Q01
メッセージ
すべてのテンプレートHealthcare & Clinical
Patient Impact of Medicare Telehealth Coverage Rollback
Measures how recent reductions in Medicare telehealth coverage are affecting beneficiaries' access to care, out-of-pocket costs, and health outcomes. Built for health systems, patient advocacy groups, and policy researchers tracking rollback effects, with an AI follow-up that reconstructs one specific care disruption in the patient's own words.
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。
全14問・約7分
Q02
選択式必須
In the last 6 months, has your Medicare coverage for telehealth (video or phone) visits changed?
- Yes, coverage was reduced or ended for some visits
- Yes, but coverage has stayed about the same
- No change that I'm aware of
- Not sure
Q03
選択式必須
Which types of telehealth visits have you used in the last 12 months?
- Primary care check-ins
- Mental or behavioral health counseling
- Specialist consultations
- Chronic disease management (e.g., diabetes, blood pressure)
- Prescription refills or medication management
- Physical or occupational therapy
- Other
Q04
オピニオンスケール必須
How much has the recent change in telehealth coverage affected your ability to get the care you need?
スケール: 1 – 7
最小:Not affected at all最大:Severely affected
Q05
マトリクス必須
Since the coverage change, how much do you agree with each statement about your own experience?
5行 × 5列
- I have delayed or skipped a needed appointment
- I have paid more out-of-pocket for care
- I have switched to in-person visits I would rather have done remotely
- I have had trouble reaching my regular doctor or provider
- My overall health has gotten worse
列: Strongly disagree · Disagree · Neutral · Agree · Strongly agree
Q06
選択式
Think of the most recent time a telehealth visit you wanted was no longer covered. What did you do?
- Paid out of pocket for the telehealth visit
- Switched to an in-person visit
- Delayed getting care
- Skipped the visit entirely
- Found a different, lower-cost provider or option
- This hasn't happened to me
Q07
評価スケール必須
How would you rate your current ability to access telehealth visits under Medicare?
範囲: 1 – 5
最小:Very poor最大:Excellent
Q08
ベスト・ワースト選択（MaxDiff）必須
Which of these changes would help you the most versus the least in getting the care you need?
- Restoring coverage for mental health telehealth visits
- Restoring coverage for specialist telehealth consultations
- Lower copays or cost-sharing for telehealth visits
- Coverage for audio-only (phone-only) visits
- Being able to keep seeing the same doctor via telehealth
- Faster approval or reimbursement for telehealth claims
- Expanded telehealth options for chronic disease management
- Clearer information about what is currently covered
各セットで最も良いもの・最も悪いものを選択最も良い:Would help most最も悪い:Would help least
Q09
AIインタビュー
Reconstruct in detail what happened the most recent time this patient's Medicare telehealth coverage change affected their care: what the visit or need was, what they tried, what got in the way, and how it was ultimately resolved or not. If they say the change hasn't affected them yet, probe whether they're worried about future changes and what specifically concerns them, anchoring on any condition they manage regularly.
Q10
メッセージ
Just a few last questions about you — these help us see whether the impact differs across patient groups. All are optional.
Q11
選択式
Which best describes your Medicare coverage?
- Original Medicare
- Medicare Advantage
- Medicare plus a Medigap supplemental plan
- Dual eligible (Medicare and Medicaid)
- Not sure
- Prefer not to say
Q12
選択式
What is your age range?
- Under 65 (disability or other qualifying reason)
- 65-74
- 75-84
- 85 or older
- Prefer not to say
Q13
選択式
Which best describes where you live?
- Urban
- Suburban
- Rural
- Prefer not to say
Q14
メッセージ
Thank you for sharing your experience. Your responses will be combined with others to build a report on how telehealth coverage changes are affecting Medicare patients' access to and continuity of care.
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
- Directly measures the patient impact of the Medicare telehealth coverage rollback — coverage changes, care disruptions, out-of-pocket costs, and health outcomes — rather than general satisfaction or intake data
- Includes an adaptive AI follow-up interview that reconstructs one specific recent care disruption in the patient's own words, capturing detail a fixed-choice form can't
- Combines opinion scale, matrix, rating, and MaxDiff questions to quantify perceived access change and prioritize which policy fixes (e.g., restoring specific visit types) would help patients most
- Segments results by Medicare coverage type, age, and location so health systems, advocacy groups, and policy researchers can see who is hit hardest by the rollback
Jotform
Outpatient Telehealth Consent Form TemplateThis is a consent/intake form for authorizing outpatient telehealth services, not a survey instrument for measuring policy impact. It's easy to customize as a static form but isn't built to capture patient experience, access changes, or cost impact data. Best suited to clinical onboarding workflows rather than research or advocacy data collection.
優れている点
- Purpose-built for telehealth consent/intake workflows
- Simple, quick to deploy as a standard form
- Familiar Jotform form-builder ecosystem for clinics
物足りない点
- No mechanism to measure coverage changes, care disruption, or out-of-pocket cost impact
- Static form fields only — no adaptive follow-up questioning to surface patient stories
- Not designed for demographic segmentation or policy-impact reporting
SurveyMonkey
Patient Satisfaction Survey TemplateA generic post-visit patient satisfaction template aimed at gauging care experience, not telehealth coverage policy effects. It's a ready-to-field static questionnaire, which is a plus for quick deployment, but it doesn't address Medicare coverage changes, cost burden, or care access disruption specifically. Would require substantial rebuilding to fit this use case.
優れている点
- Ready-to-field, widely used survey platform with fast setup
- Established benchmarking and reporting tools for general patient satisfaction
- Broad distribution options across a large existing user base
物足りない点
- Not focused on telehealth coverage rollback, access, or cost impact — would need heavy customization
- Fixed question set with no adaptive AI probing to reconstruct specific disruption events
- No published methodology or per-response quality scoring for open-ended answers
よくあるご質問
「Patient Impact of Medicare Telehealth Coverage Rollback」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 share your experience with Medicare's telehealth coverage changes. Your answers help…」・「In the last 6 months, has your Medicare coverage for telehealth (video or phone) visits changed?」・「Which types of telehealth visits have you used in the last 12 months?」。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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