CMS-10399 Appendix C Beneficiary Interview Protocol

Appendix C
INTERVIEW PROTOCOL FOR
AMERICAN INDIAN AND ALASKA NATIVE MEDICARE BENEFICIARIES

INTERVIEW PROTOCOL FOR
AMERICAN INDIAN AND ALASKA NATIVE MEDICARE BENEFICIARIES
I.

Introduction
All information pertinent to the background and purpose of this study, the recruitment, contact and consent

processes, and the logistics of the semi-structured interviews are provided in the Supporting Statement. The
Interview Protocol contains the scripts and guide for the Medicare Beneficiary Interview:

II.

Interview Scripts and Guide for Medicare Beneficiaries

II.a. Introduction Script
Hello. My name is [insert name], from Kauffman and Associates, Inc. Kauffman & Associates, Inc., is an American Indian,
woman-owned company based in Spokane, WA, and we have been contracted by the Centers for Medicare and Medicaid
Services (CMS) to conduct interviews with [insert American Indian or Alaska Native] Medicare Beneficiaries to understand the
transportation barriers to health care.
The purpose of today’s interview is to help determine what kinds of transportation issues you face regarding access to health care,
and what kind of effects transportation has on your health and your ability to access needed health care. We have invited you
here today because of your experience with Medicare and the health care system. We value your opinions and encourage your
honest and complete feedback in response to our questions, and we are thankful that you’ve agreed to come to this interview to
share your thoughts and perspectives. While we encourage your full participation to help us understand the transportation issues
you face and how they affect your health and health care access, there will be no negative consequences for choosing not to respond
to any questions during the course of this interview.
We want to remind you that everything you tell us today will be kept confidential. What you share here today will be aggregated
with all of the other interviews we will be conducting, and no names or identifying information will be associated with responses or
appear on any presentation or report. We will be using a recording device to ensure that we preserve a complete rendering of what
is shared in this interview; however, if there are any objections to recording this interview we will rely on note-taking exclusively.
Are there any questions? [respond to any questions]

Kauffman & Associates, Inc.

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II.b. Informed Consent Script
[Interviewer provides participant with Informed Consent Form]
Everything I have just described is written on this Informed Consent form. If you have no other questions on the Informed
Consent process at this time, then to express your written consent to participate in this interview, we ask that you sign the form.
I will sign the form as well, and you will receive a copy of this statement for your records, which contains within it the contact
information for the persons responsible for this project, should any questions arise after we leave here today.
[Participant and interviewer sign Informed Consent Form].

II.c. Semi-Structured Interview Script

DEMOGRAPHICS
[QUESTION 1 IS DIRECTED TO THE INTERVIEWER.]
01.
[Interviewer: Please indicate the respondent’s gender.]
1 Male
2 Female
[INTERVIEWER: THE REMAINING QUESTIONS ARE ASKED OF THE RESPONDENT, UNLESS OTHERWISE NOTED.]
I am going to start by asking you some basic questions.
02. A) What is the month and year of your birth?
____ ____ MONTH

19 ____ ____ YEAR

B) [Interviewer: If unknown or there was no response, please ask for approximate age.]
____ ____ years
03.

What is your race? Please indicate and complete all that apply.
1
2
3
4
5
6

American Indian or Alaska Native
Native Hawaiian or other Pacific Islander
Black or African American
Asian
White
Other:___________________________________________________

[End Interview if ONLY
these racial categories
are mentioned]

04. What are your tribal affiliations?
1

__________________________________

2

__________________________________

3

__________________________________

05.

What is your ZIP Code?
___ ___ ___ ___ ___

Kauffman & Associates, Inc.

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06.

What is your marital status?

1
2
3
4
5
6

Married
Living together as a couple with another person
Separated
Divorced
Widowed
Never married

07.

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

08.
1
2
09.
1
2
10.

Did you attend a trade school or receive other specialized training?
Yes
No
Do you have a job?
Yes -----------------------------------------------------GO TO Q 11
No
What is the main reason you do not work?

1
2
3
4

Retired
Disabled
Homemaker
Other (specify)___________________________________________

8
9

Don’t know/not sure
No response

------------------------------------------- Go to Q 12 --------------------------------------------------

Kauffman & Associates, Inc.

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11.
1
2
3
4

What is your employment status?
Full-time employed
Part-time employed
Self-employed
Seasonally employed

[INTERVIEWER: DO NOT READ THESE OPTIONS TO RESPONDENT; CIRCLE ONLY IF THEY APPLY.]
8
9
12a.
1
2
3
12b.

Don’t know/ Not sure
No response
Which of the following Indian Health Service (IHS) services are you eligible for?
Direct care at an IHS facility
Contract health services
Neither direct care at IHS facility nor contract health services
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]

12c.

Please indicate all the Medicare Services in which you are currently enrolled in?

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

Kauffman & Associates, Inc.

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12d. Do you have a Medicare-recognized disability?
1
2

Yes
No

8
9

Don’t know/not sure
No response

13.

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

14.

In general, how would you rate your health?

1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

15.

During the past 12 months, where did you go for most of your health care services?

1
2
3
4
5
6

Indian Health Service
Tribal health care center
Private health care
Veterans Administration
Other
I did not use any health care services during the past 12 months

TRANSPORTATION BARRIERS AND ACCESSING HEALTH CARE
Now, I would like to ask you some questions about transportation services and getting to and from your medical
appointments and procedures. I would like to hear about your experiences as well as your views and opinions.
16. What are the different kinds of transportation services you can use to get to and from a health clinic/center
appointment?
1

_________________________________________________________________

2

__________________________________________________________________

3

__________________________________________________________________

4

__________________________________________________________________

Kauffman & Associates, Inc.

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17. What are the different kinds of transportation services you can use to get to and from a referred appointment or
procedure at another facility?
1
_________________________________________________________________
2

_________________________________________________________________

3

_________________________________________________________________

4

_________________________________________________________________

18. Please describe the cost, reliability, schedule, and overall convenience of each of the transportation services you
have used in the past 12 months. [INTERVIEWER: complete each numbered blank with the services identified in
Q17]
1) _____________________________________________________________________________
a. Cost __________________________________________________________________
b. Reliability _____________________________________________________________
c. Schedule ______________________________________________________________
d. Convenience ___________________________________________________________
Additional comment:

2)

_____________________________________________________________________________
a.
b.
c.
d.

Cost __________________________________________________________________
Reliability______________________________________________________________
Schedule ______________________________________________________________
Convenience ___________________________________________________________

Additional comment:

3)

_____________________________________________________________________________
a. Cost ________________________________________________________________
b. Reliability____________________________________________________________
c. Schedule _____________________________________________________________
d. Convenience __________________________________________________________

Additional comment:

Kauffman & Associates, Inc.

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4)

______________________________________________________________________________
a. Cost________________________________________________________________
b. Reliability_____________________________________________________________
c. Schedule _____________________________________________________________
d. Convenience __________________________________________________________
Additional comment:

19. How, if at all, do your family members help you get to your doctors’ appointments?

20a. Has a family member ever accompanied you to a doctor’s appointment?
1
2

Yes
No

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

GO TO Q 21

b.

What arrangements did this family member have to make to bring you to your appointment?

c.

Was your appointment delayed?
1
2

Yes
No
If so, how did this delay affect your family member’s schedule and/or other responsibilities?

21. When you live in an isolated and rural area there are many things you have to think about when you make a trip.
a.

What are your major concerns about traveling to and from your medical appointments?

1

_________________________________________________________________

2

__________________________________________________________________

3

__________________________________________________________________

4

__________________________________________________________________

Kauffman & Associates, Inc.

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b.

What would improve this situation for you?

1

_________________________________________________________________

2

__________________________________________________________________

3

__________________________________________________________________

4

__________________________________________________________________

22a. Over the past 12 months, how, if at all, has the cost of transportation affected your ability to keep or make a
doctor’s appointment or get a procedure done?

b.

What did you decide to do?

c.

How did this decision affect your health or medical care?

23a.
1

What would be the best service or services the tribe, clinic, or government could offer that would help you get to
your doctors’ appointments?
_________________________________________________________________

2

_________________________________________________________________

3

_________________________________________________________________

4

_________________________________________________________________
b.

What do you see as your biggest transportation problem?
__________________________________________________________________

Kauffman & Associates, Inc.

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24a.

Please describe a situation in the last 12 months in which you missed or had to cancel an appointment because of
a transportation problem.

b.

How did this cancellation affect your health or medical condition?

c.

How, if at all, did this cancellation affect your relationship with your doctor?

25a.

b.

c.

26.

27a.

b.

Have you ever had to choose between staying for a doctor’s appointment and getting a ride home?
1
Yes
2
No
-------------------GO TO Q 26
If so, what did you decide to do?

How did this decision affect your health?

How would you describe your doctor and your doctor’s staff’s knowledge about the transportation problems or
concerns of their Medicare patients?

In what way, if any, do you think your doctor adjusts or changes your care based on what he or she thinks your
transportation problems are?

What do you think about these changes?

Kauffman & Associates, Inc.

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28.

III.

Is there anything else about transportation and medical care that we have not discussed that you would like to
mention?

Conclusion and Compensation
At the conclusion of the interview session, the Medicare beneficiary will be thanked and compensated for

her/his time and effort in the form of a $50 gift card.

III.a. Conclusion and Compensation Script
This concludes our questions. We are very thankful for your time and your thoughtful responses. As an expression of our
gratitude, we have a thank you gift card for you, and we ask that you sign that you have received it.
[Interviewer records the name of each participant who receives a gift card, and participant signs to indicate
their receipt.]

IV.

Handling of Data
Interview data, once transcribed, will be scrubbed of identifiers. All data will ultimately be electronically

entered and password protected with limited access.
Viewing of the raw data will be limited to the following personnel: interviewer, note taker, project manager,
and transcriber. Of the staff, only the interviewer and note taker will have direct knowledge of the person who
participated in the study.

Kauffman & Associates, Inc.

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