Form CMS-10399 Appendix B PROVIDERS TBS

Appendix B
HEALTH CARE PROVIDER SURVEY

Centers for Medicare and Medicaid Services
HEALTH CARE PROVIDER SURVEY
American Indian and Alaska Native Transportation Barriers
Please answer all of the following questions as honestly and completely as you can. The survey should
take you no longer than 30 minutes to complete.

DEMOGRAPHIC INFORMATION
001.

Please indicate your gender.

1 Male
2 Female
002. What is the month and year of your birth?
____ ____ MONTH
003.
1
2
3
4
004.

19 ____ ____ YEAR

What languages do you understand and/or speak? Please indicate all that apply.
English
Native language (specify)_____________________________
Spanish
Other (specify) ___________________________________

American Indian or Alaska Native (tribal affiliation(s)):

2
3
4
5
6

Native Hawaiian or other Pacific Islander
Black or African American
Asian
White
Other: __________________________________

1
2
3
4
5
6
7
8

Speak

1
1
1
1

2
2
2
2

What is your race? Please circle and complete all that apply.

1

005.

Understand

______________________________
______________________________

What type of position do you hold at your facility?
Primary Care Physician
Other Physician (specialty) _________________________________
Nurse Practitioner
Registered Nurse
Physician’s Assistant
Health Educator
Laboratory Technician
Registered Dietician
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10
11
12
13
006.

Community Health Representative
Clinic Administrator
Hospital Administrator
Contract Health Services Manager
Other (specify) ____________________________________________________
How long have you been in your current position?

1
2
3
4
5
007a.

Less than 1 year
1 – 2 years
3 – 4 years
5 – 6 years
7 years and more
What is your facility’s Zip Code?
____ ____ ____ ____ ____

007b. Your facility serves American Indian and Alaska Native Medicare beneficiaries in which of the
following capacities? Please choose one of the following.
1
2
3
4
5
6
7
8
008.
1
2
3
4
5
6
7
8
9
10
11
12
13

Indian Health Service (IHS) Clinic
Tribal health center
Contractor for primary care
IHS referral source or contractor for specialty services
Outpatient surgeries
IHS referral source or contractor for behavioral health services
An IHS referral source or contractor for rehabilitation services
Other (specify) ___________________________________________________
What are the primary services accessed by American Indian and Alaska Native Medicare
beneficiaries at your facility? Please indicate all that apply.
Primary care
Diagnostic tests
Pharmacy services
Specialist services
Surgeries
Mental health care
Substance abuse treatment
Urgent care
Emergency care
Dialysis
Physical therapy
Therapeutic services
Health education
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009.

In your estimation, American Indians and Alaska Natives represent the following percentage of
patients seen at your health care facility.

1
2
3
4
5

4 % or under
5 – 25 %
26 – 50 %
51 – 75 %
76 – 100 %

8

Don’t know/not sure

010.

In your estimation, American Indian and Alaska Native patients enrolled in Medicare represent
the following percentage of patients seen at your health care facility.

1
2
3
4
5

4 % or under
5 – 25 %
26 – 50 %
51 – 75 %
76 – 100 %

8

Don’t know/not sure

011.
1
2
3
4
5
8

Approximately how many of the Medicare beneficiaries seen at your facility are also Medicaid
recipients?
4 % or under
5 – 25 %
26 – 50 %
51 – 75 %
76 – 100 %
Don’t know/not sure

1
2
3
4
5

Approximately how many Medicare beneficiaries receive Medicaid-funded transportation
services?
4 % or under
5 – 25 %
26 – 50 %
51 – 75 %
76 – 100 %

8

Don’t know/not sure

012.

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ENVIRONMENT

013.

Approximately how far away do most American Indian and Alaska Native Medicare beneficiaries
live from your facility?

1
2
3
4
5

Within a half mile
Between a half mile to 5 miles
Between 5 to 10 miles
Between 10 to 50 miles
Over 50 miles

8

Don’t know/not sure

014.
1
2
3
4

Other than roadways, how would you describe most means of travel Medicare beneficiaries
have to use to get to your facility?
Excellent
Good
Fair
Poor

7
8
9

Not applicable
Don’t know/not sure
No response

TRANSPORTATION AVAILABILITY FOR MEDICARE BENEFICIARIES
015.

A.
B.
C.
D.
E.
016.

A.
B.
C.
D.
E.
F.

What kinds of transportation services, public and/or private, are available to Medicare
beneficiaries to bring them to a medical appointment or procedure? Please answer each item.
Public transportation
Tribal transportation
Private transportation service
Clinic or social service agency vans
Other (specify) _________________________________

YES

NO

1
1
1
1
1

2
2
2
2
2

What kinds of transportation services, public and/or private, are available to Medicare
beneficiaries with disabilities to bring them to a medical appointment or procedure? Please
answer each item.
Handicap-equipped public transportation
Handicap-equipped Tribal transportation
Handicap-equipped private transportation service
Specialty vans for people with disabilities
Handicap-equipped clinic or social service agency vans
Other (specify) ________________________________

YES

NO

1
1
1
1
1
1

2
2
2
2
2
2
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017.

Are you or is your facility or staff accommodating transportation barriers by providing home
visits?

1
2

Yes
No

8
9

Don’t know/not sure
No response

018.

Through vouchers, reduced rates, or subsidies, how much of the cost of the following is
defrayed through IHS or tribal health care budgets? Using a scale of 0 to 5, with 1 = “not at all”
and 5 = “a lot,” please rate each of the following transportation options for Medicare
beneficiaries. Please mark the number that best agrees with your answer. If a service is not
available, mark “N/A.”
A lot

Not at all

A. Public transportation

4

3

2

1

0

N/A

B. Tribal transportation

4

3

2

1

0

N/A

C. Private transportation service (e.g., shuttle)

4

3

2

1

0

N/A

D. Specialty vans for people with disabilities

4

3

2

1

0

N/A

E. Clinic or social service agency vans

4

3

2

1

0

N/A

F. Other (specify)________________________________

4

3

2

1

0

N/A

-----------------------If respondent answered “N/A” to all of the above, GO TO Q 019b--------------------------019a.

How familiar are you and/or your staff with the transportation schedules of the service(s)
available to Medicare beneficiaries?

1
2
3
4

Very familiar
Somewhat familiar
Slightly familiar
Not at all familiar

9

No response

019b. How familiar are you and/or your staff with the transportation assistance available to
beneficiaries who are dually eligible for Medicare and Medicaid?
1
2
3
4

Very familiar
Somewhat familiar
Slightly familiar
Not at all familiar

9

No response
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020.

Overall, how would you rate the public and/or private transportation services available to
Medicare beneficiaries (without disabilities) using your facility?

1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

8
9

Don’t know/not sure
No response

021.

GO TO Q 022

Generally, what are the most significant problems with the existing transportation services
available to Medicare beneficiaries? Please indicate all that apply.

1
2
3
4
5
6
7
8

Schedules are erratic
Schedules are limited
Drivers are untrained to work with people with serious medical conditions
Transportation services are inadequate for the number of people needing to be served
Vehicles are frequently breaking down
Transportation is underfunded
Transportation services are not linked or coordinated
Other (Please specify: __________________________________________________)

9

There are no significant problems with the existing transportation services available to Medicare
beneficiaries using our facility

88 Don’t know/not sure
99 No response
022.

Overall, how would you rate the public and/or private transportation services available to
Medicare beneficiaries with disabilities using your facility?

1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

8
9

Don’t know/not sure
No response

023.
1
2

GO TO Q 024

Generally, what are the most significant problems with the existing transportation services
available to disabled Medicare beneficiaries? Please indicate all that apply.
Schedules are erratic
Schedules are limited
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3
4
5
6
7
8
9
10
11

Transportation services are inadequate for people with disabilities
Transportation services are inadequate for the number of people with disabilities
Drivers are untrained to work with people with disabilities
Drivers are untrained to work with people with serious medical conditions
Vehicles frequently breaking down
Transportation is underfunded
Transportation services not linked or coordinated
Transportation services not linked or coordinated appropriately for people with disabilities
Other _____________________________________________________________________

12

There are no significant problems with the existing transportation services available to disabled
Medicare beneficiaries

88
99

Don’t know/not sure
No response

TRANSPORTATION BARRIERS AND PATIENT UNMET NEEDS
024.
1
2
3
4
5
6
7
8
025.

What do you see as the biggest transportation problem affecting Medicare beneficiaries
(without disabilities)? Please choose one item.
Cost
Road/weather conditions
Distance
Not having a family member available to take them
Inadequate transportation schedules
Poor or no public or Tribal transportation
Other _____________________________________________________________________
There are no significant transportation barriers
During the past 12 months, how frequently have Medicare beneficiaries in your practice or at
your clinic been unable to follow through with a prescribed medical regiment because of
transportation barriers?

1
2
3
4
5

Always
Most of the time
Sometimes
Rarely
Not at all

8
9

Don’t know/not sure
No response

026.
1
2

Transportation problems prevent Medicare beneficiaries from receiving the following treatment
or services in a timely manner. Please indicate all that apply.
Medical devices
Outpatient surgery
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3
4
5
6
7
8
9
10
11
12

027.
0
1
2
3
4
5
6
028a.

Diagnostic services
Therapeutic services
Self-care training
Dialysis
Referral to a specialist
Monitoring of medical condition
Regular checkups
Health and nutrition programs
Other ____________________________________________________________________
Transportation is never a barrier to receiving treatment or services in a timely manner for
Medicare beneficiaries
During the past 12 months, approximately how frequently has an unmet need due to
transportation barriers resulted in a Medicare beneficiary’s condition worsening?
Never ---------------------------------------GO TO Q 029
1 time
2 - 3 times
4 - 5 times
6 - 7 times
8 - 9 times
10 or more times
How often did these occasions result in the Medicare beneficiary getting sicker?

1
2
3
4

Very often
Often
Not often
Not at all often

8
9

Don’t know/not sure
No response

028b. How often did these occasions result in the Medicare beneficiary getting hospitalized?
1
2
3
4

Very often
Often
Not often
Not at all often

8
9

Don’t know/not sure
No response

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028c.
0
1
2
3
4
5
6

During the past 12 months, how many times did this result in a Medicare beneficiary’s death?
Never
1 time
2 - 3 times
4 - 5 times
6 - 7 times
8 - 9 times
10 or more times

028d. How often has an unmet need that was caused by a transportation barrier resulted in a change
in the relationship between you and the patient?
1 Very often
2 Often
3 Not often
4 Not at all often
8
9

Don’t know/not sure
No response

028e. How often has an unmet need that was caused by a transportation barrier resulted in a change
in the relationship between you and a referral source?
1 Very often
2 Often
3 Not often
4 Not at all often
8
9
029.

1
2
3
4
5
6
7
8

Don’t know/not sure
No response
What do you see as the biggest transportation problem affecting Medicare beneficiaries with
disabilities, End Stage Renal Disease (ESRD), or ALS (“Lou Gehrig’s Disease”)? Please choose one
item.
Cost
Road/weather conditions
Distance
Not having a family member available to take them to an appointment
Inadequate transportation schedules
Poor or no public or Tribal transportation
Other __________________________________________________________________
There are no significant transportation barriers

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030.

During the past 12 months, how frequently have Medicare beneficiaries with disabilities, in your
practice or at your clinic, been unable to follow through with a prescribed medical regiment
because of transportation barriers?

1
2
3
4
5

Always
Most of the time
Sometimes
Rarely
Not at all

8
9

Don’t know/not sure
No response

031.
1
2
3
4
5
6
7
8
9
10

032.
0
1
2
3
4
5
6

Transportation problems prevent Medicare beneficiaries with disabilities from receiving the
following treatment or services in a timely manner. Please indicate all that apply.
Medical devices (including prostheses and wheelchairs)
Outpatient surgery
Diagnostic services
Therapeutic services
Self-care training
Dialysis
Referral to a specialist
Monitoring of medical condition
Other __________________________________________________________________
Transportation is never a barrier to Medicare beneficiaries receiving treatment or services in a
timely manner
During the past 12 months, approximately how often has an unmet need due to transportation
barriers resulted in a disabled Medicare beneficiary’s condition worsening?
Never ---------------------------------------GO TO Q 034
1 time
2 - 3 times
4 - 5 times
6 - 7 times
8 - 9 times
10 or more times

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033a.

How often did these occasions result in the disabled Medicare beneficiary getting sicker?

1
2
3
4

Very often
Often
Not often
Not at all often

8
9

Don’t know/not sure
No response

033b. How often did these occasions result in the disabled Medicare beneficiary getting hospitalized?
1
2
3
4

Very often
Often
Not often
Not at all often

8
9

Don’t know/not sure
No response

6

During the past 12 months, how many times did this result in a disabled Medicare beneficiary’s
death?
Never
1 time
2 - 3 times
4 - 5 times
6 - 7 times
8 - 9 times
10 or more times

8
9

Don’t know/not sure
No response

033c.
0
1
2
3
4
5

033d. How often has an unmet need that was caused by a transportation barrier resulted in a change
in the relationship between you and the patient?
1 Very often
2 Often
3 Not often
4 Not at all often
8
9

Don’t know/not sure
No response

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033e. How often has an unmet need that was caused by a transportation barrier resulted in a change
in the relationship between you and a referral source?
1 Very often
2 Often
3 Not often
4 Not at all often
8
9

Don’t know/not sure
No response

TRANSPORTATION DECISIONS AND HEALTH CONSEQUENCES
034a.

1
2
3
4

During the past 12 months, how often did you feel that the Medicare beneficiaries you see
decided not to go to a medical appointment or get a procedure done because they did not want
to deal with transportation issues?
Very often
Often
Not often
Not at all often

034b. Did any of these decisions result in the beneficiary’s condition getting worse?
1
2

Yes
No

8
9

Don’t know/not sure
No response

034c.

Did any of these decisions result in the beneficiary getting hospitalized?

1
2

Yes
No

8
9

Don’t know/not sure
No response

034d. Did any of these decisions result in you or a staff member limiting or refusing to see a
beneficiary in the future?
1 Yes
2 No
8
9

Don’t know/not sure
No response

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035a.

1
2
3
4

During the past 12 months, how often do you feel that the Medicare beneficiaries you see
decided not to go to a medical appointment or get a procedure done because they did not want
to go without a family member?
Very often
Often
Not often
Not at all often

035b. Did any of these decisions result in the beneficiary’s condition getting worse?
1
2

Yes
No

8
9

Don’t know/not sure
No response

035c.
1
2
8
9

Did any of these decisions result in the beneficiary getting hospitalized?
Yes
No
Don’t know/not sure
No response

035d. Did any of these decisions result in you or a staff member limiting or refusing to see a
beneficiary in the future?
1 Yes
2 No
8
9
036a.

1
2
3
4

Don’t know/not sure
No response
During the past 12 months, how often do you feel that the Medicare beneficiaries you see
decided not to go to a medical appointment or get a procedure done because of the cost of the
trip?
Very often
Often
Not often
Not at all often

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036b. Did any of these decisions result in the beneficiary’s condition getting worse?
1
2

Yes
No

8
9

Don’t know/not sure
No response

036c.

Did any of these decisions result in the beneficiary getting hospitalized?

1
2

Yes
No

8
9

Don’t know/not sure
No response

036d. Did any of these decisions result in you or a staff member limiting or refusing to see a
beneficiary in the future?
1 Yes
2 No
8
9

Don’t know/not sure
No response

TRANSPORTATION BARRIERS AND MEDICAL CARE DECISIONS
037.
1
2
3
038.
1
2
3
4
039.
1
2
3
4
5

Do you consider transportation when making referrals?
Yes
No
Sometimes
In your estimation, how significant a role does the cost of transportation play in Medicare
beneficiaries canceling or not scheduling regular medical appointments?
Very significant
Significant
Not significant
Not significant at all
How often do you consider the cost of transportation when referring a patient for treatment or
a procedure for a non-life-threatening problem?
Always
Most of the time
Sometimes
Rarely
Not at all
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040.
1
2
3
4
5
041.
1
2
3
4
5
042a.

How often do you consider the distance a beneficiary will have to travel when referring a patient
for treatment or a procedure for a non-life-threatening problem?
Always
Most of the time
Sometimes
Rarely
Not at all
How often do you consider the logistics of travel for the beneficiary when referring a patient for
treatment or a procedure for a non-life-threatening problem?
Always
Most of the time
Sometimes
Rarely
Not at all
During the past 12 months, what kinds of treatment and/or medical service have you not
referred a Medicare beneficiary to because you thought there would be a transportation
problem?

1

______________________________________________________________________

2

______________________________________________________________________

3

______________________________________________________________________

4

______________________________________________________________________

8

There has never a situation in which I did not refer a beneficiary for treatment because I felt
there would be a transportation problem.
-------------------- GO TO Q 043

042b. What did you do instead?
1
2
3
4
043.

Monitored the condition
Referred patient to someone/place that was not your first choice
Consulted with a specialist regarding care of patient
Did nothing
During the past 12 months, how frequently do you feel Medicare beneficiaries at your health
center cancelled or missed medical appointments because of transportation problems?

1
2
3
4

Very often
Often
Not often
Not at all often

8
9

Don’t know/not sure
No response
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044.

Do you sometimes feel beneficiaries use “transportation problems” as an excuse for not making
or keeping an appointment?

1
2

Yes
No

8
9

Don’t know/not sure
No response

045.
1
2
3
4
5

046.
1
2
3
4
5

047.
1
2
3
4
5

048.
1
2
3
4
5
6

How much do you feel transportation barriers affect a beneficiary’s ability to comply with
prescribed medical procedures or directives?
Very much
Much
Somewhat
Slightly
Not at all
How much do transportation barriers affect beneficiaries’ ability to access optimal services
available at another location?
Very much
Much
Somewhat
Slightly
Not at all
How much do transportation barriers affect the ongoing treatment of beneficiaries’ medical
condition?
Very much
Much
Somewhat
Slightly
Not at all

GO TO Q 049

What kinds of procedures or treatments are most affected by beneficiaries’ transportation
problems? Please indicate all that apply.
Monitoring of chronic conditions
Catching acute medical problems early enough to treat them
Getting regular checkups
Having lab tests completed and x rays done in a timely manner
Getting prescriptions filled
Other _________________________________________________________________
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049a.

What do you do when it appears that the Medicare beneficiary’s transportation barriers have
compromised the care of the patient?
_________________________________________________________________________
_________________________________________________________________________

049b. Do you feel this is an adequate handling of the medical situation?
1
2

Yes
No

8
9

Don’t know/not sure
No response

050.

Overall, using a scale of 1 to 5, with 1 = “not at all difficult” and 5 = “extremely difficult,” how
difficult is it for you to provide good medical care for beneficiaries who have difficulties with
transportation?
1
not at all difficult

051.

2

3

4

5
extremely difficult

Have transportation concerns from prior patients—being late for, missing, or cancelling
appointments—interfered with your ability to refer subsequent patients?

1
2

Yes
No

8
9

Don’t know/not sure
No response

TRANSPORTATION BARRIERS AND THE USE OF TELEMEDICINE
The following questions are concerned with telemedicine and its use in addressing
transportation barriers.
052.
1
2
053.
1
2
3

Have you ever used telemedicine to communicate with another health professional about a
patient?
Yes
No
Did you ever use this method because you thought your patient would not be able to meet in
person with the health professional because of transportation difficulties?
Yes
No
Maybe

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054.
1
2
3
055.
1
2
3
4
5
6

Do you think your patients would have been able to see the health professional if you did not
use this method of consulting?
Yes
No
Maybe
How many times during the past 12 months have you used telemedicine to talk to a health
professional because of a patient’s transportation access issues?
Never
1 - 2 times
3 - 4 times
5 - 6 times
7 - 8 times
9 or more times

ANY ADDITIONAL COMMENTS
056.
1
2

Are there any transportation problems related to delivering health care that we have not
mentioned that you feel are important and need addressing?
Yes
No
Thank you for your participation!

9
057.

No response
Please explain.

1

_______________________________________________________________________

2

_______________________________________________________________________

3

_______________________________________________________________________

Thank you for your participation!

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