CMS-10310 Attachment B3_Screening Form_Professionals_REV

Hospital Outpatient Measures

Consumer Testing

Screener: Clinicians

Austin, TX – January 27 & 28, 2010

In-Depth Interviews: Recruit 4

Target Population:

• 2 Primary care physicians

• 2 Radiologists (excluding Interventional Radiologists)

Recruitment Criteria:

• 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.

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 company with headquarters in Washington, D.C that conducts research on many different health issues.”

I’m calling today about a project that we are doing for the Centers for Medicare & Medicaid Services, the federal agency that runs Medicare, about adding new outpatient quality and efficiency measures as part of the government’s Hospital Compare website. I’m calling to find out if you would be available to review these new measures and share your expertise and opinions on how best to present the information. If you are interested in helping, we will invite you to come for an interview on __________________. It would take about 60 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.

1. What type of medicine do you practice?

____ Primary care, internal medicine, or family medicine _→ Continue to Question 2

____ Radiology _→ Continue, skip to Question 4

____ Other _{→ Thank and end call}

2. Do you treat mostly adult patients in your practice (at least 50% of patients are 18 or older)?

____ YES _→ Continue

____ NO _→ Thank and end call

3. Do you ever refer patients for outpatient surgical services or outpatient radiology services?

____ YES → Skip to Question 6 {RECRUIT 2}

____ NO → Thank and end call

4. Do you specialize in Interventional Radiology?

____ YES → Thank and end call

____ NO → Continue

5. Do you perform MRIs, mammograms, or CT scans on an outpatient basis?

____ YES → Continue {RECRUIT 2}

____ NO → Thank and end call

6. Do you currently serve on a hospital QI (quality improvement) committee?

____ YES _→ Thank and end call

____ NO _→ Continue

7. 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

8. Have you participated in a health or health insurance related interview, focus group, or other group discussion in the past year?

____ YES _→ Thank and end call

____ NO _→ Continue

____ NOT SURE _→ Thank and end call

9. Have you participated in any other interview, focus group, or group discussion in the past 6 months?

____ YES _→ Thank and end call

____ NO _→ Continue

____ NOT SURE _→ Thank and end call

CONTINUE TO INVITATION 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 [January XX]_ at _____________________________ located in ___________________. The interview will last about 60 minutes. As a thank you for your participation, you will be paid $___.

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

And if you use reading glasses, 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.

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