S1

Development of the Patient Experience Survey
for Medicare Shared Savings Accountable Care
Organizations

Rebecca Anhang Price, Julie A. Brown, Robin M. Weinick

RAND Health

October 30, 2012
Prepared for the Centers for Medicare & Medicaid Services

Project Overview
The goal of this project is to inform efforts by the Centers for Medicare & Medicaid Services (CMS)
to develop and implement a patient experience with care survey to collect data on fee-for- service
Medicare beneficiaries’ experiences with care in Accountable Care Organizations (ACOs) participating
in the Medicare Shared Savings Program and Pioneer Model ACOs. Survey development will also
inform the future use of patient experience with care surveys for group practices participating in the
Physician Quality Reporting System (PQRS). Patient experience scores from this survey will comprise
one-quarter of each ACO’s total quality score, which is used to determine the ACO’s shared savings
payment.

Survey Development Overview
CMS’ final Federal Rule requires that the survey be based on the CAHPS® Clinician & Group Survey
(CG-CAHPS), and specifies required survey domains. 1 To identify relevant items within each of these
domains, as well as possible new domains, we consulted with a Technical Expert Panel (TEP) and
conducted focus groups with fee-for-service Medicare beneficiaries. Combining input from these sources,
we developed a draft survey instrument, conducted cognitive interviews with beneficiaries to refine item
wording, and revised the instrument accordingly. We tested this instrument in the field in the spring of
2012 and further revised the survey based on analyses of the field test data. Each of these steps is
described in detail below.

Federal Rule and CG-CAHPS Required Domains
The initial draft of the ACO patient experience survey comprised survey domains that were specified
for inclusion by CMS’ Federal Rule for the Shared Savings Program:
1. Getting Timely Care, Appointments, and Information
2. How Well Your Providers Communicate
3. Patients’ Rating of Provider
4. Access to Specialists
5. Health Promotion and Education
6. Shared Decision Making
7. Health Status/Functional Status

1

The Medicare Shared Savings Program final rule is available at:
http://www.cms.gov/SharedSavingsProgram/30_Statutes_Regulations_Guidance.asp#TopOfPage

1

The first 6 of these domains are derived from CG-CAHPS core or supplemental item sets. 2
The health status/functional status domain includes items required by Section 4302 of the Affordable
Care Act relating to race, ethnicity, sex, primary language, and disability status,3 as well as additional
items regarding health and functional status, including questions from the SF-36, a widely used and wellvalidated health outcomes survey. Because the Section 4302 items focus on disabilities and more severe
physical limitations, we consulted with one of the developers of the RAND SF-36 (Dr. Ron Hays) to
identify social- and role-functioning items. The selected items were also assessed based on their
performance as outcomes measures in the developmental work conducted by Dr. Hays and others on the
Patient Reported Outcomes Measurement Information System (PROMIS), funded by the National
Institutes of Health. 4

The initial draft of the survey also included the CG-CAHPS domain Courteous and Helpful Office
Staff, as this domain is part of the CG-CAHPS core item set and is thus required for all CG-CAHPS
surveys.

Focus Groups
To inform the development of new survey content to assess consumer experience with ACOs, we
conducted two focus groups in November and December 2011. The first, in Washington, DC, included 8
Medicare beneficiaries enrolled in either fee-for-service Medicare or Medicare Advantage preferred
provider organizations who had visited a specialist in the prior 6 months. The second, conducted in Los
Angeles, CA, included 8 Medicare fee-for-service beneficiaries who had an overnight hospital stay in the
prior 6 months. Participants in both groups were diverse with regard to both race/ethnicity and education.
We used an exploratory and confirmatory approach to investigate concepts related to features of ACOs,
such as care coordination and patient-centeredness, and to elicit reaction to and feedback regarding
specific issues, such as the health care providers who participants consider to be a part of their health care
team.

2

CG-CAHPS Core measures are questions which survey sponsors are required to field in order to refer to their survey as a
CG-CAHPS survey. CAHPS supplemental items explore topics or domains that are not covered by core measures, or explore
core measures in richer detail.
3
The Department of Health and Human Services Office of Minority Health (OMH) Final Data Collection Standard relating to
Section 4302 of the Affordable Care Act is available at:
http://minorityhealth.hhs.gov/templates/content.aspx?ID=9227&lvl=2&lvlID=208
4
The mission of the PROMIS project is to develop and disseminate methodological standards and tools to collect self-reported
health outcomes measures. Details on the project and measures can be found at http://www.nihpromis.org/

2

Among the fee-for-service or Medicare Advantage beneficiaries with one or more recent specialist
visits, focus group participants noted that they sought assistance from their primary care providers in
identifying specialists; perceived that they are individually responsible for assuring the communication
and coordination of information between their health care providers; and referred to the doctors and
others who participate in their health care as their “health care team” or “personal health care team.”

Among the fee-for-service Medicare beneficiaries with one or more recent hospital stays, focus group
participants perceived that inpatients require an advocate (self, spouse, other family member) to assure
communication and coordination of information between doctors and between doctors and nurses; and
referred to the doctors and others who participate in their health care as their “team” or “network.”

Beneficiaries in both focus groups interpreted questions regarding involvement of family and friends
in health care decisions to mean decisions related to end-of-life care.
As a result of these findings, we adapted CG-CAHPS questions in the Health Promotion and
Education and Care Coordination domains by using the term “health care team” in questions referring to
the set of health care providers responsible for an individual’s care, and by developing new survey items
regarding the involvement of friends and family in health care decision making.

Technical Expert Panel
In December 2011, we convened a Technical Expert Panel (TEP), including representatives of
accrediting groups, purchasers and consumers, health care organizations and providers, as well as experts
on survey research and performance measurement and improvement. The TEP provided feedback
regarding the applicability of existing CAHPS domains to ACOs, revision or expansion of existing
CAHPS domains, and new suggested domains. TEP members recommended inclusion of questions from
the CAHPS Care Coordination domain, as the subject matter is relevant for evaluation of ACOs, but is
not required by the Federal Rule. The TEP further suggested possible expansions of the shared
decisionmaking domain to include questions regarding whether
1. the provider understands the patients’ values and preferences;
2. the patient is confused / lacks clinical understanding required to make health care choices; and
3. the provider involved friends / family in decisionmaking if patients’ wished them to do so.
New questions regarding (3) were added to the ACO CAHPS field test survey. Our focus group
discussions with beneficiaries suggested that questions related to suggestions (1) and (2) would likely be
viewed by survey respondents as closely related to end-of-life care issues. Since ACOs are not
specifically designed to focus on end-of-life care, we did not include these suggestions in the field test
survey.
In addition, the TEP suggested several new domains for the field test. Table 1 lists these domains, and
indicates whether the suggestion was incorporated into the field test survey instrument, and describes the
rationale for inclusion or exclusion.

3

Table 1. Proposed Domains Resulting from TEP Meeting

New Domain

Description

Rationale for Inclusion or
Exclusion in ACO CAHPS
Field Test

Included TEP-Suggested Domains Addressed by Existing CAHPS Questions
Awareness of care
provided by other
providers

The degree to which providers seem
knowledgeable about care the patient
received from other providers

Addressed by the CAHPS
coordination of care questions

Care team
functioning,
stability, attitudes
toward one another

How well the beneficiaries perceive that
their care team works together, team
members mention each other by name,
team shares information

Addressed by the CAHPS
coordination of care questions

Lifestyle measures

Patient report about whether provider
discussed the importance of nutrition and
lifestyle for maintaining good health

Addressed by the existing
CAHPS questions on provider
helping you make changes to
prevent illness, healthy diet,
and other behaviors

Included TEP-Suggested Domains Addressed by Adding CAHPS Supplemental Items to Field Test
Survey
Medication
adherence

Patient reports about whether providers
asked them about whether they’re taking
their medications, medication
reconciliation (from previous visits to the
same provider, other providers,
hospitalizations); not a self-report
regarding medication adherence

Relevant CG-CAHPS Health
Literacy Supplemental items

Stewardship of
patient resources

The degree to which providers and
patients discuss out-of-pocket expenses
(e.g., prescription drug costs) and the
affordability of care; not a self-report
regarding patient perception of
affordability

Relevant CG-CAHPS
supplemental item

Between-visit
communication

Patient report of follow-up between visits,
including reminders for tests, calls
regarding prescriptions, and side effects

Relevant questions from
Primary Care Medical Home
(PCMH) CAHPS

4

TEP-Suggested Domains Excluded from the ACO CAHPS Field Test Survey
Hospital discharge
instructions

Patients’ receipt and understanding of
instructions

Hospital discharges may be
too distant from the survey
date to allow for good
measurement.

Inpatient to
outpatient
continuity

Patient report about whether they left the
hospital with a provider appointment
already scheduled

Hospital discharges may be too
distant from the survey date to
allow for good measurement.

Provider reports
about the ACOs

Patient report about whether the provider
speaks well / poorly / at all about the
ACO

Beneficiaries likely will not
know what an ACO is and
therefore will not be able to
report.

ACO functions

Patient report about the availability of,
and/or their experience with ACO
programs, such as case management

Beneficiaries likely will not
know what an ACO is and
therefore will not be able to
report.

Perceived provider
restrictions

Patient report regarding feelings of
limitation about the providers from whom
they could seek care

Beneficiaries likely will not
know what an ACO is and
therefore will not be able to
report.

Resources in
community

The degree to which providers and
patients discussed resources the patient
could access in the community to support
their care, such as meal programs

Likely not relevant for many
patients.

Avoiding
unnecessary uses of
the hospital

Patient reports on non-urgent uses of the
emergency department, and whether they
were aware of how to seek non-urgent
after-hours care

Include existing CAHPS
questions on after-hours care
instead. The patient may not
be the best source of
information on unnecessary
ED use.

5

Cognitive Interviews
To inform the order of survey topics and the wording of individual survey items, we conducted 12
cognitive interviews in February 2012. Six interviews were conducted in English and 6 were conducted
in Spanish. All interviewees were Medicare beneficiaries enrolled in fee-for-service Medicare.
Participants were diverse with regard to both race/ethnicity and education. Participants were recruited to
assure a mix of experiences with care. We assessed how the flow of survey topics and items influenced
participant comprehension and interpretation, and whether survey items were interpreted consistently
across beneficiaries and across English and Spanish versions of the draft survey. Cognitive interview
findings resulted in refinement of question content and in re-ordering of topics, but did not result in
removal of any topic domains from the survey.

Field Test Survey
We field tested the draft survey among beneficiaries assigned to 9 participating physician groups
from the Medicare Physician Group Practice Demonstration (PGPs) in spring 2012. The methods and
implementation details of the field test will be described in later documents.
The field test survey contained 12 domains, as described in Table 2. The survey contained 96 items
and was formatted into two versions to allow testing of the patterns of response obtained using the
Section 4302 race, ethnicity, and disability items in comparison to the existing OMB race/ethnicity items
used by CAHPS and the CAHPS chronic condition questions. Individuals in the field test sample were
randomized to a survey version that presented the 4302 race and ethnicity measures before the OMB race
and ethnicity measures or a version that presented the OMB race and ethnicity measures before the 4302
race and ethnicity items. (Appendix A provides a list of field test survey questions in each domain.)
Table 2: ACO CAHPS Field Test Survey Content by CMS Regulatory Domain, Rationale for Inclusion,
and Source

Number
1-6

Regulatory Domain
•
•
•
•
•
•

Getting Timely Care, Appointments,
& Information
How Well Your Providers
Communicate
Patient’s Rating of Provider
Access to Specialists
Health Promotion and Education
Shared Decisionmaking

Rationale for
Inclusion

Source*

Medicare Shared
Savings Program Final
Rule

CG-CAHPS Core,
CG-CAHPS
Supplemental Items

6

7

•

Health Status & Functional Status

Medicare Shared
Savings Program Final
Rule

Office of Minority
Health (OMH) Data
Collection
Standards for
Section 4302

8

•

Courteous & Helpful Office Staff

Required for CGCAHPS

CAHPS Core

9-12

•
•
•

Care Coordination
Between Visit Communication
Educating Patient about Medication
Adherence
Stewardship of Patient Resources

Developed based on
focus groups with
beneficiaries and input
from the TEP

CAHPS
Supplemental
Items, New
Measures

•
*

CG-CAHPS Core measures are questions which survey sponsors are required to field in order to call their survey CGCAHPS. CAHPS supplemental items explore topics or domains that are not covered by core measures, or explore core
measures in richer detail.

7

National Implementation Survey
The field test data were analyzed to assess floor and ceiling effects and the reliability of measures in
discriminating between PGPs. Additionally, new measures and CAHPS supplemental items were
analyzed to determine whether any new composites could be constructed, and data from the four SF-36
measures were analyzed to see if they contributed unique information on functional health, distinct from
the information contributed by the Section 4302 disability measures. Based on the results of these
analyses, and the removal of duplicative race and ethnicity items included for testing purposes, the survey
content was trimmed to 83 items. Table 3 lists the items deleted as a result of the field test analysis, and
the rationale that informed the decision to delete each item. Item deletions occurred in multiple domains
but did not result in the deletion of the entire content of any domain. The end result is a final survey for
national implementation that contains all 12 domains included in the field test.

Appendix B displays the contents of the final national implementation survey.

8

Table 3. Deleted Field Test Survey Questions by Survey Domain

Health Promotion and Education

Source of Measure

Rationale for Deletion

Care team asked if there are things that
make it hard for you to take care of your
health

CAHPS
Supplemental Item

Item is vaguely worded. Item does
not contribute to the reliability of
the health promotion and education
composite.

Care team talked with you about a
personal problem, family problem,
alcohol use, drug use, mental or
emotional illness

CAHPS
Supplemental Item

Other items have better
measurement reliability. This item
has weak reliability.

Shared Decisionmaking
Provider talked about including family or
friends in making health decisions

You brought a family member or friend
with you to talk with this provider

Health Status & Functional Status

Source of Measure

Factor analysis indicated that this
item contributed no unique
information to shared
decisionmaking composites. Other
items had better performance in
measuring the concept.

New

Factor analysis indicated that this
item contributed no unique
information to shared
decisionmaking composites. Other
items had better performance in
measuring the concept.

New

Source of Measure

Rationale for Deletion

Rationale for Deletion

Health limits you in moderate activities

SF-36

These items do not contribute
unique information and overlap
with the Section 4302 disability
items.

Health limits you in bending, kneeling,
or stooping

SF-36

These items do not contribute
unique information and overlap
with the Section 4302 disability
items.

Health limits you in lifting or carrying
groceries

SF-36

These items do not contribute
unique information and overlap
with the Section 4302 disability
items.

9

Care Coordination

Source of Measure

Rationale for Deletion

You got help from your care team to
manage care, tests, or treatment from
different providers

CAHPS
Supplemental Item

This item did not contribute to a
composite measure of care
coordination. Other items were
identified to comprise a care
coordination composite.

Satisfaction with help from your care
team to manage care, tests, or treatment
from different providers

CAHPS
Supplemental Item

This item did not contribute to a
composite measure of care
coordination. Other items were
identified to comprise a care
coordination composite.

You needed help from your care team to
manage care, tests, or treatment from
different providers

CAHPS
Supplemental Item

This item is a screener for the
items on getting help for managing
care, tests, or treatment from
different providers.

10

Appendix A: ACO Patient Experience Survey – Field Test Questions by
CMS Regulatory Domain*

1.

Getting Timely Care, Appointments, & Information

Got urgent care appointment as soon as you needed

CG-CAHPS Core

Got appointment for check-up or routine care as soon as you needed

CG-CAHPS Core

Called provider’s office during regular hours and got answer to medical
questions same day

CG-CAHPS Core

Called provider’s office after hours and got answer to medical questions as soon
as you needed

CG-CAHPS Core

Saw provider within 15 minutes of appointment time

CG-CAHPS Core

Ease of getting care, tests, or treatment you thought you needed

CAHPS Supplemental
Item

2.

How Well Your Providers Communicate

Source of Measure

Provider explained things in a way that was easy to understand

CG-CAHPS Core

Provider listened carefully to you

CG-CAHPS Core

Provider gave you easy to understand instructions about health problem or
concern

CG-CAHPS Core

Provider knew the important information about your medical history

CG-CAHPS Core

Provider showed respect for what you had to say

CG-CAHPS Core

Provider spent enough time with you

CG-CAHPS Core

Source of Measure

3.

Patient’s Rating of Provider

0 to 10 Rating of Provider

Source of Measure
CG-CAHPS Core

11

4.

Access to Specialists

Ease of making appointments with specialists

CAHPS Supplemental
Item

Specialist you saw most often knew the important information about your
medical history

CAHPS Supplemental
Item

Number of specialists seen

CAHPS Supplemental
Item

Source of Measure

5.

Health Promotion and Education

Source of Measure

Care team talked with you about specific things you could do to prevent illness

CAHPS Supplemental
Item

Care team talked with you about healthy diet and healthy eating habits

CAHPS Supplemental
Item

Care team talked with you about your exercise or physical activity

CAHPS Supplemental
Item

Care team talked with you about specific goals for your health

CAHPS Supplemental
Item

Care team asked if there are things that make it hard for you to take care of your
health

CAHPS Supplemental
Item

Care team talked with you about all your prescription medicines

CAHPS Supplemental
Item

Care team asked if you had a period of feeling sad, empty or depressed

CAHPS Supplemental
Item

Care team talked with you about things that worry you or cause you stress

CAHPS Supplemental
Item

Care team talked with you about a personal problem, family problem, alcohol
use, drug use, mental or emotional illness

CAHPS Supplemental
Item

12

6.

Shared Decisionmaking

Source of Measure

Provider talked about the reasons you might want to take a prescription medicine

CAHPS Supplemental
Item

Provider talked about the reasons you might not want to take a prescription
medicine

CAHPS Supplemental
Item

When talking about starting or stopping a prescription medicine, provider asked
you what was best for you.

CAHPS Supplemental
Item

Provider talked about the reasons you might want to have surgery or procedure

CAHPS Supplemental
Item

Provider talked about the reasons you might not want to have surgery or
procedure

CAHPS Supplemental
Item

When talking about surgery or procedure, provider asked you what was best for
you.

CAHPS Supplemental
Item
New Item

Provider talked about including family or friends in making health decisions
Provider talked about how much of your personal health information you wanted
to share with family or friends

New Item

Provider respected your wishes about sharing personal health information with
family or friends
You brought a family member or friend with you to talk with this provider

New Item
New Item

13

7.

Health Status & Functional Status

Source of Measure

Rating of overall health

CG-CAHPS Core

Rating of overall mental or emotional health

CG-CAHPS Core

You had 3 or more visits for the same health condition or problem

CAHPS Supplemental
Item

You take prescription medicine for a condition that has lasted 3 months or longer

CAHPS Supplemental
Item

Extent to which physical health interferes with normal social activities

SF-36

Frequency with which physical health interferes with social activities

SF-36

Health limits you in moderate activities

SF-36

Health limits you in bending, kneeling, or stooping

SF-36

Health limits you in lifting or carrying groceries

SF-36

Deafness or serious difficulty hearing

OMH Section 4302

Blindness or serious difficulty seeing

OMH Section 4302

Serious difficulty concentrating, remembering, or making decisions

OMH Section 4302

Serious difficulty walking or climbing stairs

OMH Section 4302

Serious difficulty dressing or bathing

OMH Section 4302

Difficulty doing errands alone

OMH Section 4302

8.

Courteous & Helpful Office Staff

Source of Measure

Clerks and receptionists at this provider’s office were helpful

CG-CAHPS Core

Clerks and receptionists at this provider’s office treated you with courtesy and
respect

CG-CAHPS Core

14

9.

Care Coordination

CAHPS Supplemental
Item

Provider had medical records during your visits
Provider’s office followed up to give you results of text or x-ray

CG-CAHPS Core

You needed help from your care team to manage care, tests, or treatment from
different providers

CAHPS Supplemental
Item

You got help from your care team to manage care, tests, or treatment from
different providers

CAHPS Supplemental
Item

Satisfaction with help from your care team to manage care, tests, or treatment
from different providers

CAHPS Supplemental
Item

10.

Between Visit Communication

Got reminders from provider’s office between visits

Got reminder from provider’s office to make an appointment for tests or
treatment
11.

Educating Patient about Medication Adherence

Source of Measure
CAHPS Supplemental
Item
New Item

Source of Measure

Provider gave you easy to understand instructions about how to take prescription
medicines

CAHPS Supplemental
Item

Provider gave you information in writing about how to take prescription
medicines that was easy to understand

CAHPS Supplemental
Item

Provider suggested ways to help you remember to take your medicines

CAHPS Supplemental
Item

Source of Measure

12.

Stewardship of Patient Resources

Care team talked with you about cost of your prescription medicines

Source of Measure
CAHPS Supplemental
Item

*

In addition to the survey questions listed here, a number of other “screener” questions are used to identify whether
respondents are eligible to answer subsequent questions. For example, one question asks respondents if they have
tried to make an appointment with a specialist. Only those answering “yes” are asked subsequent questions about
specialists. Additional questions address items not related to these 12 domains, such as confirming the respondent’s
knowledge of the main or “focal” provider named in the survey and demographic information.

15

Appendix B: Contents of the Final National Implementation Survey
Your Provider
1.

Our records show that you visited the provider named below in the last 6 months.
Name of provider label goes here
Is that right?
Yes
No → If No, go to #44 on page 5

The questions in this survey will refer to the provider named in Question 1 as “this provider.” Please think
of that person as you answer the survey.
2.

Is this the provider you usually see if you need a check-up, want advice about a health problem, or get
sick or hurt?
Yes
No

3.

How long have you been going to this provider?
Less than 6 months
At least 6 months but less than 1 year
At least 1 year but less than 3 years
At least 3 years but less than 5 years
5 years or more

16

Your Care From This Provider in the Last 6 months
These questions ask about your own health care. Do not include care you got when you stayed overnight
in a hospital. Do not include the times you saw a dentist.
4.

In the last 6 months, how many times did you visit this provider to get care for yourself?
None → If None, go to #44 on page 5
1 time
2
3
4
5 to 9
10 or more times

5.

In the last 6 months, did you phone this provider’s office to get an appointment for an illness, injury
or condition that needed care right away?
Yes
No → If No, go to #7

6.

In the last 6 months, when you phoned this provider’s office to get an appointment for care you
needed right away, how often did you get an appointment as soon as you needed?
Never
Sometimes
Usually
Always

7.

In the last 6 months, did you make any appointments for a check-up or routine care with this
provider?
Yes
No → If No, go to #9

8.

In the last 6 months, when you made an appointment for a check-up or routine care with this
provider, how often did you get an appointment as soon as you needed?
Never
Sometimes
Usually
Always

17

9.

In the last 6 months, did you phone this provider’s office with a medical question during regular
office hours?
Yes
No → If No, go to #11

10. In the last 6 months, when you phoned this provider’s office during regular office hours, how often
did you get an answer to your medical question that same day?
Never
Sometimes
Usually
Always
11. In the last 6 months, did you phone this provider’s office with a medical question after regular office
hours?
Yes
No → If No, go to #13
12. In the last 6 months, when you phoned this provider’s office after regular office hours, how often did
you get an answer to your medical question as soon as you needed?
Never
Sometimes
Usually
Always
13. Some offices remind patients about tests, treatment, or appointments in between their visits. In the
last 6 months, did you get any reminders from this provider’s office between visits?
Yes
No → If No, go to #15
14. In the last 6 months, did this provider’s office contact you to remind you to make an appointment
for tests or treatment?
Yes
No

18

15. Wait time includes time spent in the waiting room and exam room. In the last 6 months, how often did
you see this provider within 15 minutes of your appointment time?
Never
Sometimes
Usually
Always
16. In the last 6 months, how often did this provider explain things in a way that was easy to understand?
Never
Sometimes
Usually
Always
17. In the last 6 months, how often did this provider listen carefully to you?
Never
Sometimes
Usually
Always
18. In the last 6 months, did you talk with this provider about any health questions or concerns?
Yes
No → If No, go to #20
19. In the last 6 months, how often did this provider give you easy to understand information about these
health questions or concerns?
Never
Sometimes
Usually
Always
20. In the last 6 months, how often did this provider seem to know the important information about your
medical history?
Never
Sometimes
Usually
Always

19

21. When you visited this provider in the last 6 months, how often did he or she have your medical
records?
Never
Sometimes
Usually
Always
22. In the last 6 months, how often did this provider show respect for what you had to say?
Never
Sometimes
Usually
Always
23. In the last 6 months, how often did this provider spend enough time with you?
Never
Sometimes
Usually
Always
24. In the last 6 months, did this provider order a blood test, x-ray, or other test for you?
Yes
No → If No, go to #26
25. In the last 6 months, when this provider ordered a blood test, x-ray, or other test for you, how often
did someone from this provider’s office follow up to give you those results?
Never
Sometimes
Usually
Always
26. In the last 6 months, did you and this provider talk about starting or stopping a prescription medicine?
Yes
No → If No, go to #35
27. Did you and this provider talk about the reasons you might want to take a medicine?
Yes
No

20

28. Did you and this provider talk about the reasons you might not want to take a medicine?
Yes
No
29. When you and this provider talked about starting or stopping a prescription medicine, did this
provider ask what you thought was best for you?
Yes
No
30. After you and this provider talked about starting or stopping a prescription medicine, did you start a
prescription medicine?
Yes
No → If No, go to #35
31. In the last 6 months, how often did this provider give you easy to understand instructions about how
to take your medicines?
Never
Sometimes
Usually
Always
32. In the last 6 months, other than a prescription, did this provider give you written information or write
down information about how to take your medicines?
Yes
No → If No, go to #34
33. Was the written information this provider gave you easy to understand?
Yes
No
34. In the last 6 months, did this provider suggest ways to help you remember to take your medicines?
Yes
No
35. In the last 6 months, did you and this provider talk about having surgery or any type of procedure?
Yes
No → If No, go to #39

21

36. Did you and this provider talk about the reasons you might want to have the surgery or procedure?
Yes
No
37. Did you and this provider talk about the reasons you might not want to have the surgery or
procedure?
Yes
No
38. When you and this provider talked about having surgery or a procedure, did this provider ask what
you thought was best for you?
Yes
No

39. In the last 6 months, did you and this provider talk about how much of your personal health
information you wanted shared with your family or friends?
Yes
No

40. In the last 6 months, did this provider respect your wishes about how much of your personal health
information to share with your family or friends?
Yes
No
41. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider
possible, what number would you use to rate this provider?
0 Worst provider possible
1
2
3
4
5
6
7
8
9
10 Best provider possible

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Clerks and Receptionists at This Provider’s Office
42. In the last 6 months, how often were clerks and receptionists at this provider’s office as helpful as you
thought they should be?
Never
Sometimes
Usually
Always
43. In the last 6 months, how often did clerks and receptionists at this provider’s office treat you with
courtesy and respect?
Never
Sometimes
Usually
Always

Your Care From Specialists in the Last 6 months
44. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors
who specialize in one area of health care. Is the provider named in Question 1 of this survey a
specialist?
Yes→ If Yes, go to #48
No
45. In the last 6 months, did you try to make any appointments with specialists?
Yes
No → If No, go to #49
46. In the last 6 months, how often was it easy to get appointments with specialists?
Never
Sometimes
Usually
Always

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47. In the last 6 months, how often did the specialist you saw most seem to know the important
information about your medical history?
Never
Sometimes
Usually
Always
48.

How many specialists have you seen in the last 6 months?
None
1 specialist
2
3
4
5 or more specialists

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All Your Care in the Last 6 Months
These questions ask about all your health care. Include all the providers you saw for health care in the last
6 months. Do not include the times you saw a dentist.
49. Your health care team includes all the doctors, nurses and other people you see for health care. In the
last 6 months, did you and anyone on your health care team talk about specific things you could do to
prevent illness?
Yes
No
50. In the last 6 months, did you and anyone on your health care team talk about a healthy diet and
healthy eating habits?
Yes
No
51. In the last 6 months, did you and anyone on your health care team talk about the exercise or physical
activity you get?
Yes
No
52. In the last 6 months, did anyone on your health care team talk with you about specific goals for your
health?
Yes
No
53. In the last 6 months, how often was it easy to get the care, tests or treatment you thought you needed?
Never
Sometimes
Usually
Always
54. In the last 6 months, did you take any prescription medicine?
Yes
No → If No, go to #57

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55. In the last 6 months, how often did you and anyone on your health care team talk about all the
prescription medicines you were taking?
Never
Sometimes
Usually
Always
56. In the last 6 months, did you and anyone on your health care team talk about how much your
prescription medicines cost?
Yes
No
57. In the last 6 months, did anyone on your health care team ask you if there was a period of time when
you felt sad, empty, or depressed?
Yes
No
58. In the last 6 months, did you and anyone on your health care team talk about things in your life that
worry you or cause you stress?
Yes
No

About You
59. In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
60. In general, how would you rate your overall mental or emotional health?
Excellent
Very good
Good
Fair
Poor

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61. In the last 12 months, have you seen a doctor or other health provider 3 or more times for the same
condition or problem?
Yes
No → If No, go to #63
62. Is this a condition or problem that has lasted for at least 3 months?
Yes
No
63. Do you now need or take medicine prescribed by a doctor?
Yes
No → If No, go to #65
64. Is this medicine to treat a condition that has lasted for at least 3 months?
Yes
No
65. During the last 4 weeks, how much did your physical health interfere with your normal social
activities with family, friends, neighbors or groups?
Not at all
Slightly
Moderately
Quite a bit
Extremely
66. During the last 4 weeks, how much of the time did your physical health interfere with your social
activities (like visiting with friends, relatives, etc.)?
All of the time
Most of the time
Some of the time
A little of the time
None of the time

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67. What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 69
70 to 74
75 to 79
80 to 84
85 or older
68. Are you male or female?
Male
Female
69. What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
70. How well do you speak English?
Very well
Well
Not well
Not at all
71. Do you speak a language other than English at home?
Yes
No → If No, go to #73

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72. What is the language you speak at home?
Spanish
Chinese
Some other language
Please print:

73. Are you deaf or do you have serious difficulty hearing?
Yes
No
74. Are you blind or do you have serious difficulty seeing, even when wearing glasses?
Yes
No
75. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating,
remembering, or making decisions?
Yes
No
76. Do you have serious difficulty walking or climbing stairs?
Yes
No
77. Do you have difficulty dressing or bathing?
Yes
No
78. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone
such as visiting a doctor’s office or shopping?
Yes
No
79. Are you of Hispanic, Latino, or Spanish origin?
Yes, Hispanic, Latino, or Spanish
No, not Hispanic, Latino, or Spanish → If No, go to #81

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80. Which group best describes you?
Mexican, Mexican American, Chicano → Go to #81
Puerto Rican → Go to #81
Cuban → Go to #81
Another Hispanic, Latino, or Spanish origin → Go to #81
81. What is your race? Mark one or more.
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
82. Did someone help you complete this survey?
Yes
No → Thank you.
Please return the completed survey in the postage-paid envelope.
83. How did that person help you? Mark one or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
Please print:

Thank you
Please return the completed survey in the postage-paid envelope.
[VENDOR NAME AND ADDRESS HERE]

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