2013 Health Care Public Opinion Survey

A Survey of Massachusetts Adults Health Care in the Commonwealth

August 2013

Table of Contents
Introduction ...........................................................................................................3 Executive Summary ............................................................................................... 4 Summary of Key Findings ....................................................................................... 7 Health care landscape ...................................................................................................................... 7 Overall satisfaction with health care over the last 12 months .......................................................8 Access to health care .......................................................................................................................11 Identifying barriers to health care access ..................................................................................... 14 Perceived price of health care ........................................................................................................ 14 Primary care appointments ........................................................................................................... 16 Appointments for serious medical care ........................................................................................ 19 Non-doctor medical visits .............................................................................................................. 21 Deciding where to go for care ........................................................................................................25 Emergency department utilization............................................................................................... 28 New health insurance options ....................................................................................................... 31 Legislation restricting pain medication prescription...................................................................34 Appendix: Topline Results ....................................................................................36

This study was conducted by Anderson Robbins Research for the Massachusetts Medical Society.
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Introduction
This document reports the findings of a telephone survey of Massachusetts adults commissioned by the Massachusetts Medical Society (MMS). The survey, which has been conducted periodically over the past decade, examines a range of factors related to Massachusetts residents’ satisfaction with and access to health care services. Many of the graphs included in this report present historical trend data. It is important to note, when examining this trend data, that the survey was not conducted in 2009, 2010, and 2011. Additionally, not all questions were asked each year. This report includes an Executive Summary, followed by a detailed Summary of Findings. Complete survey findings are included as an Appendix. Methodology A total of 417 telephone interviews were conducted by trained professionals working from a central, monitored location from May 14 to 16, 2013. The margin of error on questions involving the whole sample is +/- 4.8 percentage points. Respondents were selected for the survey using a random digit dial (RDD) selection process, which gives every household in the state an equal chance of receiving a call. Respondents were interviewed on their landlines and cellphones. Respondents were screened to ensure they were in fact residents of Massachusetts and at least 21 years of age. Region and gender quotas were established to produce a representative sample of residents statewide. Slight age weights were applied to the final data to bring the overall results in accordance with the overall adult population.

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Executive Summary
Most Massachusetts adults believe that affordability is the single most important health care issue facing the state. Residents are more likely to cite affordability and cost-related issues than mention issues related to health care access by a three-to-one margin. When asked to choose among cost of care, access to care, and quality of care as the most pressing issue, nearly eight-inten residents select cost. Perceptions of Health Care Costs When asked directly, most Massachusetts residents believe that the cost of the health care services they utilized in the last year was more expensive than the year before (65%) – including 28% who believe that their health care has gotten much more expensive. Another 28% believe that the price of their health care has stayed the same, while just 3% believe their care has become less expensive. Access to Health Care in Massachusetts Consistent with the finding that access to care is not the most pressing issue for Massachusetts adults, a variety of measures indicate that residents have relatively little difficulty in accessing the services they need. Three-quarters (73%) report that accessing the care they need is not difficult, which is a slight decrease from 2012 (78%). Residents’ Satisfaction with Health Care Services As has been the case since 2004, most Massachusetts residents are generally satisfied with the health care they receive. Nearly six-in-ten residents (56%) are very satisfied with the health care they received last year, and another 28% are somewhat satisfied. These numbers have remained highly stable for the past eight years. While the survey findings are largely positive in terms of residents’ feelings about health care quality and access, there are clear divisions with regard to socioeconomic status. Those with higher income levels and more education are more likely to be satisfied with their health care and report less difficulty in obtaining care than those with lower income and less education. • • • 90% of those with household income over $100,000 are at least somewhat satisfied with their health care, compared to 76% of those with income under $50,000 Satisfaction is 10 percentage points lower among those with just a high school education or less (76%) than among those with at least some college education (86%) 82% of those with household income over $100,000 report that obtaining the health care they need was not difficult, compared to 64% of those with income under $50,000

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Utilization of Quality and Cost of Care Data Most residents remain unaware that data on quality and cost of care is available online, and less than a third have actually used this data to decide where to go for care. Instead of using this information, residents continue to rely on their primary care physician for opinions about where to go for care. Older adults – particularly men over 50 – as well as those with a high school education or less are especially unlikely to use online quality and cost of care data to inform their choice of doctor. Visits to Primary Care Physicians and Other Medical Professionals Nearly nine-in-ten Massachusetts residents have seen their primary care physician in the past year. Residents report waiting longer for appointments with primary care doctors than in past years – 42% of respondents who saw a PCP last year reported waiting more than two weeks, up from 32% who said the same last year. However, for nearly 90% of residents, this wait was not problematic. Four-in-ten residents also report seeing medical professionals other than medical doctors (i.e. nurses, nurse practitioners, or physician’s assistants) for care in the last year. When residents learned that a new law allows nurse practitioners and physician’s assistants to serve as primary care providers for the purpose of increasing the number of medical professionals available to patients, two-thirds of Massachusetts adults indicated that they would rather see a medical doctor than a nurse practitioner or physician’s assistant. However, twothirds of Massachusetts residents indicated that they are either very likely or somewhat likely to make an appointment with a nurse practitioner or physician’s assistant in the future, especially if they are likely to have a shorter wait time. Emergency Department Utilization Approximately three-in-ten Massachusetts residents report visiting an emergency department at a hospital in the past year – a slight increase from 2012, when one-quarter of residents did so. Younger residents and those on a government-backed insurance plan (e.g. Medicare and MassHealth) were more likely than others to utilize the emergency department. Most of those who visited an emergency department did so because they had a “serious but not life-threatening medical problem that required immediate attention.” One-third of those who went to an emergency room indicate that the fact that “the emergency room is the easiest place to get care” was a major factor behind their utilization of the ER. Opinions of New Health Insurance Models Similarly to last year, reactions to limited and tiered health plans are generally unfavorable. By a roughly two-to-one margin, residents are more likely to react unfavorably than favorably to brief descriptions of each type of plan.
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Overall awareness of Accountable Care Organizations (ACOs) is low, with more than six-in-ten residents unable to offer an opinion on ACOs after hearing a brief, generic description. When provided with more information on the coordination of care offered by ACOs, Massachusetts adults have favorable overall impressions of ACOs. However, residents are more likely to react unfavorably to the global payments structure of ACOs.

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Summary of Key Findings
This section of the report provides a detailed discussion of the survey results, organized by topic. Health care landscape Issues of cost and affordability continue to dominate residents’ concerns related to health care in Massachusetts. When asked an open-ended question (Table 1) about the single most important health care issue facing the state, the most common responses – by a wide margin – focus on cost and affordability. Over four-in-ten residents (45%) believe that “affordability,” “cost,” or “expenses” are the most important health care issues facing the state. Access-related issues are a distant second, mentioned by slightly more than one-in-ten residents (13%). Seven percent of residents reported “access to care” as the single most important health care issue, while 6% mentioned “access to health insurance.” Table 1

(Q1: What do you think is the single most important health care issue facing Massachusetts today?)

Similarly, when asked to choose among cost of care, access to care and quality of care as the most important health care issue facing the state, four times as many residents indicate that cost concerns are the most pressing issue as those selecting health care access or quality, as can be seen in Figure 1. As Table 2 indicates, cost concerns are lower among residents of Western Massachusetts (67%, compared to 82% among those not living in the western part of the state).
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Figure 1

Table 2

Table 2 (Q2: Which one of the following do you think is the most important health care issue facing Massachusetts today?)

(Q2: Which one of the following do you think is the most important health care issue facing Massachusetts today?)

Overall satisfaction with health care over the last 12 months The vast majority (84%) of Massachusetts residents are satisfied with the health care they have received over the past year. This percentage includes 56% of residents who are very satisfied and 28% who are somewhat satisfied with the health care they have received. As Figure 2 shows, overall levels of satisfaction dipped slightly compared to 2012, when 87% of Massachusetts residents were satisfied. This three percentage point change is not statistically significant. Satisfaction with health care by this measure has remained highly stable since the Massachusetts Medical Society first reported this data in 2004, when 88% of Massachusetts adults were satisfied with the care they had received.

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Figure 2

(Q3: All things considered, have you been satisfied or dissatisfied with the health care you have received during the last 12 months?)

Massachusetts residents without any college education (76% satisfied) are significantly less likely to be satisfied with the health care they have received than those who have attended college (86% satisfied). Similarly, households making under $50,000 per year are less likely to be satisfied than households earning more (Figure 2, inset). Table 3

(Q4: Specifically, why are you (satisfied / dissatisfied) with your care?)

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As indicated in Table 3, above, amongst the small number of residents who are somewhat or very dissatisfied with their health care over the last year, “too expensive” (50%) is the most common explanation, followed by complaints about poor medical care (27%), poor insurance coverage (23%), limited access (18%), and long wait times (12%). As Table 4 shows, when those who say they are either very or somewhat satisfied are asked to explain why, they are most likely to explain their satisfaction in terms of the quality of care they have received. More than four-in-ten (45%) report that their satisfaction is based on “quality of care / good doctors,” while another 6% report that they “like their doctor / have a good relationship with their doctor.” After quality of care-related explanations, residents explain their satisfaction in terms related to the ease of access to health care (27%) as well as positive experiences with health insurance (20%). Finally, 11% mention affordability as the main reason for their satisfaction (Table 4). Table 4

(Q4: Specifically, why are you (satisfied / dissatisfied) with your care?)

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Access to health care Overall, most Massachusetts residents (73%) report that gaining access to the health care they need is not difficult. However, the number of residents reporting that accessing health care was not difficult decreased slightly, down from 78% in 2012 (Figure 3). This year, 54% of adults indicate that obtaining the care they needed was not difficult at all, down from 62% in 2012. Despite these declines, ease of access to care remains dramatically higher than 2008, when just 57% of residents indicated that accessing the care they needed was not difficult. Much like satisfaction with care, there is variation among Massachusetts residents based on household income (Figure 3, inset). Households that earn less than $50,000 annually (64% not difficult) are less likely to report that accessing necessary care was not difficult than those earning over $100,000 (82% not difficult). Figure 3

(Q5: In general, how would you rate the difficulty in obtaining the health care you need for you and your family – whether it be for a routine problem or a serious problem – over the last few years? On a scale of “1” to “5”, where “1” means “not difficult at all”, and “5” means “extremely difficult,” please rate the level of difficulty you’ve experienced in obtaining this care.)

Residents who report difficulty accessing needed health care offer a range of explanations, but cost issues are the most frequently-cited individual reason, as shown in Table 5. Nearly four-inten (38%) of those who found obtaining care difficult mention expense. Many other explanations center on insurance: 17% mention “red tape / paperwork,” 15% report “poor coverage,” 13% indicate “limits on where I can go,” and another 10% mention difficulty in accessing health insurance. Just over one-in-ten residents (13%) cite “poor care” or “bad doctors” for their difficulty obtaining health care.
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Table 5

(Q6: Specifically, why do you feel that way? Multiple responses accepted)

As shown in Figure 4, this study finds that most Massachusetts residents get the care they believe they need when they need it. Approximately one-fifth (21%) of residents say that at some point during the last 12 months they waited to get medical care they thought they needed, which is similar to last year, when 19% reported waiting to get needed care. Older residents are much less likely than others to put off needed care – only 11% of those over 60 report waiting to get care, compared to 25% of adults 60 and younger (Figure 4, inset).

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Figure 4

(Q8: Was there any time during the past 12 months when you waited to get medical care you thought you needed?)

When asked, the most common reason provided by those who waited to get care is that the desired physician was booked (42%). Issues with insurance coverage and approval are cited by one-quarter of adults, while less than two-fifths (17%) mention issues of affordability (Table 6). Table 6

(Q9: (IF YES TO Q8) What was the primary reason you waited to get that medical care?)

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Identifying barriers to health care access All residents – including those who indicated no difficulty obtaining the care they needed – were asked to select one of eight factors that might contribute to difficulties in accessing health care. As Figure 5 shows, the most common response, selected by 27% of residents, places the blame on insurance companies. Another 15% of adults believe the government is most responsible for difficulties in access, while 11% select the economy or personal economic circumstances. Nearly one-quarter (24%) volunteer that they had no problems accessing care. These numbers are all relatively consistent with data from 2012, although residents were somewhat less likely to volunteer that they had no access problems (24% this year compared to 30% last year). Figure 5

(Q7: Which ONE of the following do you believe is most responsible for any problems you might have had gaining access to health care over the last few years?)

Perceived price of health care More than six-in-ten (65%) Massachusetts residents believe that the health care services they use were more expensive last year than the year before. This includes 28% who believe that their health care is much more expensive, and 37% who think costs have increased somewhat. Only 3% believe that the care they use has gotten less expensive (Figure 6).

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Figure 6

(Q10: In general, do you think the price of the health care services you and your family used over the past 12 months was much more expensive now than the same services would have been two years ago, somewhat more expensive, about the same, somewhat less, or much less expensive than the same services would have been two years ago?)

As Table 7 shows, Massachusetts adults with a high school degree or less education are particularly likely to believe the health care services they use have gotten much more expensive (42%, compared to 27% of college graduates and just 18% of those with graduate degrees). Residents on a government-backed health insurance program (e.g. Medicare or MassHealth) are less likely to think that health care has gotten much more expensive (23%), compared to those using private insurance or managed care (30%).

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Table 7

(Q10: In general, do you think the price of the health care services you and your family used over the past 12 months was much more expensive now than the same services would have been two years ago, somewhat more expensive, about the same, somewhat less, or much less expensive than the same services would have been two years ago?)

Primary care appointments Approximately nine out of ten residents (88%) report seeing a primary care physician (PCP) sometime over the last year. As Figure 7 shows, the percentage of Massachusetts adults visiting a PCP has remained high and fairly steady since 2005. Figure 7

(Q16: Have you had an appointment with a primary care physician in the last year?)

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A slight majority (52%) of residents who saw a PCP last year waited less than two weeks between making an appointment and seeing the doctor. This continues an eight-year downward trend, as shown in Figure 8. Moreover, the percentage of residents reporting a wait of a month or more is at its highest level in the history of this study, increasing from 21% in 2012 to 28% this year. Figure 8

((IF HAD APPOINTMENT IN THE LAST YEAR, n = 369) Q17: Please think back to your last routine visit to a primary care physician. How long did you have to wait between the time you made the appointment and the day you actually saw the doctor?)

Despite the increases in wait times before PCP appointments, Figure 9 shows that most (89%) of those who saw a PCP last year report that the amount of time they waited was not a problem for them. Massachusetts residents without college degrees were more likely to report problematic wait times (15%, compared to 6% for college graduates)(Figure 9, inset).

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Figure 9

((IF HAD APPOINTMENT IN THE LAST YEAR, n = 369) Q19: Was the length of time you had to wait for an appointment a problem for you, or not?)

Among those who waited more than a few days to see a PCP, 46% indicate that the wait was due to the doctor’s availability, while 30% cite their own personal schedule as the reason for the delay. Figure 10

((IF MORE THAN A FEW DAYS, n = 232) Q18: Was the delay in seeing the doctor primarily due to:) 2013 MMS Health Care Public Opinion Survey © 2013 Massachusetts Medical Society. All rights reserved. Page 18 of 47 www.massmed.org/poll2013

Appointments for serious medical care When thinking about the last time they visited a primary care physician or a specialist for a serious medical problem (as opposed to a routine matter), Massachusetts residents report a slightly different picture with regard to wait times. This year, 62% indicate that they waited less than two weeks – an increase over 2012, when 57% reported waits of less than two weeks (Figure 11). This year, waits for serious medical problems compare favorably to waits for PCP appointments, for which 52% report waiting less than two weeks (Figure 8, page 17). Figure 11

(Q23: Please think back to your last appointment with either a specialist or your primary care physician for a serious but not life threatening medical problem. How long did you have to wait between the time you made an appointment and the day you actually saw the doctor?)

Similarly to wait times for PCP appointments, most (86%) of respondents indicate that the amount of time they needed to wait for an appointment was not a problem for them. This is unchanged compared to 2012 (Figure 12).

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Figure 12

(IF HAD AN APPOINTMENT IN Q23, n = 366) Q25: Was the length of time you had to wait for an appointment a problem for you, or not?)

While three-in-ten respondents blame their own schedules for delays in seeing their PCP (Figure 10, page 18), only 19% do so for delays in seeing a doctor about a serious medical problem. Instead, 70% of residents indicate that the doctor’s availability was the cause of the delay. As shown in Figure 13, this is up from 58% in 2012.

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Figure 13

((IF MORE THAN A FEW DAYS IN Q23, n = 179) Q24: Was the delay in seeing the doctor primarily due to:)

Non-doctor medical visits Fewer residents report seeing a nurse, nurse practitioner or physician’s assistant for a medical appointment than last year (43% now, compared to 48% last year), and the percentage reporting seeing a clinician other than a medical doctor is at comparable levels to 2007 (Figure 14).

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Figure 14

(Q20: During the past year, have you had a medical appointment in which you saw a nurse, a nurse practitioner or a physician’s assistant, but did not see a doctor?)

Of those who saw a clinician other than a medical doctor, less than half (46%) did so by choice – as Figure 15 indicates, this is the lowest such percentage in the history of this study. Four-in-ten (40%) saw a nurse, nurse practitioner, or physician’s assistant because they could not get an appointment with a medical doctor, and another 10% were unaware before the appointment that they would not be seeing a physician. Older residents (55%) are more likely than residents aged 60 or younger (41%) to see a non-physician by choice (Figure 15, inset).

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Figure 15

((IF SAW A NURSE, NURSE PRACTITIONER, OR PHYSICIAN’S ASSISTANT, n = 178) Q21: Did you make this appointment by choice, or because you couldn’t get an appointment with a medical doctor?)

Among those who saw a nurse, nurse practitioner, or physician’s assistant, two-thirds (66%) feel the care they received was about the same as the care they typically receive from a medical doctor, while 13% feel the care from a medical doctor is generally superior. Two-in-ten (19%) believe the care from the non-clinician they saw was better than typical care from a medical doctor (Figure 16).

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Figure 16

((IF SAW A NURSE, NURSE PRACTITIONER, OR PHYSICIAN’S ASSISTANT, n = 178) Q22: How would you rate the care you received from the nurse practitioner or physician’s assistant compared to the care you typically receive from a medical doctor?)

When told of a new law in Massachusetts that allows nurse practitioners and physician’s assistants to serve as primary care physicians in an effort to increase the number of practitioners available to patients, two-thirds (66%) of residents indicated that they would be very (29%) or somewhat (37%) likely to schedule an appointment with a nurse practitioner or physician’s assistant (Figure 17). However, as Figure 18 shows, two-thirds (67%) of residents would prefer to receive care from a medical doctor, and just 15% would rather receive care from either a nurse practitioner (12%) or physician’s assistant (3%).

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Figure 17

Figure 18

(Q34: As you may know, a new law in Massachusetts allows nurse practitioners and physician’s assistants to serve as primary care providers. The goal of this change was to increase the number of medical professionals available to patients. Knowing this, how likely would you be to schedule an appointment with a nurse practitioner or physician’s assistant rather than scheduling an appointment with a medical doctor?)

(Q35: Would you prefer to receive care from a medical doctor, physician’s assistant, or nurse practitioner?)

Deciding where to go for care When deciding where to go for medical care, Massachusetts residents are far more likely to ask their primary care physician for advice than to rely on other sources (Figure 19). Three-quarters (74%) report that they have asked their doctor for a suggestion, which is comparable to findings in 2012, when 77% indicated that they would ask their doctor for an opinion. Fewer than half (45%) of residents have asked their friends where to go for care. Residents utilize online options – whether looking online to see what others have said about a doctor (38%) or using the internet to find quality and cost of care data (31%) – less frequently. Unsurprisingly, there are differences between age groups when it comes to using the internet to find a health care provider (Figure 19, inset). Half (50%) of adults 50 years old or younger indicate that they have used the internet to read what others have said about a doctor, while only a quarter (27%) of residents over 50 have done so. Men over 50 are particularly unlikely to use the internet in this manner. Residents without any college education are also much less likely to use the internet to find out what others have said about a doctor or hospital (15%, compared to 44% of those with at least some collegiate experience).
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The above age- and education-based differences in internet utilization also hold true for individuals using the internet to look up data about the quality and cost of care delivered by specific doctors and hospitals, though the differences between groups are less pronounced. For the first time, respondents were also asked this year whether they had considered going to a limited service clinic (e.g. CVS Minute Clinic) for care. A quarter (24%) of residents had considered doing so (Figure 19). Figure 19

(Q11-15: Now I am going to mention different things some people do to help them decide where to go for medical care. For each one, please tell me if it is something you do or have done prior to making an appointment with a new doctor or hospital. Have you…)

One explanation for the relatively low number (31%, Figure 19) of Massachusetts adults using the internet to look up data on cost and quality is that few residents are aware that this data is publicly available. This year, 39% of residents report being aware that this information is online (Figure 20). This suggests – but does not prove – that most of those who know the data is available utilize it. Overall, awareness of the availability of cost and quality data declined three percentage points relative to 2012, but increased compared to 2007 and 2008, when a third of all residents were aware of the information.

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Figure 20

(Q32: A variety of sources, including the state and insurers, recently began posting information regarding the quality and cost of care provided by medical groups and in some cases individual physicians on the Internet and in health plan directories. Were you aware that this information is available?)

Once residents are made aware that data on cost and quality is available online, many say that they would be likely to use it to help inform their decision the next time they have to choose a doctor. This year, 57% say they are very or somewhat likely to use the data (Figure 21). Younger adults (age 40 and younger) are particularly likely to indicate that they would use the data (76% very / somewhat likely, compared to 41% of adults over 60). Similarly, those with college degrees are more likely to say they will use the data than those with only a high school education or less (Figure 21, inset).

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Figure 21

(Q33: Now that you know that you can get this type of information about medical groups and physicians, how likely are you to use it the next time you have to choose a doctor? Are you…)

Emergency department utilization Just over three-in-ten (31%) Massachusetts residents report utilizing the emergency department in the last year, a slight increase over 2012, when a quarter (25%) reported doing so (Figure 22). Self-reported emergency room utilization was higher among younger residents – 40% among adults 40 and younger, compared to 22% among those over 60 (Table 8). Similarly, those on a government-backed insurance plan (Medicare or MassHealth) are more likely to indicate visiting the emergency department than those on private insurance. There were no significant differences in emergency department utilization based on household income.

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Figure 22

Table 8

(Q26: Have you visited an emergency department at a hospital in the past year?)

(Q26: Have you visited an emergency department at a hospital in the past year?)

For those who used an emergency department last year, the biggest factor in the decision to go to the ER was that they faced a “serious but not life-threatening medical problem that needed immediate attention.” As Figure 23 shows, fully six-in-ten (60%) adults who had been to an emergency department in the last year indicate that the availability of immediate attention for serious problems was a significant factor in their decision. A third (34%) of those who used an emergency department in the last year indicate that the fact that “the ER is the easiest place to get care” was a significant factor in their decision. Issues related to primary care physicians were important factors for a smaller percentage of residents, with 18% citing “difficulty getting an appointment with my primary care physician” and 16% indicating “not having a primary care physician” as major factors involved in their decision to seek care at the emergency department (Figure 23). The rationales provided by those who utilized an emergency department in the last year have not changed significantly compared to 2012.

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Figure 23

(Q27-31: I am going to mention some different reasons why some people use emergency departments. Please rate how big of a reason each one was for you when you last visited an emergency department using a scale from 1, meaning not a factor at all, to 10, meaning it was a major factor.)

When all residents – not just those who have utilized an emergency department in the last year – are asked about the factors behind the decision to go to the ER the last time they went, the relative importance of the ratings is similar, but the percentages of those indicating that each explanation was a major factor is lower across the board (Figure 24). Figure 24

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(Q27-31: I am going to mention some different reasons why some people use emergency departments. Please rate how big of a reason each one was for you when you last visited an emergency department using a scale from 1, meaning not a factor at all, to 10, meaning it was a major factor.)

New health insurance options For the second consecutive year, survey respondents were asked for their opinions of tiered health plans, limited network plans, and Accountable Care Organizations (ACOs). Respondents were first asked if they had favorable or unfavorable opinions of each new option based on a onesentence description, then provided more information and asked for their opinion again. After a brief description of each new health insurance option, many respondents are unable to offer a concrete opinion: 37% are not able to offer an opinion about tiered plans, and 62% don’t know enough to opine about ACOs (Figure 25a). Among those who do offer opinions, residents have generally negative views of limited network and tiered insurance plans. As Figure 25a, Figure 25b, and Figure 25c indicate, twice as many residents have unfavorable views of these plans as have favorable views (43% unfavorable versus 20% favorable for tiered plans; 36% unfavorable to 18% favorable for limited network plans). Views of ACOs are more balanced. Figure 25a a) Accountable Care Organizations, which seek to integrate physicians and hospitals and provide different payment structures
80% 70% 60% 50% 40% 30% 20% 10% 0% Favorable Unfavorable Never heard of/Don't know enough 20% 20% 16% May, 2013 February, 2012 13% 62% 67%

(Q36: Now I am going to mention a few different types of health care options offered by some Massachusetts insurers. Please tell me if you have a generally favorable or unfavorable opinion of each. If you have never heard of one, or don’t know enough about it to have an opinion, please just say so.)

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Figure 26b b) Limited network plans where care is covered among some doctors and hospitals
50% 40% 30% 20% 10% 0% Favorable Unfavorable Never heard of/Don't know enough 18% 19% May, 2013 February, 2012 36% 37% 45% 43%

(Q37: Now I am going to mention a few different types of health care options offered by some Massachusetts insurers. Please tell me if you have a generally favorable or unfavorable opinion of each. If you have never heard of one, or don’t know enough about it to have an opinion, please just say so.)

Figure 27c c) Tiered plans that have higher co-pays and deductibles for seeing some doctors and hospitals than for others
50% 40% 30% 20% 10% 0% Favorable Unfavorable Never heard of/Don't know enough 20% 23% 43% 42% 37% 35%

May, 2013 February, 2012

(Q38: Now I am going to mention a few different types of health care options offered by some Massachusetts insurers. Please tell me if you have a generally favorable or unfavorable opinion of each. If you have never heard of one, or don’t know enough about it to have an opinion, please just say so.)

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When provided with more detailed information about tiered plans, residents’ opinions do not shift much. After hearing about the payment structure of tiered plans, 53% of residents have unfavorable views of the plans, compared to 32% with favorable views (Figure 26). This 21-point gap is similar to the gap in favorability before the plan was explained (Figure 25c). Providing more information about limited network plans nearly doubles unfavorable views – from 36% unfavorable based on a brief description (Figure 25b) to 69% unfavorable after the detailed description (Figure 26). Figure 26

(Q39-42: Now I’d like to give you a little more information about each of these three types of health care coverage options and then ask your opinion again.)

Upon hearing more about ACOs, respondents are much more likely to offer an opinion, with those volunteering “don’t know enough / not sure” dropping from 62% (Figure 25a) based on a brief description to between 18% and 23% (Figure 27). As Figure 27 shows, Massachusetts adults react very differently to different aspects of ACOs. Residents strongly favor the coordinated care aspect of ACOs, with favorable opinions outnumbering unfavorable ones by a 37 percentage point margin (60% favorable versus 23% unfavorable). However, unfavorable views outnumber favorable ones by a 13 percentage point margin when residents consider the global budgets reimbursement structure of ACOs.

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Figure 28

Q39-42: Now I’d like to give you a little more information about each of these three types of health care coverage options and then ask your opinion again.

Legislation restricting pain medication prescription The Massachusetts state legislature recently passed a law that restricts physicians from prescribing certain pain medications. As a result, for the first time this year, this study included a question asking residents whether or not they were concerned that this legislative action might limit their access to pain medications they might need. Overall, most residents are not concerned that the law might limit their access to pain medication, 55% report being unconcerned. Slightly more than one-third (37%) are concerned, however (Figure 28). As Table 9 indicates, residents with graduate degrees are particularly unlikely to be concerned.

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Figure 29

Table 9

(Q43: As you may know, the legislature recently passed a law that restricts physicians from prescribing certain pain medications, such as narcotics. Are you concerned this will limit your access to these medications when necessary?)

(Q43: As you may know, the legislature recently passed a law
that restricts physicians from prescribing certain pain medications, such as narcotics. Are you concerned this will limit your access to these medications when necessary?)

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Appendix: Topline Results
Interviewing dates: May 14 – 16, 2013 Sample: 417 Massachusetts adults age 21+ FINAL TOPLINE RESULTS 0A. First of all, are you 21 years of age or older? Yes No 1.

100% -

What do you think is the single most important health care issue facing Massachusetts today? (RECORD VERBATIM) 1. May 2013 Feb 2012 47% Affordability / cost 43% Access to care / access to doctors Access to health insurance Mention specific condition / disease Health care for the elderly ObamaCare Poor health insurance Mandated health insurance Paying for others / illegal immigrants Quality of care Drug expense Controlling cost Government interference Need single payer Other Nothing Don’t know/Refused 7 6 6 5 5 4 3 2 1 1 1 3 1 12 9 7 6 1 1 4 2 3 3 1 2 2 4 3 6

2.

Which ONE of the following do you think is the most important health care issue facing Massachusetts today? (RANDOMIZE) Cost of health care 78% Quality of health care 9 Access to health care 10 (Don’t know) 2

All things considered, have you been satisfied or dissatisfied with the health care you have received during the last 12 months? (IF SATISFIED OR DISSATISFIED) Is that very (satisfied / dissatisfied), or just somewhat? Very satisfied 56% 61% 62% 65% 60% 62% 56% Somewhat satisfied 28 26 26 26 32 26 32 Somewhat dissatisfied 7 4 6 6 4 5 5 Very dissatisfied 8 7 6 3 3 4 4 (Don’t know) 2 2 1 1 3 4 3 Page 36 of 47 www.massmed.org/poll2013

May 2013 Feb 2012 April 2008 April 2007 April 2006 April 2005 March 2004

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3.

Specifically, why are you (satisfied / dissatisfied) with your care? (RECORD VERBATIM) (NOTE: MULITPLE RESPONSES WERE ACCEPTED) Satisfied Quality of care / Good doctors Easy access / can go anywhere Needs have been met Good health insurance / plan Affordable Able to get an appointment when needed Good coverage Like my doctor / relationship with doctor Too expensive Poor care / poor doctor Long wait for appointment Poor coverage / care not covered Don’t get sick / Haven’t needed Other Nothing Don’t know / Refused Dissatisfied Too expensive Poor care/poor doctor Poor coverage/care not covered Lack of access/limits on where I can go Long wait for appointment Needs haven’t been met Poor health insurance plan Quality of care/good doctors Other May 2013 (n=349) 45% 16 15 12 11 11 8 6 4 2 1 1 9 2 1 May 2013 (n=60) 50% 27 23 18 12 5 3 3 13 Feb 2012 (n=348) 38% 7 17 18 12 9 9 11 2 11 2 1 2 Feb 2012 (n=47) 56% 23 18 13 6 11 14 13

(RESUME ALL) 4. In general, how would you rate the difficulty in obtaining the health care you need for you and your family – whether it be for a routine problem or a serious problem – over the last few years? On a scale of “1” to “5”, where “1” means “not difficult at all”, and “5” means “extremely difficult,” please rate the level of difficulty you’ve experienced in obtaining this care. Mean 1.90 1.73 2.37 2.06 2.21 2.29 2.18 2.06 1 (Not difficult at all) 2 54% 19 62% 16 42% 49% 48% 45% 46% 49% 15 19 15 15 17 16 3 15 11 17 14 15 17 18 16 4 5 4 11 7 9 7 9 10 5 (Extremely difficult) 6 5 13 9 12 15 9 7 (Don’t know) 2 2 2 1 2 1 2

May 2013 Feb 2012 April 2008 April 2007 April 2006 April 2005 March 2004 January 2003

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5.

Specifically, why do you feel that way? (RECORD VERBATIM) (NOTE: MULITPLE RESPONSES WERE ACCEPTED) Not difficult (Q5 = 1 or 2) No problems Quality of care / good doctors Good coverage / good insurance Not wait for appointment / fast access Ease of getting an appointment Have access to doctors Large network / can go anywhere Have access to health insurance Covered by employer Affordable Long wait for appointment Too much red tape / paperwork Too expensive Limits on where I can go Hard to get appointment Poor coverage Can’t get needed care Poor care / bad doctors No health insurance Don’t get sick / haven’t needed Other Nothing Don’t know / Refused May 2013 (n=306) 23% 21 17 13 9 8 8 8 7 7 5 3 2 2 2 1 1 3 4 1 Feb 2012 (n=315) 21% 17 15 16 8 12 8 4 8 2 4 1 3 1 1 1 1 6 3 1 3

Difficult (Q5 = 4 or 5) Too expensive Too much red tape / paperwork Poor coverage Poor care/bad doctors Limits on where I can go Long wait for appointment Can’t get needed care No health insurance Hard to get appointment Insurance not provided by employer Access to doctors Access to health insurance No problems / satisfied Quality of care / good doctors Don’t get sick / haven’t needed Other

May 2013 (n=48) Feb 2012 (n=39) 38% 26% 17 10 15 13 13 8 6 6 4 2 2 2 2 2 10 5 20 19 22 18 4 2 3

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6.

Which ONE of the following do you believe is most responsible for any problems you might have had gaining access to health care over the last few years? [READ AND ROTATE 1-8] May 2013 Insurance companies Government The economy or your economic circumstances Physicians Your own fault Drug companies Hospitals New, expensive technologies (All of them) (No problems) (Not sure / Refused) 27% 15 11 5 4 3 3 2 3 24 3 Feb 2012 29% 13 8 4 3 5 3 2 2 30 3

7.

Was there any time during the past 12 months when you waited to get medical care you thought you needed? Yes, waited to get care 21% 19% 25% 21% 18% 17% 22% 29% No, did not wait to get care 79 80 74 79 81 82 78 70 (Not sure / Refused) 1 1 1 1 1 1

May 2013 February 2012 April 2008 April 2007 April 2006 April 2005 March 2004 January 2003 (IF YES TO Q8) 8.

What was the primary reason you waited to get that medical care? (RECORD VERBATIM) May 2013 (n=86) Feb 2012 (n=75) 42% 22% 19 13 13 9 7 5 3 3 2 2 1 8 1 18 12 8 4 7 4 3 4 -

Physician booked Couldn’t afford treatment Not approved by insurance / waiting for approval Too busy / No time No insurance Poor coverage / not covered Had to find provider who accepted insurance High deductible / co-pay Routine/not urgent Paperwork Disagreed with treatment Insurance too expensive Pre-existing condition Other Don’t know/Refused

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9.

In general, do you think the price of the health care services you and your family used over the past 12 months was much more expensive now than the same services would have been two years ago, somewhat more expensive, about the same, somewhat less, or much less expensive than the same services would have been two years ago? Much more expensive Somewhat more expensive About the same Somewhat less expensive Much less expensive (Not sure / Refused) 28% 37 28 3 5

Now I am going to mention different things some people do to help them decide where to go for medical care. For each one, please tell me if it is something you do or have done prior to making an appointment with a new doctor or hospital. Have you…(RANDOMIZE) Yes No (Not sure) (Refused) 10. Asked your primary care physician for his or her opinion? May 2013 74% 25 1 February 2012 77% 23 11. Used the internet to look up data about the quality and cost of care provided by specific doctors or hospitals? May 2013 31% February 2012 12. Used the internet to see what other people have to say about a doctor or hospital? May 2013 February 2012 13. Asked friends about where to go for care? May 2013 February 2012 14. 34%

67 64

1 1

-

38% 36%

61 64

1 -

-

45% 49%

55 50

1 1

-

Considered going to a limited service clinic, like a CVS Minute Clinic, for medical care instead of a doctor’s office? May 2013 24% 15.

75

1

-

Have you had an appointment with a primary care physician in the last year? Yes 88% 90% 86% 89% 83% 85% 77% No 12 9 14 11 18 16 22 (Not sure) 1

May 2013 February 2012 April 2008 April 2007 April 2006 April 2005 March 2004*

January 2003* 83% 16 1 *Have you had a routine doctor’s appointment in the last year? 2013 MMS Health Care Public Opinion Survey © 2013 Massachusetts Medical Society. All rights reserved. Page 40 of 47 www.massmed.org/poll2013

(IF YES TO Q16) 16. Please think back to your last routine visit to a primary care physician. How long did you have to wait between the time you made the appointment and the day you actually saw the doctor? [DO NOT READ]

May 2013 Feb 2012 Apr 2008 Apr 2007 Apr 2006 Apr 2005 Mar 2004* Jan 2003* (A few days) 30% 36% 37% 34% 44% 45% 18% 26 (More than a few days, <1 week) 11 7 11 8 9 8 10 6 (Between 1 – 2 weeks) (Between 2 – 3 weeks) (Between 3 weeks and 1 month) (Between 1 – 2 months) (Between 2 – 3 months) (More than 3 months) 11 7 7 7 7 14 13 6 5 8 6 7 9 5 6 5 6 11 17 5 6 6 5 10 10 3 5 7 6 10 12 6 6 6 3 7 14 7 9 12 8 15 14 8 8 11 7 13

(Don’t remember / Refused) 7 12 9 9 7 7 7 7 *Please think back to your last doctor’s appointment. How long did you have to wait between the time you made the appointment and the day you actually saw the doctor? (IF MORE THAN A FEW DAYS IN Q17) 17. Was the delay in seeing the doctor primarily due to: Your own schedule The inability of the doctor making it hard to see the to see you sooner doctor sooner May 2013 February 2012 April 2008 April 2007 April 2006 April 2005 March 2004 (IF YES TO Q16) 18. Was the length of time you had to wait for an appointment a problem for you, or not? Yes May 2013 February 2012 April 2008 April 2007 April 2006 April 2005 (RESUME ALL) 10% 9% 8% 8% 9% 8% No 89 89 89 92 90 91 (Not sure) 1 1 2 1 1 46% 47% 42% 50% 51% 47% 49% 30 34 40 27 27 39 28 Because financial or insurance issues made it hard to schedule (Not sure) 5 5 4 2 2 2 2 19 15 14 21 20 12 21

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19.

During the past year, have you had a medical appointment in which you saw a nurse, a nurse practitioner or a physician’s assistant, but did not see a doctor? [IF YES, PROBE: Do you remember if that was with a nurse, nurse practitioner, or a physician’s assistant?] Yes, nurse 3% 4% 7% 5% Yes, NP 29 34 26 26 Yes, PA 9 9 5 8 Yes, not a doctor but don’t know who it was 2 2 1 2 No 56 51 60 58 (Not sure) 1 1 1 2

May 2013 February 2012 April 2008 April 2007 (IF YES TO Q20) 20.

Did you make this appointment by choice, or because you couldn’t get an appointment with a medical doctor? Couldn’t get an appointment with a medical doctor 40 36 36 35 (Didn’t know I wasn’t going to see a medical doctor until the appointment) 10 6 8 6

May 2013 February 2012 April 2008 April 2007 (IF YES TO Q20) 21.

By choice 46% 53% 51% 53%

(Not sure) 4 5 4 6

How would you rate the care you received from the nurse practitioner or physician’s assistant compared to the care you typically receive from a medical doctor? Would you say…[ROTATE 1-2] The care from the nurse practitioner or physician’s assistant was better The care from the medical doctor is typically better Or, the care was about the same (Not sure / Refused) 19% 13 66 2

(RESUME ALL) 22. Please think back to your last appointment with either a specialist or your primary care physician for a serious but not life threatening medical problem. How long did you have to wait between the time you made an appointment and the day you actually saw the doctor? [DO NOT READ] May 2013 Feb 2012 40% 40% 10 12 6 5 4 4 1 12 5 7 10 3 4 4 2 2 18 11

(A few days) (More than a few days, <1 week) (Between 1 – 2 weeks) (Between 2 – 3 weeks) (Between 3 weeks and 1 month) (Between 1 – 2 months) (Between 2 – 3 months) (More than 3 months) (Haven’t made an appointment) (Don’t remember / Refused) (IF MORE THAN A FEW DAYS IN Q23)

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23.

Was the delay in seeing the doctor primarily due to: Your own schedule The inability of the doctor making it hard to see the to see you sooner doctor sooner May 2013 70% 19 February 2012 58% 22

Because financial or insurance issues made it hard to schedule (Not sure) 3 8 4 15

(SKIP IF “HAVEN’T MADE AN APPOINTMENT” IN Q23) 24. Was the length of time you had to wait for an appointment a problem for you or not? Yes May 2013 February 2012 (RESUME ALL) 25. Have you visited an emergency department at a hospital in the past year? Yes 31% 25% No 69 75 (Not sure) 14% 8% No 86 86 (Not sure) 6

May 2013 February 2012

I am going to mention some different reasons why some people use emergency departments. Please rate how big of a reason each one was for you when you last visited an emergency department using a scale from 1, meaning not a factor at all, to 10, meaning it was a major factor. (RANDOMIZE) Mean 26. Difficulty getting an appointment with your primary care physician May 2013 February 2012 27. Not having a primary care physician May 2013 February 2012 28. It was a serious but not life threatening medical problem that needed immediate attention May 2013 February 2012 29. 1-3 4-6 7-10 (Not sure)

2.37 2.20

75% 78%

6 5

12 10

7 7

2.43 2.36

75% 76%

4 3

14 12

7 9

5.86 5.34

31% 40%

16 11

44 41

10 8

It was a life threatening problem that needed emergency attention May 2013 4.77 February 2012 4.57 30. The emergency department is the easiest place to get care May 2013 February 2012

45% 46%

11 10

34 32

10 12

4.02 3.76

54% 58%

10 6

27 25

8 11

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31.

A variety of sources, including the state and insurers, recently began posting information regarding the quality and cost of care provided by medical groups and in some cases individual physicians on the Internet and in health plan directories. Were you aware that this information is available? Yes, aware May 2013 February 2012 April 2008 April 2007 39% 42% 33% 32% No, not aware 60 55 65 67 (Not sure) 1 3 2 2

32.

Now that you know that you can get this type of information about medical groups and physicians, how likely are you to use it the next time you have to choose a doctor? Are you… Very likely 27% 29% 33% 24% Somewhat likely Not very likely 30 14 25 15 32 30 8 20 Not at all likely 28 29 24 23 (Not sure) 1 2 4 3

May 2013 February 2012 April 2008 April 2007 33.

As you may know, a new law in Massachusetts allows nurse practitioners and physician’s assistants to serve as primary care providers. The goal of this change was to increase the number of medical professionals available to patients. Knowing this, how likely would you be to schedule an appointment with a nurse practitioner or physician’s assistant rather than scheduling an appointment with a medical doctor? Very likely May 2013 29% Somewhat likely Not very likely 37 15 Not at all likely 18 (Not sure) 2

34.

Would you prefer to receive care from a medical doctor, physician’s assistant, or nurse practitioner? [DO NOT READ] (Medical doctor) (Physician’s assistant) (Nurse practitioner) (MD and PA but not NP) (MD and NP but not PA) (PA and NP but not MD) (All of the above) (Not sure / Refused) 67% 3 12 1 1 12 4

Now I am going to mention a few different types of health care options offered by some Massachusetts insurers. Please tell me if you have a generally favorable or unfavorable opinion of each. If you have never heard of one, or don’t know enough about it to have an opinion, please just say so. (RANDOMIZE) Never heard Don’t know Favorable Unfavorable of enough (Refused) 35. Tiered plans that have higher co-pays and deductibles for seeing some doctors and hospitals than for others May 2013 20% 43 15 22 1 February 2012 36. 23% 42 14 21 -

Limited network plans where care is covered among some doctors and hospitals May 2013 18% February 2012 19% 2013 MMS Health Care Public Opinion Survey © 2013 Massachusetts Medical Society. All rights reserved.

36 37

21 18

24 25

1 -

Page 44 of 47 www.massmed.org/poll2013

37.

Accountable Care Organizations, which seek to integrate physicians and hospitals and provide different payment structures 20% 20% 16 13 29 33 33 34 1 -

May 2013 February 2012

Now I’d like to give you a little more information about each of these three types of health care coverage options and then ask your opinion again. (RANDOMIZE ORDER OF NEXT FOUR QUESTIONS) 38. An Accountable Care Organization is a group of health care providers and/or hospitals that work as a team to manage the coordination of care for the range of services that patients are expected to need. Hearing this, do you have a favorable or unfavorable opinion of Accountable Care Organizations? (IF FAVORABLE OR UNFAVORABLE) Is that very or just somewhat (favorable / unfavorable)? Very favorable 22% 18% Somewhat favorable 38 36 Somewhat unfavorable 12 14 Very unfavorable (Not sure) 11 18 9 23

May 2013 February 2012 39.

In these new Accountable Care Organizations, physicians may be reimbursed differently – physicians may receive global budgets for the year per patient, rather than a payment per visit or procedure. Hearing this, do you have a favorable or unfavorable opinion of global budgets? (IF FAVORABLE OR UNFAVORABLE) Is that very or just somewhat (favorable / unfavorable)? Very favorable May 2013 February 2012 8% 12% Somewhat favorable 24 16 Somewhat unfavorable 20 18 Very unfavorable (Not sure) 25 26 23 27

40.

Tiered health insurance plans often offer lower annual premiums than other similar plans, but co-pays and deductibles are higher for some doctors and hospitals than others. Insurance companies usually use internal quality and cost ratings to develop their tiers of doctors and hospitals. Members pay low or no copays to visit providers who are deemed to provide the best value, and higher co-pays for providers that insurance companies believe are too expensive for the level of care they provide. Hearing this, do you have a favorable or unfavorable opinion of Tiered health insurance plans? (IF FAVORABLE OR UNFAVORABLE) Is that very or just somewhat (favorable / unfavorable)? Very favorable 7% 11% Somewhat favorable 25 20 Somewhat unfavorable 27 24 Very unfavorable (Not sure) 26 16 29 16

May 2013 February 2012 41.

Limited network plans offer lower premiums than other comparable plans, but limit the doctors and hospitals covered to a list approved by the insurance company. If you choose to see doctors outside the network, the cost is higher. Hearing this, do you have a favorable or unfavorable opinion of Limited Network Plans? (IF FAVORABLE OR UNFAVORABLE) Is that very or just somewhat (favorable / unfavorable)? Very favorable May 2013 February 2012 6% 8% Somewhat favorable 17 17 Somewhat unfavorable 32 27 Very unfavorable (Not sure) 37 36 9 11

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42.

As you may know, the legislature recently passed a law that restricts physicians from prescribing certain pain medications, such as narcotics. Are you concerned this will limit your access to these medications when necessary? Yes May 2013 37% No 55 (Not sure) 8

Now, I'd like to ask you some final questions for statistical purposes only. 43. Do you have health insurance through either a government plan or a private health care plan? Government plan Private plan No health insurance (Both private and government) (Don’t know) (Refused) (SKIP IF NO HEALTH INSURANCE IN Q44) 44. Is your health insurance through a managed care plan such as an HMO like Harvard Pilgrim, Tufts, Fallon, Blue Care, or the Neighborhood Health Plan? Yes No (Don’t know) (Refused) 52% 41 4 2 24% 59 3 11 1 2

(SKIP IF NO HEALTH INSURANCE IN Q44) 45. How well do feel like you understand your health care plan benefits? Do feel like you understand them… Entirely Very well, but not entirely Just somewhat Not very well Not at all (Not sure / Refused) 46. 16% 47 26 8 1 2

How much would you estimate that you spend on your health care needs per year?

[READ ALL GROUPS EXCEPT RESPONSES 9 AND 10] $0-100 $100-250 $250-500 $500-1,000 $1,000-2,500 $2,500-5,000 $5,000-10,000 $10,000 or more (Don't know) (Refused) 5% 8 12 12 21 17 10 6 6 3

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47.

What was the last grade you completed in school? Less than high school (1-11) Graduated high school Some college/Tech.Voc. Graduated college Graduate/professional school (Don't know) (Refused) 2% 19 21 28 27 2

48.

In which of the following categories is your age? 21-34 35-40 41-50 51-60 61-75 Over 75 (Not sure / Refused) 12% 11 24 23 20 9 1

49.

How many individuals, including yourself, live in your household? One Two Three Four More than four (Not sure / Refused) 23% 35 17 14 9 2

50.

Would you please tell me in which of the following categories I read is your total household income – that is, of everyone living in your household?

[READ ALL GROUPS EXCEPT RESPONSES 11 AND 12] $0-11,999 $12-14,999 $15-19,999 $20-24,999 $25-34,999 $35-49,999 $50-74,999 $75-99,999 $100-124,999 $125,000 or more (Don't know) (Refused) 51. Gender: [OBSERVATION] Male Female 2013 MMS Health Care Public Opinion Survey © 2013 Massachusetts Medical Society. All rights reserved. 46% 54 Page 47 of 47 www.massmed.org/poll2013 4% 4 2 2 7 13 16 12 7 16 2 15

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