Journal of ExtensionJune 2000
Volume 38 Number 3

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Ideas at Work


Nebraska's Insurance Purchasing Group Project

Mary Ellen Rider
Consumer Health Policy
Extension Specialist
University of Nebraska
Internet address: merider1@unl.edu

Sam Cordes
Professor of Agricultural Economics
University of Nebraska

The proportion of United States citizens without health care coverage continues to increase. By 1997, more than 16% of the population, or 43 million people, were without coverage. Persons least likely to have health coverage are persons employed in small businesses, the self-employed, and/or low-wage workers (Monheit & Vistness, 1997).

In 1994, Nebraska enacted the Small Employer Health Insurance Availability Act (LB 1222), which allows at least 25 individuals to voluntarily band together for the sole purpose of purchasing insurance. The formation process requires the group to meet certain legal requirements before soliciting a bid from a health insurance company or health care provider.

The initial response to LB 1222 was somewhat disappointing in that no groups had formed by late 1995. Those closest to the legislation felt an education and outreach effort was needed to help establish one or more groups that could be used as a "model" for others. Nebraska Cooperative Extension, in partnership with the University of Nebraska Medical Center (UNMC) and the Nebraska Departments of Health and Insurance, took the lead in developing and implementing such a strategy.

Phase One of the Project

Cooperative Extension and the Nebraska Department of Health provided $5000 each to initiate the project. A seven-person steering committee was established and began meeting in the summer of 1996. This committee included representatives from the four sponsoring agencies plus two Nebraskans who had been active in health issues at local and state levels and had worked closely with the University of Nebraska. Cooperative Extension's representative convened the committee and implemented the resulting plan. Committee deliberations focused on various educational, promotional, outreach, and technical assistance strategies.

The educational and outreach strategy developed by the committee involved three components: awareness, educational follow up, and organizational development.

1. Awareness

Funds were used to develop and pay for "advertisements" with radio stations whose aggregate coverage area included much of rural Nebraska. Initial airing of these advertisements was for two days per week over a three-week period. These ads included an 800 number that interested persons could call. A second round of radio advertisements focused on those areas and stations from which relatively few calls had been received in the initial blitz.

Although these paid radio advertisements were the primary vehicle used for the awareness phase, "gratis" radio and television programming produced by Extension and UNMC were also used. Additionally, a 13-minute videotape containing the 800 number was developed by Cooperative Extension for use with civic organizations and for other opportunities that might arise to heighten the awareness of LB 1222.

2. Educational Follow Up

The 800 number that interested persons could call was answered by a recorded message asking the caller to leave his or her name, address, and phone number. Within one week of each call, a follow-up mailing was sent that included a personally addressed letter and an Extension publication focusing on general information about LB 1222, how to form groups, etc.

3. Organizational Development.

Each call received was logged onto a map of Nebraska to determine which geographical locations would likely have the needed critical mass of interest to generate an insurance purchasing group. An area in Northeast Nebraska was selected in fall 1996. The local Extension Educator took responsibility for bringing together those interested in forming an insurance purchasing group. An Extension Specialist and personnel from the Nebraska Department of Health supported the Educator's efforts.

Project Transition

Unfortunately, the retirement of the local Educator, coupled with the resignation of the resource person provided by the Department of Health, occurred at a critical time, and the momentum for the project slowed. Fortunately, the basic value of the three-part strategy had already been validated.

The leadership for the project then migrated to one of the citizen advocates on the initial steering committee. In late 1997, this person secured $50,000 for follow up and expansion of the initial effort. Two groups, one in Western Nebraska and another in Central Nebraska, began to work toward the formation of insurance purchasing groups. Merging into one group for purposes of obtaining a lower bid with a larger group remained a possibility. Extension continued to be involved in an educational support role and in evaluating the first phase of the project.

Successes and Implications

The project provided an example of the role Extension can play in health policy issues. Other lessons learned included the following.

  • The implementation of legislation often offers an important educational opportunity.

  • A broad-based steering committee was key to the project's success.

  • The promotional methods were successful, especially the 800 number and paid radio advertisements.

  • Although Extension's role is primarily educational, the connection between education and organizational development is often interwoven.

  • The program was seen as having value as evidenced by the willingness of others to contribute to and continue the project. This is an important measure of success.

    Education on health insurance and related issues is important, given today's changing health care system. The Nebraska project met an important need and was also successful in attracting support from persons outside Extension in an effort to bring the innovations of legislation to reality.

    Reference

    Monheit, A. C. & Vistness, J. P. (1997). Health insurance status of workers and their families: 1996. Agency for Health Policy and Research. Available: http://meps.achpr.gov/highlit/97-0065.htm#w/w/oworkingadults Accessed September 10, 1998.


    Learning from Those Who Leave

    Linda M. Kutilek
    Assistant Professor
    Employee Data Network
    Ohio State University Extension
    Columbus, Ohio
    Internet address: kutilek.1@osu.edu

    The primary resource of the Cooperative Extension Service is its staff and volunteers. Because local Extension staff members lead the program process, their loss interrupts program continuity and possibly even creates program voids for periods of time. While some level of staff departure is inevitable, turnover and prolonged vacancies are a financial and time drain for the organization. An Ohio State University Extension study concluded that net costs to Extension are $80,000 each year. This reflects costs to replace all individuals minus salary savings created by the vacancies.

    However, an equally serious aspect of the issue is the loss of program effort that most surely accompanies a staff vacancy. To date, no acceptable method exists to determine just how costly the factor of loss is to the clientele, the Extension system, or to staff morale.

    In 1995, Rousan studied a group of 67 county agents who had voluntarily left the Ohio State University Extension system. As a result, he made a series of recommendations that challenged OSU Extension to investigate further why staff leave and what similar characteristics they might share.

    That work has led to an organizational commitment to gather information to help better understand what motivates staff to leave. Behind the commitment is an expectation that the information will improve recruitment efforts, hiring processes, staff development, supervisory practices, worker expectations, job satisfaction, and the organizational environment as it relates to diversity issues.

    Exit Interviews

    To further the original work, Ohio State University Extension began in 1997 to conduct exit interviews with all staff who left employment. While Rousan (1995) had studied the agent, the current exit interview process extends to all staff. Agents, specialists, administrators, secretaries, and program assistants are included in the interview process. The expanded analysis enables Extension administrators to gain and examine information from individuals with disparate job responsibilities.

    The 1997 group consisted of 84 individuals who voluntarily left the Ohio Extension system; the 1998 group included 87 individuals. All were offered an opportunity for an exit interview; 87% were interviewed in 1997, and 78% in 1998. Interviews were conducted in person or via phone, and the same set of questions was asked each exiting employee.

    A series of open-ended questions was asked of the exiting employee. Questions focused on areas of satisfaction about employment with Extension, reasons for leaving, work environment, relationship with supervisor, and opportunities for professional development. Interviews averaged 50 minutes in length, and ranged from 25 minutes to 2 hours. All conversations were recorded in writing and read back to the exiting employee to confirm accuracy.

    Key words were then coded for data collection. The key words' code came from a pilot study conducted in 1996. In that pilot study, exiting employees at all levels were interviewed to build the initial data pool that led to the development of key word codes.

    All interviews in 1997 and 1998 were conducted by one of two people. Both interviewers independently coded narrative comments to assure some consistency in use of the key codes. Results of the independent activity were then compared to determine how similarly the two used the codes. To address issues of confidentiality, interview forms were coded by a numeric system instead of by name.

    The questionnaire included 15 questions covering 5 categories. Categories of questions included positive aspects of Ohio State University Extension; supervision and support; working conditions; benefits and salary; and career development.

    The four concluding questions were:

  • "What insights or advice about the work setting or job/position would you give to your successor?";

  • "Explain any complaints or areas of dissatisfaction you may have about the total Ohio State University Extension organization";

  • "Other suggestions you may have to help improve the Ohio State University Extension organization"; and

  • "Additional comments concerning the Ohio State University Extension organization, including previously discussed questions and other things that may not have been discussed."

    After the interview was completed, the interviewer noted the key word codes, and the information was entered into the data pool.

    Questionnaire Analysis

    Because the individuals interviewed had uniquely different position descriptions, in addition to the total summary of results, analysis was reviewed by:

    • Gender,
    • Title,
    • Ethnicity,
    • Program area,
    • Level of appointment (i.e., full-time or part-time), and
    • Administrative regions within the state.

    At this point, extensive analysis of data is difficult because the categories created had relatively small numbers of respondents. However, based upon frequency of recurring responses, some observations are emerging.

    The turnover rate of program assistants is much higher than for all other classification of individuals. They reported that job stress and low pay were the reasons for leaving. Agents also noted issues of stress and low pay, but added the dimension of concern about lack of supervisory support.

    These observations led to an expectation that a larger data pool will provide considerable information for improved organizational policies and priorities. The numbers of individuals within each category will continue to grow as additional interviews are conducted. The database is continually updated and will be reviewed annually to assess organizational trends that could provide insight into virtually every area of organizational life. Additional observations can be made based upon the 1997 and 1998 samples as 1999 data are compiled.

    Conclusion

    Rousan's challenges to the organization included the need to study on an ongoing basis the reasons for employee turnover. Ohio has begun to build an ever-increasing database of information that can be applied to strengthening support to the current staff. Turnover rates have remained around 7% for the total Extension staff, 5% for agents. Compared to industry standards, this is a very low rate of turnover and an encouraging indicator of staff stability.

    However, taking the next step in comparing this state's turnover rate to the turnover rate of other Extension systems around the country will be important. Also, making a comparison to other educational institutions may provide insight into the relative significance of a 6-7% turnover rate.

    Reflecting on a 20% turnover rate for the paraprofessional role of program assistant is also important. Is there a clear path of career development for individuals in these roles, or is exiting the system the only opportunity for change? Information gathered from exit interviews may only lead to the development of more questions; however, they are questions that Extension must ask of itself if it is to continue to recognize and meet the needs of staff members.

    Reference

    Rousan, L. (1995). Agent turnover in Ohio State University Extension. Unpublished doctoral dissertation, Ohio State University, Columbus.


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