Adult Survey
Welborn HMO
1. Our records show that you are now in (Welborn HMO). Is that right?
100% Yes -> Go to Question 3
0% No
3. Is this the health plan you use for all or most of your health care?
99% Yes
1% No
4. How many months or years in a row have you been in this health plan?
2% Less than 12 months
14% 12 up to 24 months
28% 2 up to 5 years
24% 5 up to 10 years
32% 10 or more years
Your Personal Doctor or Nurse
The next questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits.
5. A personal doctor or nurse is the health provider who knows you best. This can be a general doctor, a specialist doctor, a nurse practitioner, or a physician assistant. When you joined your health plan or at any time since then, did you get a new personal doctor or nurse?
72% Yes
28% No -> Go to Question 7
6. With the choices your health plan gave you, how much of a problem, if any, was it to get a personal doctor or nurse you are happy with?
9% A big problem
16% A small problem
75% Not a problem
0% I didn't get a new personal doctor or nurse
7. Do you have one person you think of as your personal doctor or nurse?
95% Yes
5% No -> Go to Question 9
8. We want to know your rating of your personal doctor or nurse: Use any number from 0 to 10 where 0 is the worst personal doctor or nurse possible, and 10 is the best personal doctor or nurse possible. How would you rate your personal doctor or nurse now?
1% 0 - Worst personal doctor or nurse possible
0% 1
1% 2
1% 3
1% 4
6% 5
3% 6
10% 7
23% 8
18% 9
37% 10 - Best personal doctor or nurse possible
0% I don't have a personal doctor or nurse
Getting Health Care From a Specialist
When you answer the next questions, do not include dental visits.
9. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and others who specialize in one area of health care.
In the last 12 months, did you or a doctor think you needed to see a specialist?

60% Yes
40% No -> Go to Question 11
10. In the last 12 months, how much of a problem, if any, was it to get a referral to a specialist that you needed to see?
7% A big problem
16% A small problem
77% Not a problem
0% I didn't need to see a specialist in the last 12 months.
11. In the last 12 months, did you see a specialist?
61% Yes
39% No -> Go to Question 14
12. We want to know your rating of the specialist you saw most often in the last 12 months, including a personal doctor if he or she is a specialist. Use any number from 0 to 10 where 0 is the worst specialist possible, and 10 is the best specialist possible. How would you rate the specialist?
2% 0 - Worst specialist possible
0% 1
1% 2
1% 3
2% 4
4% 5
2% 6
7% 7
17% 8
25% 9
39% 10 - Best specialist possible
0% I didn't see a specialist in the last 12 months.
13. In the last 12 months, was the specialist you saw most often the same doctor as your personal doctor?
8% Yes
92% No
0% I don't have a personal doctor or I didn't see a specialist in the last 12 months.
Calling Doctors' Offices
14. In the last 12 months, did you call a doctor's office or clinic during regular office hours to get help or advice for yourself?
78% Yes
22% No -> Go to Question 16
15. In the last 12 months, when you called during regular office hours, how often did you get the help or advice you needed?
0% Never
8% Sometimes
25% Usually
67% Always
0% I didn't call for help or advice during regular office hours in the last 12 months.
Your Health Care in the Last 12 Months
16. A health provider could be a general doctor, a specialist doctor, a nurse practitioner, a physician assistant, a nurse, or anyone else you would see for health care.
In the last 12 months, did you make any appointments with a doctor or other health provider for regular or routine health care?
90% Yes
10% No -> Go to Question 19
17. In the last 12 months, how often did you get an appointment for regular or routine health care as soon as you wanted?
3% Never
11% Sometimes
35% Usually
51% Always
0% I didn't need an appointment for regular or routine care in the last 12 months.
18. In the last 12 months, how many days did you usually have to wait between making an appointment for regular or routine care and actually seeing a provider?
17% Same day
16% 1 day
24% 2-3 days
15% 4-7 days
11% 8-14 days
7% 15-30 days
8% 31 days or longer
3% I didn't need an appointment for regular or routine care in the last 12 months.
19. In the last 12 months, did you have an illness or injury that needed care right away from a doctor's office, clinic, or emergency room?
44% Yes
56% No -> Go to Question 22
20. In the last 12 months, when you needed care right away for an illness or injury, how often did you get care as soon as you wanted?
2% Never
7% Sometimes
22% Usually
69% Always
0% I didn't need care right away for an illness or injury in the last 12 months.
21. In the last 12 months, how long did you usually have to wait between trying to get care and actually seeing a provider for an illness or injury?
58% Same day
23% 1 day
10% 2 days
2% 3 days
4% 4-7 days
1% 8-14 days
1% 15 days or longer
1% I didn't need to get care right away for an illness or injury in the last 12 months.
22. In the last 12 months, how many times did you go to an emergency room to get care for yourself?
85% None
15% _______ Number of times (Write in.)
23. In the last 12 months (not counting times you went to an emergency room), how many times did you go to a doctor's office or clinic to get care for yourself?
7% None -> Go to Question 38
11% 1
15% 2
19% 3
13% 4
19% 5 to 9
15% 10 or more
24. In the last 12 months, how much of a problem, if any, was it to get the care you or a doctor believed necessary?
3% A big problem
10% A small problem
87% Not a problem
0% I had no visits in the last 12 months.
25. In the last 12 months, how much of a problem, if any, were delays in health care while you waited for approval from your health plan?
4% A big problem
10% A small problem
85% Not a problem
1% I had no visits in the last 12 months.
26. In the last 12 months, how often did you wait in the doctor's office or clinic more than 15 minutes past your appointment time to see the person you went to see?
31% Never
47% Sometimes
12% Usually
9% Always
0% I had no visits in the last 12 months.
27. In the last 12 months, how often did office staff at a doctor's office or clinic treat you with courtesy and respect?
0% Never
3% Sometimes
17% Usually
79% Always
0% I had no visits in the last 12 months.
28. In the last 12 months, how often were office staff at a doctor's office or clinic as helpful as you thought they should be?
1% Never
6% Sometimes
26% Usually
66% Always
0% I had no visits in the last 12 months.
29. In the last 12 months, how often did doctors or other health providers listen carefully to you?
0% Never
7% Sometimes
29% Usually
63% Always
1% I had no visits in the last 12 months.
30. In the last 12 months, how often did doctors or other health providers explain things in a way you could understand?
0% Never
7% Sometimes
26% Usually
66% Always
1% I had no visits in the last 12 months.
31. In the last 12 months, how often did doctors or other health providers show respect for what you had to say?
0% Never
10% Sometimes
25% Usually
64% Always
0% I had no visits in the last 12 months.
32. In the last 12 months, how often did doctors or other health providers spend enough time with you?
2% Never
10% Sometimes
34% Usually
53% Always
0% I had no visits in the last 12 months.
33. We want to know your rating of all your health care in the last 12 months from all doctors and other health providers. Use any number from 0 to 10 where 0 is the worst health care possible, and 10 is the best health care possible. How would you rate all your health care?
0% 0 - Worst health care possible
0% 1
1% 2
1% 3
1% 4
4% 5
4% 6
9% 7
25% 8
23% 9
30% 10 Best health care possible
0% 11 I had no visits in the last 12 months.
Your Health Plan
The next questions ask about your experience with your health plan.
34. Claims are sent to a health plan for payment. You may send in the claims yourself, or doctors, hospitals, or others may do this for you.
In the last 12 months, did you or anyone else send in any claims to your health plan?
64% Yes
31% No -> Go to Question 38
6% Don't Know -> Go to Question 38
35. In the last 12 months, how often did your health plan handle your claims in a reasonable time?
3% Never
10% Sometimes
25% Usually
53% Always
9% Don't Know
0% No claims were sent for me in the last 12 months.
36. In the last 12 months, how often did your health plan handle your claims correctly?
1% Never
8% Sometimes
26% Usually
56% Always
9% Don't Know
0% No claims were sent for me in the last 12 months.
37. In the last 12 months, before you went for care, how often did your health plan make it clear how much you would have to pay?
12% Never
8% Sometimes
21% Usually
53% Always
6% Don't Know
0% No claims were sent for me in the last 12 months.
38. In the last 12 months, did you look for any information in written materials from your health plan?
46% Yes
54% No -> Go to Question 40
39. In the last 12 months, how much of a problem, if any, was it to find or understand information in the written materials?
7% A big problem
34% A small problem
59% Not a problem
1% I didn't look for information from my health plan in the last 12 months.
40. In the last 12 months, did you call your health plan's customer service to get information or help?
42% Yes
58% No -> Go to Question 42
41. In the last 12 months, how much of a problem, if any, was it to get the help you needed when you called your health plan's customer service?
14% A big problem
26% A small problem
59% Not a problem
2% I didn't call my health plan's customer service in the last 12 months.
42. In the last 12 months, have you called or written your health plan with a complaint or problem?
18% Yes
82% No -> Go to Question 45
43. How long did it take for the health plan to resolve your complaint?
37% Same day
14% 1 week
5% 2 weeks
1% 3 weeks
18% 4 or more weeks
24% I am still waiting for it to be settled
0% I haven't called or written with a complaint or problem in the last 12 months.
44. Was your complaint or problem settled to your satisfaction?
71% Yes
25% No
4% I am still waiting for it to be settled
0% I haven't called or written with a complaint or problem in the last 12 months.
45. Paperwork means things like getting your ID card, having your records changed, processing forms, or other paperwork related to getting care. In the last 12 months, did you have any experiences with paperwork for your health plan?
35% Yes
65% No -> Go to Question 47
46. In the last 12 months, how much of a problem, if any, did you have with paperwork for your health plan?
4% A big problem
7% A small problem
89% Not a problem
0% I didn't have any experience with paperwork for my health plan in the last 12 months.
47. We want to know your rating of all your experience with your health plan.
Use any number from 0 to 10 where 0 is the worst health plan possible, and 10 is the best health plan possible. How would you rate your health plan now?
0% 0 - Worst health plan possible
1% 1
2% 2
1% 3
1% 4
6% 5
5% 6
11% 7
23% 8
20% 9
30% 10 - Best health plan possible
About You
48. In general, how would you rate your overall health now?
16% Excellent
38% Very good
33% Good
11% Fair
2% Poor
49. Have you ever smoked at least 100 cigarettes in your entire life?
?? Yes
?? No -> Go to Question 53
?? Don't Know -> Go to Question 53
50. Do you now smoke every day, some days, or not at all?
?? Yes -> Go to Question 52
?? Some days -> Go to Question 52
?? Not at all
?? Don't Know -> Go to Question 53
51. How long has it been since you quit smoking cigarettes?
?? Less than 12 months
?? 12 months or more -> Go to Question 53
?? Don't Know -> Go to Question 53
52. In the last 12 months, on how many visits were you advised to quit smoking by a doctor or other health provider in your plan?
?? None
?? 1 visit
?? 2 to 4 visits
?? 5 to 9 visits
?? 10 or more visits
?? I had no visits in the last 12 months.
53. What is your age now?
5% 18 to 24
15% 25 to 34
20% 35 to 44
35% 45 to 54
23% 55 to 64
2% 65 to 74
0% 75 or older
54. Are you male or female?
35% Male
65% Female
55. What is the highest grade or level of school that you have completed?
1% 8th grade or less
4% Some high school, but did not graduate
37% High school graduate or GED
35% Some college or 2-year degree
9% 4-year college graduate
14% More than 4-year college degree
56. Are you of Hispanic or Latino origin or descent?
2% Hispanic or Latino
98% Not Hispanic or Latino
57. What is your race? Please mark one or more.
96% White
3% Black or African-American
0% Asian
0% Native Hawaiian or other Pacific Islander
0% American Indian or Alaska Native
58. Did someone help you complete this survey?
2% Yes -> Go to Question 59
98% No -> Please return the survey in the postage paid envelope.
59. How did that person help you? Check all that apply.
23% Read the questions to me.
31% Wrote down the answers I gave.
31% Answered the questions for me.
0% translated the questions into my language.
15% (please print) _____________