Attachment B - Updates to Survey Instrument Following Submission of 60-day Federal Register Notice
Overall: Questions were renumbered throughout the survey to update alphanumeric designations (e.g. 14e3) assigned to newly added survey items. Questions now number 1 – 72.
Front Cover Introductory text:
Original: Your privacy is protected. All information that would let someone identify you or your family will be kept private. Thoroughbred will not share your personal information with anyone without your OK. You may choose to answer this survey or not. If you choose not to, this will not affect the benefits you get. You may notice a number on the cover of this survey. This number is ONLY used to let us know if you returned the survey so we don’t have to send you reminders.
If you want to know more about this study, please call Thoroughbred 1-800-xxx-xxxx.
Revised to: The Centers for Medicare and Medicaid Services is conducting this survey of people with Medicaid to learn more about the care and services they receive. This survey will ask about your recent experiences receiving health care and should take about 20 minutes to complete. You may skip any questions that you do not feel comfortable answering. Your participation in this research is confidential, and we will not share your name or any other identifying information with any outside organization. You may notice a number on the cover of this survey. This number is ONLY used to let us know if you returned the survey. Please contact Thoroughbred Research Group at (XXX) XXX-XXXX with questions about this research.
Rationale: Updated consent language to fulfill NORC's IRB requirements for what information should be included in the informed consent process.
Q4a (now Q5):
Original: About how long has it been since you had a check-up by a doctor or other health professional? A check-up is a visit with a doctor or other health professional for…
Description of Change: Removed word "routine" before "check-up" and underlined "check-up".
Revised to: About how long has it been since you had a check-up by a doctor or other health professional? A check-up is a visit with a doctor or other health professional for…
Rationale: To make question clearer.
Q6a (now Q8):
Original: During the past 6 months, how many times have you gone to a hospital emergency room about your own health (This includes emergency room visits that resulted in a hospital admission.)?
Description of Change: Removed period at end of "admission"; removed "hospital" from before "emergency room".
Revised to: During the past 6 months, how many times have you gone to an emergency room about your own health (This includes emergency room visits that resulted in a hospital admission)?
Rationale: Fixed a typo and made the question clearer.
Q6b (now Q9):
Original: Which of these best describes your last hospital emergency room visit? Choose one.
Description of Change:
Changed
to “What was the main reason for…”; deleted
“hospital” before “emergency room”.
Revised to: What was the main reason for your last emergency room visit? Choose one.
Rationale: To make question clearer.
Q7 (now Q10):
Original:
In the last 6 months, not counting the times you went to an
emergency room, how many times did you go to a doctor’s office
or clinic to get health care for yourself?
None → If None,
Go to Question 14d1.
Description of Change: Changed skip pattern for "None" to go to Question 16.
Revised to:
In
the last 6 months, not counting the times you went to an emergency
room, how many times did you go to a doctor’s office or clinic
to get health care for yourself?
None → If None, Go to
Question 16.
Rationale: To point skip pattern to correct question - Because it is possible an individual did not have an office visit but still went to the ED, we still want to collect information on their ratings of the health care received.
Q14a (now Q18):
Original: In the last 6 months, how often was it easy to get special medical equipment, such as a cane, a wheelchair, or oxygen equipment, you needed?
Description of Change: Underlined “special medical equipment” to be consistent with 14b and 14c (now Q19, Q20).
Revised to: In the last 6 months, how often was it easy to get special medical equipment, such as a cane, a wheelchair, or oxygen equipment, you needed?
Rationale: To be consistent with similar questions and make subject of question stand out.
Q14d2 (now Q21):
Original: Which of these best describes the main reason you were unable to get medical care, tests, or treatments you or a doctor believed necessary? Choose one.
Description of Change:
Changed to “What was the main reason…”
Revised to: What was the main reason you were unable to get medical care, tests, or treatments you or a doctor believed necessary? Choose one.
Rationale: To make question clearer.
Q14b (now Q19):
Original: In the last 6 months, how often was it easy to get the mental health or behavioral health treatment or counseling you needed?
Never
Sometimes
Usually
Always
Did not need this type of treatment
Description of Change: Replaced underlined statement with “mental health or behavioral health services”; replaced “Did not need this type of treatment” response option with “Did not need these services”.
Revised to: In the last 6 months, how often was it easy to get the mental health or behavioral health services you needed?
Never
Sometimes
Usually
Always
Did not need these services
Rationale: To make question and response option clearer.
Q14c (now Q20):
Original: In the last 6 months, how often was it easy to get the dental services you needed?
Never
Sometimes
Usually
Always
Did not need this type of treatment
Description of Change: Replaced “Did not need this type of treatment” response option with “Did not need these services”.
Revised to: In the last 6 months, how often was it easy to get the dental services you needed?
Never
Sometimes
Usually
Always
Did not need these services
Rationale: To make response option clearer and consistent across question type.
Q14d1 (now Q21):
Original: In the last 6 months, were you unable to get medical care, tests, or treatments you or a doctor believed necessary?
Description of Change: Underlined “unable to get” to be consistent with 14d2 (now Q22).
Revised to: In the last 6 months, were you unable to get medical care, tests, or treatments you or a doctor believed necessary?
Rationale: To be consistent with similar questions and make subject of question stand out.
Q14d2 (now Q22):
Original: What is the main reason you were unable to get medical care, tests, or treatments you or a doctor believed necessary? Choose one.
Couldn’t afford care
My health plan wouldn’t approve, cover, or pay for care
Doctor refused to accept my insurance
Problems getting to doctor's office
Speak a different language
Couldn’t get time off work
Didn’t know where to go to get care
Couldn’t get child care
Didn’t have time or took too long
Description of Change: Modified response option “Speak a different language” to “Doctor doesn’t speak my language”; moved new “Doctor doesn’t speak my language” response option to appear immediately after the “Doctor refused to accept my insurance” response option; moved “Couldn’t get child care” response option to appear immediately after “Couldn’t get time off work” response option.
Revised to: What is the main reason you were unable to get medical care, tests, or treatments you or a doctor believed necessary? Choose one.
Couldn’t afford care
My health plan wouldn’t approve, cover, or pay for care
Doctor refused to accept my insurance
Doctor doesn’t speak my language
Couldn’t get time off work
Couldn’t get child care
Problems getting to doctor's office
Didn’t know where to go to get care
Didn’t have time or took too long
Rationale: To streamline and clarify response options.
Q14e2 (now Q24):
Original: Why don’t you have a usual source of medical care? Mark one or more, then →Go to Question 24
Don't need a doctor/Haven't had any problems
Don't like/trust/believe in doctors
Don't know where to go
Previous doctor is not available/moved
No doctors take my insurance
Speak a different language
No care available/Care too far away, not convenient
Put it off/Didn't get around to it
Other
Description of Change: Deleted the following response options: “Don’t like/trust/believe in doctors”, “Don’t know where to go”, “Previous doctor is not available/moved”, and “Put it off/Didn’t get around to it”.
Modified “Don't need a doctor/Haven't had any problems” response option to “Haven't had any medical problems” [added “medical”]. Split “No care available/Care too far away, not convenient” response option into two separate responses: “No doctor is available” [deleted “care” and added “doctor”] and “Doctor’s office is too far away or not convenient” [deleted “care” and added “Doctor’s office is” and “or”].
Replaced “Speak a different language” response option with “No doctors speak my language”. Added response option “Don't plan to see a doctor when I'm sick or need advice about my health”.
Revised to: Why don’t you have a usual source of medical care? Mark one or more, then →Go to Question 35
Haven't had any medical problems
No doctors take my insurance
No doctors speak my language
No doctor is available
Doctor's office is too far away or not convenient
Don't plan to see a doctor when I'm sick or need advice about my health
Other
Rationale: To clarify and reduce the number of potentially overlapping response options.
Q14e3 (now Q25):
Original: What kind of place do you go to most often - a clinic, doctor's office, emergency room, or some other place? Choose one.
Description of Change: Removed “- a clinic, doctor's office, emergency room, or some other place” and replace with “for your medical care”
Revised to: What kind of place do you go to most often for your medical care? Choose one.
Rationale: To clarify question.
Q28 (Q40):
Original: In the last 6 months, how often did your health plan’s customer service give you the information or help you needed?
Description of Change: Added response option and skip pattern.
Revised to: "Did not try to get information or help → If No, Go to Question 42".
Rationale: Added response option and skip pattern for individuals who did not interact with the health plan's customer service - previously these individuals would have been asked to answer questions that do not apply to them.
Q34 (now Q55):
Original: In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider in your plan?
Description of Change: Underline “quit smoking or using tobacco”
Revised to: In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider in your plan?
Rationale: To make subject of question stand out.
Q35 (now Q56):
Original: In the last 6 months, how often was medication recommended or discussed by a doctor or health provider to assist you with quitting smoking or using tobacco? Examples of medication are: nicotine gum, patch, nasal spray, inhaler, or prescription medication.
Description of Change: Underline “quit smoking or using tobacco”
Revised to: In the last 6 months, how often was medication recommended or discussed by a doctor or health provider to assist you with quitting smoking or using tobacco? Examples of medication are: nicotine gum, patch, nasal spray, inhaler, or prescription medication.
Rationale: To make subject of question stand out and to make be consistent with similar questions.
Q36 (now Q57):
Original: In the last 6 months, how often did your doctor or health provider discuss or provide methods and strategies other than medication to assist you with quitting smoking or using tobacco? Examples of methods and strategies are: telephone helpline, individual or group counseling, or cessation program.
Description of Change: Underline “quit smoking or using tobacco”
Revised to: In the last 6 months, how often did your doctor or health provider discuss or provide methods and strategies other than medication to assist you with quitting smoking or using tobacco? Examples of methods and strategies are: telephone helpline, individual or group counseling, or cessation program.
Rationale: To make subject of question stand out and to be consistent with similar questions.
Q40/Q41 (now Q61)
Original:
Q40.
Are
you aware that you have any of the following conditions? Mark one or
more.
High cholesterol
High blood pressure
Parent or
sibling with heart attack before the age of 60
Q41. Has a
doctor ever told you that you have any of the following conditions?
Mark one or more.
A heart attack
Angina or coronary heart
disease
A stroke
Any kind of diabetes or high blood sugar
Description of Change:
Combined
Q40 and Q41; Removed "Parent or sibling with heart attack
before the age of 60" option; Added “yes/no”
response option for each of the conditions; add additional
conditions listed in the MA & PDP CAHPS question; to the extent
possible, used language and added additional information from the
corresponding Medicare CAHPS question.
Revised to:
Has
a doctor ever told you that you have any of the following
conditions? Mark one or more.
Response options: Yes No
High
cholesterol?
High blood pressure?
A heart attack?
Angina
or coronary heart disease?
A stroke?
Any kind of
diabetes or high blood sugar?
Cancer, other than skin cancer?
Emphysema, asthma or COPD (chronic obstructive pulmonary
disease)?
Rationale: Needed a response option for if the individual does not have any of the conditions. The MA & PDP CAHPS survey has a question like this so we used the question from this survey.
Q50 (now Q70):
Original: 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
Description of Change: Add response option “Some other race”
Revised to: What is your race? Mark one or more.
White
Black or African-American
…
Samoan
Other Pacific Islander
Some other race
Rationale: To capture responses that do not match to existing race categories in the list.
Q51 (now Q71):
Original:
Did
someone help you complete this survey?
Yes →If Yes, Go to
Question 52.
No Thank you. Please return the completed survey
in the postage-paid envelope.
Description of Change: Added arrow between the “No” option and the instruction to return the survey.
Revised to: Did
someone help you complete this survey?
Yes →If Yes, Go to
Question 72.
No →Thank you. Please return the completed
survey in the postage-paid envelope.
Rationale: To be consistent with other skip pattern responses.
New addition before Q33:
Original: N/A
Description of Change: Added new question and response options.
Revised to: Have you had a flu shot since September 1, 2013?
Yes
No
Don’t know
Rationale: Question added due to CMS request.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | M Colicchia |
| File Modified | 0000-00-00 |
| File Created | 2021-01-28 |