Literacy and Health Literacy: Prerequisites to Effective Health Care Decision Making

National Coalition for Literacy

December 5, 2007Washington, DC

Presented by Joyce Dubow, AARP

Presentation Overview

Profile of the Medicare population Information burden and the

importance of patient engagement Implications of poor health literacy

skills on ability to navigate Medicare

Strategies to meet needs Policy implications

75-7920%

85+13%

70-7423%

80-415%

65-6929%

Source:http://www.cms.hhs.gov/DataCompendium/018_2006_Data_Compendium.asp

People on Medicare:Age, 2005

Some college or more

41%

High School30%

Not a High School Grad

29%

Education

Source: MedPAC analysis of the Medicare Current Beneficiary Survey, Cost and Use file, 2004

People on Medicare:

Today’s Medicare Program

Medicare

The OriginalMedicare Plan

Coordinated Care Plans

Private FFS

HMOs

POS

PPOs

MSA

PSO

Demos

Part D Part D

What is expected of Medicare beneficiaries

Recognize differences among Medicare coverage options

Decide whether to buy Rx coverage Identify differences among similar

plans Choose “best” doctors and hospitals Navigate within a plan Choose most appropriate treatment

options Understand rights and responsibilities

Numeracy

Source: Kripalani and Jacobson, www/ahrq.gov/qual/pharmlit/pharmtrain2.htm

Health Literacy

“The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”

IOM, Health Literacy: a Prescription to End Confusion

Source: Kripalani and Jacobsonwww.ahrq.gov/qual/pharmlit/pharmtrain2.htm

Average Health Literacy Scores of Adults by Age,

2003

190

200

210

220

230

240

250

260

16-18 19-24 25-39 40-49 50-64 65+

Age

Ave

rag

e S

core

Source: Results from the 2003 NAAL

Source: Literacy in Everyday Life: Results from the 2003 NAAL

Source Kripalani and Jacobson, www.ahrq.gov/qual/pharmlit/pharmtrain

Consequences of Inadequate Health

Literacy Poor health outcomes Low health literacy is an independent risk

factor for hospital admission among Medicare managed care enrollees.

Risk of non-compliance Errors Poor decisions Anxiety Inertia

People with Chronic Conditions Report Getting Conflicting Advice

18%

17%

16%

14%

0% 2% 4% 6% 8% 10% 12% 14% 16% 18% 20%

Had duplicate tests orprocedures

Received conflictinginformation from

providers

Received informationabout drug interactionsupon filling prescription

Received differentdiagnoses from different

providers

Percent of Population with Chronic Conditions Reporting Problem

Source: Jane Horvath, Partnership for Solutions (Chronic Illness and Caregiving, a survey conducted by Harris Interactive, Inc., 2000.)

Engagement Fosters Desirable Patient Behaviors (Hibbard)

Informed choice role —using performance information to validate choice of provider

Co-producer role —having skills and confidence to partner with providers and to be vigilant in ensuring that one’s own care is safe

Evaluator role —understanding and acting on information on performance and understanding how such information affects one’s life.

Health Literacy Level and Decision Making

Health literacy influences decision making confidence to make decisions ability to use comparative information

(Patient activation influences engagement in self-management

behaviors )

Challenges Cognitive overload

Need to help people take into account multiple variables in making decisions

Statistical concepts not well understood (e.g., absolute vs. relative performance; average/percentage; benchmarks; statistical uncertainty.

Lack of Interest? Adequacy and timeliness of relevant

and meaningful information

What Works? Symbols vs. numbers Simplifying

Focus on key messages Present recommended actions steps

clearly Rank ordering by performance vs.

alphabetical ordering Summarizing

“Teach Back”

What Works? “Evaluable” formats (can be

as important as content) Framing makes a difference. Use of alternative media (e.g.,

interactive data bases)

Other Strategies

Test materials with diverse groups for comprehension and appeal

Use simple language, (e.g., “plain English”) white space, large fonts culturally sensitive; “age-appropriate” colors; avoid fancy graphics

Policy Challenges

Medicare must address needs of a very diverse beneficiary population: diverse skills diverse preferences diverse needs diverse SES

Advance health literacy as a policy issue

Summary: Help Beneficiaries

Use Information Lower cognitive effort required to use information

Reduce amount of information Computer-aided decision tools Evaluable displays

Highlight meaning and significance Framing; Provide information that helps consumers understand the

implications of their choices Give a better idea of what the actual experience of a choice might

be like. Narratives

Design information displays to highlight the meaning of important information that might otherwise be overlooked

Conclusions

Emphasis on private plans/market competition and consumerism in Medicare requires an “informed consumer”

Adequate funding for information and education programs, including counseling programs, is required to address diverse beneficiary needs