Patient Survey on Cancer Costs
Are you (1) older than 18 years of age, (2) female, (3) a patient with breast cancer, (4) currently receiving or within 5 years of breast cancer treatment of any kind, and (5) English-speaking? c Yes c No
✚✚✚IF THE ANSWER TO THE ABOVE QUESTION IS YES, PROCEED WITH QUESTIONS BELOW✚✚✚1. Have you discussed the costs of your cancer care with your doctor? c Yes c No
If yes, who started the discussion, you or your doctor? c I started it. c My doctor started it.
2. When should a conversation between patients and their doctors about the costs of their cancer care occur? Please check all that apply.
c Doctors should not discuss the costs of cancer care with their patients.
c Doctors should initiate a conversation regarding costs of care at every visit.
c Doctors should initiate a conversation regarding costs of care when a new treatment is being considered.
c Doctors should only discuss costs when patients ask to discuss costs of care.
c Doctors should discuss costs of care whenever a patient misses a visit or is not taking their medications.
c Other: (Please specify)
3. Please answer the following questions regarding the impact of the costs of cancer on your life and whether you spoke to your doctor about each particular issue.
Yes / No / Spoke to Doctor about this / Did Not Speak to Doctor1) I have experienced hardship as a result of the costs of my cancer care. / c / c / c / c
2) Sometimes I don’t go to the doctor because of co-payments for office visits. / c / c / c / c
3) Sometimes I don’t go to the doctor because of other costs (such as travel, childcare, parking, time off from work). / c / c / c / c
4) Sometimes I turn down a test or treatment because of the copayment. / c / c / c / c
5) Sometimes I turn down a test or treatment because of other costs (such as travel, childcare, parking, time off from work). / c / c / c / c
6) I avoid treatment of other medical problems because of the cost of my cancer care. / c / c / c / c
7) The costs I pay for my cancer care has affected my medical decisions (choice of doctor or treatment). / c / c / c / c
8) The costs to Medicare, society or my insurance company have affected my medical decisions (choice of doctor or treatment). / c / c / c / c
9) I have had difficulty paying for basic necessities (like food, housing and clothing) as a result of paying my cancer care. / c / c / c / c
10) I have used up all or most of my savings paying for my cancer treatment. / c / c / c / c
4. How frequently do you discuss the costs of your cancer treatment with your doctor when making treatment decisions?
Always / Very Frequently / Sometimes / Rarely / Neverc / c / c / c / c
5. Please answer the following questions regarding the costs of your cancer care.
Yes / No / Not sure1) I have been well informed about the costs of my cancer treatment.
2) I have been surprised by the costs of my cancer treatment.
3) I understand the costs that I will have to pay for my treatment.
4) I understand the costs which society will have to pay for my treatment.
6. Please tell us whether you agree or disagree with the following statements:
Strongly Agree / Agree / Neither Agree Nor Disagree / Disagree / Strongly Disagree1) Doctors should explain to patients the costs the patient will have to pay for his or her cancer treatment. / c / c / c / c / c
2) Doctors should explain to patients the costs society (the insurance company, the government) will have to pay for his or her cancer treatment. / c / c / c / c / c
3) When choosing a new treatment, doctors should consider the amount of money it will cost the patient. / c / c / c / c / c
4) When choosing a new treatment, doctors should consider the amount of money it will cost the insurance company or government. / c / c / c / c / c
5) Society should only pay for treatments which cure cancer, not treatments which simply delay death from cancer. / c / c / c / c / c
6) If two treatments are the same, the doctor should prescribe the cheaper medicine. / c / c / c / c / c
7) If there is only a small chance a treatment will improve the length or quality of life of a patient, it should not be used. / c / c / c / c / c
7. If there is a shortage of a drug, which patients should get priority?
c Patients with the ability to pay more c Patients with the greatest medical need
8. Have you had assistance paying for your copayments and other costs associated with your cancer care?
c Yes c No
IF yes, please check all sources that helped you pay for the costs of care
c family/friends c drug company program c co-payment assistance foundation
c church or religious group c clinic/hospital program c other______
9. If you have had a discussion concerning costs with your physician, were you satisfied with the discussion?
Very Satisfied / Satisfied / Neither Satisfied nor Dissatisfied / Dissatisfied / Very Dissatisfiedc / c / c / c / c
10. How should we try to lower the costs of cancer care? Please check all statements with which you agree.
c Allow government control of the cost of cancer drugs
c Require patients to pay more of the costs of their care
c Require wealthier patients to pay more for treatments
c I don’t think we should care about lowering costs of cancer care.
c Use guidelines to make sure doctors only do what is recommended
c Pay doctors less money
c Use more nurses and physicians assistants instead of doctors
c Always use the least expensive treatment when there are two good options available
c Other: ______
11. What prevents you from discussing costs of care with your doctor? Please check all that apply.
c Nothing prevents me from discussing costsc Not enough time
c Discussing costs will hurt the quality of my care
c My doctors doesn’t know about costs of care / c My doctor is not comfortable talking about money
c My doctor can’t help with the costs of my care
c I am not comfortable discussing costs with my doctor
c Other: ______
Directions: Circle or check the responses that are most appropriate for your situation.
12. What do you feel is the level or your financial stress today?
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10Overwhelming Stress / High Stress / Low Stress / No Stress at All
13. On the stair steps below, mark (with a circle) how satisfied you are with your present financial situation. The “1” at the bottom of the steps represents complete dissatisfaction. The “10” at the top if the star steps represents complete satisfaction. The more dissatisfied you are, the lower the number you should circle. The more satisfied you are, the higher the number you should circle.
Satisfied10
9
8
7
6
5
4
3
2
1
Dissatisfied
14. How do you feel about your current financial situation?
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10Feel Overwhelmed / Sometimes Feel Worried / Not Worried / Feel Comfortable
15. How often do you worry about being able to meet normal monthly living expenses?
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10Feel Overwhelmed / Sometimes Feel Worried / Not Worried / Feel Comfortable
16. How confident are you that you could find the money to pay for a financial emergency that costs about $1,000?
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10No Confidence / Little Confidence / Some Confidence / High Confidence
17. How often does this happen to you? You want to go about to eat, go to a movie or do something else and don’t go because you can’t afford to?
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10All the time / Sometimes / Rarely / Never
18. How frequently do you find yourself just getting by financially and living paycheck to paycheck?
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10All of the time / Sometimes / Rarely / Never
19. How stressed do you feel about your personal finances in general?
1 / 2 / 3 / 4 / 5 / 6 / 7 / 8 / 9 / 10Overwhelming Stress / High Stress / Low Stress / No Stress at All
Please Tell us About Yourself
Are you currently receiving therapy?c No
c Yes / Which of the following describes your cancer?
c Limited to the breast and lymph nodes on the same side
c Spread to other parts of your body (liver, lung, bone, etc)
What is your age? / What is your race/ethnicity? Please check all that apply
c White alone
c Black or African-American alone
c American Indian or Alaska Native alone
c Asian alone
c Hispanic
c Native Hawaiian or other Pacific Islander
c Other
What is your yearly household income?
c Less than $15,000
c From $15,000 to $29,999
c From $30,000 to $49,999
c From $50,000 to $99,999
c More than $100,000 / What is the highest level of education you achieved?
c Elementary School
c High School
c 2 year college
c 4 year college
c Post-college graduate degree
What is your employment status?
c Full-time employed
c Part-time employed
c Retired
c Homemaker
c Disabled from cancer
c Disabled from another cause
c Student / What type of insurance do you have? Please check all that apply
c Medicaid
c Medicare
c Health insurance from my employer or my spouse’s employer
c Health insurance that I purchase personally out of pocket
c Supplemental insurance that I and/or my spouse pays
c No health insurance
c Other: Please specify below
What is your relationship status?
c Married
c Single, never married
c Single, divorced, or separated
c Single, widowed / Thank you for your participation in this survey. Your assistance is greatly appreciated. Please contact us if you have any questions or comments. Please place your survey in the response box in clinic.
Please do not write your name or medical record number on the survey. Your completion of the survey indicates that you agree to participate in this survey research study.