results showed an almost uniform agreement among the subjects that Taiwan's system was the most convenient.
Knowledge Questions - These were questions that measure some basic
knowledge about the relative pricing and the structure of the NHI. The answers to them determined what the interviewee knew about the relative costs and provisions of the NHI.
All of these questions have answers which are plain facts.
Between the Taiwan and American healthcare system, which is more expensive?
(If asked to clarify, as a share of National GDP)
▪ This question wanted to see if the subject was cognizant of the fact that the US was more expensive.
Which do you think has higher administration costs, the US or Taiwan?
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▪ This question checked to see if they knew that Taiwan's system was much more efficient than the US system.
Who pays the bulk of the NHI premium, the insured, their employer or the government?
▪ This question was important because the cost sharing structure of the NHI is a crucial part of making policy and, to make cogent policy, people need to know how that structure looks like. It was also one of the areas where there was the most difference between laypeople and experts. All of the experts knew that the employers paid the most while only two laypeople from each of groups A and B did.
How long does someone have to live in Taiwan to use the NHI?
▪ This question was considered and then dropped. The problem was that it is only relevant for Taiwanese people who are still living in the United States. It also covers something very specific while the rest of the questions dealt with the system as a whole.
Are drugs more expensive in the US than in Taiwan?
▪ This question was there because I had heard complaints about the expense of certain drugs before the research started. I wanted to know if Taiwanese people understood that drugs in Taiwan are fairly cheap and, if they didn't, would exposure to the US system change their views? As it was, every subject interviewed understood that drugs were cheaper in Taiwan.
What is the percentage of an insured person's income that is used to calculate the NHI premium?
▪ As detailed earlier by the literature review, newspapers and health experts, raising the premium rate has been an acrimonious issue, subject to
political blocks, grandstanding, and arguments. One of the central points of many articles was that even a small raise in the premium spurred
political blocks, grandstanding, and arguments. One of the central points of many articles was that even a small raise in the premium spurred