Crystal-Clear Communication

AHIP Coverage (March/April 2008)

Crystal-Clear Communication
A flurry of recent activity puts health literacy in the spotlight.
By Aileen Kantor

Consumers who understand health care information—medication directions, their physicians’ guidance, package inserts, instructions provided over nurse advice lines, and Web sites—benefit in improved health status as a result. When patients don’t understand—and can’t act on—medical information and instructions, the impact on health and well-being can be devastating: poor control of diabetes, more hospitalizations and longer lengths of stay, improperly taken medications, and so on.

Given the country’s epidemic of chronic disease, it is imperative that patients play a role on a daily basis in managing disease, and to do that requires clear information. There are an estimated 90 million American adults with “low health literacy,” 40 million of whom read below a fifth grade level. Stress, fatigue, and fear can make health literacy a challenge for anyone. There is growing awareness of the problem and momentum is building as the health plan community and other stakeholders address the challenge of clear health communication head-on.

How Much Does Health Literacy Really Cost Our Health Care System?

There is extensive research that links low health literacy and its direct costs with health care and outcomes, but specific information regarding the overall economic effect on the health care industry has been scarce.

Last year, however, researchers from the University of Connecticut School of Business combined research methodologies from other sources and created a new modeling to produce a report entitled “Low Health Literacy: Implications for National Health Policy.” With funding from Pfizer and support from the University of Central Florida and George Washington University researchers, this report offers a new look at health literacy’s economic impact.

The University of Connecticut investigators combined researcher Robert Friedland’s assumptions about low health literacy levels and data from the 2003 Medical Expenditure Panel Survey (MEPS), among other resources. The findings suggest that the cost of low health literacy to the U.S. economy is in the range of $106 billion to $236 billion. In addition to this cost estimate, the report authors make three larger points:

First, the intent of the report is to approximate the order of the economic cost of low health literacy in the United States to raise awareness of the relative amount involved. Second, the authors believe that when one accounts for the future costs of low health literacy (i.e., those associated with compromised health status that is the down-the-line outcome of poor health literacy today) that will result from current actions (or inaction), the true cost is closer to somewhere between $1.6 trillion and $3.6 trillion. Third, the authors contend that the savings that could be achieved by improving health literacy translate into enough funds to insure all of the 47 million uninsured individuals in the United States today.

“Our findings suggest that low health literacy exacts enormous costs on both the health system and society, and that current expenditures would be far better directed through a commitment to improving health literacy,” said John A. Vernon, Ph.D., department of finance, University of Connecticut, the lead author of the report. In addition to reducing disparities in health coverage and developing specific actions to improve the way health care providers and health insurers relate to and interact with patients, the report recommends the following reforms to address low health literacy:

Incentivize insurers and health care professionals to identify and address health literacy-related problems in the health care system.
Remind public and private health insurers to recognize and build costs into their payment systems to include services such as translation and interpretation services and development of oral and written instructions that are accessible to all consumers.
Ask federal policymakers to increase funding for innovative clinical research and health interventions in various health settings to improve health literacy, particularly for populations at elevated risk for chronic conditions.
Encourage and support the inclusion of health literacy skills as a basic component of federally supported education and training programs, such as programs that train professionals in the fields of medicine, nursing pharmacy, and other direct patient interaction.
Ask federal policymakers to consider revisiting their approach to estimating the impact of federal policy reforms to incorporate a health literacy impact assessment.
Encourage health literacy by creating centers of excellence to promote its study and the adoption of best practices and known interventions that improve health literacy. There should be particular emphasis on funding state and local health agencies, such as community health centers, that care for populations at highest risk for adverse health outcomes.

Last December, Sens. Tom Harkin (D-Iowa) and Norm Coleman (R-Minn.) introduced the National Health Literacy Act, which aims to ensure that the 90 million Americans needing assistance with health information are empowered to make better health care decisions. The bill, which had five co-sponsors at press time, had been referred to the Senate Health Committee. If passed, the legislation would require the Secretary of Health and Human Services to establish a Health Literacy Implementation Center within the Agency for Health Care Research and Quality (AHRQ).

This Center would gather and disseminate resources and best practices, sponsor demonstration projects, coordinate research, assist other federal agencies, and determine national health literacy strategies and goals. Allocating $10 million annually for fiscal years 2008-2012, the bill also calls for an annual public meeting and the establishment of state-based health literacy centers to identify and understand health literacy challenges, coordinate public and private efforts to deliver health literacy services, and provide technical and policy assistance to state and local governments.

So far, the bill has received support or endorsement from the following organizations: AARP; America’s Health Insurance Plans (AHIP); the U.S. Chamber of Commerce; the National Health Council; Families USA; the Institute of Medicine; the Roundtable on Health Literacy; the American Medical Association; the Institute for Healthcare Advancement; UCLA/Johnson & Johnson Health Care Institute; the American College of Physicians Foundation; the American College of Physicians; and the American Physical Therapy Association.

“We know that 90 million Americans have inadequate health literacy and that low health literacy leads to delayed diagnosis, poorer physical and mental health, and increased risk of death,” said George Isham, medical director and chief health officer, HealthPartners, as well as an AHIP board member and current chair of the IOM Roundtable on Health Literacy. “The establishment of implementation resource centers at AHRQ and in the states fills an important need for practical tools that health care organizations across the country can use to address this critical issue.”

In a letter expressing support for the legislation, AHIP President and CEO Karen Ignagni said, “Our members share your strong commitment to improving health literacy to ensure that consumers have a clear understanding of their coverage and treatment options and are able to make informed health care decisions….These issues have significant implications for both the cost and quality of health care, particularly for persons who have chronic conditions and need to carefully follow the treatment regimens prescribed by their physicians.”

Aileen Kantor is the founder of PR Healthcare, Bethesda, Maryland.

[SIDEBAR]

Health Insurers and Health Literacy

As individual health insurance plans continue to build their capacity for clearer health communication for their members, the industry is taking important steps as a community to address the need for information that consumers understand and can act on. In November, the AHIP Board of Directors accepted a report from the AHIP Health Literacy Task Force that encourages all health insurance plans to follow four basic “best practices,” including training for all staff who prepare written communications for members and those who interact with members directly either on the phone or in person.

At the same time, AHIP has formed a task force that includes individuals who work on the development of personal health records as well as individuals with responsibility for health literacy. The group is working to identify principles that should result in easier to use and understand Web-based content, including PHRs. The result will be a guide that can be shared with in-house experts as well as vendors who help insurers with structure and content for their Web sites.

AHIP will also offer training programs later in the year for companies that are starting up or want to advance their emphasis on clear health communication. The training will include case studies from companies that have more advanced health literacy programs, continuing a tradition among health insurers of sharing best practices that lead to better quality.

[SIDEBAR]

Medicaid and Health Literacy

Research confirms that low health literacy can be more dangerous for certain health consumers than for others. A study conducted with 400 Medicaid patients revealed that patients with low reading skills had higher medical costs, more hospitalizations, fewer primary care physician visits, and poorer compliance with doctors’ advice than those with higher reading ability. A 2004 Institute of Medicine report found that groups considered at highest risk for low health literacy are the elderly and low-income individuals.

To assess states’ commitment to health literacy, Health Literacy Innovations (HLI), a company that creates tools to enhance health literacy, conducted a national survey on Medicaid guidelines. The survey was designed to provide the health care industry with information about the disparate standards among Medicaid agencies. Many insurers are trying to create communication materials that will be distributed throughout several states.

In 2007, HLI contacted the 50 state Medicaid agencies, as well as the District of Columbia, by telephone and e-mail to determine specific state policy for health literacy standards for printed and Web materials. HLI achieved a 94 percent survey response rate. Responses came from a variety of sources within the Medicaid agencies. Survey respondents offered general information on written materials rather than readability information for the Web or printed materials.

The results revealed that while the overwhelming majority—90 percent—of all states have specific readability guidelines for their Medicaid materials, 66 percent of all Medicaid agencies call for at least a sixth grade reading level (or a range that includes sixth grade reading level) for written health material, making this standard the most popular among states.

Among other findings:

56 percent of states call for a sixth grade reading level.
66 percent call for a sixth grade reading level or a range that includes sixth grade.
14 percent call for a fourth grade reading level.
6 percent call for a reading level between fourth and sixth grade.
2 percent call for a third grade reading level.
14 percent offer providers some variance in readability guidelines, asking
that materials be produced within a reading grade level range—between sixth and eighth grade, fifth and seventh, or fourth and sixth.
8 percent have no health literacy readability guidelines.

With 90 percent of all states requesting health literacy standards for printed material for their Medicaid populations, HLI’s survey highlights several trends.

The majority of states have health literacy standards for their Medicaid programs.
Among states, there isn’t one specific department responsible for ensuring that printed materials meet health literacy standards. Rather, the responsibility for compliance with health literacy standards varies from state to state.
The majority of states have set goals to improve the health literacy level of their Medicaid populations.
While most states request a sixth grade reading level, there is a range of different grade levels requested by other states.
Despite differences in readability indices, most Medicaid agencies are taking positive steps to provide reading level standards for their Medicaid members, making the long-term implications for health literacy at the state level encouraging.

“This growing trend in the Medicaid program toward lower readability levels is important news for states and for the health care community in general,” says Aracely Rosales, chief content expert and multilingual director, Health Literacy Innovations. “It not only reveals that states are requesting clear language for their Medicaid members, and at a level that takes real work, but it shows a positive trend toward closing the gap between what consumers can understand and can read and the information the health care industry produces, which today is about a 10th grade reading level.”

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What Is Health Literacy?

Many Americans cannot read or understand their health care information. The Institute of Medicine defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”