CMS-10399 Appendix A BENEFICIARY TBS

Analysis of Transportation Barriers to Utilization of Medicare Services by American Indian and Alaska Native Medicare Beneficiaries

Appendix A BENEFICIARY TBS

Survey

OMB: 0938-1182

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Appendix A
MEDICARE BENEFICIARY SURVEY

Centers for Medicaid and Medicare Services
American Indian and Alaska Native Transportation Barriers
MEDICARE BENEFICIARY SURVEY

Identification Number _______________

Interviewer Initials ____________

Status of Interview:

_____

Complete

_____

Incomplete

_____

Reviewed by _________________

_____

Missing Information:
(a)

______________

(b)

______________

(c)

______________

TIME INTERVIEW BEGAN: ____ ____ : ____ ____

DEMOGRAPHICS
PERSONAL BACKGROUND
QUESTION 001 IS DIRECTED TO THE INTERVIEWER
001. INTERVIEWER: INDICATE SEX OF RESPONDENT.
1
Male
2
Female
[INTERVIEWER: The remaining questions are asked of the respondent, unless otherwise noted.]
To begin, we are going to talk about basic things like age, where you live, your health, and education.
002.

What is your Zip Code?
___ ___ ___ ___ ___

003a. What is the month and year of your birth?
____ ____ MONTH

19 ____ ____ YEAR

8 8 = Don’t know/not sure
9 9 = No response
003b. [ INTERVIEWER: If the respondent answered unknown or there was no response, please ask for
approximate age.]
____ ____ years
004a. Which of the following Indian Health Service (IHS) services are you eligible for?
1
2
3

Direct care at IHS facility
Contract health services
Neither direct care at IHS facility nor contract health services

004b. Do you have health insurance covered by any of the following? Please indicate all that apply.
1
2
3
4
5
6

Medicare---------------------------------------------------- END INTERVIEW IF NOT INDICATED
Medicaid
Veterans Administration
Tribal
Private
Other (not including IHS) __________________________

8
9

Don’t know/not sure
No response -----------------------------------------------END INTERVIEW

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004c.

Please indicate all the Medicare services in which you are currently enrolled.

1
2
3
4

Part A: Hospitalization
Part B: Doctor’s services, outpatient care
Medicare Advantage: Part A and Part B and is covered by private insurance companies
Part D: Prescription drug services

8
9

Don’t know/not sure
No response

004d. Do you have a Medicare-recognized disability?
1
2

Yes
No

8
9

Don’t know/not sure
No response

005.
1
2
3
4
5
6
006.

What is your race? Please circle and complete all that apply.
American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Black or African American
Asian
White
Other (specify: ______________________________
What are your tribal affiliations?

_______________________

007.
1
2
3
4

INTERVIEWER: End Interview if ONLY
these racial categories are mentioned

What languages do you understand and/or speak? [INTERVIEWER: Mark all that apply.]
English
Native language (specify)_____________________________
Spanish
Other (specify) _____________________________________

Understand

Speak

1
1
1
1

2
2
2
2

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Kauffman & Associates, Inc.

008.
1
2
3
4
5
6

What is your marital status?
Married
Living together as a couple with another person
Separated
Divorced
Widowed
Never married

EDUCATION
009. How many years of school have you completed?
[INTERVIEWER: Please read the following options and enter the appropriate code; see below.]
____ ____
00 = 00 to less than 1 year
01 = 01-04 years
02 = 05-08 years
03 = 09-12 years (no high school diploma)
04 = High school diploma or GED
05 = Attended but did not complete college or university
06 = College degree or more
010. Did you attend a trade school or receive other specialized training?
1
2

Yes
No

EMPLOYMENT AND INCOME
011. Do you have a job?
1
2

Yes
No -----------------------------------------------------

GO TO Q 013

012. What is your employment status?
1 Full-time employed
2 Part-time employed
3 Self-employed
4 Seasonally employed
[INTERVIEWER: Do not read these options to respondent; circle only if they apply.]
8 Don’t know/Not sure
9 No response
------------------------------------------------GO TO Q 014-----------------------------------------------------------3|P age
Kauffman & Associates, Inc.

013.

What is the main reason you do not work now?

1
2
3
4

Retired
Disabled
Homemaker
Other (specify)___________________________________________

8
9

Don’t know/not sure
No response

014.

How many people, including yourself, live at least 4 days per week in your house?
___ ___

PEOPLE

8 8 = Don’t know/not sure
015. Including you, how many household members received income from any source for the year
ending this past December? If no one, enter “0 0.”
____ ____
88
99

Number of household members with any income

Don’t know/not sure
No response

016. For the year ending this past December, what was the annual income of your household, before
taxes and deductions, for all household members, including you? Please look at the following
choices and tell me which range best fits the income of your household.
1

Income loss

$25,000-$29,999

No income

$30,000-$34,999

$1-$4,999

$35,000-$39,999

$5,000-$9,999

$40,000-$49,999

$10,000-$14,999

$50,000-$59,999

$15,000-$19,999

$60,000-$60,999

$20,000-$24,999

$70,000 AND OVER

88
99

Don’t know/not sure
No response

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017. In the past 12 months, did your family receive any kind of food or economic assistance?
1
2

Yes
No

8
9

Don’t know/not sure
No response

018. Do you or any of your household members have:
YES

DON’T KNOW

NO RESPONSE

a. A telephone or cell phone with service?

b. A computer?

c. A connection to the Internet?

d. A functioning truck or car?

LOCATION OF RESIDENCE
019. How far away do you live from your health center/clinic?
1
2
3
4

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

020.
1
2
3
4
5

How would you describe the condition of the roads around and near your residence?
Excellent
Very good
Good
Fair
Poor

HEALTH STATUS AND HEALTH CARE DELIVERY
021a.
1
2
3
4
5

In general, how would you rate your health?
Excellent
Very good
Good
Fair
Poor

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021b. Do you have a disability that requires special transportation options?
1
2
022.
1
2
3
4
5
6

Yes
No
During the past 12 months, where did you go for most of your health care services?
Indian Health Service
Tribal health care center
Private health care
Veterans Administration
Other (specify: ______________________________)
During the past 12 months, I did not access health care services

TRANSPORTATION AVAILABLITY FOR HEALTH CARE DELIVERY
023.

a.
b.
c.
d.
e.
f.
g.
h.

What kinds of transportation services, public and/or private, are available for you to use to get
to a medical appointment or procedure?
Public transportation
Tribal transportation
Private transportation service
Transportation for people with disabilities
Transportation by clinic or social service agency
Household car
Walking or hitchhiking
Other ___________________________

Available
1
1
1
1
1
1
1
1

Not Available
2
2
2
2
2
2
2
2

Don’t Know
3
3
3
3
3
3
3
3

024. Which of the following transportation services have you used for medical appointments and/or
referrals within the past 12 months? [INTERVIEWER: Check “N/A” if service is unavailable to
respondent.]

a.
b.
c.
d.
e.
f.

Public transportation
Tribal transportation
Private transportation service
Transportation for people with disabilities
Transportation provided by clinic or social
service agency
Other (specify_______________________)

Regular
Appointments

Referrals

N/A

1
1
1
1
1

2
2
2
2
2

3
3
3
3
3

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Kauffman & Associates, Inc.

025. Please rate the transportation services you have used to get to and from a medical appointment in
the past 12 months in terms of: 1) how often they are on time; 2) how convenient their schedules are;
and 3) how reasonable the cost is. [INTERVIEWER: Check “N/A” if service is never used or is not
available.]

a. Public
transportation
_______N/A

b. Tribal
transportation
_______N/A

c. Private
transportation
service
_______N/A

d. Transportation
for people with
disabilities
_______N/A

e. Transportation
offered by
clinic/social
service agency
(medical taxi
service or van)
_______N/A

1
2
3
4
5

Timeliness of Service
Always on time
Mostly on time
Sometimes on time
Rarely on time
Never on time

1
2
3
4
5

Schedules
Very convenient
Somewhat convenient
Slightly convenient
Not convenient
Not at all convenient

1
2
3
4
5

Cost
Good deal
Reasonable
A little high
High
Unaffordable

8
9
1
2
3
4
5

Don’t recall
No response
Always on time
Mostly on time
Sometimes on time
Rarely on time
Never on time

8
9
1
2
3
4
5

Don’t recall
No response
Very convenient
Somewhat convenient
Slightly convenient
Not convenient
Not at all convenient

8
9
1
2
3
4
5

Don’t recall
No response
Good deal
Reasonable
A little high
High
Unaffordable

8
9
1
2
3
4
5

Don’t recall
No response
Always on time
Mostly on time
Sometimes on time
Rarely on time
Never on time

8
9
1
2
3
4
5

Don’t recall
No response
Very convenient
Somewhat convenient
Slightly convenient
Not convenient
Not at all convenient

8
9
1
2
3
4
5

Don’t recall
No response
Good deal
Reasonable
A little high
High
Unaffordable

8
9
1
2
3
4
5

Don’t recall
No response
Very convenient
Somewhat convenient
Slightly convenient
Not convenient
Not at all convenient

8
9
1
2
3
4
5

Don’t recall
No response
Good deal
Reasonable
A little high
High
Unaffordable

8
9
1
2
3
4
5

Don’t recall
No response
Very convenient
Somewhat convenient
Slightly convenient
Not convenient
Not at all convenient

8
9
1
2
3
4
5

Don’t recall
No response
Good deal
Reasonable
A little high
High
Unaffordable

8 Don’t recall
9 No response
1
2
3
4
5

Always on time
Mostly on time
Sometimes on time
Rarely on time
Never on time

8 Don’t recall
9 No response
1
2
3
4
5

Always on time
Mostly on time
Sometimes on time
Rarely on time
Never on time

8 Don’t recall
9 No response

8 Don’t recall
9 No response
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f. Other (specify)
______________
_______N/A

1
2
3
4
5

Timeliness of Service
Always on time
Mostly on time
Sometimes on time
Rarely on time
Never on time

8 Don’t recall
9 No response

1
2
3
4
5

Schedules
Very convenient
Somewhat convenient
Slightly convenient
Not convenient
Not at all convenient

8 Don’t recall
9 No response

1
2
3
4
5

Cost
Good deal
Reasonable
A little high
High
Unaffordable

8 Don’t recall
9 No response

TRANSPORTATION BARRIERS AND UNMET NEEDS
The following questions will ask you about different transportation issues and whether any of these
issues affected your medical care.
026a.

During the past 12 months did you ever miss an appointment or procedure because of a
schedule delay or a breakdown of a bus, van, or airplane?

Yes

-----------------------------------------------

GO TO Q 029a

026b. What kinds of appointments did you miss because of this delay? Please indicate all that apply.
1
2
3
4
5
6
7
8
9
10
11

Checkup for a medical condition or disability
Monitoring of a chronic condition (like diabetes or arthritis)
Procedure for a medical condition or disability
New or worsening symptoms for an existing medical condition or disability
Sudden onset of an illness or condition
Physical or occupational therapy session
Diagnostic tests (like a lab test or x ray)
Outpatient surgery
Regular checkup
Health and or nutrition education
Other (specify: ___________________________________________________________)

88
99

Don’t know/not sure
No response

027.
1
2
3
4

GO TO Q 029a

How often during the past 12 months did schedule delays or breakdowns in a service cause you
to miss a doctor’s appointment or not get a medical procedure done?
1 time
2 - 3 times
4 - 5 times
6 - 7 times
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Kauffman & Associates, Inc.

8 - 9 times
10 or more times

No response

028a.

Did any of these occasions result in you getting sicker?

1
2

Yes
No

No response

028b. Did any of these occasions result in you having to go to the hospital?
1
2

Yes
No

No response

029a.
1
2

During the past 12 months did you ever miss an appointment or not get a procedure done
because of bad weather or bad roads?
Yes
No

-----------------------------------------------

GO TO Q 032a

029b. What kinds of medical appointments or procedures did you miss? Please indicate all that apply.
1
2
3
4
5
6
7
8
9
10
11

88
99

Don’t know/not sure
No response

030.

GO TO Q 032a

How often in the past 12 months has bad weather or bad roads caused you to miss a doctor’s
appointment or get a procedure done?

9|P age
Kauffman & Associates, Inc.

1
2
3
4
5
6

1 time
2 - 3 times
4 - 5 times
6 - 7 times
8 - 9 times
10 or more times

No response

031a.

Did any of these occasions result in you getting sicker?

1
2

Yes
No

No response

031b. Did any of these occasions result in you having to go to the hospital?
1
2

Yes
No

No response

032a.

During the past 12 months did you ever miss an appointment or not get a procedure done
because of how far you had to travel?

Yes

-----------------------------------------------

GO TO Q 035a

032b. What kinds of medical appointments or procedures did you miss? Please indicate all that apply.
1
2
3
4
5
6
7
8
9
10
11

88
99

Don’t know/not sure
No response

GO TO Q 035a

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033.

How often in the past 12 months has the distance you had to travel caused you to miss a
doctor’s appointment or get a procedure done?

1
2
3
4
5
6

1 time
2 - 3 times
4 - 5 times
6 - 7 times
8 - 9 times
10 or more times

No response

034a.

Did any of these occasions result in you getting sicker?

1
2

Yes
No

No response

034b. Did any of these occasions result in you having to go to the hospital?
1
2

Yes
No

No response

035a.

Do you feel you have to travel a long distance to get to your health center/clinic?

1
2
3

Yes
No
Sometimes

No response

035b. What is the worst thing about traveling a long distance to a medical appointment?
1
2
3
4
5
6
7

It is tiring
It is stressful
It is uncomfortable
It is dangerous
It makes my medical condition worse (e.g., raises blood pressure)
It is costly
Other (specify _________________________________________________________)

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TRANSPORATION DECISIONS AND HEALTH CONSEQUENCES
036a.

During the past 12 months did you ever decide not to go to a doctor’s appointment or get a
procedure done because of transportation scheduling problems?

Yes

-----------------------------------------------

GO TO Q 039a

036b. What kind of medical appointments or procedures did you miss? Please indicate all that apply.
1
2
3
4
5
6
7
8
9
10
11

Checkup for a medical condition or disability
Monitoring of a chronic condition
Procedure for a medical condition or disability
New or worsening symptoms for an existing medical condition or disability
Sudden onset of an illness or condition
Physical or occupational therapy session
Diagnostic tests (like a lab test or x ray)
Outpatient surgery
Regular checkup
Health and or nutrition education
Other (specify: __________________________________________________________)

88
99

Don’t know/not sure
No response

037.

GO TO Q 039a

1
2
3
4
5
6

How often within the past 12 months did you decide not to go to a doctor’s appointment or get
a procedure done because you did not want to deal with scheduling your transportation?
1 time
2 - 3 times
4 - 5 times
6 - 7 times
8 - 9 times
10 or more times

No response

038a.

Did any of these occasions result in you getting sicker?

1
2

Yes
No

No response
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038b. Did any of these occasions ever result in you having to go to the hospital?
1
2

Yes
No

No response

039a.
1
2

During the past 12 months, did you ever decide not to go to a doctor’s appointment or get a
procedure done because you did not want to deal with traveling a long distance?
Yes
No

-----------------------------------------------

GO TO Q 042a

039b. What kinds of medical appointments or procedures did you miss? Please indicate all that apply.
1
2
3
4
5
6
7
8
9
10
11

88
99

Don’t know/not sure
No response

040a.

GO TO Q 042a

1
2
3
4
5
6

During the past 12 months, how often did you decide not to go to a doctor’s appointment or get
a procedure done because you did not want to deal with traveling a long distance?
1 time
2 - 3 times
4 - 5 times
6 - 7 times
8 - 9 times
10 or more times

No response

040b. How long would it have taken you to get there?
1
Under 30 minutes
2
Between 30 minutes and 1 hour
3
Between 1 and 2 hours
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4
5
041a.

Between 2 and 3 hours
Over 3 hours
Did any of these occasions result in you getting sicker?

1
2

Yes
No

No response

041b. Did any of these occasions result in you having to go to the hospital?
1
2

Yes
No

No response

042a.
1
2

During the past 12 months, did you ever decide not to go to a doctor’s appointment or get a
procedure done because a family member was not able to take you?
Yes
No

-----------------------------------------------

GO TO Q 045a

042b. What kinds of medical appointments or procedures did you miss? Please indicate all that apply.
1
2
3
4
5
6
7
8
9
10
11

88
99

Don’t know/not sure
No response

GO TO Q 045a

043. How often within the past 12 months did you decide not to go to a doctor’s appointment or get a
procedure done because a family member was not available to take you?
1
2
3

1 time
2 - 3 times
4 - 5 times
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4
5
6

6 - 7 times
8 - 9 times
10 or more times

No response

044a.

Did any of these occasions result in you getting sicker?

1
2

Yes
No

No response

044b. Did any of these occasions result in having to go to the hospital?
1
2

Yes
No

No response

045.
1
2
046.

During the past 12 months, did you ever decide not to go to a doctor’s appointment or get a
procedure done because of the cost of transportation?
Yes
No

-----------------------------------------------

GO TO Q 049

What kinds of medical appointments or procedures did you miss? Please indicate all that apply.

1
2
3
4
5
6
7
8
9
10
11

Checkup for a medical condition or disability
Monitoring of a chronic condition (like diabetes or arthritis)
Procedure for a medical condition or disability
New or worsening symptoms for an existing medical condition or disability
Sudden onset of an illness or condition
Physical or occupational therapy session
Diagnostic tests (like a lab test or x ray)
Outpatient surgery
Regular checkup
Health and or nutrition education
Other (specify:__________________________________________________)

88
99

Don’t know/not sure
No response

GO TO Q 049

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047.

How often within the past 12 months did you decide not to go to a doctor’s appointment or get
a procedure done because of the cost of transportation?

1
2
3
4
5
6

1 time
2 - 3 times
4 - 5 times
6 - 7 times
8 - 9 times
10 or more times

No response

048a.

Did any of these occasions result in you getting sicker?

1
2

Yes
No

No response

048b. Did any of these occasions result in you having to go to the hospital?
1
2

Yes
No

No response

049.

During the past 12 months, have you ever had to leave the health center/clinic before you could
see the doctor or before you could get your medications because you did not want to miss your
transportation/ride home?

1
2

Yes
No

8
9

Don’t know/not sure
No response

050.
1
2
3
4
5
6
7
8
9

GO TO Q 053

Please indicate the type of appointment that was scheduled.
Checkup for a medical condition or disability
Monitoring of a chronic condition (like diabetes or arthritis)
Procedure for a medical condition or disability
New or worsening symptoms for an existing medical condition or disability
Sudden onset of an illness or condition
Physical or occupational therapy session
Diagnostic tests (like lab test or x ray)
Outpatient surgery
Regular checkup
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10
11

Health and or nutrition education
Other (specify: _______________________________________________________)

88
99

Don’t know/not sure
No response

051.

During the past 12 months, how often have you had to make this kind of decision?

1
2
3
4
5
6

1 time
2 - 3 times
4 - 5 times
6 - 7 times
8 - 9 times
10 or more times

No response

052a.

GO TO Q 053

Did any of these occasions result in you getting sicker?

1
2

Yes
No

No response

052b. Did any of these occasions result in you having to go to the hospital?
1
2

Yes
No

No response

053.

Have you ever had an appointment with a specialist that you had to change because of the
scheduled pickup times of your transportation service?

1
2

Yes
No

No response

054.

-----------------------------------------------

GO TO Q 055

Was it easy to make the changes in your appointment?

1
2

Yes
No

No response

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055.

How helpful are scheduling personnel in helping you change an appointment when you have a
transportation problem for the scheduled time?

1
2
3
4

Very helpful
Somewhat helpful
Slightly helpful
Not at all helpful

No response

TRANSPORTATION AND COST TO BENEFICIARY
056a.

During the past 12 months, have you ever received any help to cover the cost of transportation
to medical appointments or procedures?

1
2

Yes
No

8
9

Don’t know/not sure
No response

-----------------------------------------------

GO TO Q 057

056b. Have you received any help with transportation costs from any of the following? Please indicate
all that apply.
1
2
3
4
5
057.

Medicaid
Contract Health Service
Tribe
Family and friends
Other (specify: ________________________________________________________)
During the past 12 months, have you ever had to choose between paying for transportation to a
doctor’s appointment and using the money for food, rent, or another family need?

1
2

Yes
No

No response

058.

How big a problem is the cost of getting to a medical appointment for you?

1
2
3
4
5

Very big problem
Big problem
Problem
Small problem
Not a problem

8
9

Don’t know/not sure
No response
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059.

How big a problem is the cost of getting to a specialist for you?

1
2
3
4
5

Very big problem
Big problem
Problem
Small problem
Not a problem

8
9

Don’t know/not sure
No response

060.

If you are eligible for Contract Health Services, does it cover costs for transportation services?

1
2

Yes
No

7
8
9

Not applicable
Don’t know/not sure
No response

TRANSPORTATION BARRIERS AND HEALTH PROVIDERS
061.

Overall, how much do you think transportation problems affect your health care?

1
2
3
4
5

Very much
Much
Somewhat
Slightly
Not at all

No response

062.

GO TO Q 063

Do you feel that your doctor and your doctor’s staff know about your problems with
transportation?

1
2

Yes
No

7
8
9

Don’t have any problems with transportation
Don’t know/not sure
No response

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063.

How much do you think your doctor knows about the transportation problems in your
community?

1
2
3
4
5

Knows a lot about them
Knows about them
Knows something about them
Knows very little about them
Knows nothing about them

7
8
9

There are no transportation problems in my community
Don’t know/not sure
No response

064.

Does your doctor or members of your doctor’s staff ever ask if you have any transportation
problems when they make referrals for care outside of the health center/clinic?

1
2

Yes
No

8
9

Don’t know/not sure
No response

065a.

Have transportation problems ever resulted in a doctor not seeing you or limiting his or her time
to see you?

1
2

Yes
No

8
9

Don’t know/not sure
No response

GO TO Q 066

065b. What happened?
___________________________________________________________________________
___________________________________________________________________________
066.

Using a scale of 1 to 10, with 1 = “not at all hard” and 10 = “very hard,” how hard is it for you to
get health care because of transportation problems?
1

not at all hard

10
very hard

TRANSPORTATION BARRIERS AND THE USE OF TELEMEDICINE
Next, I would like to ask you a few questions about telemedicine and your experience with it.
Telemedicine is a process in which you talk to and are seen by a doctor or other health professional
through the use of a camera and TV-like screen. This person can be a long distance away from you and
your community.
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067.

Have you ever communicated with a doctor or other health profession using telemedicine?

1
2
068.

Yes
No

1
2
3
4
5
6
7
070.

GO TO Q 071

Would you have been able to see the health professional if you did not use this method of
consulting?

1
2
3
069.

----------------------------------------

Yes
No
Maybe

----------------------------------------

GO TO Q 070

----------------------------------------

GO TO Q 070

What prevented you from traveling to see the health professional in person? (Please indicate all
that apply.)
Cost of travel
Distance to travel
Uncomfortable to travel
No one to accompany me there
No one to drive me there
It was an emergency situation
Other (specify: ___________________________________________________________)
How many times in the past 12 months have you used telemedicine to talk to a health
professional?

1
2
3

1 -2 times
3 - 4 times
5 or more times

Don’t know/not sure

ADDITIONAL COMMENTS
071.

Lastly, are there any transportation problems or related health care issues that we have not
talked about that you feel we should have discussed?

1
2

Yes
No

No response

Thank you for your participation!

072. What are those problems?
1

_______________________________________________________________________

Thank you for your participation!
TIME INTERVIEW ENDED: ____ ____ : ____ ____
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File Type	application/pdf
File Title	Appendix A Medicare Beneficiary Survey
Subject	transportation barriers, medicare beneficiary, survey, American Indian, Alaska Native, Centers for Medicare and Medicaid Service
Author	CMS
File Modified	2012-03-07
File Created	2012-03-03