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Welcome to the "Health Communication Matters! The Ongoing Challenge to Implement the Affordable Care Act" webinar sponsored by the California Pacific Public Health Training Center (CALPACT) at UC Berkeley's School of Public Health. The most sweeping health policy change in decades – the Affordable Care Act, has created a myriad of challenges in how to convey a complex subject to the public, the media, policymakers, and other professionals. Experts in ACA-related health literacy and health insurance literacy initiatives walk us through ongoing areas of challenge after the passage of the ACA and health communication principles to deliver understandable and compelling content to diverse audiences. Follow Us on Twitter: @CALPACT Facebook: http://www.facebook.com/CALPACTUCB Website: www.calpact.org
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Welcome to the Webinar
Communica*on Ma,ers: The Ongoing Challenge to Explain & Implement
the Affordable Care Act
We will begin shortly…
Today you’ll be hearing from. . .
Nancy Murphy, Metropolitan
Group, Moderator
Linda Neuhauser, DrPH, University of California, Berkeley
Kathy Paez, RN, PhD, American
Institutes for Research
Agenda 1. Review of session objec*ves 2. Introduc*on of today’s speakers 3. Overview of effec*ve communica*on in the public health
context – why does it ma,er? 4. Ques*ons & Answers 5. Mee*ng the Challenge of Health Insurance Literacy aSer the
ACA 6. Ques*ons & Answers 7. Specific ac*ons and resources 8. Next steps & conclusion
Objectives • Understand health literacy principles and why they are
important • Know where to find key resources and guidelines on health
literacy • List the specific components of health insurance literacy • List specific ways to apply health literacy principles to
improve communica*on, especially about health insurance • Iden*fy specific ways in which ACA will help improve health
insurance literacy
Health Literacy: Undervalued by Public Health? A tool for public health professionals. Prepared for the American Public Health Associa*on Community Health Planning & Policy Development Sec*on
Tammy Pilisuk, MPH AUG 2011
Who is in our audience
0 5
10 15 20 25 30 35 40 45 50
Employer/Organiza=on
Who is in our audience
0 10 20 30 40 50 60 70
Community Health Worker
Health Administrator
Health Promo*on/Educa*on
Med/Dental Prac**oner
Health Policy
Teacher/Faculty
Occupa=on
Who is in our audience Geography
West of MS River
East of MS River
40% from California
Who is in our audience
0 10 20 30 40 50 60 70 80
Not familiar
Limited familiarity
Somewhat familiar
Moderately familiar
Very familiar
Familiarity with Health Literacy Principles
What do you want to learn about this topic?
• Be,er understanding of health literacy principles • Be,er understanding of promo*ng ACA to popula*ons with
different levels of heath literacy • To be able to apply some of the core health literacy principles
in both my professional and personal life • Be,er ways to talk about health, preven*on and the ACA • More about ACA implementa*on • How to be a stronger advocate for the ACA in community/
municipal level policy discussions • Understanding of health literacy's inclusion in ACA-‐-‐
expecta*ons for implementa*on, measurement, etc.
How to Participate
• Phone line is automa*cally on mute
• Send facilitator a ques*on or comment using Ready Talk’s chat func*on
• Click “raise hand” bu,on to be taken off mute and ask a ques*on verbally
• Slides will be posted online following webinar – link will be shared with all par*cipants
Who is speaking today: Linda Neuhauser, DrPH
Linda Neuhauser, DrPH Clinical Professor of Community Health & Human Development, UC-Berkeley School of Public Health e: [email protected] w: www.healthresearchforaction.org
Who is speaking today: Kathryn Paez, RN, PhD
Kathryn Paez, RN, PhD Principal Researcher, American Institutes for Research e: [email protected] w: www.air.org
Who is moderating our discussion today:
Nancy Murphy, MSHC Nancy Murphy, MSHC Executive Vice President, Metropolitan Group e: [email protected] w: www.metgroup.com
Questions welcomed • Submit a ques*on at any *me during this Webinar using the
chat func*on OR clicking the “raise hand” bu,on to be taken off mute.
• We will consolidate ques*ons and pose them to the speakers throughout the Webinar and during the Q&A session at the end.
• We also may host addi*onal webinars on related health communica*on topics depending on the results of the evalua*on, so please tell us if you want more!
Before we launch into our presenta=ons, here is a ques=on for you:
What percentage of Americans have the skills to understand complex health informa*on, such as insurance choices?
a. 4% b. 12% c. 32% d. 49%
Introducing Linda Neuhauser
Linda Neuhauser, DrPH Clinical Professor of Community Health & Human Development, UC-Berkeley School of Public Health
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Health Literacy & Communica=on about Health Care Reform
Linda Neuhauser, DrPH
Clinical Professor School of Public Health, UC Berkeley
Health Communica=on MaUers! The Ongoing Challenge to explain and Implement the ACA Webinar: September 27, 2012
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Ques=ons
Health Research for Ac=on
Over 20 years of experience:
• Assessing literacy levels and effec*veness of health informa*on.
• Developing and distribu*ng informa*on for large, diverse, and mul*lingual audiences (over 15 languages, plus Braille, MP3, and more).
• Conduc*ng forma*ve and evalua*ve research.
• Providing trainings to improve the readability and usability of health materials.
Recipients of na-onal print, Web, health literacy, and public health awards
Communica*ng about Health Care Reform
Over 50% of consumers don’t understand it Many health care providers don’t either
CA Consumer Assistance Survey 8/2012*
• Informa=on from 77 organiza=ons
• 74% educa=ng clients about ACA • 72% said materials are “too complex” for clients
• Want simple, aUrac=ve materials in many languages; accessible
• Mul=-‐media, including video *Funded by: CA Office of the Patient Advocate and CA Dept of Managed Health Care
Survey (cont.): Most Important Topics
• Medicaid changes • Health Benefit Exchange • Finding insurance • Pa=ent rights; language access • Medicare changes • Preven=ve care • Drug coverage, & 12 other topics
A ques*on for Linda
What is health literacy -‐-‐-‐ and why is it important for ACA-‐related communica=on?
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Health Literacy
“The degree to which individuals have the capacity to obtain, process, understand, and act on basic health informa=on and services needed to make appropriate health decisions.”*
Components: Reading, listening, speaking, using numbers, mo*va*on, health ac*ons
*Institute of Medicine, 2004
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Health literacy is also… “The capacity of professionals and ins=tu=ons to communicate effec=vely so that community members can make informed decisions and take appropriate ac=ons to protect and promote their health.”*
-Joanne G. Schwartzberg, MD, American Medical Association
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What is it like?
GNINAELC – Ot erussa hgih ecnamrofrep, yllacidoirep naelc eht epat sdaeh dna natspac revenehw uoy eciton na noitalumucca fo tsud dna nworb-‐red edixo selcitrap. Esu a noUoc baws denetsiom h=w lyporposi lohocla. Eb erus on lohocla sehcuot eht rebbur strap, sa = sdnet ot yrd dna yllautneve kcarc eht rebbur. Esu a pmad tholc ro egnops ot naelc eht tenibac. A dlim paos, ekil gnihsawhsid tnegreted, lliw pleh evomer esaerg ro lio.
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Na=onal Assessment of Adult Literacy, 2003
Below Basic: No more than the most simple & concrete literacy ac*vi*es
Basic: Can perform simple everyday literacy ac*vi*es
Intermediate: Can perform moderately challenging literacy ac*vi*es
Proficient: Can perform complex and challenging literacy
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Health Literacy Skills by Level
Below Basic: Circle the date of a medical appointment on a hospital appointment slip.
Basic: Give 2 reasons for gepng tested for a specific disease, based on informa*on in a clearly wri,en pamphlet.
Intermediate: Determine what *me to take a prescrip*on medicine, based on informa*on on the drug label rela*ng *ming of medica*on to ea*ng.
Proficient: Calculate an employee’s share of health insurance costs for a year, using a table.
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Hispanic Health Literacy Levels Hispanic adults have lower average health literacy than adults in any other racial/ethnic groups.
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How well do people read and write?
• The average American reads at the 7th-‐8th grade level-‐-‐3 to 4 grades below last grade completed • 20% read below the 5th grade level • Most health informa*on is wri,en at the 10-‐12th grade level
US Reading Levels Compared to Health Informa=on Readability
Computer Literacy Requires More Skills
• Ability to search • Ability to spell • Ability to navigate pages • Ability to use links & move between documents
• Ability to use interac*ve features Most Internet health info is at 10-‐12th grade
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Mismatched Communica=on
Information is too complicated for people’s health literacy abilities.
Aler a clinical visit, pa=ents may…
Forget or remember incorrectly over 50% of what the physician said
A ques=on for Linda
What are the public health implica=ons of these healthy literacy challenges?
Most of the US popula=on may be at risk for… • Medical misunderstandings
• Mistakes taking medica=ons, etc.
• Excess hospitaliza=ons (2X) • Poor health outcomes (1.5-‐3X)
• Unnecessary deaths
38 38
Es=mated Costs of Limited Health Literacy on the
Economy
$106 -‐ $238 Billion This represents 7% -‐ 17% of all personal health care expenditures
Vernon J. et al, 2007
Na=onal HL Policy Evolu=on
AHRQ 2001 – top 11 pa*ent safety prac*ces
IOM Report on health literacy, 2004
Healthy People 2010: Objec*ve 11
Joint Commission: pa*ent communica*on requirements
Surgeon General’s Workshop on Health Literacy -‐ 2006
Na*onal Ac*on Plan to Improve Health Literacy -‐ 2010
U.S. Plain Language Act -‐ 2010
A ques=on for Linda
So given all of this, what can we do to improve Health Communication?
“Clear Health Communica=on” Tips • Write informa=on at appropriate user level • Put info in small “chunks” • Leave 1/3 to 1/2 page as “white space” • Limit info to 1-‐3 main messages • Focus on behaviors rather than facts • Use photos of real people • Make informa=on culturally sensi=ve Involve users as co-‐designers!
Measure the Readability of Materials
• Many tests (mostly measure # words in a sentence and # syllables per word)
• SMOG • Frye • Flesch Reading Ease • Flesch-‐Kinkaid (avoid!)
Aim for about a 6th-‐7th grade reading level
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“Universal Design”
Studies show that even people who read at a college level prefer materials wriUen at a 6th-‐8th grade level, and understand them beUer.
Davis TC, Crouch MA, Willis G. et al. The gap between pa*ent reading comprehension and the readability
of pa*ent educa*on materials. J Fam Pract 1990; 31: 533-‐8.
44
Suitability Assessment of Materials (SAM)
22-‐item assessment tool: Readability and
• Organiza*on of content • Formapng • Cultural relevance
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What do YOU think?
What do YOU find most difficult to explain about the ACA?
a. The *metable for implementa*on b. The different components of the law c. How the Exchanges will work/cost of plans d. All of the above
Some of Our Work to Improve Consumer Informa=on about Health
Care & the ACA
Guides created by HRA and State of California
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Health Research for Ac=on ACA Research Ac=vi=es
-‐ Survey of CA organiza=ons providing ACA informa=on to consumers
-‐ Assessment of available ACA resources in California
CA Study: Assessment of ACA materials – We tested 10 ACA fact sheets for readability with 3 tests
– Results: 8 of 10 items tested at 12th grade to college reading levels (!!)
– Organiza=ons wanted simple customizable fact sheets in many languages
– Videos on using consumer assistants, gerng preven=ve care, and reques=ng an interpreter, calcula=ng health care costs, etc.
– Easy-‐to-‐understand glossary – PowerPoint presenta=ons for providers
*Funded by: CA Office of the Patient Advocate and CA Dept of Managed Health Care
Health Research for Ac=on ACA Communica=on Development
• Glossary of easy-‐to-‐understand terms
• Fact Sheets on 8 key topics in 3 languages • Videos on key ACA issues: 3 languages • Postcards for Medicaid changes
• Customizable informa=on templates
• PowerPoint presenta=ons on ACA
Key takeaways -‐ Health insurance informa*on requires a high level of health literacy skills. Only about 12% of American adults are es=mated to have that level of skills. -‐ Available ACA informa*on has a high readability level (college) and is too hard for people to understand. Such informa=on should be wriUen at a 6th-‐8th grade level.
-‐ Besides wri,en informa*on, people will need other media, such as videos, and also people to help them. -‐ There many good principles to develop easier to understand materials, both for print and the web.
Join the Conversa=on!
Questions or comments for Linda? Please submit questions by using the chat function OR clicking the “raise hand” button to be taken off mute We have our first question for Linda . . .
Discussion/Q&A
Ask Linda! Share with Linda!
It’s YOUR turn! Have you ever misunderstood your own health insurance rules and been surprised with a bill or a coverage denial?
a. Yes b. No
Introducing Kathy Paez
Kathy Paez, RN, PhD American Institutes for Research
Copyright © 2012 American Institutes for Research. All rights reserved.
Mee=ng the Challenge of Health Insurance Literacy Aler the ACA
Kathryn Paez, R.N., Ph.D.
. Source: The Congressional Budget Office, Letter to the Honorable Nancy Pelosi, Mar. 20, 2010, http://www.cbo.gov/doc.cfm?index=11379.
By 2014, 20 million Americans are expected to have access to health insurance
14%
12%
22%
29%
22%
33%
44%
53%
33%
13%
13%
13%
Prose
Document
Quan*ta*ve
Percentage of adults in each literacy level, 2003
Below Basic Basic Intermediate Proficient
Source: National Center for Education Statistics, 2003 National Assessment of Adult Literacy
Literacy in the United States
Consumer
Health insurance is one of the most complex commodi=es sold to consumers
Consumers are required to navigate through layers of complicated jargon to effec=vely select and use health
insurance
Consumer
Premium Deductible
Copay
Coinsurance
Tiered Benefits OOP Max
Coverage Limit
Plan Year
1st Dollar Coverage
In & Out of Network
Formulary
Brand
Member ID Group ID
Preexisting Condition
Guaranteed Renewal
Life
time
Max
imum
Cap
Member Services
Denial of Payment
Rehabilitation Services
Preventive
Care
Provider Types
Health Care Services
U=liza=on of Services
Enrollment
Rx Drug Coverage
Plan Type & Accounts
Cost Sharing
Medical
Providers
Midlevel
Providers
What will I pay for a bunionectomy?
Copay? Deduc*ble?
How much met already?
Out of Network? usual charge=$4,500; actual charge=$5,450
Coinsurance? 20% before or aSer copay and deduc*ble?
$100
$1000
$690 or
$900
$950
Out-of-pocket = $2,740 or $2,950
A ques=on for Kathy
What is health INSURANCE literacy? How is it different from health literacy?
Health insurance literacy defined
“The degree to which individuals have the knowledge, ability, and confidence to find and evaluate informa-on about health plans, select the best plan for their own (or their family’s) financial and health circumstances, and use the plan once enrolled.”
Health Insurance Literacy = Selec=on + Use
Measuring Health Insurance Literacy: A Call to Action. A Report from the Health Insurance Literacy Roundtable, February 2012 http://www.consumersunion.org/pub/Health_Insurance_Literacy_Roundtable_rpt.pdf
Knowledge e.g., Understand insurance
terms and concepts
Document Literacy e.g., Understand an explana*on
of benefits statement
Informa*on-‐Seeking Skills
e.g., Find in-‐network providers on plan Web site
Cogni*ve Skills e.g., Project use and out-‐of-‐pocket cost
Self-‐Efficacy The confidence to act
Breaking down health insurance literacy into its parts
A question for Kathy
How health insurance literate are consumers?
Overly confident that insurance covers the cost of care
“People have the tendency to assume that because you have a par-cular policy from a par-cular carrier, you have good insurance, which is not true. You can have Blue Cross Blue Shield, but it doesn’t mean that it’s a good policy.’’
“We’ve actually encountered a fair number of people who say, ‘I’m not going to pay $300 a month because I’m not going to use $300 a month of anything.’ Some-mes they don’t get the concept that if you don’t need it now, it’s for a poten-al future health problem and you have to pay in advance. You don’t sign up when you get sick.”
Don’t understand insurance mi=gates financial risk
Have difficulty assessing value
• Gravitate towards cheaper, high-‐risk op*ons or more expensive but less cost-‐effec*ve op*ons
Have difficulty appropriately using insurance
• Don’t get established with a physician • Assume physicians will refer them to in-‐network providers or don’t consider network at all.
• Have trouble applying plan rules: “Is a referral needed or not?”
• Pay out-‐of-‐pocket costs without pursuing insurance nonpayment.
What do YOU think?
• Where should consumers turn to find out details about their coverage?
a. Health care provider b. Health plan or Medicaid office c. Employer HR department d. Health care advocacy group e. I’m not sure
Bridging the gap
Reducing the tremendous cogni=ve demand on consumers
• Standardize • Simplify informa*on • Harness technology
How the ACA will help
ACA Reforms September 23, 2012 January 1, 2014
Standardize choice • No life*me limits • 100% coverage for some
preven*ve services
• 4 comparable actuarial value *ers
• Coverage of “essen*al benefits”
• Plans offered in health insurance exchanges (HIX) are “qualified”
Simplify consumer informa*on • Limit • Standardize • Plain language
Summary of benefits and coverage (SBC) materials with coverage examples
Harness technology Plans on HIX must have a method to calculate OOP cost
Reforms apply to small group and individual plans in private market and sometimes large group plans.
Coverage levels under the ACA “the metals”
Metal Tier Actuarial Value
Pla*num 90%
Gold 80%
Silver 70%
Bronze 60%
70 percent actuarial value: the plan pays 70 percent on average for covered medical services; 30 percent on average is paid for by beneficiaries.
More Co
verage
Versus
Standardized “essen=al benefits” required by the ACA
• Ambulatory pa*ent services, such as doctor’s visits and outpa*ent services
• Emergency services • Hospitaliza*on • Maternity and newborn care • Mental health and substance use disorder services • Prescrip*on drugs • Rehabilita*ve and habilita*ve services and devices • Laboratory services • Preven*ve and wellness services and chronic disease management • Pediatric services, including oral and vision care
Standardize summary of benefits and coverage
• Mandated that all insurance plans use this form beginning in 2012
• Standardized and tested format • Allows comparison of coverage op*ons • Includes coverage examples • Includes glossary of terms
8 pages!!!
Summary of benefits and coverage
Summary of benefits and coverage
Deductible The amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay. For example, if your deductible is $1000, your plan won’t pay anything until you’ve met your $1000 deductible for covered health care services subject to the deductible. The deductible may not apply to all services.
Glossary of terms
Glossary of terms
Tools to calculate consumer cost
It’s YOUR turn ACA and it’s implementa*on will make it easier for consumers to make good decisions about health insurance
a. Agree b. Disagree c. Not sure
Reducing the tremendous cogni=ve demand on consumers
• Standardize • Simplify informa*on • Harness technology
Choice architecture
Organizes and frames informa*on • Filtering to limit what appears on the screen • Sor*ng informa*on • Comparing side by side (quality, cost)
Filter, sort and compare
Compare side by side
Key takeaways • Selecting and using health insurance is tremendously complex!
• We, as health care professionals, all need to become health insurance navigators and support the less health insurance literate. • Attention is needed on navigating insurance once consumers get into the system.
Join the Conversa=on!
Questions or comments for Kathy? Please submit questions by using the chat function OR clicking the “raise hand” button to be taken off mute We have our first question for Kathy. . .
Discussion/Q&A
Ask Kathy! Share with Kathy!
Ques=ons for our speakers
Kathryn Paez, RN, PhD, American Institutes for Research
Linda Neuhauser, DrPH University of California-Berkeley,
Health Literacy: Undervalued by Public Health? A tool for public health professionals. Prepared for the American Public Health Associa*on Community Health Planning & Policy Development Sec*on
Tammy Pilisuk, MPH AUG 2011
Next steps
• Today’s slides will be posted online, along with an archived version of this webinar, for future access
• An evaluation will be sent to you shortly ─ please let us know if you would like to follow-up on anything we touched on today
• Have additional questions? Contact our presenters or moderator.
Thanks to our speakers!
Kathryn Paez, RN, PhD, American Institutes for Research
Linda Neuhauser, DrPH, University of California-Berkeley
Resources • CDC: Health Literacyh,p://www.cdc.gov/healthliteracy/index.html
• Literacy Informa*on and Communica*on System (LINCS): h,ps://community.lincs.ed.gov/
• American Medical Associa*on’s health literacy site: h,p://www.ama-‐assn.org/ama/pub/about-‐ama/our-‐people/affiliated-‐groups/ama-‐founda*on/our-‐programs/public-‐health/health-‐literacy-‐program.shtml
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• US Department of Health and Human Services Web Usability Guidelines: www.usability.gov h,p://www.usability.gov/guidelines/index.html
Resources (cont.)
• Communica*ng Risks and Benefits: An Evidence-‐Based User’s Guide: h,p://www.fda.gov/AboutFDA/ ReportsManualsForms/Reports/ucm268078.htm (see especially Chapter 9, “Health Literacy” and Chapter 14, “Readability, Comprehension, and Usability”)
Resources (cont.)
• ACA Regula*ons and Guidance: h,p://www.dol.gov/ebsa/healthreform/index.html#5
• Web Portal for the public www.healthcare.gov
• Qualita*ve research reports by Consumers Union evalua*ng health insurance tools for consumers h,p://www.consumersunion.org/health.html
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Speaker Contact Informa*on
Linda Neuhauser, DrPH, MPH [email protected] hUp://www.healthresearchforac=on.org Kathy Paez, RN, PhD [email protected] hUp://www.air.org
Thank you to our Sponsors
Community Health Planning and Policy Development Section, APHA
Thank you to our planning commiUee
• Tammy Pilisuk, MPH, APHA-‐CHPPD • Erin Brigham, MPH, CareSource, APHA-‐CHPPD • Amanda Crowe, MA, MPH, Impact Health Communica*ons, LLC
• Meghan Bridgid Moran, PhD, San Diego State University, School of Communica*ons
• Nancy Murphy, MSHC, Metropolitan Group
Conclusion
Thank you!
