Form 1 Third Party Billing Survey

OMB Control Number 0925-0458

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0458*).  Do not return the completed form to this address.

Survey of Patients’ Perceptions of the Impact of Third Party Billing

on the Clinical Center Research Experience

As a partner in the clinical research process at the National Institutes of Health Clinical Center, your perceptions of the care and services provided at the Clinical Center are critical to the leadership of the Clinical Center’s ongoing efforts to improve the experience of our patients/research volunteers. In the coming year, the Clinical Center will begin a pilot program designed to assess the feasibility of billing patients’ health insurance companies for some aspects of care received at the Clinical Center. We ask that you take a few moments of your time to provide us with your thoughts about the impact of this planned initiative. Thank you for time and candid feedback.

1. If the Clinical Center implemented a program to bill your health insurance carrier for some aspects of the care you receive at the Clinical Center, would you consider leaving the study in which you are enrolled?

• Yes, definitely

• Yes, mostly

• Yes, somewhat

• No

• Do not have health insurance

2. Does the fact that your medical information will be shared with your insurance company, or any other entity influence the likelihood of your continued participation in the study in which you are enrolled at the Clinical Center?

• Yes

• No

• Do not have health insurance

3. Would you considered withdrawing from the NIH study in which you are enrolled because your insurance company may be billed for some aspects of the care you receive at the NIH Clinical Center?

• Yes, definitely

• Yes, mostly

• Yes, somewhat

• No

• Do not have health insurance

• Did not know that my insurance company would be billed

4. Does the fact that your insurance company may be billed for some of the care you receive at the Clinical Center make you less likely to enroll in future clinical research studies at the Clinical Center?

• Yes, definitely

• Yes, mostly

• Yes, somewhat

• No

• Do not have health insurance

• Did not know that my insurance company would be billed

The following questions will be directed to specific patients identified who have left or withdrawn from the study in which they were enrolled.

1. Recently you decided to stop participating in study: (INSERT PROTOCOL TITLE AND NUMBER). Please share with us the reasons that you left the study? (Please check/indicate all that apply)

• Took too much time

• Made me too ill

• I didn’t think that I was getting better

• Things happened in the study that I did not expect

• My insurance company was billed for some of my care

• Information about my care was shared with my insurance company

• Dissatisfaction with the study team

• Did not feel safe

• Too far away from my family and home

• Other: __________________

• Other: __________________