Department  of  Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
SURVEYING  MEDICARE  HMO  BENEFICIARIES  Department  of  Health  and  Human  Services 
OFFICE  OF 
INSPECTOR  GENERAL 
SURVEYING  MEDICARE  HMO  BENEFICIARIES  
4.*   % 
:  DEPARTMENT  OF HEALTH&  HUMAN  SERVICES  OffIce of Inspector General 
s 
%%. Washington, D.C. 20201 
November 8, 1995 
This report describes the rationales  for and protocols of surveying Medcare  beneficiaries in 
risk WOS. 
In 1995, the (l&e  of Inspector General completed a series of four reports on Medicare risk 
HMOS. We started in 1993 by surveying beneficiaries enrolled in or recently disenrolled from 
Medicare risk HMOS. We hoped to better understand enrollment procedures and service 
access issues horn their perspective.  Using tne beneficiary data set, we also examined the 
enrollment procedures  and access issues for the HMOS as a group, for indkidual  HMOS, and 
for developing HMO performance indicators. 
We selected a stratified, random sample of 4,132 enrollees and disenrollees from 45 Medicare 
risk HMOS in the Health Care Financing Administrations (HCFA) database.  Of these, 2,882 
beneficiaries returned usable surveys.  Since our primaq  f~us  was Mdlcare  beneficiaries 
perceptions and experiences, we collected information directly from them.  We did not attempt 
to validate their responses through record review or HMO contact, nor did we attempt to 
assess the quality or propriety of medical care rendered by the HMOS to these beneficiaries. 
Our intent was not to prescribe specific corrective actions, but to identi$,  based on 
tiorrnation  from beneficiaries, areas apparently needing improvement and to suggest 
techniques HCFA can use to firther  monitor these areas. 
AS a follow-up to our first four reports, we prepared this one on survey protocols and 
summary findings for HCFASinternal use.  HCFA stti,  who may conduct or arrange for 
similar or related surveys in the fhture, had requested details of our survey methods and 
lessons learned about conducting such surveys.  We hope this report will be usefhl to them and 
others interested in improving HMO services. 
This report was prepared in the Dallas Regional Office of the Oflice of Evaluation and 
Inspections under the direction of Chester B. Slaughter, Regional Inspector General.  Project 
stafTincluded Michelle Adarns and Judith Tyler, both of the Dallas OffIce. 
For additional copies, call (800) 848-8960 
*E!! 
Evaluation and Inspections  TABLE  OF  CONTENTS

SURVEY  GUIDELINES  . . . . . . . . . . .  . . . . . . . . . . . . . . . .. . . . . . . . ...1

Overall Approach  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...1

Sampling Plan  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...1

Survey Conduct  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...2

Survey Construction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...2

Survey Response  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...4

Practical Points ofSurveyProtocol  . . . . . . . . . . . . . . . . . . . . . . .  .  .  .  .  . ...5

Data Analysis  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..6

CONCLUSIONS  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

ENDNOTES  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

APPENDICES 
A:  Summary ofHMO  Report Findings  . . . . . . . . . . . . . . . . . . . . . . . . . ..A-l 
B:  Sample Demographics  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..B-l 
C:  Survey Letters  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..C-l 
D:  Survey Instrument  ..,...  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..D-l  SURVEY  GUIDELINES 
OVERALL  APPROACH:  Why Do A Beneficiary  Survey? 
Our fwst reason for choosing a beneficiary  survey  as a method  for studying Medicare  risk 
HMOS was the particular  issues on which we had focused.  Generally,  a serious concern 
about risk HMOS is that capitated payments,  which will not vary with the actual  services 
provided  to enrollees,  may encourage  HMOS to provide  fewer services than necessary  or 
to restrict  access to services.  In addition,  HMOS may  possibly  encourage  disenrollment  of 
beneficiaries  whose expected  medical costs will exceed the cavitation  rate.  Our focus was 
to gauge the extent to which beneficiaries  perceived  Medicare  risk HMOS provided  needed 
health care,  and if beneficiary  disenrollment  rates,  either done  or combined  with certain 
other factors,  are a reliable HMO performance  indicator.  Directly  asking beneficiaries 
detailed  questions about their access to health  services and reasons for leaving an HMO 
was, in our opinion,  the best way to answer our study questions. 
Our second reason for a beneficiary  survey was our positive prior  experience  with these 
surveys.  Beneficiaries  have been an important  and direct source of information  about 
program  effectiveness.  We have conducted  several armual surveys of Medicare 
beneficiaries  to provide  program  managers  feedback on topics such as claims processing 
experiences,  knowledge  of program  rules and benefits,  and use of program  materials.  We 
believe the results of our HMO beneficiary  survey support our cotildence  in this method. 
(See Appendix  A for summaries  of the four reports in the HMO  series.) 
SAMPLING  PLAN:  Considerations  For Choosing The Beneficiaries 
To select our beneficiary  sample,  we needed a sampling technique  that best suited our 
study focus and data analysis goals.  We decided to use a stratil%d,  two-stage  sample in 
which the fust  stage would be selecting Medicare  risk HMOS, and the second stage, 
beneficiaries  associated  with these HMOS.*  The strata at the frost stage were based on 
the HMO disenrollment  rates for a defined period.  At the second stage we categorized 
beneficiaries  as currently  enrolled  or as recently  disem-oiled.  We believed  that this 
sampling technique  would provide  the greatest  flexibility  in data analysis.  For example,  if 
we had selected just  current  enrollees  or just recent  disenrollees,  we could not know if, or 
how, their HMO experiences  with service access were different.  Without this contrasting 
data,  we could not make any inferences  about what is most likely to cause a beneficiary  to 
leave or remain  in an HMO.  Another example  is that selecting HMOS frost permitted  an 
analytical  linkage  between  service access problems  reported  by beneficiaries  and speciilc 
HMOS, HMO characteristics,  or problem  pervasiveness  among HMOS. 
1
 SURVEY  CONDUCT:  Resources,  Processes And Time Frames 
We conducted  the beneficiary  survey with a core project  team of three  OIG program 
analysts over a 19-month period.  The core team,  who was responsible  for the whole 
project,  had substantial  experience  with project  design and management,  the Medicare 
program,  interviewing  techniques,  survey construction,  various  methods of data analysis, 
and report  layout and writing.  In addition,  other OIG personnel  provided,  at key 
junctures  in the study process,  support to the core project  team in statistics,  Spanish 
translation,  sample selection,  data management/tracking,  data input,  and administrative 
tasks.  A computer  system that could run DBase IV and SPSS-PC was used for data input 
and analysis.  The overall process  for completing  the study included: 
P  Study Design  (1 month):  Selecting and developing  a study focus,  sampling frame and 
task schedule. 
E  Survey  Construction  (3 months);  Researching,  writing,  pre-testing  and revising  the 
beneficiary  survey instrument. 
  D@a Collection  @ months):  Actual selection of sample,  set-up of sample tracking  log 
in DBase IV, 2 initial and second mailings of survey form,  telephone  interviews  and 
follow-up  with beneficiaries  when necessary. 
  Dala  Input  (2 months):  Concurrent  with data collection,  postcoding  surveys where 
applicable,  keying responses,  and cleaning  data for inconsistent,  impossible  or erroneous 
entries. 
E  Dafa AnaZysis (5 months):  Finalizing  analysis plan and actual data manipulation 
including  non-response  bias cheek,  frequencies,  cross-tabulations,  measures  of central 
tendency  and variability,  tests of statistical  signiilcance,  and regression  analyses. 
E  Repoti  Writing (5 months):  Determining  content,  organization,  and number  of reports 
supported by data analysis results;  actual production  of the draft reports  issued for 
comment  and revision. 
SURVEY  CONSTRUCTION:  Accommodating  Study Focus And Survey Population 
  Study Focus:  The primary  focus of this study was the Medicare  beneficiarys 
access to medical  care through the HMO.  We did not intend to study quality of care as 
such.  Further,  we specflcally  excluded  a line of inquiry  about beneficiary  satisfaction 
with the HMOS, as the concept of satisfaction  is less objective  than,  and sometimes 
independent  of, the issues of membership  in a Medicare  risk HMO.  Collateral 
information  that we did solicit from the beneficiaries,  however,  was their  demographic 
data,  health  status, and appraisal  of HMO philosophy  or priorities. 
2
 In order to construct  a survey instrument  that adequately  covered access to services,  we 
adapted a defhition  from the literature. 34   Basically,  it uses five dimensions
(availability,  accessibility,  accommodation,  affordability,  and acceptability)  that represent 
the degree  of fit between the patient  and the health care system, e.g.  existing  services 
and the patients  medical  needs,  or price  of services and the patients  ability to pay.  To 
tailor the survey for Medicare  risk HMOS, we expanded the idea of service availability  to 
include the role of gatekeepers,  primary  physicians  or others associated  with the HMO,  in 
preventing  or facilitating  beneficiaries  receipt  of covered  services.  Operationally,  we 
divided access into four areas:  appointments,  including waiting time and administrative 
processes  for making them;  restrictions  on medical  services;  incidence  and reasons for 
out-of-plan  care;  and behavior  of primary  HMO doctors and other HMO personnel 
towards  beneficiaries. 
To accommodate  our study focus,  the survey questions are written predominantly  in terms 
of the processes  of HMO membership,  or the beneficiaries  perceptions  of those 
processes.  For example,  instead of asking if the beneficiaries  were satisfied with their 
primary  physicians,  we asked if they were referred  for services when they believed  they 
needed to be,  or if their physicians  took their health complaints  seriously. 
b  Survey Format:  We wrote two separate  surveys (enrollee  and disenrollee)  in a 
parallel  format.  (See survey forms in Appendix D.)  Each is divided into seven clearly 
labelled  sections:  1) directions  for completing  the survey;  2) beneficiary  demographics 
and self-assessment  of their propensity  to use medical  services;  3) enrollment  experience 
and understanding  of HMOS; 4) self-reported  health assessment;  5) and 6) coverage  of the 
four operational  areas defined for access to medical  services,  plus two questions  on appeal 
rights;  and 7) future plans for medical care  (enrollees),  or reasons for leaving  an HMO 
(disenrollees).  The sequence of the sections is basically  chronological,  starting with the 
time the beneficiaries  enrolled  and ending with their current  status and evaluation  of 
medical  care received. 
We also formatted  the survey document  in a user-friendly  style that we thought was 
responsive  to the needs of the study population.  First,  for easier reading,  we used a 
larger  (13-point) font and slightly expanded  spacing between lines.s  Second,  we used 
simple,  one-idea  questions with follow-up  questions to capture  details.  For example, 
instead of asking  How often,  if ever,  did your primary  HMO doctor  fail to refer  you to a 
specialist  when you thought you needed to see one? we asked two questions  -- Did your 
primary  HMO doctor ever fail to refer  you to a specialist...   AND  How ofien did your 
primary  HMO physician  fail to refer  you to a specialist?  While these methods  required 
more page  space,  we felt they improved  the readability  and comprehension  of the survey, 
and thus,  the quality of our data. 
F  Refinements:  Despite the good response  rate on the survey,  we analyzed  what in 
particular  had worked well and what hadnt.  Although the survey was 62 questions long, 
the majority  of respondents  successt%lly worked their way through  to the end.  If we had 
it  to do over again,  we would,  nevertheless,  eliminate  unproductive  questions and add 
others for areas we hadnt covered.  Questions,  that we might add,  cover beneficiaries 
3  reasons for joining  an HMO,  comfort  with premium  costs and co-payments,  or coverage 
problems  with emergent  or urgent  care.  Examples  of candidates  for deletion  are: 
question  6	 how benefici arv atmlied for membership) -- no discernible  pattern  or 
linkage  with other questions, 
question  17	 occurrence  of surgery  -- overkill  on establishing  health status, and 
beneficiaries  often did not link it to the preceding  question on 
hospital  admission, 
questions  30-32  lost/misPlaced  medical  records  -- apparently  a rare problem 
questions 41-42	 medical  socialists  {which ones) not covered  bv the HMO --
beneficiaries  often did not link the two questions,  and tended to 
respond  in terms  of specialists they needed to see or had seen. 
Because of our decision to write simple,  one-idea questions,  we frequently  used skip 
directions  (e.g.  Go to question  18) when beneficiaries  answered  the screening  question in 
the negative.  Many beneficiaries  initially  failed to follow the skip directions.  However, 
the process  seemed to be self-instructing,  and eventually,  most caught on to our meaning. 
Even if they did not, their answers  on the screening  questions were still usable.  Several 
of our questions listed six or more response  options,  each one to be marked  yes or 
no.  The length of the response  list per  se was not as problematic  as having the 
respondents  clearly  mark each option.  Our approach  tends to encourage  answering  each 
option,  but directing  the respondent  instead to Mark all that apply is an alternative 
worth experimentation. 
SURVEY  RESPONSE:  Achieving High Response Rates And Managing  Inquiries 
The sampled beneficiaries  were highly responsive  to the survey.  Of the 4,132

beneficiaries  to whom we mailed  surveys,  2,882 returned  a usable document.  The

unweighed  return  rate was 70 percent  overall,  77 percent  for enrollees  (N= 1705), and 61

percent  for disenrollees  (N= 1177).  Respondents  were predominantly  female,  white,  and

age 65 or older  (average  age of 74 years).  Interestingly,  they were better educated  than

we expected. G Forty-three  percent  reported  education  beyond the high school level,  such

as vocationalkchnical  training,  college  and postgraduate  work.  Another 29 percent  were

high school graduates.  (See Appendix B for more demographic  data.)

This good rate of return  was achieved  in about two months with only two follow-up

mailings  required.  After initially  sending the survey,  we sent a reminder  letter three

weeks later to all those beneficiaries  who had not returned  the survey.  In this letter,  we

answered  the questions most commonly posed by beneficiaries  who had called our  800

number  after the fwst mailing.  After two more weeks,  we sent another  reminder  letter

(different  wording  and appearance)  and a replacement  survey document  (different  cover

color).  (See Appendix  C for samples of cover letters  sent to beneficiaries.)

Our experience  and informal  discussions  with other OEI staff revealed  that,  as a group,

Medicare  beneficiaries  are relatively  easy to survey because of their keen interest  in the

4  program.  After both mailings of the survey,  many contacted  us, in a largely  informed, 
cooperative  manner,  by calling our  800 number and in writing.  The highest volume of 
contact occurred  from two to ten days after we completed  a mailing.  Disenrollees,  who 
called in, often needed more encouragement  to respond.  We sometimes had to overcome 
the estrangement  they felt about their HMO experience  or their mistaken belief that we 
didnt really want responses  from disenrollees.  We found that frequent,  but short,  team 
meetings to rehearse  answers  to the most commonly  asked questions and a list of HCFA 
Beneficiary  Services contacts in the Regional  Offices were invaluable tools for the data 
collection period.  Study team members  were also ready to complete the survey on the 
telephone  with beneficiaries  who required  assistance.  We believe that our preparation  for 
answering  beneficiary  questions and being easily accessible to them by an 800 telephone 
number improved  our response rate. 
Examples  of questions the beneficiaries  typically  asked: 
Source	 of Survey 
Who are you? 
Are you trying to sell me something  (e.g.  health insurance)? 
Do you work for the HMO? 
Do you really work for the government? 
Reuuest for Assistance 
Can you tell me what HMO I should join?

How can I get my HMO to ...?

What does this question  mean?

Will you help me f~  out the survey?

Reauest  for Additional  Information/Misconceptions 
Whats  the purpose  of this survey? 
Why are you wasting taxpayers  money on this? 
Im not in an HMO;  I have a health plan. 
Am I in trouble  if I cant complete  it by the due date? 
Do I have to fti  this out to get my Social Security check? 
I dont belong to the HMO anymore.  Should I still answer the survey? 
Thats not the name of my HMO.  Did you change my HMO? 
PRACTICAL  POINTS OF SURVEY PROTOCOL 
In surveying the Medicare  population  on their HMO experiences,  we were also reminded 
of some practical  considerations  for communicating  with our respondents. 
F  Dont assume that beneficiaries  know what an HMO is or that they are enrolled. 
	 Dont assume that beneficiaries  know the HMO by the Medicare  product  name; 
mention other names of the HMO. 
5
 F	 State clearly  in several places  that the survey was@  sent by the HMO or a 
representative  of an HMO physician. 
Be sure to arrange  for an 800 telephone  contact or other method so that 
b	
beneficiaries  can ask questions about the survey to a real person. 
	 Whoever  takes calls from the beneficiaries  should bepatient  and prepared  with 
answers for the most commonly  asked questions. 
F	 Let beneficiaries  know that answering  the survey a little late is better than not 
answering  at all. 
	 Be relentless  in eliminating  Medicare jargon,  acronyms  and complex  wording from 
the survey document. 
	 If the study team intends to do any follow-up  with the respcmding beneficiaries,  be 
sure to request their telephone  numbers  on the survey form. 
DATA ANALYSIS:  Understanding  What The Numbers  Say 
After analyzing  the survey data in a number  of different ways,  we presented  the results in 
four different  reports  keyed to our study focus,  issues and analysis plan. 
b  Beneficiary  Perspectives:  To provide  a summary of beneficiary  perspectives,  we 
completed  separate  frequency  distributions  and cross-tabulations  for weighted enrollee  and 
disenrollee  data and compared  their answers per question.  We also analyzed  sub-
populations  of enrollees  and disenrollees  in the same way.  Generally,  beneficiary 
responses  indicated  Medicare  risk HMOS provide  adequate  service access for most 
beneficiaries  who have joined.  In some instances,  however,  enrollees  and disenrollees 
differed  markedly  in reporting  their HMO experiences  with disenrollees  citing some 
problems  more frequently. 
  Issues Across  HMOS:  To provides  insights into how beneficiaries  responses  may 
have varied across  our sampled 45 HMOS, we aggregated  the unweighed  enrollee  and 
disenrollee  data to the HMOS in our sample to identify distribution  and intensity  of access 
problems  among HMOS.  We explored  HMO  structural  characteristics,  such as model 
type,  as well.  We concluded  that using beneficiary-level  data linked back to the HMO 
provides  additional  insights into the issues of HMO enrollment  procedures  and service 
access.  This type of information  may prove  especially useful in focusing monitoring 
efforts. 
  Individual  HMO Projiles:  Each of the 45 sampled HMOS was proffled for  18 key 
survey questions  grouped under  5 categories  -- health  screening,  understanding  of HMOS, 
appointments,  services  and personal  treatment.  For each key question,  we compared  the 
mean response  for all sampled HMOS to the mean response for each sampled HMO.  A 
6  positive  or negative  difference  between the means of at least one standard deviation was 
designated  respectively  as above or below average.  The profiles  differentiate  the many 
aspects of enrollment  procedures  and service access within any HMO.  The profde  data 
means also suggested two other uses,  i.e.,  the development  of tolerance  levels for 
acceptable  HMO performance  and as a supplement  usefid in the interpretation  of other 
data sets. 
  Performance  Indicafons:  To determine  if our data could be used to assess HMO 
performance,  we analyzed  both beneficiary-level  and HMO-level  data to construct 
regression  models that explain the relationship  between beneficiary  survey data and future 
disenrollment,  and spectilcally,  how service access relates to disenrollment  status.  We 
also calculated  more recent  disenrollment  rates for our sampled HMOS. 
We found the questions most predictive  of beneficiaries  l%ture disenrollment  included: 
  Were complaints  taken seriously by their HMO doctors? 
	 Did their primary  HMO doctors provide  Medicare  services,  admit them to the 
hospital,  or refer  them to a specialist when needed? 
	 Did they perceive  their HMOS as giving too high a priority  to holding down the 
cost of medical  care compared  to giving the best medical  care? 
	 Did they perceive  their health got worse as a result of the medical  care they 
received  in their HMO? 
	 Did they experience  long waits (1 hour or more) in their primary  HMO doctors 
offices? 
7
 CONCLUSIONS 
We believe  our beneficiary  survey and resulting  reports  have implications  for the 
Medicare  risk HMO program. 
  Program Irzformahon: Our findings are another indicator  or an update of progmm 
weaknesses that have previously  been suggested by others.  In addition,  our data have 
highlighted  some areas as problematic  that earlier  were viewed as functioning  sufficiently 
well.  Beneficiaries  awareness  of their appeal rights is an example.  The beneficiary  data 
also show that,  while disenrollees  may be more intense in their criticism  of HMOS, 
enrollees  are also encountering  some of the same difficulties  in accessing HMO medical 
services. 
b  Program  Management:  Our experience  with this survey has convinced us that 
Medicare  beneficiaries,  both enrollees  and disenrollees,  are an excellent  source of detailed 
information  about program  operations.  More  than satisfaction  ratings,  we were able to 
gather data on the process  and experience  of HMO membership.  We acknowledge  that 
the survey data,  not validated  by review  of medical fdes or HMO records,  have 
limitations.  Nevertheless,  they still represent  reality for beneficiaries  who are free to act 
on their perceptions  of their HMO experiences. 
  Ongoing Evalu@on:  For both purposes  of current program  information  and 
management,  we urge HCFA  to systematically  and repeatedly  collect data from both 
enrollees  and disenrollees,  with linkage to their  speeitlc HMOS.  Such an approach,  in 
combination  with data from other sources,  is a powerful  management  tool that allows the 
development  of performance  standards and trends  over time,  and the ability to judge  if 
problems  are pervasive  or confiied  to specfIc  HMOS. 
8
 ENDNOTES

1.	 We selected a stratifkd  random  sample from HCFAS Group Health Plan  (GHP) 
data base.  First,  we sampled 45 HMOS from the 87 HMOS under a risk contract 
with HCFA  as of February  1993.  Beginning  with the GHP data,  we counted the 
number of enrollments  occurring  within calendar  years  1991 and 1992.  For this 
cohort,  we then calculated  the proportion  of disenrolhnents  within the following  12 
months.  Based on this disenrollment  rate,  we divided the 87 risk HMOS into three 
strata of 29 HMOS each.  Within each strata,  we selected  15 HMOS by simple 
random  sampling.  Second, from each sampled HMO,  we randomly  selected 50 
Medicare  beneficiaries  who were enrolled  as of February  28,  1993 and 50 who had 
disenrolled  between November  1992 and February  1993 inclusive.  When the total 
number per HMO for either group was less than 50, we selected them all.  Using 
HCFAS Enrollment  Data Base,  we excluded,  from the sampling universe, 
beneficiaries  who had died or who appeared  as current  enrollees,  but had actually 
disenrolled  since the last update to the GHP ffle.  This process  resulted  in 2,217 
enrollees  and  1,915 disenrollees  for a total of 4,132 beneficiaries. 
2.	 We setup  a case log in DBase to track each beneficiarys  survey form from the 
time we mailed the survey until the time we entered  the responses  on a usable 
survey into our database. 
3.	 Penchansky,  Roy,  DBA, and J. William  Thomas,  PhD,  The Concept of Access: 
Deftition  and Relationship  to Consumer  Satisfaction,  Medical  Care, February 
1981,  12:2:127-140. 
Thomas,  J. William,  PhD,  and Roy Penchans@,  DBA,  Relating Satisfaction With 
Access to Utilization  of Services,  Medical  Care, June  1984, 22:6:553-568. 
4.  The Penchans&  and Thomas  five dimensions  of access to services are: 
a.  AvaiZubi2ity - the relationship  of the volume  and type of existing  services 
(and resources)  to the clients volume  and types of need.  It refers to the 
adequacy  of supply of medical providers,  facilities  and specialized  programs 
and services,  such as mental health and emergency  care. 
b.  Accessibility  - the relationship  between the location of supply and the 
location  of clients,  taking  account of client transportation  resources  and 
travel time,  distance  and cost, 
c.  Accommodation  - the relationship  between the manner  in which the supply 
resources  are organized  to accept clients  (including appointment  systems, 
hours of operation,  walk-in facilities,  telephone  services) and the clients 
ability to accommodate  to these factors  and the clients perception  of their 
appropriateness. 
d.  A&ordability  - The relationship  of prices  of services and the providers 
insurance  (or deposit requirements)  to clients income,  ability to pay and 
9  existing health insurance.  Client perception  of worth relative  to total cost is 
a concern,  as is client knowledge  of prices,  total cost and possible credit 
arrangements. 
e.	 Acceptability  - the relationship  of clients attitudes  about personal  and 
practice  characteristics  of providers  to the actual characteristics  of existing 
providers,  as well as to provider  attitudes  about acceptable  personal 
characteristics  of clients.  In turn,  providers  have attitudes  about the 
preferred  attributes  of clients or their financing  mechanisms.  Providers 
may be unwilling to serve certain  types of clients or, through 
accommodation,  make themselves  more or less available. 
5.	 A study funded by AARP,  Public Benefit Application  Forms:  How They Impede 
the Application  Process,  #9105,  Public Policy Institute,  December  1991 notes
II
...when writing  documents  for the elderly,  it is essential to heed such factors  as 
print  size, typeface,  graphics  and layout,  any of which could significantly  interfere 
with reading  comprehension.  
6.	 Based on their average  age,  many would have been of high-school  age during the 
Depression  which would have limited their access to higher education  for financial 
reasons. 
AARP,  1991, op.  cit.,  ,. the  majority  of the [forms and material  assessed] is 
written  at the high school to college level.  Yet... many older adults lack the 
education  needed to read and understand  the forms.  
7.	 We weighted  data to reflect the enrollment  size of their Medicare  risk HMOS, their 
enrollment  status when sampled,  and our decision not to assume knowledge  about 
non-respondents. 
10  APPENDIX  A 
SUMMARY  OF  REPORT  FINDINGS 
Below,  for each of the four reports,  is a summary of findings.  Throughout  the reports, 
several recurrent  themes are discernible.  Overall,  responses  from Medicare  beneficiaries 
in risk HMOS indicated  adequate access to medical  services.  However,  disenrollees  more 
oilen reported  problems  than enrollees,  as did ESRD/disabled  beneficiaries  compared  to 
aged beneficiaries.  Predictably,  some HMOS performed  better than others.  When 
problems  were reported,  they were,  despite the analysis method used,  consistently  in the 
areas of health  screening  at application,  lack of awareness  of appeal rights,  difficulty with 
appointments  and access to some services,  and perceptions  of declining  health due to 
HMO care.  The failure  of physicians  to take beneficiaries  health complaints  seriously, 
and HMOS emphasizing  cost control  over providing  the best care were two other problems 
beneficiaries  perceived. 
Beneficiary  Perspectives  of Medicare  Risk HMOS, 0EI-06-91-O0730 
Generally,  beneficiary  responses  indicated  Medicare  risk HMOS provide  adequate  service 
access for most beneficiaries  who have joined.  The majority  of enrollees  and disenrollees 
reported  medical  care that maintained  or improved  their health,  timely appointments  for 
primary  and specialty care,  good access to Medicare  covered  services and to hospital, 
specialty and emergency  care,  and sympathetic personal  treatment  by their HMOS and 
HMO doctors.  In some instances,  however,  enrollees  and disenrollees  differed  markedly 
in reporting  their HMO experiences  with disenrollees  citing some problems  more 
frequently. 
Our survey results also indicated  some serious problems  with enrollment  procedures  and 
service access that,  we believed,  required  HCFAs  attention.  Three  items need immediate 
exploration:  1) better  informing  of beneficiaries  about their appeal rights as required  by 
Federal  standards;  2)  carefully  examining  service access problems  reported  by 
disabled/ESRD  beneficiaries,  an especially  vulnerable  group;  and 3) monitoring  HIvlOs for 
inappropriate  screening  of beneficiaries  health  status at application.  Other service access 
issues meriting  examination  by HCFA  in the near future concerned  beneficiaries 
perceptions  of problems  with making routine  appointments,  declining  health caused by 
HMO care,  and HMOS refusal to provide  certain  services. 
Medicare Risk HMOS:  Beneficiary  Enrollment  and Service Access problems,  OEI-
06-91-00731 
Most enrollment  and service access problems  reported  by beneficiaries  are widespread 
among Medicare  risk HMOS, but at varying  degrees  of htensity.  Disenrollees  generally 
A -1
 experienced  problems  at a higher degree  of intensity than enrollees.  Spectilc problems 
that were fairly or very wide-spread  and intensive  were: HMOS asking beneficiaries  about 
their health problems  at application,  beneficiaries  lack of awareness  of appeal rights, 
disenrollees  perception  of problems  with access to medical  services,  and beneficiaries 
perceptions  that primary  HMO doctors failed to take their health complaints  seriously and 
that holding down the cost of medical care was more important  to HMOS and HMO 
doctors  than giving the best medical care possible.  Beneficiaries  in group or staff models 
and in non-profit  HMOS were more likely to report  enrollment  and service access 
problems. 
We concluded  that using beneficiary-level  data linked back to the HMO provides 
additional  insights into the issues of HMO enrollment  procedures  and services access. 
This type of information  may prove especially  useful in focusing monitoring  efforts.  For 
example,  it could answer questions  such as,  Are problems  widely distributed  among 
HMOS or isolated incidents?  or If the problem  is wide-spread  among HMOS, does it 
involve a substantial percentage  of beneficiaries?  We also suggest that HCFA  establish 
acceptable  tolerance  levels for monitoring,  since a problem  may be pervasive,  but not 
necessarily  critical. 
Individual Profiies  of Medkxwe Risk HMOS, 0EI-06-91-O0733 
The proffles differentiate  the many aspects of enrollment  procedures  and service access 
within any HMO.  This level of data could be used to pinpoint  specific problematic 
HMOS and to indicate  when corrective  actions are needed.  The profde  data means also 
suggested two other uses,  i.e.,  the development  of tolerance  levels for acceptable  HMO 
performance  and as a supplement useful in the interpretation  of other data sets. 
Medicare Risk HMO Performance  Indicators,  OEI-06-91-00734 
Overall,  we found that adjusted disenrollment  rates may provide  an early alert of possible 
problems  among Medicare  risk HMOS.  Adjustments  include  1) annualizing  rates among 
newer HMO risk contracts,  and 2) accounting  for administrative  disenrollrnents,  e. g., 
beneficiaries  moving from  service area,  which tend to inflate disenrollment  rates.  After 
adjustments,  HMOS with higher disenrollment  rates had more enrollees  who reported 
service access problems.  Beneficiaries  more likely to disenroll tended to report  declining 
health due to their HMO care,  being disabled/13SRD, an HMO emphasis  of holding down 
the cost of care over giving the best medical  care possible,  and experiencing  long waits in 
primary  HMO doctors  offices. 
A -2
 The questions  we found most predictive  of beneficiaries  fimre  disenrollment  included: 
  Were complaints  taken seriously by their HMO doctors? 
*	 Did their primary  HMO doctors provide  Medicare  services,  admit them to the 
hospital,  or refer them to a specialist  when needed? 
	 Did they perceive  their HMOS as giving too high a priority  to holding down the 
cost of medical  care compared  to giving the best medical care? 
	 Did they perceive  their health got worse as a result of the medical care they 
received  in their HMO? 
	 Did they experience  long waits (1 hour or more) in their primary  HMO doctors 
offices? 
We recommended  that HCFA:  1) use adjusted disenrollment  rates along with other 
available  HMO information  to target reviews  of HMOS; 2) track disenrollment  rates over 
time to detect potential  problems  among HMOS; 3) conduct disenrollment  surveys that 
fully capture  all the beneficiarys  reasons for leaving the Medicare  risk HMO;  4) monitor 
Medicare  risk HMOS with high disenrollment  rates and reported  service access problems 
and work with HMOS to respond  to the needs of beneficiaries  at risk of disenrolling;  5) 
systematically  and routinely  survey enrollees  on key indicators  of service access to 
complement  disenrollment  data. 
A -3
 APPENDIX  B 
DEMOGRAPHIC  PROFILE  OF  RESPONDENTS 
(Weighted Data) 
TOTALPOPULATION  DISENROLLEES  ENROLLEES 
GENDER 
Female  60%(666,049)  53%(15,065)  60%(650,984) 
Male  40% (446,205)  47% (13,139)  40% (433,067) 
RACE/ETHNICITY 
White  90% (991 ,084)  88% (24,872)  90% (966,213) 
Non-White  7% (83,684)  12%  (3,332)  7%  (80,352) 
Unknown  3% (37,486)  o  3%  (37,486) 
AVERAGE  AGE  74 Years  73 Years  74 Years 
EDUCATION 
<  Than High School  24% (274, 156)  20%  (5,683)  25% (268,473) 
High School Diploma  29% (318,440)  22%  (6,238)  29% (312,201) 
>  Than High School  43% (474,317)  49% (13,778)  42% (460,539) 
No Response  4%  (45,342)  9%  (2,504)  4%  (42,838) 
MEDICARE 
CATEGORY 
Aged  97% (1 ,078,445)  92% (25,907)  97% (1,052,538) 
Disabled/ESRD  3%  (33,809)  8%  (2,296)  3%  (31,513) 
COMPETITIVE  AREA 
Competitive  63% (700,103)  53% (14,878)  63% (685,225) 
Noncompetitive  37% (412,152)  47% (13,325)  37% (398,826) 
HMO  EXPERIENCE 
Prior Experience  14% (154,069)  21%  (5,997)  14% (148,072) 
No Experience  82% (906,961)  71% (19,905)  82% (887,056) 
No Response  4% (51,226)  8%  (2,302)  4%  (48,923) 
AVERAGE  LENGTH

OF TIME IN HMO  36 Months
 29 Months  36 Months 
SERIOUS  HEALTH

CONDITIONS 
2+  conditions  6% (61,003)  5%  (1,254)  6%  (59,749) 
1 condition  24% (265,866)  22%  (6,153)  24% (259,713) 
None  60% (669,619)  58% (16,440)  60% (653,180) 
No Response  10% (115,767)  15%  (4,357)  10% (111,410) 
1  A competitive  area is a county in which 2 or more of all  Medicare risk HMOS, not just sampled HMOS,
provide services.  Beneficiaries  were then matched to counties by zip codes of their mailing address. 
2	 Health conditions  are self-reported,  and me for example,  broken bones,  cancer, heart attack, pneumonia or 
stroke. 
B-1
 APPENDIX  C 
SAMPLES  OF  COVER  LETTERS  TO  BENEFICIARIES 
c-1  ,  .,
A-. 
April  14,  1993 
Dear  Medicare  Member: 
Please  help  us make  the Medicare  program  better.  All you  need  to do is complete  the enclosed 
survey  and  return  it by April  23,  1993.  No pos~ge  is reamed  for  the  return  envelope. 
We  want  to  improve  health  care  senices  provided  to Medicine  beneficiaries  by  health 
maintenance  organizations  -- HMOS.  Since  you  have  been  an HMO  member,  your  valuable 
experience  will  help  us identi~  areas  that  need  improvement. 
Please  take  the time  to complete  the survey.  It may seem  long,  but the questions  are short,  and 
you  wont  have  to answer  every  one.  Also,  it is okay  if someone  helps  you. 
Anything  you  say will be strictly  con.fidentid.  NO  one, including  your  HMO,  will  know  your 
answers.  To  assure  this,  please  do not  write your  name  on the  survey. 
If you have  any  questions,  call  us toll  free  at l-S()()-84&fJ9@.  Thank  you  very  much  for your 
help. 
Sincerely,  , 
q&/7-@_ 
Judith  V.  Tyler 
Survey  Project  Leader  /-%4 
($< 
DEPARTMENT  OF  HEALTH  AND  HUMAN  SERVICES 
\. 
May  5,  1993 
Dear  Medicare  Member: 
Several  weeks  ago,  we  sent  you  a survey  asking  about  your  experiences  as a member  of a 
health  maintenance  organization  (HMO).  We  are  concerned  because  we  havent  received 
your  completed  survey  yet. 
Maybe  you  thought  the  survey  didnt  apply  to you  for  the  following  reasons.  If so,  please 
consider  our  explanations. 
10  We  had  the  wrong  name  for  your  HMO  on the  survey. 
Answer:	 HMOS often  have several  names.  Check  your  HMO  card  or  call  us for 
other  names  your  HMO  uses. 
2.	 You belong  to a health  plan,  NOT  an HMO. 
Answer:  A health plan  is another  name  for  an HMO. 
3.  You dont belong  to the HMO  anymore. 
. 
Answer:  We  know  some  Medicare  members  have lefi  their HMOS.  Information 
on WHY  you left is very  usefil  to us. 
4.  You  couldnt  complete  the survey  by the date we requested. 
Answer:	 Dont  worry  about the return date.  What you have to say about your 
HMO  is the most important thing. 
Please  take  the  time  to complete  the  survey  if you  still  have  it.  Anything  you  say  will  be 
strictly  confidential. 
Please call us toll-ffee  at 18W8484960 if you need another survey,  if you would like 
the survey written  in Spanish,  or if you have any questions. 
Sincerely, 
%-5+ 
Survey  Project  Leader  May  19, 1993 
Dear Medicare  Member: 
Several  weeks ago,  we wrote  to you of our concern  that we hadnt received  your completed  survey 
about your health maintenance  organization  (HMO).  Our thanks to the many of you who called us. 
If you said you needed another survey, here it is.  If you have already returned  the survey, thank you. 
If you didnt call us, you may think the survey doesnt apply to you.  You may be wrong.  Please call 
us at l-80&848-8%0  so we can be sure. 
Finally,  some of you simply may not wish to complete  the survey.  But,  before  you throw it away, 
please consider that we need information  from you about the Medicare HMO program.  We are sincere 
about wanting to improve  Medicare.  You can help us. 
All you need to do is: 
1.	 Return the completed  sumey to us by June  2.  If you need a few extm days, thats okay.  What 
you have to say about your HMO is the most important  thing. 
2.  Use  the enclosed envelope.  No postage is required. 
3.	 Remember anythingyou say will be strictly confidential.  No one, including your HMO, will 
know your answers. 
Phase  call us toll-free  at 1-800-848-8%0  if you would like the survey written in Spanish, or if you 
have any questions. 
sincerely, 
Judith V. Tyler 
Survey project Leader  APPENDIX  D

ENROLLEE  AND  DISENROLLEE  SURVEY  FORMS3 
3	 The enrollee  and disenrollee  forms are nearly identical,  except for changes  in verb 
tense,  for the frost 55 questions.  Therefore,  we have included  a complete  enrollee 
survey form,  but just  questions 56 through  64 for the disenrollee  survey form. 
D-1  mmc** 
,#  4% 
[(c
DEPARTMENT  OF  HEALTH  AND  HUMAN  SERVICES
%+
4vam 
HEALTH  MAINTENANCE  ORGANIZATIONS  (HMOS) 
A  Survey  of  Medicare  Members 
Form E 
/	 Is w  HMOs  name  printed  in the  box  above?  Sometimes  an  HMO  will 
have  several  names.  If  you  are  not  surer  call  the  HMO.  If you  are  sure  this 
is ~  your  HMO,  answer  question  1 only. 
/	 Anything  you  say  will  be  strictly  confidential.  To  assure  this,  please  do  not 
write  your  name  on the  survey. 
#  Please  read  the  directions  on the  next  page. 
/  Callus  toll  free  at  1-800-848-8960  if you  have  questions.  ~	 When  the  question  says  HMO,  we  mean  the  HMO  you  belong  to  now.  Your 
HMOs  name  is in the  box  on the  front  cover. 
/	 YOU will  NOT  answer  every  question.  skip  a question  when  we  say  -- (Go  to 
question  _  ). 
/	 For  most  questions,  you  Should  choose  just  ONIS answer.  We  will  tell  you  when 
you  should  do  something  different. 
/	 You  may  change  your  answer.  Mark  out  the  answer  you  DONT  want.  Make  sure 
we  know  which  answer  you  ~  want. 
/  You  may  add  comments.  Write  them  by  the  questions. 
Directions  HMO Survey (Form E) - Page i  Section  1:  Tell  Us  About  You

These  questions  ask  for  some  basic  information  about  you.

/  May  we  call  you  if we  have  further  questions  about  your  HMO? 
yes  (area  code: _)(telephone  number:  ) 
no 
1. Are  you  currently  a member  of  the  HMO  named  on  the  front  cover? 
(Remember,  you  may  know  the  HMO  by  another  name.) 
A)  yes

B)  no,  I left  the  HMO  (Stop.  Return  the  survey  to  us.)

C)	 I have  never  been  a member  of  that  HMO. 
(Stop.  Return  the  survey  to  us.) 
2.  What  is the  highest  level  of  education  you  completed? 
A)  less  than  high  school 
B)  high  school  diploma 
C)	 vocational/technical  training

D)  some  college,  no  degree

E)  college  degree

F)  postgraduate  or  professional  degree

3.	 Immediately  before  ioininq  the  HMO,  where  did  you  usually  receive  your 
health  care? 
A)  another  HMO 
B)  doctors  office 
C)  community  clinic  or health  center

D)  hospital  outpatient  clinic

E)  hospital  emergency  room

F)  no  regular  place

Section 1:  Tell Us About You  HMO  Survey (Form E) -Page 1  4.  I worry  about  my  health  &  than  other  people  my  age. 
A)  true 
B)  false 
C)  I dont  know 
5.  I usually  go  to  the  doctor  as soon  as  I start  to  feel  bad. 
_  A)  true 
B)  false 
_  C)  I dont  know 
Section  2:  When  You  Joined  The  HMO

These  questions  ask  about  what  happened  when  you  joined  the  HMO.

6.  How  did  you  apply  for  membership  in the  HMO?  Did  you: 
A)  tell  an  HMO  representative,  who  contacted  you,  that  you  wanted  to 
apply? 
B)  contact  the  HMO  on  your  own  to  apply? 
C)	 sign  up  for  membership  at  work?  (Go  to  question  10) 
D)  I didnt  apply  for  membership.  (Go  to  question  10) 
7.	 When  you  applied  for  HMO  membership,  were  you  asked  about  your  health 
problems?  (Dont  count  questions  about  kidney  failure  or  Medicare  hospice 
coverage.  ) 
A)  yes 
B)  no 
_  C)  I dont  remember 
Section 2:  When You Joined The HMO  HMO Survey (Form E)  - Page 2  8.  Were  you  required  to  have  a physical  exam  before  you  could  join  the  HMO? 
A)  yes 
B)  no 
C)  I dont  remember 
9.	 When  you  applied  for  HMO  membership,  did  you  know  you  could  change 
your  mind  and  back  out  before  the  HMO  membership  took  effect? 
A)  yes 
B)  no 
_  C)  I dont  remember 
10.	 Did  you  know,  from  the  beginning,  that  an  HMO  member  must  be  referred  to 
a specialist  by  a primary  HMO  doctor? 
A)  yes 
_  B)  no 
_  C)  1 dont  remember 
11.	 Did  you  know,  from  the  beginning,  that  an  HMO  member  could  only  use 
HMO  doctors  and  hospitals  (except  in emergencies  outside  the  HMOs 
service  area)? 
A)  yes 
B)  no 
_  C)  I dont  remember 
Section 2:  When You Joined The HMO  HMO  Survey (Form E)  - Page 3  Section  3:  How  Is  Your  Health?

These  questions  ask  about  your  health  while  you  have  been  an  HMO  member.

12.  When  you  first  joined  the  HMO,  how  would  you  rate  your  health  overall? 
A)  excellent 
B)  good 
C)  fair

D)  poor

E)  very  poor

13.	 Have  you  seen  an  HMO  doctor  or received  any  health  care  services  through 
the  HMO  while  you  have  been  a member? 
A)  yes 
B)  no  (Go  to  question  55) 
C)  I dont  remember  (Go  to  question  55) 
14.	 While  you  have  been  in the  HMO,  have  you  ever  had  serious  health 
problems,  such  as:  (Mark  each  answer  yes  or  no.) 
yes  no 
A)  a heart  attack 
B)  cancer 
C)  kidney  failure 
D)  a stroke 
_  E)  broken  bones 
F)  internal  bleeding 
G)  pneumonia 
Section 3:  How Is Your Health?  HMO Survey (Form E)  - Page 4  15.	 While  you  have  been  a member  of  the  HMO,  have  you  ever  had  any  of  the 
following  health  problems?  (Mark  each  answer  yes  or  no.) 
yes  no 
A)  high  blood  pressure 
B)  a heart  condition 
c)  diabetes

D)  difficulty  breathing

E)  joint  pain  or swelling

F)  poor  blood  circulation

G)  problems  with  urinating

H)  poor  digestion

1)  womens  problems

J)  eye  problems,  other  than  needing  glasses

K)  ear,  nose  or throat  problems

L)  skin  problems

M)  memory  loss

N)  difficulty  swallowing

o)  dizziness  or  loss  of  balance

P)  mental  health  problems  including  depression

Q)  weight  too  high  or too  low

R)	 a health  problem  not  listed  here  or in question  14.  (Please  explain 
the  health  problem  briefly.  ) 
16.	 While  you  have  been  in the  HMO,  have  you  ever  been  admitted  to  the 
hospital? 
A)  yes

B)  no  (Go  to  question  18)

C)  I dont  remember  (Go  to  question  18) 
Section 3:  How Is Your Health?  HMO Survey (Form E) - Page 5  17.  Did  you  ever  have  Surgery  While  you  Were  a  patient  in the  hospital? 
A)  yes 
B)  no 
C)  I dont  remember 
18.	 During  the  last  vear,  have  you  seen  your  primary  HMO  doctor  or 
specialist(s),  by  referral,  to  check  your  health? 
A)  yes

B)  no  (Go  to  question  20)

C)  I dont  remember  (Go  to  question  20) 
19.	 During  the  last  vear,  about  how  many  total  visits  have  you  had  with  your 
primary  HMO  doctor  or specialists? 
A)  1 to  3  visits 
_  B)  4  to  6 visits 
C)  7  to  9  visits

D)  10  to  12  visits

E)  more  than  12  visits

20.  During  the  last  vear,  have  you  ever  been  a patient  in a nursing  home? 
A)  yes 
B)  no 
_  C)  I dont  remember 
Section 3:  How Is Your Health?  HMO Survey (Form E)  - Page 6  Section  4:  How  Has  The  HMO  Treated  You?

These  questions  ask  what  it has  been  like  to  be  a member  of  the  HMO.

21,	 Has  your  primary  HMO  doctor  ever  failed  to  take  your  complaints  about  your 
health  seriously? 
A)  yes

B)  no  (Go  to  question  23)

C)  I dont  remember  (Go  to  question  23) 
22.	 How  often  has  your  primary  HMO  doctor  failed  to  take  your  complaints 
about  your  health  seriously? 
_  A)  all the  time 
_  B)  most  of  the  time 
_  C)  about  half  the  time 
_  D)  a few  times 
E)  I dont  remember 
23.	 HOW  long  do you  usually  have  to  wait  for  a scheduled  appointment  with  your 
primary  HMO  doctor? 
A)  1 to  4  days 
B)  5 to 8 days 
C)  9 to  12  days

D)  13t016  days

E)  17  to  20  days

F)  longer  than  20  days

Section 4:  How Has The HMO  Treated  You?  HMO  Survey  (Form  E)  - Page 7  24.	 When  you  go to  the  appointment,  how  long  do  you  usually  have  to  wait  m 
the  office  before  you  see  your  primary  HMO  doctor? 
A)  less  than  a  %  hour 
B)  1A hour  to  1 hour 
C)	 1 hour to 1 % hours 
D)  1  %  hours  to  2  hours 
E)  longer  than  2  hours 
25.	 When  you  have  been  verv  sick,  has  your  primary  HMO  doctor,  his  staff  or 
HMO  office  staff  made  sure  you  had  an  appointment  within  a day  or two? 
A)  yes 
_  B)  no 
C)  I havent  been  very  sick 
D)  I dont  remember 
26.	 How  long  do  you  usually  have  to  wait  for  a scheduled  appointment  with  a 
specialist? 
A)  1 to  4  days 
B)  5 to 8 days 
C)	 9 to  12  days

D)  13t016  days

E)  17  to  20  days

F)  longer  than  20  days

27.	 When  you  have  telephoned  to  make  an  appointment  with  your  primary  HMO 
doctor,  has  the  line  ever  been  busy? 
A)  yes

B)  no  (Go  to  question  30)

C)  I dont  remember  (Go  to  question  30) 
Section  4:  How Has The HMO  Treated  You?  HMO  Survey  (Form  E) - Page  8  28.  How  often  has  the  line  been  busy? 
A)  all the  time

B)  most  of  the  time

C)  about  half  the  time

D)  a few  times

E)  I dont  remember

29.	 Have  you  ever  given  up  on  making  appointments  because  of the  busy 
telephone  line? 
A)  yes 
_  B)  no 
C)  I dont  remember 
30.	 Has  your  primary  HMO  doctor,  his  staff  or the  HMO  office  staff  ever  lost  or 
misplaced  your  medical  records,  including  test  results? 
A)  yes

B)  no  (Go  to  question  33)

C)  I dont  remember  (Go  to  question  33) 
31.  How  often  have  your  medical  records  been  lost  or  misplaced? 
_  A)  all the  time 
B)  most  of  the  time 
C)  about  half  the  time 
D)  a few  times 
_  E)  I dont  remember 
32.	 Have  lost  or  misplaced  medical  records  ever  kept  you  from  using  HMO 
services? 
A)  yes 
B)  no 
C)  I dont  remember 
Section 4:  How Has The HMO Treated You?  HMO Survey (Form E) - Page 9  33.  Has  your  primary  HMO  doctor,  his  staff  or  HMO  office  staff  ever  told  you: 
(Mark  each  answer  yes  or  no.) 
yes  no 
  A)  you  are  too  sick  to  be  in the  HMO? 
.  B)  the  HMO  cant  afford  to  provide  the  medical  care  you  need? 
_  c)  you  would  probably  receive  better  care  if you  left  the  HMO? 
  D)  you  ask  for  too  many  appointments  or services? 
_  E)  you  must  leave  the  HMO  if you  need  nursing  home  care? 
Section  5:  Available  HMO  Services 
These  questions  ask  about  services  that  the  HMO  has  made  available  to  you. 
34.	 Has  your  primary  HMO  doctor  ever  failed  to  provide  Medicare  covered 
services  that  you  believed  you  needed? 
A)  yes

B)  no  (Go  to  question  36)

C)  I dont  remember  (Go  to  question  36) 
35.	 How  often  has  your  primary  HMO  doctor  failed  to  provide  these  Medicare 
covered  services  that  you  believed  you  needed? 
_  A)  all the  time 
_  B)  most  of  the  time 
_  C)  about  half  the  time 
_  D)  a few  times 
_  E)  I dont  remember 
Section 5:  Available  HMO  Services  HMO Survey (Form E) - Page 10  36.	 Has  your  primary  HMO  doctor  ever  failed  to  admit  you  to  the  hospital  when 
you  believed  you  needed  to  be  admitted? 
A)  yes

B)  no  (Go  to  question  38)

C)  I dont  remember  (Go  to  question  38) 
37.	 How  many  times  has  your  primary  HMO  doctor  failed  to  admit  you  to  the 
hospital? 
A)  1 time 
B)  2 times 
_  C)  3  times 
_  D)  4  times 
_  E)  more  than  4  times 
_  F)  I dont  remember 
38.	 Has  your  primary  HMO  doctor  ever  failed  to  refer  you  to  a specialist  when 
YOU thought  you  needed  to  see  one? 
A)  yes

B)  no  (Go  to  question  40)

C)  I dont  remember  (Go  to  question  40) 
39.  How  often  has  your  primary  HMO  doctor  failed  to  refer  you  to  a specialist? 
_  A)  all the  time 
_  B)  most  of  the  time 
_  C)  about  half  the  time 
_  D)  a few  times 
_  E)  I dont  remember 
40.  Overall,  what  do  you  think  is most  important  to  your  primary  HMO  doctor? 
A)  holding  down  the  cost  of  your  medical  care 
B)  giving  you  the  best  medical  care  possible 
_  C)  I dont  know 
Section 5:  Available  HMO  Services  HMO  Survey  (Form  E) - Page  11  41.	 Has  your  primary  HMO  doctor,  his  staff  or  HMO  office  staff  ever  told  you  a 
medical  specialist  that  you  need  is not  covered  by  your  HMO? 
A)  yes

B)  no  (Go  to  question  43)

C)  I dont  remember  (Go  to  question  43) 
42.  What  medical  specialist(s)  have  they  mentioned?  (Mark  each  specialist  they 
mentioned.  )  Doctors  that  specialize  in: 
A)  the  heart 
B)  feet 
C)  urinary  system  including  kidneys
 and  bladder 
D)  skin

E)  digestion  including  stomach  and
 intestines 
F)  womens  problems

G)  ears  and  hearing  only

H)  ears,  nose  and  throat

1)  eyes,  other  than  glasses

J)  bones,  joints  and  muscles

K)  arthritis  and  joints

L)  lungs

M)  nervous  system,  including  the  brain

N)  mental  health

O)  surgery

P)  cancer

Q)  diabetes

R)  other  (explain)

Section 5:  Available  HMO  Servic~  HMO  Survey  (Form  E) - Page  12  43.	 Has  your  primary  HMO  doctor,  his  staff  or  HMO  office  staff  ever  told  you  a 
medical  service  that  you  need  is not  covered  by  your  HMO? 
A)  yes

B)  no  (Go  to  question  45)

C)  I dont  remember  (Go  to  question  45) 
44.	 Are  the  following  medical  services  the  ones  they  said  the  HMO  does  not 
cover?  (Mark  each  answer  yes  or  no.) 
yes  no 
  A)  care  in a skilled  nursing  home

  B)  second  opinion  by  another  HMO  doctor  before  surgery

c) 
drugs  you  cannot  give  to  yourself,  such  as  medicine  given  in a

shot

  D)  laboratory  tests  and  X-rays  that  help  your  doctor  decide  what  is

wrong

  E)  chiropractors

	 H  artificial  legs,  arms  or breast  forms  after  surgery

G)  kidney  dialysis  -- a way  to  clean  your  blood  when  your  kidneys

dont  work  anymore

H)  medical  equipment  for  home  use,  such  as  oxygen  equipment  or a

wheelchair

45.	 Has  the  HMO  ever  refused  to  approve  a Medicare  covered  service  that  your 
primary  HMO  doctor  wanted  you  to  have? 
A)  yes 
  B)  no  (Go  to  question  47) 
  c)  I dont  remember  (Go  to  question  47) 
Section 5:  Available HMO Services  HMO  Survey  (Form  E) - Page 13  46.	 HOW  often  has  the  HMO  refused  to  approve  a Medicare  covered  service  that 
your  primary  HMO  doctor  wanted  you  to  have? 
A)  all the  time 
  B)  most  of  the  time 
c)	 about  half  the  time

D)  a few  times

E)  I dont  remember

47.	 Has  the  HMO  ever  refused  to  pay  a doctor  or  hospital  for  your  emergency 
care  that  you  were  billed  for? 
A)  yes 
_  B)  no 
  c)  I dont  remember 
48.	 Have  you  ever,  on  vour  own,  gotten  Medicare  covered  services  that  your 
primary  HMO  doctor  or the  HMO  did  not  first  approve?  (Do  not  include 
dentists,  glasses  or emergency  care. ) 
A)  yes 
  B)  no  (Go  to  question  51) 
  c)  I dont  remember  (Go  to  question  51) 
Section  5:  Available  HMO  Services  HMO Survey (Form E) - Page  14  49.	 Do  the  following  statements  explain  why  you  got  Medicare  covered  services 
on  vour  own  that  your  primary  HMO  doctor  or the  HMO  did  not  first 
approve?  (Mark  each  answer  yes  or  no.) 
yes  no 
  A)  I needed  the  care,  even  if they  would  not  approve  it.
  B)  I couldnt  get  services  quickly  enough  through  the  HMO.
c)	
My  primary  HMO  doctor  wasnt  helping  me. 
D)  My  primary  HMO  doctor  failed  to  refer  me  to  a specialist. 
  E)  The  HMO  staff  didnt  care  about  me.
  F)  My  HMO  was  wrong  when  they  said  the  service  wasnt  covered
by  Medicare. 
  G)  I didnt  want  to  go  through  my  primary  HMO  doctor  to  see  a
specialist. 
  H)  1 didnt  know  that  I would  have  to  pay  for  it.
50.	 During  the  last  vear,  how  many  times  have  you  gotten  Medicare  covered 
services  on  vour  own  that  your  primary  HMO  doctor  or the  HMO  did  not  first 
approve?  (Your  best  estimate  is fine.  ) 
_  A)  1 to  3  times 
B)  4 to 6 times 
_  C)  7  to  9 times 
_  D)  10t012  times 
_  E)  more  than  12  times 
51.  Overall,  what  do  you  think  is most  important  to  your  HMO? 
A)  holding  down  the  cost  of  your  medical  care 
B)  giving  you  the  best  medical  care  possible 
_  C)  1 dont  know 
Section  5:  Available  HMO  Services  HMO  Survey  (Form  E) - Page  15  52.  Do  you  know  that  you  have  the  right  to  appeal  your  HMOs  refusal  to 
provide  or  pay  for  services? 
A)  yes  (Go  to  question  54) 
_  B)  no 
_  C)  I dont  remember 
53.	 [f you  had  known  about  your  rights,  would  you  have  appealed  any  of  your 
HMOs  refusals  to  provide  or  pay  for  services? 
A)  yes 
B)  no 
C)  My  HMO  has  not  refused  to  provide  or  pay  for  services. 
Section  6:  Future  Health  Care  Plans 
These  questions  ask  about  your  current  health  and  plans  for  HMO  membership. 
54.	 Has  the  medical  care  that  you  have  received  through  your  HMO  caused  your 
health  to: 
A)  improve  a lot 
B)  improve  a little 
c)	 stay  about  the  same

D)  get  a little  worse

E)  get  much  worse

F)  I dont  know

55.  How  would  you  rate  your  overall  health  now? 
A)  excellent 
B)  good 
C)	 fair

D)  poor

E)  very  poor

Section 6:  Future Health Care Plans  HMO  Survey  (Form  E) - Page  16  56.  Do  you  plan  to  leave  the  HMO  in the  near  future? 
A)  yes,  because  I didnt  agree  to  join  the  HMO  in the  first  place 
(Stop.  Return  the  survey  to  us.) 
B)  yes,  because  I am  moving  out  of  the  HMOs  service  area 
(Go  to  question  57) 
C)  yes  (Go  to  question  60) 
D)  no  (Go  to  question  58) 
57.	 If you  were  not  moving,  would  you  have  planned  to  leave  the  HMO  in the 
near  future  for  other  reasons? 
A)  yes  (Go  to  question  60)

B)  no  (Stop.  Return  the  survey  to  us.)

C)  I dont  know  (Stop.  Return  the  survey  to  us.) 
58,  Do  you  want  to  leave  the  HMO,  but  feel  that  you  cant  leave? 
A)  yes

B)  no  (Stop.  Return  the  survey  to  US.)

59.	 Do  the  following  statements  explain  why  you  cant  leave  the  HMO?  (Mark 
each  answer  yes  or  no.) 
yes  no 
A)  I cant  afford  private  health  insurance. 
B)  I cant  afford  non-HMO  doctors. 
c)	 The  HMO  is the  only  way  I can  afford  all the  medical  care  I need.

D)  I cant  get  Medicaid.

E)  There  isnt  another  HMO  close-by.

F)  Its  too  much  trouble  to  find  other  health  care.

G)  My  family  doesnt  want  me  to  leave.

H)  Medicine  is too  expensive  outside  the  HMO.

Section 7:  Future  Health  Care  Plans  HMO  Survey  (Form  E) - Page  17 
.  60,  Do  the  following  statements  about  personal  preferences  explain  why  you 
plan  to  leave  (or  want  to  leave)  the  HMO?  (Mark  each  answer  yes  or 
no.) 
yes  no 
  A)  I dont  like  the  choice  of  primary  HMO  doctors. 
.  B)  I cant  see  the  same  primary  HMO  doctor  every  time. 
  c)  I dont  like  going  through  my  primary  HMO  doctor  to  get  medical
services 
  D)  My  primary  HMO  doctor  left  the  HMO.
  E)  I want  to  use  the  doctor  I had  before  I joined  the  HMO.
  H  The  HMO  services  have  changed.
G)  The  premium  and/or  copayments  are  too  expensive. 
  H)  A  friend  or relative  has  encouraged  me  to  leave.
1)  I want  to  use  another  hospital. 
J)  Getting  to  the  HMO  is too  difficult. 
  K)  I dont  like  the  HMO  building
  L)  I dont  like  where  the  HMO  is located.
/  (If  you  marked  ALL  answers  no,  go to  question  62.) 
Section 7:  Future  Health  Care  Plans  HMO  Survey  (Form  E) - Page  18  62.	 Do  the  following  statements  about  HMO  services  explain  why  you  plan  to 
leave  (or  want  to  leave)  the  HMO?  (Mark  each  answer  yes  or  no.) 
yes  no 
  A)  I cant  see  my  primary  HMO  doctor  or specialist  as  often  as  I need. 
  B)  My  primary  HMO  doctor  has  failed  to  provide  treatments  I need. 
  c)  I cant  get  medical  services  fast  enough  when  1 am  really  sick. 
	 D)  I am  not  allowed  to  see  the  specialist(s)  I need. 
E)  I am  not  allowed  to  go  to  the  hospital  when  I need  to. 
  F)  Too  many  of the  medical  services  I need  are  not  covered. 
	 G)  The  HMO  wont  approve  Medicare  covered  services  that  my 
primary  HMO  doctor  wants  me  to  have. 
	 H)  My  primary  HMO  doctor,  his  staff  or  HMO  office  staff  have 
encouraged  me  to  leave. 
1)  Making  appointments  by  telephone  is too  difficult. 
  J)  I have  to  wait  too  long  for  scheduled  appointments. 
  W  [ have  to  wait  too  long  at  the  office  to  see  the  doctor. 
  U  I am  getting  sicker  because  of  the  care  I receive  through  the  HMO. 
/  (If  you  marked  ALL  answers  no,  go  to  question  64.) 
64.	 Now  look  back  at  your  answers  for  question  61  and  question  63.  Circle  & 
one  answer  that  is THE  MOST  IMPORTANT  REASON  you  plan  to  leave  (or 
want  to  leave)  the  HMO. 
/  (Go  to  question  65  if we  have  not  mentioned  your  most  important  reason.) 
Section 7:  Future  Health  Care  Plans  HMO  Survey  (Form  E) - Page  19  65.	 Please  explain  the  most  imDOrtant  reason  you  plan  to  leave  (or  want  to 
leave)  the  HMO  if we  have  not  mentioned  it. 
66.	 (This  question  is ONLY  for  those  who  plan  to  leave  the  HMO.  )  After  YOU 
leave  the  HMO,  where  will  you  usually  go  to  receive  your  health  care? 
  A)  another  HMO 
  B)  doctors  office 
c)  community  clinic  or health  center 
  D)  hospital  outpatient  clinic 
  E)  hospital  emergency  room 
  F)  no  regular  place 
/  Please  return  your  completed  survey  to  us  in the  envelope  provided. 
Section 7:  Future  Health  Care  Plans  HMO Survey (Form E)  - Page 20  /  Please  write  here  any comments  you  have  about  the  Survey  or your  HMO.  Questions 56 through 64 for the disenrollee  survey form. 
D-2  56.	 Do  the  following  statements  explain  why  you  are  no  longer  in the  HMO? 
(Mark  each  answer  yes  or noll.) 
yes  no 
_  A)  I moved  out  of  the  HMO  service  area. 
_  B)  The  HMO  was  no  longer  a part  of  Medicare. 
_  C)  The  company  I worked  for  dropped  the  HMO. 
_  D)  1 was  taken  out  of  the  HMO  without  my  knowledge. 
#  (If  you  marked  ALL  answers  no,  go to  question  58.) 
57.  Would  you  have  left  the  HMO  anyway  for  other  reasons? 
A)  yes

B)  no  (Stop.  Return  the  survey  to  us. )

c) 
I dont  know 
Section  6:  When  You  Left  The HMO  HMO  Survey  (Form  D) - Page  17  58.	 Do  the  following  statements  about  personal  Preferences  explain  why  you  left 
(or  would  have  left)  the  HMO?  (Mark  each  answer  yes  or  no.) 
yes  no 
A)  I didnt  like  the  choice  of  primary  HMO  doctors. 
B)  I couldnt  see  the  same  primary  HMO  doctor  every  time. 
c)  I didnt  like  going  through  my  primary  HMO  doctor  to  get  medical 
services. 
D)  My  primary  HMO  doctor  left  the  HMO. 
E)  I wanted  to  use  the  doctor  I had  before  I joined  the  HMO. 
F)  The  HMO  services  changed. 
G)  The  premium  and/or  copayments  were  too  expensive. 
H)  A  friend  or relative  encouraged  me  to  leave. 
1)  I wanted  to  use  another  hospital. 
J)  Getting  to  the  HMO  was  too  difficult. 
K)  I didnt  like  the  HMO  building 
L)  I didnt  like  where  the  HMO  was  located. 
#  (If  you  marked  ALL  answers  no,  go to  question  60.) 
Section  6:  When  You  Left  The HMO  HMO  Survey  (Form  D) - Page  18  60.	 Do  the  following  statements  about  HMO  services  explain  why  you  left  (or 
would  have  left)  the  HMO?  (Mark  each  answer  yes  or  no.) 
yes  no 
_  A)  I couldnt  see  my  primary  care  doctor  or specialist  as  often  as  1 
needed. 
_  B)  My  primary  HMO  doctor  refused  to  provide  treatments  I needed. 
_  c)  I couldnt  get  services  fast  enough  when  I was  really  sick. 
D)  I was  not  allowed  to  see  the  specialist(s)  I needed. 
. 
_  E)  I was  not  allowed  to  go  to  the  hospital  when  I needed  to. 
.  F)  Too  many  of  the  medical  services  I needed  werent  covered. 
.  G)  The  HMO  wouldnt  approve  Medicare  covered  services  that  my 
primary  HMO  doctor  wanted  me  to  have. 
_  H)  My  primary  HMO  doctor,  his  staff  or  HMO  office  staff  encouraged 
me  to  leave. 
_  1)  Making  appointments  by  telephone  was  too  difficult. 
_  J)  I had  to  wait  too  long  for  scheduled  appointments. 
.  K)  I had  to  wait  too  long  at  the  office  to  see  the  doctor. 
_  L)  I was  getting  sicker  because  of  the  care  I received  through  the 
HMO. 
~  (If  you  marked  ALL  answers  no,  go to  question  62.) 
62.	 Now  look  back  at  your  answers  for  question  59  and  question  61.  Circle  & 
one  answer  that  was  THE  MOST  IMPORTANT  REASON  you  left  (or  would 
have  left)  the  HMO. 
d  (Go  to  question  63  if we  have  not  mentioned  your  most  important  reason.  ) 
Section 6:  When You Left The HMO  HMO  Survey  (Form  D) - Page  19  63.	 Please  explain  the  most  imDortant  reason  you  left  (or  would  have  left)  the 
HMO  if we  have  not  mentioned  it. 
64.  After  you  left  the  HMO,  where  did  you  usually  receive  your  health  care? 
  A)  another  HMO
  B)  doctors  office 
  c)  community  clinic  or health  center 
	 D)  hospital  outpatient  clinic 
E)  hospital  emergency  room 
F)  no  regular  place 
/  Please  return  your  completed  survey  to  us  in the  envelope  provided. 
Section 6:  When You Left The HMO  HMO  Survey  (Form  D) - Page 20  /  Please  write  here  any  comments  you  have  about  the  survey  or your  HMO.