Healthcare Costs & Financial Burden Survey
Measures how much people actually pay for healthcare, how financially burdensome those costs feel, and whether cost causes them to delay or skip care. Built for health plans, providers, employers, and benefits teams tracking affordability; the AI follow-up interview reconstructs the real story behind a specific delay-or-skip-care decision instead of a checkbox answer.
設問の例
テンプレートの内容をプレビューできます。すべての設問は公開前に自由に編集できます。
Which of these best describes your current health insurance coverage?
- Employer-sponsored insurance
- Marketplace/individual plan
- Medicare
- Medicaid
- Uninsured
- Other
Roughly how much did you personally pay out of pocket for healthcare in the last 12 months — premiums, copays, deductibles, and prescriptions combined (in USD)?
Overall, how much of a financial burden have your healthcare costs been over the past year?
In the past 12 months, did you delay or skip any medical care because of the cost?
- No, I got all the care I needed
- Yes, I delayed care but eventually got it
- Yes, I skipped care entirely
- Not sure / can't recall
How concerned are you about affording each of the following, if you needed it in the next year?
- Prescription drugs
- Doctor or specialist visits
- Dental care
- Mental health services
- Emergency care
- ほか1件
Which of these changes would do the most, and the least, to ease your healthcare financial burden?
- Lower monthly premiums
- Lower deductibles before coverage kicks in
- Clear pricing shown before treatment
- Lower cost telehealth options
- Cheaper prescription drugs
- Simpler, easier-to-understand bills
- More in-network provider choices
Think about a routine, in-network visit to a primary care doctor, before any insurance reimbursement.
- At what price for that visit would you start to question the quality of care being provided?
- At what price for that visit would you consider it a bargain — great value for the money?
- At what price for that visit would you start to feel it's expensive, though still worth paying?
- At what price for that visit would you consider it too expensive to pay at all?
Focus on the respondent's answer about delaying or skipping care due to cost. If they delayed or skipped care, reconstruct exactly what care was involved, what it would have cost, what happened to their health or plans as a result, and whether they've since gotten that care. If they said they got all needed care despite cost concerns, probe how they made that possible (borrowing, cutting other spending, payment plans) and whether that felt sustainable. Anchor on their reported financial burden level and their top-ranked cost-reduction change, and ask which single change would most have altered their actual decision.
How satisfied are you with how your insurance provider handles your healthcare costs (claims, coverage clarity, billing)?
What is your age range?
- Under 25
- 25-34
- 35-44
- 45-54
- 55-64
- 65 or older
- Prefer not to say
What is your total annual household income?
- Under $25,000
- $25,000-$49,999
- $50,000-$74,999
- $75,000-$99,999
- $100,000-$149,999
- $150,000 or more
- Prefer not to say
How do you describe your gender?
- Woman
- Man
- Non-binary
- Prefer to self-describe
- Prefer not to say
Thank you for sharing this — it's genuinely useful. Your responses will be combined with others (never shared individually) to help identify where healthcare costs are creating the most real-world strain, and what changes would actually help.
含まれる機能
AIによる深掘り
自由回答に合わせてAIが追加で質問し、固定のフォームでは拾えない具体的な内容を引き出します。
注意確認設問
急いだ回答や質の低い回答者を除外する仕組みを標準で備えています。
AIが作成する設問文
文言、設問の順序、条件分岐をAIが調査の目的に合わせて作成します。
自動レポート
回答が集まると、テーマ、引用、わかりやすい要約が自動で作成されます。
他ツールとの比較
ほかのアンケートツールで最も近いテンプレートを調べました。それぞれの優れている点と、このテンプレートがさらに踏み込んでいる点をまとめています。
このテンプレートを選ぶ理由
- Includes a dedicated AI follow-up interview that probes the specific delay-or-skip-care decision a respondent reports, reconstructing the real story instead of stopping at a checkbox
- Combines hard cost data (out-of-pocket spend, Van Westendorp pricing on a routine primary care visit) with subjective burden and concern measures (opinion scale, matrix of concern-if-needed items)
- Uses a MaxDiff exercise to rank which cost-relief changes would matter most/least, giving benefits teams and health plans prioritized, actionable levers rather than just descriptive stats
- Automated per-response quality scoring and an auto-generated report mean health plans, providers, and employer benefits teams get analysis-ready output without manual coding of open-ends
SurveyMonkey
Healthcare Expenses Survey TemplateA directly comparable, fielding-ready template focused on healthcare expenses, likely covering similar ground on out-of-pocket costs and coverage. It's a static questionnaire built on SurveyMonkey's established survey infrastructure and benchmarking tools, not an interview-style instrument. Good for quick deployment but leaves follow-up probing to manual analysis.
優れている点
- Established, well-known survey platform with broad respondent panel and distribution options
- Likely benefits from SurveyMonkey's built-in benchmarking and reporting dashboards
- Purpose-built specifically around healthcare expenses, so questions are topically aligned
物足りない点
- Static question set with no adaptive AI follow-up to dig into why someone delayed or skipped care
- No voice AI interview or guided screen-share task option
- No published methodology on how questions were validated or scored, unlike a transparent-prompt approach
Jotform
500+ Healthcare Assessment FormsThis is a broad category/library page listing hundreds of healthcare-related form templates (intake, assessment, consent, etc.), not a single fielding-ready cost-and-affordability survey. It's useful as a form-builder starting point but requires the researcher to assemble or heavily customize a cost-burden instrument themselves. The page itself does not demonstrate a purpose-built financial-burden or delay-of-care survey.
優れている点
- Large library of pre-built healthcare form templates covering many use cases
- Drag-and-drop form builder makes customization accessible to non-researchers
- Supports general data collection features like conditional logic and integrations
物足りない点
- No template specifically designed to measure cost burden, delayed/skipped care, or affordability
- Static form fields only — no adaptive AI interview or voice AI follow-up to probe individual decisions
- No automated quality scoring or narrative report generation from open-ended responses
よくあるご質問
「Healthcare Costs & Financial Burden Survey」テンプレートにはどのような設問が含まれていますか?
すぐに使える設問が14問含まれており、最初の設問は次のとおりです:「Thanks for taking a few minutes to talk about healthcare costs — your own experience, not general opinions. Nothing here…」・「Which of these best describes your current health insurance coverage?」・「Roughly how much did you personally pay out of pocket for healthcare in the last 12 months — premiums, copays, deductibl…」。すべての設問は上でプレビューでき、自由に編集できます。
このアンケートの回答にはどのくらい時間がかかりますか?
回答者は通常、14問を約7分で回答し終えます。
テンプレートは編集できますか?
はい。公開前であれば、すべての設問、選択肢、順序を編集できます。設問の追加や削除のほか、調査の目的に合わせた作り直しをAIエディターに依頼することもできます。
このテンプレートは無料で使えますか?
はい。エディターで開けば、すぐに編集を始められます。お試しにアカウントは不要で、無料プランでアンケートを公開できます。
公開の準備はできましたか?
このテンプレートをエディターで開いてみてください。最初の回答者が目にする前に、すべてを自由に変更できます。
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