CMS-10310 Attachment B1_Screening Form_Consumers

Hospital Outpatient Measures

Consumer Testing

Screener: Healthcare Consumers

Austin, TX – January 27 & 28, 2010

Target Population: Recruit 12 (10 participants and 2 floaters) consumers:

Group A: At least 3 who have had experience with an emergency department visit for chest pain, heart attack, or other heart problem

Group B: At least 3 who have had experience with outpatient surgery

Group C: At least 3 who have had outpatient radiology services (such as a CT scan, mammogram, or MRI)

Group D: At least 3 who have never had any of these experiences

Recruitment Criteria:

• Above requirements are not mutually exclusive. A participant can fall into more than one category (except for the last category).

• Ages 40-70

• All participants should regularly use the Internet (at least four times per week)

• Exclude individuals who currently work or previously worked in the health care industry or who have an immediate family member who is currently working in the health care industry.

• Exclude individuals who are current or former employees of the Social Security Administration or the Department of Health and Human Services or one of its related agencies (such as the Centers for Medicare & Medicaid Services, the Health Care Financing Administration, the Agency for Healthcare Research and Quality, the Centers for Disease Control, the Food and Drug Administration)

• Exclude individuals who have participated in a health or health insurance related IDI or focus group within the past year and/or who have participated in an IDI or focus group within the past 6 months.

Recruitment Mix:

• Recruit approximately 50% female and 50% male

• Recruit a mix of race/ethnicity (Caucasian vs. Non-Caucasian)

• Recruit a mix of education level (less than high school, high school graduate/GED, some college, college graduate, post graduate). No more than 8 recruits of the 12 should have education higher than a high-school diploma. (i.e. Some College/Associates, Bachelors, or higher.)

IntroDUCTION

Hello, my name is _____________ from ______________, a local research firm here in the ____________ area. We are working with L&M Policy Research on a project about health care.

If needed: If recruit asks about L&M Policy Research, please say the following: “L&M Policy Research is a company with headquarters in Washington, D.C that conducts research on many different healthcare issues.”

I’m calling today about a project that we are doing about the quality of certain hospital services for the Centers for Medicare & Medicaid Services, the federal government agency that runs Medicare. For this study we’d like your help figuring out the clearest way to tell people about this hospital information. If you are interested in helping with the project and you meet its requirements, we will invite you to come for an interview on [January TBD]. It would take about 90 minutes of your time, and we would pay you [$XX] at the end of the interview. May I ask you a few questions to see if you qualify to participate? If yes, continue to #1. If no, thank and end.

If needed: Since we need to include people who are a mix of different backgrounds and experiences, there are some requirements that I have to check on for all of the people that we bring in to participate. I need to ask you a few questions to see if you meet the requirements for participating in the discussion.

1. Are you currently working or have you ever worked in the health care industry? (e.g., working for a hospital, nursing home, pharmacy, home health agency, medical office, clinic, diagnostic imaging center, health plan, HMO, health insurance company, or pharmaceutical company)

____ YES _→ Thank and end call

____ NO _→ Continue

____ NOT SURE _→ Thank and end call

2. Is an immediate family member currently working in the health care industry? (e.g., working for a hospital, nursing home, pharmacy, home health agency, medical office, clinic, diagnostic imaging center, health plan, HMO, health insurance company, or pharmaceutical company)

____ YES _→ Thank and end call

____ NO _→ Continue

____ NOT SURE _→ Thank and end call

3. Are you currently or have you ever been employed by the Social Security Administration or the Department of Health and Human Services or one of its related agencies, such as the Centers for Medicare & Medicaid Services, the Health Care Financing Administration, the Agency for Healthcare Research and Quality, the Centers for Disease Control, or the Food and Drug Administration?

____ YES _→ Thank and end call

____ NO _→ Continue

4. Have you been paid to participate in an interview, focus group, or other group or individual discussion in the past 6 months?

____ YES _→ Thank and end call

____ NO _→ Continue

____ NOT SURE _→ Thank and end call

5. Have you been paid to participate in a health or health insurance related interview, focus group, or other individual or group discussion in the past year?

____ YES _→ Thank and end call

____ NO _→ Continue

____ NOT SURE _→ Thank and end call

6. Which category best describes your age? {Read list below.} {RECRUIT MIX}

____ 39 or younger_→ Thank and end call

____ 40 – 49 _→ Continue

____ 50 – 59 _→ Continue

____ 60 – 70 _→ Continue

____ 71 or older _{→ Thank and end call}

7. Have you visited Web sites on the Internet?

____ YES _→ Continue

____ NO _{→ Thank and end call}

8. How often do you use the Internet for things other than for checking e-mail (e.g., for things such as checking news, online shopping, or searching for information)?

____ At least once per day _→ Continue

____ At least four times per week _→ Continue

____ About twice per week _→ Continue {RECRUIT NO MORE THAN 2}

____ About once per week _→ Thank and end call

____ Twice per month or less frequently _→ Thank and end call

9. If you were looking to make a major purchase (i.e. shopping for a car, a computer, or any other major purchase), which of the following sources would you use for researching and comparing items before purchasing? {Read EVERY item and check ALL that apply. At least 9 of 12 participants must indicate that they would use the Internet to search for information.}

____ Friends and family → Continue

____ Trade magazines or literature (Car and Driver, Consumer Reports, etc.) → Continue

____ Internet (blue book, AAA) _→ Continue {RECRUIT AT LEAST 9}

____ Other → Continue

10. If you were looking for information to find a hospital for a planned health care service or procedure, which of the following sources would you use? {Read EVERY item and check ALL that apply.}

____ Friends and family → Continue

____ Magazines or other literature (US News & World Report, etc.) → Continue

____ Internet (hospital websites) → Continue

____ Other → Continue

11. Have you ever needed to go to an emergency department or “emergency room” to receive care/services?

____ Yes _→ Continue to 12a

____ No _{→ Continue/skip to13}

_{12a. What was the primary complaint that took you to the emergency department?}

_{____ Chest pain, angina, heart attack, heart trouble, coronary trouble, etc. {Recruit at least 3 for group A}}

____ I do not have a primary care or regular doctor so I use the emergency room for basic/primary care _→ Thank and end call

____ Other _→ continue

12. Have you ever had a planned or scheduled surgery for which you were not admitted to the hospital? This kind of surgery is typically in an outpatient facility or an outpatient department of a hospital.

____ Yes _→ Continue (Recruit at least 3 for Group B)

____ No _{→ Continue}

13. Have you ever had a radiology or imaging procedure, without being admitted to the hospital, such as a mammogram, CT scan, or MRI?

____ Yes _→ Continue (Recruit at least 3 for Group C)

____ No _{→ Continue}

[Note – if respondent answers “no” to Questions 12, 13 and 14, he/she qualifies for Group D]

14. During the interview, you will be asked to navigate an Internet website and look for and review specific information on the website. Is this something you feel comfortable doing?

____ YES _{→ Continue}

____ NO _→ Thank and end call

____ NOT SURE _→ Thank and end call

I have a few more questions about your background. Again, this information will enable us to make sure we have a broad mix of people participating in the interviews. If you feel uncomfortable answering any of these questions, please let me know and we’ll go on to the next question.

15. Gender. {Confirm if needed.}

____ MALE _→ Continue {RECRUIT ~50%}

____ FEMALE _→ Continue {RECRUIT ~50%}

16. What is the last or highest grade that you finished in school? {Do not read options.} {RECRUIT MIX BUT NO MORE THAN 8 PARTICIPANTS WITH “SOME COLLEGE” OR ABOVE}

____ Less than high school degree _→ Continue

____ High school degree or GED_→ Continue

____ Some college or two year degree _→Continue {RECRUIT NO MORE THAN 8 TOTAL IN LAST THREE CATEGORIES}

____ College graduate/4-year college degree _→ Continue

____ More than 4-year college degree _→Continue

17. Are you of Hispanic or Latino origin or descent?

____ Yes, Hispanic or Latino _→ Continue

____ No, not Hispanic or Latino _→ Continue

18. Are you White?

____ Yes, White _→ Continue {RECRUIT NO MORE THAN 8}

____ No, Not White _→ Continue

19. Are you Black or African-American?

____ Yes, Black or African-American _→ Continue

____ No, not Black or African-American _→ Continue

20. Are you Asian?

____ Yes, Asian _→ Continue

____ No, not Asian _→ Continue

21. Are you Native Hawaiian or Other Pacific Islander?

____ Yes, Native Hawaiian or Other Pacific Islander _→ Continue

____ No, not Native Hawaiian or Other Pacific Islander _→ Continue

22. Are you American Indian or Alaska Native?

____ Yes, American Indian or Alaska Native _→ Continue

____ No, not American Indian or Alaska Native _→ Continue

CONTINUE TO INVITATION BELOW

INVITATION:

Thank you for answering all of my questions. We would like to invite you to participate in the study that will take place on _________________________ located in ____________________. The interview will last about 90 minutes. As a thank you for your participation, you will be paid $XX.

Are you willing to participate? Yes____(CONTINUE) No____(THANK/END)

[Schedule date and time]

Now, let me just verify the spelling of your name and your address, so we can send you a confirmation letter with directions. (RECORD RESPONDENT’S INFORMATION)

Name:_______________________________Telephone:________________________

Email:_______________________________________

Address:_______________________________________________________________

City, State:____________________________________________Zip:__________________

[IF EMAIL PROVIDED:] Would you rather receive a reminder by email or regular mail?

Email

Regular mail

As I mentioned during our conversation, you will be asked to read and discuss some materials during the interview. So if you use reading glasses or assistive hearing devices, please remember to bring them with you.

If you have any questions or find that you can’t attend, please call us right away at ___________________ so that we can find a replacement. Thank you for your time and for agreeing to help.

8