revised IC

Form Approved

OMB NO. XXXXXXX

Exp. Date. XXXXXXX

Assessment of Unreimbursed Care in Primary Care Practice

Public reporting burden of this collection of information is estimated to average 12 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to:

Doris Lefkowitz

ARHQ Reports Clearance Officer

Attn: PRA (XXX-XXXX)

540 Gaither Road, Room #5036

Rockville, MD 20850

(301) 427–1477

Thank you for taking the time to complete this survey. Your answers are very important and will be used to analyze the current state of unreimbursed care provided in the offices of primary care physicians.

If you have any questions about your rights as a research subject, you are encouraged to contact Jacqelyn Admire, AAFP IRB Administrator, at (800)274-2237 ex. 3110 or [email protected].

This survey is interested in analyzing the unreimbursed care provided in the setting where you spend the majority of your professional time. This does not include volunteer time spent outside of your office or inpatient care provided that is unrelated to patients previously seen in your office.

Survey Number

For this survey, unreimbursed care refers to free or reduced-cost care.

This includes, but is not limited to:

• Discounts offered to patients based upon a demonstrated financial need.

• Encounters when care is delivered and the patient is not charged or billed.

• Scenarios when a bill is generated for administrative purposes, but the office and patient understand payment is not expected.

This does NOT include:

 Scenarios when payment is expected and not received.

 Payment from insurers (including Medicare and Medicaid) that is below a physician’s posted billable rates.

Care provided as a professional courtesy to colleagues or their friends and families.

1) Are you currently a resident or a full-time resident faculty?

Yes	□		GO TO Question 21 on page 15
No	□

2) How many hours do you provide direct patient care during a typical week?

□	<16		GO TO Question 21 on page 15
□	16-25
□	26-35
□	36-45
□	>45

3) Approximately how many patients do you personally see during a typical week?

□	<25
□	25-50
□	51-75
□	76-100
□	101-125
□	>125

For this survey, unreimbursed care refers to free or reduced-cost care.

This includes, but is not limited to:

• Discounts offered to patients based upon a demonstrated financial need.

• Encounters when care is delivered and the patient is not charged or billed.

• Scenarios when a bill is generated for administrative purposes, but the office and patient understand payment is not expected.

This does NOT include:

• Scenarios when payment is expected and not received.

• Payment from insurers (including Medicare and Medicaid) that is below a physician’s posted billable rates.

• Care provided as a professional courtesy to colleagues or their friends and families.

4) Whether or not you provide unreimbursed care, some people have done the following. Have you ever….? (All responses to this survey are strictly confidential and will not be able to be linked to you in any way.)

		Never	Monthly or less	Several times/month	Weekly	Daily
		1	2	3	4	5
Down coded a visit for an unreimbursed care patient
Discarded or voided the billing slip for an unreimbursed care patient
Evaluated an unreimbursed care patient before insurance coverage is verified
Provided more than usual information during a phone consult to an unreimbursed care patient in order to avoid an office visit
Used email to prevent unreimbursed care patients from having to incur office visit charges
Wrote a prescription for an insured patient that is meant for a family member
Called a colleague (including specialists) on behalf of an unreimbursed care patient
Called a lab/radiology service on behalf of an unreimbursed care patient
Gave an unreimbursed care patient medical supplies from your office
Examined two family members but only billed for the insured person
Personally provided an administrative service that would otherwise be charged to the patient
Provided unreimbursed care patients with sample medications from your office
Other (Specify)

5) In your current practice setting do you provide unreimbursed care to patients?

Yes	□		GO TO question 6
No	□

5a) In the past did you provide unreimbursed care to your patients?

(Please do not include your time spent in a residency program)

Yes	□		GO TO question 5c
No	□

5b) What are the reasons you do not provide unreimbursed care?

Please check all that apply.
□	I am not in a position to decide which patients I see and which I do not see
□	The need in my community is met by other free clinics or community organizations
□	There is no tradition in my practice of providing unreimbursed care
□	I do not have the financial ability to provide unreimbursed care
□	I do not think that it is part of my responsibilities as a physician to provide unreimbursed care
□	I am not able to take on unreimbursed care patients because I am fully booked with my other patients
□	Other (Specify)

GO TO Question 5d

5c) What are the reasons you no longer provide unreimbursed care?

Please check all that apply.
□	The practice has considered the matter and feels it no longer has the financial ability to provide unreimbursed care
□	The practice has considered the matter and for reasons other than financial has decided not to provide unreimbursed care
□	I have changed practices and my new practice has a policy discouraging unreimbursed care
□	I have recently started a new practice and I am just getting established. I may provide unreimbursed care in the future
□	There are newly available community resources, such as free clinics, and I refer patients to them
□	I felt like my patients took advantage of me in the past when I provided unreimbursed care
□	Other (Specify)

5d) Which of the following would be needed in order for you to begin providing unreimbursed care?

Please check all that apply.
□	A system to determine eligibility for unreimbursed care that reduces decision making burden
□	Tax credits to allow me to defray some of the costs of providing unreimbursed care
□	More support from the local health care system with referrals and hospitalizations
□	Increased availability of state and Federal assistance for unreimbursed care
□	Increased appreciation from the patients to whom I provide unreimbursed care
□	More flexibility in determining the patients that I am able to see
□	More time to get my medical practice established
□	Increased need within my community
□	Creation of a new referral network for unreimbursed care patients
□	More support from ancillary services (labs, radiology, pharmacy)
□	None of the above
□	Other (Specify)

GO TO Question 21 on Page 15

6) How often do you provide these types of unreimbursed care?

		Never	Monthly or less	Several times/month	Weekly	Daily
		1	2	3	4	5
Free service in the office
Discounted service in the office
Discounted or free service to your regular patients who are unable to be seen in your regular practice setting
Other (Specify)

6a) How often do you provide unreimbursed care to patients in each age group?

	Never	Monthly or less	Several times/month	Weekly	Daily
	1	2	3	4	5
<19 years
19-65 years
>65 years

6b) How often do you provide the following services for your unreimbursed care patients?

		Never	Monthly or less	Several times/month	Weekly	Daily
		1	2	3	4	5
Evaluation of acute problem
Chronic problem (routine follow-up)
Chronic problem (flare up)
Pre/post surgery/injury follow-up
Non-illness care (prevention, screening)
Other (Specify)

7) Have you provided unreimbursed care to patients with whom you have not established a relationship (i.e. new patients)?

□	Yes
□	No

8) When a patient receives unreimbursed care from you, who determines his/her eligibility?

		Never	Rarely	Sometimes	Frequently	Always
		1	2	3	4	5
It is my individual determination
It is a determination made by the administrative staff within my office
It is a determination made by the administrative staff within our institution but not in my office
It is a determination made by another agency that reports a patient's eligibility to our practice
Other (Specify)

9) What does your practice or outside agency require to determine a patient's eligibility for unreimbursed care?

Please check all that apply.
□	No written verification required
□	Previous year's tax returns
□	Recent W2 or pay stub
□	Qualification for other Federal/State assistance
□	Document that another organization has previously verified eligibility (e.g. hospital social services)
□	Enrollment in another assistance program (e.g. drug assistance program)
□	Do not know
□	Other (Specify)

10) Over the past year, how has the amount of unreimbursed care you provided changed?

Decreased a lot	Decreased	Stayed about the same	Increased	Increased a lot
1	2	3	4	5

If you answered “Stayed about the same,” Please GO TO Question 11

10a) What was the reason for this change?

Please check all that apply.
□	Change in leadership/ownership of practice
□	Change in the need for unreimbursed care
□	Change in the environment outside the practice (e.g. closing or opening of a free clinic or other community organization)
□	Other (Specify)

11) What do you expect will happen to the level of unreimbursed care that you provide in the next year? (At the location where you provide most of your patient care)

Decrease a lot	Decrease	Stay about the same	Increase	Increase a lot
1	2	3	4	5

12) How important are the following factors in determining your willingness to offer unreimbursed care?

		Very Unimportant	Unimportant	Neither Unimportant or Important	Important	Very Important
		1	2	3	4	5
Desire to provide continuity of care to patients who have lost their insurance coverage
Requests from new patients needing appointments
Responsibility for follow-up care of patients I have seen in the ER
Tradition in my practice
Tradition among my peers and colleagues
Requests from the friends and family of clinic staff
The economic stability of my practice to allow me to provide unreimbursed care
My personal or religious values
My involvement in a teaching program
My desire to help my community
My patient's appreciation of the unreimbursed care they receive from me
My personal satisfaction as a physician
Other (Specify)

13) How important are the following factors in limiting your ability to provide unreimbursed care?

		Very Unimportant	Unimportant	Neither Unimportant or Important	Important	Very Important
		1	2	3	4	5
Medical liability concerns
Discomfort of regular patients with the presence of charity patients in my waiting room
The policies of my employer or manager
Providers’ time to offer unreimbursed care
Pressure to be productive with time
Declining financial stability of practice or revenue per patient
Other (Specify)

14) Many physicians feel that pressure to be productive with their time limits the amount of unreimbursed care they can provide. If this is a concern for your practice, what is the source of the pressure?

Please check all that apply.
□	This is not a concern for my practice
□	The need for higher volume of paying patients to maintain profitability
□	The need for higher volume of paying patients to keep practice profitability growing
□	Specific incentives or demands from employer/manager
□	Specific financial incentives from managed care organizations or other payers
□	My obligations to paying patients leaves little time for non-paying patients
□	Other (Specify)

15) Many physicians feel that the financial instability of their practice limits the amount of unreimbursed care they are able to provide. If this is a concern for your practice, what has been the cause for this concern?

Please check all that apply.
□	This is not a concern for my practice
□	The need to create profitability for the practice
□	Declining payments
□	Other (Specify)

16) To what extent do your own personal financial gains derived from your practice affect the amount of unreimbursed care you are willing to provide?

Not at All	Somewhat			Greatly
1	2	3	4		5

The next few questions involve your experience in referring patients out to specialists for follow-up, for lab services, for radiological testing, and in acquiring medications.

17) How often do you have difficulty referring unreimbursed care patients out for specialist care?

Never	Rarely	Sometimes	Frequently	Always
1	2	3	4	5

If you selected “Never,” Please GO TO Question 18

17a) Is this difficulty in referring to specialists related to?

Please check all that apply.
□	A general lack of specialists in the region
□	A lack of a mechanism for referring unreimbursed patients from the office
□	General unwillingness of specialists to accept unreimbursed care patients
□	Unwillingness of patients to see specialists
□	Formal policies that restrict referral of patients
□	Cost associated with specialist care
□	None of the above
□	Other (Specify)

18) How often do you have difficulty referring unreimbursed care patients out for lab services?

Never	Rarely	Sometimes	Frequently	Always
1	2	3	4	5

If you selected “Never,” Please GO TO Question 19

18a) Is this difficulty in referring unreimbursed patients to labs related to?

Please check all that apply.
□	A general lack of laboratory services in the region
□	A lack of a mechanism for referring unreimbursed patients from the office
□	General unwillingness of laboratories in your region to accept unreimbursed care patients
□	The existence of formal policies that restrict the patient's ability to obtain laboratory services
□	Cost associated with laboratory testing
□	None of the above
□	Other (Specify)

19) How often do you have difficulty referring unreimbursed care patients out for radiology or imaging services?

Never	Rarely	Sometimes	Frequently	Always
1	2	3	4	5

If you selected “Never” Please GO TO Question 20

19a) Is this difficulty in referring unreimbursed care patients out for radiology or imaging services related to?

Please check all that apply.
□	A general lack of radiology services in your region
□	A lack of a mechanism for referring unreimbursed patients from the office
□	General unwillingness of radiology or imaging departments to accept unreimbursed care patients
□	The existence of formal policies that restrict a patient's ability to obtain radiology services
□	The cost associated with radiology service
□	None of the above
□	Other (Specify)

20) How often do you have difficulty accessing medications for unreimbursed care patients? (This question refers to both generic and branded medications)

Never	Rarely	Sometimes	Frequently	Always
1	2	3	4	5

If you selected “Never” Please GO TO Page 14

20a) Is this difficulty in accessing medications related to?

Please check all that apply.
□	A general lack of available pharmacies in your region
□	The inability to refer patients to outside assistance programs for help with medications
□	General unwillingness of pharmacies to accept unreimbursed care patients
□	The existence of formal policies that restrict a patient's ability to obtain medications
□	A lack of prescription medication samples to distribute to unreimbursed care patients
□	The cost associated with filling prescriptions
□	Pharmaceutical company medication assistance program requirements are too onerous
□	There are no local medication assistance programs accessible to my patients
□	Requirements for community medication programs (e.g. IDP) are too onerous
□	None of the above
□	Other (Specify)

The previous questions have focused on the unreimbursed care you may provide to patients in your main practice setting. The next three questions concern the volunteer service you may perform outside of, or in addition to your regular practice.

21) Do you provide unreimbursed care to patients in a setting outside of your practice, for example in a health center or free clinic?

□ Yes

□ No

22) Are you aware of the Free Clinic Federal Tort Claims Act (FTCA) Medical Malpractice Program which offers medical malpractice protection at no cost for volunteer free clinic health professionals?

□ Yes

□ No

If you selected “No” Please GO TO Page 16

23) To what extent does the FTCA Medical Malpractice program increase your willingness to volunteer at a free clinic?

Not at All	Somewhat			Greatly
1	2	3	4		5

Please tell us a little about yourself

What is your gender?

□ Male

□ Female

What is your age?

□	25-29 years
□	30-39 years
□	40-49 years
□	50-59 years
□	60-69 years
□	70-79 years
□	80-89 years
□	90-99 years

What year did you graduate from medical school?

Are you of Hispanic/Latino origin?

□ Yes

□ No

What is your race?

Please check all that apply.
□	American Indian or Alaskan Native
□	Asian
□	Black or African American
□	Pacific Islander/Native Hawaiian
□	White
□	Other

Please tell us a little about your practice

We understand that many practices have more than one physical location. For this next section, please tell us about the entire practice including all locations (if applicable)

Does your practice have more than one location?

□ Yes

□ No

Including yourself, how many clinicians (MD, DO, NP, PA) are associated with your group? Please include full and part time clinicians.

□	1
□	2-3
□	4-7
□	8-12
□	>12

Is this a single- or multi- specialty practice?

□	Single Specialty Practice
□	Multi-Specialty Practice
□	Other

Are you a full- or part-owner, employee, or an independent contractor?

□	Owner
□	Employee
□	Contractor
□	Other

Who owns the practice?

□	Physician or physician group
□	HMO
□	Community health center
□	Academic health center
□	Non-academic hospital system
□	Other health care corporation
□	Other

Please tell us about the practice location where you see most of your ambulatory patients

Including yourself, how many clinicians (MD, DO, NP, PA) provide direct patient care at the location where you see most of your patients? Please include full and part time clinicians.

□	1
□	2-3
□	4-7
□	8-12
□	>12

How would you identify the geographic location where you provide the most direct patient care?

□	Urban
□	Suburban
□	Rural

Please enter the first three (3) digits of the zip code of the location at which you provide the most direct patient care? (This information will be used to describe the individual characteristics of your practice location, not to identify you personally)

Thank you for taking the survey. The information will assist the Agency for Healthcare Research and Quality (AHRQ) and the American Academy of Family Physicians (AAFP) to understand the factors affecting the current state of safety net care in the family practice environment.

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