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6
Reflections on Lessons Learned
George Isham, roundtable chair and workshop moderator, invited
members of the roundtable and members of the workshop planning
committee to reflect upon lessons learned during the workshop. Cindy
Brach, roundtable member, noted that vastly simplified written materials
and easy-to-navigate websites are necessary for individuals facing health
insurance choices, but that even with these tools available, some individu-
als will need personal help. Brach indicated that navigators are going to
be critical to achieving the enrollment goals of the Patient Protection and
Affordable Care Act (ACA), and, in addition, to ensuring that individu-
als are able to make appropriate insurance choices. She highlighted the
opportunity to incorporate health literacy into the training of patient
navigators through the work of the National Association of Insurance
Commissioners as they create a training template for the exchange patient
navigators. Roundtable member Susan Pisano agreed that an excellent
training program for navigators is one of the most important contribu -
tions that could be made to assure optimal functioning of the state health
insurance exchanges.
Melissa Houston, roundtable alternate member, highlighted the
importance of standardizing some of the core elements of the health
exchanges. She said that standardization is necessary to prevent dupli -
cation of effort and to maximize the efficiency and effectiveness of the
exchanges. Standardization could apply to the training of navigators and
to the development of consumer-friendly websites and other communica-
tion aids.
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80 FACILITATING STATE HEALTH EXCHANGE COMMUNICATION
Roundtable member Yolanda Partida applauded the involvement of
health plans in promoting health literacy, and in particular, the focus on
developing standards for user-friendly language and improving meth-
ods to communicate complex health insurance information. Once this
information is available in an understandable format in English, it will be
easier to translate information across languages and culture.
Ruth Parker, roundtable member, discussed the potential importance
of the Plain Language Act of 2010 to the operation of the exchanges,
particularly the enrollment processes. Parker said she was impressed by
how large a segment of the population will be engaged with the health
insurance exchanges. She suggested that the enrollment process will
improve, in part, because of the magnitude of the audience that needs to
be reached. It may be that individuals will liken the process of enrolling
in a health plan to the national tax system. There is a federal process to
file taxes, and there is a state process. People are aware that there are mul-
tiple forms and that some of these forms are relevant to some and not to
others. When filing taxes, personal assistance is available through accoun-
tants. Navigators will be available to assist those needing help in making
insurance choices. Exchanges need to be demystified and their functions
understood by using clear, standardized language. Isham added that the
analogy to the tax system should stop short of the frustrations that many
experience. Instead, the model of the tax system is appropriate in the use
of easy-to-use forms with customization where necessary.
Martha Gragg, roundtable member, noted that the awareness of health
literacy principles has increased in the last few years, especially among
health plans. She suggested that employers, as critical determinants of
employee insurance options, need to become more aware of issues related
to health literacy.
Linda Harris, roundtable member, expressed concern that some states
might be overwhelmed in trying to develop a health insurance exchange.
Effort will be needed to assure clear communication that incorporates con-
siderations of health literacy, cultural competency, and language diversity.
States will need to create mechanisms to inform and enroll hard-to-reach
populations that are currently not insured, she said. Community-based
organizations will have to be engaged to bring such individuals into the
system. Harris said that a repository of the literature and materials on
health literacy relevant to the exchanges would be potentially very useful.
Will Ross, roundtable member, noted that enrollment in some of the
exchanges has been lower than expected and that it is the responsibil-
ity of the exchanges and health plans to improve their relationship with
consumers. Market research has shown that consumers are overwhelmed
and fearful of making health insurance choices, he said. The onus is on
the exchanges to improve the experience of choosing and then enrolling
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REFLECTIONS ON LESSONS LEARNED
in a health plan. Ross highlighted the importance of standards that apply
to health plans. If high-performing health plans were certified in some
way, the plans would have an incentive to adhere to the standards, and it
would be easier for consumers to identify quality plans.
Arthur Culbert, roundtable member, said he was encouraged by
the availability of market research that reveals some of the barriers and
opportunities to reaching consumers with information about health insur-
ance options. There are tremendous opportunities to build trust with
clients at the state level through the health insurance exchanges. In addi -
tion, the growing number of state centers of health literacy can partner
with the exchanges to promote best practices in health communication.
Culbert added that the development of successful state health insurance
exchanges should be considered apolitical and a responsibility of the
nation.
Margaret Loveland, roundtable member, was impressed by the com-
plexity of health insurance exchanges. Health literacy considerations, the
use of plain language, and recognition of language diversity are key to
improving the process of health insurance enrollment for consumers, she
said.
Benard Dreyer, roundtable member, found the research that has been
conducted on consumer experiences with health insurance very informa -
tive. He noted, however, that while the research identifies what consum -
ers want to know, there is less research related to how to communicate
health insurance information to consumers. There is a very large cogni-
tive load associated with health insurance information. Health literacy
comes into play in any attempt to reduce this cognitive load. Strategies
are needed to condense the amount of information that people need to
make informed choices among plans, Dreyer said. He discussed the par-
ticular challenges faced by people whose primary language is not English
and the need to incorporate appropriate accommodation for speakers of
other language into the exchanges. Dreyer also cautioned that although
the Internet is a powerful tool, it is not a solution to many communica -
tion challenges. Many people do not use the Internet, and other popular
communication modes such as texting and tweeting are not particularly
well suited to complex decision making. In-person assistance through
the navigators will be critical to an exchange’s success, Dryer said, and
he expressed some concern that there would be an inadequate supply of
navigators to meet the needs of the many individuals who will be gaining
access to health insurance through the state exchanges.
Andrew Pleasant, roundtable member, noted that 75 percent of health
care expenditures are spent on treating or managing preventable chronic
disease. Health literacy is one of the most powerful tools to prevent these
unnecessary expenditures. One of the positive messages of the day’s pro -
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82 FACILITATING STATE HEALTH EXCHANGE COMMUNICATION
ceedings, he said, is the advancement that health literacy has made in the
last decade. There are remarkable opportunities to infuse health literacy
into the 50 state health exchanges. These exchanges could help foster a
paradigm shift, from thinking of health insurance as a product to assist
with acute and chronic care conditions to thinking of it as a product to
help reach optimal health. This paradigm shift will occur if health literacy
is infused into the health communications enacted by the state exchanges,
he said.
Debbie Fritz, roundtable member, stated that some sort of interface is
needed for the exchange of information among exchanges so best prac-
tices are shared among the states. To effectively communicate with con-
sumers, information will have to be condensed to be useful in decision
making. Lessons from quality improvement endeavors may be instruc-
tive, she said. Many initiatives have invested in measuring quality within
health systems and monitoring consumers’ perspectives of quality. There
are also lessons on communication from Medicare’s Part D program. The
Centers for Medicare and Medicaid Services (CMS) has developed a star
program so consumers can look at overarching plan information instead
of having to read all of the plan details. Consumers may access the plan
details, but CMS has assembled the information so consumers are not
subject to cognitive overload.
Scott Ratzan, roundtable member, commended Frank Funderburk
for incorporating consumer motivation in the roundtable’s health literacy
framework. That framework included the skills and abilities of consum -
ers, and the demands and complexity of health decision making. Moti-
vation is key to consumer behavior, Ratzan said, whether that behavior
involves the renewal of a health plan or engaging in preventive health
programs. The lessons from health literacy permit the tailoring of mes -
sages through social marketing to increase motivation. Ratzan added that
new technologies hold great promise. For example, mobile phones have
fully penetrated the United States, with some members of the population
having multiple phones or devices. Links between these devices and CMS
or health exchanges must incorporate health literacy attributes.
Isham discussed the existence of a policy gap between the design of
the health insurance exchanges and their anticipated performance. In his
experience as a leader in a large, not-for-profit health care system with a
track record of significantly improving patient experience, progress does
not occur by chance. Change occurs through thoughtful deliberation and
careful design of key elements of large systems. A concern raised dur-
ing the day’s proceedings related to the capacity to meet the need for
person-to-person assistance as part of the navigator program. Such sup -
port will likely be in demand and is costly to deliver, Isham said. It will
be important in program design to use the navigators judiciously and
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REFLECTIONS ON LESSONS LEARNED
allow individuals with some familiarity with technology to benefit from
web-enabled information systems.
Isham indicated that the population served by the state health insur-
ance exchanges would differ from the Medicaid and Medicare population
in terms of demographic characteristics, distribution of risk, and level of
health literacy. The population served by the exchanges will have its own
unique characteristics. Nevertheless, lessons learned from the Medicare
and Medicaid programs will be applicable to the exchanges. He noted
that there is a great deal of opportunity associated with the ACA. In some
sense, this is the current generation’s mechanism to address the chronic
problem of access to health care in the United States. It is not perfect, but
it represents an opportunity.
Isham invited questions from the audience. Ms. Garcia, from the Uni-
versity of Maryland, expressed a concern that complex health insurance
information would be oversimplified and “dumbed down” under the
guise of health literacy. There may be missed opportunities to educate
patients about some of the complexities of health insurance coverage that
they may want or need to know. There is a danger to simplification and
presenting information at the level of the lowest common denominator.
Isham responded that a very clear, simple interface is necessary for those
needing basic information, but in addition, any system has to have the
flexibility to provide detailed information to those who need it. This rep -
resents a complex design challenge. Funderburk added that the intent is
not to aim communications to the lowest common denominator, because
this level of information does not generally meet anyone’s needs. It is
important to understand the unique needs of segments of the population
and then to provide those audience segments with the information they
need. People have different cognitive styles and different experiences in
dealing with health care information. Initial interfaces can be designed to
be responsive to most people’s needs most of the time. Systems can then
be designed to alert consumers when further information can be accessed.
Pisano discussed the notion of consumers liking a simple template,
but at the same time wanting to know where to get more information.
Some of her research with physicians showed a similar pattern. They
wanted clinical information to be presented in a simplified manner but
to be able to drill down to obtain detailed information. This desire for
information needed at the moment, but available in more detail, is likely
a universal principle.
Isham concluded the workshop by thanking the roundtable members
for their participation and their questions and the presenters for their
contributions to a very informative workshop.
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