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CMS-10197
Table of Contents
CMS Response to Public Comments Received for CMS-10197 ..................................................... 1
Addendum: charts showing changes to data collection instruments
Survey of Oxygen Users ..........................................................................................23
Survey of CPAP Users .............................................................................................57
Survey of Walker Users ...........................................................................................79
Survey of Hospital Bed Users ................................................................................102
Survey of Power Wheelchair Users .......................................................................123
Non-Statistical Instruments ....................................................................................149
Fact Sheet ...............................................................................................................153
CMS Response to Public Comments Received for
CMS-10197
The Centers for Medicare & Medicaid Services (CMS) received five comments on CMS-10197,
which pertains to data collection for the Evaluation of the National DMEPOS Competitive
Bidding Program. The comments contained numerous useful suggestions, and we have revised
the data collection instruments and data collection plan in response. Below is a summary of the
specific comments and our response to each one.
1. GENERAL COMMENTS
Comment:
Problems with oxygen payment levels that create oxygen classes which pay
most for the least expensive devices, and less for the most expensive devices that encourage
ambulation.
Comment:
Payment system is outdated and the CMN requires physicians to speculate about
the oxygen a patient is actually getting, based on an outdated form.
Response:
This request for public comment deals specifically with CMS’s information collection plans for
an evaluation study of the national DME competitive bidding program. Comments about the
program itself are outside the scope of the information collection solicitation.
Comment:
Survey form after competitive bidding does not reference need for some
beneficiaries to change suppliers
Response:
We would first like to clarify the timing of data collection for the evaluation. The survey design
is a before/after study in which we will survey beneficiaries in competitive bidding areas and
non-competitive bidding areas twice. Competitive bidding goes into effect January 1, 2011. In
order to obtain accurate measures of the state of quality, access and beneficiary satisfaction in
the study areas, our survey plan is to conduct the first survey before competitive bidding (mid2010) and the second survey at least one year after competitive bidding begins. We believe that
waiting at least one year will allow a fresh population of new users of DMEPOS to accumulate,
as well as allow us to sample a period when the competitive bidding market has returned to
stability after the transition. In this way, we hope to achieve an unbiased comparison of the
state of quality, access, and beneficiary satisfaction between the two time points. The following
describes the timing and contents of each wave of data collection.
Surveys
Survey Wave 1
Survey Wave 2
mid-2010
mid-2012
Qualitative Data Collection (focus groups, interviews)
Wave 1
mid-2010 (focus groups and interviews)
Wave 2
transition early 2011 (newly added) (interviews)
Wave 3
mid-2011 (interviews)
1
Wave 4
mid-2012 (focus groups and interviews)
Many of the survey questions ask about initial experiences with suppliers: finding a supplier,
obtaining DMEPOS products and services, quality of those products and services, and so on. To
minimize recall bias, the survey population will be beneficiaries who began using their
DMEPOS products within the nine months prior to survey administration. Thus baseline survey
respondents (surveyed in the summer of 2010) will have begun using their products after
September, 2009, and follow-up survey respondents (surveyed in 2012) will have begun using
their products after January 1, 2011. Neither the baseline respondent group, nor the follow-up
respondent group will have experienced the transition period. It therefore is not possible to
survey beneficiaries about the transition.
In response to this comment, we have added response categories to a survey question to capture
whether a respondent changed suppliers because the supplier became ineligible to provide the
equipment. This response category could address circumstances such as those pointed out by
the commenter, as well as (rare) circumstances where suppliers are sanctioned, lose
accreditation, or otherwise are excluded from the Medicare program. We expect little change in
the frequency of this response between baseline and follow-up surveys, due to the timing of the
survey administrations and the fact that respondents will all be relatively new DMEPOS users,
none of whom will have experienced the transition.
Old Question:
Why did you make these changes? (Please check all that apply.)
1
2
3
4
5
6
99
Equipment needed to be replaced because it did not work
My condition/breathing changed
I found new equipment that was better for me
Equipment no longer available through supplier
Supplier told me Medicare no longer covered equipment
Doctor prescribed a different type of equipment
Other, please specify:
____________________________
New Question:
If you have different oxygen equipment, why did you make a change? (Please
check all that apply.)
1
2
3
4
5
6
7
99
Equipment needed to be replaced because it did not work
My condition/breathing changed
I found new equipment that was better for me
My supplier became ineligible to provide my equipment under Medicare
My supplier told me Medicare no longer covered equipment
Doctor prescribed a different type of equipment
My supplier did not tell me why they changed my equipment
Other, please specify:
2
Comment:
Grandfathering policy should be extended to enteral nutrition and evaluation
research should collect data on grandfathering policy impact on enteral nutrition patients,
including possible adverse health outcomes.
Response:
The commenter recommends that surveys should address the grandfathering concern for enteral
nutrition users. We have determined that conducting a survey of enteral nutrition users is not
feasible, for several reasons. Many users of enteral nutrition products reside in nursing homes,
and it is not clear if data collected from nursing home residents or their proxies would be
consistent with data collected from Medicare beneficiaries living at home. Also, there are many
differences between the experiences of nursing home residents and beneficiaries who live at home
with regard to obtaining DMEPOS, which would have implications for the evaluation. For
example, when nursing home residents do use DMEPOS products they most often obtain these
products through nursing home staff. In addition, many services such as training in the use of the
equipment or maintenance may be provided by nursing home staff in addition to or instead of the
DMEPOS supplier. And some DMEPOS items may not be used directly by nursing home
resident. For example, the nursing home staff may use the beneficiary’s diabetic supplies (e.g.,
monitor, test strips, and lancets, enteral nutrition products) in the care of the patient, rather than
the patient using these items directly. Each of these differences could harm the validity of the
survey.
Another set of reasons has to do with our survey design, in which the timing will not encompass a
period when any effects from the grandfathering policy will be measurable. As described above,
none of the survey respondents will have experienced the transition, and any associated issues
related to grandfather. Thus, it is not feasible to query survey respondents about the
grandfathering policy, as new arrangements will have been made long before the follow-up
survey is conducted. Nor is it feasible for CMS to create an additional wave of the survey due to
the prohibitive expense of that form of data collection.
This is not to say that the evaluation will ignore information about the transition. The commenter
recommends that interviews of beneficiaries and suppliers should address the grandfathering
concern. We have added a new wave of qualitative data collection, timed during the transition in
early 2011, and we intend to contact representatives in approximately 16 beneficiary/disease
advocacy organizations, as well as other sources in a position to witness the impact of
grandfathering policy in the competitive bidding areas shortly after the new contracts go into
effect. We have developed interview guides for these contacts (see Appendix C section titled: Key
Informant Discussion Guide: COMPARISON AREA: Beneficiary Groups/Advocates [Wave 2]
for further description of this new component of data collection we are proposing in response to
this and similar comments). We also plan to collect information from the competitive bidding
Ombudsman, the 1-800-Medicare call center, the CMS regional offices, Areas on Aging, and
other appropriate sources to gauge whether service interruptions are widespread for enteral
nutrition users, and other DMEPOS users. We will ask these sources about the volume of
complaints and problems they are handling during the transition, related to grandfathering; any
special education sessions or materials they distribute related to grandfathering concerns; and
whether enteral nutrition users (and those using other DMEPOS products) experience access
problems related specifically to grandfathering.
The commenter recommends collecting data on possible adverse health outcomes, such as deaths
and prolonged hospitalization or re-hospitalization. We noted in response to our original PRA
3
package in 2007 that tracing health outcomes to medical equipment quality is highly problematic.
Frequently, there are too many intervening variables, particularly physician quality, that affect
the final outcome but that cannot be accounted for in such an analysis. Further, studies can be
hindered by lack of data on specific physiological measures, such as test results, which affect
treatment decisions and eventually outcomes. Because of the expense and complexity of data
collection required to conduct such studies, and because the state of the art for such research is
not well developed, a properly conceived study, whose success is not assured, is not within the
scope of the evaluation. As part of our contacts with sources in early 2011, we will attempt to
collect information on these consequences to the extent interruptions in service are identified.
Comment:
Report to Congress due before the evaluation is complete
Response:
The timeline for the national competitive bidding program and the schedule for Report to
Congress are the prerogatives of the Congress, which enacted these provisions in Section 154 of
the Medicare Improvements for Patients and Providers Act of 2008. CMS is planning its
reporting on the evaluation in accordance with the law. We respectfully disagree with the
implication of the commenter that the report will have no value because of its timing. Contents
of the report will include savings estimates, reports of preliminary (baseline site visits), a
description of the research design, and other information about the evaluation. It should be
noted that other provisions of the law mandate reports from additional agencies, including the
Government Accountability Office. We have indicated in the Information Collection Request
that the remaining results of the evaluation will be forthcoming after additional data collection
is completed. We intend to post these final evaluation reports on the CMS website.
Comment:
CMS should fully incorporate views of diabetic patients and the evaluation
should examine not only ‘direct costs’ associated with diabetes supplies, but more importantly
what impact the program will have had on beneficiary access to the most commonly prescribed
products and on beneficiary compliance with prescribed therapy.
Response:
To address access concerns of this and other commenters, as described above, we have added
qualitative data collection in early 2011 with 16 advocacy organizations to obtain information
about the transition to the new program for all types of DMEPOS products affected by
competitive bidding. (Please see Wave 2 discussion guide in revised Appendix C: Non-statistical
Instruments.) We also include in our plans interviews with government officials, such as the
competitive bidding Ombudsman, who will be conducting outreach and program monitoring.
Interviews with CMS officials at Central and Regional Offices will address the nature and extent
of the outreach and education effort. Interviews with patient advocates will address the
adequacy of these outreach efforts, and any problems or confusion beneficiaries encountered
during the transition. Focus groups in 2010 and 2012 with suppliers and referral agents will
address their perceptions before and after the transition, including the adequacy of information
to prepare them for the transition. (See Appendix C: Non-statistical Instruments, Waves 1 and
4.) It should also be noted that the DMEPOS Ombudsman will prepare annual reports which
should be expected to cover any problems encountered during the transition, and CMS will
assemble information from the Medicare helpline regarding calls for DMEPOS competitive
bidding information.
From these contacts and sources, the evaluation team expects to improve its understanding of
access impacts and will include these results in the evaluation reports. The evaluation will also
analyze claims to examine changes in patterns of mail order diabetic supplies and other
4
DMEPOS products. Access to DMEPOS is of concern and while it is not possible to directly
measure access using claims data, we will use statistical models to estimate the impact of
competitive bidding on Medicare expenditures, considering both changes in unit prices and
changes in the volume of claims for each product category, in each competitive bidding area (as
compared with changes in comparison areas). Such analyses are potentially interpretable as a
type of information about access impacts. We will further report changes in estimates of out-ofpocket costs, which is a traditional measure of access. We can also use claims aggregated to the
supplier level to analyze supplier statistics that are likely related to beneficiary access.
Specifically, we will measure the change in the number of suppliers for each product category in
each competitive bidding area, and how the change in the number of suppliers (measured in
terms of number of suppliers and supplier to beneficiary ratio) of given product categories
differs between the CAAs and the comparison areas.
Comment: Evaluation study should encompass how well CMS informed beneficiaries about the
program and how well CMS responded to access problems.
Response:
CMS plans an extensive outreach and education campaign targeting patients, providers and
suppliers, and the agency plans to monitor this outreach effort carefully. There are many
components of this outreach and monitoring; for example: public presentations held by CMS
Regional Office staff in the nine communities, conference calls CMS holds with advocacy
organizations around the country, information about calls placed by beneficiaries to the 1-800MEDICARE helpline, and information about complaints submitted to the DMEPOS
Ombudsman. The Office of Medicare Ombudsman will submit an annual report to Congress and
the Secretary of Health & Human Services (HHS) that includes the Ombudsman's
recommendation for improvement in the administration of the Medicare competitive bidding
program.
The evaluators plan to interview CMS officials about the implementation of competitive bidding,
including the metrics of the outreach and education campaign (for example, numbers of mailings
and listservs, and their volumes and timing; staff presentations at meetings and conferences;
other types of contacts such as explanation of benefits messages, conference calls, complaints,
and so on). Evaluators will interview, among others, the Provider communications group in the
CMS Central Office, the DMEPOS Ombudsman, the Office of External Affairs, and outreach staff
in CMS Regional Offices in regions that contain the first nine competitive bidding areas, as well
as the competitive bidding implementation contractor (CBIC). Through these activities, the
evaluation team will be collecting information about the level of effort and volumes of public
education contacts with the various audiences and stakeholders in order to round out the
description of the public education activities. The evaluation Report to Congress and the
subsequent report on the evaluation will include these measures of process undertaken by the
agency and its partners to prepare and assist beneficiaries and various stakeholders with respect
to the new competitive bidding program. At this writing, these activities have already begun.
We agree with the commenter that transition issues are important, not least for what they can
reveal about how CMS should implement future rounds of competitive bidding. The evaluation
project has added qualitative data collection in early 2011, during the transition, to learn about
adequacy of information, any disruptions due to changing suppliers, etc. The new wave of
qualitative data collection in early 2011 will include about 16 advocacy organizations for all
types of DMEPOS products affected by competitive bidding. The evaluators will ask these
advocates about the perceived adequacy of CMS’ outreach and education efforts. An additional
interview guide has been prepared to gather information about these transition issues from
patient advocacy organizations (see Appendix C: Non-statistical Instruments, Wave 2).
5
Adding a survey or other large-scale data collection to study outreach effectiveness is beyond
the scope of the evaluation and its budget.
Comment: CMS should collaborate with interested organizations to help the agency address
beneficiary questions and concerns during program implementation
Response:
As discussed above, CMS is planning for an extensive and multi-faceted outreach and education
program for beneficiaries, suppliers and healthcare providers affected by the competitive
bidding program. The outreach program strongly emphasizes a role for CMS’ many partners in
this effort. Partners include national advocacy organizations such as the American Diabetes
Association. CMS welcomes additional partners; they can join the partner community by visiting
the “How to Partner with CMS” webpage and clicking on “Submit Feedback”
(http://www.cms.hhs.gov/Partnerships/04_HTP.asp#TopOfPage).
Comment:
instruments
CMS should consult with the diabetes community before finalizing new
Response:
We believe the PRA ICR process provides for this consultation through the review and comment
process. As part of this process, we are providing for public comment additional interview
guides that we will use shortly after competitive bidding is launched on 1/1/11, as well as
revisions to previously developed interview guides. We have augmented the qualitatative data
collection to include interviews with patient advocacy organizations – including those
representing patients with diabetes – during the transition. We have also enhanced focus group
guides to include issues concerning the outreach and education effort, and whether patients had
sufficient information to support a smooth transition. We refer readers to the guides for the
added wave of data collection, Wave 2, in Appendix C, Nonstatistical Instruments, and to
revisions to the existing interview guides, revisions that are detailed in the Addendum to these
comments and responses.
Comment:
Data collection instruments should be clear and easy to follow.
Response:
CMS believes that we have designed our survey forms to meet the criteria that the commenter
mentions. These forms were thoroughly tested during the 2007 baseline data collection, before
the program was delayed. We welcome any specific suggestions from the public on clarity and
flow of the survey instruments. No other forms in this information collection package are for use
by the public.
Comment:
Ensure representation in the study of populations at high risk of diabetes,
including racial/ethnic minorities.
Response:
Resources do not permit surveying users of all nine DMEPOS products, and there will be no
survey of users of mail-ordered diabetic supplies. The evaluators will be analyzing claims for
diabetic supplies, to study access issues, and these claims will be stratified by race/ethnicity to
the extent possible. (It is important to recognize, however, that CMS administrative data have a
6
degree of error in race/ethnicity classification.)
Qualitative data collection will take place before and after the competitively bid contracts begin,
and we have added data collection during the transition (early 2011) to identify issues that arise
related to changing suppliers or information needs. During this transition data collection phase,
the evaluators will contact organizations like the National Alliance for Hispanic Health, and the
National Caucus and Center on Black Aged, as well as organizations with a disease specific
focus (e.g., American Diabetes Association) to explore the concerns raised by the commenter.
We welcome identification of relevant patient advocacy groups.
Comment: Evaluation overlooks impacts on rural beneficiaries.
Response:
This comment is outside the scope of this evaluation because the law prohibits conducting
competitive bidding competitions in rural areas before 2015. Section 1847(a)(1)(B) of the Social
Security Act (the Act) requires that both the Round 1 rebid and Round 2 occur in specific
metropolitan statistical areas. Furthermore, section 1847(a)(1)(D)(iii) of the Act requires the
Secretary to exempt rural areas from subsequent competitions occurring before 2015 (except for
national mail order).
Comment:
Survey forms are too long.
Response:
These forms were thoroughly tested with thousands of respondents during the 2007 baseline data
collection, before the program was delayed. In response to several comments, we have been
able to reduce the length of the oxygen users survey somewhat, eliminating two questions and
consolidating four others. While we agree that the surveys are lengthy, they address several
critical access and quality issues that are central to the evaluation.
Comment:
Dropping supplier survey will produce skewed data
“CMS states that it plans to drop the supplier survey used in 2007 in favor of focus groups and
key informant interviews with suppliers and referral agents. […] HCC members would argue
that the proposed approach will also produce skewed data from the supplier community. […]
[T]he only data that will be collected will be from those who have achieved accreditation,
secured a surety bond and been able to maintain their existence in the face of the implementation
of competitive bidding.”
Response:
The focus of the previous supplier survey was narrow: to identify makes and models of DMEPOS
products offered before and after competitive bidding, to measure changes that may in part be
due to the program. We will not be collecting this information in a supplier survey. However,
CMS requires bidding suppliers to specify the makes and models of products they intend to
provide, and requires winning suppliers to report each quarter on what was actually furnished
to beneficiaries. This information will be used by the evaluation team determine whether
suppliers continue to provide the makes and models of equipment listed on their bid forms. This
alternative mechanism for tracking changes in makes and models will take the place of the
supplier survey.
7
Our original evaluation plan for qualitative data collection with suppliers has not changed, and
in fact has been expanded in response to comments received. We will conduct focus groups with
suppliers in four of the nine competitive bidding areas rather than just three, interview industry
representatives, before and after program implementation, and will check in with them by phone
between these two rounds of focus groups as well. The qualitative data are not intended as a
substitute for the supplier survey, but rather as an independent data source oriented towards a
different set of questions (questions other than product diversity).
Using bidder data and claims, the evaluation will be analyzing changes in the supplier market:
which types of suppliers submitted bids, which types won/lost bids, etc. The purpose of this
analysis will be to document the number and types of suppliers serving each market before and
after competitive bidding, and to understand which types of suppliers were successful in the first
round of competitive bidding – and might be expected to be successful in future rounds, when
many more communities will be added to the competitive bidding program.
We would like to note that the Government Accountability Office has been tasked by Congress to
study the impacts of competitive bidding on suppliers. The Medicare Improvements for Patients
and Providers Act (MIPPA) of 2008, Section 154, requires the GAO to submit a report on the
following topics:
(i) Beneficiary access to items and services under the program, including the impact
on such access of awarding contracts to bidders that-(I) did not have a physical presence in an area where they received a
contract; or
(II) had no previous experience providing the product category they were
contracted to provide.
(ii) Beneficiary satisfaction with the program and cost savings to beneficiaries under
the program.
(iii) Costs to suppliers of participating in the program and recommendations about
ways to reduce those costs without compromising quality standards or savings to the
Medicare program.
(iv) Impact of the program on small business suppliers.
(v) Analysis of the impact on utilization of different items and services paid within the
same Healthcare Common Procedure Coding System (HCPCS) code.
(vi) Costs to the Centers for Medicare & Medicaid Services, including payments
made to contractors, for administering the program compared with administration of
a fee schedule, in comparison with the relative savings of the program.
(vii) Impact on access, Medicare spending, and beneficiary spending of any
difference in treatment for diabetic testing supplies depending on how such supplies
are furnished.
(viii) Such other topics as the Comptroller General determines to be appropriate.'.
This GAO report is in addition to CMS’ evaluation report to Congress.
One commenter submitted transcripts from many communications, such as telephone calls,
they received from Medicare beneficiaries. These are summarized below:
Ability to use DME supplier of choice: 29 transcripted phone calls from: 28 beneficiaries or
caretakers, 1 licensed social worker expressed concerns that beneficiaries will no longer have the
ability to choose their DME supplier (loss of consumer choice); that competitive bidding will
create monopolies; that small businesses will be harmed; and that beneficiaries will be forced to
stop working with the suppliers that they know and trust.
8
Quality of supplier service: 23 transcripted phone calls from oxygen suppliers, beneficiaries or
caretakers expressed concern that competitive bidding will force patients to use a supplier who
does not provide them with the same level of quality service that they enjoy with their current
supplier, such as equipment set-up and explanation, round the clock on-call assistance, and
respectful treatment.
Diabetic supplies: transcripted phone calls from three beneficiaries raised concerns about
being forced to use a national instead of a local suppliers, having to pay out of pocket if the new
supplier does not work out, and receiving poorer quality service from a new supplier.
Response:
This request for public comment deals specifically with CMS’s information collection plans for
an evaluation study of the national DME competitive bidding program. Comments about the
program itself are outside the scope of the information collection solicitation.
2. COMMENTS RELATED TO QUANTITATIVE DATA COLLECTION
Oxygen Equipment Survey
Comment: Logical flaw in opening statement: “First page, opening statement: The last sentence
makes no sense when combined with the boxes one is supposed to check off. Since the first
sentence asks the person to check off the appropriate box if they are unable to complete the
survey, the last sentence is redundant. We suggest deleting it.”
Response:
Survey instrument revised - it now has one check box to indicate that the person to whom the
survey was mailed is unable to respond and there is no one available to can serve as a proxy.
Previous opening statement
If the person this survey was mailed to cannot complete the survey and there is no one
else who can do so for him or her, please check the appropriate box below and return
the blank survey in the enclosed postage-paid envelope. The person this survey was
mailed to is:
1
There is nobody available who can complete this survey
99 Other reason, please specify: __________________________
Revised opening statement
1
If the person this survey was mailed to cannot complete the survey, and there is
no one else who can do so for him or her, please check here and return the blank
survey in the enclosed postage-paid envelope.
9
Comment: Provide a definition of CPAP in Question A3.
Response:
We have added a simple description of a CPAP machine: A CPAP machine blows air through
a hose into a face mask or ventilator, to improve breathing while asleep.
Comment:
“A3a. Add a new item 8, ‘I was embarrassed to wear it.’”
Response:
This response category has been added; the response categories are now:
A3a. Why did you stop using oxygen? (Please check all that apply and then go to
SECTION G on p. 19.)
1
2
3
4
5
6
7
8
96
Comment:
I believed that my breathing got better so I did not need it anymore
My doctor said I did not need it
Oxygen therapy costs too much
I just did not like using it
Equipment was too heavy or cumbersome
Equipment kept breaking down
I had a problem getting the supplies from my oxygen supplier
I was embarrassed to use it
Other, please specify:
Delete question A5 on origination site of oxygen therapy
“A5. This is misleading. Most patients start home oxygen within 48 hrs prior to discharge. If
they go home on an E cylinder, and receive home oxygen with an E cylinder, they will likely
answer ‘yes’ and data will be skewed away from those on the least portable oxygen system.
Those that go home on a portable liquid system are in the same predicament. Adding this
question is also problematic because if the answer is ‘yes,’ all the other questions relating to the
equipment are skipped. It adds little value and we suggest deleting it altogether.”
Response:
We agree with the comment and have eliminated the Skip instruction for those who answer “yes”
to this question.
Comments Concerning Questions A7 through A 10:
Comment:
Relocate definition of respiratory therapist in Question A7.
“A7. While the description of a respiratory therapist is reasonable, we would recommend 1)
either incorporating it into the question in parentheses to be consistent with other definitions, or
2) perhaps consider including a section by itself with definitions or a glossary.”
10
Comment: Add question about site of respiratory therapist contact.
“A7 – A10. Respiratory therapists (RTs) who work in the home setting should be distinguished
from doctors, nurses and hospital-based respiratory therapists. Asking questions about what
information was given by professionals outside the home is clinically important. However, since
RTs in the home setting have been available in the past, it is of great interest to know if
competitive bidding has taken away this clinical support, especially if it is not provided outside
the home.
Comment:
Improve question A8 about goal of oxygen therapy.
“A8. This question is misleading – the clinical goal of oxygen therapy is to reach a certain
oxygen saturation level. For some patients that might mean a flow rate of 2 LPM, while for
others it would be a different flow rate. Asking a question about quantity is not as relevant as
knowing the end point for adequate oxygenation with rest and exertion.”
□ I don’t know”
Response to Comments on questions A7 through A10:
We agree that the issue for this series of questions is really whether a clinician (rather than a
supplier’s delivery person) adequately explained equipment options and use to patients. It is also
important to know whether instruction happened in the hospital or after the patient returned
home and began using the equipment without medical supervision. And we are interested in
identifying patients who are not well-educated by medical personnel, as their answers to other
survey questions may differ from those who did receive adequate education. The questionnaire
has been revised to combine questions A7 through A10 into one question (check all that apply);
we believe that this simplification is warranted and has the added benefit of shortening the
questionnaire.
Previous questions A7 through A10
A7.
A respiratory therapist is a specially trained professional who helps you improve
your breathing. Did a doctor or another medical person like a nurse or a
respiratory therapist ever explain to you why you needed oxygen?
1 Yes
2 No
98 I don’t know
A8.
Did a doctor or another medical person like a nurse or a respiratory therapist ever
explain to you how much oxygen you needed?
1 Yes
2 No
98 I don’t know
A9.
Did a doctor or another medical person like a nurse or a respiratory therapist ever
explain to you when you are supposed to use your oxygen system?
1 Yes
11
2 No
98 I don’t know
A10.
Did a doctor or another medical person like a nurse or a respiratory therapist
ever explain oxygen equipment options and which might be best for you?
1 Yes
2 No
98 I don’t know
Revised questions A7
A7.
Did a respiratory therapist or another medical person like a doctor or a nurse ever
explain the following to you (Please check all that apply):
1 Oxygen equipment options and which might be best for you
2 Why you need to use oxygen equipment
3 How much oxygen you need
4 When to use your oxygen equipment
98 None of these things were explained by a respiratory therapist, doctor,
or nurse
“A13a needs to be revised to better tie it into A13. We suggest revising it to
Comment:
read: “If you have different oxygen equipment, why did you make a change? (Please check all
that apply.)’ Also, add ‘My supplier did not tell me why they changed my equipment.’
Response:
The survey instrument has been revised as suggested in this comment.
Previous questions A13 and A13a
A13.
Are you still using the same oxygen equipment as when you first started using
oxygen at home?
1 Yes (→Skip to A14)
2 No
I don’t know (→Skip to A14)
98
A13a. Why did you make these changes? (Please check all that apply.)
1 Equipment needed to be replaced because it did not work
2 My condition/breathing changed
3 I found new equipment that was better for me
4 Equipment no longer available through supplier
5 Supplier told me Medicare no longer covered equipment
6 Doctor prescribed a different type of equipment
99 Other, please specify:
____________________________
12
Revised questions
A11. Are you still using the same oxygen equipment as when you first started using oxygen
at home?
1 Yes (→Skip to A12)
2 No
I don’t know (→Skip to A12)
98
A11a.
If you have different oxygen equipment, why did you make a change?
(Please check all that apply.)
1 Equipment needed to be replaced because it did not work
2 My condition/breathing changed
3 I found new equipment that was better for me
4 My supplier became ineligible to provide my equipment under Medicare
5 My supplier told me Medicare no longer covered equipment
6 Doctor prescribed a different type of equipment
7 My supplier did not tell me why they changed my equipment
99 Other, please specify:
____________________________
Responses to Question A15a do not address the question. Recommend splitting
Comment:
the question into two parts.
Response:
We do not agree that this question should be divided into two parts. Moreover we are asking for
individuals’ subjective judgments about what is or is not difficult or uncomfortable for them.
Equipment one person finds to be heavy or cumbersome may not be a problem for another
person. We have modified the response categories in an effort to clarify this purpose.
Subject of Question A17a is not clear. Does ‘less oxygen’ mean lower dose, but
Comment:
prescribed duration, shorter duration but prescribed dose, or both? The responses fit more with
shorter duration. Shorter duration is proven to reduce survival (NOTT study). Also, response 9
does not make sense in the context of this question and should be deleted.”
Response:
We have modified the question in response to this comment, as follows:
Are you using less oxygen than your doctor, nurse or respiratory therapist
recommended?
1 Yes, I use it for fewer hours per day than my doctor recommended
2 Yes, I use it for fewer days each week than my doctor recommended
3 Yes, I use a lower flow rate than my doctor recommended
4 No (→Skip to SECTION B)
13
98 I don’t know (→ Skip to SECTION B)
Comment:
Line drawings for devices are not to scale and therefore are misleading.
Response:
It is not possible to make pictures to scale on an 8 x 10 paper survey questionnaire. We cannot
show images of all types of equipment, because they are so diverse – each manufacturer’s
concentrator looks somewhat different. Moreover, we cannot use photographs of any particular
manufacturer’s product(s). We believe the current approach of combining ‘generic’ pictures
with text descriptions is the best solution, and these pictures/descriptions were tested successfully
in the 2007 data collection. We have, however, added additional descriptors to clarify some of
the products, especially to distinguish concentrators (which concentrate room air) from liquid
oxygen units (which must be refilled).
Comment:
Revise Response 2 of Question B2.
“B2. Response 2 infers that a liquid oxygen vessel resembles a large thermos. A liquid reservoir
placed in a patient’s home is not generally moved, and one can infer from your description that
the device is actually much smaller.”
Response:
The survey instrument has been revised as suggested. Response 2 now reads: “Liquid oxygen
vessel (large tank that is usually placed in the home and not moved).”
Comment:
Rephrase response category 3 of Question B7a.
“B7a. Response 3 uses ‘apples and oranges’ in its description. We recommend using the phrase
‘liquid oxygen or compressed oxygen’ rather than liquid or cylinder. Many people would
describe a liquid system as cylindrical.”
Response:
Response 3 changed to “Unit ran out of liquid oxygen or compressed oxygen.”
Comment: Section B line drawings for devices are not to scale and therefore are misleading.
Response:
It is not possible to show images of every type of equipment, because as this commenter points
out, they are so diverse. Moreover, we cannot use photographs of any particular manufacturer’s
product(s). We believe the current approach of combining ‘generic’ pictures with text
descriptions is the best solution. These pictures/descriptions were tested successfully in the 2007
data collection.
“C2. Response 1 should say ‘can roll on a cart’ to fit with ‘can carry’ responses
Comment:
– It cannot be carried. Response 4 is inappropriate. ALL examples usually use pulse dose.”
Response:
14
Response category 6 has been revised.
Previous question
C2.
What type of portable oxygen system(s) do you use? (Please check all that apply.)
1 Mid-sized compressed oxygen tank (E-cylinder, resembles a diving tank)
[pictured below at left]
2 Very small and light compressed oxygen tank (can carry on your shoulder)
[pictured below at right]
3 Mid-sized or standard portable liquid oxygen unit [pictured below in center]
4 Very small liquid portable unit (i.e., can carry on your shoulder or belt and
delivers pulses of oxygen) [not pictured]
5 Small portable oxygen concentrator [not pictured]
6 Small portable concentrator that also serves as a stationary source [not
pictured]
98 I don’t know
96 Other portable oxygen system: _________________________
Revised question
C2.
What type of portable oxygen system(s) do you use? (Please check all that
apply.)
1 Mid-sized compressed oxygen tank (E-cylinder, resembles a diving tank and
can roll on a cart) [pictured below at left]
2 Very small and light compressed oxygen tank that concentrates room oxygen
(can carry on your shoulder) [pictured below at right]
3 Mid-sized or standard portable liquid oxygen unit [pictured below in center]
4 Very small liquid portable unit (can carry on your shoulder or belt and that
must be refilled) [not pictured]
5 Small portable oxygen concentrator that concentrates room oxygen [not
pictured]
6 Small portable concentrator that concentrates room oxygen and also serves
as a stationary source [not pictured]
98 I don’t know
96 Other portable oxygen system: ________________________
Add a response category to Question C5a about oxygen not meeting needs: ‘I’m
afraid I’ll run out of oxygen’ as was also used in A15a.”
Comment:
Response:
A response category has been added, as suggested; the revised question is:
C5a. Please tell us why your portable oxygen system is not meeting your needs.
(Please check all that apply.)
15
1
2
3
4
5
6
7
8
9
10
96
I believe that my breathing got better so I don’t need oxygen as much
Oxygen therapy costs too much
I just don’t like using it
I am embarrassed to use it
Equipment is too heavy or cumbersome
Equipment keeps breaking down
Equipment is too complicated for me to use
I have a problem getting the supplies from my oxygen supplier
I’m using a different oxygen system
I’m afraid I will run out of oxygen
Other, please specify:
Comment:
Clarify response category 6 of question C6 on refills frequency. Suggest revising
response 6 to say ‘I don’t need refills of any type.’
Response:
The survey has been revised as suggested; the revised question is:
C6.
In general, how often do you get deliveries/refills from your oxygen supplier for
your portable oxygen system? This may include oxygen tank deliveries, liquid
oxygen refills, etc.
1
2
3
4
5
6
98
4 times a month
2-3 times a month
Once a month
Once every year
Less than once per year
I don’t get refills of any type
I don’t know
Number of tanks question not interpretable, unless there is also specific
Comment:
information about the size of the tanks being refilled. In addition, while the description of the
intermittent flow device is reasonable, neither small liquid units nor portable concentrators are
examples of these flow devices; rather they are examples of devices that may use a pulse dosing
oxygen regulator. “Suggest modifying the definition to read as follows: ‘. . . Examples of these
oxygen-conserving devices are pulse-dosing oxygen regulators, or small liquid portable units or
portable concentrators that use a pulse dosing oxygen regulator.’”
Response:
Rather than asking respondents how frequently oxygen is delivered to their homes, and how many
tanks are delivered, we have reconsidered our approach and will ask instead whether
respondents are getting enough oxygen delivered to meet their needs. Question F6a asks about
16
reasons for changing suppliers, and two answer categories now ask whether the respondent
changed suppliers because they were unhappy with the amount of oxygen being delivered to their
home for their stationary units, or were unhappy with the amount of oxygen being delivered for
their portable units. In addition, questions about difficulty or discomfort with using equipment
include an answer category about fear of running out of oxygen. These more direct questions will
provide more accurate information and will also shorten the survey.
The definition has been modified as suggested by this commenter.
Correct assumption behind question C7a about who adjusted new device. This
Comment:
question infers that the patient was titrated as part of the initial oxygen set up process. That is
not a valid assumption in all cases. “We would recommend changing the wording to ‘When you
first received your oxygen equipment that was equipped with an intermittent flow device (not all
oxygen users actually use these regulators), who adjusted the device . . . ’.
Response:
The wording of the question has been revised, as suggested by the commenter.
Previous question
C7a. When you first got your intermittent flow device, who adjusted the device and
tested you while you were using it? (Please check all that apply.)
1 Home oxygen supplier
2 Doctor
3 Other medical personnel
4 No one
5 Don’t remember if anyone did
98 I don’t know
Revised question
C7a. When you first received your oxygen equipment that was equipped with an
intermittent flow device, who adjusted the device? (Please check all that apply.)
1 Home oxygen supplier or a respiratory therapist from the supplier
2 Doctor
3 Other medical personnel
4 No one
5 Don’t remember if anyone did
98 I don’t know who it was
Add a response category to question D3 about expenses for oxygen equipment
Comment:
which may be above $1,000.
Response:
17
The wording of the question has been revised, as suggested by the commenter. The response
categories for question D3 are now:
1
2
3
4
98
Less than $100
$100-$500
$500 to $1,000
$1,000 to $2,000
I don’t know
Comment:
Questions in Section E do not address beneficiaries experience changing
suppliers during the transition.
Response:
Differences in survey responses between pre and post competitive bidding will be analyzed to
identify changes in access or supplier performance after competitive bidding goes into effect,
taking into account environmental changes that affect everyone (as measured in comparison
areas). This is the strength of the difference-in-differences evaluation design. The first round of
the survey will take place before the competitive bidding program begins and respondents will
all have started using their DMEPOS equipment within the previous nine months. The second
round of the survey will be given only to beneficiaries who started to receive their DMEPOS
items in the year or more after the competitive bidding program began. Therefore surveyed
beneficiaries in the post-competitive bidding environment will not include continuing oxygen
users who have had to change suppliers as a result of the competitive bidding program. In other
words, by administering these questions in a before/after survey design, we intend to learn about
ease of negotiating the oxygen marketplace before and after competitive bidding, and then we
will compare the two sets of information. A separate part of our research will address the
transition to competitive bidding. It will be based on qualitative data collection, as described
above and in Appendix C – non-statistical instruments.
Comment:
Misuse of word “order” in Question E8 about how quickly equipment arrived;
beneficiaries do not order oxygen, physicians do.
Response:
The revised question now reads: “after the order was placed for your oxygen equipment, how long
did it take to arrive?”
Comment:
Add a “don’t know” response category to Question E10 about specialty of
visiting clinician.
Response:
An additional response has been added: “I don’t know or recall the clinical specialty of the person
who came to my home.”
Comment:
Revise Question E13 about equipment offerings explained by supplier. Suggest
revising the question as follows:
18
E13. Before deciding on the oxygen equipment you use now, did your supplier tell you about all
the options available to you, even ones that the supplier did not have in inventory?
□ Yes, all options were explained
□ No, the supplier only told me what was in his/her inventory
□ I don’t know”
Response:
The response categories for Question E13 (now renumbered E3a) are revised as follows:
1
2
3
98
Yes, all equipment designs were explained
No, the supplier only told me what he/she has in stock
No, I already knew the equipment designs available to me
I don’t know
Comment:
Revise order of question in Section E.
E1-E2: Okay as is
E13 should become E3
E8 should become E4
E14 should become E5
E9 and 9a should become E6 and 6a
E6 should become E7
E7 should become E8
E10, 11 and 12 should become E9, 10 and 11
E3, 4 and 5 should become E12, 13 and 14”
Response:
The order of questions has been revised as suggested in this comment. The same reordering has
been applied to the questionnaires for other types of equipment.
Comment:
Prior to the current Section A of each questionnaire, include a brief new section to ask patients
about their experience changing suppliers during the transition.
Response:
We did not change the survey as recommended. The reason is that the first round of the survey
will be before the competitive bidding program begins, and the second round of the survey will be
given only to beneficiaries who started to receive their DMEPOS items after the program begins;
therefore none of the surveyed beneficiaries will have been part of the “transition” cohort that
may need to change suppliers.
“[…] a number of the questions included in the early part of the survey (A7Comment:
A12) designed for use with patients on oxygen really do not focus on the responsibilities of the
DMEPOS supplier, but rather on the professional medical services provided by the physician
who ordered the oxygen equipment for the patient or by the hospital or nursing home personnel
that may have been serving the patient at the time oxygen equipment was ordered. While this
may be a worthy focus for a CMS evaluation, it really does not relate to the activities of a
19
DMEPOS supplier in a competitive bidding environment.”
Response:
To address this and several other comments, questions A7 – A10 have been combined into one
question (as discussed above), which has two purposes. First, we wish to identify patients who do
not receive adequate education from medical personnel – their answers to other survey questions
may differ from patients who are well-educated. Second, there is some concern that competitive
bidding may reduce patient education services, particularly if suppliers who previously paid
respiratory therapists to provide this education no longer do so.
3. COMMENTS RELATED TO STUDY FACT SHEETS
Comment:
The Fact Sheet does not accurately state the purpose of the study.
Response:
We agree with this comment and have added a introductory statement about the Purpose of the
Study. Use of the term “competitive bidding” will likely confuse beneficiaries, because the timing
of the first survey administration predates the public information campaign about competitive
bidding by several months, and the timing of the second administration occurs well beyond the
time of competitive bidding implementation. Thus, we expect many beneficiaries will be
perplexed by specific mention of this policy change. However, we agree that it is worthwhile to
be more precise about the purpose of the study, which is to provide policymakers a source of
information about the home medical equipment benefit in relation to Medicare policy changes.
The purpose of the study, as included in the FAQs, will be added to each questionnaire, as
follows:
The purpose of the study is to learn more about your satisfaction with the
equipment, supplies, and service you receive from your oxygen (or other
durable medical equipment) supplier. We also hope to better understand
your experiences in obtaining and using this equipment. Results of the
survey will be compared with results from patients in different metropolitan
areas and results from patients who received their equipment in a different
year. These comparisons will help reveal how new ways of administering
the Medicare program affect beneficiaries.
4. COMMENTS RELATED TO QUALITATIVE DATA COLLECTION
(FOCUS GROUPS AND KEY INFORMANT INTERVIEWS)
Key Informant Discussion Guide: Beneficiary Groups/Advocates (Wave 1)
“Question 7 ‘Have you heard of the Medicare plan to use Competitive Bidding
Comment:
to modify the DMEPOS fee schedule for reimbursing suppliers?’ should be expanded to include
a Question 7c, Have any of the beneficiaries you work with/represent changed their DME
supplier(s) as a result of competitive bidding? If so, how has the change affected them?”
Response:
20
The focus groups will be conducted well before competitively bid contracts begin, and again
more than a year after the start. It would be inappropriate to ask these questions before the
program begins, but in response to this comment we have added questions on this topic to the
moderators’ guides for the second round of focus groups.
Comment:
“The term ‘clients’ in Question 7b should be replaced by a neutral term that does not imply a
financial relationship.”
Response:
The term “clients” has been replaced by “beneficiaries”.
“The Center For Regulatory Effectiveness should be named as one of the
Comment:
Beneficiary Groups/Advocates that CMS works with on this study in light of our: 1) longstanding work on competitive bidding, and 2) unique access to/outreach program for Medicare
beneficiaries through our Competitive Bidding IPD and toll-free Hotline.”
Response:
We respectfully respond that this comment is premature. The evaluation team, in consultation
with the CMS project officer, will select appropriate patient advocacy organizations to interview
in the context of the program phase at the time of the interview, in accordance with the evaluation
design, in recognition of the potential value of the source given information that has come to the
team’s attention at the time sources are being recruited, and in consideration of the fact that
sources must be prioritized to avoid duplication. As with all studies, resources are limited.
Key Informant Discussion Guide: CMS Officials or CMS’ Bidding Program Managers (All
Waves)
“The focus group discussion should be expanded to ask CMS officials: 1)
Comment:
whether they have received complaints from beneficiaries about competitive bidding, and 2) to
discuss/characterize those complaints. The Competitive Acquisition Ombudsman should be
among the officials interviewed.”
Response:
CMS officials will be interviewed individually rather than participating in any focus groups.
They will be asked about their process for tracking complaints/calls/issues, and the types of
issues that arose during the transition period.
The DME Ombudsman will be among the officials interviewed by the evaluation team. The
competitive bidding ombudsman will also prepare a separate report covering, among other
things, the competitive bidding program implementation.
21
Addendum: charts showing changes to data
collection instruments
22
DMEPOS Survey of Oxygen Users: Changes from December 2009 ICR Draft to March 2010 ICR Draft
2009 ICR Draft Survey
Title. Survey of Medicare Patients Who Use
Oxygen Equipment
Qualifying Question. If the person this
survey was mailed to cannot complete the
survey and there is no one else who can do so
for him or her, please check the appropriate
box below and return the blank survey in the
enclosed postage-paid envelope. The person
this survey was mailed to is:
There is nobody available who can
1
complete this survey
99 Other reason, please specify:
__________________________
Section Title. A.USE OF OXYGEN
SYSTEMS
A1.When did you begin using oxygen
equipment and tanks at home?
1 2010
2 2009
3 2008
4 Before 2008
5 I have never used oxygen equipment at
home (Skip to SECTION G on page 16)
Page
1
1
3
3
2010 ICR Draft Survey
Title. Survey of Medicare Patients Who Use
Oxygen Equipment
Qualifying Question.
If the person this survey was mailed
1
to cannot complete the survey, and there is no
one else who can do so for him or her, please
check here and return the blank survey in the
enclosed postage-paid envelope.
Section Title. A. USE OF OXYGEN
SYSTEMS
A1. When did you begin using oxygen
equipment and tanks at home?
1 2010
2 2009
3 2008
4 Before 2008
5 I have never used oxygen equipment at
home (Skip to SECTION G on page 19)
Page
1
Reason for Change
No Change
1
The last sentence did not make sense when
combined with the boxes one was supposed
to check off. A single check box is
sufficient.
3
No Change
2
No Change
2009 ICR Draft Survey
A2.When you first began using oxygen
equipment and tanks at home, how long did
you expect to use it?
Less than 1 month
1
1 to 6 months
2
More than 6 months
3
Forever
4
I don’t know
98
A3.Do you use any type of oxygen system
now? This includes using oxygen all of the
time, with exercise or walking only, at night
only, or using it with another medical device
such as a CPAP machine or ventilator.
Yes (→Skip to A4)
1
No, I no longer use Oxygen
2
Page
3
3
2010 ICR Draft Survey
A2. When you first began using oxygen
equipment and tanks at home, how long did
you expect to use it?
1 Less than 1 month
2 1 to 6 months
3 More than 6 months
4 Forever
98 I don’t know
A3. Do you use any type of oxygen system
now? This includes using oxygen all of the
time, with exercise or walking only, at night
only, or using it with another medical device
such as a ventilator or a CPAP machine? (A
CPAP machine blows air through a hose into
a face mask or ventilator, to improve
breathing while asleep.)
Yes (→Skip to A4)
1
No, I no longer use Oxygen
2
Page
2
2
Reason for Change
Clarified by adding definition of a CPAP
machine.
24
2009 ICR Draft Survey
A3a. Why did you stop using oxygen?
(Please check all that apply and then go to
SECTION G on page 16.)
I believed that my breathing got better
1
so I did not need it anymore
My doctor said I did not need it
2
Oxygen therapy costs too much
3
I just did not like using it
4
5
Equipment was too heavy or
cumbersome
Equipment kept breaking down
6
I had a problem getting the supplies
7
from my oxygen supplier
Other, please specify:
96
________________________
Page
3
Subsection Title. YOUR CURRENT USE
OF OXYGEN SYSTEM
A4. When did you first get the oxygen
equipment you use now?
1 Less than 6 months ago
2 6-12 months ago
3 More than 12 months ago
A5. Did you get your current oxygen system
while you were in a nursing home or hospital?
1 Yes (→Skip to SECTION G on page 16)
2 No
3
3
3
2010 ICR Draft Survey
A3a. Why did you stop using oxygen?
(Please check all that apply and then go to
SECTION G on p. 19.)
I believed that my breathing got better
1
so I did not need it anymore
My doctor said I did not need it
2
Oxygen therapy costs too much
3
I just did not like using it
4
5
Equipment was too heavy or
cumbersome
Equipment kept breaking down
6
I had a problem getting the supplies
7
from my oxygen supplier
I was embarrassed to use it
8
Other, please specify:
96
________________________
Subsection Title. YOUR CURRENT USE
OF OXYGEN SYSTEM
A4. When did you first get the oxygen
equipment you use now?
1 Less than 6 months ago
2 6-12 months ago
3 More than 12 months ago
A5. Did you get your current oxygen system
while you were in a nursing home or hospital?
1 Yes
2 No
Page
2
Reason for Change
Added new response category “I was
embarrassed to use it” which may prevent
some patients from using their equipment.
2
No Change
2
No Change
2
No Change
25
2009 ICR Draft Survey
A6.Does someone regularly help you use your
oxygen equipment (for example, a relative,
friend, or home health aide)?
Yes
1
No
2
This description was part of the question in
the 2010 survey.
Page
4
A7. A respiratory therapist is a specially
trained professional who helps you improve
your breathing. Did a doctor or another
medical person like a nurse or a respiratory
therapist ever explain to you why you needed
oxygen?
1
Yes
No
2
I don’t know
98
A8.Did a doctor or another medical person
like a nurse or a respiratory therapist ever
explain to you how much oxygen you needed?
Yes
1
No
2
I don’t know
98
4
4
2010 ICR Draft Survey
A6. Does someone regularly help you use
your oxygen equipment (for example, a
relative, friend, or home health aide)?
Yes
1
No
2
A respiratory therapist is a specially trained
professional who helps you improve your
breathing.
A7. Did a respiratory therapist or another
medical person like a doctor or a nurse ever
explain the following to you (Please check all
that apply):
Page
3
3
3
Reason for Change
No Change
The definition of respiratory therapist now
precedes this set of questions, rather than
being incorporated as part of Question A.7
Several questions were combined into one,
to shorten the survey and focus on patient
perceptions.
Oxygen equipment options and which
1
might be best for you
2
Why you need to use oxygen
equipment
How much oxygen you need
3
When to use your oxygen equipment
4
None of these things were explained
98
by a respiratory therapist, doctor, or nurse
26
2009 ICR Draft Survey
A9.Did a doctor or another medical person
like a nurse or a respiratory therapist ever
explain to you when you are supposed to use
your oxygen system?
Yes
1
No
2
I don’t know
98
A10. Did a doctor or another medical person
like a nurse or a respiratory therapist ever
explain oxygen equipment options and which
might be best for you?
Yes
1
No
2
I don’t know
98
This question was not in the previous
survey.
Page
4
2010 ICR Draft Survey
Page
Reason for Change
A8. If a respiratory therapist was the
professional who explained your oxygen
equipment, where was the information
provided? (Please check all that apply.)
Information was provided in my
1
home
Information was provided while I was
2
in the hospital
A respiratory therapist did not provide
3
me with information
98
I don’t know
3
Revised to indicate where patient education
took place (prior to hospital discharge, or in
the patient’s home).
4
27
2009 ICR Draft Survey
A11. How often does a medical person like a
nurse or a respiratory therapist come to your
home and clip an oxygen measurement device
to your fingertip, to measure your oxygen?
At least once each month
1
A few times each year
2
No one ever comes to my home to do
2
a fingertip oxygen measurement
98
I don’t know
A12. When was the last time you discussed
your need for oxygen with a doctor or another
medical person like a nurse or a respiratory
therapist?
Within the last 6 months
1
Between 6 months and 1 year ago
2
Between 1 and 3 years ago
3
More than 3 years ago
4
I don’t know
98
A13. Are you still using the same oxygen
equipment as when you first started using
oxygen at home?
Yes (→Skip to A14)
1
No
2
I don’t know (→Skip to A14)
98
Page
4
4
5
2010 ICR Draft Survey
A9. How often does a medical person like a
nurse or a respiratory therapist come to your
home and clip an oxygen measurement device
to your fingertip, to measure your oxygen?
At least once each month
1
A few times each year
2
No one ever comes to my home to do
3
a fingertip oxygen measurement
98
I don’t know
A10. When was the last time you discussed
your need for oxygen with a doctor or another
medical person like a nurse or a respiratory
therapist?
Within the last 6 months
1
Between 6 months and 1 year ago
2
Between 1 and 3 years ago
3
More than 3 years ago
4
I don’t know
98
A11. Are you still using the same oxygen
equipment as when you first started using
oxygen at home?
Yes (→Skip to A12)
1
No
2
I don’t know (→Skip to A12)
98
Page
3
Reason for Change
No Change
4
No Change
4
No Change
28
2009 ICR Draft Survey
A13a. Why did you make these changes?
(Please check all that apply.)
Equipment needed to be replaced
1
because it did not work
My condition/breathing changed
2
I found new equipment that was
3
better for me
Equipment no longer available
4
through supplier
5
Supplier told me Medicare no longer
covered equipment
Doctor prescribed a different type of
6
equipment
Other, please specify:
99
____________________________
Page
5
A14. Do you believe that you now have the
oxygen equipment that is right for you?
Yes
1
2
No
I don’t know
98
A15. Is using your current oxygen equipment
difficult or uncomfortable?
1Yes
2No (→Skip to A16)
98I don’t know (→Skip to A16)
5
5
2010 ICR Draft Survey
A11a. If you have different oxygen
equipment, why did you make a change?
(Please check all that apply.)
Equipment needed to be replaced
1
because it did not work
My condition/breathing changed
2
I found new equipment that was
3
better for me
4
My supplier became ineligible to
provide my equipment under Medicare
My supplier told me Medicare no
5
longer covered equipment
Doctor prescribed a different type of
6
equipment
My supplier did not tell me why they
7
changed my equipment
Other, please specify:
99
____________________________
A12. Do you believe that you now have the
oxygen equipment that is right for you?
Yes
1
2
No
I don’t know
98
A13. Is using your current oxygen equipment
difficult or uncomfortable?
1
Yes
No (→Skip to A14)
2
I don’t know (→Skip to A14)
98
Page
4
Reason for Change
Clarified question language; clarified one
response category to focus on supplier
becoming ineligible for Medicare (most
relevant for the follow-up survey in 2012);
added a response category of “ My supplier
did not tell me why they changed my
equipment” because patient may not know
the reason.
4
No Change
5
No Change
29
2009 ICR Draft Survey
A15a. What is it about your current
oxygen equipment that makes it difficult
or uncomfortable to use? (Please check all
that apply.)
1Cannot move freely around my home
2 Cannot go outside of my home for a short
walk
3Cannot go to the doctor when I need to
4Cannot go to church, visit friends, shop, or
leave the house for more than a short time
5Equipment is too heavy or cumbersome
(hard to lift, doesn’t fit easily into the car)
6Equipment doesn’t supply enough
oxygen/I’m afraid I’ll run out of oxygen
7Equipment breaks down a lot
8Equipment is too complicated for me to
use
9I am embarrassed to use it
99Other, please specify:
___________________________
Page
5
2010 ICR Draft Survey
A13a. What is it about your current oxygen
equipment that makes it difficult or
uncomfortable to use? (Please check all that
apply.)
Equipment makes it difficult to move
1
freely around my home
Equipment makes it difficult to go
2
outside of my home for a short walk
3
Equipment makes it difficult to go to
the doctor when I need to
Equipment makes it difficult to go to
4
church, visit friends, shop, or leave the house
for more than a short time
Equipment is too heavy or
5
cumbersome (hard to lift, doesn’t fit easily
into the car)
Equipment doesn’t supply enough
6
oxygen
7 I’m afraid I will run out of oxygen
Equipment breaks down a lot or is
8
undependable
Equipment is too complicated for me
9
to use
I am embarrassed to use the
10
equipment outside my home
Other, please specify:
99
___________________________
Page
5
Reason for Change
Revised language of response categories for
grammatical consistency; separated one
response category into two (equipment
doesn’t supply enough oxygen; I’m afraid
I’ll run out of oxygen).
30
2009 ICR Draft Survey
A16. Does using the oxygen equipment
make you feel better?
Yes
1
No
2
I don’t know
98
A17. Are you using less oxygen than your
doctor, nurse or respiratory therapist
recommended?
Yes
1
No (→Skip to SECTION B)
2
I don’t know (→ Skip to SECTION
98
B)
Page
5
6
2010 ICR Draft Survey
A14. Does using the oxygen equipment make
you feel better?
Yes
1
No
2
I don’t know
98
A15. Are you using less oxygen than your
doctor, nurse or respiratory therapist
recommended?
Yes, I use it for fewer hours per day
1
than my doctor recommended
Yes, I use it for fewer days each week
2
than my doctor recommended
3
Yes, I use a lower flow rate than my
doctor recommended
No (→Skip to SECTION B)
4
I don’t know (→ Skip to SECTION
98
B)
Page
5
5
Reason for Change
No Change
Clarified answer categories to specify
whether less oxygen is used per day, on
fewer days, or at a lower flow rate than
doctor recommended.
31
2009 ICR Draft Survey
A17a. Please tell us why you are using less
oxygen than your doctor or other medical
person recommended. (Please check all that
apply.)
I believe that my breathing got better
1
so I don’t need oxygen as much
Oxygen therapy costs too much
2
I just don’t like using it
3
4
I am embarrassed to use it
Equipment is too heavy or
5
cumbersome
Equipment keeps breaking down
6
Equipment is too complicated for me
7
to use
I have a problem getting the supplies
8
from my oxygen supplier
I’m using a different oxygen system
9
96
Other, please specify:
__________________________
Section Title. B. STATIONARY OXYGEN
Description. Stationary oxygen systems are
heavy pieces of equipment that you cannot
move easily.
These include non-portable oxygen
concentrators, liquid oxygen vessels, and
large compressed gas oxygen cylinders.
Page
6
2010 ICR Draft Survey
A15a. Please tell us why you are using less
oxygen than your doctor or other medical
person recommended. (Please check all that
apply.)
I believe that my breathing got better
1
so I don’t need oxygen as much
Oxygen therapy costs too much
2
I just don’t like using it
3
4
I am embarrassed to use it
Equipment is too heavy or
5
cumbersome
Equipment keeps breaking down
6
Equipment is too complicated for me
7
to use
I have a problem getting the supplies
8
from my oxygen supplier
Other, please specify:
96
__________________________
Page
6
6
6
Section Title. B. STATIONARY OXYGEN
Description. Stationary oxygen systems are
heavy pieces of equipment that you cannot
move easily.
These include non-portable oxygen
concentrators, liquid oxygen vessels, and
large compressed gas oxygen cylinders.
7
7
Reason for Change
Removed one answer category that is
unnecessary due to prior skip pattern.
No Change
No Change
32
2009 ICR Draft Survey
B1. Do you use any type of stationary oxygen
system now?
Yes
1
No (→Skip to SECTION C)
2
B2.What type of stationary oxygen system(s)
do you usually use at home? (Please check all
that apply.)
Oxygen concentrator machine (unit
1
that plugs into the wall and produces oxygen)
[pictured below at left]
2
Liquid oxygen vessel (large tank that
resembles a large thermos) [pictured below at
center]
3
Large compressed oxygen cylinder
(resembles a welding tank) [pictured below at
right]
4
Oxygen concentrator system that
allows you to fill small cylinders [not
pictured]
98
I don’t know
Page
6
7
2010 ICR Draft Survey
B1. Do you use any type of stationary oxygen
system now?
Yes
1
No (→Skip to SECTION C)
2
B2. What type of stationary oxygen system(s)
do you usually use at home? (Please check all
that apply.)
Oxygen concentrator machine (unit
1
that plugs into the wall and produces oxygen)
[pictured below at left]
2
Liquid oxygen vessel (large tank that
is usually placed in the home and not moved)
[pictured below at center]
3
Large compressed oxygen cylinder
(resembles a welding tank) [pictured below at
right]
4
Oxygen concentrator system that
allows you to fill small cylinders [not
pictured]
98
I don’t know
Page
7
7
Reason for Change
No Change
Clarified one answer category.
33
2009 ICR Draft Survey
B3. What type of oxygen delivery device do
you breathe from to get your oxygen? (Please
check all that apply.)
Nasal cannula (nose prongs/tubes)
1
Transtracheal catheter (very thin tube
2
that goes directly in your throat)
Reservoir cannula: small oxygen
3
storage chamber positioned below nose or on
your chest
Oxygen mask
4
Connection to your tracheostomy tube
5
Connection to my CPAP machine, bi6
level device, or ventilator
I don’t know
98
B4. In general, how often do you use your
stationary oxygen system?
Less than one day a week
1
1-2 days per week
2
3-4 days per week
3
5-6 days per week
4
Every day
5
B5. On the days that you do use stationary
oxygen, for how many hours do you use it
(out of 24 hours in a day)?
______ hours per day
Page
8
8
8
2010 ICR Draft Survey
B3. What type of oxygen delivery device do
you breathe from to get your oxygen? (Please
check all that apply.)
Nasal cannula (nose prongs/tubes)
1
Transtracheal catheter (very thin tube
2
that goes directly in your throat)
Reservoir cannula: small oxygen
3
storage chamber positioned below nose or on
your chest
Oxygen mask
4
Connection to your tracheostomy tube
5
Connection to my CPAP machine, bi6
level device, or ventilator
I don’t know
98
B4. In general, how often do you use your
stationary oxygen system?
Less than one day a week
1
1-2 days per week
2
3-4 days per week
3
5-6 days per week
4
Every day
5
B5. On the days that you do use stationary
oxygen, for how many hours do you use it
(out of 24 hours in a day)?
Page
8
Reason for Change
No Change
8
No Change
8
No Change
______ hours per day
34
2009 ICR Draft Survey
Description. Sometimes people have serious
problems with their stationary systems and are
forced to stop using oxygen or to use another
source of oxygen, such as a portable tank or
emergency back-up tank.
B7. During the past six months did you have
any serious problems that made you stop
using your stationary oxygen system?
Yes
1
No (→ Skip to SECTION C)
2
I don’t know (→ Skip to SECTION
98
C)
B7a. Can you describe the kind of problem(s)
that you had? (Please check all that apply.)
1
Power outage in my home
Equipment failed or did not work
2
Unit ran out of oxygen (liquid or
3
cylinder)
Other, please specify:
96
___________________________
98 I don’t know
B7b. How many times did you have these
kinds of problems in the past year?
One time
1
2 or 3 times
2
4 or more times
3
Don’t recall the exact number of
4
times
Section Title C. PORTABLE OXYGEN
Page
8
8
8
9
2010 ICR Draft Survey
Description. Sometimes people have serious
problems with their stationary systems and are
forced to stop using oxygen or to use another
source of oxygen, such as a portable tank or
emergency back-up tank.
B6. Have you had any serious problems that
made you stop using your stationary oxygen
system?
Yes
1
No (→ Skip to SECTION C)
2
I don’t know (→ Skip to SECTION
98
C)
B6a. Can you describe the kind of problem(s)
that you had? (Please check all that apply.)
1
Power outage in my home
Equipment failed or did not work
2
Unit ran out of liquid oxygen or
3
compressed oxygen
Other, please specify:
96
___________________________
98 I don’t know
B6b. How many times did you have these
kinds of problems in the past year?
One time
1
2 or 3 times
2
4 or more times
3
Don’t recall the exact number of
4
times
Section Title C. PORTABLE OXYGEN
Page
8
Reason for Change
No Change
8
Removed reference to past six months
9
Clarified language of one response category.
9
No Change
10
No Change
35
2009 ICR Draft Survey
Description. Portable oxygen systems let you
keep using oxygen when you are away from
the stationary system. They may be light
enough to carry on a strap over your shoulder
or to pull on a wheeled cart.
Your portable oxygen system may be a small
gaseous oxygen tank, a small liquid oxygen
cylinder, or a small portable oxygen
concentrator.
C1. Do you use any type of portable oxygen
system now?
1
Yes
No (→Skip to SECTION D)
2
98 I don’t know
Page
9
9
2010 ICR Draft Survey
Description. Portable oxygen systems let you
keep using oxygen when you are away from
the stationary system. They may be light
enough to carry on a strap over your shoulder
or to pull on a wheeled cart.
Your portable oxygen system may be a small
gaseous oxygen tank, a small liquid oxygen
cylinder, or a small portable oxygen
concentrator.
C1. Do you use any type of portable oxygen
system now?
1
Yes
No (→Skip to SECTION D)
2
98 I don’t know
Page
10
Reason for Change
No Change
10
No Change
36
2009 ICR Draft Survey
C2. What type of portable oxygen system(s)
do you use? (Please check all that apply.)
Mid-sized compressed oxygen tank
1
(E-cylinder, resembles a diving tank)
[pictured below at left]
2
Very small and light compressed
oxygen tank (can carry on your shoulder)
[pictured below at right]
Mid-sized or standard portable liquid
3
oxygen unit [pictured below in center]
Very small liquid portable unit (i.e.,
4
can carry on your shoulder or belt and
delivers pulses of oxygen) [not pictured]
Small portable oxygen concentrator
5
[not pictured]
6
Small portable concentrator that also
serves as a stationary source [not pictured]
98 I don’t know
Other portable oxygen system:
96
__________________________
Page
9
2010 ICR Draft Survey
C2. What type of portable oxygen system(s)
do you use? (Please check all that apply.)
Mid-sized compressed oxygen tank
1
(E-cylinder, resembles a diving tank and can
roll on a cart) [pictured below at left]
Very small and light compressed
2
oxygen tank that concentrates room oxygen
(can carry on your shoulder) [pictured below
at right]
Mid-sized or standard portable liquid
3
oxygen unit [pictured below in center]
Very small liquid portable unit (can
4
carry on your shoulder or belt and that must
be refilled) [not pictured]
Small portable oxygen concentrator
5
that concentrates room oxygen [not pictured]
Small portable concentrator that
6
concentrates room oxygen and also serves as a
stationary source [not pictured]
98 I don’t know
Other portable oxygen system:
96
__________________________
Page
10
Reason for Change
Revised descriptions of portable oxygen
systems to clarify distinctions between
different types of systems.
37
2009 ICR Draft Survey
C3. In general, how often do you use your
portable oxygen system?
Less than one day a week
1
1-2 days per week
2
3-4 days per week
3
5-6 days per week
4
Every day
5
C4. On the days that you use portable oxygen,
for how many hours do you use it (out of 24
hours in a day)?
______ hours per day
C5. Is your portable oxygen system meeting
your needs?
Yes (→Skip to C6)
1
2
No
I don’t know (→Skip to C6)
98
Page
10
10
10
2010 ICR Draft Survey
C3. In general, how often do you use your
portable oxygen system?
Less than one day a week
1
1-2 days per week
2
3-4 days per week
3
5-6 days per week
4
Every day
5
C4. On the days that you use portable oxygen,
for how many hours do you use it (out of 24
hours in a day)?
______ hours per day
C5. Is your portable oxygen system meeting
your needs?
Yes (→Skip to C6)
1
2
No
I don’t know (→Skip to C6)
98
Page
11
Reason for Change
No Change
11
No Change
11
No Change
38
2009 ICR Draft Survey
C5a. Please tell us why your portable oxygen
system is not meeting your needs. (Please
check all that apply.)
I believe that my breathing got better
1
so I don’t need oxygen as much
Oxygen therapy costs too much
2
I just don’t like using it
3
I am embarrassed to use it
4
5
Equipment is too heavy or
cumbersome
Equipment keeps breaking down
6
Equipment is too complicated for me
7
to use
I have a problem getting the supplies
8
from my oxygen supplier
I’m using a different oxygen system
9
Other, please specify:
96
Page
10
2010 ICR Draft Survey
C5a. Please tell us why your portable oxygen
system is not meeting your needs. (Please
check all that apply.)
I believe that my breathing got better
1
so I don’t need oxygen as much
Oxygen therapy costs too much
2
I just don’t like using it
3
I am embarrassed to use it
4
5
Equipment is too heavy or
cumbersome
Equipment keeps breaking down
6
Equipment is too complicated for me
7
to use
I have a problem getting the supplies
8
from my oxygen supplier
I’m using a different oxygen system
9
I’m afraid I will run out of oxygen
10
96
Other, please specify:
Page
11
Reason for Change
Added one response category, for patients
who are concerned about running out of
oxygen.
39
2009 ICR Draft Survey
C6. In general, how often do you get
deliveries/refills from your oxygen supplier
for your portable oxygen system? This may
include oxygen tank deliveries, liquid oxygen
refills, etc.
4 times a month
1
2-3 times a month
2
Once a month
3
4
Once every year
Less than once per year
5
I don’t get refills of any type
6
(→ Skip to C7)
I don’t know
98
C6a. If you get tank refills for your portable
oxygen system, how many tank refills do you
normally get at one time (that is, number of
tanks per delivery)?
____ Number of tanks at one time
98 I don’t know
Description. An intermittent flow device
gives you oxygen only when you breathe in.
Examples of these oxygen-conserving devices
are pulse-dosing oxygen regulators, small
liquid portable units, or portable
concentrators.
Page
10
2010 ICR Draft Survey
C6. In general, how often do you get
deliveries/refills from your oxygen supplier
for your portable oxygen system? This may
include oxygen tank deliveries, liquid oxygen
refills, etc.
4 times a month
1
2-3 times a month
2
Once a month
3
4
Once every year
Less than once per year
5
I don’t get refills of any type
6
I don’t know
98
Page
11
11
11
Reason for Change
Removed Skip instruction because question
C6a has been deleted.
Removed this question because we are not
trying to determine volume of oxygen used.
Description. An intermittent flow device
gives you oxygen only when you breathe in.
Examples of these oxygen-conserving devices
are pulse-dosing oxygen regulators and small
liquid portable units or portable concentrators
that use a pulse-dosing oxygen regulator.
12
Revised description so it will apply to all
intermittent flow devices.
40
2009 ICR Draft Survey
C7. Do you use any type of intermittent flow
device with your portable system now?
Yes
1
No (→ Skip to SECTION D
2
98 I don’t know (→ Skip to SECTION D)
C7a. When you first got your intermittent
flow device, who adjusted the device and
tested you while you were using it? (Please
check all that apply.)
Home oxygen supplier
1
Doctor
2
3
Other medical personnel
No one
4
Don’t remember if anyone did
5
I don’t know
98
Page
11
Section Title. D. MEDICAL EXPENSES
D1. In the past year, have you bought any
oxygen equipment or supplies with your own
money because your insurance did not cover
it? (This does not include any copay or
deductible amounts that are due from you.)
Yes
1
No (→ Skip to SECTION E)
2
I don’t know (→ Skip to SECTION
98
E)
11
11
11
2010 ICR Draft Survey
C7. Do you use any type of intermittent flow
device with your portable system now?
Yes
1
No (→ Skip to SECTION D)
2
98 I don’t know (→ Skip to SECTION D)
C7a. When you first received your oxygen
equipment that was equipped with an
intermittent flow device, who adjusted the
device? (Please check all that apply.)
Home oxygen supplier or a
1
respiratory therapist from the supplier
2
Doctor
Other medical personnel
3
No one
4
Don’t remember if anyone did
5
I don’t know who it was
98
Section Title. D. MEDICAL EXPENSES
D1. In the past year, have you bought any
oxygen equipment or supplies with your own
money because your insurance did not cover
it? (This does not include any copay or
deductible amounts that are due from you.)
Yes
1
No (→ Skip to SECTION E)
2
I don’t know (→ Skip to SECTION
98
E)
Page
12
Reason for Change
No Change
12
Clarified language of the question; revised
language of the ‘don’t know’ answer
category.
12
12
No Change
No Change
41
2009 ICR Draft Survey
D2. In the past year, what oxygen equipment
or supplies did you buy with your own
money? (Please check all that apply.)
Extra portable oxygen system
1
Extra stationary oxygen system
2
Oxygen conserving/intermittent flow
3
device
Special nasal cannula
4
5
Transtracheal supplies
I don’t know
98
Other, please specify:
96
___________________________
D3. Thinking about everything you paid for
with your own money in the past year for the
oxygen equipment and supplies that were not
covered by insurance, how much did you
spend? (This does not include any copay or
deductible amounts.)
Less than $100
1
$100-$500
2
$500 or more
3
98 I don’t know
Section Title. E. YOUR SUPPLIER
Page
11
12
12
2010 ICR Draft Survey
D2. In the past year, what oxygen equipment
or supplies did you buy with your own
money? (Please check all that apply.)
Extra portable oxygen system
1
Extra stationary oxygen system
2
Oxygen conserving/intermittent flow
3
device
Special nasal cannula
4
5
Transtracheal supplies
I don’t know
98
Other, please specify:
96
___________________________
D3. Thinking about everything you paid for
with your own money in the past year for the
oxygen equipment and supplies that were not
covered by insurance, how much did you
spend? (This does not include any copay or
deductible amounts.)
Less than $100
1
$100-$500
2
$500 to $1,000
3
4
$1,000 to $2,000
I don’t know
98
Section Title. E. YOUR SUPPLIER
Page
12
Reason for Change
No Change
13
Added another category for patients with
higher out-of-pocket costs.
13
No Change
42
2009 ICR Draft Survey
E1. Considering the oxygen equipment you
have now, did you have any problems finding
an equipment supplier to get it from?
Yes
1
No (→ Skip to E3)
2
I don’t know (→ Skip to E3)
98
E1a. What kinds of problems did you have
finding an oxygen supplier? (Please check all
that apply.)
Hard to find a supplier who covered
1
my area
2
Supplier did not carry what I needed
Supplier could not deliver equipment
3
when I needed it
Supplier did not accept Medicare
4
Other, please describe:
96
______________________
I don’t know
98
E2. Considering the oxygen equipment you
have now, did you have a choice of suppliers?
Yes, many
1
Yes, a few
2
No, only one supplier available
3
I don’t know
98
Page
12
12
12
2010 ICR Draft Survey
E1. Considering the oxygen equipment you
have now, did you have any problems finding
an equipment supplier to get it from?
Yes
1
No (→ Skip to E2)
2
I don’t know (→ Skip to E2)
98
E1a. What kinds of problems did you have
finding an oxygen supplier? (Please check all
that apply.)
Hard to find a supplier who covered
1
my area
2
Supplier did not carry what I needed
Supplier could not deliver equipment
3
when I needed it
Supplier did not accept Medicare
4
Other, please describe:
96
______________________
I don’t know
98
E2. Considering the oxygen equipment you
have now, did you have a choice of suppliers?
Yes, many
1
Yes, a few
2
No, only one supplier available
3
I don’t know
98
Page
13
Reason for Change
Corrected erroneous Skip instruction.
13
No Change
13
No Change
43
2009 ICR Draft Survey
E3. Considering the oxygen equipment you
have now, do you get your current oxygen
equipment, supplies, maintenance and repairs
from more than one equipment supplier?
Yes
1
No
2
I don’t know
98
E4. Overall, how would you rate the supplier
that you use most?
Poor
1
Fair
2
3
Good
Very good
4
Excellent
5
E5. Would you recommend this oxygen
supplier to a friend who needed similar
services?
1 Yes
2 No
E6.
How do you get your oxygen refills
and supplies? (Please check all that apply.)
Delivered to my home by my supplier
1
Mailed to my home by my supplier
2
I pick them up from my oxygen
3
supplier
Someone picks them up for me
4
I don’t know
98
96
Some other way, please tell us how:
_____________________________
Page
12
12
12
13
2010 ICR Draft Survey
E11. Do you currently get your current
oxygen equipment, supplies, maintenance and
repairs from more than one equipment
supplier?
Yes
1
No
2
I don’t know
98
E12. Overall, how would you rate the
supplier that you use most?
Poor
1
Fair
2
3
Good
Very good
4
Excellent
5
E13. Would you recommend this oxygen
supplier to a friend who needed similar
services?
Yes
1
No
2
E9. How do you get your oxygen refills and
supplies? (Please check all that apply.)
Delivered to my home by my supplier
1
Mailed to my home by my supplier
2
I pick them up from my oxygen
3
supplier
Someone picks them up for me
4
I don’t know
98
96
Some other way, please tell us how:
_____________________________
Page
16
Reason for Change
Clarified language of question.
16
No Change
16
No Change
15
No Change
44
2009 ICR Draft Survey
E7. Considering the oxygen equipment you
have now, how much time and energy does it
take to get your oxygen equipment, supplies,
maintenance and repairs from your supplier?
No time and energy
1
A little time and energy
2
Some time and energy
3
A lot of time and energy
4
98
I don’t know
E8. After you ordered the oxygen equipment
you have now, how long did it take to arrive?
1
Same day
Next day
2
Within a week
3
More than 1 week later
4
I don’t know
98
Page
13
13
2010 ICR Draft Survey
E10. Considering the oxygen equipment you
have now, how much time and energy does it
take to get your oxygen equipment, supplies,
maintenance and repairs from your supplier?
No time and energy
1
A little time and energy
2
Some time and energy
3
A lot of time and energy
4
98
I don’t know
E5. After the order was placed for your
oxygen equipment, how long did it take to
arrive?
Same day
1
Next day
2
Within a week
3
More than 1 week later
4
I don’t know
98
Page
16
14
Reason for Change
No Change
Clarified language of question because
patients do not directly order their own
equipment.
45
2009 ICR Draft Survey
E9.When you got the oxygen equipment you
use now, what kind of training or help did the
supplier give you or the person who takes care
of you? (Please check all that apply.) Did
he/she…
Give you written instructions on how
1
to use the equipment or supplies
Show you how to use the equipment
2
or supplies
3
Choose a safe and convenient place to
store the equipment or supplies
Show you how to clean and maintain
4
the equipment or supplies
Show you how to use oxygen safely
5
Let you practice how to use and
6
maintain your equipment and supplies while
they watched
Give you the manufacturer’s
7
customer assistance toll-free telephone
number
I did not get any training or help from
8
my oxygen supplier (→ Skip to E10)
I don’t know (→ Skip to E10)
98
Page
13
2010 ICR Draft Survey
E6. When you got the oxygen equipment you
use now, what kind of training or help did the
supplier give you or the person who takes care
of you? (Please check all that apply.) Did
he/she…
Give you written instructions on how
1
to use the equipment or supplies
Show you how to use the equipment
2
or supplies
3
Choose a safe and convenient place to
store the equipment or supplies
Show you how to clean and maintain
4
the equipment or supplies
Show you how to use oxygen safely
5
Let you practice how to use and
6
maintain your equipment and supplies while
they watched
Give you the manufacturer’s
7
customer assistance toll-free telephone
number
I did not get any training or help from
8
my oxygen supplier (→ Skip to E7)
I don’t know (→ Skip to E7)
98
Page
14
Reason for Change
No Change
46
2009 ICR Draft Survey
E9a. As a result of that training, how
comfortable do you feel using and
maintaining your oxygen equipment?
Very comfortable
1
Comfortable
2
Uncomfortable
3
Very uncomfortable
4
My comfort level has nothing to do
5
with the training that my supplier gave me
E10. In the first 3 months after you got the
oxygen equipment you use now, how often
did a nurse or respiratory therapist come to
your home to check on how you are doing and
if you are getting enough oxygen?
Once in the 3 months after you got
1
the oxygen equipment
More than once in the 3 months after
2
you got the oxygen equipment
Not at all in the 3 months after you
3
got the oxygen equipment
Page
14
14
2010 ICR Draft Survey
E6a. As a result of that training, how
comfortable do you feel using and
maintaining your oxygen equipment?
Very comfortable
1
Comfortable
2
Uncomfortable
3
Very uncomfortable
4
My comfort level has nothing to do
5
with the training that my supplier gave me
E7. In the first 3 months after you got the
oxygen equipment you use now, how often
did a nurse or respiratory therapist come to
your home to check on how you are doing and
if you are getting enough oxygen?
Once in the 3 months after you got
1
the oxygen equipment
More than once in the 3 months after
2
you got the oxygen equipment
Not at all in the 3 months after you
3
got the oxygen equipment
I don’t know or recall the clinical
4
specialty of the person who came to my home.
Page
15
15
Reason for Change
No Change
Added another answer category for patients
who don’t know or don’t recall.
47
2009 ICR Draft Survey
E11. In the first 3 months after you got the
oxygen equipment you use now, how often
did your supplier send someone to your home
to check the equipment? (Do not include
times when you called them.)
Once in the 3 months after you got
1
the oxygen equipment
More than once in the 3 months after
2
you got the oxygen equipment
3
Not at all in the 3 months after you
got the oxygen equipment
E12. Considering the oxygen equipment you
have now, when you asked your supplier
questions, did you get answers that you could
understand?
Yes, completely
1
Yes, somewhat
2
No
3
I did not ask any questions
4
I don’t know
98
E13. Before deciding on the oxygen
equipment you use now, did your supplier tell
you as much as you wanted to know about the
options for your oxygen equipment?
1
Yes, completely
Yes, somewhat
2
No
3
I don’t know
98
Page
14
14
14
2010 ICR Draft Survey
E8. In the first 3 months after you got the
oxygen equipment you use now, how often
did your supplier send someone to your home
to check the equipment? (Do not include
times when you called them.)
Once in the 3 months after you got
1
the oxygen equipment
More than once in the 3 months after
2
you got the oxygen equipment
3
Not at all in the 3 months after you
got the oxygen equipment
E3. Considering the oxygen equipment you
have now, when you asked your supplier
questions, did you get answers that you could
understand?
Yes, completely
1
Yes, somewhat
2
No
3
I did not ask any questions
4
I don’t know
98
E4. Before deciding on the oxygen
equipment you use now, did your supplier tell
you as much as you wanted to know about the
options for your oxygen equipment?
1
Yes, completely
Yes, somewhat
2
No
3
Page
15
Reason for Change
No Change
14
No Change
14
Removed the “don’t know” answer category.
48
2009 ICR Draft Survey
This question was not in the previous
survey.
E12. When you got the oxygen equipment
you use now, did your supplier spend as much
time with you as you wanted?
Yes
1
No
2
Section Title. F. RECENT EXPERIENCES
F1. During the past six months, how reliable
was your oxygen supplier in making
deliveries?
Very reliable
1
Somewhat reliable
2
Not reliable at all
3
Does not apply
4
Page
2010 ICR Draft Survey
E4a. Before you decided on the oxygen
equipment that you use now, did your supplier
tell you about all the equipment designs
available to you, even those which the
supplier did not have in stock?
Yes, all equipment designs were
1
explained
No, the supplier only told me what
2
he/she has in stock
3
No, I already knew the equipment
designs available to me
I don’t know
98
Page
14
Deleted this question to shorten the survey,
and because this issues is addressed in
previous questions.
14
15
15
Reason for Change
Added this question out of concern that
suppliers will not keep as many makes and
models in their inventory after competitive
bidding.
Section Title. F. RECENT EXPERIENCES
F1. During the past six months, how reliable
was your oxygen supplier in making
deliveries?
Very reliable
1
Somewhat reliable
2
Not reliable at all
3
Does not apply
4
17
17
No Change
No Change
49
2009 ICR Draft Survey
F2. In the past six months, have you
contacted your oxygen supplier with a
complaint or a problem?
Yes
1
No (→ Skip to F4)
2
I don’t know (→ Skip to F4)
98
Don’t know how to contact my
4
oxygen supplier (→ Skip to F4)
F2a.
When you contacted your oxygen
supplier, was your complaint or problem
settled to your satisfaction?
Yes
1
No
2
I am waiting for it to be settled
3
I don’t know
98
F3. In the past six months, have you
contacted your oxygen supplier to get
emergency service or advice?
Yes
1
No (→ Skip to F4)
2
I don’t know (→ Skip to F4)
98
F3a. In general, how fast did the supplier
respond to your needs, either by phone or in
person? Would you say…
Within 1 day
1
Within 2 days
2
Within 1 week
3
4
Longer than 1 week
I don’t know
98
Page
15
15
15
15
2010 ICR Draft Survey
F2. In the past six months, have you
contacted your oxygen supplier with a
complaint or a problem?
Yes
1
No (→ Skip to F4)
2
I don’t know (→ Skip to F4)
98
Don’t know how to contact my
4
oxygen supplier (→ Skip to F4)
F2a.
When you contacted your oxygen
supplier, was your complaint or problem
settled to your satisfaction?
Yes
1
No
2
I am waiting for it to be settled
3
98 I don’t know
F3. In the past six months, have you
contacted your oxygen supplier to get
emergency service or advice?
Yes
1
No (→ Skip to F4)
2
I don’t know (→ Skip to F4)
98
F3a. In general, how fast did the supplier
respond to your needs, either by phone or in
person? Would you say…
Within 1 day
1
Within 2 days
2
Within 1 week
3
4
Longer than 1 week
I don’t know
98
Page
17
Reason for Change
No Change
17
No Change
17
No Change
17
No Change
50
2009 ICR Draft Survey
F3b. Were you able to get the emergency
service or advice you needed?
Yes
1
No
2
98 I don’t know
F4. In the past six months, have you needed
to contact your supplier after regular business
hours?
Yes
1
No (→ Skip to F5)
2
I don’t know (→ Skip to F5)
98
F4a. When you contacted your supplier after
business hours, in general were you able to
get the service or advice you needed?
Yes
1
No
2
I don’t know
98
F5. In the past six months, how reliable has
your oxygen equipment been? Would you say
…
Very reliable
1
Somewhat reliable
2
Somewhat unreliable
3
Very unreliable
4
I don’t know
98
Page
15
15
16
16
2010 ICR Draft Survey
F3b. Were you able to get the emergency
service or advice you needed?
Yes
1
No
2
98 I don’t know
F4. In the past six months, have you needed
to contact your supplier after regular business
hours?
Yes
1
No (→ Skip to F5)
2
I don’t know (→ Skip to F5)
98
F4a. When you contacted your supplier after
business hours, in general were you able to
get the service or advice you needed?
Yes
1
No
2
I don’t know
98
F5. In the past six months, how reliable has
your oxygen equipment been? Would you say
…
Very reliable
1
Somewhat reliable
2
Somewhat unreliable
3
Very unreliable
4
I don’t know
98
Page
17
Reason for Change
No Change
17
No Change
18
No Change
18
No Change
51
2009 ICR Draft Survey
F6. In the past six months, have you changed
your oxygen supplier?
Yes
1
No (→ Skip to SECTION G)
2
I don’t know (→ Skip to SECTION
98
G)
Page
16
2010 ICR Draft Survey
F6. In the past six months, have you changed
your oxygen supplier?
Yes
1
No (→ Skip to SECTION G)
2
I don’t know (→ Skip to SECTION
98
G)
Page
18
Reason for Change
No Change
52
2009 ICR Draft Survey
F6a. Why did you change your oxygen
supplier? (Please check all that apply.)
I moved
1
Supplier no longer accepted Medicare
2
Supplier went out of business
3
I was not happy with the quality of
4
service
I was not happy with equipment
5
6
I was not happy with the choices of
equipment or service I could get
I was not happy with the assistance I
7
got in handling the insurance
Supplier did not provide the oxygen
8
equipment or accessories I needed
I changed to an HMO and had to use
9
a different supplier
Other, please specify:
96
__________________________
Section Title G. ABOUT YOU
Page
16
16
2010 ICR Draft Survey
F6a. Why did you change your oxygen
supplier? (Please check all that apply.)
I moved
1
Supplier no longer accepted Medicare
2
Supplier went out of business
3
I was not happy with the quality of
4
service
I was not happy with equipment
5
6
I was not happy with the choices of
equipment or service I could get
I was not happy with the assistance I
7
got in handling the insurance
Supplier did not provide the oxygen
8
equipment or accessories I needed
I was not happy with the amount of
9
oxygen my supplier was delivering to my
home for my stationary oxygen unit
10 I was not happy with the amount of
oxygen my supplier was delivering for my
portable unit
I changed to an HMO and had to use
11
a different supplier
Supplier became ineligible to provide
12
the equipment under Medicare
Other, please specify:
96
__________________________
Section Title G. ABOUT YOU
Page
18
19
Reason for Change
Added several answer categories to better
reflect supplier service and timely delivery
of oxygen refills, and to address the
circumstance of suppliers becoming
ineligible for Medicare.
No Change
53
2009 ICR Draft Survey
Description Section G is about you, the
person whose name is on the mailing label of
this survey.
G1. In general, how would you rate your
overall health?
Excellent
1
Very good
2
Good
3
Fair
4
Poor
5
G2. Compared to 1 year ago, how would you
rate your health now? Would you say…
1 Much better now
2 Somewhat better now
3 About the same
4 Somewhat worse now
5 Much worse now
G3. Do you currently live alone?
Yes (→Skip to G5)
1
No
2
G4. Which best describes your living
situation now? (Please check all that apply.) I
live…
With spouse/partner
1
With parent/step-parent
2
With child/children
3
With other relative(s)
4
With friend
5
With other person(s) not related to me
6
Page
16
16
17
17
17
2010 ICR Draft Survey
Description Section G is about you, the
person whose name is on the mailing label of
this survey.
G1. In general, how would you rate your
overall health?
Excellent
1
Very good
2
Good
3
Fair
4
Poor19
5
G2. Compared to 1 year ago, how would you
rate your health now? Would you say…
1 Much better now
2 Somewhat better now
3 About the same
4 Somewhat worse now
5 Much worse now
G3. Do you currently live alone?
1
Yes (→Skip to G5)
No
2
G4. Which best describes your living
situation now? (Please check all that apply.) I
live…
With spouse/partner
1
With parent/step-parent
2
With child/children
3
With other relative(s)
4
With friend
5
With other person(s) not related to me
6
Page
19
Reason for Change
No Change
19
No Change
19
No Change
19
No Change
19
No Change
54
2009 ICR Draft Survey
G5. What is the highest grade or level of
school that you have completed?
8th grade or less
1
Some high school but did not
2
graduate
High school graduate or GED
3
Some college or technical school
4
College graduate
5
6
More than a 4-year college degree
G6. What was your household’s annual
income during 2009 before taxes?
1
Less than $5,000 ($416 per month)
Between $5,001 and $10,000 ($417–
2
$833 per month)
Between $10,001 and $20,000 ($834–
3
$1,666 per month)
Between $20,001 and $30,000
4
($1,667–2,500 per month)
Between $30,001 and $50,000
5
($2,501–$4,167 per month)
Over $50,000 (over $4,168 per
6
month)
G7. Are you of Hispanic or Latino heritage?
1 Yes
2 No
Page
17
17
17
2010 ICR Draft Survey
G5. What is the highest grade or level of
school that you have completed?
8th grade or less
1
Some high school but did not
2
graduate
High school graduate or GED
3
Some college or technical school
4
College graduate
5
6
More than a 4-year college degree
G6. What was your household’s annual
income during 2009 before taxes?
1
Less than $5,000 ($416 per month)
Between $5,001 and $10,000 ($417–
2
$833 per month)
Between $10,001 and $20,000 ($834–
3
$1,666 per month)
Between $20,001 and $30,000
4
($1,667–2,500 per month)
Between $30,001 and $50,000
5
($2,501–$4,167 per month)
Over $50,000 (over $4,168 per
6
month)
G7. Are you of Hispanic or Latino heritage?
1 Yes
2 No
Page
19
Reason for Change
No Change
19
No Change
19
No Change
55
2009 ICR Draft Survey
G8. How would you describe your race?
(Please check all that apply.)
American Indian or Alaskan Native
1
Asian
2
Black or African American
3
Native Hawaiian or other Pacific
4
Islander
White or Caucasian
5
99
Other, please tell us:
_________________________
Section Title. H. OTHER INFORMATION
H1. Please check the correct statement:
I am the person to whom this survey
1
was addressed (→ Skip to END)
2
I filled this survey out or
helped fill it out for someone else
H2.
How did you help the person with this
survey?
1
I wrote the answers that the person
told me
I answered the questions myself based
2
on my knowledge of the person’s condition
Both of the above
3
Page
17
18
18
18
2010 ICR Draft Survey
G8. How would you describe your race?
(Please check all that apply.)
American Indian or Alaskan Native
1
Asian
2
Black or African American
3
Native Hawaiian or other Pacific
4
Islander
White or Caucasian
5
99
Other, please tell us:
_________________________
Section Title. H. OTHER INFORMATION
H1. Please check the correct statement:
I am the person to whom this survey
1
was addressed (→ Skip to END)
2
I filled this survey out or helped fill it
out for someone else
H2.
How did you help the person with this
survey?
I wrote the answers that the person
1
told me
I answered the questions myself based
2
on my knowledge of the person’s condition
Both of the above
3
Page
20
Reason for Change
No Change
20
20
No Change
No Change
20
No Change
56
DMEPOS Survey of CPAP Users: Changes from December 2009 ICR Draft to March 2010 ICR Draft
2009 ICR Draft Survey
Title. Survey of Medicare Patients Who Use a
Continuous Positive Airway Pressure (CPAP)
Machine
Qualifying Question. If the person this
survey was mailed to cannot complete the
survey and there is no one else who can do so
for him or her, please check the appropriate
box below and return the blank survey in the
enclosed postage-paid envelope. The person
this survey was mailed to is:
1 There is nobody available who can
complete this survey
96 Other reason, please specify:
__________________________
Section Title. A. USE OF CPAP
MACHINES
Page
1
1
3
2010 ICR Draft Survey
Title. Survey of Medicare Patients Who Use a
Continuous Positive Airway Pressure (CPAP)
Machine
Qualifying Question. The purpose of the
study is to learn more about your satisfaction
with the equipment, supplies, and service you
receive from your hospital bed supplier. We
also hope to better understand your
experiences in obtaining and using this
equipment.
If the person this survey was mailed
1
to cannot complete the survey, and there is no
one else who can do so for him or her, please
check here and return the blank survey in the
enclosed postage-paid envelope.
Section Title. A. USE OF CPAP
MACHINES
Page
1
Reason for Change
No Change
1
The last sentence did not make sense when
combined with the boxes one was supposed
to check off. A single check box is
sufficient.
3
No Change
57
2009 ICR Draft Survey
A1. When did you begin using a CPAP
machine?
1 2010
2 2009
3 2008
4 Before 2008
5 I have never used a CPAP machine
(Skip to SECTION E on page 11)
A2. When you first began using a CPAP
machine, how long did you expect to use it?
Less than 1 month
1
1 to 6 months
2
3
More than 6 months
Forever
4
I don’t know
98
A3.
Do you use a CPAP machine now?
This includes using a CPAP machine all of
the time or just occasionally.
Yes (→Skip to A4)
1
No, I no longer use a CPAP
2
machine
Page
3
3
3
2010 ICR Draft Survey
A1. When did you begin using a CPAP
machine?
1 2010
2 2009
3 2008
4 Before 2008
5 I have never used a CPAP machine
(Skip to SECTION E on page 11)
A2. When you first began using a CPAP
machine, how long did you expect to use it?
Less than 1 month
1
1 to 6 months
2
3
More than 6 months
Forever
4
I don’t know
98
A3.
Do you use a CPAP machine now?
This includes using a CPAP machine all of
the time or just occasionally.
Yes (→Skip to A4)
1
No, I no longer use a CPAP
2
machine
Page
3
Reason for Change
No Change
3
No Change
3
No Change
58
2009 ICR Draft Survey
A3a. Why did you stop using your CPAP
machine? (Please check all that apply and
then skip to SECTION E on page 11.)
My condition got better so I did
1
not need it anymore
My condition got worse so I
2
couldn’t use it anymore
I was embarrassed to use it
3
4
I was not comfortable using it
I just did not like using it
6
It was too difficult to use
7
It kept breaking down
8
The mask did not fit properly
9
10 It did not have the features I
needed
Other, please specify: _________
96
Subsection Title. YOUR CURRENT USE
OF CPAP MACHINE
A4. When did you first get the CPAP
machine you use now?
1 Less than 6 months ago
2 6-12 months ago
3 More than 12 months ago
A5. Did you get your current CPAP machine
when you were in a nursing home or hospital?
1 Yes (→ Skip to SECTION
E on page 11)
No
2
Page
3
3
3
3
2010 ICR Draft Survey
A3a. Why did you stop using your CPAP
machine? (Please check all that apply and
then skip to SECTION E on page 11.)
My condition got better so I did
1
not need it anymore
My condition got worse so I
2
couldn’t use it anymore
I was embarrassed to use it
3
4
I was not comfortable using it
I just did not like using it
6
It was too difficult to use
7
It kept breaking down
8
The mask did not fit properly
9
10 It did not have the features I
needed
Other, please specify: _________
96
Subsection Title. YOUR CURRENT USE
OF CPAP MACHINE
A4. When did you first get the CPAP
machine you use now?
1 Less than 6 months ago
2 6-12 months ago
3 More than 12 months ago
A5. Did you get your current CPAP machine
when you were in a nursing home or hospital?
1 Yes
2 No
Page
3
Reason for Change
No Change
3
No Change
3
No Change
3
The skip prompt was removed from this
question in order to capture subsequent
information related to the equipment.
59
2009 ICR Draft Survey
A6. Does someone regularly help you use
your CPAP machine (for example, a relative,
friend or home health aide)?
1 Yes
2 No
This definition was not in the 2010 survey
as a separate definition.
Page
4
A7. Did a doctor or another medical person
like a nurse or respiratory therapist ever
explain to you why you needed to use a CPAP
machine?
1 Yes
2 No
98 I don’t know
A8. Did a doctor or another medical person
like a nurse or respiratory therapist ever
explain to you the different types of CPAP
machines, controls options and accessories
that exist?
1 Yes, a medical person explained
CPAP machines
2 No, no medical person explained
CPAP machines
98 I don’t know or don’t recall if a
medical person explained CPAP
machines
4
4
2010 ICR Draft Survey
A6. Does someone regularly help you use
your CPAP machine (for example, a relative,
friend or home health aide)?
1 Yes
No
2
Definition. A respiratory therapist is a
specially trained professional who helps you
improve your breathing.
A7. Did a respiratory therapist or another
medical person like a doctor or nurse ever
explain the following to you (Please check all
that apply):
Why you needed to use a CPAP
1
machine
The different types of CPAP
2
machines, control options, and accessories
3
None of these things were explained
by a medical person
I don’t know or don’t recall if a
98
medical person explained anything to me
Page
4
4
Reason for Change
No Change
The definition of respiratory therapist now
precedes this set of questions, rather than
being incorporated as part of Question A.7
Questions A7 and A8 in the 2010 survey
were combined into one to shorten the
survey and focus on patient perceptions.
60
2009 ICR Draft Survey
A9. When was the last time you discussed
your needs or issues related to your CPAP
machine with a doctor or another medical
person like a nurse or respiratory therapist?
1 Within the last 6 months
2 Between 6 months and 1 year ago
3 Between 1 and 3 years ago
4 More than 3 years ago
98 I don’t know
A10. Have you had more than one CPAP
machine in the past year, or changed
accessories (for example, hoses, mask) in the
past year? (Please check all that apply.)
No (→Skip to A11)
1
Yes, I changed my CPAP machine
2
3
Yes, I changed or added
accessories
I don’t know (→Skip to A11)
98
Page
4
2010 ICR Draft Survey
A8. When was the last time you discussed
your needs or issues related to your CPAP
machine with a respiratory therapist or
another medical person like a doctor or nurse?
Within the last 6 months
1
Between 6 months and 1 year ago
2
Between 1 and 3 years ago
3
More than 3 years ago
4
98
I don’t know
Page
4
Reason for Change
No Change
4
A9.
Have you had more than one CPAP
machine in the past year, or changed
accessories (for example, hoses, mask) in the
past year? (Please check all that apply.)
No (→Skip to A10)
1
Yes, I changed my CPAP machine
2
3
Yes, I changed or added
accessories
I don’t know (→Skip to A10)
98
4
No Change
61
2009 ICR Draft Survey
A10a. Why did you make this (these)
change(s)? (Please check all that apply.)
CPAP machine needed to be
1
replaced because the original one
did not work
My medical condition changed, so
2
I needed something different
Found a new CPAP machine that
3
was better for me
4
Found new features/accessories
that were better for me
Doctor/ health care provider
5
prescribed a different type of
CPAP machine
Supplier changed
6
Other, please specify: _________
96
A11. Do you believe that you now have the
CPAP machine that is right for you?
Yes
1
No
2
I don’t know
98
Page
4
2010 ICR Draft Survey
A9a.Why did you make this (these)
change(s)? (Please check all that apply.)
Page
5
1
My CPAP machine needed to be
replaced because the original one did not
work
My medical condition changed, so I
2
needed something different
3
I found a new CPAP machine that
was better for me
I found new features/accessories that
4
were better for me
My doctor/ health care provider
5
prescribed a different type of CPAP machine
My supplier became ineligible to
6
provide my equipment under Medicare
My supplier did not tell me why they
7
changed my equipment
96 Other, please specify:
________________________
4
A10. Do you believe that you now have the
CPAP machine that is right for you?
Yes
1
No
2
I don’t know
98
5
Reason for Change
Clarified question language; clarified one
response category to focus on supplier
becoming ineligible for Medicare (most
relevant for the follow-up survey in 2012);
added a response category of “ My supplier
did not tell me why they changed my
equipment” because patient may not know
the reason.
No Change
62
2009 ICR Draft Survey
A12. Is using your CPAP machine difficult
or uncomfortable?
Yes
1
No (→Skip to A13)
2
I don’t know (→Skip to A13)
98
A12a. What is it about your CPAP machine
that makes it difficult or uncomfortable to
use? (Please check all that apply.)
Unable to move in my sleep
1
Unable to sleep well
2
CPAP machine is too noisy (for
3
myself or my partner)
3
The mask is uncomfortable
Unable to travel away from home
6
because it is difficult to take the
machine along
It’s difficult to take the machine
7
with me when I travel
Do not like to be dependent on a
8
machine
Do not understand the controls or
9
controls hard to use
96
Other, please tell us what else:
________________________
Page
5
5
2010 ICR Draft Survey
A11. Is using your CPAP machine difficult
or uncomfortable?
Yes
1
No (→Skip to A12)
2
I don’t know (→Skip to A12)
98
A11a. What is it about your CPAP machine
that makes it difficult or uncomfortable to
use? (Please check all that apply.)
Equipment makes it difficult to move
1
in my sleep
Equipment makes it difficult to sleep
2
well
3
CPAP machine is too noisy (for me or
my partner)
The mask is uncomfortable
4
It’s difficult to take the machine with
5
me when I travel away from home
Do not like to be dependent on a
6
machine
Do not understand the controls or
7
controls hard to use
96
Other, please tell us what else:
________________________
Page
5
5
Reason for Change
No Change
Revised language of response categories for
grammatical consistency
63
2009 ICR Draft Survey
A13. In general, how often do you use your
CPAP machine?
Less than one day or night each
1
week
1-2 days or nights per week
2
3-4 days or nights per week
3
5-6 days or nights per week
4
Every day or night
5
A14. On the days that you do use your CPAP
machine, for how long do you use it (out of 24
hours)?
______ hours per day
Page
5
2010 ICR Draft Survey
A12. In general, how often do you use your
CPAP machine?
Less than one day or night each week
1
1-2 days or nights per week
2
3-4 days or nights per week
3
5-6 days or nights per week
4
Every day or night
5
Page
5
No Change
5
A13. On the days that you do use your CPAP
machine, for how long do you use it (out of 24
hours)?
6
No Change
A15. How reliable is the CPAP machine
you use now? Would you say …
1
Very reliable
Somewhat reliable
2
Somewhat unreliable
3
Very unreliable
4
I don’t know
98
A16. In the past year, did you have any
problems that made you stop using your
CPAP machine or switch to a different CPAP
machine?
Yes
1
No (→Skip to SECTION B)
2
I don’t know (→Skip to
98
SECTION B)
5
6
No Change
6
No Change
5
______ hours per day
A14. How reliable is the CPAP machine you
use now? Would you say …
Very reliable
1
Somewhat reliable
2
Somewhat unreliable
3
Very unreliable
4
I don’t know
98
A15. In the past year, did you have any
problems that made you stop using your
CPAP machine or switch to a different CPAP
machine?
Yes
1
No (→Skip to SECTION B)
2
I don’t know (→Skip to SECTION B)
98
Reason for Change
64
2009 ICR Draft Survey
A16a. How many times did you have these
kinds of problems in the past year?
One time
1
2 or 3 times
2
4 or more times
3
Don’t recall the exact number of
4
times
A16b. Can you describe the kind of
problem(s) that you had? (Please check all
that apply.)
CPAP machine did not work
1
2
CPAP accessories did not work
Reservoir/humidifier did not work
7
Did not understand the controls
8
Other, please specify: __________
96
Section Title. B MEDICAL EXPENSES
B1. In the past year, have you bought any
accessories or parts for your current CPAP
machine with your own money, or paid for
maintenance or repairs with your own money,
because your insurance did not cover it? (This
does not include any copay or deductible
amounts that are due from you.)
Yes
1
No (→Skip to SECTION C)
2
98
I don’t know (→Skip to
SECTION C)
Page
5
6
6
6
2010 ICR Draft Survey
A15a. How many times did you have these
kinds of problems in the past year?
One time
1
2 or 3 times
2
4 or more times
3
Don’t recall the exact number of
4
times
A15b. Can you describe the kind of
problem(s) that you had? (Please check all
that apply.)
CPAP machine did not work
1
2
CPAP accessories did not work
Reservoir/humidifier did not work
7
Did not understand the controls
8
Other, please specify:
96
________________________
Section Title. B MEDICAL EXPENSES
B1. In the past year, have you bought any
accessories or parts for your current CPAP
machine with your own money, or paid for
maintenance or repairs with your own money,
because your insurance did not cover it? (This
does not include any copay or deductible
amounts that are due from you.)
Yes
1
No (→Skip to SECTION C)
2
98
I don’t know (→Skip to
SECTION C)
Page
6
Reason for Change
No Change
6
No Change
7
7
No Change
No Change
65
2009 ICR Draft Survey
B2. In the past year, what parts or service
did you buy with your own money for your
CPAP machine? (Please check all that apply.)
Mask
1
Tubing
2
Power supply or battery
3
Head or chin straps / Headgear
4
Repairs
5
6
Routine maintenance
Filters
7
Humidifier or reservoir
8
Other, please specify: _________
96
B3. Thinking about everything you paid for
with your own money in the past year for your
CPAP machine accessories, parts,
maintenance or repairs not covered by
insurance, how much did you spend? (This
does not include any copay or deductible
amounts.)
Less than $100
1
$100-$500
2
3
$500 or more
I don’t know
98
Section Title. C. YOUR SUPPLIER
Page
6
7
7
2010 ICR Draft Survey
B2. In the past year, what parts or service
did you buy with your own money for your
CPAP machine? (Please check all that apply.)
Mask
1
Tubing
2
Power supply or battery
3
Head or chin straps / Headgear
4
Repairs
5
6
Routine maintenance
Filters
7
Humidifier or reservoir
8
Other, please specify: _________
96
B3. Thinking about everything you paid for
with your own money in the past year for your
CPAP machine accessories, parts,
maintenance or repairs not covered by
insurance, how much did you spend? (This
does not include any copay or deductible
amounts.)
Less than $100
1
$100-$500
2
3
$500 or more
I don’t know
98
Section Title. C. YOUR SUPPLIER
Page
7
Reason for Change
No Change
7
No Change
8
No Change
66
2009 ICR Draft Survey
C1. Considering the CPAP machine you use
now, did you have any problems finding an
equipment supplier to get your CPAP
machine from?
Yes
1
No (→Skip to C2)
2
I don’t know (→Skip to C2)
98
C1a. What kinds of problems did you have
finding a CPAP machine supplier? (Please
check all that apply.)
Hard to find a supplier who
1
covered my area
2
Supplier did not carry what I
needed
Supplier could not deliver
3
equipment when I needed it
Supplier did not accept Medicare
4
Other, please specify: __________
96
C2. Considering the CPAP machine you use
now, did you have a choice of suppliers?
Yes, many
1
Yes, a few
2
No, only one supplier available
3
I don’t know
98
Page
7
7
7
2010 ICR Draft Survey
C1. Considering the CPAP machine you use
now, did you have any problems finding an
equipment supplier to get your CPAP
machine from?
Yes
1
No (→Skip to C2)
2
I don’t know (→Skip to C2)
98
C1a. What kinds of problems did you have
finding a CPAP machine supplier? (Please
check all that apply.)
Hard to find a supplier who
1
covered my area
2
Supplier did not carry what I
needed
Supplier could not deliver
3
equipment when I needed it
Supplier did not accept Medicare
4
Other, please specify: __________
96
C2. Considering the CPAP machine you use
now, did you have a choice of suppliers?
Yes, many
1
Yes, a few
2
No, only one supplier available
3
I don’t know
98
Page
8
Reason for Change
No Change
8
No Change
8
No Change
67
2009 ICR Draft Survey
C3. How did you get your CPAP machine?
Delivered to my home by my
1
supplier
Mailed to my home by my
2
supplier
3
I (or someone on my behalf)
picked it up from my supplier
98
I don’t know
99
Some other way, please specify:
_______________________
Page
7
2010 ICR Draft Survey
C6. How did you get your CPAP machine?
Delivered to my home by my supplier
1
Mailed to my home by my supplier
2
I (or someone on my behalf) picked it
3
up from my supplier
I don’t know
98
Some other way, please specify:
99
_______________________
Page
9
No Change
C4. Considering the CPAP machine you use
now, how much time and energy did it take to
get the CPAP machine, accessories, parts,
maintenance and repairs from your supplier?
No time and energy
1
A little time and energy
2
Some time and energy
3
A lot of time and energy
4
I don’t know
98
C5. After you ordered your CPAP machine,
how long did it take to arrive?
Next day
1
Within a week
2
3
1-2 weeks later
More than 2 weeks later
4
I don’t know
98
7
C9. Considering the CPAP machine you use
now, how much time and energy did it take to
get the CPAP machine, accessories, parts,
maintenance and repairs from your supplier?
No time and energy
1
A little time and energy
2
Some time and energy
3
A lot of time and energy
4
I don’t know
98
C5. After you ordered your CPAP machine,
how long did it take to arrive?
Next day
1
Within a week
2
3
1-2 weeks later
More than 2 weeks later
4
I don’t know
98
10
No Change
9
No Change
8
Reason for Change
68
2009 ICR Draft Survey
C6. When you got the CPAP machine you
use now, what kind of training or help did the
supplier give you or the person who takes care
of you? Did he/she … (Please check all that
apply.)
Give you written instructions on
1
how to use the CPAP machine
Show you how to use the CPAP
2
machine
3
Choose a safe and convenient
place to store and charge the
CPAP machine
Show you how to clean and
4
maintain the CPAP machine
Let you practice how to use and
5
maintain your CPAP machine
while they watched
Gave me the manufacturer’s
6
customer assistance toll-free
telephone number
Sent someone to my home to
7
explain how to use it
I did not get any training or help
8
from my supplier (→Skip to C7)
I don’t know (→Skip to C7)
98
Page
8
2010 ICR Draft Survey
C7. When you got the CPAP machine you
use now, what kind of training or help did the
supplier give you or the person who takes care
of you? Did he/she … (Please check all that
apply.)
Give you written instructions on how
1
to use the CPAP machine
Show you how to use the CPAP
2
machine
3
Choose a safe and convenient place to
store and charge the CPAP machine
Show you how to clean and maintain
4
the CPAP machine
Let you practice how to use and
5
maintain your CPAP machine while they
watched
Gave me the manufacturer’s customer
6
assistance toll-free telephone number
Sent someone to my home to explain
7
how to use it
I did not get any training or help from
8
my supplier (→Skip to C8)
I don’t know (→Skip to C8)
98
Page
9
Reason for Change
No Change
69
2009 ICR Draft Survey
C6a. As a result of that training, how
comfortable do you feel using and
maintaining your CPAP machine?
Very comfortable
1
Comfortable
2
Uncomfortable
3
Very uncomfortable
4
My comfort level has nothing to
5
do with the training that my
supplier gave me
C7. In the 3 months after you got the CPAP
machine you use now, how often did your
supplier send someone like a nurse or a
respiratory therapist to your home to check
the equipment or see how well you are doing
with the equipment? (Do not include times
when you called them.)
Once in the 3 months after you got
1
the CPAP machine
More than once in the 3 months
2
after you got the CPAP machine
3
Not at all in the 3 months after you
got the CPAP machine
Page
8
8
2010 ICR Draft Survey
C7a. As a result of that training, how
comfortable do you feel using and
maintaining your CPAP machine?
Very comfortable
1
Comfortable
2
Uncomfortable
3
Very uncomfortable
4
My comfort level has nothing to
5
do with the training that my
supplier gave me
C8. In the 3 months after you got the CPAP
machine you use now, how often did your
supplier send someone like a nurse or a
respiratory therapist to your home to check
the equipment or see how well you are doing
with the equipment? (Do not include times
when you called them.)
Once in the 3 months after you got
1
the CPAP machine
More than once in the 3 months
2
after you got the CPAP machine
3
Not at all in the 3 months after you
got the CPAP machine
Page
10
Reason for Change
No Change
10
No Change
70
2009 ICR Draft Survey
C8. Considering the CPAP machine you use
now, when you asked your supplier questions,
did you get answers that you could
understand?
Yes, completely
1
Yes, somewhat
2
No
3
I did not ask any questions
4
98
I don’t know
C9. Before deciding on the CPAP machine
you use now, did your supplier tell you as
much as you wanted to know about the
options for your CPAP machine?
Yes, completely
1
Yes, somewhat
2
No
3
I don’t know
98
This question did not appear in the 2009
Survey
Page
9
9
2010 ICR Draft Survey
C3. Considering the CPAP machine you use
now, when you asked your supplier questions,
did you get answers that you could
understand?
Yes, completely
1
Yes, somewhat
2
No
3
I did not ask any questions
4
98
I don’t know
C4. Before deciding on the CPAP machine
you use now, did your supplier tell you as
much as you wanted to know about the
options for your CPAP machine?
Yes, completely
1
Yes, somewhat
2
No
3
I don’t know
98
C4a. Before you decided on the CPAP
machine that you use now, did your supplier
tell you about all the equipment designs
available to you, even those which the
supplier did not have in stock?
Yes, all equipment designs were
1
explained
2
No, the supplier only told me what
he/she has in stock
No, I already knew the equipment
3
designs available to me
I don’t know
98
Page
8
Reason for Change
No Change
8
No Change
8
Added this question out of concern that
suppliers will not keep as many makes and
models in their inventory after competitive
bidding.
71
2009 ICR Draft Survey
C10. When you got the CPAP machine you
use now, did your supplier spend as much
time with you as you wanted?
Yes
1
No
2
Section Title. D. RECENT EXPERIENCES
Description. Please answer the following
questions about the supplier that you use most
often for your CPAP machine and accessories.
D1. During the past six months, how reliable
was your supplier in making deliveries or
repairs?
Very reliable
1
Somewhat reliable
2
Not reliable at all
3
Does not apply
4
D2. In the past six months, have you
contacted your supplier with a complaint or a
problem?
Yes
1
No (→Skip to D5)
2
98
I don’t know (→Skip to D5)
Don’t know how to contact my
4
supplier (→Skip to D5)
Page
9
9
9
9
9
2010 ICR Draft Survey
This question does not appear in the 2010
ICR Draft Survey.
Section Title. D. RECENT EXPERIENCES
Description. Please answer the following
questions about the supplier that you use most
often for your CPAP machine and accessories.
D1. During the past six months, how reliable
was your supplier in making deliveries or
repairs?
Very reliable
1
Somewhat reliable
2
Not reliable at all
3
Does not apply
4
D2. In the past six months, have you
contacted your supplier with a complaint or a
problem?
Yes
1
No (→Skip to D5)
2
98
I don’t know (→Skip to D5)
Don’t know how to contact my
4
supplier (→Skip to D5)
Page
Reason for Change
Deleted this question to shorten the survey,
and because this issues is addressed in
previous questions.
11
11
No Change
No Change
11
No Change
11
No Change
72
2009 ICR Draft Survey
D2a. When you contacted your supplier, was
your complaint or problem settled to your
satisfaction?
Yes
1
No
2
I am waiting for it to be settled
3
I don’t know
98
D3. In the past six months, have you
contacted your supplier to get emergency
service or advice?
Yes
1
2
No ( →Skip to D4)
I don’t know (→Skip to D4)
98
D3a. In general, how fast did the supplier
respond to your needs, either by phone or in
person? Would you say …
Within 1 day
1
Within 2 days
2
Within 1 week
3
Longer than 1 week
4
I don’t know
98
D3b. Were you able to get the emergency
service or advice you needed?
Yes
1
No
2
I don’t know
98
Page
9
10
10
10
2010 ICR Draft Survey
D2a. When you contacted your supplier, was
your complaint or problem settled to your
satisfaction?
Yes
1
No
2
I am waiting for it to be settled
3
I don’t know
98
D3. In the past six months, have you
contacted your supplier to get emergency
service or advice?
Yes
1
2
No ( →Skip to D4)
I don’t know (→Skip to D4)
98
D3a. In general, how fast did the supplier
respond to your needs, either by phone or in
person? Would you say …
Within 1 day
1
Within 2 days
2
Within 1 week
3
Longer than 1 week
4
I don’t know
98
D3b. Were you able to get the emergency
service or advice you needed?
Yes
1
No
2
I don’t know
98
Page
11
Reason for Change
No Change
11
No Change
11
No Change
11
No Change
73
2009 ICR Draft Survey
D4. In the past six months, have you needed
to contact your supplier after regular business
hours?
Yes
1
No (→Skip to D5)
2
I don’t know (→Skip to D5)
98
D4a. When you contacted your supplier after
business hours, were you able to get the
service or advice you needed?
Yes
1
No
2
98
I don’t know
D5. Overall, how would you rate the supplier
that you use most?
1
Poor
Fair
2
Good
3
Very good
4
Excellent
5
D6. Would you recommend this CPAP
machine supplier to a friend who needed
similar equipment and services?
Yes
1
No
2
Page
10
10
10
10
2010 ICR Draft Survey
D4. In the past six months, have you needed
to contact your supplier after regular business
hours?
Yes
1
No (→Skip to D5)
2
I don’t know (→Skip to D5)
98
D4a. When you contacted your supplier after
business hours, were you able to get the
service or advice you needed?
Yes
1
No
2
98
I don’t know
D5. Overall, how would you rate the supplier
that you use most?
Poor
1
Fair
2
Good
3
Very good
4
Excellent
5
C10. Would you recommend this CPAP
machine supplier to a friend who needed
similar equipment and services?
Yes
1
No
2
Page
12
Reason for Change
No Change
12
No Change
12
No Change
10
There was no change to the content of this
question however it is now located in
Section C due to its subject matter
74
2009 ICR Draft Survey
D7. In the past six months, have you
changed your CPAP machine supplier?
Yes
1
No (→Skip to SECTION E)
2
I don’t know (→Skip to
98
SECTION E)
D7a. Why did you change your CPAP
machine supplier? (Please check all that
apply.)
I moved
1
Supplier no longer accepted
2
Medicare
3
Supplier went out of business
I was not happy with the quality of
4
service
I was not happy with equipment
5
I was not happy with the choices
6
of equipment or service I could get
I was not happy with the
7
assistance I got in handling the
insurance
Supplier did not provide CPAP
8
machine, accessories or repair
service I needed
I changed to an HMO and had to
9
use a different supplier
Other, please specify: __________
96
Section Title. E. ABOUT YOU
Page
11
11
11
2010 ICR Draft Survey
D6. In the past six months, have you
changed your CPAP machine supplier?
Yes
1
No (→Skip to SECTION E)
2
I don’t know (→Skip to
98
SECTION E)
D6a. Why did you change your CPAP
machine supplier? (Please check all that
apply.)
I moved
1
Supplier became ineligible to provide
2
the equipment under Medicare
3
Supplier went out of business
I was not happy with the quality of
4
service
I was not happy with equipment
5
I was not happy with the choices of
6
equipment or service I could get
I was not happy with the assistance I
7
got in handling the insurance
Supplier did not provide CPAP
8
machine, accessories or repair service I
needed
I changed to an HMO and had to use
9
a different supplier
Other, please specify:
96
__________________________
Section Title. E. ABOUT YOU
Page
12
Reason for Change
No Change
12
Added/modified several answer categories to
better reflect supplier service and to address
the circumstance of suppliers becoming
ineligible for Medicare.
13
No Change
75
2009 ICR Draft Survey
Description. Section E is about you, the
person whose name is on the mailing label of
this survey.
E1. In general, how would you rate your
overall health?
Excellent
1
Very good
2
Good
3
Fair
4
Poor
5
E2. Compared to 1 year ago, how would you
rate your health now? Would you say …
Much better now
1
Somewhat better now
2
About the same
3
Somewhat worse now
4
5
Much worse now
E3. Do you currently live alone?
Yes (→Skip to E5)
1
No
2
Page
11
2010 ICR Draft Survey
Description. Section E is about you, the
person whose name is on the mailing label of
this survey.
Page
13
No Change
11
E1. In general, how would you rate your
overall health?
Excellent
1
Very good
2
Good
3
Fair
4
Poor
5
E2. Compared to 1 year ago, how would you
rate your health now? Would you say …
Much better now
1
Somewhat better now
2
About the same
3
Somewhat worse now
4
5
Much worse now
E3. Do you currently live alone?
1
Yes (→Skip to E5)
No
2
13
No Change
13
No Change
13
No Change
11
11
Reason for Change
76
2009 ICR Draft Survey
E4. Which best describes your living
situation now? (Please check all that apply.)
I live….
With spouse/partner
1
With parent/step-parent
2
With child/children
3
With other relative(s)
4
With friend
5
6
With other person(s) not related to
me
E5. What is the highest grade or level of
school that you have completed?
8th grade or less
1
Some high school but did not
2
graduate
High school graduate or GED
3
Some college or technical school
4
College graduate
5
More than a 4-year college degree
6
Page
11
12
2010 ICR Draft Survey
E4. Which best describes your living
situation now? (Please check all that apply.)
I live….
With spouse/partner
1
With parent/step-parent
2
With child/children
3
With other relative(s)
4
With friend
5
6
With other person(s) not related to
me
E5. What is the highest grade or level of
school that you have completed?
8th grade or less
1
Some high school but did not
2
graduate
High school graduate or GED
3
Some college or technical school
4
College graduate
5
More than a 4-year college degree
6
Page
13
Reason for Change
No Change
13
No Change
77
2009 ICR Draft Survey
E6. What was your household’s annual
income during 2009, before taxes?
Less than $5,000 ($416 per month)
1
Between $5,001 and $10,000
2
($417–$833 per month)
Between $10,001 and $20,000
3
($834–$1,666 per month)
Between $20,001 and $30,000
4
($1,667–2,500 per month)
5
Between $30,001 and $50,000
($2,501–$4,167 per month)
Over $50,000 (over $4,168 per
6
month)
E7. Are you of Hispanic or Latino origin or
descent?
Yes, Hispanic or Latino
1
No, not Hispanic or Latino
2
E8.
How would you describe your race?
(Please check all that apply.)
American Indian or Alaskan
1
Native
Asian
2
Black or African American
3
Native Hawaiian or other Pacific
4
Islander
5
White or Caucasian
Other, please tell us:
96
________________________
Page
12
12
12
2010 ICR Draft Survey
E6. What was your household’s annual
income during 2009, before taxes?
Less than $5,000 ($416 per month)
1
Between $5,001 and $10,000
2
($417–$833 per month)
Between $10,001 and $20,000
3
($834–$1,666 per month)
Between $20,001 and $30,000
4
($1,667–2,500 per month)
5
Between $30,001 and $50,000
($2,501–$4,167 per month)
Over $50,000 (over $4,168 per
6
month)
E7. Are you of Hispanic or Latino origin or
descent?
Yes, Hispanic or Latino
1
No, not Hispanic or Latino
2
E8.
How would you describe your race?
(Please check all that apply.)
American Indian or Alaskan
1
Native
Asian
2
Black or African American
3
Native Hawaiian or other Pacific
4
Islander
5
White or Caucasian
Other, please tell us:
96
________________________
Page
13
Reason for Change
No Change
14
No Change
14
No Change
78
2009 ICR Draft Survey
Section Title. F. OTHER INFORMATION
F1. Please check the correct statement:
1
I am the person to whom this
survey was addressed (→Skip to
END)
I filled this survey out or helped
2
fill it out for someone else
F2. How did you help the person with this
survey?
I wrote the answers that the person
1
told me
I answered the questions myself
2
based on my knowledge of the
person’s condition
Both of the above
3
Page
12
12
12
2010 ICR Draft Survey
Section Title. F. OTHER INFORMATION
F1. Please check the correct statement:
I am the person to whom this
1
survey was addressed (→Skip to
END)
I filled this survey out or helped
2
fill it out for someone else
F2. How did you help the person with this
survey?
I wrote the answers that the person
1
told me
I answered the questions myself
2
based on my knowledge of the
person’s condition
Both of the above
3
Page
14
14
Reason for Change
No Change
No Change
14
No Change
DMEPOS Survey of Walker Users: Changes from December 2009 ICR Draft to March 2010 ICR Draft
2009 ICR Draft Survey
Survey Title. Survey of Medicare Patients
Who Use a Walker
Page
1
2010 ICR Draft Survey
Survey Title. Survey of Medicare Patients
Who Use a Walker
Page
[no #]
Reason for Change
No Change
79
2009 ICR Draft Survey
Qualifying Question. If the person this
survey was mailed to cannot complete the
survey and there is no one else who can do so
for him or her, please check the appropriate
box below and return the blank survey in the
enclosed postage-paid envelope. The person
this survey was mailed to is:
There is nobody available who can
1
complete this survey
99 Other reason, please specify:
__________________________
Section Title. A. USE OF WALKERS
A1. When did you begin using a walker?
1 2010
2 2009
3 2008
4 Before 2008
5 I have never used a walker (Skip to
SECTION E on page 10)
A2. When you first began using a walker,
how long did you expect to use it?
Less than 1 month
1
1 to 6 months
2
More than 6 months
3
Forever
4
I don’t know
98
Page
1
2
2
2
2010 ICR Draft Survey
Qualifying Question. The purpose of the
study is to learn more about your satisfaction
with the equipment, supplies, and service you
receive from your walker supplier. We also
hope to better understand your experiences in
obtaining and using this equipment.
If the person this survey was mailed
1
to cannot complete the survey, and there is no
one else who can do so for him or her, please
check here and return the blank survey in the
enclosed postage-paid envelope.
Section Title. A. USE OF WALKERS
A1. When did you begin using a walker?
1 2010
2 2009
3 2008
4 Before 2008
5 I have never used a walker (Skip to
SECTION E on page 11)
A2. When you first began using a walker,
how long did you expect to use it?
Less than 1 month
1
1 to 6 months
2
More than 6 months
3
Forever
4
98 I don’t know
Page
[no #]
Reason for Change
The last sentence did not make sense when
combined with the boxes one was supposed
to check off. A single check box is
sufficient.
2
2
No Change
No Change
2
No Change
80
2009 ICR Draft Survey
A3. Do you use a walker now? This
includes using a walker all of the time or just
occasionally.
Yes (→ Skip to A4)
1
No, I no longer use a walker
2
A3a. Why did you stop using your walker?
(Please check all that apply and then skip to
SECTION E on page 10.)
My condition got better so I did
1
not need it anymore
My condition got worse so I
2
couldn’t use it anymore
3
I was embarrassed to use it
I was not comfortable using it
4
I did not feel safe using it
5
I just did not like using it
6
It was too difficult to use
7
It kept breaking
8
It was not the type of walker I
9
needed
Other, please specify: __________
96
Subsection Title. YOUR CURRENT USE
OF WALKER
A4. When did you first get the walker you
use now?
1 Less than 6 months ago
2 6-12 months ago
3 More than 12 months ago
Page
2
2
2
2
2010 ICR Draft Survey
A3. Do you use a walker now? This
includes using a walker all of the time or just
occasionally.
Yes (→ Skip to A4)
1
No, I no longer use a walker
2
A3a. Why did you stop using your walker?
(Please check all that apply and then skip to
SECTION E on page 10.)
My condition got better so I did
1
not need it anymore
My condition got worse so I
2
couldn’t use it anymore
3
I was embarrassed to use it
I was not comfortable using it
4
I did not feel safe using it
5
I just did not like using it
6
It was too difficult to use
7
It kept breaking
8
It was not the type of walker I
9
needed
Other, please specify: __________
96
Subsection Title. YOUR CURRENT USE
OF WALKER
A4. When did you first get the walker you
use now?
1 Less than 6 months ago
2 6-12 months ago
3 More than 12 months ago
Page
2
Reason for Change
No Change
2
No Change
2
No Change
2
No Change
81
2009 ICR Draft Survey
A5. Did you get your current walker while
you were in a nursing home or hospital?
1 Yes (→Skip to SECTION E on page
10)
2 No
A6. Does someone regularly help you use
your walker (for example, a relative, friend or
home health aide)?
Yes
1
No
2
A7. Did a doctor or another medical person
like a nurse or physical/occupational therapist
ever explain to you why you needed to use a
walker?
1
Yes
No
2
I don’t know
98
A8. Did a doctor or another medical person
like a nurse or physical/occupational therapist
ever explain to you the different types of
walkers and accessories that exist?
Yes, a medical person explained
1
walkers
No, no medical person explained
2
walkers
I don’t know or don’t recall if a
98
medical person explained walkers
Page
2
2010 ICR Draft Survey
A5. Did you get your current walker while
you were in a nursing home or hospital?
1 Yes
2 No
Page
2
3
A6. Does someone regularly help you use
your walker (for example, a relative, friend or
home health aide)?
Yes
1
No
2
A7. Did a doctor or another medical person
like a nurse or physical/occupational therapist
ever explain the following to you (Please
check all that apply):
1
Why you needed to use a walker
The different types of walkers and
2
accessories that exist
None of these things were explained
3
by a medical person
I don’t know or don’t recall if a
98
medical person explained anything to me
3
No Change
3
Questions A7 and A8 in the 2010 survey
were combined into one to shorten the
survey and focus on patient perceptions.
3
3
Reason for Change
The skip prompt was removed from this
question in order to capture subsequent
information related to the equipment.
82
2009 ICR Draft Survey
A9. When was the last time you discussed
your mobility needs or issues related to your
walker with a doctor or another medical
person like a nurse or physical/occupational
therapist?
Within the last 6 months
1
Between 6 months and 1 year ago
2
Between 1 and 3 years ago
3
4
More than 3 years ago
I don’t know
98
A10. Have you had more than one walker in
the past year, or changed accessories (e.g.
glides, basket) in the past year? (Please check
all that apply.)
No (→Skip to A11)
1
Yes, I changed my walker
2
Yes, I changed or added
3
accessories
I don’t know (→Skip to A11)
98
Page
3
3
2010 ICR Draft Survey
A8. When was the last time you discussed
your mobility needs or issues related to your
walker with a doctor or another medical
person like a nurse or physical/occupational
therapist?
Within the last 6 months
1
Between 6 months and 1 year ago
2
Between 1 and 3 years ago
3
4
More than 3 years ago
I don’t know
98
A9. Have you had more than one walker in
the past year, or changed accessories (e.g.
glides, basket) in the past year? (Please check
all that apply.)
No (→Skip to A10)
1
Yes, I changed my walker
2
Yes, I changed or added
3
accessories
I don’t know (→Skip to A10)
98
Page
3
Reason for Change
No Change
3
No Change
83
2009 ICR Draft Survey
A10a. Why did you make this (these)
change(s)? (Please check all that apply.)
Walker needed to be replaced
1
because the original one did not
work
My medical condition changed, so
2
I needed something different
Found a new walker that was
3
better for me
4
Found new features/accessories
that were better for me
Doctor or health care provider
5
prescribed a different walker or
different accessories
Supplier changed
6
Other, please specify: __________
96
A11. Do you believe that you now have the
walker that is right for you?
1
Yes
No
2
I don’t know
98
Page
4
2010 ICR Draft Survey
A9a. Why did you make this (these)
change(s)? (Please check all that apply.)
Walker needed to be replaced because
1
the original one did not work
My medical condition changed, so I
2
needed something different
Found a new walker that was better
3
for me
4
Found new features/accessories that
were better for me
Doctor or health care provider
5
prescribed a different walker or different
accessories
My supplier became ineligible to
6
provide my equipment under Medicare
My supplier did not tell me why they
7
changed my equipment
96
Other, please specify:
_______________________
Page
3
4
A10. Do you believe that you now have the
walker that is right for you?
1
Yes
No
2
I don’t know
98
4
Reason for Change
Clarified question language; clarified one
response category to focus on supplier
becoming ineligible for Medicare (most
relevant for the follow-up survey in 2012);
added a response category of “ My supplier
did not tell me why they changed my
equipment” because patient may not know
the reason.
No Change
84
2009 ICR Draft Survey
A12. Is using your walker difficult or
uncomfortable?
Yes
1
No (→Skip to A13)
2
I don’t know (→Skip to A13)
98
A12a. What is it about your walker that
makes it difficult or uncomfortable to use?
(Please check all that apply.)
Unable to support myself with my
1
walker
Unable to walk with my walker
2
3
Hard to use the walker inside my
home
Hard to use the walker outside of
4
my home
Unable to put the walker in a
5
car/taxi to go places
Unable to get up from a sitting
6
position with my walker
Walker is too heavy and
7
cumbersome
96
Other, please tell us what else:
_________________________
Page
4
4
2010 ICR Draft Survey
A11. Is using your walker difficult or
uncomfortable?
Yes
1
No (→Skip to A12)
2
I don’t know (→Skip to A12)
98
A11a. What is it about your walker that
makes it difficult or uncomfortable to use?
(Please check all that apply.)
It is difficult to support myself with
1
my walker
It is difficult to walk with my walker
2
3
It is difficult to use the walker inside
my home
It is difficult to use the walker outside
4
of my home
It is difficult to put the walker in a
5
car/taxi to go places
It is difficult to get up from a sitting
6
position with my walker
Walker is too heavy and cumbersome
7
Other, please tell us what else:
96
_________________________
Page
4
4
Reason for Change
No Change
Revised language of response categories for
grammatical consistency
85
2009 ICR Draft Survey
A13. In general, how often do you use your
walker?
Less than one day a week
1
1-2 days per week
2
3-4 days per week
3
5-6 days per week
4
Every day
5
A14. On the days that you do use your
walker, how many times per day do you use
it?
______ times per day
A15. How reliable is the walker you use
now? Would you say …
Very reliable
1
2
Somewhat reliable
Somewhat unreliable
3
Very unreliable
4
I don’t know
98
A16. In the past year, did you have any
problems that made you stop using your
walker or switch to a different walker instead?
1 Yes
2 No (→Skip to SECTION B)
98 I don’t know (→Skip to SECTION B)
Page
4
4
5
5
2010 ICR Draft Survey
A12. In general, how often do you use your
walker?
Less than one day a week
1
1-2 days per week
2
3-4 days per week
3
5-6 days per week
4
Every day
5
A13. On the days that you do use your
walker, how many times per day do you use
it?
______ times per day
A14. How reliable is the walker you use
now? Would you say …
Very reliable
1
2
Somewhat reliable
Somewhat unreliable
3
Very unreliable
4
I don’t know
98
A15. In the past year, did you have any
problems that made you stop using your
walker or switch to a different walker instead?
1 Yes
2 No (→Skip to SECTION B)
98 I don’t know (→Skip to SECTION B)
Page
4
Reason for Change
No Change
4
No Change
4
No Change
4
No Change
86
2009 ICR Draft Survey
A17a. How many times did you have these
kinds of problems in the past year?
One time
1
2 or 3 times
2
4 or more times
3
Don’t recall the exact number of
4
times
A17b. Can you describe the kind of
problem(s) that you had? (Please check all
that apply.)
The walker collapsed
1
2
The wheels wouldn’t turn or
would stick
The walker glides cracked or fell
3
off
The walker wouldn’t easily fit
4
through a doorway
It was difficult to move the walker
5
around furniture
It was difficult to move the walker
6
in the bathroom
7
It was difficult to the walker lift up
or down over roadside curbs
It was difficult to move the walker
8
up or down stairs
Other, please specify: __________
96
Section Title. B. MEDICAL EXPENSES
Page
5
5
6
2010 ICR Draft Survey
A15a. How many times did you have these
kinds of problems in the past year?
One time
1
2 or 3 times
2
4 or more times
3
Don’t recall the exact number of
4
times
A15b. Can you describe the kind of
problem(s) that you had? (Please check all
that apply.)
The walker collapsed
1
2
The wheels wouldn’t turn or
would stick
The walker glides cracked or fell
3
off
The walker wouldn’t easily fit
4
through a doorway
It was difficult to move the walker
5
around furniture
It was difficult to move the walker
6
in the bathroom
7
It was difficult to the walker lift up
or down over roadside curbs
It was difficult to move the walker
8
up or down stairs
Other, please specify: __________
96
Section Title. B. MEDICAL EXPENSES
Page
5
Reason for Change
No Change
5
No Change
5
No Change
87
2009 ICR Draft Survey
B1. In the past year, have you bought any
accessories or parts for your current walker
with your own money, or paid for
maintenance or repairs with your own money,
because your insurance did not cover it? (This
does not include any copay or deductible
amounts that are due from you.)
Yes
1
2
No (→Skip to SECTION C)
I don’t know (→Skip to SECTION
98
C)
B2. In the past year, what parts or service did
you buy with your own money for your
walker? (Please check all that apply.)
Glide covers or skis
1
Hook (for example, to hang a bag)
2
3
Bag or tote
Basket
4
Tray
5
Repairs
6
Routine maintenance
7
96
Other (please specify): _________
Page
6
6
2010 ICR Draft Survey
B1. In the past year, have you bought any
accessories or parts for your current walker
with your own money, or paid for
maintenance or repairs with your own money,
because your insurance did not cover it? (This
does not include any copay or deductible
amounts that are due from you.)
Yes
1
2
No (→Skip to SECTION C)
I don’t know (→Skip to SECTION
98
C)
B2. In the past year, what parts or service did
you buy with your own money for your
walker? (Please check all that apply.)
Glide covers or skis
1
Hook (for example, to hang a bag)
2
3
Bag or tote
Basket
4
Tray
5
Repairs
6
Routine maintenance
7
96
Other (please specify): _________
Page
5
Reason for Change
No Change
5
No Change
88
2009 ICR Draft Survey
B3. Thinking about everything you paid for
with your own money in the past year for your
walker accessories, parts, maintenance or
repairs not covered by insurance, how much
did you spend on your current walker? (This
does not include any copay or deductible
amounts.)
Less than $100
1
2
$100-$500
$500 or more
3
I don’t know
98
Section Title. C. YOUR SUPPLIER
C1. Considering the walker you use now, did
you have any problems finding an equipment
supplier to get your walker from?
Yes
1
No (→Skip to C2)
2
I don’t know (→Skip to C2)
98
Page
6
6
6
2010 ICR Draft Survey
B3. Thinking about everything you paid for
with your own money in the past year for your
walker accessories, parts, maintenance or
repairs not covered by insurance, how much
did you spend on your current walker? (This
does not include any copay or deductible
amounts.)
Less than $100
1
2
$100-$500
$500 or more
3
I don’t know
98
Section Title. C. YOUR SUPPLIER
C1. Considering the walker you use now, did
you have any problems finding an equipment
supplier to get your walker from?
Yes
1
No (→Skip to C2)
2
I don’t know (→Skip to C2)
98
Page
6
Reason for Change
No Change
6
6
No Change
No Change
89
2009 ICR Draft Survey
C1a. What kinds of problems did you have
finding a walker supplier? (Please check all
that apply.)
I didn’t know how to find a
1
supplier
Hard to find a supplier who
2
covered my area
Supplier did not carry what I
3
needed
4
Supplier could not deliver
equipment when I needed it
Supplier did not accept Medicare
5
Other, please specify: _________
96
C2. Considering the walker you use now, did
you have a choice of suppliers?
Yes, many
1
Yes, a few
2
No, only one supplier available
3
I don’t know
98
C3. Considering the walker you use now, do
you get your accessories, parts, maintenance
and repairs from more than one equipment
supplier?
Yes
1
2
No
I don’t know
98
Page
6
7
7
2010 ICR Draft Survey
C1a. What kinds of problems did you have
finding a walker supplier? (Please check all
that apply.)
I didn’t know how to find a
1
supplier
Hard to find a supplier who
2
covered my area
Supplier did not carry what I
3
needed
4
Supplier could not deliver
equipment when I needed it
Supplier did not accept Medicare
5
Other, please specify: _________
96
C2. Considering the walker you use now, did
you have a choice of suppliers?
Yes, many
1
Yes, a few
2
No, only one supplier available
3
I don’t know
98
C9. Considering the walker you use now, do
you get your accessories, parts, maintenance
and repairs from more than one equipment
supplier?
Yes
1
2
No
I don’t know
98
Page
6
Reason for Change
No Change
6
No Change
8
No Change
90
2009 ICR Draft Survey
C4. Overall, how would you rate the supplier
that you use most?
Poor
1
Fair
2
Good
3
Very good
4
Excellent
5
C5. Would you recommend this supplier to a
friend who needed similar equipment and
services?
Yes
1
2
No
C6. How did you get your walker?
Delivered to my home by my
1
supplier
2
Mailed/shipped to my home by my
supplier
I (or someone on my behalf)
3
picked it up from my supplier
I picked it up at a clinic or
5
rehabilitation center
I don’t know
98
Some other way, please specify:
96
________________________
Page
7
7
7
2010 ICR Draft Survey
C10. Overall, how would you rate the
supplier that you use most?
Poor
1
Fair
2
Good
3
Very good
4
Excellent
5
C11. Would you recommend this supplier to
a friend who needed similar equipment and
services?
Yes
1
2
No
C6. How did you get your walker?
Delivered to my home by my
1
supplier
2
Mailed/shipped to my home by my
supplier
I (or someone on my behalf)
3
picked it up from my supplier
I picked it up at a clinic or
5
rehabilitation center
I don’t know
98
Some other way, please specify:
96
________________________
Page
8
Reason for Change
No Change
8
No Change
7
No Change
91
2009 ICR Draft Survey
C7. Considering the walker you use now,
how much time and energy did it take to get
the walker, accessories, parts, maintenance
and repairs from your supplier?
No time and energy
1
A little time and energy
2
Some time and energy
3
A lot of time and energy
4
98
I don’t know
C8. After you ordered your walker, how
long did it take to arrive?
1
Next day
Within a week
2
1-2 weeks later
3
More than 2 weeks later
4
I don’t know
98
Page
7
8
2010 ICR Draft Survey
C8. Considering the walker you use now,
how much time and energy did it take to get
the walker, accessories, parts, maintenance
and repairs from your supplier?
No time and energy
1
A little time and energy
2
Some time and energy
3
A lot of time and energy
4
98
I don’t know
C5. After you ordered your walker, how
long did it take to arrive?
Next day
1
Within a week
2
1-2 weeks later
3
More than 2 weeks later
4
I don’t know
98
Page
8
Reason for Change
No Change
7
No Change
92
2009 ICR Draft Survey
C9. When you got the walker you use now,
what kind of training or help did the supplier
give you or the person who takes care of you?
Did he/she … (Please check all that apply.)
Give you written instructions on
1
how to use the walker
Show you how to use the walker
2
safely
3
Show you how to take care of the
walker
Let you practice how to use your
4
walker while they watched
Give you the manufacturer’s
5
customer assistance toll-free
telephone number
I did not get any training or help
6
from my supplier (→Skip to C10)
98
I don’t know (→Skip to C10)
C9a. As a result of that training, how
comfortable do you feel using and
maintaining your walker?
Very comfortable
1
Comfortable
2
Uncomfortable
3
Very uncomfortable
4
My comfort level has nothing to
5
do with the training that my
supplier gave me
Page
8
8
2010 ICR Draft Survey
C7. When you got the walker you use now,
what kind of training or help did the supplier
give you or the person who takes care of you?
Did he/she … (Please check all that apply.)
Give you written instructions on
1
how to use the walker
Show you how to use the walker
2
safely
3
Show you how to take care of the
walker
Let you practice how to use your
4
walker while they watched
Give you the manufacturer’s
5
customer assistance toll-free
telephone number
I did not get any training or help
6
from my supplier (→Skip to C8)
98
I don’t know (→Skip to C8)
C7a. As a result of that training, how
comfortable do you feel using and
maintaining your walker?
Very comfortable
1
Comfortable
2
Uncomfortable
3
Very uncomfortable
4
My comfort level has nothing to
5
do with the training that my
supplier gave me
Page
7
Reason for Change
No Change
8
No Change
93
2009 ICR Draft Survey
C10. Considering the walker you use now,
when you asked your supplier questions, did
you get answers that you could understand?
Yes, completely
1
Yes, somewhat
2
No
3
I did not ask any questions
4
I don’t know
98
C11. Before deciding on the walker you
use now, did your supplier tell you as much as
you wanted to know about the options for
your walker?
1
Yes, completely
Yes, somewhat
2
No
3
I don’t know
98
This question does not appear in the 2009
Survey.
Page
8
8
2010 ICR Draft Survey
C3.
Considering the walker you use now,
when you asked your supplier questions, did
you get answers that you could understand?
Yes, completely
1
Yes, somewhat
2
No
3
I did not ask any questions
4
I don’t know
98
C4.
Before deciding on the walker you
use now, did your supplier tell you as much as
you wanted to know about the options for
your walker?
1
Yes, completely
Yes, somewhat
2
No
3
I don’t know
98
C4a. Before you decided on the walker that
you use now, did your supplier tell you about
all the equipment designs available to you,
even those which the supplier did not have in
stock?
Yes, all equipment designs were
1
explained
No, the supplier only told me what
2
he/she has in stock
3
No, I already knew the equipment
designs available to me
I don’t know
98
Page
7
Reason for Change
No Change
7
No Change
7
Added this question out of concern that
suppliers will not keep as many makes and
models in their inventory after competitive
bidding.
94
2009 ICR Draft Survey
C12. When you got the walker you use
now, did your supplier spend as much time
with you as you wanted?
Yes
1
No
2
Section Title. D. RECENT EXPERIENCES
Description. Please answer the following
questions about the supplier that you use most
often if you use more than one supplier for
your walker and accessories.
D1. During the past six months, how reliable
was your supplier in making deliveries or
repairs?
Very reliable
1
Somewhat reliable
2
Not reliable at all
3
Does not apply
99
D2. In the past six months, have you
contacted your supplier with a complaint or a
problem?
Yes
1
2
No (→Skip to D5)
I don’t know (→kip to D5)
98
Don’t know how to contact my
4
supplier (→Skip to D5)
Page
9
9
9
9
9
2010 ICR Draft Survey
This question does not appear in the 2010
ICR Draft Survey.
Section Title. D. RECENT EXPERIENCES
Description. Please answer the following
questions about the supplier that you use most
often if you use more than one supplier for
your walker and accessories.
D1. During the past six months, how reliable
was your supplier in making deliveries or
repairs?
Very reliable
1
Somewhat reliable
2
Not reliable at all
3
Does not apply
99
D2. In the past six months, have you
contacted your supplier with a complaint or a
problem?
Yes
1
2
No (→Skip to D5)
I don’t know (→Skip to D5)
98
Don’t know how to contact my
4
supplier (→Skip to D5)
Page
Reason for Change
Deleted this question to shorten the survey,
and because this issues is addressed in
previous questions.
9
9
No Change
No Change
9
No Change
9
No Change
95
2009 ICR Draft Survey
D2a. When you contacted your supplier,
was your complaint or problem settled to your
satisfaction?
Yes
1
No
2
I am waiting for it to be settled
3
I don’t know
98
D3. In the past six months, have you
contacted your supplier to get emergency
service or advice about your walker?
Yes
1
2
No (→Skip to D4)
I don’t know (→Skip to D4)
98
D3a. In general, how fast did the supplier
respond to your needs, either by phone or in
person? Would you say …
Within 1 day
1
Within 2 days
2
Within 1 week
3
Longer than 1 week
4
I don’t know
98
D3b. Were you able to get the emergency
service or advice you needed?
Yes
1
No
2
I don’t know
98
Page
9
9
9
9
2010 ICR Draft Survey
D2a. When you contacted your supplier,
was your complaint or problem settled to your
satisfaction?
Yes
1
No
2
I am waiting for it to be settled
3
I don’t know
98
D3. In the past six months, have you
contacted your supplier to get emergency
service or advice about your walker?
Yes
1
2
No (→Skip to D4)
I don’t know (→Skip to D4)
98
D3a. In general, how fast did the supplier
respond to your needs, either by phone or in
person? Would you say …
Within 1 day
1
Within 2 days
2
Within 1 week
3
Longer than 1 week
4
I don’t know
98
D3b. Were you able to get the emergency
service or advice you needed?
Yes
1
No
2
I don’t know
98
Page
9
Reason for Change
No Change
9
No Change
9
No Change
9
No Change
96
2009 ICR Draft Survey
D4. In the past six months, have you needed
to contact your supplier after regular business
hours?
Yes
1
No (→Skip to D5)
2
I don’t know (→Skip to D5)
98
D4a. When you contacted your supplier after
business hours, were you able to get the
service or advice you needed?
Yes
1
No
2
98
I don’t know
D5. In the past six months, have you
changed your walker supplier?
1
Yes
No (→Skip to SECTION E on
2
page 10)
I don’t know (→Skip to SECTION
98
E on page 10)
Page
10
10
10
2010 ICR Draft Survey
D4. In the past six months, have you needed
to contact your supplier after regular business
hours?
Yes
1
No (→Skip to D5)
2
I don’t know (→Skip to D5)
98
D4a. When you contacted your supplier after
business hours, were you able to get the
service or advice you needed?
Yes
1
No
2
98
I don’t know
D5. In the past six months, have you
changed your walker supplier?
1
Yes
No (→Skip to SECTION E on
2
page 11)
I don’t know (→Skip to SECTION
98
E on page 11)
Page
9
Reason for Change
No Change
10
No Change
10
No Change
97
2009 ICR Draft Survey
D5a. Why did you change your walker
supplier? (Please check all that apply.)
I moved
1
Supplier no longer accepted
2
Medicare
Supplier went out of business
3
I was not happy with the quality of
4
service
5
I was not happy with equipment
I was not happy with the choices
6
of equipment or service I could get
I was not happy with the
7
assistance I got in handling the
insurance
Supplier did not provide walker,
8
accessories or repair service I
needed
I changed to an HMO and had to
9
use a different supplier
96 Other, please specify: __________
Section Title. E.
ABOUT YOU
Description. Section E is about you, the
person whose name is on the mailing label of
this survey.
Page
10
2010 ICR Draft Survey
D5a. Why did you change your walker
supplier? (Please check all that apply.).
I moved
1
Supplier no longer accepted Medicare
2
Supplier went out of business
3
I was not happy with the quality of
4
service
I was not happy with equipment
5
6
I was not happy with the choices of
equipment or service I could get
I was not happy with the assistance I
7
got in handling the insurance
Supplier did not provide walker,
8
accessories or repair service I needed
I changed to an HMO and had to use
9
a different supplier
Supplier became ineligible to provide
10
the equipment under Medicare
96 Other, please specify:
_________________________
Page
10
10
10
Section Title. E.
ABOUT YOU
Description. Section E is about you, the
person whose name is on the mailing label of
this survey.
11
11
Reason for Change
Added/modified several answer categories to
better reflect supplier service and to address
the circumstance of suppliers becoming
ineligible for Medicare.
No Change
No Change
98
2009 ICR Draft Survey
E1. In general, how would you rate your
overall health?
Excellent
1
Very good
2
Good
3
Fair
4
Poor
5
E2. Compared to 1 year ago, how would you
rate your health now? Would you say …
Much better now
1
Somewhat better now
2
3
About the same
Somewhat worse now
4
Much worse now
5
E3. Do you currently live alone?
Yes (→Skip to E5)
1
No
2
E4. Which best describes your living
situation now? (Please check all that apply.) I
live…
With spouse/partner
1
With parent/step-parent
2
With child/children
3
With other relative(s)
4
With friend
5
With other person(s) not related to
6
me
Page
10
11
11
11
2010 ICR Draft Survey
E1. In general, how would you rate your
overall health?
Excellent
1
Very good
2
Good
3
Fair
4
Poor
5
E2. Compared to 1 year ago, how would you
rate your health now? Would you say …
Much better now
1
Somewhat better now
2
3
About the same
Somewhat worse now
4
Much worse now
5
E3. Do you currently live alone?
1
Yes (→Skip to E5)
No
2
E4. Which best describes your living
situation now? (Please check all that apply.) I
live…
With spouse/partner
1
With parent/step-parent
2
With child/children
3
With other relative(s)
4
With friend
5
With other person(s) not related to
6
me
Page
11
Reason for Change
No Change
11
No Change
11
No Change
11
No Change
99
2009 ICR Draft Survey
E5. What is the highest grade or level of
school that you have completed?
8th grade or less
1
Some high school but did not
2
graduate
High school graduate or GED
3
Some college or technical school
4
College graduate
5
6
More than a 4-year college degree
E6. What was your household’s annual
income during 2006 before taxes?
1
Less than $5,000 ($416 per month)
Between $5,001 and $10,000
2
($417–$833 per month)
Between $10,001 and $20,000
3
($834–$1,666 per month)
Between $20,001 and $30,000
4
($1,667–2,500 per month)
Between $30,001 and $50,000
5
($2,501–$4,167 per month)
Over $50,000 (over $4,168 per
6
month)
E7. Are you of Hispanic or Latino origin or
descent?
1
Yes, Hispanic or Latino
No, not Hispanic or Latino
2
Page
11
11
11
2010 ICR Draft Survey
E5. What is the highest grade or level of
school that you have completed?
8th grade or less
1
Some high school but did not
2
graduate
High school graduate or GED
3
Some college or technical school
4
College graduate
5
6
More than a 4-year college degree
E6. What was your household’s annual
income during 2006 before taxes?
1
Less than $5,000 ($416 per month)
Between $5,001 and $10,000
2
($417–$833 per month)
Between $10,001 and $20,000
3
($834–$1,666 per month)
Between $20,001 and $30,000
4
($1,667–2,500 per month)
Between $30,001 and $50,000
5
($2,501–$4,167 per month)
Over $50,000 (over $4,168 per
6
month)
E7. Are you of Hispanic or Latino origin or
descent?
1
Yes, Hispanic or Latino
No, not Hispanic or Latino
2
Page
11
Reason for Change
No Change
11
No Change
11
No Change
100
2009 ICR Draft Survey
E8. How would you describe your race?
(Please check all that apply.)
American Indian or Alaskan Native
1
Asian
2
Black or African American
3
Native Hawaiian or other Pacific
4
Islander
White or Caucasian
5
96
Other, please specify: __________
Section Title. F. OTHER INFORMATION
F1. Please check the correct statement:
I am the person to whom this
1
survey was addressed (→ Skip to
END)
I filled this survey out or helped
2
fill it out for someone else
F2. How did you help the person with this
survey?
1
I wrote the answers that the person
told me
I answered the questions myself
2
based on my knowledge of the
person’s condition
Both of the above
3
Page
11
12
12
2010 ICR Draft Survey
E8. How would you describe your race?
(Please check all that apply.)
American Indian or Alaskan Native
1
Asian
2
Black or African American
3
Native Hawaiian or other Pacific
4
Islander
White or Caucasian
5
96
Other, please specify: __________
Section Title. F. OTHER INFORMATION
F1. Please check the correct statement:
I am the person to whom this
1
survey was addressed (→ Skip to
END)
I filled this survey out or helped
2
fill it out for someone else
F2. How did you help the person with this
survey?
1
I wrote the answers that the person
told me
I answered the questions myself
2
based on my knowledge of the
person’s condition
Both of the above
3
Page
12
Reason for Change
No Change
12
12
No Change
No Change
12
No Change
101
DMEPOS Survey of Hospital Bed Users: Changes from December 2009 ICR Draft to March 2010 ICR
Draft
2009 ICR Draft Survey
Title. Survey of Medicare Patients Who Use a
Hospital Bed
Qualifying Question. If the person this
survey was mailed to cannot complete the
survey and there is no one else who can do so
for him or her, please check the appropriate
box below and return the blank survey in the
enclosed postage-paid envelope. The person
this survey was mailed to is:
There is nobody available who can
1
complete this survey
96 Other reason, please specify:
__________________________
Page
1
Section Title. A.USE OF HOSPITAL BEDS
A1. When did you begin using a hospital
bed?
2010
1
2009
2
2008
3
Before 2008
4
I have never used a hospital bed (Skip
5
to SECTION E on page 10)
2
2
1
2010 ICR Draft Survey
Title. Survey of Medicare Patients Who Use a
Hospital Bed
Qualifying Question.
The purpose of the study is to learn more
about your satisfaction with the equipment,
supplies, and service you receive from your
hospital bed supplier. We also hope to better
understand your experiences in obtaining and
using this equipment.
If the person this survey was mailed
1
to cannot complete the survey, and there is no
one else who can do so for him or her, please
check here and return the blank survey in the
enclosed postage-paid envelope.
Section Title. A.USE OF HOSPITAL BEDS
A1. When did you begin using a hospital
bed?
2010
1
2009
2
2008
3
Before 2008
4
I have never used a hospital bed (Skip
5
to SECTION E on page 10)
Page
[no #]
[no #]
2
2
Reason for Change
No Change
The last sentence did not make sense when
combined with the boxes one was supposed
to check off. A single check box is
sufficient.
No Change
No Change
102
2009 ICR Draft Survey
A2. When you first began using a hospital
bed, how long did you expect to use it?
Less than 1 month
1
2 to 6 months
2
More than 6 months
3
Forever
4
I don’t know
98
A3. Do you use a hospital bed now? This
includes using a hospital bed all of the time or
just occasionally.
Yes (→ Skip to A4)
1
2
No, I no longer use a hospital bed
A3a. Why did you stop using your hospital
bed? (Please check all that apply and then
skip to SECTION E on page 10)
My condition got better so I did not
1
need it anymore
My condition got worse
2
I was not comfortable in it
3
I did not feel safe in it
5
I just did not like it
6
It was too difficult to use
7
It kept breaking
8
It did not have the features I needed
10
96
Other, please specify:
__________________________
Subsection Title. YOUR CURRENT USE
OF HOSPITAL BED
Page
2
2
2
2
2010 ICR Draft Survey
A2. When you first began using a hospital
bed, how long did you expect to use it?
1 Less than 1 month
2 2 to 6 months
3 More than 6 months
4 Forever
98 I don’t know
A3. Do you use a hospital bed now? This
includes using a hospital bed all of the time or
just occasionally.
Yes (→ Skip to A4)
1
2
No, I no longer use a hospital bed
A3a. Why did you stop using your hospital
bed? (Please check all that apply and then
skip to SECTION E on page 10)
My condition got better so I did not
1
need it anymore
My condition got worse
2
I was not comfortable in it
3
I did not feel safe in it
5
I just did not like it
6
It was too difficult to use
7
It kept breaking
8
It did not have the features I needed
10
96
Other, please specify:
__________________________
Subsection Title. YOUR CURRENT USE
OF HOSPITAL BED
Page
2
Reason for Change
No Change
2
No Change
2
No Change
2
No Change
103
2009 ICR Draft Survey
A4. When did you first get the hospital bed
you use now?
1 Less than 6 months ago
2 6-12 months ago
3 More than 12 months ago
A5. Does someone regularly help you use
your hospital bed (for example, a relative,
friend or home health aide)?
1 Yes
2 No
A6. Did a doctor or another medical person
like a nurse or physical/occupational therapist
ever explain to you why you needed to have a
hospital bed?
1
Yes
No
2
I don’t know
98
A7. Did a doctor or another medical person
like a nurse or physical/occupational therapist
ever explain to you the different types of
hospital beds and controls options?
Yes, a medical person explained
1
hospital beds
No, no medical person explained
2
hospital beds
I don’t know or don’t recall if a
98
medical person explained hospital beds
Page
2
2
3
3
2010 ICR Draft Survey
A4. When did you first get the hospital bed
you use now?
1 Less than 6 months ago
2 6-12 months ago
3 More than 12 months ago
A5. Does someone regularly help you use
your hospital bed (for example, a relative,
friend or home health aide)?
1 Yes
2 No
A6.
Did a doctor or another medical
person like a nurse or physical/occupational
therapist ever explain the following to you
(Please check all that apply):
1
Why you needed to have a hospital
bed
The different types of hospital beds
2
and controls
None of these things were explained
3
by a medical person
I don’t know or don’t recall if a
98
medical person explained anything to me
Page
2
Reason for Change
No Change
2
No Change
3
Questions A6 and A7 in the 2010 survey
were combined into one to shorten the
survey and focus on patient perceptions.
104
2009 ICR Draft Survey
A8. When was the last time you discussed
your needs or issues related to your medical
bed with a doctor or another medical person
like a nurse or physical / occupational
therapist?
Within the last 6 months
1
Between 6 months and 1 year ago
2
Between 1 and 3 years ago
3
4
More than 3 years ago
I don’t know
98
A9. Have you had more than one hospital bed
in the past year?
1
No (→ Skip to SECTION B)
Yes, I changed my hospital bed
2
I don’t know (→ Skip to SECTION
98
B)
Page
3
3
2010 ICR Draft Survey
A7. When was the last time you discussed
your needs or issues related to your medical
bed with a doctor or another medical person
like a nurse or physical / occupational
therapist?
Within the last 6 months
1
Between 6 months and 1 year ago
2
Between 1 and 3 years ago
3
4
More than 3 years ago
I don’t know
98
A8. Have you had more than one hospital bed
in the past year?
No (→ Skip to SECTION B)
1
Yes, I changed my hospital bed
2
I don’t know (→ Skip to SECTION
98
B)
Page
3
Reason for Change
No Change
3
No Change
105
2009 ICR Draft Survey
A9a. Why did you make this (these)
change(s)? (Please check all that apply.)
Hospital bed needed to be replaced
1
because the original one did not work
My medical condition changed, so I
2
needed something different
Found a new hospital bed that was
3
better for me
4
Found new features / controls that
were better for me
Doctor/ health care provider
5
prescribed a different type of hospital bed
Supplier changed
6
Other, please specify:
96
Page
3
A10. Do you believe that you now have the
hospital bed that is right for you?
Yes
1
No
2
I don’t know
98
A11. Is using your hospital bed difficult or
uncomfortable?
Yes
1
No (→Skip to A12)
2
I don’t know (→Skip to A12)
98
3
4
2010 ICR Draft Survey
A8a. Why did you make this (these)
change(s)? (Please check all that apply.)
1
Hospital bed needed to be replaced
because the original one did not work
My medical condition changed, so I
2
needed something different
Found a new hospital bed that was
3
better for me
4
Found new features / controls that
were better for me
Doctor/ health care provider
5
prescribed a different type of hospital bed
My supplier became ineligible to
6
provide my equipment under Medicare
My supplier did not tell me why they
7
changed my equipment
Other, please specify:
96
A9. Do you believe that you now have the
hospital bed that is right for you?
Yes
1
No
2
I don’t know
98
A10. Is using your hospital bed difficult or
uncomfortable?
Yes
1
No (→Skip to A11)
2
I don’t know (→Skip to A11)
98
Page
3
Reason for Change
Clarified question language; clarified one
response category to focus on supplier
becoming ineligible for Medicare (most
relevant for the follow-up survey in 2012);
added a response category of “ My supplier
did not tell me why they changed my
equipment” because patient may not know
the reason.
3
No Change
4
No Change
106
2009 ICR Draft Survey
A11a. What is it about your hospital bed that
makes it difficult or uncomfortable for you to
use? (Please check all that apply.)
Unable to sit up
1
Unable to reach controls
2
Unable to shift weight for pressure
3
relief
Unable to transfer in and out of the
4
hospital bed easily
5
Cannot lie comfortably in it
The tray or other attachments are hard
6
to adjust or use
It takes up a lot of space
8
Other, please tell us what else:
96
_______________________
Page
4
A12. In general, how often do you use your
hospital bed?
Less than one day or night per week
1
1-2 days or nights per week
2
3-4 days or nights per week
3
4
5-6 days or nights per week
Every or night day
5
A13. On the days that you are in your
hospital bed, for how long do you use it (out
of 24 hours)?
______ hours per day
4
4
2010 ICR Draft Survey
A10a. What is it about your hospital bed that
makes it difficult or uncomfortable for you to
use? (Please check all that apply.)
It is difficult for me to sit up
1
It is difficult for me to reach controls
2
It is difficult for me to shift my
3
weight for pressure relief
It is difficult for me to transfer in and
4
out of the hospital bed easily
5
I cannot lie comfortably in it
The tray or other attachments are hard
6
to adjust or use
It takes up a lot of space
8
Other, please tell us what else:
96
_______________________
A11. In general, how often do you use your
hospital bed?
Less than one day or night per week
1
1-2 days or nights per week
2
3-4 days or nights per week
3
4
5-6 days or nights per week
Every or night day
5
A12. On the days that you are in your
hospital bed, for how long do you use it (out
of 24 hours)?
______ hours per day
Page
4
Reason for Change
Revised language of response categories for
grammatical consistency
4
No Change
4
No Change
107
2009 ICR Draft Survey
A14. How reliable is the hospital bed you use
now? Would you say …
Very reliable
1
Somewhat reliable
2
Somewhat unreliable
3
Very unreliable
4
I don’t know
98
A15. In the past year, did you have any
problems that made you stop using a hospital
bed or switch to a different hospital bed?
Yes
1
2
No (→ Skip to SECTION B)
I don’t know (→ Skip to SECTION
98
B)
A15a. How many times did you have these
kinds of problems in the past year?
One time
1
2 or 3 times
2
4 or more times
3
Don’t recall the exact number of
4
times
Page
4
4
4
2010 ICR Draft Survey
A13. How reliable is the hospital bed you use
now? Would you say …
Very reliable
1
Somewhat reliable
2
Somewhat unreliable
3
Very unreliable
4
I don’t know
98
A14. In the past year, did you have any
problems that made you stop using a hospital
bed or switch to a different hospital bed?
Yes
1
2
No (→ Skip to SECTION B)
I don’t know (→ Skip to SECTION
98
B)
A14a. How many times did you have these
kinds of problems in the past year?
One time
1
2 or 3 times
2
4 or more times
3
Don’t recall the exact number of
4
times
Page
4
Reason for Change
No Change
No Change
4
No Change
108
2009 ICR Draft Survey
A15b. Can you describe the kind of
problem(s) that you had? (Please check all
that apply.)
Hospital bed did not work
1
Hospital bed adjustments did not
2
work
Other, please specify:
96
_________________________
Section Title. B. MEDICAL EXPENSES
B1. In the past year, have you bought any
accessories or parts for your current hospital
bed with your own money, or paid for
maintenance or repairs with your own money,
because your insurance did not cover it? (This
does not include the copay amounts that are
due from you.)
Yes
1
No (→ Skip to SECTION C)
2
I don’t know (→ Skip to SECTION
98
C)
Page
5
5
5
2010 ICR Draft Survey
A14b. Can you describe the kind of
problem(s) that you had? (Please check all
that apply.)
Hospital bed did not work
1
Hospital bed adjustments did not
2
work
Other, please specify:
96
_________________________
Section Title. B. MEDICAL EXPENSES
B1. In the past year, have you bought any
accessories or parts for your current hospital
bed with your own money, or paid for
maintenance or repairs with your own money,
because your insurance did not cover it? (This
does not include the copay amounts that are
due from you.)
Yes
1
No (→ Skip to SECTION C)
2
I don’t know (→ Skip to SECTION
98
C)
Page
5
Reason for Change
No Change
5
5
No Change
No Change
109
2009 ICR Draft Survey
B2. In the past year, what parts or service did
you buy with your own money for your
hospital bed? (Please check all that apply.)
Mattress
1
Bed board
2
3
Bed cradle
Bed side rails
4
Safety enclosure frame
5
6
Trapeze bars
Repairs
7
Routine maintenance
8
Other, please specify:
96
_______________________
Page
5
2010 ICR Draft Survey
B2. In the past year, what parts or service did
you buy with your own money for your
hospital bed? (Please check all that apply.)
Mattress
1
Bed board
2
3
Bed cradle
Bed side rails
4
Safety enclosure frame
5
6
Trapeze bars
Repairs
7
Routine maintenance
8
Other, please specify:
96
_______________________
Page
5
No Change
B3. Thinking about everything you paid for
with your own money in the past year for your
hospital bed accessories, parts, maintenance
or repairs not covered by insurance, how
much did you spend on your current hospital
bed? (This does not include any copay or
deductible amounts.)
Less than $100
1
$100-$500
2
$500 or more
3
I don’t know
98
Section Title. C. YOUR SUPPLIER
6
B3. Thinking about everything you paid for
with your own money in the past year for your
hospital bed accessories, parts, maintenance
or repairs not covered by insurance, how
much did you spend on your current hospital
bed? (This does not include any copay or
deductible amounts.)
Less than $100
1
$100-$500
2
$500 or more
3
I don’t know
98
Section Title. C. YOUR SUPPLIER
6
No Change
6
No Change
6
Reason for Change
110
2009 ICR Draft Survey
C1. Considering the hospital bed you use
now, did you have any problems finding an
equipment supplier to get your hospital bed
from?
Yes
1
No (→Skip to C7)
2
I don’t know (→Skip to C7)
98
C1a. What kinds of problems did you have
finding a hospital bed supplier? (Please check
all that apply.)
Hard to find a supplier who covered
1
my area
2
Supplier did not carry what I needed
Supplier could not deliver equipment
3
when I needed it
Supplier did not accept Medicare
4
Other, please describe:
96
C2. Considering the hospital bed you use
now, did you have a choice of suppliers?
1
Yes, many
Yes, a few
2
No, only one supplier available
3
I don’t know
98
Page
6
6
6
2010 ICR Draft Survey
C1. Considering the hospital bed you use
now, did you have any problems finding an
equipment supplier to get your hospital bed
from?
Yes
1
No (→Skip to C7)
2
I don’t know (→Skip to C7)
98
C1a. What kinds of problems did you have
finding a hospital bed supplier? (Please check
all that apply.)
Hard to find a supplier who covered
1
my area
2
Supplier did not carry what I needed
Supplier could not deliver equipment
3
when I needed it
Supplier did not accept Medicare
4
Other, please describe:
96
_______________________
C2. Considering the hospital bed you use
now, did you have a choice of suppliers?
Yes, many
1
Yes, a few
2
No, only one supplier available
3
I don’t know
98
Page
6
Reason for Change
No Change
6
No Change
6
No Change
111
2009 ICR Draft Survey
C3. How did you get your hospital bed?
Delivered or shipped to my home by
1
my supplier
I (or someone on my behalf) picked it
2
up from my supplier
I don’t know
98
Some other way, please specify:
96
_________________________
Page
6
2010 ICR Draft Survey
C6.
How did you get your hospital bed?
Delivered or shipped to my home by
1
my supplier
I (or someone on my behalf) picked it
2
up from my supplier
I don’t know
98
Some other way, please specify:
96
_________________________
Page
7
No Change
C4. Considering the hospital bed you use
now, how much time and energy did it take to
get the hospital bed, accessories, parts,
maintenance and repairs from your supplier?
No time and energy
1
A little time and energy
2
Some time and energy
3
A lot of time and energy
4
I don’t know
98
C5. After you ordered your hospital bed, how
long did it take to arrive?
Same day
1
Next day
2
Within a week
3
More than 1 week later
4
98
I don’t know
7
C8. Considering the hospital bed you use
now, how much time and energy did it take to
get the hospital bed, accessories, parts,
maintenance and repairs from your supplier?
No time and energy
1
A little time and energy
2
Some time and energy
3
A lot of time and energy
4
I don’t know
98
C5. After you ordered your hospital bed, how
long did it take to arrive?
Same day
1
Next day
2
Within a week
3
More than 1 week later
4
98
I don’t know
8
No Change
7
No Change
7
Reason for Change
112
2009 ICR Draft Survey
C6. When you got your the hospital bed you
use now, what kind of training or help did the
supplier give you or the person who takes care
of you? Did he/she… (Please check all that
apply.)
Give you written instructions on how
1
to use the hospital bed
Show you how to use the hospital bed
2
3
Choose a safe and convenient place to
place the hospital bed
Show you how to clean and maintain
4
the hospital bed
Show you how to use the hospital bed
5
safely
Let you practice how to use and
6
maintain your hospital bed while they
watched
Give you the manufacturer’s
7
customer assistance toll-free telephone
number
I did not get any training or help from
8
my supplier (→Skip to C7)
I don’t know (→Skip to C7)
98
Page
7
2010 ICR Draft Survey
C7. When you got your the hospital bed you
use now, what kind of training or help did the
supplier give you or the person who takes care
of you? Did he/she… (Please check all that
apply.)
Give you written instructions on how
1
to use the hospital bed
Show you how to use the hospital bed
2
3
Choose a safe and convenient place to
place the hospital bed
Show you how to clean and maintain
4
the hospital bed
Show you how to use the hospital bed
5
safely
Let you practice how to use and
6
maintain your hospital bed while they
watched
Give you the manufacturer’s
7
customer assistance toll-free telephone
number
I did not get any training or help from
8
my supplier (→Skip to C8)
I don’t know (→Skip to C8)
98
Page
8
Reason for Change
No Change
113
2009 ICR Draft Survey
C6a. As a result of that training, how
comfortable do you feel using and
maintaining your hospital bed?
Very comfortable
1
Comfortable
2
Uncomfortable
3
Very uncomfortable
4
My comfort level has nothing to do
5
with the training that my supplier gave me
C7. Considering the hospital bed you use
now, when you asked your supplier questions,
did you get answers that you could
understand?
Yes, completely
1
Yes, somewhat
2
No
3
I did not ask any questions
4
I don’t know
98
C8. Before deciding on the hospital bed you
use now, did your supplier tell you as much as
you wanted to know about the options for
your hospital bed?
Yes, completely
1
Yes, somewhat
2
3
No
I don’t know
98
Page
8
8
8
2010 ICR Draft Survey
C7a. As a result of that training, how
comfortable do you feel using and
maintaining your hospital bed?
Very comfortable
1
Comfortable
2
Uncomfortable
3
Very uncomfortable
4
My comfort level has nothing to do
5
with the training that my supplier gave me
C3. Considering the hospital bed you use
now, when you asked your supplier questions,
did you get answers that you could
understand?
Yes, completely
1
Yes, somewhat
2
No
3
I did not ask any questions
4
I don’t know
98
C4. Before deciding on the hospital bed you
use now, did your supplier tell you as much as
you wanted to know about the options for
your hospital bed?
Yes, completely
1
Yes, somewhat
2
3
No
I don’t know
98
Page
8
Reason for Change
No Change
7
No Change
7
No Change
114
2009 ICR Draft Survey
This question did not appear in the 2009
Survey.
C9. When you got the hospital bed you use
now, did your supplier spend as much time
with you as you wanted?
Yes
1
No
2
Section Title. D. RECENT EXPERIENCES
Description. Please answer the following
questions about the supplier that you use most
often if you use more than one supplier for
your walker and accessories.
D1. During the past six months, how reliable
was your supplier in making deliveries or
repairs?
Very reliable
1
Somewhat reliable
2
Not reliable at all
3
Does not apply
99
Page
8
8
8
8
2010 ICR Draft Survey
C4a. Before you decided on the hospital bed
that you use now, did your supplier tell you
about all the equipment designs available to
you, even those which the supplier did not
have in stock?
Yes, all equipment designs were
1
explained
No, the supplier only told me what
2
he/she has in stock
3
No, I already knew the equipment
designs available to me
I don’t know
98
This question does not appear in the 2010
ICR Draft survey.
Page
7
Reason for Change
Added this question out of concern that
suppliers will not keep as many makes and
models in their inventory after competitive
bidding.
Section Title. D. RECENT EXPERIENCES
Description. Please answer the following
questions about the supplier that you use most
often if you use more than one supplier for
your walker and accessories.
D1. During the past six months, how reliable
was your supplier in making deliveries or
repairs?
Very reliable
1
Somewhat reliable
2
Not reliable at all
3
Does not apply
99
9
9
No Change
No Change
9
No Change
Deleted this question to shorten the survey,
and because this issues is addressed in
previous questions.
115
2009 ICR Draft Survey
D2. In the past six months, have you
contacted your supplier with a complaint or a
problem?
Yes
1
No (→Skip to D5)
2
I don’t know (→Skip to D5)
98
Don’t know how to contact my
4
supplier (→Skip to D5)
D2a. When you contacted your supplier, was
your complaint or problem settled to your
satisfaction?
Yes
1
No
2
I am waiting for it to be settled
3
I don’t know
98
D3. In the past six months, have you
contacted your supplier to get emergency
service or advice?
Yes
No (→ Skip to D5)
2
I don’t know (→ Skip to D5)
98
D3a. In general, how fast did the supplier
respond to your needs, either by phone or in
person? Would you say…
Within 1 day
1
Within 2 days
2
Within 1 week
3
4
Longer than 1 week
I don’t know
98
Page
8
9
9
9
2010 ICR Draft Survey
D2. In the past six months, have you
contacted your supplier with a complaint or a
problem?
Yes
1
No (→Skip to D5)
2
I don’t know (→Skip to D5)
98
Don’t know how to contact my
4
supplier (→Skip to D5)
D2a. When you contacted your supplier, was
your complaint or problem settled to your
satisfaction?
Yes
1
No
2
I am waiting for it to be settled
3
I don’t know
98
D3. In the past six months, have you
contacted your supplier to get emergency
service or advice?
Yes
No (→ Skip to D5)
2
I don’t know (→ Skip to D5)
98
D3a. In general, how fast did the supplier
respond to your needs, either by phone or in
person? Would you say…
Within 1 day
1
Within 2 days
2
Within 1 week
3
4
Longer than 1 week
I don’t know
98
Page
9
Reason for Change
No Change
9
No Change
9
No Change
9
No Change
116
2009 ICR Draft Survey
D3b. Were you able to get the emergency
service or advice you needed?
Yes
1
No
2
I don’t know
98
D4. In the past six months, have you needed
to contact your supplier after regular business
hours?
Yes
1
No (→ Skip to D5)
2
I don’t know (→ Skip to D5)
98
D4a. When you contacted your supplier
Question the requirement for this after
business hours, were you able to get the
service or advice you needed?
Yes
1
No
2
I don’t know
98
D5. Overall, how would you rate the supplier
that you use most?
Poor
1
Fair
2
Good
3
Very good
4
Excellent
5
Page
9
9
9
9
2010 ICR Draft Survey
D3b. Were you able to get the emergency
service or advice you needed?
Yes
1
No
2
I don’t know
98
D4. In the past six months, have you needed
to contact your supplier after regular business
hours?
Yes
1
No (→ Skip to D5)
2
I don’t know (→ Skip to D5)
98
D4a. When you contacted your supplier
Question the requirement for this after
business hours, were you able to get the
service or advice you needed?
Yes
1
No
2
I don’t know
98
C9. Overall, how would you rate the supplier
that you use most?
Poor
1
Fair
2
Good
3
Very good
4
Excellent
5
Page
9
Reason for Change
No Change
10
No Change
10
No Change
8
There was no change to the content of this
question however it is now located in
Section C due to its subject matter
117
2009 ICR Draft Survey
D6. Would you recommend this hospital bed
supplier to a friend who needed similar
equipment and services?
Yes
1
No
2
D7. In the past six months, have you changed
your hospital bed supplier?
Yes
1
No (→ Skip to SECTION E on page
2
10)
I don’t know (→ Skip to SECTION
98
E on page 10)
Page
9
10
2010 ICR Draft Survey
C10. Would you recommend this hospital
bed supplier to a friend who needed similar
equipment and services?
Yes
1
No
2
D5.
In the past six months, have you
changed your hospital bed supplier?
Yes
1
No (→ Skip to SECTION E on page
2
10)
I don’t know (→ Skip to SECTION E
98
on page 10)
Page
8
9
Reason for Change
There was no change to the content of this
question however it is now located in
Section C due to its subject matter
No Change
118
2009 ICR Draft Survey
D7a. Why did you change your hospital
bed supplier? (Please check all that apply.)
I moved
1
Supplier no longer accepted Medicare
2
Supplier went out of business
3
I was not happy with the quality of
4
service
I was not happy with equipment
5
6
I was not happy with the choices of
equipment or service I could get
I was not happy with the assistance I
7
got in handling the insurance
Supplier did not provide hospital bed,
8
accessories or repair service I needed
I changed to an HMO and had to use
9
a different supplier
Other, please specify:
96
_________________________
Page
10
2010 ICR Draft Survey
D5a. Why did you change your hospital
bed supplier? (Please check all that apply.)
I moved
1
Supplier no longer accepted Medicare
2
Supplier went out of business
3
I was not happy with the quality of
4
service
I was not happy with equipment
5
6
I was not happy with the choices of
equipment or service I could get
I was not happy with the assistance I
7
got in handling the insurance
Supplier did not provide hospital bed,
8
accessories or repair service I needed
I changed to an HMO and had to use
9
a different supplier
Supplier became ineligible to provide
10
the equipment under Medicare
96
Other, please specify:
_________________________
Page
10
Section Title. E. ABOUT YOU
Description. Section E is about you, the
person whose name is on the mailing label of
this survey.
10
10
Section Title. E. ABOUT YOU
Description. Section E is about you, the
person whose name is on the mailing label of
this survey.
11
11
Reason for Change
Added/modified several answer categories to
better reflect supplier service and to address
the circumstance of suppliers becoming
ineligible for Medicare.
No Change
No Change
119
2009 ICR Draft Survey
E1. In general, how would you rate your
overall health?
Excellent
1
Very good
2
Good
3
Fair
4
Poor
5
E2. Compared to 1 year ago, how would you
rate your health now? Would you say…
Much better now
1
Somewhat better now
2
3
About the same
Somewhat worse now
4
Much worse now
5
E3. Do you currently live alone?
1 Yes (→Skip to E5)
2 No
E4. Which best describes your living
situation now? (Please check all that apply.) I
live …
With spouse/partner
1
With parent/step-parent
2
With child/children
3
With other relative(s)
4
With friend
5
With other person(s) not related to me
6
Page
10
10
10
11
2010 ICR Draft Survey
E1. In general, how would you rate your
overall health?
Excellent
1
Very good
2
Good
3
Fair
4
Poor
5
E2. Compared to 1 year ago, how would you
rate your health now? Would you say…
Much better now
1
Somewhat better now
2
3
About the same
Somewhat worse now
4
Much worse now
5
E3. Do you currently live alone?
1 Yes (→Skip to E5)
2 No
E4. Which best describes your living
situation now? (Please check all that apply.) I
live …
With spouse/partner
1
With parent/step-parent
2
With child/children
3
With other relative(s)
4
With friend
5
With other person(s) not related to me
6
Page
11
Reason for Change
No Change
11
No Change
11
No Change
11
No Change
120
2009 ICR Draft Survey
E5. What is the highest grade or level of
school that you have completed?
8th grade or less
1
Some high school but did not
2
graduate
High school graduate or GED
3
Some college or technical school
4
College graduate
5
6
More than a 4-year college degree
E6. What was your household’s annual
income during 2006 before taxes?
1
Less than $5,000 ($416 per month)
Between $5,001 and $10,000 ($417–
2
$833 per month)
Between $10,001 and $20,000 ($834–
3
$1,666 per month)
Between $20,001 and $30,000
4
($1,667–2,500 per month)
Between $30,001 and $50,000
5
($2,501–$4,167 per month)
Over $50,000 (over $4,168 per
6
month)
E7. Are you of Hispanic or Latino origin or
descent?
1
Yes, Hispanic or Latino
No, not Hispanic or Latino
2
Page
11
11
11
2010 ICR Draft Survey
E5. What is the highest grade or level of
school that you have completed?
8th grade or less
1
Some high school but did not
2
graduate
High school graduate or GED
3
Some college or technical school
4
College graduate
5
6
More than a 4-year college degree
E6. What was your household’s annual
income during 2006 before taxes?
1
Less than $5,000 ($416 per month)
Between $5,001 and $10,000 ($417–
2
$833 per month)
Between $10,001 and $20,000 ($834–
3
$1,666 per month)
Between $20,001 and $30,000
4
($1,667–2,500 per month)
Between $30,001 and $50,000
5
($2,501–$4,167 per month)
Over $50,000 (over $4,168 per
6
month)
E7. Are you of Hispanic or Latino origin or
descent?
1
Yes, Hispanic or Latino
No, not Hispanic or Latino
2
Page
11
Reason for Change
No Change
11
No Change
12
No Change
121
2009 ICR Draft Survey
E8. How would you describe your race?
(Please check all that apply.)
American Indian or Alaskan Native
1
Asian
2
Black or African American
3
Native Hawaiian or other Pacific
4
Islander
White or Caucasian
5
96
Other, please tell us:
_______________________
Section Title. F. OTHER INFORMATION
F1. Please check the correct statement:
I am the person to whom this survey
1
was addressed (→Skip to END)
2
I filled this survey out or helped fill it
out for someone else
F2. How did you help the person with this
survey?
I wrote the answers that the person
1
told me
I answered the questions myself based
2
on my knowledge of the person’s condition
\Both of the above
3
Page
11
12
12
12
2010 ICR Draft Survey
E8. How would you describe your race?
(Please check all that apply.)
American Indian or Alaskan Native
1
Asian
2
Black or African American
3
Native Hawaiian or other Pacific
4
Islander
White or Caucasian
5
96
Other, please tell us:
_______________________
Section Title. F. OTHER INFORMATION
F1. Please check the correct statement:
I am the person to whom this survey
1
was addressed (→Skip to END)
2
I filled this survey out or helped fill it
out for someone else
F2. How did you help the person with this
survey?
I wrote the answers that the person
1
told me
I answered the questions myself based
2
on my knowledge of the person’s condition
Both of the above
3
Page
12
Reason for Change
No Change
12
12
No Change
No Change
12
No Change
122
DMEPOS Survey of Power Wheelchair Users: Changes from December 2009 ICR Draft to March 2010
ICR Draft
2009 ICR Draft Survey
Title. Survey of Medicare Patients Who Use
A Power Wheelchair
Qualifying Question. If the person this
survey was mailed to cannot complete the
survey and there is no one else who can do so
for him or her, please check the appropriate
box below and return the blank survey in the
enclosed postage-paid envelope. The person
this survey was mailed to is:
Page
1
1
There is nobody available who can
1
complete this survey
99 Other reason, please specify:
__________________________
Section Title. A.
USE OF POWER
WHEELCHAIRS
A1. When did you begin using a power
wheelchair?
2010
1
2009
2
2008
3
Before 2008
4
5
I have never used a power wheelchair
(Skip to SECTION E on page 11)
3
3
2010 ICR Draft Survey
Title. Survey of Medicare Patients Who Use
A Power Wheelchair
Qualifying Question. The purpose of the
study is to learn more about your satisfaction
with the equipment, supplies, and service you
receive from your oxygen (or other durable
medical equipment) supplier. We also hope to
better understand your experiences in
obtaining and using this equipment.
If the person this survey was mailed
1
to cannot complete the survey, and there is no
one else who can do so for him or her, please
check here and return the blank survey in the
enclosed postage-paid envelope.
Page
1
Reason for Change
1
The last sentence did not make sense when
combined with the boxes one was supposed
to check off. A single check box is
sufficient.
Section Title. A.
USE OF POWER
WHEELCHAIRS
A1. When did you begin using a power
wheelchair?
2010
1
2009
2
2008
3
Before 2008
4
5
I have never used a power wheelchair
(Skip to SECTION E on page 11)
2
No Change
2
No Change
No Change
123
2009 ICR Draft Survey
A2. When you first began using a power
wheelchair, how long did you expect to use it?
Less than 1 month
1
1 to 6 months
2
More than 6 months
3
Forever
4
I don’t know
98
A3. Do you use a power wheelchair now?
This includes using a power wheelchair all of
the time or just occasionally.
Yes (→Skip to A4)
1
2
No, I have never used a power
wheelchair
Page
3
3
2010 ICR Draft Survey
A2. When you first began using a power
wheelchair, how long did you expect to use it?
Less than 1 month
1
1 to 6 months
2
More than 6 months
3
Forever
4
98 I don’t know
A3. Do you use a power wheelchair now?
This includes using a power wheelchair all of
the time or just occasionally.
Yes (→Skip to A4)
1
2
No, I have never used a power
wheelchair
Page
2
Reason for Change
No Change
2
No Change
124
2009 ICR Draft Survey
A3a. If you are no longer using your power
wheelchair, why did you stop? (Please check
all that apply and then skip to SECTION E on
page 11.)
My condition got better so I did
1
not need it anymore
My condition got worse so I
2
couldn’t use it anymore
3
I was embarrassed to use it
I was not comfortable sitting in it
4
I did not feel safe driving it
5
I just did not like using it
6
It was too difficult to use
7
It kept breaking down
8
I had no place to charge it and/or
9
store it
It did not have the features I
10
needed
96
Other, please specify: __________
Subsection Title. USE OF YOUR
CURRENT POWER WHEELCHAIR
A4. When did you first get the power
wheelchair you use now?
1 Less than 6 months ago
2 6-12 months ago
3 More than 12 months ago
Page
3
3
3
2010 ICR Draft Survey
A3a. If you are no longer using your power
wheelchair, why did you stop? (Please check
all that apply and then skip to SECTION E on
page 11.)
My condition got better so I did
1
not need it anymore
My condition got worse so I
2
couldn’t use it anymore
3
I was embarrassed to use it
I was not comfortable sitting in it
4
I did not feel safe driving it
5
I just did not like using it
6
It was too difficult to use
7
It kept breaking down
8
I had no place to charge it and/or
9
store it
It did not have the features I
10
needed
96
Other, please specify: __________
Subsection Title. USE OF YOUR
CURRENT POWER WHEELCHAIR
A4. When did you first get the power
wheelchair you use now?
1 Less than 6 months ago
2 6-12 months ago
3 More than 12 months ago
Page
2
Reason for Change
No Change
2
No Change
2
No Change
125
2009 ICR Draft Survey
A5. Did you get your current power
wheelchair while you were in a nursing home
or hospital?
1 Yes (→Skip to SECTION E on page
11)
2 No
A6. Does someone regularly help you use
your power wheelchair (e.g. a relative, friend
or home health aide)?
Yes
1
No
2
A7. Did a doctor or another medical person
like a nurse or physical/ occupational therapist
ever explain to you why you needed to use a
power wheelchair?
1
Yes
No
2
I don’t know
98
Page
3
2010 ICR Draft Survey
A5. Did you get your current power
wheelchair while you were in a nursing home
or hospital?
1 Yes
2 No
Page
2
4
A6. Does someone regularly help you use
your power wheelchair (e.g. a relative, friend
or home health aide)?
Yes
1
No
2
A7. Did a doctor or another medical person
like a nurse or physical/occupational therapist
ever explain the following to you (Please
check all that apply): why you needed to
use a power wheelchair?
Why you needed to use a power
1
wheelchair
3
No Change
3
Questions A7 and A8 in the 2010 survey
were combined into one to shorten the
survey and focus on patient perceptions.
4
Reason for Change
The skip prompt was removed from this
question in order to capture subsequent
information related to the equipment.
126
2009 ICR Draft Survey
A8. Did a doctor or another medical person
like a nurse or physical/ occupational therapist
ever explain to you the different types of
power wheelchairs, controls options and
accessories that exist?
Yes, a medical person explained
1
power wheelchairs
No medical person explained
2
power wheelchairs
98
I don’t know or don’t recall if a
medical person explained power
wheelchairs
A9. When was the last time you discussed
your needs or issues related to your power
wheelchair with a doctor or another medical
person like a nurse or physical/ occupational
therapist?
Within the last 6 months
1
Between 6 months and 1 year ago
2
Between 1 and 3 years ago
3
More than 3 years ago
4
98
I don’t know
Page
4
2010 ICR Draft Survey
The different types of power
2
wheelchairs, control options, and accessories
that exist
None of these things were explained
3
by a medical person
I don’t know or don’t recall if a
98
medical person explained anything to me
Page
4
A8. When was the last time you discussed
your needs or issues related to your power
wheelchair with a doctor or another medical
person like a nurse or physical/ occupational
therapist?
Within the last 6 months
1
Between 6 months and 1 year ago
2
Between 1 and 3 years ago
3
More than 3 years ago
4
98
I don’t know
3
Reason for Change
No Change
127
2009 ICR Draft Survey
A10. Have you had more than one power
wheelchair in the past year or changed
accessories (for example, controls, cushion) in
the past year?
No (→Skip to A11)
1
Yes, I changed my power
2
wheelchair
Yes, I changed or added
3
accessories
98
I don’t know (→Skip to A11)
Page
4
2010 ICR Draft Survey
A9. Have you had more than one power
wheelchair in the past year or changed
accessories (for example, controls, cushion) in
the past year?
No (→Skip to A10)
1
Yes, I changed my power wheelchair
2
Yes, I changed or added accessories
3
I don’t know (→Skip to A10)
98
Page
Reason for Change
No Change
128
2009 ICR Draft Survey
A10a. Why did you make this (these)
change(s)? (Please check all that apply.)
Wheelchair needed to be replaced
1
because the original one did not
work
My medical condition changed, so
2
I needed something different
Found a new wheelchair that was
3
better for me
4
Found new features/accessories
that were better for me
Doctor or health care provider
5
prescribed a different type of
wheelchair or different accessories
Supplier changed
6
Other, please specify: _________
96
A11. Do you believe that you now have the
power wheelchair that is right for you?
1
Yes
No
2
I don’t know
98
Page
5
2010 ICR Draft Survey
A9a. Why did you make this (these)
change(s)? (Please check all that apply.)
Wheelchair needed to be replaced
1
because the original one did not work
My medical condition changed, so I
2
needed something different
Found a new wheelchair that was
3
better for me
4
Found new features/accessories that
were better for me
Doctor or health care provider
5
prescribed a different type of wheelchair or
different accessories
My supplier did not tell me why they
6
changed my equipment
My supplier became ineligible to
6
provide my equipment under Medicare
96
Other, please specify:
____________________________
Page
3
5
A10. Do you believe that you now have the
power wheelchair that is right for you?
1
Yes
No
2
I don’t know
98
4
Reason for Change
Clarified question language; clarified one
response category to focus on supplier
becoming ineligible for Medicare (most
relevant for the follow-up survey in 2012);
added a response category of “ My supplier
did not tell me why they changed my
equipment” because patient may not know
the reason.
No Change
129
2009 ICR Draft Survey
A12. Is using your power wheelchair
difficult or uncomfortable?
Yes
1
No (→Skip to A13)
2
I don’t know (→Skip to A13)
98
Page
5
2010 ICR Draft Survey
A11. Is using your power wheelchair difficult
or uncomfortable?
Yes
1
No (→Skip to A12)
2
I don’t know (→Skip to A12)
98
Page
4
Reason for Change
No Change
130
2009 ICR Draft Survey
A12a. What is it about your power wheelchair
that makes it difficult or uncomfortable to
use? (Please check all that apply.)
Battery range not sufficient for
1
daily activities
Not enough power to get over
2
barriers such as ramps, thresholds
and curbs
Not enough speed to safely cross
3
the street during a traffic light
change
Unable to shift weight for pressure
4
relief
Unable to use the chair easily
5
inside my home
Unable to use the chair easily
6
outside of my home
7
Unable to transport the chair to
where I want to go
Cannot sit comfortably in it for a
8
long time
Cannot transfer in and out of the
9
wheelchair easily
It is too heavy and cumbersome to
10
use
I have trouble charging it
11
Other, please tell us what else:
96
___________________________
Page
5
2010 ICR Draft Survey
A11a. What is it about your power
wheelchair that makes it difficult or
uncomfortable to use? (Please check all that
apply.)
Battery range not sufficient for daily
1
activities
Not enough power to get over barriers
2
such as ramps, thresholds and curbs
3
Not enough speed to safely cross the
street during a traffic light change
It is difficult to shift my weight for
4
pressure relief
It is difficult to use the chair easily
5
inside my home
It is difficult to use the chair easily
6
outside of my home
It is difficult to transport the chair to
7
where I want to go
8
It is difficult sit comfortably in it for a
long time
It is difficult transfer in and out of the
9
wheelchair easily
It is too heavy and cumbersome to use
10
I have trouble charging it
11
Other, please tell us what else:
96
___________________________
Page
4
Reason for Change
Revised language of response categories for
grammatical consistency
131
2009 ICR Draft Survey
A13. In general, how often do you use your
power wheelchair?
Less than one day a week
1
1-2 days per week
2
3-4 days per week
3
5-6 days per week
4
Every day
5
A14. On the days that you do use your
power wheelchair, for how long do you use it?
(out of 24 hours in a day)?
______ hours per day
A15. How reliable is the power wheelchair
you use now? Would you say…
1
Very reliable
Somewhat reliable
2
Somewhat unreliable
3
Very unreliable
4
I don’t know
98
A16. In the past year, did you have any
problems that made you stop using your
power wheelchair or switch to a different
power wheelchair?
Yes
1
No (→Skip to SECTION B)
2
I don’t know (→Skip to SECTION
98
B)
Page
6
6
6
6
2010 ICR Draft Survey
A12. In general, how often do you use your
power wheelchair?
Less than one day a week
1
1-2 days per week
2
3-4 days per week
3
5-6 days per week
4
Every day
5
A13. On the days that you do use your power
wheelchair, for how long do you use it? (out
of 24 hours in a day)?
______ hours per day
A14. How reliable is the power wheelchair
you use now? Would you say…
Very reliable
1
Somewhat reliable
2
Somewhat unreliable
3
Very unreliable
4
I don’t know
98
A15. In the past year, did you have any
problems that made you stop using your
power wheelchair or switch to a different
power wheelchair?
Yes
1
No (→Skip to SECTION B)
2
I don’t know (→Skip to SECTION B)
98
Page
5
Reason for Change
No Change
5
No Change
5
No Change
5
No Change
132
2009 ICR Draft Survey
A16a. How many times did you have these
kinds of problems in the past year?
One time
1
2 or 3 times
2
4 or more times
3
A16b. Can you describe the kind of
problem(s) that you had? (Please check all
that apply.)
Page
6
6
Page
5
Reason for Change
No Change
5
No Change
6
6
No Change
No Change
Batteries did not work
1
Motor did not work
2
3
Controls or joystick did not work
Other, please specify:
96
_________________________
Batteries did not work
1
Motor did not work
2
3
Controls or joystick did not work
Other, please specify:
96
_________________________
Section Title. MEDICAL EXPENSES
B1.
In the past year, have you bought any
accessories or parts for your current power
wheelchair with your own money, or paid for
maintenance or repairs with your own money
because your insurance did not cover it?
(This does not include any copay or
deductible amounts that are due from you.)
Yes
1
No (→Skip to SECTION C)
2
I don’t know (→Skip to SECTION
98
C)
2010 ICR Draft Survey
A16a. How many times did you have these
kinds of problems in the past year?
One time
1
2 or 3 times
2
4 or more times
3
A16b. Can you describe the kind of
problem(s) that you had? (Please check all
that apply.)
7
7
Section Title. MEDICAL EXPENSES
B1.
In the past year, have you bought any
accessories or parts for your current power
wheelchair with your own money, or paid for
maintenance or repairs with your own money
because your insurance did not cover it?
(This does not include any copay or
deductible amounts that are due from you.)
Yes
1
No (→Skip to SECTION C)
2
I don’t know (→Skip to SECTION
98
C)
133
2009 ICR Draft Survey
B2. In the past year, what parts or service
did you buy with your own money for your
current power wheelchair? (Please check all
that apply.)
Seat or back cushions
1
Tires
2
Batteries
3
Motors
4
5
Crutch holder
Lap tray
6
Repairs
7
Routine maintenance
8
Other, please specify: _________
96
B3. Thinking about everything you paid for
with your own money in the past year for your
wheelchair accessories, parts, maintenance or
repairs not covered by insurance, how much
did you spend on your current power
wheelchair? (This does not include any copay
or deductible amounts.)
Less than $100
1
2
$100-$500
$500 or more
3
I don’t know
98
Section Title. C. YOUR SUPPLIER
Page
7
7
8
2010 ICR Draft Survey
B2. In the past year, what parts or service
did you buy with your own money for your
current power wheelchair? (Please check all
that apply.)
Seat or back cushions
1
Tires
2
Batteries
3
Motors
4
5
Crutch holder
Lap tray
6
Repairs
7
Routine maintenance
8
Other, please specify: _________
96
B3. Thinking about everything you paid for
with your own money in the past year for your
wheelchair accessories, parts, maintenance or
repairs not covered by insurance, how much
did you spend on your current power
wheelchair? (This does not include any copay
or deductible amounts.)
Less than $100
1
2
$100-$500
$500 or $1,000
3
$1,000- $2,000
4
I don’t know
98
Section Title. C. YOUR SUPPLIER
Page
6
Reason for Change
No Change
6
Added another category for patients with
higher out-of-pocket costs.
7
No Change
134
2009 ICR Draft Survey
C1. Considering the power wheelchair you
use now, did you have any problems finding
an equipment supplier to get your wheelchair
from?
Yes
1
No (→Skip to C2)
2
I don’t know (→Skip to C2)
98
C1a. What kinds of problems did you have
finding a power wheelchair supplier? (Please
check all that apply.)
Hard to find a supplier who
1
covered my area
2
Supplier did not carry what I
needed
Supplier could not deliver
3
equipment when I needed it
Supplier did not accept Medicare
4
Other, please specify: __________
96
C2. Considering the power wheelchair you
use now, did you have a choice of suppliers?
Yes, many
1
Yes, a few
2
No, only one supplier available
3
I don’t know
98
Page
8
8
8
2010 ICR Draft Survey
C1. Considering the power wheelchair you
use now, did you have any problems finding
an equipment supplier to get your wheelchair
from?
Yes
1
No (→Skip to C2)
2
I don’t know (→Skip to C2)
98
C1a. What kinds of problems did you have
finding a power wheelchair supplier? (Please
check all that apply.)
Hard to find a supplier who
1
covered my area
2
Supplier did not carry what I
needed
Supplier could not deliver
3
equipment when I needed it
Supplier did not accept Medicare
4
Other, please specify: __________
96
C2. Considering the power wheelchair you
use now, did you have a choice of suppliers?
Yes, many
1
Yes, a few
2
No, only one supplier available
3
I don’t know
98
Page
7
Reason for Change
No Change
7
No Change
7
No Change
135
2009 ICR Draft Survey
C3. Considering the power wheelchair you
use now, do you get your accessories, parts,
maintenance and repairs from more than one
equipment supplier?
Yes
1
No
2
I don’t know
98
C4. How did you get the power wheelchair
you use now?
Delivered to my home by my
1
supplier
2
Mailed/shipped to my home by my
supplier
I (or someone on my behalf)
3
picked it up from my supplier
I picked it up at a seating clinic or
4
rehabilitation center
I don’t know
98
Some other way, please specify:
96
_________________
Page
8
8
2010 ICR Draft Survey
C3. Considering the power wheelchair you
use now, do you get your accessories, parts,
maintenance and repairs from more than one
equipment supplier?
Yes
1
No
2
I don’t know
98
C6. How did you get the power wheelchair
you use now?
Delivered to my home by my supplier
1
Mailed/shipped to my home by my
2
supplier
3
I (or someone on my behalf) picked it
up from my supplier
I picked it up at a seating clinic or
4
rehabilitation center
I don’t know
98
Some other way, please specify:
96
Page
7
Reason for Change
No Change
8
No Change
136
2009 ICR Draft Survey
C5. Considering the power wheelchair you
use now, how much time and energy did it
take to get the power wheelchair, accessories,
parts, maintenance and repairs from the
supplier?
No time and energy
1
A little time and energy
2
Some time and energy
3
4
A lot of time and energy
I don’t know
98
C6. After you ordered your power
wheelchair, how long did it take to arrive?
1
less than 2 weeks
2 weeks to 1 month
2
1 to 2 months
3
2 to 3 months
4
More than 3 months
5
I don’t know
98
Page
8
9
2010 ICR Draft Survey
C9. Considering the power wheelchair you
use now, how much time and energy did it
take to get the power wheelchair, accessories,
parts, maintenance and repairs from the
supplier?
No time and energy
1
A little time and energy
2
Some time and energy
3
4
A lot of time and energy
I don’t know
98
C5. After you ordered your power
wheelchair, how long did it take to arrive?
1
less than 2 weeks
2 weeks to 1 month
2
1 to 2 months
3
2 to 3 months
4
More than 3 months
5
I don’t know
98
Page
9
Reason for Change
No Change
8
No Change
137
2009 ICR Draft Survey
C7.
When you got the power wheelchair
you use now, what kind of training or help did
the supplier give you or the person who cares
for you? Did he/she … (Please check all that
apply.)
Give you written instructions on
1
how to use the power wheelchair
Show you how to drive the power
2
wheelchair
3
Show you how to charge your
chair battery
Show you how to clean and
4
maintain the power wheelchair
Show you how to use the power
5
wheelchair safely
Let you practice how to use and
6
maintain your power wheelchair
while they watched
Gave me the manufacturer’s
7
customer assistance toll-free
telephone number
I did not get any training or help
8
from my supplier (→ Skip to C8)
I don’t know (→ Skip to C8)
98
Page
9
2010 ICR Draft Survey
C7. When you got the power wheelchair you
use now, what kind of training or help did the
supplier give you or the person who cares for
you? Did he/she … (Please check all that
apply.)
Give you written instructions on how
1
to use the power wheelchair
Show you how to drive the power
2
wheelchair
3
Show you how to charge your chair
battery
Show you how to clean and maintain
4
the power wheelchair
Show you how to use the power
5
wheelchair safely
Let you practice how to use and
6
maintain your power wheelchair while they
watched
Gave me the manufacturer’s customer
7
assistance toll-free telephone number
I did not get any training or help from
8
my supplier (→ Skip to C8)
I don’t know (→ Skip to C8)
98
Page
8
Reason for Change
No Change
138
2009 ICR Draft Survey
C7a. As a result of that training, how
comfortable do you feel using and
maintaining your power wheelchair?
Very comfortable
1
Comfortable
2
Uncomfortable
3
Very uncomfortable
4
My comfort level has nothing to
5
do with the training that my
supplier gave me
C8. In the 3 months after you got the power
wheelchair you use now, how often did your
supplier send someone to your home to check
the equipment or see how well you are doing
with the equipment? (Do not include times
when you called them.)
Once in the 3 months after you got
1
the power wheelchair
More than once in the 3 months
2
after you got the power wheelchair
Not at all in the 3 months after you
3
got the power wheelchair
Page
9
9
2010 ICR Draft Survey
C7a. As a result of that training, how
comfortable do you feel using and
maintaining your power wheelchair?
Very comfortable
1
Comfortable
2
Uncomfortable
3
Very uncomfortable
4
My comfort level has nothing to
5
do with the training that my
supplier gave me
C8. In the 3 months after you got the power
wheelchair you use now, how often did your
supplier send someone to your home to check
the equipment or see how well you are doing
with the equipment? (Do not include times
when you called them.)
Once in the 3 months after you got
1
the power wheelchair
More than once in the 3 months
2
after you got the power wheelchair
Not at all in the 3 months after you
3
got the power wheelchair
Page
8
Reason for Change
No Change
9
No Change
139
2009 ICR Draft Survey
C9. Considering the power wheelchair you
use now, when you asked your supplier
questions, did you get answers that you could
understand?
Yes, completely
1
Yes, somewhat
2
No
3
I did not ask any questions
4
98
I don’t know
C10. Before deciding on the power
wheelchair you use now, did your supplier tell
you as much as you wanted to know about the
options for your power wheelchair?
Yes, completely
1
Yes, somewhat
2
No
3
I don’t know
98
This question does not appear in the 2009
Survey.
Survey.
Page
10
10
2010 ICR Draft Survey
C3. Considering the power wheelchair you
use now, when you asked your supplier
questions, did you get answers that you could
understand?
Yes, completely
1
Yes, somewhat
2
No
3
I did not ask any questions
4
98
I don’t know
C4. Before deciding on the power wheelchair
you use now, did your supplier tell you as
much as you wanted to know about the
options for your power wheelchair?
Yes, completely
1
Yes, somewhat
2
No
3
I don’t know
98
C4a. Before you decided on the power
wheelchair that you use now, did your
supplier tell you about all the equipment
designs available to you, even those which the
supplier did not have in stock?
Yes, all equipment designs were
1
explained
2
No, the supplier only told me what
he/she has in stock
No, I already knew the equipment
3
designs available to me
I don’t know
98
Page
7
Reason for Change
No Change
7
No Change
7
Added this question out of concern that
suppliers will not keep as many makes and
models in their inventory after competitive
bidding.
140
2009 ICR Draft Survey
C11. When you got the power wheelchair
you use now, did your supplier spend as much
time with you as you wanted?
Yes
1
No
2
Section Title. D. RECENT EXPERIENCES
Description. If you use more than one
supplier for your wheelchair and accessories,
please answer the following questions about
the supplier that you use most often.
D1. During the past six months, how reliable
was your supplier in making repairs, if
needed?
Very reliable
1
Somewhat reliable
2
Not reliable at all
3
Does not apply
99
D2. In past six months, have you contacted
your supplier with a complaint or a problem?
Yes
1
No (→Skip to D3)
2
98
I don’t know (→Skip to D3)
Don’t know how to contact my
4
supplier (→Skip to D3)
Page
10
10
10
10
10
2010 ICR Draft Survey
This question does not appear in the 2010
ICR Draft Survey
Section Title. D. RECENT EXPERIENCES
Description. If you use more than one
supplier for your wheelchair and accessories,
please answer the following questions about
the supplier that you use most often.
D1. During the past six months, how reliable
was your supplier in making repairs, if
needed?
Very reliable
1
Somewhat reliable
2
Not reliable at all
3
Does not apply
99
D2. In past six months, have you contacted
your supplier with a complaint or a problem?
Yes
1
No (→Skip to D3)
2
98
I don’t know (→Skip to D3)
Don’t know how to contact my
4
supplier (→Skip to D3)
Page
Reason for Change
Deleted this question to shorten the survey,
and because this issue is addressed in
previous questions.
10
10
No Change
No Change
10
No Change
10
No Change
141
2009 ICR Draft Survey
D2a. When you contacted your supplier, was
your complaint or problem settled to your
satisfaction?
Yes
1
No
2
I am waiting for it to be settled
3
I don’t know
98
D3. In the past six months, have you
contacted your supplier to get emergency
service or advice?
Yes
1
2
No (→Skip to D5)
I don’t know (→Skip to D5)
98
D3a. In general, how fast did the supplier
respond to your needs, either by phone or in
person? Would you say …
Within 1 day
1
Within 2 days
2
Within 1 week
3
Longer than 1 week
4
I don’t know
98
D3b. Were you able to get the emergency
service or advice you needed?
Yes
1
No
2
I don’t know
98
Page
10
11
11
11
2010 ICR Draft Survey
D2a. When you contacted your supplier, was
your complaint or problem settled to your
satisfaction?
Yes
1
No
2
I am waiting for it to be settled
3
I don’t know
98
D3. In the past six months, have you
contacted your supplier to get emergency
service or advice?
Yes
1
2
No (→Skip to D5)
I don’t know (→Skip to D5)
98
D3a. In general, how fast did the supplier
respond to your needs, either by phone or in
person? Would you say …
Within 1 day
1
Within 2 days
2
Within 1 week
3
Longer than 1 week
4
I don’t know
98
D3b. Were you able to get the emergency
service or advice you needed?
Yes
1
No
2
I don’t know
98
Page
10
Reason for Change
No Change
10
No Change
10
No Change
10
No Change
142
2009 ICR Draft Survey
D4. In the past six months, did you need to
contact your supplier after regular business
hours?
Yes
1
No (→Skip to D5)
2
I don’t know (→Skip to D5)
98
D4a. When you contacted your supplier
after business hours, were you able to get the
service or advice you needed?
Yes
1
No
2
98
I don’t know
D5. Overall, how would you rate the supplier
that you use most?
1
Poor
Fair
2
Good
3
Very good
4
Excellent
5
D6. Would you recommend this power
wheelchair supplier to a friend who needed
similar equipment and services?
Yes
1
No
2
Page
11
11
11
11
2010 ICR Draft Survey
D4. In the past six months, did you need to
contact your supplier after regular business
hours?
Yes
1
No (→Skip to D5)
2
I don’t know (→Skip to D5)
98
D4a. When you contacted your supplier
after business hours, were you able to get the
service or advice you needed?
Yes
1
No
2
98
I don’t know
C11. Overall, how would you rate the
supplier that you use most?
Poor
1
Fair
2
Good
3
Very good
4
Excellent
5
C12. Would you recommend this power
wheelchair supplier to a friend who needed
similar equipment and services?
Yes
1
No
2
Page
11
Reason for Change
No Change
11
No Change
9
There was no change to the content of this
question however it is now located in
Section C due to its subject matter
9
There was no change to the content of this
question however it is now located in
Section C due to its subject matter
143
2009 ICR Draft Survey
D7. In the past six months, have you
changed your power wheelchair supplier?
Yes
1
No (→Skip to SECTION E on
2
page 11)
I don’t know (→Skip to SECTION
98
E on page 11)
Page
11
2010 ICR Draft Survey
D5. In the past six months, have you changed
your power wheelchair supplier?
Yes
1
No (→Skip to SECTION E on page
2
11)
I don’t know (→Skip to SECTION E
98
on page 11)
Page
11
Reason for Change
No Change
144
2009 ICR Draft Survey
D5a. Why did you change your power
wheelchair supplier? (Please check all that
apply.)
I moved
1
Supplier no longer accepted
2
Medicare
Supplier went out of business
3
I was not happy with the quality of
4
service
5
I was not happy with equipment
I was not happy with the choices
6
of equipment or service I could get
I was not happy with the
7
assistance I got in handling the
insurance
Supplier did not provide power
8
wheelchair, accessories or repair
service I needed
I changed to an HMO and had to
9
use a different supplier
Other, please describe: _________
96
Section Title. E. ABOUT YOU
Description. Section E is about you, the
person whose name is on the mailing label of
this survey.
Page
12
2010 ICR Draft Survey
D5a. Why did you change your power
wheelchair supplier? (Please check all that
apply.)
I moved
1
Supplier no longer accepted Medicare
2
Supplier went out of business
3
I was not happy with the quality of
4
service
5
I was not happy with equipment
I was not happy with the choices of
6
equipment or service I could get
I was not happy with the assistance I
7
got in handling the insurance
Supplier did not provide power
8
wheelchair, accessories or repair service I
needed
I changed to an HMO and had to use
9
a different supplier
10
Supplier became ineligible to provide
the equipment under Medicare
Other, please describe:
96
____________________________
Page
11
12
12
Section Title. E. ABOUT YOU
Description. Section E is about you, the
person whose name is on the mailing label of
this survey.
12
12
Reason for Change
Added/modified several answer categories to
better reflect supplier service and to address
the circumstance of suppliers becoming
ineligible for Medicare.
No Change
No Change
145
2009 ICR Draft Survey
E1. In general, how would you rate your
overall health?
Excellent
1
Very good
2
Good
3
Fair
4
Poor
5
E2. Compared to 1 year ago, how would you
rate your health now? Would you say…
Much better now
1
Somewhat better now
2
3
About the same
Somewhat worse now
4
Much worse now
5
E3. Do you currently live alone?
Yes (→Skip to E5)
1
No
2
E4. Which best describes your living
situation now? (Please check all that apply.) I
live ….
With spouse/partner
1
With parent/step-parent
2
With child/children
3
With other relative(s)
4
With friend
5
With other person(s) not related to
6
me
Page
12
12
12
12
2010 ICR Draft Survey
E1. In general, how would you rate your
overall health?
Excellent
1
Very good
2
Good
3
Fair
4
Poor
5
E2. Compared to 1 year ago, how would you
rate your health now? Would you say…
Much better now
1
Somewhat better now
2
3
About the same
Somewhat worse now
4
Much worse now
5
E3. Do you currently live alone?
1
Yes (→Skip to E5)
No
2
E4. Which best describes your living
situation now? (Please check all that apply.) I
live ….
With spouse/partner
1
With parent/step-parent
2
With child/children
3
With other relative(s)
4
With friend
5
With other person(s) not related to
6
me
Page
12
Reason for Change
No Change
12
No Change
12
No Change
12
No Change
146
2009 ICR Draft Survey
E5. What is the highest grade or level of
school that you have completed?
8th grade or less
1
Some high school but did not
2
graduate
High school graduate or GED
3
Some college or technical school
4
College graduate
5
6
More than a 4-year college degree
E6. What was your household’s annual
income during 2006 before taxes?
1
Less than $5,000 ($416 per month)
Between $5,001 and $10,000
2
($417–$833 per month)
Between $10,001 and $20,000
3
($834–$1,666 per month)
Between $20,001 and $30,000
4
($1,667–2,500 per month)
Between $30,001 and $50,000
5
($2,501–$4,167 per month)
Over $50,000 (over $4,168 per
6
month)
E7. Are you of Hispanic or Latino origin or
descent?
1
Yes, Hispanic or Latino
No, not Hispanic or Latino
2
Page
13
13
13
2010 ICR Draft Survey
E5. What is the highest grade or level of
school that you have completed?
8th grade or less
1
Some high school but did not
2
graduate
High school graduate or GED
3
Some college or technical school
4
College graduate
5
6
More than a 4-year college degree
E6. What was your household’s annual
income during 2006 before taxes?
1
Less than $5,000 ($416 per month)
Between $5,001 and $10,000
2
($417–$833 per month)
Between $10,001 and $20,000
3
($834–$1,666 per month)
Between $20,001 and $30,000
4
($1,667–2,500 per month)
Between $30,001 and $50,000
5
($2,501–$4,167 per month)
Over $50,000 (over $4,168 per
6
month)
E7. Are you of Hispanic or Latino origin or
descent?
1
Yes, Hispanic or Latino
No, not Hispanic or Latino
2
Page
12
Reason for Change
No Change
13
No Change
13
No Change
147
2009 ICR Draft Survey
E8. How would you describe your race?
(Please check all that apply.)
American Indian or Alaskan
1
Native
Asian
2
Black or African American
3
Native Hawaiian or other Pacific
4
Islander
5
White or Caucasian
Other, please tell us: ___________
96
Section Title. F. OTHER INFORMATION
F1. Please check the correct statement:
I am the person to whom this
1
survey was addressed (→Skip to
END)
I filled this survey out or helped
2
fill it out for someone else
F2. How did you help the person with this
survey?
I wrote the answers that the person
1
told me
I answered the questions myself
2
based on my knowledge of the
person’s condition
Both of the above
3
Page
13
13
13
13
2010 ICR Draft Survey
E8. How would you describe your race?
(Please check all that apply.)
American Indian or Alaskan
1
Native
Asian
2
Black or African American
3
Native Hawaiian or other Pacific
4
Islander
5
White or Caucasian
Other, please tell us: ___________
96
Section Title. F. OTHER INFORMATION
F1. Please check the correct statement:
I am the person to whom this
1
survey was addressed (→Skip to
END)
I filled this survey out or helped
2
fill it out for someone else
F2. How did you help the person with this
survey?
I wrote the answers that the person
1
told me
I answered the questions myself
2
based on my knowledge of the
person’s condition
Both of the above
3
Page
13
Reason for Change
No Change
13
13
No Change
No Change
13
No Change
148
Non-Statistical Instruments: Changes from December 2009 ICR Draft to March 2010 ICR Draft
2009 ICR Draft
This wave did not appear in the 2010
Survey
Page
2010 ICR Draft
Key Informant Discussion Guide:
Beneficiary Groups/Advocates (WAVE 2:
Transition to DMEPOS Competitive
Bidding)
Wave 2
Wave 3
Wave 3
Wave 4
Wave 2
7. Have you noticed any impact of the
program on beneficiaries?
a. Access to DMEPOS?
b. Quality of DMEPOS?
c. Diversity of products? Choice?
d. Ancillary services – education,
maintenance, et
Wave 1 7b.
How do you think it might affect (positively
and negatively) your clients?
2
2
Wave 3
7. Have you noticed any impact of the
program on Medicare beneficiaries?
Access to DMEPOS?
Quality of DMEPOS?
Diversity of products? Choice?
Quantity and quality of support
services – education,
maintenance, etc.?
Health consequences for patients?
Lower out of pocket costs for
beneficiaries?
Wave 1 7.b
How do you think it might affect (positively
and negatively) beneficiaries?
Page
1
2
2
Reason for Change
This Wave was added in order to obtain
more information regarding transition issues.
It is a modification of Wave 2 in the 2010
Survey.
Due to the new Wave 2: Transition,
subsequent Waves of all the nonstatistical
instruments have been renumbered
Due to the new Wave 2: Transition,
subsequent Waves of all the nonstatistical
instruments have been renumbered
Prompts were added and refined in order to
obtain more information regarding transition
issues. Note that Wave 2 in the 2010 Survey
is Wave 3 in the 2010 Revision Survey.
Language was modified to be more neutral.
149
2009 ICR Draft
This question does not appear in the 2010
Survey.
Page
2010 ICR Draft
Wave 2: Transition
8. With respect to the adequacy
and timing of information
received by beneficiaries:
Page
2
Reason for Change
Question was added in order to obtain more
information regarding transition issues
Were beneficiaries
adequately informed about the
transition?
In what manner were they
informed and by whom?
Was this information
received enough in advance?
In your opinion, were
beneficiaries aware of what
they needed to do?
What other information
might they have found helpful?
150
2009 ICR Draft
This question does not appear in the 2010
Survey.
Page
2010 ICR Draft
Wave 2: Transition
9. What issues have been arising
during the transition for
beneficiaries using DMEPOS
products?
Page
2
Reason for Change
Question was added in order to obtain more
information regarding transition issues
Confusion about
grandfathering rules for certain
DME products?
Delayed delivery of mailorder supplies (enteral
nutrition products, diabetic
suppliers)?
Difficulty finding suppliers
to serve beneficiaries in some
areas?
Delays in getting
DMEPOS products or
services?
Any other transition
issues?
151
2009 ICR Draft
Focus Group Guides for Referral Agents
and Suppliers, Wave 3
2. What changes have you noticed since the
program began a year ago?
a. Changes in the referral process
b. Suppliers
i. Quantity of suppliers?
ii. Quality of suppliers?
iii. How and to whom they market?
iv. Product changes?
Page
2
2010 ICR Draft
Focus Group Guides for Referral Agents
and Suppliers, Wave 4
2. Looking back, what do you think about
the information that was provided to you
regarding this program?
In terms of general information about the
program
What information did you receive?
In what form? From whom?
Was it provided in a timely manner?
Information regarding which supplies
was covered?
Did you find it to be helpful? Why
or why not?
CMS’ availability or contractors?
Did you receive information about
this program from anyone else?
What other information would you
have wanted?
Page
2
Reason for Change
Prompts were added and refined in order to
obtain more information regarding transition
issues. Note that Wave 32 in the 2010
Survey is Wave 4 in the 2010 Revision
Survey.
152
Fact Sheet: Changes from December 2009 ICR Draft to March 2010 ICR Draft
2009 ICR Draft
The purpose of the study is to learn more
about your satisfaction with the equipment,
supplies, and service you receive from your
oxygen (or other durable medical
equipment) supplier. We also hope to better
understand your experiences in obtaining
and using this equipment.
Page
[no #]
2010 ICR Draft
The purpose of the study is to learn more
about your satisfaction with the equipment,
supplies, and service you receive from your
oxygen (or other durable medical equipment)
supplier. We also hope to better understand
your experiences in obtaining and using this
equipment. Results of the survey will be
compared with results from patients in
different metropolitan areas and results from
patients who received their equipment in a
different year. These comparisons will help
reveal how new ways of administering the
Medicare program affect beneficiaries.
Page
[no #]
Reason for Change
Expanded the explanation of the study’s
purpose in order to be more precise about its
design and intent.
153
| File Type | application/pdf |
| File Title | CMS Response to Public Comments Received for CMS-10197 |
| File Modified | 2010-03-26 |
| File Created | 2010-03-26 |