Form CMS-10482 Attachment D - Medicare Beneficiaries Survey and Corresp

Attachment D: Survey of Medicare Beneficiaries and Correspondence




Survey of Medicare Beneficiaries
Survey of Medicare Beneficiaries Correspondence

D-1

Survey of Medicare Beneficiaries
Date
United States Department of Health and Human Services
Centers for Medicare & Medicaid Services

[First], [Last]
[MPRID]
[BARCODE]

Survey Instructions


Answer each question by marking the box to the left of your answer.



You are sometimes told to skip over some questions in this survey. When this happens you will see
an arrow with a note that tells you what question to answer next, like this:
Yes
No



Go to #1

If you have any questions or need help completing the survey, please call Mathematica toll-free at
XXX-XXX-XXXX or email [email address].

Please begin the survey now.
3

YOUR CARE FROM THIS PROVIDER IN THE
LAST 12 MONTHS

YOUR PROVIDER
1.

Our records show that you got care from the
provider named below in the last 12 months.

Name of provider label goes here

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 went for dental care visits.
4.

In the last 12 months, how many times did you
visit this provider to get care for yourself?
0

Is that right?
1

Yes

0

No → Go to #50

None → Go to #50
1 time
2
3
4
5 to 9
10 or more times

1a. What is this provider’s specialty?
1

5

Internal Medicine
2
Family Medicine
3
Cardiology
4
Nephrology

6

APPOINTMENTS AND WAIT TIMES
Oncology
Other: __________
__________ _____

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.

Yes

0

No

How long have you been going to this provider?
1

Less than 6 months
At least 6 months but less than 1 year
3
At least 1 year but less than 3 years
4
At least 3 years but less than 5 years
5
5 years or more
2

In the last 12 months, did you make any
appointments for a check-up or routine care
with this provider?
1

6.

Is this the provider you usually see if you need a
check-up, want advice about a health problem, or
get sick or hurt?
1

3.

5.

0

No → Go to #8

Some offices remind patients between visits
about tests, treatment or appointments. In the last
12 months, did you get any reminders from this
provider’s office between visits?
1

7.

Yes

Yes

0

No

Wait time includes time spent in the waiting
room and exam room. In the last 12 months, how
often did you see this provider within 15
minutes of your appointment time?
1

Never
Sometimes
3
Usually
4
Always
2

14. In the last 12 months, how often did this provider
spend enough time with you?

COMMUNICATION
8.

In the last 12 months, how often did this provider
explain things in a way that was easy to
understand?
1

Never
Sometimes
3
Usually
4
Always

1

Never
Sometimes
3
Usually
4
Always
2

2

9.

TESTING AND TEST RESULTS

In the last 12 months, how often did this provider
listen carefully to you?

15. In the last 12 months, did this provider order a
blood test, x-ray, or other test for you?
1

Yes

0

No→ Go to #17

1

Never
Sometimes
3
Usually
4
Always
2

16. In the last 12 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?

10. In the last 12 months, did you talk with this
provider about any health questions or concerns?

1

Never
Sometimes
3
Usually
4
Always
2

1

Yes

0

No→ Go to #12

11. In the last 12 months, how often did this provider
give you easy to understand information about
these health questions or concerns?
1

Never
2
Sometimes
3
Usually
4
Always
12. In the last 12 months, how often did this provider
seem to know the important information about
your medical history?

PRESCRIPTION MEDICATIONS
17. In the last 12 months, did you take any
prescription medicine?
1

1

13. In the last 12 months, how often did this provider
show respect for what you had to say?
Never
Sometimes
3
Usually
4
Always
2

No → Go to #23

Yes

0

No→ Go to #21

19. When you talked about starting or stopping a
prescription medicine, how much did this
provider talk about the reasons you might want to
take a medicine?
1

Not at all
A little
3
Some
4
A lot
2

1

0

18. In the last 12 months, did you and this provider
talk about starting or stopping a prescription
medicine?

1

Never
2
Sometimes
3
Usually
4
Always

Yes

20. When you talked about starting or stopping a
prescription medicine, how much did this
provider talk about the reasons you might not
want to take a medicine?
1

Not at all
A little
3
Some
4
A lot
21. In the last 12 months, did this provider ask about
medications prescribed for you by another health
professional such as a specialist or a dentist?
Yes

0

No → Go to #23

22. Did this provider review the medications you
were prescribed by other health professionals to
make sure they were okay to take with
medications prescribed by him or her?
1

Yes

1

Yes

0

No

EMOTIONAL HEALTH & PERSONAL ISSUES

2

1

25. Do you believe the care you have received in the
last 12 months has been focused on your specific
goals for your health?

0

No

-9

Don’t know

26. In the last 12 months, did anyone in this
provider’s office ask you if there was a period of
time when you felt sad, empty, or depressed?
1

Yes

0

No

27. In the last 12 months, did you and anyone in this
provider’s office talk about things in your life
that worry you or cause you stress?
1

Yes

0

No

28. In the last 12 months, did you and anyone in this
provider’s office talk about a personal problem,
family problem, alcohol use, drug use, or a
mental or emotional illness?

RATING OF PROVIDER
1

23. 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

0

No

TOBACCO USE
29. Do you now smoke cigarettes or use tobacco
every day, some days, or not at all?
Every day
Some days
3
Not at all→ Go to #31
2

30. In the last 12 months, how often were you
advised to quit smoking or using tobacco by this
provider?
1

Never
Sometimes
3
Usually
4
Always
2

24. In the last 12 months, did anyone in this
provider’s office talk with you about specific
goals for your health?
Yes

0

1

INVOLVEMENT IN CARE

1

Yes

No → Go to #26

ALCOHOL USE

OSTEOPOROSIS SCREENING & DIAGNOSIS

31. In the past 12 months, have you had excessive
use of alcohol?
1
0
Yes
No

36. Has this provider talked to you about
osteoporosis and fracture prevention?
1

32. In the past 12 months, has this provider talked
with you about alcohol use?
1

0

Yes

33. Have you had a flu shot within the past year?
0

Yes

0

No

-9

Don’t know

NOTE: If you are 65 years or older AND female,
please answer #37 and #38. Otherwise, skip to #39.

No

VACCINATIONS

1

Yes

37. Have you ever had a bone density test to check
for osteoporosis, sometimes thought of as
“brittle bones”? This test may have been done to
your back, hip, wrist, heel or finger.
1

No

34. Have you ever had a pneumonia shot? This shot
is usually given only once or twice in a person’s
lifetime and is different from a flu shot. It is also
called the pneumococcal vaccine.
1

Yes
No
-9
Don’t know

Yes

0

No

-9

Don’t know

38. Have you been diagnosed with osteopenia or
osteoporosis?
1

Yes

0

No

-9

Don’t know

WEIGHT CONTROL

0

39. In the past 12 months, has anyone in this
provider’s office told you your body mass index
(BMI) value?

COLON CANCER SCREENING
NOTE: If you are 50 years or older, please answer
#35. Otherwise, skip to #36.
35. Sigmoidoscopy and colonoscopy are exams in
which a tube is inserted in the rectum to view the
colon for signs of cancer or other health
problems. Have you ever had either of these
exams?
1

Yes

0

No

-9

Don’t know

1

Yes
No
-9
Don’t know→ Go to note before #41.
0

40. In the past 12 months, has anyone in this
provider’s office given you advice about your
weight based on your BMI?
1

Yes, lose weight
Yes, gain weight
3
Yes, maintain current weight
0
No
2

URINARY LEAKAGE

SPECIALIST CARE

NOTE: If you are female, please answer #41 and, if
applicable, #42 and #43. If you are male, skip to #44.

48. Specialists are doctors like surgeons, heart
doctors, allergy doctors, skin doctors, and other
doctors who specialize in one area of health care.
In the last 12 months, did you see a specialist for
a particular health problem?

41. Many people experience problems with urinary
incontinence, the leakage of urine. In the past 12
months, have you accidentally leaked urine?

1
1

Yes

0

Yes

0

0

No → Go to #50

No → Go to #44

42. Have you talked with this provider about your
urine leakage problem?
1

Yes

No

49. In the last 12 months, how often did the provider
named in Question 1 seem informed and up-todate about the care you got from specialists?
1

Never
Sometimes
3
Usually
4
Always
2

43. Has this provider explained options available to
you to treat urinary incontinence? These may
include bladder training, exercises, medication
and surgery.
1

Yes

0

No

ABOUT YOU
50. In general, how would you rate your overall
health?
1

BLOOD PRESSURE

Excellent
Very good
3
Good
4
Fair
5
Poor
2

44. About how long has it been since you last had
your blood pressure taken at this provider’s
office?
1

Within the past 6 months (1 to 6 months ago)
Within the past year (7 to 12 months ago)
3
Within the past 2 years (1 to 2 years ago)
4
More than 2 years ago
2

51. In general, how would you rate your overall
mental or emotional health?
1

Excellent
Very good
3
Good
4
Fair
5
Poor
2

45. Has this provider EVER told you that you have
high blood pressure?
1

Yes

0

No → Go to #47
52. What is your age?

46. Are you currently taking medicine for your high
blood pressure?

1

18 to 24
25 to 34
3
35 to 44
4
45 to 54
5
55 to 64
6
65 to 69
7
70 to 74
8
75 to 79
9
80 to 84
10
85 or older
2

1

Yes

0

No

FALLS
47. Has this provider asked you if you have fallen in
the past year?
1

Yes

0

No

53. Are you male or female?
1
2

Male
Female

THANK YOU!

54. What is the highest grade or level of school that
you have completed?
1
2
3
4
5
6

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

55. Are you of Hispanic or Latino origin or descent?
1
2

Yes, Hispanic or Latino
No, not Hispanic or Latino

56. What is your race? Mark one or more.
1
2
3
4
5
6

White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaskan Native
Other

HELP COMPLETING THE SURVEY
57. Did someone help you complete this survey?
1

Yes

0

No → Thank you.

58. How did that person help you? Mark one or
more.
1
2
3
4
5

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 describe the help received:
______________________
_
_________________________________

Please return the completed survey in the
postage-paid envelope.

Attachment D2. Survey of Medicare Beneficiaries: Correspondence

CMS LETTERHEAD

CMS Pre-Notification Letter to Medicare Beneficiaries
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
In recent years, the Centers for Medicare & Medicaid Services (CMS) has implemented a number of
programs and initiatives aimed at making health care more accessible, less costly, and of higher quality.
As a Medicare beneficiary, you have valuable insight into how well we are doing at achieving these
access, cost, and quality goals.
This letter is to invite you to participate in the Survey of Medicare Beneficiaries. The results from
the survey will help CMS (1) better understand the health status of Medicare beneficiaries, (2) learn how
beneficiaries communicate with their health care providers, and (3) learn about ways in which
beneficiaries are involved in their own care. As a courtesy, you will be sent a gift card for $2.
CMS has hired Mathematica Policy Research (Mathematica) to conduct this survey. In the near
future, Mathematica will be mailing you a copy of the survey. Although participating is your choice, we
strongly encourage you to complete the brief survey and return it the postage-paid envelope Mathematica
provides. Your input is critical so that CMS can determine if its programs and initiatives are meeting the
needs of Medicare beneficiaries.
The information you provide on the survey will be kept private to the full extent allowable by law.
You do not have to participate and, if you do participate, you can skip items you do not want to answer.
Information that is shared will be done in ways that do NOT allow you to be identified. Also,
participating in the survey will in no way impact your current or future Medicare benefits or the health
care that you receive.
If you have any questions, please call Kirsten Barrett, Mathematica’s Survey Director, at (202) 5547564 or email her at [email protected].
Thank you in advance for your assistance.
Sincerely,

Kate Goodrich, M.D., M.H.S.
Acting Director
Quality Measurement & Health Assessment Group
Center for Clinical Standards and Quality
Centers for Medicare & Medicaid Services

MATHEMATICA LETTERHEAD

Invitation Letter From Mathematica to Medicare Beneficiaries
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
We need your help with an important survey being conducted for the Centers for Medicare
& Medicaid Services (CMS). Your input is needed so that CMS can learn if and how its
programs and initiatives are meeting the goals of improving access to health care, reducing
health care cost, and improving health care quality for people like you.
You have been chosen to participate in the Survey of Medicare Beneficiaries. This brief,
10-minute survey will help CMS (1) better understand the health status of Medicare
beneficiaries, (2) learn how beneficiaries communicate with their health care providers, and (3)
learn about ways in which beneficiaries are involved in their own care. As a courtesy, you will be
sent a gift card for $2.

We hope you choose to complete this important survey. The information you provide will be
kept private to the extent allowable by law. Information that is shared will be done in ways that
do NOT allow you to be identified. Also, completing the survey will in no way affect your
current or future Medicare benefits or the health care that you receive.
We have included the survey as well as a postage-paid return envelope. If you have trouble
completing the survey by mail, please call Mathematica at . We will be happy to
help you complete the survey over the phone.
If you have any questions, please call our help desk number at or email us at
.
Thank you in advance for helping us with this important effort.
Sincerely,

Kirsten Barrett, Ph.D.
Senior Survey Researcher
Mathematica Policy Research
Enclosures: (2)

MATHEMATICA LETTERHEAD

Reminder Letter #1 from Mathematica to Medicare Beneficiaries
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
A couple of weeks ago, we sent you a letter inviting you to participate in the Survey of
Medicare Beneficiaries. This important survey, sponsored by the Centers for Medicare &
Medicaid Services (CMS), will help CMS learn if and how its programs and initiatives are
meeting the goals of improving access to health care, reducing health care cost, and improving
health care quality for people like you.
If you have completed and returned the survey, please accept our thanks. If you have not yet
completed and returned the survey, please do so as soon as possible. The survey takes about 10
minutes to complete. The information you provide will be kept private. Information that is shared
will be done in ways that do NOT allow you to be identified. Also, completing the survey will in
no way affect your current or future Medicare benefits or the health care that you receive.
If you have trouble completing the survey by mail, please call Mathematica at .
We will be happy to help you complete the survey over the phone.
If you have any questions or need a new copy of the survey, please call our help desk
number at or email us at .
Thank you in advance for helping us with this important effort.
Sincerely,

Kirsten Barrett, Ph.D.
Senior Survey Researcher
Mathematica Policy Research

MATHEMATICA LETTERHEAD

Reminder Letter #2 from Mathematica to Medicare Beneficiaries
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
The Survey of Medicare Beneficiaries will soon be ending. This important survey,
sponsored by the Centers for Medicare & Medicaid Services (CMS), will help CMS learn if and
how its programs and initiatives are meeting the goals of improving access to health care,
reducing health care cost, and improving health care quality for people like you.
Please consider completing and returning the survey today. It takes about 10 minutes to
complete. The information you provide will be kept private. Information that is shared will be
done in ways that do NOT allow you to be identified. Also, completing the survey will in no way
affect your current or future Medicare benefits or the health care that you receive.
If you have trouble completing the survey by mail, please call Mathematica at .
We will be happy to help you complete the survey over the phone.
If you have any questions or need a new copy of the survey, please call our help desk
number at or email us at .
Thank you in advance for helping us with this important effort.
Sincerely,

Kirsten Barrett, Ph.D.
Senior Survey Researcher
Mathematica Policy Research

MATHEMATICA LETTERHEAD

Final Letter from Mathematica to Medicare Beneficiaries
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
The Survey of Medicare Beneficiaries will end on [MONTH DATE, YEAR]. There is still
time for you to complete the 10-minute survey! The survey, sponsored by the Centers for
Medicare & Medicaid Services (CMS), will help CMS learn if and how its programs and
initiatives are meeting the goals of improving access to health care, reducing health care cost,
and improving health care quality for people like you.
The information you provide will be kept private. Information that is shared will be done in
ways that do NOT allow you to be identified. Also, completing the survey will in no way affect
your current or future Medicare benefits or the health care that you receive.
If you have trouble completing the survey by mail, please call Mathematica at .
We will be happy to help you complete the survey over the phone.
If you have any questions or need a new copy of the survey, please call our help desk
number at or email us at .
Thank you in advance for helping us with this important effort.
Sincerely,

Kirsten Barrett, Ph.D.
Senior Survey Researcher
Mathematica Policy Research