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 individuals 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 individuals 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 contributions 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 duplication 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 communication aids.



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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. 79

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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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81 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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83 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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