STANDARD QUESTIONNAIRE FORMAT



Supplemental Appendix A: Screener and Survey Instruments

[Private Health Insurance]

November, 2010

- Questionnaire -

[DISPLAY]

THANK YOU FOR CONTINUING TO BE A PART OF THE KNOWLEDGEPANEL. THIS SURVEY ASKS ABOUT YOUR EXPERIENCES WITH DOCTORS AND HEALTH INSURANCE AND TAKES ABOUT 10 MINUTES TO COMPLETE. IT IS BEING CONDUCTED BY THE YALE SCHOOL OF MEDICINE AND IS FUNDED BY WOMEN’S HEALTH RESEARCH AT YALE AND THE ROBERT WOOD JOHNSON FOUNDATION CLINICAL SCHOLARS PROGRAM.

As with all Knowledge Networks surveys, your response to this survey, or any individual question on the survey, is completely voluntary. All information that would let someone identify you will be kept private and secure.

Thank you for taking the time to participate in this important survey. If you have questions please contact Knowledge Networks at 800-782-6899.

[DISPLAY]

THESE QUESTIONS ASK ABOUT YOUR OWN HEALTH CARE, NOT A FAMILY MEMBER’S. IF YOU NEED HELP UNDERSTANDING ONE OF THE WORDS THAT IS IN BLUE, YOU CAN CLICK ON IT FOR MORE INFORMATION.

This survey asks about your experiences with doctors. Many people receive care from health professionals such as nurse practitioners and physicians’ assistants, but for this survey we ask just about your doctors.

[ALL BLUE WORDS SHOULD BE CLICKABLE AND DISPLAY A CORRESPONDING DEFINITION LISTED AT THE END OF THE QUESTIONNAIRE]

SCREENER QUESTIONS (1 minute)

[MP]

H1 Are you CURRENTLY covered by any of the following types of health insurance or health coverage plans?

1. Private health insurance through a current or former employer or union (of you or another family member)

2. Private health insurance purchased directly from an insurance company (by you or another family member)

3. Medicare, for people with certain disabilities

4. Medicaid, Medical Assistance, or any kind of government-assistance plan for those with low incomes or a disability

5. VA

6. TRICARE or other military health care

7. Indian Health Service

8. No coverage of any type (uninsured) [SP]

[IF H1 = 1 AND/OR 2, CONTINUE. IF ANY OTHER VALUE IS ENTERED, TERMINATE]

[SP]

[PROMPT IF SKIP; TERMINATE IF SKIP AGAIN AFTER PROMPT]

1. DOES YOUR HEALTH INSURANCE PLAN HAVE A NETWORK? A NETWORK IS A LIST OF DOCTORS OR HOSPITALS THAT TAKES YOUR INSURANCE. USUALLY YOU PAY LESS (OR NOTHING) FOR SERVICES FROM DOCTORS IN THE NETWORK.

⇨ Yes

⇨ No [TERMINATE]

[SP]

[PROMPT IF SKIP; TERMINATE IF SKIP AGAIN AFTER PROMPT]

2. IN THE LAST 12 MONTHS, HAVE YOU SEEN A DOCTOR? THIS INCLUDES OFFICE OR CLINIC VISITS, EMERGENCY ROOM VISITS, OR HOSPITALIZATIONS. DO NOT INCLUDE DENTAL CARE.

Yes

No

[SP]

[PROMPT IF SKIP; TERMINATE IF SKIP AGAIN AFTER PROMPT]

3. IN THE LAST 12 MONTHS, HAVE YOU SEEN A MENTAL HEALTH PROFESSIONAL? THIS INCLUDES OFFICE VISITS, EMERGENCY ROOM VISITS, OR HOSPITALIZATIONS.

Yes

No

[IF S2 = NO AND S3 = NO, TERMINATE]

[SP]

4. IN GENERAL, HOW WOULD YOU RATE YOUR OVERALL HEALTH?

⇨ Excellent

⇨ Very Good

⇨ Good

⇨ Fair

⇨ Poor

[SP]

[PROMPT IF SKIP; TERMINATE IF SKIP AGAIN AFTER PROMPT]

5. IN THE LAST 12 MONTHS, HAVE YOU BEEN SEEN BY A DOCTOR OR MENTAL HEALTH PROFESSIONAL NOT IN YOUR INSURER’S NETWORK? INCLUDE THOSE YOU HAVE SEEN IN THE HOSPITAL, OFFICE, OR CLINIC.

⇨ Yes

⇨ No [TERMINATE]

SURVEY QUESTIONS

[SP]

[PROMPT IF SKIP]

1. IN THE LAST 12 MONTHS, HOW MANY DIFFERENT DOCTORS HAVE SEEN YOU IN A HOSPITAL OR AN EMERGENCY ROOM THAT WERE NOT IN YOUR INSURER’S NETWORK? THIS COULD INCLUDE DOCTORS YOU CHOSE OR THOSE THAT WERE ASSIGNED TO YOU. THERE MAY HAVE BEEN MORE THAN ONE DOCTOR PER HOSPITAL VISIT.

1. None

2. 1

3. 2

4. 3 or more

Q2A/2B THROUGH Q15 IS LOOP 1

IF Q1 = 1 (NONE) OR SKIP, SKIP TO Q16

IF Q1 = 2 (1), GO THROUGH LOOP 1 ONCE STARTING AT Q2A

IF Q1 = 3 OR 4 (2, 3 OR MORE), GO THROUGH LOOP 1 TWICE STARTING AT Q2B

[START LOOP 1]

[SP, IF Q1 = 2]

Q2A. WE ARE GOING TO ASK YOU SOME QUESTIONS ABOUT THE DOCTOR YOU SAW IN THE HOSPITAL OR EMERGENCY ROOM THAT WAS NOT IN YOUR INSURER’S NETWORK.

What type of doctor was it?

← Emergency Room

⇨ Anesthesiologist (for epidural or other anesthesia given during childbirth)

⇨ Anesthesiologist (for anesthesia other than childbirth)

⇨ Intensive Care (ICU)

⇨ Obstetrician/Gynecologist

⇨ Radiologist (reads X-rays or other imaging tests)

⇨ Surgeon

⇨ General Practitioner (Internal Medicine, Family Medicine, hospitalist)

⇨ Psychiatrist or other mental health professional

⇨ Other Specialist (for example, cardiologist or gastroenterologist)

[SP, IF Q1 = 3 OR 4]

Q2B.

[IF FIRST LOOP]

We are going to ask you some questions about each of the doctors you saw in the hospital or emergency room that were NOT in your insurer’s network. Let’s start with the first doctor you saw in the last 12 months, and then we’ll ask the same questions again for the next doctor.

[IF SECOND LOOP]

Now we are going to ask you the same questions for the second doctor you saw in the last 12 months in the hospital or emergency room that was not in your insurer’s network.

For the [IF FIRST LOOP, SHOW ‘first’, IF SECOND LOOP, SHOW ‘second’]

doctor, what type of doctor was it?

⇨ Emergency Room

⇨ Anesthesiologist (for epidural or other anesthesia given during childbirth)

⇨ Anesthesiologist (for anesthesia other than childbirth)

⇨ Intensive Care (ICU)

⇨ Obstetrician/Gynecologist

⇨ Radiologist (reads X-rays or other imaging tests)

⇨ Surgeon

⇨ General Practitioner (Internal Medicine, Family Medicine, hospitalist)

⇨ Psychiatrist or other mental health professional

⇨ Other Specialist (for example, cardiologist or gastroenterologist)

[SP]

3. WHEN YOU WENT TO THE EMERGENCY ROOM OR WERE ADMITTED TO THE HOSPITAL, WAS IT FOR A MEDICAL EMERGENCY? DO NOT INCLUDE LABOR AND DELIVERY (CHILDBIRTH) AS AN EMERGENCY.

⇨ Yes

⇨ No

[SP, IF PPGENDER = 2 AND PPAGE = 18-49]

4. DID YOU SEE THIS DOCTOR FOR PREGNANCY OR DURING LABOR AND DELIVERY (CHILDBIRTH)?

← Yes

← No

[SP]

5. WHEN DID YOU FIRST KNOW THAT THIS DOCTOR WAS NOT IN YOUR INSURER’S NETWORK? YOU MAY HAVE BEEN TOLD BY THE DOCTOR, THE HOSPITAL OR THE INSURANCE COMPANY.

1. Before the doctor saw me in the hospital

2. At the time the doctor saw me

3. After the hospital visit (for example, when you received the bill)

[MP, IF Q5 = 1]

Q6A. WHY DID YOU DECIDE TO USE THIS DOCTOR WHEN THEY WERE NOT IN YOUR INSURER’S

network?

⇨ I thought the doctor was skilled

⇨ I wanted a second opinion

⇨ Another doctor, family member, or friend recommended the doctor

⇨ I was seeing the doctor before and wanted to stay with him/her even though he/she no longer took my insurance

⇨ I tried to find a doctor who takes my insurance but there was no one available in the hospital

⇨ I could schedule a surgery or procedure quicker

⇨ The hospital was closer or in an convenient location

⇨ Other (please specify) [txt]

[MP, IF Q5 = 2]

6B. WHY DID YOU DECIDE TO USE THIS DOCTOR WHEN THEY WERE NOT IN YOUR INSURER’S

network?

⇨ I thought the doctor was skilled

⇨ I wanted a second opinion

⇨ Another doctor, family member, or friend recommended the doctor

⇨ I was seeing the doctor before and wanted to stay with him/her even though he/she no longer took my insurance

⇨ I tried to find a doctor who takes my insurance but there was no one available in the hospital

⇨ I could schedule a surgery or procedure quicker

⇨ I had an illness, injury or condition that needed care right away

⇨ Other (please specify) [txt]

[SP, IF MORE THAN ONE REASON MARKED IN Q6A OR Q6B, DISPLAY THE REASONS LISTED IN Q6A AND Q6B]

7. YOU CHECKED THESE REASONS. OF THEM, WHICH WOULD YOU SAY IS THE ONE MAIN REASON YOU DECIDED TO USE THIS DOCTOR WHEN THEY WERE NOT IN YOUR INSURER’S NETWORK?

[SP]

8. WAS THE HOSPITAL IN YOUR INSURER’S NETWORK?

⇨ Yes

⇨ No

⇨ Don’t know

[SP]

9. BEFORE YOU RECEIVED CARE FROM THIS DOCTOR, DID YOU KNOW HOW MUCH YOU WOULD HAVE TO PAY? THIS INFORMATION COULD HAVE COME FROM THE HOSPITAL, DOCTOR OR THE INSURANCE COMPANY.

⇨ Yes

⇨ No

[SP]

10. DID THE DOCTOR CHARGE YOU MORE THAN WHAT YOUR INSURANCE PLAN COVERED? DO NOT INCLUDE ANY COPAYMENTS, COINSURANCE, AND DEDUCTIBLE YOU MAY HAVE BEEN RESPONSIBLE FOR.

⇨ Yes

⇨ No

⇨ I haven’t received the bill yet

⇨ Don’t know

[SP]

11. DID YOU TRY TO BARGAIN WITH THE DOCTOR FOR A LOWER PRICE (EITHER BEFORE OR AFTER SEEING THE DOCTOR)?

1. Yes

2. No

[SP, IF Q11 = 1]

12. WERE YOU SUCCESSFUL IN BARGAINING FOR A LOWER PRICE WITH THE DOCTOR?

⇨ Yes

⇨ No

[SP]

13. DID YOU TRY TO BARGAIN WITH THE INSURANCE COMPANY FOR A LOWER PRICE (EITHER BEFORE OR AFTER SEEING THE DOCTOR)?

⇨ Yes

⇨ No

[SP, IF Q13 = 1]

14. WERE YOU SUCCESSFUL IN BARGAINING FOR A LOWER PRICE WITH THE INSURANCE COMPANY?

⇨ Yes

⇨ No

[SP]

15. WERE YOU EVER CONTACTED BY A DEBT COLLECTION AGENCY FOR PAYMENT OF THE BILL FROM THIS VISIT?

⇨ Yes

⇨ No

[END LOOP 1]

[SP]

[PROMPT IF SKIP]

16. IN THE LAST 12 MONTHS, HOW MANY DIFFERENT DOCTORS OR MENTAL HEALTH PROFESSIONALS HAVE YOU SEEN IN A DOCTOR’S OFFICE OR CLINIC THAT WERE NOT IN YOUR INSURER’S NETWORK? DO NOT INCLUDE DOCTORS YOU SAW IN THE HOSPITAL, THE EMERGENCY ROOM, OR FOR DENTAL CARE.

1. None

2. 1

3. 2

4. 3 or more

Q17A/17B THROUGH Q27 IS LOOP 2

IF Q16 = 1 (NONE) OR SKIP, SKIP TO Q28

IF Q16 = 2 (1), GO THROUGH LOOP 2 ONCE STARTING AT Q17A

IF Q16= 3 OR 4 (2, 3 OR MORE), LOOK AT HOW MANY TIMES THE PERSON WENT THROUGH LOOP 1

IF 0 OR 1 PASS THROUGH LOOP 1; GO THROUGH LOOP 2 TWICE STARTING AT Q17B

IF 2 PASSES THROUGH LOOP 1; GO THROUGH LOOP 2 ONCE STARTING AT Q17B

[START LOOP 2]

[SP, IF Q16 = 2]

17A. WE ARE GOING TO ASK YOU SOME QUESTIONS ABOUT THE DOCTOR YOU SAW IN A DOCTOR’S OFFICE OR CLINIC THAT WAS NOT IN YOUR INSURER’S NETWORK.

What type of doctor was it?

⇨ Mental health professional (psychiatrist, therapist, psychologist)

⇨ Primary care doctor (internist, family doctor, general practitioner)

⇨ Specialist (for example, cardiologist or dermatologist)

[SP, IF Q16 = 3 OR 4]

17B.

[IF DONE LOOP 1 TWICE AND DOING LOOP 2 ONCE]

We are going to ask you some questions about the first doctor you saw in the last 12 months in a doctor’s office or clinic that was NOT in your insurer’s network.

[IF DONE LOOP 1 NONE OR ONCE AND IF FIRST ROUND FOR LOOP 2 ]

We are going to ask you some questions about each of the doctors you saw in a doctor’s office or clinic that were NOT in your insurer’s network. Let’s start with the first doctor you saw in the last 12 months, and then we’ll ask the same questions again for the next doctor.

[IF DONE LOOP 1 NONE OR ONCE AND IF SECOND ROUND FOR LOOP 2 ]

Now we are going to ask you the same questions for the second doctor you saw in the last 12 months in a doctor’s office or clinic that was not in your insurer’s network.

For the [IF FIRST LOOP, SHOW ‘first’, IF SECOND LOOP, SHOW ‘second’]

doctor, what type of doctor was it?

⇨ Mental health professional (psychiatrist, therapist, psychologist)

⇨ Primary care doctor (internist, family doctor, general practitioner)

⇨ Specialist (for example, cardiologist or dermatologist)

For the last 12 months, think about your first visit (or surgical procedure) with this doctor when he/she was not in your insurer’s network.

[SP]

18. For this visit, when did you first know that this doctor was not in your insurer’s network? You may have been told by the front desk, the doctor, or the insurance company.

1. Before arriving at the visit

2. At the time of the visit

3. After the visit (for example, when you received the bill)

[MP, IF Q18 = 1]

19a. Why did you decide to use this doctor when they were not in your insurer’s

network? Check all that apply.

⇨ I thought the doctor was skilled

⇨ I wanted a second opinion

⇨ I was seeing the doctor before and wanted to stay with him/her even though he/she no longer took my insurance

⇨ Another doctor, family member, or friend recommended the doctor

⇨ I tried to find a doctor who takes my insurance but there was no one available in my area

⇨ I could schedule an appointment sooner

⇨ I had an illness, injury or condition that needed care right away

⇨ The doctor was in a convenient location

⇨ Other

[MP, IF Q18 = 2]

19B. WHY DID YOU DECIDE TO USE THIS DOCTOR WHEN THEY WERE NOT IN YOUR INSURER’S

network?

⇨ I thought the doctor was skilled

⇨ I wanted a second opinion

⇨ I was seeing the doctor before and wanted to stay with him/her even though he/she no longer took my insurance

⇨ Another doctor, family member, or friend recommended the doctor

⇨ I did not want to wait and reschedule my appointment with a doctor in my network

⇨ I had an illness, injury or condition that needed care right away

⇨ The doctor was in a convenient location

⇨ Other

[SP, IF MORE THAN ONE REASON MARKED IN Q19A OR Q19B, DISPLAY THE REASONS LISTED IN Q19A AND Q19B]

20. YOU CHECKED THESE REASONS. OF THEM, WHICH WOULD YOU SAY IS THE ONE MAIN REASON YOU DECIDED TO USE THIS DOCTOR WHEN THEY WERE NOT IN YOUR INSURER’S NETWORK?

[SP]

21. BEFORE YOU RECEIVED CARE AT THIS VISIT, DID YOU KNOW HOW MUCH YOU WOULD HAVE TO PAY TO SEE THE DOCTOR? THIS INFORMATION COULD HAVE COME FROM THE FRONT DESK, DOCTOR OR THE INSURANCE COMPANY.

⇨ Yes

⇨ No

[SP]

22. DID THE DOCTOR CHARGE YOU MORE THAN WHAT YOUR INSURANCE PLAN COVERED? DO NOT INCLUDE ANY COPAYMENTS, COINSURANCE, AND DEDUCTIBLE YOU MAY HAVE BEEN RESPONSIBLE FOR.

⇨ Yes

⇨ No

⇨ I have not received the bill yet

⇨ Don’t know

[SP]

23. DID YOU TRY TO BARGAIN WITH THE DOCTOR FOR A LOWER PRICE (EITHER BEFORE OR AFTER SEEING THE DOCTOR)?

1. Yes

2. No

[SP, IF Q23 = 1]

24. WERE YOU SUCCESSFUL IN BARGAINING FOR A LOWER PRICE WITH THE DOCTOR?

⇨ Yes

⇨ No

[SP]

25. Did you try to bargain with the insurance company for a lower price (either before or after seeing the doctor)?

⇨ Yes

⇨ No

[SP, IF Q25 = 1]

26. Were you successful in bargaining for a lower price with the insurance company?

⇨ Yes

⇨ No

[SP]

27. Were you ever contacted by a debt collection agency for payment of the bill from this visit?

⇨ Yes

⇨ No

[END LOOP 2]

[The following instruction will be displayed at the top of the page above question #28]

[SP]

28. WE ARE NOW GOING TO ASK YOU SOME GENERAL QUESTIONS ABOUT ALL OF THE DOCTORS YOU SAW WHO WERE NOT IN YOUR INSURANCE NETWORK.

Do you think you had enough information on the costs of using a doctor not in your insurance network?

⇨ Yes

⇨ No

[SP]

29. IN THE LAST 12 MONTHS, HAVE YOU HAD ANY FINANCIAL DIFFICULTY PAYING MEDICAL BILLS FROM DOCTORS NOT IN YOUR INSURER’S NETWORK?

1. Yes

2. No

[SP, IF Q29 = 1]

30. In the last 12 months, because of financial difficulty paying medical bills from doctors NOT in your insurer’s network, did you:

Yes No

Have problems paying for other necessities? ( (

Put off major purchases, such as a new home or car? ( (

Have to take money out of savings? ( (

Have to borrow? ( (

[SP]

31. THANK YOU FOR COMPLETING THIS SURVEY. WE ARE INTERESTED IN YOUR EXPERIENCES AND OPINIONS. WOULD YOU BE WILLING TO BE CONTACTED BY PHONE TO DISCUSS YOUR EXPERIENCES IN USING A DOCTOR NOT IN YOUR INSURER'S NETWORK? YOU WILL BE GIVEN AN EXTRA $10 FOR PARTICIPATING.

← Yes

← No

DEFINITIONS (for those words in blue)

Copayment: A fixed sum that a person pays for health services, regardless of the actual charge (the insurer pays the rest of the actual charge). For example, the person may pay $10 for each office visit, $75 for each day in the hospital, and $5 for each drug prescription.

Coinsurance: Similar to a copayment except that it is defined as a percent of the total charges for the health care service. For example, a beneficiary may pay 20% of charges for a doctor's visit or 10% of charges for a hospital stay.

Deductible: The amount of money an insured person must pay "at the front end" before the insurance plan will start paying any of your medical bills. For example, if you have a plan with an annual $100 deductible, you would be responsible for the first $100 of your health care bills for the year before the insurance plan would start paying.

Emergency: Refers to immediate care intended to assess and address an acute problem that has the patient in extreme discomfort or threatens his/her life.

Epidural (Spinal): Injection of a local anesthesia into the spinal column in order to anesthetize the abdominal and pelvic area during childbirth. The purpose of an epidural or spinal is to decrease the amount of pain the mother feels during childbirth.

Mental Health Professional: A person trained to diagnose and treat emotional or mental health problems: including, psychiatrists, psychologists, counselors, social workers.

Network: An insurance network is a list of preferred doctors or hospitals that takes your insurance. Usually you pay less (or nothing) for services from doctors in the network and more for doctors not in the network.

Primary Care Doctor: A primary care doctor or provider is the person or place an individual would go to if they had a new health problem, needed preventive health care, or needed a referral to a specialist. Examples of primary care providers include general practitioners, family practitioners, and internists.

Specialist: A medical doctor (M.D.) who specializes in a particular medical field. For example, dermatologists specialize in skin disorders, cardiologists specialize in problems of the heart, etc.

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