Cms-p-0015a Mcbs

Usual Source of Care (USQ)
Variable Name
MR Screen Name
PLACEPAR
US1

Question type
yes/no

Question text/description
Is there a particular medical person doctor or other health professional, or a clinic [you/(SP)] usually
[go/goes] to when [you are/he is/she is] sick or for advice about [your/his/her] health?

PLACEKND

code one

What kind of place [do you/does (SP)] usually go to when [you are/he is/she is] sick or for advice about
[your/his/her] health -- is that a managed care plan or HMO center, a clinic, a doctor's or other health
professional's office, a hospital, or some other place?

US2

IF CLINIC, ASK: Is it a hospital outpatient clinic, or some other kind of clinic?
IF SOME OTHER PLACE, ASK: Where is this?

PLACEOS

US2
BOX USB

text
routing

PLACEMCP

US2A

yes/no

BOX USC

routing

US3A

verbatim text

CLNAME

OTHER (SPECIFY)
IF SP WAS COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND, GO TO US2A PLACEMCP.
ELSE IF US2 - PLACEKND = 1/DoctorsOffice, GO TO US5A - MDNAME.
ELSE GO TO US3A - CLNAME.
Is this (doctor or other health professional/medical clinic) associated with [your/his/her] [READ MANAGED (01) YES
CARE PLAN NAME(S) BELOW] plan?
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
IF US2 - PLACEKND = 1/DoctorsOffice, GO TO US5A - MDNAME.
ELSE GO TO US3A - CLNAME.
What is the complete name of the [place/managed care plan or HMO center/(US2 RESPONSE)] that [you go (01) continuous answer
to/(SP) goes to]?
[ENCOURAGE THE RESPONDENT TO REFER TO A BILL, TELEPHONE DIRECTORY, APPOINTMENT CARD, ETC.,
FOR COMPLETE INFORMATION.]
Is there a particular doctor or other health professional [you usually see/(SP) usually sees] at this
[place/managed care plan or HMO center/(US2 RESPONSE)]?

USUALDOC

US4

yes/no

MDNAME

US5A

verbatim text

What is the complete name of that doctor or other health professional?

code one

[ENCOURAGE THE RESPONDENT TO REFER TO A BILL, TELEPHONE DIRECTORY, APPOINTMENT CARD, ETC.,
FOR COMPLETE INFORMATION.]
Is (US5A PROVIDER NAME) a male or female?

MDSEX

US5B

Code List
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) DOCTOR'S OFFICE OR GROUP PRACTICE
(02) MEDICAL CLINIC
(03) MANAGED CARE PLAN CENTER/HMO
(04) NEIGHBORHOOD/FAMILY HEALTH CENTER
(05) FREESTANDING SURGICAL CENTER
(06) RURAL HEALTH CLINIC
(07) COMPANY CLINIC
(08) OTHER CLINIC
(09) WALK-IN URGENT CENTER
(10) DOCTOR COMES TO SP'S HOME
(11) HOSPITAL EMERGENCY ROOM
(12) HOSPITAL OUTPATIENT DEPARTMENT/CLINIC
(13) VA FACILITY
(14) MENTAL HEALTH CENTER
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER

(01) MALE
(02) FEMALE
(-8) DON’T KNOW
(-9) REFUSED

Usual Source of Care (USQ)
Variable Name
MR Screen Name
MDSPEC
US6A

Question type
code one

MDSPECOS

text

US6A

Question text/description
SHOW CARD AC1

Code List
(01) ALLERGY/IMMUNOLOGY
(02) ANESTHESIOLOGY
What is (US5A PROVIDER NAME)'s specialty?
(03) CARDIOLOGY (HEART)
(05) DERMATOLOGY (SKIN)
[PROBE FOR RESPONDENT TO SELECT A CHOICE FROM THE CARD IF THEY MENTION A 'GENERIC' SPECIALITY (06) EMERGENCY ROOM PHYSICIAN
LIKE ‘HEART DOCTOR.’ IF RESPONDENT ONLY GIVES A 'GENERIC' SPECIALTY AND THE GENERIC WORD IS
(07) ENDOCRINOLOGY/ METABOLISM (DIABETES, THYROID)
SHOWN IN PARENTHESES FOLLOWING ONE OF THE RESPONSES, SELECT THE RESPONSE CATEGORY FOR
(08) FAMILY PRACTICE
THAT SPECIALTY (E.G., 'CARDIOLOGY'). OTHERWISE SELECT 'OTHER DR SPECIALTY'.]
(09) GASTROENTEROLOGY
(10) GENERAL PRACTICE
(11) GENERAL SURGERY
(12) GERIATRICS (ELDERLY)
(13) GYNECOLOGY - OBSTETRICS
(14) HEMATOLOGY (BLOOD)
(15) HOSPITAL RESIDENCE
(16) INTERNAL MEDICINE (INTERNIST)
(17) NEPHROLOGY (KIDNEYS)
(18) NEUROLOGY
(19) NUCLEAR MEDICINE
(20) ONCOLOGY (TUMORS, CANCER)
(21) OPHTHALMOLOGY (EYES)
(22) ORTHOPEDICS
(24) OSTEOPATHY (DO)
(25) OTORHINOLARYNGOLOGY (EAR, NOSE, THROAT)
(26) PATHOLOGY
(27) PHYS MED/REHAB
(28) PLASTIC SURGERY
(29) PROCTOLOGY
(30) PSYCHIATRY/PSYCHIATRIST
(31) PULMONARY (LUNGS)
OTHER DR SPECIALTY (SPECIFY)
(01) CONTINUOUS ANSWER
[PROBE FOR RESPONDENT TO SELECT A CHOICE FROM THE CARD IF THEY MENTION A 'GENERIC' SPECIALITY
LIKE ‘HEART DOCTOR.’ IF RESPONDENT ONLY GIVES A 'GENERIC' SPECIALTY AND THE GENERIC WORD IS
SHOWN IN PARENTHESES FOLLOWING ONE OF THE RESPONSES, SELECT THE RESPONSE CATEGORY FOR
THAT SPECIALTY (E.G., 'CARDIOLOGY'). OTHERWISE SELECT 'OTHER DR SPECIALTY'.]

GETUSHOW

BOX US1

routing

US8

code one

IF US2 - PLACEKND = 10/AtHome, GO TO US15 - USHOWLNG.
ELSE GO TO US8 - GETUSHOW.
How [do you/does (SP)] usually get to [(US5A PROVIDER NAME)'S office/(US3A PROVIDER NAME)]?
[EXPLAIN IF NECESSARY: [Do you/Does (SP)] get there by walking, driving, being driven by someone else,
by ambulance or other special vehicle for disabled people, by taxi, other public transportation, or some
other way?]

GETUSOS

US8

verbatim text

SOME OTHER WAY (SPECIFY)

(01) WALKING
(02) DRIVING
(03) BEING DRIVEN
(04) AMBULANCE OR OTHER SPECIAL VEHICLE
(05) TAXI
(06) OTHER PUBLIC TRANSPORTATION
(07) DR. USUALLY COMES TO HOME
(08) SeniorCitizenVan DO NOT DISPLAY.
(91) SOME OTHER WAY
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer

Usual Source of Care (USQ)
Variable Name
MR Screen Name
GETUSUNT
US9

Question type
code one

Question text/description
About how long does it usually take for [you/(SP)] to get there?

GETUSHRS
GETUSMIN
ACCOMPUS

numeric
numeric
yes/no

[Do you/Does (SP)] usually have someone accompany [you/him/her] there?

roster

Who usually goes with [you/(SP)]?

US9
US9
US10

PERSON_USUALGOUS11

PERSWITH

US11A1

code one

ACCREAS

US11AA

code all

ACCOTHOS
USHOWLNG

US11AA
US15

verbatim text
code one

PREVMEDC

US17

yes/no

BOX US2A

routing

Code List
(01) HOURS ONLY
(02) MINUTES ONLY
(03) HOURS AND MINUTES
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER

SELECT OR ADD ONLY ONE PERSON
How often [are you/is that person] with [you/(SP)] while [you/(SP)] [see/sees] the doctor or other medical (01) ALWAYS
person health professional? Would you say always, sometimes, or never?
(02) SOMETIMES
(03) NEVER
(-8) DON'T KNOW
(-9) REFUSED
What are the reasons [you accompany (SP)/this person accompanies you/this person accompanies (SP)]
(01) WRITES DOWN WHAT DOCTOR SAYS/RECORDS
there? What [do you/does this person] do?
INSTRUCTIONS/TAKES NOTES/REMEMBERS
(02) GIVES INFORMATION/EXPLAINS SP'S MEDICAL
[PROBE: Any other reason?]
CONDITION OR NEEDS TO THE DOCTOR
(03) EXPLAINS DOCTOR’S INSTRUCTIONS TO SP
CHECK ALL THAT APPLY.
(04) ASKS QUESTIONS
(05) TRANSLATES LANGUAGE
(06) SCHEDULES APPOINTMENTS
(07) NOTHING/KEEPS SP COMPANY/SITS WITH SP/MORAL
SUPPORT
(08) TRANSPORTATION
(09) SP NEEDS PHYSICAL ASSISTANCE
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
(01) continuous answer
SHOW CARD US1
(01) LESS THAN 1 YEAR
(02) 1 YEAR TO LESS THAN 3 YEARS
How long [have you/has (SP)] been [seeing (US5A PROVIDER NAME)/going to (US3A PROVIDER NAME)]?
(03) 3 YEARS TO LESS THAN 5 YEARS
(04) 5 YEARS TO LESS THAN 10 YEARS
(05) 10 YEARS OR MORE
(-8) DON'T KNOW
(-9) REFUSED
Before [you/(SP)] started [seeing (US5A PROVIDER NAME)/going to (US3A PROVIDER NAME)], had
(01) YES
[you/(SP)] usually been going to some other place or seeing some other doctor or other health professional (02) NO
for medical care?
(-8) DON'T KNOW
(-9) REFUSED
IF SP IS IN THE SUPPLEMENTAL SAMPLE, GO TO US27 - USCKEVRY.
ELSE GO TO US37A - SPCLCARE.

Usual Source of Care (USQ)
Variable Name
MR Screen Name
USCKEVRY
US27

Question type
list

USCOMPET

US27

list

USUNHIST

US27

list

USUNWRNG

US27

list

USHURRY

US27

list

USEXPPRB

US32

list

USDISCUS

US32

list

Question text/description
SHOW CARD US3

Code List
(01) STRONGLY AGREE
(02) AGREE
Now I am going to read some statements people have made about their health care. Think about the care (03) DISAGREE
[you receive/(SP) receives] from (US5A PROVIDER NAME/US3A PROVIDER NAME). For each statement,
(04) STRONGLY DISAGREE
please tell me whether you strongly agree, agree, disagree, or strongly disagree.
(05) NOT APPLICABLE
(-8) Don't Know
[(US5A PROVIDER NAME) is/The doctors or other health professionals at (US3A PROVIDER NAME) are] very (-9) Refused
careful to check everything when examining [you/him/her].
SHOW CARD US3
(01) STRONGLY AGREE
(02) AGREE
[(US5A PROVIDER NAME) is/The doctors or other health professionals at (US3A PROVIDER NAME) are]
(03) DISAGREE
competent and well-trained.
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
SHOW CARD US3
(01) STRONGLY AGREE
(02) AGREE
[(US5A PROVIDER NAME) has/The doctors or other health professionals at (US3A PROVIDER NAME) have] a (03) DISAGREE
good understanding of [your/his/her] medical history.
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
SHOW CARD US3
(01) STRONGLY AGREE
(02) AGREE
[(US5A PROVIDER NAME) has/The doctors or other health professionals at (US3A PROVIDER NAME) have] a (03) DISAGREE
complete understanding of the things that are wrong with [you/him/her].
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
SHOW CARD US3
(01) STRONGLY AGREE
(02) AGREE
[(US5A PROVIDER NAME) often seems/The doctors or other health professionals at (US3A PROVIDER
(03) DISAGREE
NAME) often seem] to be in a hurry.
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
SHOW CARD US3
(01) STRONGLY AGREE
(02) AGREE
[Think about the care [you/(SP)] [receive/receives] from [(US5A PROVIDER NAME)/(US3A PROVIDER
(03) DISAGREE
NAME)].]
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
[(US5A PROVIDER NAME) often does/The doctors or other health professionals at (US3A PROVIDER NAME) (-8) Don't Know
often do] not explain [your/his/her] medical problems to [you/him/her].
(-9) Refused
SHOW CARD US3
(01) STRONGLY AGREE
(02) AGREE
[You/(SP)] often [have/has] health problems that should be discussed but are not.
(03) DISAGREE
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused

Usual Source of Care (USQ)
Variable Name
MR Screen Name
USFAVOR
US32

Question type
list

USTELALL

US32

list

USANSQUX

US32

list

USCONFID

US37

list

USDEPEND

US37

list

SPCLCARE

US37A

yes/no

DRINFRMD

US37B

code one

Question text/description
SHOW CARD US3

Code List
(01) STRONGLY AGREE
(02) AGREE
[(US5A PROVIDER NAME) often acts/The doctors or other health professionals at (US3A PROVIDER NAME) (03) DISAGREE
often act] as though [(he/she) was/they were] doing [you/(SP)] a favor by talking to [you/him/her].
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
SHOW CARD US3
(01) STRONGLY AGREE
(02) AGREE
[(US5A PROVIDER NAME) tells/The doctors or other health professionals at (US3A PROVIDER NAME) tell]
(03) DISAGREE
[you/him/her] all [you want/he wants/she wants] to know about [your/his/her] condition and treatment. (04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
SHOW CARD US3
(01) STRONGLY AGREE
(02) AGREE
[(US5A PROVIDER NAME) answers/The doctors or other health professionals at (US3A PROVIDER NAME)
(03) DISAGREE
answer] all [your/his/her] questions.
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
SHOW CARD US3
(01) STRONGLY AGREE
(02) AGREE
[Think about the care [you/(SP)] [receive/receives] from (US5A PROVIDER NAME/US3A PROVIDER NAME).] (03) DISAGREE
(04) STRONGLY DISAGREE
[You have/(SP) has] great confidence in [(US5A PROVIDER NAME)/the doctors or other health professionals (05) NOT APPLICABLE
at (US3A PROVIDER NAME)].
(-8) Don't Know
(-9) Refused
SHOW CARD US3
(01) STRONGLY AGREE
(02) AGREE
[You depend/(SP) depends] on [(US5A PROVIDER NAME)/the doctors or other health professionals at
(03) DISAGREE
(US3A PROVIDER NAME)] in order to feel better both physically and emotionally.
(04) STRONGLY DISAGREE
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
SHOW CARD AC1
(01) YES
(02) NO
Specialists are doctors or other health professionals who specialize in one area of health care. This card
(-8) DON'T KNOW
lists some examples of specialists.
(-9) REFUSED
In the last 6 months, did [you/(SP)] receive care from any specialists outside the office of [(US5A PROVIDER
NAME)/the doctors or other health professionals at (US3A PROVIDER NAME)]?
SHOW CARD US2
(01) NEVER
(02) SOMETIMES
In general, how often [does (US5A PROVIDER NAME)/do the doctors or other health professionals at (US3A (03) USUALLY
PROVIDER NAME)] seem informed and up-to-date about the care [you get/(SP) gets] from specialists?
(04) ALWAYS
(-8) Don't Know
(-9) Refused

Usual Source of Care (USQ)
Variable Name
MR Screen Name
REMINDDR
US37C

Question type
code one

SPCLSTPM

US37D

yes/no

TALKPMS

US37E

code one

SPCLNAME

US37E1

verbatim text

Question text/description
SHOW CARD US2

Code List
(01) NEVER
(02) SOMETIMES
In general, how often [do you/does(SP)] have to remind [(US5A PROVIDER NAME)/the doctors or other
(03) USUALLY
health professionals at (US3A PROVIDER NAME)] about care [you receive/(SP) receives] from specialists?
(04) ALWAYS
(-8) Don't Know
(-9) Refused
In the last 6 months, did any specialists outside the office of [(US5A PROVIDER NAME)/the doctors or other (01) YES
health professionals at (US3A PROVIDER NAME)] prescribe medicine for [you/(SP)]?
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
SHOW CARD US2
(01) NEVER
(02) SOMETIMES
In general, how often [does (US5A PROVIDER NAME)/do the doctors or other health professionals at (US3A (03) USUALLY
PROVIDER NAME)] talk with [you/(SP)] about the medicines prescribed by these specialists?
(04) ALWAYS
(-8) Don't Know
(-9) Refused
The next four questions ask about care [you/(SP)] received from the specialist [you/he/she] saw most often (01) continuous answer
in the last 6 months outside the office of [(US5A PROVIDER NAME)/the doctors or other health
professionals at (US3A PROVIDER NAME)].
First, what is the name of the specialist [you/(SP)] saw most often in the last 6 months?

SPCLSEX

US37E2

code one

SPCLKNOW

US37F

code one

[ENCOURAGE THE RESPONDENT TO REFER TO A BILL, TELEPHONE DIRECTORY, APPOINTMENT CARD, ETC.,
FOR COMPLETE INFORMATION.]
Is [(US37E1 PROVIDER NAME)/the specialist you saw most often in the last six months] a male or female?

(01) MALE
(02) FEMALE
(-8) DON’T KNOW
(-9) REFUSED
[IF NEEDED: This question is about the last six months, that is since {CurrentMonth – 6}.]
(01) YES, DEFINITELY
(02) YES, SOMEWHAT
The next questions ask about care [you/(SP)] received from the specialist [you/he/she] saw most often in (03) NO
the last six months outside the [office of (US5A PROVIDER NAME)/the doctors or other health professionals (-8) Don't Know
at (US3A PROVIDER NAME)].
(-9) Refused
When [you see/(SP) sees] see [(US37E1-SPCLNAME)/this specialist], does [he/she/he or she] seem to know
enough information about [your/his/her] medical history?

RPTINFO

US37G

code one

KNOWTEST

US37H

code one

[IF YES, THEN PROBE: Would you say definitely yes or somewhat yes?]
SHOW CARD US2

(01) NEVER
(02) SOMETIMES
When [you see/(SP) sees] [(US37E1-SPCLNAME)/this specialist], how often [do you/does (SP)] have to
(03) USUALLY
repeat information that [you/he/she] [have/has] already given to [(US5A PROVIDER NAME)/the doctors or (04) ALWAYS
other health professionals at (US3A PROVIDER NAME)]?
(-8) Don't Know
(-9) Refused
SHOW CARD US2
(01) NEVER
(02) SOMETIMES
When [you see/(SP) sees] [(US37E1-SPCLNAME)/this specialist], how often does this specialist [he/she/he (03) USUALLY
or she] seem to know all of [your/his/her] test results from other providers?
(04) ALWAYS
(-8) Don't Know
(-9) Refused

Usual Source of Care (USQ)
Variable Name
MR Screen Name
RECORDNA
US37I

Question type
code one

UNMEDTST

US37J

code one

EMEDREC

US37K

yes/no

NUSNOTSK

US39

list

NUSMOVIN

US39

list

NUSAVAIL

US39

list

USWHYNAV

US42

code one

USWHYNO1
NUSDIFFP

US42
US43

verbatim text
list

Question text/description
Code List
Now I’m going to ask you two questions about all the doctors or other health professionals [you have/(SP) (01) YES
has] seen in the past two years.
(02) NO
(03) NOT APPLICABLE
In the past two years, when getting care for a medical problem, was there ever a time when test results,
(04) NOT SURE
medical records, or reasons for referrals were not available at the time of [your/(SP)’s] scheduled doctor’s (-9) Refused
appointment with [your/(SP)'s] doctor or other health professional?
In the past 2 years, when getting care for a medical problem, was there ever a time when doctors or other (01) YES
health professionals ordered a medical test that [you/(SP)] felt was unnecessary because the test had
(02) NO
already been done?
(03) NOT APPLICABLE
(04) NOT SURE
(-9) Refused
Many health care providers are beginning to use electronic or computer-based medical records instead of (01) YES
using paper-based records. When you visit [(US5A PROVIDER NAME)/the doctors or other health
(02) NO
professionals at (US3A PROVIDER NAME)] [does he or she/do they] generally enter your health information (-8) Don't Know
into a computer while you are present?
(-9) Refused
[EXPLAIN IF NECESSARY: An “electronic health record” is an electronic version of a patient’s medical history
maintained by a provider over time. It automates the way in which doctors can access patient health
information. "Health Information" includes information such as symptoms, vital signs, test results, or
prescribed medicines.]
I am going to read some reasons that people have given for not having a usual source of health care. For (01) YES
each one, please tell me whether or not it is a reason [you do/(SP) does] not have a usual place for health (02) NO
care.
(-8) DON'T KNOW
(-9) REFUSED
There is no reason to have a usual source of health care because [you/(SP)] seldom or never [get/gets] sick.
[Is that a reason [you do/(SP) does] not have a usual source of health care?]
[You/(SP)] recently moved into the area. [Is that a reason [you do/(SP) does] not have a usual source of
(01) YES
health care?]
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
[Your/(SP’s)] usual source of health care in this area is no longer available. [Is that a reason [you do/(SP)
(01) YES
does] not have a usual source of health care?]
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
Why is [your/(SP’s)] usual source of health care no longer available?
(01) PREVIOUS DOCTOR RETIRED
(02) PREVIOUS DOCTOR DIED
(03) PREVIOUS DOCTOR MOVED
(04) SP MOVED
(05) PREVIOUS DR/PLACE TOO FAR AWAY
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
Thinking about other possible reasons that people have for not having a usual source of health, please tell (01) YES
me if this statement applies to [you/(SP)]:
(02) NO
(-8) DON'T KNOW
[You like/(SP) likes] to go to different places for different health care needs. [Is that a reason [you do/(SP) (-9) REFUSED
does] not have a usual source of health care?]

Usual Source of Care (USQ)
Variable Name
MR Screen Name
NUSTOOFR
US43

Question type
list

Question text/description
The places where [you/(SP)] can receive health care are too far away. [Is that a reason [you do/(SP) does]
not have a usual source of health care?]

NUSTOOEX

US43

list

The cost of health care is too expensive. [Is that a reason [you do/(SP) does] not have a usual source of
health care?]

BOX USEND

routing

GO TO NEXT SECTION

Code List
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED