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 
�.*’ ‘% 

: DEPARTMENT OF HEALTH& HUMAN SERVICES OffIce of Inspector General 

s 4 ‘%%. 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 Administration’s (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 HCFA’Sinternal 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 beneficiary’s 

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

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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 patient’s medical needs, or price of services and the patient’s 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 hadn’t. 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 hadn’t covered. Questions, that we might add, cover beneficiaries’ 

3 
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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 

didn’t 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 

What’s the purpose of this survey? 

Why are you wasting taxpayers’ money on this? 

I’m not in an HMO; I have a health plan. 

Am I in trouble if I can’t complete it by the due date? 

Do I have to fti this out to get my Social Security check? 

I don’t belong to the HMO anymore. Should I still answer the survey? 

That’s 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 Don’t assume that beneficiaries know what an HMO is or that they are enrolled. 

�	 Don’t assume that beneficiaries know the HMO by the Medicare product name; 

mention other names of the HMO. 

5

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F	 State clearly in several places that the survey was@ sent by the HMO or a 

representative of an HMO physician. 

b	 Be sure to arrange for an “800” telephone contact or other method so that 

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 subpopulations 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 Irzformah”on: 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 HCFA’S 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 

HCFA’S 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 beneficiary’s 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. 

b. 

c. 

d. 

AvaiZubi2ity - the relationship of the volume and type of existing services 

(and resources) to the client’s 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. 

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, 

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 client’s 

ability to accommodate to these factors and the client’s perception of their 

appropriateness. 

A&ordability - The relationship of prices of services and the providers’ 

insurance (or deposit requirements) to client’s 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 HCFA’s 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,” OEI06-91-00731 

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 beneficiary’s 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) 

Male 40% (446,205) 

RACE/ETHNICITY 

White 90% (991 ,084) 

Non-White 7% (83,684) 

Unknown 3% (37,486) 

AVERAGE AGE 74 Years 

EDUCATION 

< Than High School 24% (274, 156) 

High School Diploma 29% (318,440) 

> Than High School 43% (474,317) 

No Response 4% (45,342) 

MEDICARE 

CATEGORY 

Aged 97% (1 ,078,445) 

Disabled/ESRD 3% (33,809) 

COMPETITIVE AREA 

Competitive’ 63% (700,103) 

Noncompetitive 37% (412,152) 

HMO EXPERIENCE 

Prior Experience 14% (154,069) 

No Experience 82% (906,961) 

No Response 4% (51,226) 

AVERAGE LENGTH


OF TIME IN HMO 36 Months


SERIOUS HEALTH


CONDITIONS 

2+ conditions 6% (61,003) 

1 condition 24% (265,866) 

None 60% (669,619) 

No Response 10% (115,767) 

53%(15,065) 60%(650,984) 

47% (13,139) 40% (433,067) 

88% (24,872) 90% (966,213) 

12% (3,332) 7% (80,352) 

o 3% (37,486) 

73 Years 74 Years 

20% (5,683) 25% (268,473) 

22% (6,238) 29% (312,201) 

49% (13,778) 42% (460,539) 

9% (2,504) 4% (42,838) 

92% (25,907) 97% (1,052,538) 

8% (2,296) 3% (31,513) 

53% (14,878) 63% (685,225) 

47% (13,325) 37% (398,826) 

21% (5,997) 14% (148,072) 

71% (19,905) 82% (887,056) 

8% (2,302) 4% (48,923) 

29 Months 36 Months 

5% (1,254) 6% (59,749) 

22% (6,153) 24% (259,713) 

58% (16,440) 60% (653,180) 

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 won’t 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 haven’t received 

your completed survey yet. 

Maybe you thought the survey didn’t 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 don’t 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 couldn’t complete the survey by the date we requested. 

Answer:	 Don’t 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 1—8W8484960 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 hadn’t 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 didn’t call us, you may think the survey doesn’t 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, that’s 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** 

,# % 

DEPARTMENT OF HEALTH AND HUMAN SERVICES [(c

%+4vam 4

HEALTH MAINTENANCE ORGANIZATIONS (HMOS) 

A Survey of Medicare Members 

Form E 

/	 Is w HMO’s 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 

HMO’s 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 DON’T 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) doctor’s 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 don’t know 

5. I usually go to the doctor as soon as I start to feel bad. 

_ A) true 

B) false 

_ C) I don’t 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 didn’t apply for membership. (Go to question 10) 

7.	 When you applied for HMO membership, were you asked about your health 

problems? (Don’t count questions about kidney failure or Medicare hospice 

coverage. ) 

A) yes 

B) no 

_ C) I don’t 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 don’t 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 don’t 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 don’t remember 

11.	 Did you know, from the beginning, that an HMO member could only use 

HMO doctors and hospitals (except in emergencies outside the HMO’s 

service area)? 

A) yes 

B) no 

_ C) I don’t 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 don’t 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) women’s 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 don’t 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 don’t 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 don’t 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 don’t 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 don’t 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 don’t 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 haven’t been very sick 

D) I don’t 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 don’t 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 don’t remember


29.	 Have you ever given up on making appointments because of the busy 

telephone line? 

A) yes 

_ B) no 

C) I don’t 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 don’t 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 don’t remember 

32.	 Have lost or misplaced medical records ever kept you from using HMO 

services? 

A) yes 

B) no 

C) I don’t 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 can’t 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 don’t 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 don’t 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 don’t 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 don’t 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 don’t 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 don’t 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 don’t 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 don’t remember (Go to question 43) 

42. What medical specialist(s) have they mentioned? (Mark each specialist they 

mentioned. ) Doctors that specialize 

A) the heart 

B) feet 

C) urinary system including kidneys


D) skin


E) digestion including stomach and


F) women’s 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


in: 

and bladder 

intestines 

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 don’t 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) 

— B) 

c) 

— D) 

— E) 

—	 H 

G) 

H) 

care in a skilled nursing home


second opinion by another HMO doctor before surgery


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


shot


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


wrong


chiropractors


artificial legs, arms or breast forms after surgery


kidney dialysis a way to clean your blood when your kidneys


don’t work anymore


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 don’t 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 don’t 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 don’t 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 don’t 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 couldn’t get services quickly enough through the HMO.

c)	 My primary HMO doctor wasn’t helping me. 

D) My primary HMO doctor failed to refer me to a specialist. 

— E) The HMO staff didn’t care about me.

— F) My HMO was wrong when they said the service wasn’t covered

by Medicare. 

G) — I didn’t want to go through my primary HMO doctor to see a

specialist. 

— H) 1 didn’t 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 don’t know 

Section 5: Available HMO Services HMO Survey (Form E) - Page 15 
52. Do you know that you have the right to appeal your HMO’s refusal to 

provide or pay for services? 

A) yes (Go to question 54) 

_ B) no 

_ C) I don’t remember 

53.	 [f you had known about your rights, would you have appealed any of your 

HMO’s 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 don’t 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 didn’t agree to join the HMO in the first place 

(Stop. Return the survey to us.) 

B) yes, because I am moving out of the HMO’s 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 don’t know (Stop. Return the survey to us.) 

58, Do you want to leave the HMO, but feel that you can’t leave? 

A) yes


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


59.	 Do the following statements explain why you can’t leave the HMO? (Mark 

each answer “yes” or “no”.) 

yes no 

A) I can’t afford private health insurance. 

B) I can’t afford non-HMO doctors. 

c)	 The HMO is the only way I can afford all the medical care I need.


D) I can’t get Medicaid.


E) There isn’t another HMO close-by.


F) It’s too much trouble to find other health care.


G) My family doesn’t 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 don’t like the choice of primary HMO doctors. 

—. B) I can’t see the same primary HMO doctor every time. 

—— c) I don’t 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 don’t like the HMO building

L) — I don’t 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 can’t 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 can’t 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 won’t 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) doctor’s 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 don’t 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) 

B) 

c) 

D) 

E) 

F) 

G) 

H) 

1) 

J) 

K) 

L) 

I didn’t like the choice of primary HMO doctors. 

I couldn’t see the same primary HMO doctor every time. 

I didn’t like going through my primary HMO doctor to get medical 

services. 

My primary HMO doctor left the HMO. 

I wanted to use the doctor I had before I joined the HMO. 

The HMO services changed. 

The premium and/or copayments were too expensive. 

A friend or relative encouraged me to leave. 

I wanted to use another hospital. 

Getting to the HMO was too difficult. 

I didn’t like the HMO building 

I didn’t 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) 

—_ B) 

—_ c) 

—. D) 

—_ E) 

—. F) 

—. G) 

—_ H) 

—_ 1) 

—_ J) 

—. K) 

—_ L) 

I couldn’t see my primary care doctor or specialist as often as 1 

needed. 

My primary HMO doctor refused to provide treatments I needed. 

I couldn’t get services fast enough when I was really sick. 

I was not allowed to see the specialist(s) I needed. 

I was not allowed to go to the hospital when I needed to. 

Too many of the medical services I needed weren’t covered. 

The HMO wouldn’t approve Medicare covered services that my 

primary HMO doctor wanted me to have. 

My primary HMO doctor, his staff or HMO office staff encouraged 

me to leave. 

Making appointments by telephone was too difficult. 

I had to wait too long for scheduled appointments. 

I had to wait too long at the office to see the doctor. 

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) doctor’s 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.