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6 How Do Insurance Companies Factor Health Literacy into Prevention Programs and Information for Enrollees? Arnold Saperstein, M.D. President MetroPlus Health Plan MetroPlus Health Plan is a wholly owned subsidiary of the New York City Health and Hospitals Corporation (HHC), which is the largest public hospital system in the United States, serving a low-income inner- city population, Saperstein said. It is made up of 11 acute care hospitals, four skilled nursing facilities, six large diagnostic and treatment centers and over 80 other community-based centers. MetroPlus offers almost only government programs such as Medicaid, Family Health Plus for uninsured adults and Child Health Plus. They also have the largest HIV special needs program for Medicaid recipients in the country. There is also a small commercial population which is for employees of HHC and a recently started Medicare program. There are two dual-eligible Medi - care programs and, beginning in January 2010 there will also be a full Medicare non-dual-eligible program. The area is small geographically, operating in four of the five counties in New York City but the network has 370,000 members and over 12,000 providers. Health literacy is important to MetroPlus, Saperstein said. It is extremely complicated for New York City residents to become eligible, get enrolled, and stay enrolled in the plan. Imagine, in such a large sys - tem, attempting to navigate through the primary care provider system and obtaining specialty care and inpatient care when necessary. From the 37

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38 PROMOTING HEALTH LITERACY health literacy perspective how does one navigate such a complicated system to even get to health care? Health literacy issues also affect mem - bers’ abilities to share their health information with providers, to engage in self-care and chronic disease management programs, and adopt healthy behaviors. MetroPlus members are at significant risk for health literacy issues and challenges in their health care. The membership is made up of a diverse population whose members speak multiple languages; at least 30 percent of the population does not speak English and many have a limited education. To address language issues, MetroPlus has about 100 customer service staff who speak 13 different languages and who are available Monday through Saturday, from 8 a.m. to 8 p.m. The automated telephone line is available in five different languages and additional languages are supported through a contracted telephone line service. The Web site is available in only English, Spanish, and Chinese, but work is under way to expand the number of languages. Sites also have language cards that allow the member to point to the language he or she uses. Member newsletters, which are mailed four times a year to all members, are published in English, Spanish, Chinese, Bengali, and Haitian Creole. There are many other materials used by case managers from marketing information, to basic health information mate - rials that are available in multiple languages. A company is employed to translate the material into different languages, but prior to publication those translations undergo quality review by MetroPlus staff who are fluent in the language. Materials also are reviewed before publication in print and on the Web by a member advisory committee. It is interesting to note that approximately 70 percent of the time the quality review results in changes to the material. The materials are written in simple, plain lan - guage at a fourth grade reading level. Case management programs are offered to persons with chronic dis- ease in the areas of behavioral health, asthma, diabetes, prenatal care, complex transplant, and HIV. Each of these has nursing staff, social work staff, or support staff who speak multiple languages so that there is an opportunity to telephonically case-manage individuals in their own lan - guage. There is also a health screening and initial health assessment for all Medicare members conducted in the appropriate language and this has a health literacy component. Finally, there are also some pilot programs, primarily in HIV, that have patient navigators. In the future, Saperstein said, MetroPlus will continue the programs already established and will also create and identify quality health educa- tion materials written at varying literacy levels, in various formats and in multiple languages. There will also be further analysis of the impact of language and literacy barriers on the clinical outcomes of the member

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39 INSURANCE COMPANIES FACTOR HEALTH LITERACY population. Finally MetroPlus will direct members to trusted health edu - cation Web sites that have the potential of enhancing the health literacy of the membership. John Montgomery, M.D. Vice President for Professional Relations Blue Cross and Blue Shield of Florida Blue Cross and Blue Shield (BCBS) is the oldest and largest family of health benefit companies in the country, Montgomery said. The 39 independent and locally operated companies provide coverage for over 100 million Americans, one-third the population of the United States. BCBS companies have more than 1.8 million beneficiaries in Medicare Advantage plans and provide prescription drug coverage to more than 1.7 million members. More than 90 percent of hospitals and 80 percent of physicians contract with BCBS companies. The BCBS Federal Employee Program (FEP) has 4.9 million federal government employees, depen - dents, and retirees. Florida’s population is unique. The state has the nation’s largest senior population, the second-largest African-American population, the third largest Hispanic population, the third largest Jewish population, and two of the largest lesbian, gay, bisexual, and transgender populations. Studies show that inadequate health literacy negatively affects the elderly, non-English speaking populations, and also the underserved. Health lit - eracy is an important focus for BCBS of Florida (BCBSF). Individuals who are more literate are more likely to have health screenings, follow medical regimens and seek help in the course of a disease. Children who learn to read by the time they start school are more likely to excel at academics and attain a higher standard of living. Montgomery said that BCBSF is committed to improving literacy skills by focusing its community invest - ments on family and health literacy programs. Low literacy members are more likely to have more frequent and more expensive hospital visits, to have difficulty accessing care, and are less likely to visit a doctor for preventive services and generally represent a higher annual health care cost.1 They are also less likely to comply with self-care instructions. The increased cost of low health literacy makes a business case for addressing health literacy and disparities. Increasing awareness of risk and improving prevention leads to a healthier work - force and lower overall medical costs. Integration of health literacy into prevention programs also helps improve member satisfaction. Success- 1 Vernon and colleagues (2007) estimated that the annual cost of low health literacy to the U.S. economy was $106 billion to $238 billion.

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40 PROMOTING HEALTH LITERACY ful programs help large groups and employers decrease absenteeism, increase “presenteeism,” and have a healthier workforce. BCBSF’s philosophy is to provide engagement and support that lead to quality and satisfaction and, ultimately, to broad access to care that leads to lower costs and lower risks for members. Another aspect of BCBSF’s care philosophy and strategy is to integrate clinical programs, processes and people to deliver high performance. BCBSF is engaged in assessing and improving health literacy. For example, members’ health literacy is identified and assessed in care man - agement interactions. Management nurses and care navigators work with members to engage them more effectively and manage their conditions. BCBSF produces all material in multiple languages and multilingual nurses are employed in care units. BCBSF has also created personalized care pathways that lead members to the specific resources they need, and a key component of these pathways is health literacy. One program that BCBSF has undertaken for large employers is the Care Advocacy and Navigation Program. This involves a dedicated, multidisciplinary team featuring nurse care advocates, financial advo - cates, and social and community advocates. The team helps individuals make more informed health care decisions by showing them how to use their benefits wisely. Members receive guidance choosing the right care, at the right place, at the right time. Better You from Blue is one of the company’s prevention and wellness programs. In this program, nurses are assigned to members for health promotion and coaching. High-risk members are identified for immedi- ate medical attention and are referred to care programs. The program also incorporates follow-up assessments; various activities such as health fairs and marketing materials. The program is adapted for populations that respond to information in different ways and takes into consideration their levels of health literacy. Another example is the Next Steps program, which is a regional lifestyle management process that focuses on specialized education for members who are identified early, for example in a pre-disease phase. Healthy lifestyles and behavioral change is promoted. Members receive direct assessments and goals are identified. Members are also given schedules to follow and high-risk individuals are referred to appropri - ate care resources. Health Dialogue is another program of BCBSF. This program is designed to help members communicate more effectively with healthcare providers. Health coaches are available 24 hours a day, 7 days a week. Educational materials are in various formats and there are 470 prerecorded messages on various healthcare topics than can be accessed by telephone 24 hours a day. In another effort BCBSF has partnered with the Florida Department of Health to administer the Hispanic Obesity

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41 INSURANCE COMPANIES FACTOR HEALTH LITERACY Prevention and Education (HOPE) program. The aims of this statewide program are to increase physical activity and good nutrition, and to pro- mote healthy lifestyles for Hispanics in Florida in order to reduce the chronic diseases and disabilities linked to obesity. The key components of the program include a bilingual website; a statewide awareness and media campaign; free personal nutrition, fitness, and health evaluations and programs; free bilingual interactive exercise DVDs; and access to bilingual lifestyle counselors. BCBSF has found that health coaching is extremely effective and that patient involvement is critical for behavior change. Effective communi - cation builds trust between providers and members so that patients feel more comfortable and empowered to ask questions and to take charge of their health. Providers are instructed to speak clearly and slowly with patients, to show respect, to use short sentences and pause every 60 sec - onds, to use common words and avoid medical jargon, to encourage a patient to take a health partner to every health encounter, and to encour- age the patient to ask three questions at every encounter. Decision sup - port tools also help members make informed decisions and allow them to access health care advisors and coaching easily. BCBSF also strives to create a wellness culture. One method is assign - ing different health awareness issues to a month. For example, September focuses on cholesterol education, and BCBSF creates special education opportunities on this topic for the month. Blue Cross and Blue Shield is also making efforts in other states to improve health literacy. Wellmark BCBS of South Dakota has created a telemedicine series to deliver information on diabetes management and depression treatment for underserved patients in rural communities and also helps connect residents in rural area with specialists across the state. Blue Cross and Blue Shield Minnesota includes health literacy as a key component for reducing health disparities. Efforts also focus on increas - ing awareness of the prevalence and impact of low health literacy and on creating a culture where health literacy best practices become the way to operate. There is an annual health literacy awareness campaign, and there are health literacy ambassadors trained in health literacy best practices. Minnesota Health Literacy Partnership involves health plans, medical groups, care systems, literacy groups and community partners to improve health literacy in the state. Blue Cross and Blue Shield New Jersey funds a multiyear program partnered with the Boys and Girls Club to establish teen mentors who read health-related books with young children in order to instill healthy habits early on. An evaluation of that project found that 62 percent of participating children increased their standardized reading test scores and 65 percent demonstrated greater knowledge about healthy lifestyle

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42 PROMOTING HEALTH LITERACY choices and nutrition. Highmark, which is Pennsylvania’s largest insurer, is actively working to improve provider and member communication, including establishing a language line with an available interpreter and a Spanish-language formulary. Highmark also participated in America’s Health Insurance Plans (AHIP) Health Literacy Task Force Pilot in June 2009, which assessed printed member information, web navigation, mem- ber services, forms, call lines and disease management efforts. Montgomery suggested that there should be a strategic focus on incorporating health literacy into policies aimed at improving literacy rates. There should also be research and measurement of the effectiveness of efforts to address health literacy, he said. Health literacy efforts can be integrated into efforts to address health care disparities and also educa - tion of health professional. DISCUSSION Roundtable member Ruth Parker asked the presenters whether they could envision a competition among health insurance companies to become branded as the most health-literate company. Montgomery replied that if health plans really want to compete to see who would be best at branding health literacy, one would see their foundation arms put- ting a significant amount of money into addressing this issue. There is a climate of distrust of insurance companies, and working toward improv - ing health literacy may help fix that. Saperstein said that MetroPlus would welcome the opportunity to brand itself as the top quality company in terms of health literacy. A major difficulty, however, is how to measure whether a plan has been successful. One can measure that an individual’s asthma is better by showing that the individual does not end up in the emergency room as often, presumably because he or she has been taught about asthma triggers and how to avoid going to the emergency room. But is there a way to really measure how successful an organization has been at improving the health literacy of its population of members? Isham said that the question relates to some of the issues that Dillaha raised earlier in terms of tailoring health literacy approaches for Arkansas. A previous Roundtable workshop addressed issues related to measures of health literacy and also raised similar kinds of questions. This clearly underscores the need for a mechanism for fur- ther work in this area, Isham said. Amy Wilson-Stronks, Roundtable member, commended the presenters for addressing the issue of language and cultural competency. She asked how the plans determine bilingual proficiency for their language access services, and how they ensure that providers are aware of these services and actually use them. Saperstein replied that MetroPlus participated in a program with HHC in which

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43 INSURANCE COMPANIES FACTOR HEALTH LITERACY translators and staff were trained and their proficiency tested in verbal and written communication in the most common languages, such as Eng- lish, Spanish, and Chinese. Unfortunately only these three languages are included in the course so the proficiency of translators in other languages has not been tested. In terms of providers, HHC offices all have dual-line phones that provide easy access to a trained translator. MetroPlus also collects language information on all providers in an attempt to match members with providers who speak the same language. Montgomery said that there are 100 different languages spoken in Miami, which presents a special challenge. Quality interactions, a continu- ing medical education-based provider assessment, is useful in identifying gaps in cultural competency. Roundtable member Will Ross asked what quality assurance measures the presenters are using to identify high-performing providers in terms of cultural competency and health literacy, and what kind of incentives are used to reward such providers. Montgomery said that BCBSF has a pay- for-performance program that uses efficiency and quality measures, one of which is whether a physician has taken cultural competency training. Saperstein said that MetroPlus does not specifically measure or reward language communication ability but it does look at preventive health and outcomes. One of the specific measures is of emergency department and inpatient visits and of the outcomes for each provider. Another, for patients with diabetes, relies on hemoglobin A1C results as well as on eye testing and on nephropathy testing. The measures are outcome-of-care measures rather than specific literacy measure. Isham said that the field of health literacy measures is not as advanced as it should be. His own organization has performance measures related to language preference, race, and ethnicity but no measures to stratify by literacy. Roundtable member Benard Dreyer asked whether health literacy training programs for providers exist, beyond those that focus on lan- guage, and if not, whether they should. Saperstein said that it is dif- ficult to introduce new materials to HHC and have providers buy into them, but HHC has provided community providers with tool kits on how to help educate patients in a variety of areas such as smoking ces - sation, well-child care, preventive care, immunizations, and asthma care. Montgomery said that he thinks the best route for education on health literacy is through programs aimed at reducing health care disparities. Furthermore, he said, comprehensive health literacy education should be incorporated at every educational level—community colleges, universi - ties, and graduate training. Yolanda Partida, another Roundtable member, commented that the issue of language services is fairly complex. One of the complexities is that

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44 PROMOTING HEALTH LITERACY while one may think of translating material into Chinese, there are actu - ally several major Chinese languages. Translation only covers traditional Chinese or simplified Chinese. Partida suggested that the Roundtable take a look at these issues and provide direction in the field. Roundtable member Jean Krause said that there were many great ideas shared about ways to involve and incentivize providers in health literacy efforts. But how, she asked are patients involved and incentiv - ized to become engaged in their own health care? How can these efforts become more patient-centered? Saperstein said that MetroPlus does have the Membership Advisory Committee that he mentioned. There are also incentives for members to achieve health goals. For example, if a mother comes in for all her prenatal care visits, for all the delivery and post- partum visits and for the first baby visit, she receives a diaper bag. The HIV program started out giving out telephone calling cards to patients who showed up to visits. Saperstein noted that member incentives are restricted by the New York Department of Health to below a specific dol- lar value. He also noted that a challenge to incentives is the distribution of the incentive. One must obtain the patient’s address and ship it to the individual. With low-income individuals they might never receive the package because it might get stolen out of their mailbox. Even with the small programs that MetroPlus has, there have been a number of chal- lenges to being able to fully implement the member incentives. Montgomery said that BCBSF uses health risk assessments to involve members. Many of BCBSF’s accounts such as school boards and electric companies are incentivizing their members in other ways. Krause asked whether BCBSF will match the $50 million it invested for providers with equal funds for patients to make behavior changes. Montgomery said BCBSF hopes to invest increased funding in patient incentives but, with the economic downturn, it is unlikely the amount will be $50 million. Roundtable member Winston Wong asked the presenters how they avoid message fatigue in the delivery of health literacy messages. Is there an annual message or some sort of periodic message that is given to pro - viders specifically on health literacy, or do the companies try to incorporate health literacy into other areas emphasized as important to provider per- formance? Montgomery said he agreed that message fatigue is a problem. The physicians have limited time, they are dealing with all the administra- tive burdens that the plan puts on them, and now BCBSF is telling them that they need to be trained in cultural competency and health literacy. Physicians are tired of being told they need training for different things. BCBSF attempts to incorporate health literacy into day-to-day interactions across the board. And there are a lot of people in addition to the health care provider who need health literacy training. But there is not an ongoing message specific to health literacy.

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45 INSURANCE COMPANIES FACTOR HEALTH LITERACY Saperstein acknowledged that MetroPlus also experiences message fatigue. While there are no health literacy-specific communications there are quarterly newsletters. There are also blast emails that go out with surveys and other types of information. The newsletter is sent out to HHC providers through the Intranet. HHC is able to measure who opens it and who does not open it. The first few newsletters had a very high reader- ship, but then readership dropped to about 30 to 40 percent. The others never even open it. The good thing is that readership hasn’t declined more over the past year or two. In the third communication method, members of the network rela- tions staff visit the offices of provider to provide toolkits and other infor- mation. If providers are willing to actually meet with the network staff, specific messages are conveyed to the providers.

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