Form #1 Form #1 Quick Response Survey Questionnaire

Q

Form Approved
OMB No. 0935-0124
Exp. Date 5/31/2014

uick Response Survey Questionnaire

December 29, 2011

Hello, my name is (YOUR NAME) from Westat. May I please speak with (ROUND 5 RESPONDENT)?

• IF ROUND 5 R NOT AVAILABLE, ASK FOR BEST TIME TO CALL BACK

• IF ROUND 5 R NO LONGER LIVES AT THIS NUMBER, ASK TO SPEAK WITH SOMEONE WHO IS KNOWLEDGEABLE ABOUT THE HEALTH CARE RECEIVED BY THIS FAMILY

• IF WRONG NUMBER OR ENTIRE ROUND 5 HOUSEHOLD HAS MOVED, SEND TO TRACING

• IF SPEAKING WITH ROUND 5 R, CONTINUE WITH INTRODUCTION

INTRODUCTION

(Hello, my name is (YOUR NAME) from Westat and) I’m calling about the Medical Expenditure Panel Survey that we are conducting for the Agency for Healthcare Research and Quality. Your household was last interviewed for this survey on (DATE OF ROUND 5 INTERVIEW). First, we want to thank you for your household’s participation in the study. You have made a valuable contribution to the collection of complete and accurate information on health care use and costs in the U.S.

A letter was sent to you recently explaining that a small number of households are being contacted again to participate in a short phone interview. The questions I will ask collect information that was not collected in your MEPS interview and will only take a few minutes of your time.

The first 4 questions ask about your experiences obtaining health care.

1. During the past 12 months, were you told by a doctor’s office or clinic that they did not accept your health care coverage?

Yes	1
No	2
Did not have health care coverage in past 12 months	3
Ref	-7
DK	-8

Public reporting burden for this collection of information is estimated to average 10 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0124) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

2. During the past 12 months, was there any time when you needed follow up care but didn’t get it because you couldn’t afford it?

Yes	1
No	2
Ref	-7
DK	-8

3. If you get sick or have an accident, how worried are you that you will be able to pay your medical bills? Are you very worried, somewhat worried, or not at all worried?

Very worried	1
Somewhat worried	2
Not at all worried	3
Ref	-7
DK	-8

4. In regard to your health insurance or health care coverage, how does it compare to a year ago? Is it better, worse, or about the same?

Better	1
Worse	2
About the same	3
No health care coverage now and/or in past year	4
Ref	-7
DK	-8

The next few questions are about medical bills for you and family members who live with you.

5. In the past 12 months did you (or anyone in the family) have problems paying or were unable to pay any medical bills? Include bills for doctors, dentists, hospitals, therapists, medication, equipment, nursing home or home care.

Yes	1
No	2
Ref	-7
DK	-8

6. Do you (or anyone in your family) currently have any medical bills that are being paid off over time? This could include medical bills being paid off with a credit card, through personal loans, or bill paying arrangements with hospitals or other providers. The bills can be from earlier years as well as this year.

Yes	1
No	2
Ref	-7
DK	-8

7. Do you (or anyone in your family) currently have any medical bills that you are unable to pay at all?

Yes	1
No	2
Ref	-7
DK	-8

BOX 1

IF Q1 = 3 (DID NOT HAVE HEALTH CARE COVERAGE IN THE PAST 12 MONTHS) SKIP TO INTRODUCTION BEFORE Q13.

IF Q1 ≠ 3, CONTINUE.

We are interested in learning more about the specific coverage or benefits people have under their current health insurance policies.  These health benefits are usually provided in a printed summary form or booklet or made available on the Internet, possibly through a link on the insurer’s website. 

1. Do you have or have access to a description of the benefits provided by your health insurance plan?

Yes	1	(Q9)
No	2	(Q13)
Ref	-7	(Q13)
DK	-8	(Q13)

8. Do you have this information in the form of a printed document, through a link to the internet, or in both forms?

Printed document only	1	(Q10)
Internet only	2	(Q11)
Both	3	(Q10)
Ref	-7	(Q13)
DK	-8	(Q13)

8. If we had asked in one of the previous interviews, would you have been willing to provide MEPS with a copy of the printed document that describes your plan?

Yes	1	(BOX 2)
No	2	(BOX 2)
Ref	-7	(Q13)
DK	-8	(Q13)

BOX 2

IF Q9 = 1 (PRINTED DOCUMENT ONLY) SKIP TO INTRODUCTION BEFORE Q13.

IF Q9 = 3 (BOTH), CONTINUE.

8. If we had asked in one of the previous interviews, would you have been willing to provide MEPS with the internet link to the site with your plan description?

Yes	1
No	2
Ref	-7
DK	-8

8. Would you have been willing to print a copy of the information about your benefits that is available on the website and provide that to MEPS?

Yes	1
No	2
Ref	-7
DK	-8

The last few questions ask about your Internet and email use.

13. Do you use the Internet?

Yes	1	Q14
No	2	Q15
Ref	-7	Q15
DK	-8	Q15

13. How often do you use the Internet?

(READ, IF NECESSARY: How many times per week, per month, or per year do you use the Internet?)

_____	Per week
_____	Per month
_____	Per year
Refused	-7
DK	-8

13. Do you send or receive emails?

Yes	1
No	2	CLOSING
Ref	-7	CLOSING
DK	-8	CLOSING

13. May I have your email address in case we need to contact you again?

ENTER EMAIL ADDRESS: __________________________ (Q.17)

Does not have an email address	1	CLOSING
Ref	-7	CLOSING
DK	-8	CLOSING

13. How often do you check this email account?

(READ, IF NECESSARY: How many times per week, per month, or per year do you check this email account?)

_____	Per week
_____	Per month
_____	Per year
Refused	-7
DK	-8

CLOSING:

This completes our interview. Once again, thank you very much for your participation in the Medical Expenditure Panel Survey.