CMS-10441 Attachment H - pre-exposure survey 100112

ID: ________________
Pre-Exposure Survey for Medicare Plan Finder Study
Questions for all experimental conditions
1.

Medicare is a health insurance program for people age 65 or older or who are younger
and have some disabilities or End Stage Renal Disease. Have you ever had to pick a
Medicare insurance plan for yourself or for someone close to you? Check all that apply.

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2.

No, I have not had to pick a Medicare plan.

Once a week or more.
Once a month.
Every few months.
Less often.

When was the last time you used the Internet to look for information about health or
medical care?

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4.

Yes, I have had to pick a Medicare plan for someone else.

In the past 12 months, how often did you use the Internet to look for health or medical
information for yourself or someone else?

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3.

Yes, I have had to pick a Medicare plan for myself.

Within the last week.
Within the last month.
Within the last year.
Over a year ago.
Never.

In the past 12 months, how often have you used the Internet to look for advice or
information about doctors, hospitals, or health insurance plans?

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Once a week or more.
Once a month.
Every few months.
Less often.

5.

How much attention do you pay to information about health or medical topics on the
Internet?

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6.

Not at all.

YES.
NO  IF NO, GO TO #7.
Not sure.

YES.
NO.
Not sure.

Did you see any information comparing the quality among different hospitals in the past
12 months, or not?

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6c.

A little.

Did you see any information comparing the quality among different doctors in the past
12 months, or not?

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6b.

Some.

Information comparing different doctors, hospitals, or health insurance plans is available
in different places. For example, it might be given out at work, come to your home by
mail, appear in a newspaper or magazine, or be found on the Internet. In the past 12
months, do you remember seeing any information comparing different doctors,
hospitals or health plans?

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6a.

A lot.

YES.
NO.
Not sure.

Did you see any information comparing the quality among different health plans in the
past 12 months, or not?

□
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YES.
NO.
Not sure.

Use the scale provided to indicate how much you agree or disagree with each of the following
statements about your health and interactions with your health care provider (that is, your
primary care doctor).
7.

When all is said and done, I am the person who is responsible for managing my health
condition.

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8.

Neither agree nor disagree.
Somewhat agree.
Strongly agree.

Strongly disagree.
Somewhat disagree.
Neither agree nor disagree.
Somewhat agree.
Strongly agree.

I am confident that I can take actions that will help prevent or minimize some symptoms or
problems associated with my health condition.

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10.

Somewhat disagree.

Taking an active role in my own health care is the most important factor in determining my
health and ability to function.

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9.

Strongly disagree.

Strongly disagree.
Somewhat disagree.
Neither agree nor disagree.
Somewhat agree.
Strongly agree.

I am confident that I can tell when I need to go get medical care and when I can handle a
health problem myself.

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Strongly disagree.
Somewhat disagree.

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11.

Strongly disagree.
Somewhat disagree.
Neither agree nor disagree.
Somewhat agree.
Strongly agree.

Strongly disagree.
Somewhat disagree.
Neither agree nor disagree.
Somewhat agree.
Strongly agree.

How confident are you that you can identify when it is necessary for you to get medical
care?

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14.

Strongly agree.

I am confident that I can follow through on medical treatments I need to do at home

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13.

Somewhat agree.

I am confident I can tell my health care provider concerns I have even when he or she does
not ask.

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12.

Neither agree nor disagree.

Not at all confident.
Somewhat confident.
Confident.
Very confident.

How frequently do you bring to your doctor visits a list of questions or concerns you want
to cover?

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Never.
Sometimes.
Usually.
Always.

These last questions are about you and will help us to describe all the people we interview.
15.

In general, how would you rate your overall health?

□ Excellent.
□ Very good.
□ Good.
□ Fair.
□ Poor.
16.
In the last 12 months, how many times did you go to a doctor’s office or clinic to get
health care for yourself?

□ None.
□ 1.
□ 2.
□ 3.
□ 4.
□ 5 to 9.
□ 10 or more times.