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Journal ArticleDOI

Medicaid managed care: Issues for beneficiaries with disabilities

01 Jan 2015-Disability and Health Journal (Elsevier)-Vol. 8, Iss: 1, pp 130-135

TL;DR: As more states move people with disabilities to Medicaid managed care, it is critically important to address identified issues for a population that often experiences substantial health disparities and a smaller margin of health.
Abstract: Background: States are increasingly turning to managed care arrangements to control costs in their Medicaid programs. Historically, such arrangements have excluded people with disabilities who use long-term services and supports (LTSS) due to their complex needs. Now, however, some states are also moving this population to managed care. Little is known about the experiences of people with disabilities during and after this transition. Objective: To document experiences of Medicaid enrollees with disabilities using long-term services and supports during transition to Medicaid managed care in Kansas. Methods: During the spring of 2013, 105 Kansans with disabilities using Medicaid long-term services and supports (LTSS) were surveyed via telephone or in-person as they transitioned to managed care. Qualitative data analysis of survey responses was conducted to learn more about the issues encountered by people with disabilities under Medicaid managed care. Results: Respondents encountered numerous disability-related difficulties, particularly with transportation, durable medical equipment, care coordination, communication, increased out of pocket costs, and access to care. Conclusions: As more states move people with disabilities to Medicaid managed care, it is critically important to address these identified issues for a population that often experiences substantial health disparities and a smaller margin of health. It is hoped that the early experiences reported here can inform policy-makers in other states as they contemplate and design similar programs. 2015 Elsevier Inc. All rights reserved.
Topics: Medicaid managed care (78%), Medicaid (68%), Managed care (62%), Population (53%), Health equity (51%)

Content maybe subject to copyright    Report

Brief Report
Medicaid managed care: Issues for beneficiaries with disabilities
Jean P. Hall, Ph.D.
a,d,
*
, Noelle K. Kurth, M.S.
a
, Shawna L.C. Chapman, Ph.D.
b
, and
Theresa I. Shireman, Ph.D.
c
a
Institute for Health and Disability Policy Studies, University of Kansas, 1122 West Campus Rd., Room 517, Lawrence, KS 66045, USA
b
Duke University School of Medicine Department of Psychiatry and Behavioral Sciences, Box 3903, Durham, NC 27710, USA
c
Department of Preventive Medicine and Public Health, University of Kansas Medical Center, 3901 Rainbow Blvd, Mailstop 1008, 4030 Robinson,
Kansas City, KS 66160, USA
d
Department of Health Policy and Management, University of Kansas Medical Center, 3901 Rainbow Boulevard, Mailstop 3044, 5001 Student Center,
Kansas City, KS 66160, USA
Abstract
Background: States are increasingly turning to managed care arrangements to control costs in their Medicaid programs. Historically,
such arrangements have excluded people with disabilities who use long-term services and supports (LTSS) due to their complex needs.
Now, however, some states are also moving this population to managed care. Little is known about the experiences of people with disabil-
ities during and after this transition.
Objective: To document experiences of Medicaid enrollees with disabilities using long-term services and supports during transition to
Medicaid managed care in Kansas.
Methods: During the spring of 2013, 105 Kansans with disabilities using Medicaid long-term services and supports (LTSS) were
surveyed via telephone or in-person as they transitioned to managed care. Qualitative data analysis of survey responses was conducted
to learn more about the issues encountered by people with disabilities under Medicaid managed care.
Results: Respondents encountered numerous disability-related difficulties, particularly with transportation, durable medical equipment,
care coordination, communication, increased out of pocket costs, and access to care.
Conclusions: As more states move people with disabilities to Medicaid managed care, it is critically important to address these iden-
tified issues for a population that often experiences substantial health disparities and a smaller margin of health. It is hoped that the early
experiences reported here can inform policy-makers in other states as they contemplate and design similar programs. Ó 2015 Elsevier Inc.
All rights reserved.
Keywords: Disabilities; Medicaid; Managed care; Long-term services and supports (LTSS)
Over the last few years, more and more states have moved
at least parts of their Medicaid populations to managed
care.
1e3
Due to their complex health care needs, people with
disabilities were often left out of such arrangements. Howev-
er, states are increasingly experimenting with adding at least
some groups with greater health care needs to managed
care.
4e7
Many Medicaid beneficiaries with disabilities use
long-term services and supports (LTSS), usually through
home and community-based service (HCBS) waivers, for
assistance with activities of daily living. While these services
are less medical in nature, they are nonetheless critical to the
health and function of many people with disabilities.
Because people with disabilities, particularly those using
LTSS, are an expensive population for state Medicaid pro-
grams,
8
the interest by states in using managed care to poten-
tially cut costs is not surprising. In 2012, 16 states placed at
least some beneficiaries using LTSS into Medicaid managed
care, with only seven doing so statewide for all LTSS, for a
total of about 390,000 beneficiaries nationally. In 2014, 26
states are projected to have managed care programs in place
for Medicaid LTSS, including HCBS, for a total of more than
1.8 million people.
7,9
The state of Kansas implemented statewide Medicaid
managed care, known as KanCare, in January 2013. Bene-
ficiaries were auto-assigned to one of three for-profit
managed care organizations (MCOs), with the option to
External funding information: Portions of data collection for this proj-
ect were conducted under a grant from the U.S. Department of Education,
National Institute on Disability and Rehabilitation Research (NIDRR)
grant number H133G100082. However, the contents do not necessarily
reflect the policy of the Department of Education, and readers should
not assume endorsement by the Federal Government.
Findings from the study were presented at the AcademyHealth Annual
Research Meeting in San Diego, CA on June 8, 2014.
The authors have no conflicts of interest to declare.
* Corresponding author. Tel.: þ1 785 864 7083; fax: þ1 785 864 7799.
E-mail address: jhall@ku.edu (J.P. Hall).
1936-6574/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.dhjo.2014.08.010
Disability and Health Journal 8 (2015) 130e135
www.disabilityandhealthjnl.com

change to one of the others if desired.
10,11
KanCare
includes the adult disabled population and all HCBS waiver
participants. Previously, the adult disabled population
had been in a fee-for-service program with access to all
Medicaid providers and with case management of their
LTSS provided by local community-based organizations.
People with disabilities are particularly sensitive to
small changes in access to care and have unique needs that
may differ substantially from those of other Medicaid ben-
eficiaries.
4,7,12
It is therefore extremely important to docu-
ment their experiences, and needed improvements in their
services, as more and more people with disabilities are
moved to managed care.
13
Other studies documenting the
use of managed care for Medicaid LTSS have been
conducted in the past few years.
5,10,14,15
None of these
studies, however, gathered data directly from the Medicaid
beneficiaries themselves, but rather based findings on pol-
icy reviews and interviews with providers, advocates, legis-
lators, and Medicai d agency staff. To fill this critical gap in
the literature, 105 adults with a variety of disabilities who
use LTSS were surveyed during the transition to the Kan-
Care program. The aim was to assess consumer satisfaction
at approximately six months into the new program and to
identify early challenges and gaps in care occurring under
this new delivery system. While a majority of study partic-
ipants reported being satisfied with KanCare, some
disability-related concerns emerged and are documented
here. These issues must be addressed by managed care
organizations to serve this population better in the future.
Methods
This study utilized a survey administered in person
or via telephone with KanCare participants receiving
LTSS through a Medicaid HCBS waiver or the Medicaid
Buy-In program in Kansas. The survey was conducted
between April and August 2013, subsequent to implemen-
tation of KanCare, to document early experiences for this
population.
Sample
The sampling frame for this study included participants
from a prior survey of Kansans with disabilities
16
aged
18e64 (n 5 69) and new participants (n 5 36) recruited
via flyers posted at C enters for Independent Living (CILs)
acro ss the state . The survey was admini ster ed by tele-
phone (n 5 69) or in -person at CILs (n 5 36) by two
researchers following scripted administration protocols
developed for the study. All potential participants were
given the option of being entered in a drawing for a
$100 gift card regardless of survey completion. Informed
consent was obtained verbally and responses de-
identified. The University of Kansas Institutional Review
Board approved this study.
Survey instrument(s)
The survey instrument contained demographic items and
health care access questions. Respondents were asked if
they were able to access certain types of health care (med-
ical care from a doctor, services from a mental health pro-
vider or counselor, and prescription drugs) when needed
‘since KanCare began. Items also included open-ended
probes for those who indicated they had access problems.
Additional questions, some open-ended, queried partici-
pants about their general experiences since implementation
of managed care, particularly regarding communication,
the managed care organizations, and satisfaction with the
KanCare plans.
Analyses
Descriptive statistics were utilized to characterize the
sample (Table 1). A researcher trained in qualitative
methods who did not administer surveys analyzed the
open-ended response data using conventional content anal-
ysis, a methodology that requires researchers to immerse
themselves in data and allows codes, categories and themes
to emerge.
17,18
The researcher initially read data, identified
pertinent areas of text, pile sorted areas into like categories
and used categories to construct codes. Data were reread
and coded and final coded text was used to construct
themes.
18,19
After discussing prelim inary themes with the
other researchers, including those who administered the
survey, and developing consensus on topics, she again
reviewed and sorted the responses into identified topics
and confirmed themes. Researchers met again to discuss
and concur with final themes. This methodology is
commonly used for analysis of data in similar studies.
20e25
Results
The study sample demographics are included in Table 1;
the sample was drawn from approximately 15,000 people
with disabilities enrolled in one of the three adult,
non-elderly waiver programs in Kansas (physical disability,
traumatic brain injury, and intellectual/developmental
disability).
26
A majority of respondents e 64% e reported
being satisfied or very satisfied overall with KanCare. Over-
all, 9.5% reported that their benefits had improved while
13.3% reported their benefits had gotten worse after imple-
mentation of managed care (Table 1). Compared to previous
surveys with this population,
16
respondents were more
likely to report fair or poor health and to have difficulties
obtaining certain types of medical care post-KanCare imple-
mentation, particularly mental health providers and
prescription drugs. Qualitative analysis of open-ended items
yielded five distinct categories of respondent comments
regarding their experiences with KanCare: 1) provider
networks, 2) limitations in covered benefits, 3) transporta-
tion, 4) communication and 5) care coordination. These
131J.P. Hall et al. / Disability and Health Journal 8 (2015) 130e135

themes are provided with representative quotations in
Table 2 and described below.
Provider networks
When asked if they were unable to access needed med-
ical services since KanCare began, 24.8% responded yes
(Table 1). One respondent, living on the border to another
state, reported that the specialists she had seen for years
in the adjacent state were unwilling to accept KanCare.
Similarly, others reported being unable to see specialists
they needed and were able to see in the past such as neu-
rologists, urologists, dentists, optometrists, and (most
commonly) mental health therapists or counselors. Having
a limited pool of providers available was also cited as chal-
lenging, especially in the more rural areas of the state. One
consumer said, ‘Speech therapy is a two-and-a-half month
wait because there’s only one provider for my MCO.
Limitations in covered benefits
Respondents particularly noted problems accessing
medications post-KanCare implementation. Medications
that were difficult to obtain included those for pain and in-
continence, as well as over-the-counter medicines that were
previously covered. Respondents now had to pay for these
medications out of pocket or simply stop taking them: ‘I
can’t get [medication name], so I’m just not taking it. I
need it, though. Additional coverage limitations were re-
ported, including one individual who explained that cathe-
ters were covered, but not the gel needed to insert them
saying, ‘It makes no logical sense. Another respondent
reported, ‘I have extreme neuropathy in my hands and have
to use a certain type of [glucose] meter because of my hand
weakness. My MCO won’t cover that type; I may have to
stop testing. Other limitations related to individuals’ dis-
abilities were also mentioned, ‘I use a wheelchair and
get pressure sores on my feet. My doctor says I need a shoe
insert to stop them, but it’s not covered. So, I wait until it
gets more major and then go to the doctor or hospital
repeatedly . And, ‘I had to pay $700 to get a joystick
on my new wheelchair; they [MCO] won’t cover it even
though I’m a quad [riplegic]. Finally, 16.2% of respon-
dents reported they had been unable to access all of the
waiver services they did before KanCare (Table 1).
Transportation
While the survey did not ask questions specifically
related to transportation, respondents independently cited
transportation as an issue. Prior to KanCare, most non-
emergency medical transportation was provided by
locally-operated and familiar entities. After KanCare im-
plementation, several respondents had difficulty obtaining
accessible, medically necessary transportation. A woman
who uses a power wheelchair reported instances of being
sent an inaccessible car and being transferred inco rrectly,
resulting in a lack of safety and consequent injury. Simi-
larly, respondents reporte d that their personal care atten-
dants, on whom they rely for assistance with transferring
and other tasks, were not allowed to be paid to accompany
them to medical appointments. Others reported that the
notice required to obtain transportation was a barrier:
‘My doctor’s office changed my appointment time, but
Table 1
Sample demographics and selected survey items (n 5 105)
Item %
Demographics
Mean age (SD, range) 50.8 (10.5, 27e82)
Gender, female 52.4
Race, white 80.0
Ethnicity, Hispanic 2.9
Disability type
Physical
a
40.0
Intellectual
b
24.8
Chronic illness
c
22.9
SPMI
d
7.6
Sensory
e
3.8
Undisclosed 1.0
Location
Frontier/rural
f
32.4
Semi-urban/urban
g
32.4
Metropolitan
h
35.2
Report fair or poor health 57.2
Access to care & satisfaction measures
Unable to access needed medical services 24.8
No access problems identified 72.3
Don’t know 2.9
Unable to access needed waiver services 16.2
No access problems identified 72.4
Don’t know 11.4
Overall satisfaction with MCO
Satisfied/very satisfied 63.8
Neither 16.2
Dissatisfied/very dissatisfied 10.5
Don’t know 9.5
Report change in Medicaid medical benefits after managed care
implementation
Improved 9.5
Gotten worse 13.3
Stayed the same 64.8
Don’t know 12.4
Respondents with comments pertaining to five themes identified via
qualitative analysis
Limitations in covered benefits 21.9
Provider networks 13.3
Communication 12.4
Care coordination 11.4
Transportation 10.5
Reported at least one problem theme 45.7
Reported two or more problem themes 18.1
a
e.g., paraplegia, spina bifida, amputations and traumatic brain injury.
b
e.g., Down syndrome, phenylketonuria, and autism.
c
e.g., end stage renal disease, lupus, epilepsy, and cystic fibrosis.
d
e.g., schizophrenia, bipolar disorder, and depression.
e
e.g., hearing and visual impairments, deafness and blindness.
f
< 40 people/sq mile.
g
41e149 people/sq mile.
h
> 150 people/sq mile.
132 J.P. Hall et al. / Disability and Health Journal 8 (2015) 130e135

the MCO won’t change the pickup time because it is not
three days notice. Finally, issues of trust arose when
MCOs contracted with new, and often non-local, transpor-
tation providers.
Communication
Respondents cited various difficulties in communicating
effectively with the MCOs. Fifty-one percent of survey
Table 2
Consumer experiences with managed care
n
a
Category/theme Representative quotes
14 Provider networks ‘None of the providers I have seen for years in Jackson County Missouri takes KanCare.
‘I can’t see my neurologist.
‘I can’t find a mental health therapist who accepts KanCare.
‘I am finding no dentists in western Kansas who will accept KanCare and our optician won’t participate because
of the hassle.
‘Speech therapy is a two and a half month wait because there’s only one provider for
my MCO.
23 Limitations in covered benefits ‘I can get all except pain relief, it is over the counter and they won’t pay for that.
‘Can’t get [medication name], so I’m just not taking it. I Need it though.
‘MCO does not cover my incontinence medicine, so now I have to pay out of pocket.
‘I have extreme neuropathy in my hands and have to use a certain type of meter because of the hand weakness.
My MCO won’t cover that type; I may have to stop testing my blood.
‘They [MCO] cover catheters, but the gel for catheter insertion is no longer covered. It is only $5-6 a tube, but it
makes no logical sense.
‘I use a wheelchair and get pressure sores on my feet. My doctor says I need a shoe insert to stop the sores, but
it’s not covered. So, I wait until it is more major and go to the doctor or hospital repeatedly for them to fix the
aftermath.
‘I had to pay $700 to get a joystick on my new wheelchair; they [MCO] won’t cover it even though I’m a quad
[riplegic].
‘I need a new cane or walker and a shower chair. I can’t get them even though I have a doctor’s note.
11 Transportation ‘The MCO sent an inaccessible car when they did actually send one.
‘The transportation people don’t transfer me correctly and I’ve gotten hurt.
‘If my PCA [personal care attendant] doesn’t go, I’m not getting strapped in correctly and it’s unsafe.
‘My PCA can’t get paid to go along with me.
‘She [the driver] can’t properly transport me without just about killing medit’s not safe.
‘Once a cab driver showed up with his dog with him. I am allergic to dogs.
‘Someone comes from out-of-statedno local providerdand I don’t know these people and they don’t treat me
well or properly. Before, you knew the person, they were local and usually the same person each time.
‘I have transportation up to appointments in Kansas City and they [MCO] provide it. But, sometimes I have two
appointments and they won’t wait. So, I have to get a hotel and they come back the next day. Very
expensive!’
‘My doctor’s office changed my appointment time, but the MCO won’t change the pickup time because it is not
three days’ notice.
‘Three days notice is hard to give sometimes.
13 Communication ‘The 800 number tells you to go online, but they don’t realize that not everyone has internet access.
‘The MCO said I could get a cell phone with 250 min for free, but as a quad, I can’t use their phone because the
buttons are too small. I Asked if I could use my existing phone (the same cell company), but was told no, they
won’t allow it.
‘Sometimes when I call the MCO the person says they can’t understand me [due to speech impairment]. It’s
rude. They aren’t taking the time to try and understand me. I mean, I’m talking on the phone with you and you
can understand me.
‘When I call the MCO toll-free line, the message says, ‘if you are mentally ill or not competent to handle these
procedures [of the automated system], perhaps you should talk to a person. That’s offensive, to have a
computer tell me I am incompetent. And, you can’t actually get a person. I am hesitant to call now.
‘Get so much mail all the time . it’s hard to remember which is which and what to do with it. I don’t
understand all of it.
‘I don’t like dealing with all the confusing paperwork and everything coming in the mail.
12 Care coordination ‘I had more direct contact with my case manager before [KanCare]. Now, I have to call a number, leave a
message e which doesn’t always get to the care coordinator e and then wait. There is no way to directly
contact them.
‘I can’t get hold of him. I call the number and leave a message, but he never calls me back.
‘No direct line to the care coordinator. It takes a long time to get through and hear backdvery frustrating.
‘You have one [coordinator] for medical, but I don’t have someone for everything else, like problems with my
wheelchair or housing.
‘No real understanding of client needs and choices.
a
Number of individual survey respondents reporting a barrier within this category/theme.
133J.P. Hall et al. / Disability and Health Journal 8 (2015) 130e135

respondents indicated they had contacted their MCO direct-
ly to ask any questions. Of those, 56.0% reported the MCO
did not return their calls in a timely manner and 45.1% indi-
cated that their questions were not answered satisfactorily.
Issues related to both accessibility and disability cul-
tural competency were also raised. Several individuals
with speech impairments reported that MCO staff did
not take the time necessary to understand them. Another
respondent stated, ‘The MCO said I could get a cell
phone with 250 minutes for free, but as a quad [riplegic],
I can’t use their phone because the buttons are too small. I
asked if I could use my existing phone with the same cell
company, but was told they won’t allow it. Consumers
are also told to go online to get their questions answered,
but respondents pointed out that not everyone has Internet
access. Indeed, people with disabilities are significantly
less likely to have access to and use the Internet than
able-bodied individuals.
27
Frequent and confusing mail-
ings and requests for paperwork were also cited as prob-
lematic and overwhelming.
Care coordin ation
KanCare services for individuals on HCBS waivers
include the provision of a Care Coordinator/Manager, a point
person assigned and employed by the MCO who works
directly with consumers to support them in managing their
services.
28
Only half of respondents knew who their Care
Coordinator/Manager was. One consumer cited an inability
to cont act her Care Coordinator/Manager directly: ‘I can’t
get hold of him. I call the number and leave a message, but
he never calls me back. In addition, respondents note that
the coordination is medically oriented and fails to address
non-medical concerns: ‘You have one [coordinator] for
medical, but I don’t have someone for everything else, like
problems with my wheelchair or housing. Prior to KanCare,
case managers at local agencies familiar with local resources
had helped to address such concerns.
Discussion
The purpose of this study was to understand the experi-
ences of Medicaid benefic iaries with disabilities who use
LTSS as they moved to managed care in Kansas. Despite
an overall satisfaction rating of 64%, a number of important
issues were raised related to provider networks, covered
benefits, transportation, communications, and care coordi-
nation. Within these broad categories, lack of disability
cultural competence and awareness of a range of accessi-
bility issues were especially problematic.
In their study of transition to managed care for LTSS
in three states, Saucier, et al
9
highlighted important consid-
erations regarding continuity of care and provider choice.
Similarly, Connolly and Paradise
6
outlined issues of partic-
ular importance for people with disabilities, such as broad
provider networks. Neither article documented the personal
experiences of consumers. Our study of a small sample of
people with disabilities moving to Medicaid managed care
in Kansas provides real-time insights from beneficiaries
during transition. They raise specific areas of concern that
warrant further investigation and remedy by the MCOs to
support enrollees in maintaining health and optimizing
function.
Findings from this study suggest that, as managed care is
extended into LTSS, MCOs will need to become more
aware of, and responsive to, the needs of individuals with
disabilities. Moreover, MCOs must be aware that non-
medical aspects of care may be equally important to the
long-term health outcomes of this population as is more
traditional medical care. Indeed, the National Council on
Disability (NCD)
14
developed 22 principles important in
managed care systems for people with disabilities, many
of which would have addressed issues identified by the
Kansas beneficiaries. Moreover, NCD
14
specifically recom-
mended that ‘States planning to enroll Medicaid benefi-
ciaries in managed long-term services should carefully
analyze the diverse support needs among people targeted
for enrollment and require managed care organizations
(MCOs) to include skilled providers of such services and
supports within their respective provider networks’ (p.
20). As Connolly and Paradise
6
suggest, and NCD
14
affirms, disability-related measures of access and quality
and rigorous monitoring are essential if people with disabil-
ities are to have positive outcomes under managed care.
A few limitations of this study should be noted. First, the
sample size is relatively small and data represent only one
state’s implementation of Medicaid managed care, thus
limiting generalizability. The surveys were administered
in the early months of KanCare implementation, and MCOs
may currently be addressing some of the issues identified.
Finally, because the purpose of the study was to identify
problem areas needing attention, participants were asked
to provide more information when dif ficulties or barriers
were experienced, while positive experiences were not soli-
cited as fully.
Conclusion
This study contributes seldom-considered first-person
experiences among Medicaid beneficiaries with disabilities
newly moved to Medicaid managed care. While not every
participant identified problems, 45.7% of the sample
reported problems in at least one of the five problem areas
identified (Table 1), potentially representing thousands of
individuals in the overall Kansas population using
community-based LTSS. The results reported here provide
specific examples of disability-related access and quality is-
sues that must be addressed as more and more people with
disabilities are placed into managed care arrangements for
both their health services and their long-term services and
supports. State policy makers and managed care organiza-
tions must be aware of these issues and address them
134 J.P. Hall et al. / Disability and Health Journal 8 (2015) 130e135

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Kiyoshi Yamaki, Coady Wing1, Dale Mitchell2, Randall Owen  +1 moreInstitutions (2)
TL;DR: Results of the difference-in-differences (DID) regression analysis suggest that there were no significant state Medicaid cost savings in transitioning people with IDD from FFS to MMC.
Abstract: States have increasingly transitioned Medicaid enrollees with disabilities from fee-for-service (FFS) to Medicaid Managed Care (MMC), intending to reduce state Medicaid spending and to provide better access to health services. Yet, previous studies on the impact of MMC are limited and findings are inconsistent. We analyzed the impact of MMC on costs by tracking Illinois's Medicaid acute health services expenditures for adults with intellectual and developmental disabilities (IDD) living in the community (n = 1,216) before and after their transition to MMC. Results of the difference-in-differences (DID) regression analysis using an inverse propensity score weight (IPW) matched comparison group (n = 1,134) design suggest that there were no significant state Medicaid cost savings in transitioning people with IDD from FFS to MMC.

7 citations


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Journal ArticleDOI
Hsiu-Fang Hsieh1, Sarah E. Shannon2Institutions (2)
TL;DR: The authors delineate analytic procedures specific to each approach and techniques addressing trustworthiness with hypothetical examples drawn from the area of end-of-life care.
Abstract: Content analysis is a widely used qualitative research technique. Rather than being a single method, current applications of content analysis show three distinct approaches: conventional, directed, or summative. All three approaches are used to interpret meaning from the content of text data and, hence, adhere to the naturalistic paradigm. The major differences among the approaches are coding schemes, origins of codes, and threats to trustworthiness. In conventional content analysis, coding categories are derived directly from the text data. With a directed approach, analysis starts with a theory or relevant research findings as guidance for initial codes. A summative content analysis involves counting and comparisons, usually of keywords or content, followed by the interpretation of the underlying context. The authors delineate analytic procedures specific to each approach and techniques addressing trustworthiness with hypothetical examples drawn from the area of end-of-life care.

25,246 citations


01 Apr 2000

17,060 citations


"Medicaid managed care: Issues for b..." refers methods in this paper

  • ...A researcher trained in qualitative methods who did not administer surveys analyzed the open-ended response data using conventional content analysis, a methodology that requires researchers to immerse themselves in data and allows codes, categories and themes to emerge.(17,18) The researcher initially read data, identified pertinent areas of text, pile sorted areas into like categories and used categories to construct codes....

    [...]


Book
01 Jan 1995
Abstract: In "Writing Ethnographic Fieldnotes", Robert M. Emerson, Rachel I. Fretz, and Linda L. Shaw present a series of guidelines, suggestions, and practical advice for creating useful fieldnotes in a variety of settings, demystifying a process that is often assumed to be intuitive and impossible to teach. Using actual unfinished notes as examples, the authors illustrate options for composing, reviewing, and working fieldnotes into finished texts. They discuss different organizational and descriptive strategies and show how transforming direct observations into vivid descriptions results not simply from good memory but from learning to envision scenes as written. A good ethnographer, they demonstrate, must learn to remember dialogue and movement like an actor, to see colors and shapes like a painter, and to sense moods and rhythms like a poet. This new edition reflects the extensive feedback the authors have received from students and instructors since the first edition was published in 1995. As a result, they have updated the race, class, and gender section, created new sections on coding programs and revising first drafts, and provided new examples of working notes. An essential tool for budding social scientists, the second edition of "Writing Ethnographic Fieldnotes" will be invaluable for a new generation of researchers entering the field.

6,607 citations


Journal ArticleDOI
TL;DR: Young adults perceive the new tobacco products positively and are willing to experiment with them, and Eliminating flavors in these products may reduce young adults' intentions to try these products.
Abstract: Objectives. We explored young adults’ perceptions of snus (spitless moist snuff packed in porous bags), dissolvable tobacco products, and electronic cigarettes and intention to try these products.Methods. We conducted 11 focus group discussions involving a total of 66 young adults (18–26 years old) on these new tobacco products (e.g., harmfulness, potential as quit aids, intention to try) held between July and December 2010. We analyzed discussions using a thematic approach.Results. Participants generally reported positive perceptions of the new products, particularly because they came in flavors. Few negative perceptions were reported. Although some participants believed these products were less harmful than cigarettes and helpful in quitting smoking, others thought the opposite, particularly regarding electronic cigarettes. Participants also commented that these products could be gateways to cigarette smoking. Half of the participants, including a mix of smokers and nonsmokers, admitted they would try t...

188 citations


Journal ArticleDOI
TL;DR: Head Start program directors face difficulty in implementing policies and practices to address obesity-and in a national survey, they identified the key barriers as lack of time, money, and knowledge.
Abstract: Head Start provides early childhood education to nearly one million low-income children, through federal grants to more than 2,000 local programs. About one-third of children who enter Head Start are overweight or obese. But program directors face difficulty in implementing policies and practices to address obesity—and in our national survey, they identified the key barriers as lack of time, money, and knowledge. Also, parents and staff sometimes shared cultural beliefs that were inconsistent with preventing obesity, such as the belief that heavier children are healthier. Minimizing those barriers will require federal resources to increase staff training and technical assistance, develop staff wellness programs, and provide healthy meals and snacks.

95 citations


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