Evergreen Co-op SurveyEvergreen Co-op Survey

4. What monthly cost can you afford to cover health care for you and your family?

What monthly cost can you afford to cover health care for you and your family? <$100

$100

$200

$300

$400

$500

$600

>$600

5. On a scale of 1 to 5 (1 = unwilling and 5 = completely willing), how willing would you be to
join or switch to a new health insurance plan provided by a newly established company?

	Unwilling				Completely Willing
Switch to or Join New Health Insurance Plan	*On a scale of 1 to 5 (1 = unwilling and 5 = completely willing), how willing would you be to join or switch to a new health insurance plan provided by a newly established company? Switch to or Join New Health Insurance Plan Unwilling	Switch to or Join New Health Insurance Plan	Switch to or Join New Health Insurance Plan	Switch to or Join New Health Insurance Plan	Switch to or Join New Health Insurance Plan Completely Willing

6. Would you be more willing if the new plan was:

	Yes	No
More affordable?	*Would you be more willing if the new plan was: More affordable? Yes	More affordable? No
Easier to use?	Easier to use? Yes	Easier to use? No
Provided an improved level of personal care?	Provided an improved level of personal care? Yes	Provided an improved level of personal care? No

7. What would a newly established health insurance company have to offer in order for you to
switch plans?

What would a newly established health insurance company have to offer in order for you to switch plans?

8. Wait Time

Wait Time In non-emergency situations, how long do you usually wait to get an appointment with your doctor?
Do you find this wait time acceptable? Yes or No.
If you ever felt that this wait was too long, how would you respond?

9. On a scale of 1 to 5 (1 = unimportant and 5 = essential), how important is it that your primary
health care provider:

	1 (Unimportant)	2	3	4	5 (Important)
Close to home with smaller patient to doctor ratio	*On a scale of 1 to 5 (1 = unimportant and 5 = essential), how important is it that your primary health care provider: Close to home with smaller patient to doctor ratio 1 (Unimportant)	Close to home with smaller patient to doctor ratio 2	Close to home with smaller patient to doctor ratio 3	Close to home with smaller patient to doctor ratio 4	Close to home with smaller patient to doctor ratio 5 (Important)
Comfortableness with telemedicine (consultations via Skype)?	Comfortableness with telemedicine (consultations via Skype)? 1 (Unimportant)	Comfortableness with telemedicine (consultations via Skype)? 2	Comfortableness with telemedicine (consultations via Skype)? 3	Comfortableness with telemedicine (consultations via Skype)? 4	Comfortableness with telemedicine (consultations via Skype)? 5 (Important)
Offers membership to the co-op/having a say in the co-op	Offers membership to the co-op/having a say in the co-op 1 (Unimportant)	Offers membership to the co-op/having a say in the co-op 2	Offers membership to the co-op/having a say in the co-op 3	Offers membership to the co-op/having a say in the co-op 4	Offers membership to the co-op/having a say in the co-op 5 (Important)
Is a doctor who you feel knows you and cares about you	Is a doctor who you feel knows you and cares about you 1 (Unimportant)	Is a doctor who you feel knows you and cares about you 2	Is a doctor who you feel knows you and cares about you 3	Is a doctor who you feel knows you and cares about you 4	Is a doctor who you feel knows you and cares about you 5 (Important)
Has medical assistants and office staff who you feel know you well	Has medical assistants and office staff who you feel know you well 1 (Unimportant)	Has medical assistants and office staff who you feel know you well 2	Has medical assistants and office staff who you feel know you well 3	Has medical assistants and office staff who you feel know you well 4	Has medical assistants and office staff who you feel know you well 5 (Important)
Has low co-payments for office visits and medications	Has low co-payments for office visits and medications 1 (Unimportant)	Has low co-payments for office visits and medications 2	Has low co-payments for office visits and medications 3	Has low co-payments for office visits and medications 4	Has low co-payments for office visits and medications 5 (Important)
Creates a comfortable and welcoming office environment	Creates a comfortable and welcoming office environment 1 (Unimportant)	Creates a comfortable and welcoming office environment 2	Creates a comfortable and welcoming office environment 3	Creates a comfortable and welcoming office environment 4	Creates a comfortable and welcoming office environment 5 (Important)
Helps you prevent disease and illness	Helps you prevent disease and illness 1 (Unimportant)	Helps you prevent disease and illness 2	Helps you prevent disease and illness 3	Helps you prevent disease and illness 4	Helps you prevent disease and illness 5 (Important)
Provides you with wellness support such as face-to-face coaching?	Provides you with wellness support such as face-to-face coaching? 1 (Unimportant)	Provides you with wellness support such as face-to-face coaching? 2	Provides you with wellness support such as face-to-face coaching? 3	Provides you with wellness support such as face-to-face coaching? 4	Provides you with wellness support such as face-to-face coaching? 5 (Important)
Has medical interpreters available for you (and/or family)?	Has medical interpreters available for you (and/or family)? 1 (Unimportant)	Has medical interpreters available for you (and/or family)? 2	Has medical interpreters available for you (and/or family)? 3	Has medical interpreters available for you (and/or family)? 4	Has medical interpreters available for you (and/or family)? 5 (Important)
Has extended hours	Has extended hours 1 (Unimportant)	Has extended hours 2	Has extended hours 3	Has extended hours 4	Has extended hours 5 (Important)
Provides care coordination, referral and follow-up services	Provides care coordination, referral and follow-up services 1 (Unimportant)	Provides care coordination, referral and follow-up services 2	Provides care coordination, referral and follow-up services 3	Provides care coordination, referral and follow-up services 4	Provides care coordination, referral and follow-up services 5 (Important)
Provides transportation services	Provides transportation services 1 (Unimportant)	Provides transportation services 2	Provides transportation services 3	Provides transportation services 4	Provides transportation services 5 (Important)
Provides clear information about health care coverage	Provides clear information about health care coverage 1 (Unimportant)	Provides clear information about health care coverage 2	Provides clear information about health care coverage 3	Provides clear information about health care coverage 4	Provides clear information about health care coverage 5 (Important)
Has less paperwork	Has less paperwork 1 (Unimportant)	Has less paperwork 2	Has less paperwork 3	Has less paperwork 4	Has less paperwork 5 (Important)
Offers more helpful support in the doctor’s office	Offers more helpful support in the doctor’s office 1 (Unimportant)	Offers more helpful support in the doctor’s office 2	Offers more helpful support in the doctor’s office 3	Offers more helpful support in the doctor’s office 4	Offers more helpful support in the doctor’s office 5 (Important)

10. What avenues do you utilize to obtain health insurance consumer information?

What avenues do you utilize to obtain health insurance consumer information? TV Commercials	Internet/Social Media	Billboards	Radio	Newspapers	Other
Other (please specify)

Demographic Information Age:
Gender:
Ethnicity:
Zip Code:
# of People in Household:

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