Form CMS--10437.GenIC#2 Beneficiary Telemedicine Survey- Questionnaire

C MS Beneficiary Telehealth

Questionnaire 06/04/20

Mode: Online

Sample size: n=500 (at least n=250 have experience with telehealth)

Length: Bid at 15 minutes

Geography: National

Target audience: Age 65+, decision maker

Fielding start: TBD

Screener

Intro: This survey is being conducted on behalf of the Centers for Medicare and Medicaid Services. The Centers for Medicare and Medicaid Services is the government agency responsible for initiatives to improve the health of all Americans. It regularly sponsors research to help them to understand information about the healthcare Americans receive. Your participation in this survey is anonymous and voluntary. Your answers will remain confidential. Please click “next” to start the survey.

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-1247.  The time required to complete this information collection is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.  Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Kymeiria Ingram-McNeil at (410)786-6725 or [email protected].

S1. [SG1]Have you or any member of your household or immediate family ever worked for a healthcare company or organization (as a doctor, nurse, other healthcare professional, in a pharmacy, for a pharmaceutical company, in a hospital, etc.), a health insurance company, or a medical practice?

1 Yes [Terminate]

2 No

8 Don’t know

9 Refused

S2. [DG2]What is your age? Please enter a whole number: _____ [TERMINATE IF PREFER NOT TO ANSWER or under 65]

S3. [SBO1]When it comes to decisions about your health care services, do you usually…?

1 Make those decisions on your own without talking to anyone else.

2 Make those decisions on your own but talk with others about it.

3 Make those decisions with someone else’s help.

4 Rely on someone else to make those decisions for you. [TERMINATE]

8 Don’t know [TERMINATE]

9 Prefer not to answer [TERMINATE]

S4.[ING2] Do you currently have Medicare?

1 Yes

2 No [TERMINATE]

8 Don’t know [TERMINATE]

9 Prefer not to answer [TERMINATE]

S5. [ING7]There are different ways that people can get Medicare, and we want to understand your Medicare. Do you have Part A, which is hospital insurance, Part B, which is medical insurance, including doctor’s visits, or do you have both Part A and Part B?

1 Both Part A (Hospital) and Part B (Medical)

2 Only Part A  (Hospital) (TERMINATE)

3 Only Part B  (Medical) [TERMINATE]

8 Don’t know

9 Prefer not to answer

S6. [ING2]How do you currently get your Medicare coverage. Do you have? [RANDOMIZE 1-2]

1 Original Medicare (sometimes called “the 80/20 plan” or “Fee-for-Service Medicare”)

2 Medicare Advantage (like an HMO or PPO) (Skip to Q1)

8 Don’t know [TERMINATE]

9 Prefer not to answer [TERMINATE]

S7. [ING6][If S6=1 (Original Medicare)] Do you have a supplemental plan, also called a Medigap plan, that helps cover the health care costs that Original Medicare doesn’t cover, like copayments and coinsurance?

1 Yes

2 No

8 Don’t know

9 Prefer not to answer

Telehealth Awareness/Usage

The next set of questions is about ways that you might interact with your doctors and other healthcare providers.

Q1.[BG3] In the past year, how many times have you visited a doctor or other healthcare provider, including primary care and specialist visits? (Insert 0, 1-3, 4-6, 6+, DK, REF)

1 I have not had any visits in the past year

2 1-3 visits

3 4-6 visits

4 7 or more visits

8 Don’t know

9 Prefer not to answer

Q2.[AWG2] Prior to today, have you heard of telehealth?

1 Yes [Q2a]

2 No [Q2b]

8 Don’t know [Q2b]

9 Prefer not to answer [Q2b]

Q2a.[AWG5] [If Q2 = 1] Where did you first hear about telehealth? [Open-ended]

Q2b. [DMG3][Ask all] Telehealth involves visiting a doctor or other healthcare provider for a routine visit or for diagnosis or treatment of a health issue using the telephone or online video in place of an in-person visit. This does not include contacting a triage nurse by phone. Have you ever had a telehealth visit with a doctor or other healthcare provider?

1 Yes

2 No

8 Don’t know

9 Prefer not to answer

Programmer Note: Need a variable – Q2b=1 - for telehealth use to use as a quota (n=250).

Q3. [PE11C][Ask all] If your doctor or insurance plan offered Telehealth visits, how likely would you be to participate in a telehealth visit in the future with…

	Not at all likely	Not very likely	Neutral	Somewhat likely	Very likely	DK	REF
A primary care provider (for example, family practitioner or internal medicine)
A specialist (for example, cardiologist, allergist, or oncologist)

Q3a.[PE6A][If Q31<3 OR Q32<3] What makes you say that you are not likely to participate in a telehealth visit in the future? (open end)

Q4. [KG3]Do any of your current doctors or healthcare providers offer telehealth services?

1 Yes

2 No

8 Don’t know

9 Prefer not to answer

Previous Telehealth Experience [Ask this section if Q2b=1]

Q5. [HSG4]How many telehealth visits have you had?

1 Only 1

2 2-3

3 4-5

4 More than 5

8 Don’t know

9 Prefer not to answer

Q6. [HSG4][If Q5>1] When was your first telehealth visit?

1 Less than 3 months ago

2 3-6 months ago

3 6-12 months ago

4 More than a year ago

8 Don’t know

9 Prefer not to answer

Q7. [HSG4][If Q5>1] When was your most recent telehealth visit?

1 Less than 3 months ago

2 3-6 months ago

3 6-12 months ago

4 More than a year ago

8 Don’t know

9 Prefer not to answer

Q8. [MTG4]What type of technology did you use for your most recent telehealth visit? Please select all that apply.

1 Landline telephone

2. Smart phone

3 Tablet

4 Computer

5 An app that I had to download

6 A website

8 Don’t know

9 Prefer not to answer

Q9.[B2] What type of doctor or healthcare provider did you see during your most recent telehealth visit?

1. A primary care provider (for example., family practitioner or internal medicine).

2. A specialist (for example, cardiologist, allergist, or oncologists).

3. Other (specify)

8. Don’t know

9. Prefer not to answer

Q10.[BG7A] Thinking about your most recent telehealth visit, why did you have a telehealth visit instead of an in-person visit? [Open-ended]

Q11. [PE11]How effective was your most recent telehealth visit compared to an in-person visit for the same issue?

1 Much less effective

2 Somewhat less effective

3 About the same

4 Somewhat more effective

5 Much more effective

8 Don’t know

9 Prefer not to answer

Q12. [ISG1]How satisfied were you with your most recent telehealth visit?

1 Very unsatisfied

2 Somewhat unsatisfied

3 Neutral

4 Somewhat satisfied

5 Very satisfied

8 Don’t know

9 Prefer not to answer

Q13. [ISG6]How much do you agree with each of the following statements regarding your most recent telehealth visit? [Randomize Item Order]

	Strongly disagree	Somewhat Disagree	Neutral	Somewhat Agree	Strongly Agree	DK	REF
The doctor or healthcare provider took enough time with me
The doctor or healthcare provider thoroughly provided my care
The doctor was able to successfully answer my questions
The doctor was able to successfully treat my condition
Having a telehealth visit saved me time
The telehealth visit was convenient
The doctor was able to fully understand my needs
The technology worked well
I did not have to wait a long time on the phone or online before my visit began

Q14. [PE11C]How likely would you be to consider a future telehealth visit for each of the following non-life-threatening illnesses or circumstances. [Randomize item order]

	Not at all Likely	Not very Likely	Neutral	Somewhat Likely	Very Likely	DK	REF
A relatively minor health condition like a sore throat, rash, or ear ache
A follow up visit from a prior health condition
A visit to help control a chronic condition
The doctor was able to successfully treat my condition
To verify whether you should schedule an in-person visit
To get a medication prescription changed or renewed

Q15. [PE8A]How has the ability to participate in telehealth visits impacted the relationship you have with your primary care providers or specialists? Has it…

1 Made the relationship much worse

2 Made the relationship somewhat worse

3 Had no impact on the relationship

4 Made the relationship somewhat better

5 Made the relationship much better

8 Don’t know

9 Prefer not to answer

Q16. [ING5]Was your telehealth visit covered by your Medicare insurance?

1. Yes

2. No

8 Don’t know

9 Prefer not to answer

[Go to D1.]

No Previous Telehealth Experience [Ask this section if Q2b>1]

Q17.[PE11C] [If Q31>1 and A32>1] How likely would you be to consider a future telehealth visit for each of the following non-life-threatening illnesses or circumstances. [Randomize item order]

	Not at all Likely	Not very Likely	Neutral	Somewhat Likely	Very Likely	DK	REF
A relatively minor health condition like a sore throat, rash, or ear ache
A follow up visit from a prior health condition
A visit to help control a chronic condition
The doctor was able to successfully treat my condition
To verify whether you should schedule an in-person visit
To get a medication prescription changed or renewed

Q18. [PE14]How much do you agree that following statements about telehealth visits? During a telehealth visit… [Randomize Item Order]

	Strongly disagree	Somewhat Disagree	Neutral	Somewhat Agree	Strongly Agree	DK	REF
The doctor or healthcare provider would take enough time with me
The doctor or healthcare provider would be able to thoroughly provide my care
The doctor or healthcare provider would be able to successfully answer my questions
The doctor or healthcare provider would be able to successfully treat my condition
Having a telehealth visit would save me time
The telehealth visit would be convenient
The doctor or healthcare provider would be able to fully understand my needs
The technology would work well
I would not have to wait a long time on the phone or online before my visit began

Q19. [PE11]How effective would you expect a telehealth visit to be compared to an in-person visit for the same issue?

1 Much less effective

2 Somewhat less effective

3 About the same

4 Somewhat more effective

5 Much more effective

8 Don’t know

9 Prefer not to answer

Q20. [PE13]How do you think participating in telehealth visits would impact the relationship you have with your primary care providers or specialists? Would it…

1 Make the relationship much worse

2 Make the relationship somewhat worse

3 Have no impact on the relationship

4 Make the relationship somewhat better

5 Make the relationship much better

8 Don’t know

9 Prefer not to answer

Q21. [ING5]Does your Medicare cover telehealth visits?

3. Yes

4. No

5. Don’t know

6. Prefer not to answer

Demographics

These last few questions are for statistical purposes only, and all your answers will be kept confidential.

D1.[HSG3] Compared to other people who are the same age as you, do you consider your health to be:

1 Excellent

2 Good

3 Fair

4 Poor

8 Don’t know (Phone: Do not read)

9 Prefer not to answer (Phone: Do not read)

D2. [HSG2]Do you currently have any chronic health conditions that require ongoing care? (for example, arthritis, chronic pain, high blood pressure, heart disease, or similar conditions)

1 Yes

2 No

8 Don’t know

9 Prefer not to answer

D3. [DG1]Please select your gender below.

1 Male

2 Female

8 Other

9 Prefer not to answer (Phone: Do not read)

D4.[DG5] What is the highest level of education you have completed?

1 Grade school or less

2 Some high school

3 Graduated high school or GED

4 Some college

5 Vocational or technical school, or an associate’s degree

6 Four year college and a bachelor’s degree

7 Post-graduate studies (no degree)

8 Post-graduate degree such as a Ph.D. or master’s degree

9 Prefer not to answer

D5.[DG6] What is your marital status?

1 Married or living with partner

2 Never married/single

3 Separated

4 Divorced

5 Widowed

9 Prefer not to answer

D6. [DG9]What is your current employment status?

1 Employed full-time

2 Employed part-time

3 Retired

4 Unemployed and looking for work

5 Self-employed

6 Disabled

7 Not in the labor force (student, homemaker, etc.)

98 Other

99 Prefer not to answer

D7. [DG3]Are you of Hispanic, Spanish, or Latino origin or descent?

1 Yes

2 No

9 Prefer not to answer

D8. [DG4]What is your race or ethnic background? Please select all that apply.

1 White or Caucasian

2 Black or African American

3 Asian

4 American Indian or Alaska Native

5 Native Hawaiian or other Pacific Islander

8 Something else

9 Prefer not to answer

D9.[DG10] Which category includes your household’s income before taxes in 2019?

1 Less than $15,000

2 $15,000 to less than $25,000

3 $25,000 to less than $50,000

4 $50,000 to less than $75,000

5 $75,000 to less than $100,000

6 $100,000 to less than $150,000

7 $150,000 to less than $200,000

8 $200,000 or more

98 Don’t know

99 Prefer not to answer

D10. [DG12]What is your 5-digit zip code? _____

Thank you very much for helping with this study!

ANR.com 1025 Boulders Pkwy, Ste 401, Richmond, VA 23225, 804.272.6100