Form CMS-R-254 NMEP Survey

NMEP Survey – Updated 07/30/08

During this period of expanding program services, the Centers for Medicare & Medicaid Services (CMS), the Federal agency that administers the Medicare program is conducting this telephone survey to help us understand what information you need about Medicare, where you go to find the information, and if you feel we have been effective in getting you the information you need to make informed decisions about Medicare benefits and medical care.

As part of our commitment to enhancing communication to meet your needs, we are asking you to take a few minutes to answer some questions. All information you provide will be held in confidence by CMS and is protected by the Privacy Act. You do not have to participate in this survey. Your help is voluntary and your decision to participate or not to participate will not affect your Medicare benefits in any way. This is a legitimate research study sponsored by the Centers for Medicare & Medicaid Services (CMS), which is part of the United States Department of Health & Human Services.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this NMEP survey is 0938-0738. The time required to complete this information collection is estimated to average less than 15 minutes. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn.: Reports Clearance Officer, 7500 Security Blvd. Baltimore, MD. 21244.

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Bottom of Form

 

NMEP 2008 SURVEY

A. screening questions

1) Have you (or has your spouse) ever worked for the Social Security Administration or the

Centers for Medicare & Medicaid Services, formerly known as the Health Care Financing Administration?

Yes

No

2) Do you currently receive Medicare or Medicaid benefits?

Yes

No

Refuse

Don’t know

3) Gender [Don’t ask]

Male

Female

B. General Medicare and Insurance Coverage

1) Which of the following types of health insurance do you have to cover your hospital

expenses or doctor visits?

Medicare, but no other medical insurance

Medicare and a supplemental insurance policy, sometimes called Medigap

A Medicare HMO or PPO plan, also known as Medicare Advantage, where you have to see a doctor from the plan’s list

Medicare plus employer or retiree coverage

Medicaid

VA, or veterans’ health insurance

Tricare

No insurance/Self-Pay

Other (Specify___________________________)

Refuse

Don’t know

2) Are you aware of Medicare prescription drug plans, also called Part D?

Yes

No

Refuse

Don’t Know

3) Are you enrolled in a Medicare prescription drug plan?

Yes

No

Don’t know

Refuse

4) Some people are not enrolled in a Medicare prescription drug plan because they already have insurance that covers the cost of prescription drugs.

Do you have other insurance that pays for your prescription drugs?

Yes

No

Don’t know

Refuse

5) Here is a list of the kinds of insurance and health plans that some people have that help pay for their prescription drugs. Please tell me which one or ones you have (READ LIST).

Medigap, or Medicare Supplemental insurance

An HMO

A PPO

Employer, Union, or retiree health insurance

Drug discount card from a pharmacy or pharmaceutical company

Other (Specify_________________________________________)

Don’t know

Refuse

C. Health Behaviors

1) When it comes to your Medicare coverage and services, do you usually make decisions on your own, with someone else’s help, or do you rely on someone else to make those decisions for you? [IF NECESSARY, READ LIST TO CLARIFY.]

I make those decisions on my own

I make those decisions with someone else’s help

I rely on someone else to make those decisions for me

2) Who usually helps you or makes these decisions for you? [DO NOT READ LIST. ACCEPT MULTIPLES.]

Spouse

Child

Other family member

A friend

Receive help at a senior center

Receive help from my state’s health insurance department

Other (Specify: ___________________)

3) Thinking about your own health, how often do you and your doctor or nurse discuss ways that you can stay healthy or improve your health?

Never

Rarely

Occasionally

Every office visit

Refuse

Don’t know

4) And how often do you and your doctor or nurse discuss ways that you can control your health care costs?

Never

Rarely

Occasionally

Every office visit

Refuse

Don’t know

5) How confident are you that you can identify when it is necessary for you to get medical care? Would you say that you are…

Very confident

Confident

Somewhat confident

Not at all confident

[DO NOT READ] Don’t go to doctors

Refuse

Don’t know

6) How often do you take a list of all your prescribed medicines to your doctor visits? [READ LIST]

Never

Sometimes

Usually

Always

Not applicable, not on prescription meds

Refuse

Don’t know

7) How confident are you that you know the right questions to ask before surgery to make sure you have a shorter, safer hospital stay? [READ LIST]

Not at all confident

Somewhat confident

Confident

Very confident

Refuse

Don’t know

8) How often do you ask your doctor questions about Medicare?

Never

Rarely

Occasionally

Every office visit

Refuse

Don’t know

9) How does your doctor usually handle these questions?

Try to answer them on their own

Refer you to someone else in their office

Refer you to Medicare

Other (Specify___________________________________)

Don’t know

d. General Satisfaction

1) Overall, how satisfied or dissatisfied are you with the information and assistance you have received from Medicare in the past year? Would you say you are

Very satisfied

Somewhat satisfied,

Somewhat dissatisfied, or

Very dissatisfied?

Refuse

Don’t know

2) How favorable or unfavorable is your opinion of the Medicare Program? Would you say…?

Very favorable

Somewhat favorable

Somewhat unfavorable

Very unfavorable

Refuse

Don’t know

3) In general, how favorable or unfavorable is your impression of health insurance companies? Would you say…?

Very favorable

Somewhat favorable

Somewhat unfavorable

Very unfavorable

Refuse

Don’t know

4) How favorable or unfavorable is your impression of the Medicare prescription drug plans (Part D)? Would you say…?

Very favorable

Somewhat favorable

Somewhat unfavorable

Very unfavorable

Refuse

Don’t know

E. Beneficiary perceptions / opinions

1) I am going to read you several statements about Medicare. For each one, please tell me if you believe the statement is true or false. If you do not know the answer, please give me your best guess.

	True	False	Don’t Know
1a) Seniors who have limited incomes can receive extra help from the Social Security Administration to help pay for Medicare premiums, deductibles, and co-payments.
1b) Medicare by itself doesn’t cover or pay for all of your health care expenses.
1c) Medicare offers a “welcome to Medicare physical exam for new enrollees which Medicare covers within the first year of Part B coverage.
1d) Medicare covers the cost of heart screening to check cholesterol among other risk factors.
1e) Medicare covers the cost of diabetes screenings.
1f) Medicare covers the cost of colon cancer screenings.
1g) Medicare covers the cost of routine mammograms to check for breast cancer.
1h) Medicare pays for screening tests for prostate cancer.
1i) Out of pocket costs are the same in all Medicare prescription drug plans.
1j) If seniors are satisfied with how their plan worked in 2007, they don’t need to review how it will work in 2008.
1k) The co-payments and deductibles for Medicare plans can change from year to year.
1l) Monthly premiums for Medicare plans can change from year to year.
1m) The drugs covered by Medicare plans can change from year to year.
1n) Seniors can switch to a drug plan that doesn’t have a coverage gap.
1o) Seniors can switch to a drug plan that covers the drugs they take if their drug needs have changed.
1p) Seniors can switch Medicare plans during the open enrollment period.
1q) I can find plan comparison information in my Medicare and You handbook.
1r) I can find plan comparison information on www.Medicare.gov.
1s) I can compare plans to help me make my health care decisions.
1t) I feel in charge of my health plan choice.
1u) All Medicare prescription drug plans covers the same list of prescription drugs.
1v) Anyone on Medicare can sign up for Part D, prescription drug coverage.
1w) Only people with low incomes can sign up for Part D.
1x) Beneficiaries have methods available to them to resolve complaints about the quality of their healthcare.
1y) Medicare health plans are allowed to raise their fees or change their benefits every year.
1z) If you are in a Medicare health plan and disagree with a decision they’ve made about your health care, you have a right to appeal that decision.
1aa) People can switch to a different Medicare health plan only once during a given year.
1ab) Recent changes have been made to Medicare coverage rules for certain medical equipment and supplies.

2) How much would you say you know about the Medicare Prescription drug benefit?

A great deal

A fair amount

Just some

Very little

Nothing

Don’t know

F. LOW INCOME SUBSIDY INFORMATION

1) Have you ever received a letter from Medicare or the Social Security Administration

advising you to apply for extra financial help with Medicare prescription drug plan costs?

Yes

No

Refuse

Don’t know

2) Have you ever received a letter or call from your prescription drug plan advising you to apply for extra financial help with Medicare prescription drug costs?

Yes

No

Refuse

Don’t know

3) Did you apply to for Extra Help to pay for Medicare prescription drug costs?

Yes

No

Refuse

Don’t know

4) Did you know that people with limited income may qualify for financial assistance to help lower their prescription drug costs?

Yes

No

Refuse

Don’t know

5a) Have you ever been given or mailed an application for extra help to pay for prescription

drug coverage? [READ LIST. IF NEEDED, EXPLAIN THAT THIS IS AN APPLICATION SENT TO SOCIAL SECURITY.]

Yes, applied and was approved

Yes, applied, but was denied

Yes, applied and am waiting to hear the results

Yes, I gave it to someone else to fill out, but I’m not sure what happened

Yes, I’ve received an application, but I have not filled it out

No, I have never been given or mailed an application

Not sure

Refuse

5b) And why haven’t you filled out and mailed in the application? [RECORD VERBATIM RESPONSE]

6) I’m going to read you a couple of statements. For each sentence I want you to tell me whether you think it is true, false or if you don’t know.

6a) People with limited income may qualify for financial assistance from the Medicare Program to help lower their prescription drug costs.

True

False

Refuse

Don’t know

6b) You would accept financial assistance from the government to help pay for your prescription drugs.

True

False

Refuse

Don’t know

6c) You would qualify as a person with limited income.

True

False

Refuse

Don’t know

7) And why do you think you might not qualify as a person with limited income?

My income is too high

I don’t take enough prescription drugs

I don’t pay much for prescription drugs

I (or spouse) is still working

I have other insurance

I have been denied as a person with limited income in the past

Other (Specify________________________________________________)

Refuse

Don’t know

8) After you applied for extra help to pay for Medicare prescription drug costs, what was the result? [READ LIST. IF NEEDED, EXPLAIN THAT THIS IS AN APPLICATION SENT TO SOCIAL SECURITY.]

Were you approved to get Extra Help

Were you denied Extra Help

Are you waiting to hear the results

Did you give it to someone else to fill out but you are not sure what happened

Refuse

Don’t know

9) How difficult or easy was it to complete the application form? Would you say it was…?

Very difficult

Somewhat difficult

Somewhat easy

Very easy

Refuse

Don’t know

10) How likely is it that you will apply for extra financial help to pay for a Medicare prescription drug plan in 2008? Would you say …?

Definitely will not apply

Probably will not apply

Probably will apply

Definitely will apply

Refuse

Don’t know

11) How difficult do you believe it is to apply for extra financial help for the Medicare Prescription Drug Program? Would you say…?

Not difficult

Somewhat difficult

Very difficult

Refuse

Don’t know

12) How concerned are you about providing personal information, such as actual dollar amounts in your bank accounts, on an application for extra financial help for the Medicare Prescription Drug Program? Would you say…?

Not concerned

Somewhat concerned

Very concerned

Refuse

Don’t know

G. Branding

1) To what extent to do you agree that Medicare is modern? Would you say you…

Disagree completely

Disagree somewhat

Agree somewhat

Agree completely

2) To what extent to do you agree that Medicare is innovative? Would you say you…

Disagree completely

Disagree somewhat

Agree somewhat

Agree completely

3) To what extent to do you agree that Medicare is your partner in healthcare? Would you

say you…

Disagree completely

Disagree somewhat

Agree somewhat

Agree completely

H. information sources

1) Where do you usually get information about Medicare coverage and services? [DO NOT READ LIST. ACCEPT MULTIPLES. IF RESPONDENT SAYS “IN THE MAIL,” CLARIFY FROM WHERE]

In the mail – from Medicare: A LETTER

In the mail – from Medicare: A PAMPHLET

In the mail – from Medicare: THE HANDBOOK

In the mail – from somewhere else (nonspecific)

Medicare and You handbook

1-800-MEDICARE

www.medicare.gov

Physician or nurse

Pharmacist

Insurance or drug plan

Friends/family

Television, radio, newspaper, magazine

Senior Center

Health Fair

Internet (specify _____________)

Library

OTHER (Specify_____________)

Refuse

Don’t know

2) I’d like to ask you how often you have looked for information about Medicare or

health insurance over the past year. Would you say that over the past year you

have looked for information about Medicare or health insurance…

Frequently

Sometimes

Rarely

Never

3) In the past 12 months, did you look for information on any of the following topics:

Insurance coverage, co-payments or billing?

Changes to your Medicare benefits?

Comparing your health plan options

Getting help to pay for your prescription drugs?

The new 2006 Prescription drug benefit?

Quality of care at hospitals?

4) Which source of information are you most comfortable with when seeking information about the Medicare program and its benefits?

The Social Security Office

The Medicare Program

AARP

A Senior Center or Aging Program (This is meant to encompass SHIP since they

Probably won’t know SHIP by name)

State Department of Insurance or Health

Insurance Company or Agent

Family Member, Friend, or Co-Worker

Other (Specify: ___________________)

Refuse

Don’t know

5. Are you familiar with the Medicare & You Handbook, mailed to beneficiaries each

year in the fall?

Yes

No

Refuse

Don’t know

6) If yes, would you say you have read it thoroughly, read parts of it, glance through it, or you really haven’t yet looked through it at all?

Read it thoroughly

Read parts of it (thoroughly or not)

Glanced through it

Really haven’t looked through it at All

Refuse

Don’t know

7) Would you say you use the Medicare & You Handbook, a lot, use it sometimes, or do you use it rarely or not at all?

Use it a lot

Use it sometimes

Rarely use it

Don’t use it at all

Refuse Don’t know

8) All in all, how satisfied or dissatisfied are you with the help it provides in answering questions about Medicare? Would you say you are

Very satisfied

Somewhat satisfied

Neither satisfied nor unsatisfied

Somewhat unsatisfied

Very unsatisfied

Refuse

Don’t know

9) Thinking of all of the information you have received in the past year about choosing or comparing health plan options, how easy was it to understand the information? Was it:

Very easy

Somewhat

Neither easy nor difficult

Somewhat difficult

Very difficult

Refuse

Don’t know

I. Internet Usage

1) Do you have access to the Internet, either on your own or with someone else’s help?

Yes

No

Refuse

Don’t know

2) Have you ever visited Medicare’s website (READ w w w dot Medicare dot gov) either on your own or with someone else’s help?

Yes, on my own

Yes, with someone else’s help

No

Refuse

Don’t know

3) How often do you access the internet on your own or with someone else’s help? [READ LIST.]

Almost daily

Once or twice a week

Once or twice a month

Only a few times a year

Don’t have internet access/don’t use the internet

Refuse

Don’t know

4) Have you ever used the internet for any of the following activities? [READ LIST]

[ACCEPT MULTIPLES]

Online banking

Shopping online

Researching health issues or topics

Reading the news

Managing your retirement funds

Visiting your health insurance website

Tracking or accessing your own personal health or medical records

Checking email

[DO NOT READ] None of these

Refuse

Don’t know

J. 1-800-medicare

1) There’s a special nationwide toll-free Medicare information helpline number run by the federal Medicare program. The number is 1-800-MEDICARE OR 1-800-633-4227. In the past year, have you ever called this number to get information about Medicare?

Yes

No

Refuse

Don’t know

2) [if yes]Thinking about the most recent call you made to this number, what was the reason you called?

Coverage for specific tests, services, products or procedures

Billing, claims, co-payments, or cost questions

General questions about coverage or what Medicare pays

Coverage while traveling

Hospitalization coverage, costs, length of stay

Prescriptions

Making insurance or HMO choices

Long term care/nursing home coverage

Generally keeping informed

Other (Specify______________________)

Refuse

Don’t know

K. Open Enrollment

Each year, Medicare has an open enrollment period between November 15 and December 31st. During the open enrollment period, people on Medicare can decide to make changes to their insurance coverage, including Medigap, Medicare Advantage, and prescription drug plans.

1) Were you aware before this interview that you could make changes in your Medicare insurance coverage during the open enrollment period?

Yes

No

Refuse

Don’t know

2) Since you started receiving Medicare, have you (or the person who helps you) ever made

changes to the type of Medicare medical or drug plan coverage you have?

Yes, I did

Not applicable – 2008 was 1st year of

enrollment in plan

Yes, the person who helped me did

No, the person who helped me did not

Don’t recall what I did

Don’t recall what the person who helped

Refuse

Don’t know

3) During the last open enrollment period, which was November 15 to December 31 of 2007, did you (or the person who helps you) review your Medicare coverage to see if, in 2008, there were going to be changes in the premium, deductibles, co-payments, or other out of pocket expenses?

Yes, I did

No, I did not

Not applicable – 2008 was 1st year of enrollment in plan

Yes, the person who helped me did

No, the person who helped me did not

Don’t recall what I did

Don’t recall what the person who helped me did

Refuse

Don’t know

4) During the last open enrollment period, did you (or the person who helps you) review your Medicare coverage to see if the kinds of treatment, drugs and services covered would still meet your health care needs in 2008?

Yes, I did

No, I did not

Not applicable – 2008 was 1st year of enrollment in plan

Yes, the person who helped me did

No, the person who helped me did not

Don’t recall what I did

Don’t recall what the person who helped me did

Refuse

Don’t know

5) Did you (or the person who helps you) compare your plan with other plans that were available in 2008?

Yes, I did

No, I did not

Not applicable – 2008 was 1st year of enrollment in plan

Yes, the person who helped me did

No, the person who helped me did not

Don’t recall what I did

Don’t recall what the person who helped me did

Refuse

Don’t know

6) What did you compare? [READ LIST. ACCEPT MULTIPLES]

Cost of the premium

Deductible amount

Co-payments

Types of treatment or services covered

Prescription drugs covered

Quality of the plan

Quality of the service provided by the plan

Don’t recall what I compared

Don’t recall what person who helped me compared

Other (Specify_______________________)

7) Thinking about the upcoming open enrollment period, do you (or the person who helps you) plan to review your current insurance plans to see if they are still the right ones OR do you plan to stick with the coverage you currently have? And do you… [READ LIST.]

Definitely plan to review current coverage

Probably plan to review current coverage

Probably plan to stick with current coverage

Definitely plan to stick with current coverage

Refuse

Don’t know

8) And of the following three, which are you (or the person who helps you) planning to review? [READ LIST]

Only health insurance

Only prescription drug coverage

Both health and prescription drug insurance coverage

Not sure

Refuse

Don’t know

9) Here are several issues that may be important in evaluating or selecting Medicare health or prescription drug insurance. Please rate each one on how important it is for you. A “0” means you think it is very unimportant and a “10” means it is very important. Remember you can use any number between 0 and 10. [READ LIST. ROTATE STATEMENTS]

When evaluating or selecting a Medicare health or prescription drug plan, how important is…	10 pt scale	DK	Refused
9a. Out of pocket expenses, including co-payments and deductibles		-1	-2
9b. Cost of the monthly premium		-1	-2
9c. Being able to see the doctor you choose		-1	-2
9d. Getting the prescription drugs your doctor prescribes, including brand name drugs		-1	-2
9e. Quality of the plan		-1	-2
9f. Customer service provided by the plan		-1	-2

10) I’m going to read you some statements that some people might say about Medicare. Please tell me whether you agree or disagree with each statement [READ LIST. ROTATE STATEMENTS].

	Strongly Disagree	Somewhat Disagree	Somewhat Agree	Strongly Agree	DK	Refused
10a. Before the open enrollment period, it’s worth it to do a “check-up” or “review”of my Medicare coverage to make sure it still meets my health needs.	1	2	3	4	-1	-2
10b. Even if my health needs haven’t changed, I need to use the open enrollment period to make sure my insurance plan hasn’t changed.	1	2	3	4	-1	-2
10c. During open enrollment, I plan to see if there is a plan with lower premiums and co-pays for me.	1	2	3	4	-1	-2
10d. The earlier in the open enrollment period that I make changes in my insurance, the more likely it is my plan will be in place by January first.	1	2	3	4	-1	-2

11) Have you or your caregiver ever asked your doctor about enrolling in or changing coverage during open enrollment?

Yes, I asked

Yes, my caregiver asked

No

Don’t know

L. Prevention

1) To the best of your knowledge, which of the following types of services does Medicare pay for? If you are not sure, please take your best guess. [READ LIST AND ROTATE. REPEAT BEFORE EACH ITEM: "Does Medicare pay for ...?"]

Preventive services, including screenings for different diseases

A physical exam when you first join Medicare

Annual physical exams

Counseling to quit smoking

Weight loss counseling

Shots for things like the flu or pneumonia

2) When I say “preventive services, including screening for different diseases,” what kinds of screenings or procedures do you think that includes? [DO NOT READ LIST. ACCEPT MULTIPLES.]

Blood tests

Bone mass measurement

Cancer screening

Cardiovascular screening/heart disease/heart problems

Colonoscopy

Diabetes screening, blood glucose or blood sugar testing

Glaucoma test

Mammogram or breast cancer screening

MRI

Pap test

Prostate cancer screening

X-rays

Immunizations for flu or pneumonia

Other (Specify_________________________)

Refuse

Don’t know

M. prescription drugs: coverage and out of pocket costs

1) Do you currently take any PRESCRIPTION medicine on a DAILY basis?

Yes

No

Refuse

Don’t know

2) How many different kinds of prescription drugs do you take? ________

3) Thinking now about how much you spend in a typical year on prescription drugs,

including your monthly premium for your prescription drug coverage, your deductible, co-pays and all of your out-of-pocket costs for your prescriptions, using your best guess what is your estimate on how much you spend in a year?

$________ (RECORD DOLLAR AMOUNT IN WHOLE NUMBERS, NO RANGES OR FRACTIONS--- ASK FOR A NUMBER BUT IF SUBJECT IS UNSURE TRY USING CATEGORIES)

$0-$20

$21-$60

$61-$100

$101-$300

$301- $400

$401 or higher

Don’t know

4) In the last year, how much of a problem, if any, have you had being able to afford the prescription drugs you needed? Would you say it was…

A big problem

A small problem

Not a problem

Refuse

Don’t know

5) Including refills of earlier prescriptions as well as new prescriptions that were written or phoned in by a doctor, in 2008, were any prescription drugs prescribed for you that you did not get?

Yes

No

Refuse

Don’t know

6) How frequently do you get prescription drugs from Canada or Mexico?

Often

Occasionally

Rarely

Never

7) Thinking about your prescription drug coverage. Some people we have talked to say they would be likely to enroll in a drug coverage plan, while others say they would not. How likely would you be to enroll in a prescription drug plan offered through Medicare? Would you be — very likely, somewhat likely, not too likely, not at all likely?

Very likely

Somewhat likely

Not too likely

Not at all likely

Refuse

Don’t know

N. Hospital / Doctor Choice

I would like you to think about how you would decide which hospital to go to if you were facing a serious health issue that might require hospitalization or surgery at some point. Please do not think here about circumstances where you would be facing an immediate medical emergency.

Please tell me if you agree or disagree with the following statements. [READ FIRST STATEMENT. WAIT FOR RESPONSE, THEN CLARIFY FOR AGREE/DISAGREE RESPONSES] Is that strongly [agree/disagree] or somewhat [agree/disagree]?

NOTE: RECORD ON SCALE AS FOLLOWS:

“1” = STRONGLY DISAGREE

“2” = SOMEWHAT DISAGREE

“3” = NEITHER AGREE NOR DISAGREE

“4” = SOMEWHAT AGREE

“5” = STRONGLY AGREE

[READ & RECORD RESPONSE. ROTATE ORDER]

1) I would insist on going to my most preferred hospital, even if that hospital were not the one recommended by or associated with my doctor

2) I would be inclined to trust any hospital suggested by my doctor, but I would still research it.

3) The choice of which hospital I would go to is primarily my doctor’s decision

4) In choosing a hospital, I would be more influenced by the opinions of my family and friends than my doctor's recommendation.

5) Would be willing to go for an initial test at the hospital recommended by my doctor, even if that hospital was not my preferred hospital

O. QUALITY OF CARE

The next questions focus on information you may have seen about quality of care.

1) Have you seen any information that compares the quality of care at different hospitals?

Yes

No

Refuse

Don’t know

2) Where did you see it?

In My Health Plan

In The Newspaper or in a Magazine

On a Television Program

On the Internet

On Medicare’s Website

In a Brochure or Booklet From Medicare

Literature From Hospital

Other (Specify____________________________)

Refuse

Don’t know

3) Have you read or heard about any programs that pay hospitals based on how good the care is at the hospital? That is, they get paid more because they give better care.

Yes

No

Refuse

Don’t know

4) When you have questions or concerns about how good the care is at a hospital, where do you get information?

Family Member or Friend

Doctor’s Office

Health Plan/Insurance Company

The Medicare Program

1-800-Medicare Toll Free Hotline

Employer/Past Employer

AARP-Type Service

The Social Security Office

The Internet

Medicare.gov Website

Someone at a Health Fair/Senior Expo

Hospital

Other (Specify____________________________)

Refuse

Don’t know

5) Have you seen or heard of the Department of Health and Human Services’ Hospital Compare, a website that provides information on how well hospitals care for their patients?

Yes

No

Refuse

Don’t know

6) Thinking about information regarding how good the care is at hospitals, how much would you trust information from:

(SOURCES)

The Federal government agency that runs Medicare

State agencies that license the facilities

A private organization or business devoted to improving the quality of health care

A consumer-oriented publication like Consumer Reports

An organization for seniors like AARP

A doctor you were seeing for your own health

Newspapers or magazines

Radio or TV

Family or friends

A health insurance plan

P. CAREGIVERs’ questions

1) Do you currently assist someone in making decisions regarding their health?

Yes

No

Don’t know

Refuse

2) What is your relationship to that person?

Paid aide who is just helping them get around

Paid aide who is more of a day-to-day caregiver

Family member/friend who is just helping you them around

Family member/friend who is more of a day-to-day caregiver

Family member/friend who is not necessarily caregiving on a daily basis, but is involved in decisions about their health

3) Which of the following types of assistance have you provided for a spouse, family
member, friend or other person with Medicare? [ACCEPT MULTIPLES. READ LIST, PAUSE AFTER EACH STATEMENT, IF NEEDED SAY, “WOULD THAT BE YES OR NO?”]

Medicare and other insurance decisions

Health care decisions

Spoken with a healthcare provider on behalf of or along with someone else

Financial and legal decisions

Paying bills

Transportation

Household chores or grocery shopping

Sorting medications, filing prescriptions, dosing medication into daily amounts

Bathing and dressing

Preparing meals

Searched for community resources and/or programs (IF NEEDED, CLARIFY

“such as church programs, social programs, senior centers”)

Other (Specify)______________________

[DO NOT READ] None of these

4) How frequently do you provide care to this person? [READ LIST IF

NEEDED]

Daily

Several times a week

About once a week

A few times a month

Once a month

Less than once a month

Q. demographics

1) What is your marital status? {Read only if necessary}

Single

Married

Unmarried but in committed relationship

Separated

Divorced

Widowed

2) What is the highest grade you completed in school? {Read if necessary}

8th Grade Or Less

Some High School, But Did Not Graduate

High School Graduate Or GED

Vocational Or Trade School

Some College Or 2-Year Degree

4-Year College Graduate

More Than 4-Year College Degree

Don’t know

3) Could you please tell me in what year you were born?

Under 65

65–66

67–70

71–75

76–80

81+

Refuse

4) Are you Hispanic or Latino?

Yes

No

Refuse

Don’t know

5) What is your racial or ethnic background? (Select one or more)

White

Black

Asian

American Indian

Other (Specify)______________________

Refuse

Don’t know

6) Compared to other people who are the same age as you, do you consider you health to be

Excellent

Very good

Good

Fair

Poor

Refuse

Don’t know

7) What is the annual income of your household? Is it - (READ. IF NEEDED, CLARIFY: INCOME BEFORE TAXES AND DEDUCTIONS)?

Under $10,000 ($0-$14,999)

$10,000-$20,000 ($24,999)

$20,000-$30,000 ($34,999)

$30,000-$,40000 ($49,999)

$40,000-$50,000 ($74,999)

$50,000-$75,000

$75,000-$100,000

$100,000 and over

Refuse

Don’t know

R. PROVIDERS’ questions

1) Which of these best describes your area of medical specialization? [DO NOT ACCEPT MULTIPLES]

Family Practice/Family Medicine Physician

General Practice Physician

Internal Medicine Physician

Physician Assistant in Family Practice, General Practice or Internal Medicine Practice

Nurse Practitioner in Family Practice, General Practice or Internal Medicine Practice

None of the above

Don’t know

2) Which of these best describes the practice in which you primarily work? [DO NOT ACCEPT MULTIPLES]

Office based practice

Hospital based practice

Don’t know

3) In what state is this practice located? __________

4) What percent of your full-time working hours are typically spent in direct patient care activities, as opposed to teaching, research or administration? Would you say that direct patient care is…?

Zero to 24% of your working time

25% to 49% of your working time

50% to 74% of your working time

75% or more of your working time

Don’t know

5) Approximately what percent of your practice’s revenues would you say come from

Medicare?

Zero to 19%

20% to 39%

40% to 59%

60% to 79%

80% or more

Don’t know

6) Do you currently accept new Medicare patients?

Yes

No

Don’t Know

7) How often would you say you are asked questions about Medicare by patients or caregivers? [DO NOT ACCEPT MULTIPLES]

Daily

Several times a week

A few times a month

A few times a year

Almost never

Don’t know

8) How do you handle these questions? Please check all that apply. [ACCEPT

MULTIPLES?]

Try to answer them yourself

Refer them to someone else in your office

Refer them to Medicare

Other (Specify___________________________________)

Don’t know

9) Is there a person in the practice where you primarily work who typically answers patients’ or caregivers’ questions about Medicare?

Yes, a Nurse

Yes, a Nurse Practitioner

Yes, an Office Manager

Yes, a Physician

Yes, a Physician Assistant

Yes, a Receptionist

Yes, a Referral Coordinator

Yes, a Other (Specify___________________________________)

No

Don’t know

10) When patients or caregivers ask you questions about Medicare, how often are the questions about these topics?

	Frequently	Sometimes	Rarely	Never	Don’t know
10a. Part A/B coverage questions	4	3	2	1	-1
10b. Part D/prescription drug coverage	4	3	2	1	-1
10c. Preventive care	4	3	2	1	-1
10d. Where to get general information	4	3	2	1	-1
10e. Whether procedures or tests are covered	4	3	2	1	-1
10f. Resolving problems with Medicare	4	3	2	1	-1
10g. Resolving problems with a Medicare drug plan or health plan	4	3	2	1	-1
10h. Other (Specify___________________________________)	4	3	2	1	-1

11) Approximately how many minutes would you say you spend on each of the following activities during an average workday in which you see patients?

	Please enter the number of minutes.
11a. Answering patient questions or counseling them on Part D/prescription drug coverage issues.	_________
11b. Looking for alternative meds for Part D patients due to co-pay or coverage issues.	_________
11c. Resolving prior authorization issues related to Part D coverage.	_________
11d. Responding to pharmacist queries regarding product switches due to lack of adequate Part D coverage or high co-pays.	_________

12) Please rate the usefulness, as you perceive it, of these Medicare channels of communication for patients and caregivers.

	Very Useful	Somewhat Useful	Not very Useful	Not at all Useful	Don’t know
12a) www.medicare.gov website	4	3	2	1	-1
12b) 1-800 Medicare	4	3	2	1	-1
12c) Medicare & You handbook	4	3	2	1	-1
12d) Other Medicare brochures available through the 800 number or website	4	3	2	1	-1

13) If you were to describe the economic status of your Medicare patients, what percent would you say are in each of these categories? Please enter percentages that add to 100%.

	Please enter a percent for each line.
a. Wealthy	_________
b. Upper middle class	_________
c. Middle class	_________
d. Lower middle class	_________
e. Poor	_________
	100%

14) To the best of your knowledge, which of the following types of information are available to the general public on the Hospital Compare website? [ACCEPT MULTIPLES]

Hospital charges

Hospital quality ratings

Mortality rates

Patient satisfaction scores

Physician quality ratings

Process improvement indicators

Don’t know

15) Have you heard of the Physician Quality Reporting Initiative (PQRI) or Personal Health Records (PHRs)?

Yes, both

Yes, PQRI

Yes, PHRs

No

16) When discussing preventive services with patients, which one of the following is most often true? [DO NOT ACCEPT MULTIPLES]

You usually raise the topic of which preventive screenings the patient is due to

have

Patient or caregiver usually raises the topic

You and the patient/caregiver raise the topic to about an equal extent

Don’t typically discuss preventive health issues with patients or caregivers

Don’t know

17) Do you feel that patients’ knowledge about the need for, and awareness of, preventive services covered by Medicare has increased, decreased or stayed about the same over the last few years?

Increased

Stayed the same

Decreased

Don’t know

18) Have you visited this website, http://www.medlearn.com/?

Yes

No

Don’t know

19) Have you heard of a website called Hospital Compare, a site that provides information to consumers about how well hospitals provide care for certain conditions?

Yes

No

Don’t know

20) How would you describe the area or areas in which your practice operates? Please check all that apply. [ACCEPT MULTIPLES]

Large city

Mid-size city

Small city

Suburban

Rural

Don’t know

21) Which of these descriptions best describes the size of your practice?

Sole practitioner

1 – 4 physician practice

5 – 9 physician practice

10 or more physicians

Don’t know

22) Finally, who is the majority owner of your practice?

Government

Hospital/integrated delivery system (IDS)

Insurance company or health maintenance organization (HMO)

MSO (Management Services Organization) or PPMC (Physician Practice Management Company)

Physicians

University or medical school

None of the above

Don’t know

S. PARTNERs’ questions

1) Which of these best describes your organization? [DO NOT ACCEPT MULTIPLES]

Health care focused

Disease focused

Prevention focused

Ethnic-group focused

Age group focused

Faith based

Other (Specify___________________________________)

None of the above

Don’t know

2) What training materials have you used?

Outreach toolkits

Web casts

Press Releases

Publications (Specify___________________________________)

Campaign Materials

Beneficiary Mailings

Podcasts

Other (Specify___________________________________)

Don’t know

3) What purpose did these training materials serve?

Used during information session

Given to beneficiaries

Circulated throughout office

Used as reference tool

Other (Specify___________________________________)

4) How well do these materials enable you to perform Medicare outreach and assistance for your constituencies?

Well

Neutral

Poorly

Don’t know

5) Do you know how to obtain additional Medicare information?

Yes

No

Don’t know

6) Which training products are most effective?

Outreach toolkits

Web casts

Press Releases

Publications (Specify___________________________________)

Campaign Materials

Beneficiary Mailings

Podcasts

Other (Specify___________________________________)

Don’t know

7) Which training products are least effective?

Outreach toolkits

Web casts

Press Releases

Publications (Specify___________________________________)

Campaign Materials

Beneficiary Mailings

Podcasts

Other (Specify___________________________________)

Don’t know

8) How can these products be improved?

Thank you very much for your time!

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