Attachment 4 -- Questionnaire

Thank you for taking the time to complete this survey. Your answers are very important and will be used to analyze the current state of unreimbursed care provided in the offices of primary care physicians.

If you have any questions about your rights as a research subject, you are encouraged to contact Jacqelyn Admire, AAFP IRB Administrator, at (800)274-2237 ex. 3110 or irb@aafp.org.

For This Survey, unreimbursed care refers to free or reduced-cost care. This does not include scenarios when payment was expected and not received, care provided to Medicare or Medicaid recipients, payments from insurance companies that are below your billable rate, or care provided as a professional courtesy to the families of colleagues.

1) How many hours do you provide direct patient care during a typical week?

□	<16		GO TO page 14
□	16-25
□	26-35
□	36-45
□	>45

2) Approximately how many patients do you personally see during a typical week?

□	<25
□	25-50
□	51-75
□	76-100
□	101-125
□	>125

3) In your current practice setting do you provide unreimbursed care to patients?

Yes	□		GO TO question 4
No	□

3a) In the past did you provide unreimbursed care to your patients?

Yes	□		GO TO question 3c
No	□

3b) What are the reasons you do not provide unreimbursed care?

Please check all that apply.
□	There is no need in my community
□	There is no tradition in my practice of providing unreimbursed care
□	I do not have the financial ability to provide unreimbursed care
□	I do not think that it is part of my responsibilities as a physician to provide unreimbursed care
□	I am not able to take on unreimbursed care patients because I am fully booked with my other patients
□	I am not in a position to decide which patients I see and which I do not see
□	Other (Specify)

GO TO Question 3d

3c) What are the reasons you no longer provide unreimbursed care?

Please check all that apply.
□	The practice has considered the matter and feels it no longer has the financial ability to provide unreimbursed care
□	The practice has considered the matter and for reasons other than financial has decided not to provide unreimbursed care
□	I have changed practices and my new practice has a policy discouraging unreimbursed care
□	I have recently started a new practice and I am just getting established. I may provide unreimbursed care in the future
□	There are new options for safety-net care in the community and I refer patients to them
□	I felt like my patients took advantage of me in the past when I provided unreimbursed care
□	Other (Specify)

3d) Which of the following would be needed in order for you to begin providing unreimbursed care?

Please check all that apply.
□	A system to determine eligibility for unreimbursed care that reduces decision making burden
□	Tax credits to allow me to defray some of the costs of providing unreimbursed care
□	More support from the local health care system with referrals and hospitalizations
□	Increased availability of state and Federal assistance for unreimbursed care
□	Increased appreciation from the patients to whom I provide unreimbursed care
□	More flexibility in determining the patients that I am able to see
□	More time to get my medical practice established
□	Increased need within my community
□	More support from ancillary services (labs, radiology, pharmacy)
□	None of the above
□	Other (Specify)

GO TO Page 14

4) What kind of unreimbursed care do you currently provide?

		Never	Daily		Weekly		Monthly or less
		0	1	2	3	4	5
Free service in the office
Discounted service in the office
Discounted or free service outside the office (i.e. home visit)
Other (Specify)

4a) How often do you provide unreimbursed care to patients in each age group?

	Never	Daily		Weekly		Monthly or less
	0	1	2	3	4	5
<19 years
19-65 years
>65 years

4b) How often do you provide the following services for your unreimbursed care patients?

		Never	Daily		Weekly		Monthly or less
		0	1	2	3	4	5
Evaluation of acute problem
Chronic problem (routine follow-up)
Chronic problem (flare up)
Pre/post surgery/injury follow-up
Non-illness care (prevention, screening)
Administrative office services (i.e. completion of forms, photocopying)
Other (Specify)

5) In the past, have you provided unreimbursed care to patients with whom you have not established a relationship (i.e. new patients)?

□	Yes
□	No

6) When a patient receives unreimbursed care from you, who determines their eligibility?

	Never	Sometimes		Always
	1	2	3
It is my individual decision
It is a decision made by the administrative staff within my office
It is a decision made by the administrative staff within our institution but not in my office
It is a decision made by an outside agency that reports a patient's eligibility to our practice

7) What does your practice or outside agency require to determine a patient's eligibility for unreimbursed care?

Please check all that apply.
□	No written verification required
□	Previous year's tax returns
□	Recent W2 or paystub
□	Qualification for other Federal/State assistance
□	Document that another organization has previously verified eligibility (i.e. Hospital Social Services)
□	Do not know
□	Other (Specify)

8) Over the past year, how has the amount of unreimbursed care you provided changed?

Decreased	Stayed about the same			Increased

If you answered “Stayed about the same,” Please GO TO Question 9

8a) What was the reason for this change?

Please check all that apply.
□	Change in leadership/ownership of practice
□	Change in the need for unreimbursed care
□	Change in the environment outside the practice (i.e. closing or opening of safety net provider)
□	Other (Specify)

9) What do you expect will happen to the level of unreimbursed care that you provide in the next year?

Decrease	Stay about the same			Increase

10) How important are the following factors in determining your willingness to offer unreimbursed care?

		Not Important			Somewhat Important			Very Important
			1	2		3	4		5
Desire to provide continuity of care to patients who have lost their insurance coverage
Needs from new patients requesting appointments
Responsibility for follow-up care of patients I have seen in the ER
Tradition in my practice
Tradition among my peers and colleagues
Requests from the friends and family of clinic staff
The economic stability of my practice allows me to provide unreimbursed care
My personal or religious values
My involvement in a teaching program
My desire to help my community
My patient's appreciation of the unreimbursed care they receive from me
My personal satisfaction as a physician
Other (Specify)

11) How important are the following factors in limiting your ability to provide unreimbursed care?

		Not Important			Somewhat Important			Very Important
			1	2		3	4		5
Availability of sufficient alternatives within the community
Medical liability concerns
Discomfort of regular patients with the presence of charity patients in my waiting room
Corporate policies
*Pressure to be productive with time
**Declining profitability of practice or revenue per patient
Other (Specify)

*11a) Many physicians feel that pressure to be productive with their time limits the amount of unreimbursed care they can provide. What is the source of the pressure?

Please check all that apply.
□	This is not a concern for my practice
□	The need for higher volume of paying patients to maintain profitability
□	The need for higher volume of paying patients to keep practice profitability growing
□	Specific incentives or demands from employer/manager
□	Specific financial incentives from managed care organizations or other payers
□	The high need of paying patients and lack of time to serve non-paying patients
□	Other (Specify)

**11b) Many physicians feel that a decline in the profitability of their practice limits the amount of unreimbursed care they are able to provide. What has been the cause of this decline?

Please check all that apply.
□	This is not a concern for my practice
□	Rising costs
□	Declining payments
□	Both rising costs and declining payments
□	Other (Specify)

12) How often have you done the following in order to provide unreimbursed care to a patient?

		Never		Daily		Weekly			Monthly or less
			0	1	2		3	4		5
Down coded a visit for an unreimbursed care patient
Discarded the billing slip for an unreimbursed care patient
Evaluated an unreimbursed care patient before insurance coverage is verified
Provided more than usual information during a phone consult to an unreimbursed care patient in order to avoid an office visit
Used email to prevent unreimbursed care patients from having to incur office visit charges
Wrote a prescription for an insured patient that is meant for a family member
Called a colleague (including specialists) on behalf of an unreimbursed care patient
Called a lab/radiology service on behalf of an unreimbursed care patient
Gave an unreimbursed care patient medical supplies from your office
Examined two family members but only billed for the insured person
Personally provided an administrative service that would otherwise be charged to the patient
Provided unreimbursed care patients with sample medications from your office
Other (Specify)

13) To what extent do your own personal financial gains derived from your practice affect the amount of unreimbursed care you are willing to provide?

Not at All	Somewhat			Greatly
1	2	3	4		5

14) How often do you have difficulty referring unreimbursed care patients out for specialist care?

Never	Sometimes			Always
1	2	3	4		5

If you selected “Never,” Please GO TO Question 15

14a) Is this difficulty in referring to specialists related to?

Please check all that apply.
□	A general lack of specialists in the region
□	A lack of a mechanism for referring unreimbursed patients from the office
□	General unwillingness of specialists to accept unreimbursed care patients
□	Unwillingness of patients to see specialist
□	Formal policies that restrict referral of patients
□	Cost associated with specialist care
□	None of the above
□	Other (Specify)

15) How often do you have difficulty referring unreimbursed care patients out for lab services?

Never	Sometimes			Always
1	2	3	4		5

If you selected “Never,” Please GO TO Question 16

15a) Is this difficulty in referring unreimbursed patients to labs related to?

Please check all that apply.
□	A general lack of laboratory services in the region
□	A lack of a mechanism for referring unreimbursed patients from the office
□	General unwillingness of laboratories in your region to accept unreimbursed care patients
□	The existence of formal policies that restrict the patient's ability to obtain laboratory services
□	Cost associated with laboratory testing
□	None of the above
□	Other (Specify)

16) How often do you have difficulty referring unreimbursed care patients out for radiology or imaging services?

Never	Sometimes			Always
1	2	3	4		5

If you selected “Never” Please GO TO Question 17

16a) Is this difficulty in referring unreimbursed care patients out for radiology or imaging services related to?

Please check all that apply.
□	A general lack of radiology services in your region
□	A lack of a mechanism for referring unreimbursed patients from the office
□	General unwillingness of radiology or imaging departments to accept unreimbursed care patients
□	The existence of formal policies that restrict a patient's ability to obtain radiology services
□	The cost associated with radiology service
□	None of the above
□	Other (Specify)

17) How often do you have difficulty accessing medications for unreimbursed care patients?

Never	Sometimes			Always
1	2	3	4		5

If you selected “Never” Please GO TO Page 14

17a) Is this difficulty in accessing medications related to?

Please check all that apply.
□	A general lack of available pharmacies in your region
□	A lack of a mechanism for referring unreimbursed patients from the office
□	General unwillingness of pharmacies to accept unreimbursed care patients
□	The existence of formal policies that restrict a patient's ability to obtain medications
□	The cost associated with filling prescriptions
□	Medication assistance program requirements are too onerous
□	There are no local medication assistance programs accessible to my patients
□	Local medication assistance program requirements are too onerous
□	None of the above
□	Other (Specify)

Please tell us a little about yourself

What is your gender?

□ Male

□ Female

What year were you born?

What year did you graduate from medical school?

Are you of Hispanic/Latino origin?

□ Yes

□ No

What is your race?

Please check all that apply.
□	American Indian or Alaskan Native
□	Asian
□	Black or African American
□	Pacific Islander/Native Hawaiian
□	White
□	Other

Please tell us a little about your group practice

Does your practice have more than one location?

□ Yes

□ No

Including yourself, how many clinicians (MDs, NPs, PAs) are associated with your group? Please include full and part time clinicians.

□	1
□	2-3
□	4-7
□	8-12
□	>12

Is this a single- or multi- specialty practice?

□	Single Specialty Practice
□	Multi-Specialty Practice
□	Other

Are you a full- or part-owner, employee, or an independent contractor?

□	Owner
□	Employee
□	Contractor
□	Other

Who owns the practice?

□	Physician or physician group
□	HMO
□	Community health center
□	Academic health center
□	Non-academic hospital system
□	Other health care corporation
□	Other

Please tell us about the practice location where you see most of your ambulatory patients.

Including yourself, how many clinicians (MDs, NPs, PAs) provide direct patient care at the location where you see most of your patients? Please include full and part time clinicians.

□	1
□	2-3
□	4-7
□	8-12
□	>12

How would you identify the geographic location where you provide the most direct patient care?

□	Urban: Central City
□	Urban: Non-central City
□	Suburban
□	Rural

In what zip code is the location at which you provide the most direct patient care? (This information will be used to describe the individual characteristics of your practice location, not to identify you personally)

Thank you for taking the survey. The information will assist the Agency for Healthcare Research and Quality (AHRQ) and the American Academy of Family Physicians (AAFP) to understand the factors affecting the current state of safety net care in the family practice environment.

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