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C Statement on Health Plan Leadership in Advancing Health Literacy and Clear Health Communication America’s Health Insurance Plans 601 Pennsylvania Avenue, NW South Building, Suite 500 Washington, DC 20004 Submitted to the Institute of Medicine Health Literacy Roundtable Meeting “Facilitating Health Exchange Communication Through the Use of Health Literate Practices” July 19, 2011 I. INTRODUCTION My name is Susan Pisano, Vice President for Communications at America’s Health Insurance Plans (AHIP), and I am pleased to be here today to discuss the important topic of health communication and health literacy. AHIP is the national trade association representing the health insurance industry. Our members provide health and supplemental ben- efits to more than 200 million Americans through employer-sponsored coverage, the individual insurance market, and public programs such as Medicare and Medicaid. AHIP advocates for public policies that expand 95
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96 FACILITATING STATE HEALTH EXCHANGE COMMUNICATION access to affordable health care coverage to all Americans through a com- petitive marketplace that fosters choice, quality, and innovation. We appreciate this opportunity to appear before the Institute of Medi - cine (IOM) Health Literacy Roundtable today. America’s health insurers are committed to improving the health of the individuals and populations they serve and to making health benefits more affordable. My remarks today focus on the following areas: • The importance of health literacy; • How health plans are engaged in addressing health literacy; and • Common approaches that can serve as models to assist other enti- ties in improving health literacy. II. THE IMPORTANCE OF HEALTH LITERACY The National Action Plan to Improve Health Literacy released in May 2010 highlights the importance of engaging all stakeholders linked in a multi-sector effort to improve health literacy. The report highlights strat - egies that particular organizations or professions can take to further the key goals identified to improve health literacy.1 Promoting change in the health care system through improved health information and communica- tion, informed decision making, and developing and disseminating health information that is accurate, accessible, and actionable can have a demon- strable impact on the health and quality of life of millions of Americans. Research shows clearly that health and benefits information plays an important role in the health status of individuals, and that those with poor health literacy who cannot easily access, understand, and act upon such information are more likely to experience poor health, less likely to be engaged in their care, have a harder time managing their chronic dis- eases, and more likely to incur significantly higher than necessary health care costs as a result. A study recently published in the Journal of the American Medical Asso- ciation by authors from the Kaiser Permanente organization found that patients with congestive heart failure and low health literacy are three times as likely to die in a given year as patients with better health literacy skills.2 Several other studies and reports, including the recent Department of Health and Human Services (HHS) National Action Plan to Improve 1 Office of Disease Prevention and Health Promotion. (May 2010). National Action Plan to Improve Health Literacy. Washington, DC: U.S. Department of Health and Human Services. 2 Peterson, P. N., S. M. Shetterly, C. L. Clarke, D. B. Bekelman, P. S. Chan, L. A. Allen, D. D. Matlock, D. J. Magid, and F. A. Masoudi. 2011. Health Literacy and Outcomes Among Patients With Heart Failure. JAMA 305(16):1695-1701. doi:10.1001/jama.2011.512
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97 APPENDIX C Health Literacy, document the importance of health literacy as a part of a person-centered process and essential to the delivery of cost-effective, safe, and high-quality health services.3 Increasingly, stakeholders across the health care system have recog- nized the important linkage between health literacy and health status, and are working to provide consumer health and benefits information that promotes “clear communication” and are (1) easy to access, understand, and act upon; (2) promote consumer engagement in their own health; and (3) result in better health outcomes.4 Achieving these goals requires a collaborative, system-wide commit - ment that involves all of the professionals, organizations, and disciplines communicating with consumers, whether directly or indirectly, via the spoken or written word. Because it brings together stakeholders from across the system, today’s IOM meeting offers a unique opportunity at an important juncture to identify patient needs and share strategies at a time when tens of millions of previously uninsured Americans soon will have insurance coverage. Nearly nine out of ten adults have difficulty using health informa- tion to make informed decisions about their health, profoundly affecting their health and access to care. Yet, by 2014, millions of newly insured populations will be accessing the system, and will need assistance in seek- ing appropriate providers and sites of care. Recognizing that consumers all too often are unable to understand medical terms and instructions, a collective effort by key stakeholders is needed to provide information consumers can understand and use to make decisions about their benefits, personal care and care for their families. III. HOW HEALTH PLANS ARE ENGAGED IN ADDRESSING HEALTH LITERACY Health plans view health literacy as a key component in engag- ing patients in self management of their chronic disease, in care during transitions (including transitions from hospital to home), in medication adherence, and in wellness and prevention. Health plan efforts to reduce disparities in care include programs such as cross-cultural training of phy- sicians and other clinicians to improve communication and address health literacy. Written and verbal communication that can be easily understood 3 Office of Disease Prevention and Health Promotion. 2010, May. National Action Plan to Improve Health Literacy. Washington, DC: U.S. Department of Health and Human Services. 4 Health Literacy Universal Precautions Toolkit. AHRQ Publication No. 10-0046-EF, April 2010. Rockville, MD: Agency for Healthcare Research and Quality. http://www.ahrq.gov/ qual/literacy/index.html.
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98 FACILITATING STATE HEALTH EXCHANGE COMMUNICATION and acted upon can improve a consumers’ ability to use their benefits to their fullest and maximize their own health. A growing number of health plans are actively engaged in working to improve health literacy. Three years ago, with interest from other stake - holders, AHIP convened a Health Literacy Task Force, which includes representatives from about 50 member plans. The Task Force includes medical directors, nurse educators, and a pharmacist, as well as profes - sionals engaged in the quality enterprise, cultural competency, disparities in health, and communications. It is focused on increasing awareness of health literacy and encouraging the development or expansion of health literacy programs. In addition, the task force identifies and develops tools to help health plans start up and advance their programs and share infor- mation and best practices. The set of tools developed includes • An organizational assessment tool, developed with Dr. Julie Gazmararian of Emory University under a grant from the Robert Wood Johnson Foundation. This tool was pilot-tested in 18 plans and is now widely used by plans to determine if they have the infrastructure in place to promote good written and verbal com- munications about health and benefits; • A toolkit outlining the five basic steps to start and advance a health literacy program, including bringing together a team, making the case for moving ahead, assessing the organization, developing policies and procedures, and making an action plan, and training of staff; • A model policy for organizations to adapt/adopt; and • A “mentoring” program that matches professionals from programs that are more advanced with companies that are just starting out. There continues to be significant startup activity in this area, with interested parties seeking information on program development and tools to sustain and advance ongoing health literacy programs. Health plans also have engaged with multiple public and private partners including the Agency for Healthcare Research and Quality to pilot test the health literacy Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey item set for health plans. This new survey item set will help examine consumers’ perspectives on how well health information is communicated by health plans and health professionals in a health plan setting. This is a step forward in improving how plans and providers are addressing the health literacy needs of individuals and delivering health information that is understandable to the vast majority of Americans.
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99 APPENDIX C One-on-one interviews with our members also are providing insights into how health literacy programs are continuing to evolve. Although some initially focused on medical information and others focus on benefits information, these programs generally are evolving to embrace both. Work in the area of written communication is generally more advanced. Many plans are now focusing more attention on verbal com- munication, and there is considerable activity in both areas. In fact, one of our member companies requires all employees to have some understand- ing of plain language by participating in a basic half-hour seminar. Some plans have begun to be interested in how they can use social media in a health literate way, as they move from a focus on more traditional means of communication to make use of the channels best suited to today’s audiences. Finally, we are beginning to see the emergence of health plan- based research from plans that are interested in contributing to the body of evidence about health literacy and its potential. Our biannual health plan surveys on disparities in health, funded by the Robert Wood Johnson Foundation, reveal increased activity in the foundational elements of health literacy programs, such as assessments and dissemination of low-literate materials, development of organiza - tional policies, and training of staff. Two years ago, this national survey showed that approximately 69 percent of plans responding had introduced some components of a health literacy program; this grew to 83 percent in 2010. About half of these pro - grams are housed as part of health plans’ disparities or quality improve - ment activities, while others are integrated into plan efforts in culturally and linguistically appropriate services, patient engagement, patient sat - isfaction, and communications and marketing. In 2010, almost all health plans were adopting a targeted reading level for written consumer communications (90 percent) and standardizing member communications in clear, plain language (81 percent). Health plans also have improved awareness and training among plan staff, spe - cifically those who prepare written communications for members or who interact directly with members, on the principles of clear health com- munication (increasing from 58.4 percent in 2008 to 70.6 percent in 2010). Sixty-seven percent of health plans in 2010 ensured that all documents, including those translated from English into other languages, meet a tar- geted reading level. Although not assessed in these surveys, the reading levels may vary across health plans and among states, with ranges from
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100 FACILITATING STATE HEALTH EXCHANGE COMMUNICATION 4th to 8th grade reading levels.5,6 About two-thirds of health plans adopt a company-wide approach to clear communication through the develop - ment of policy and procedures. Other common approaches to improving clarity and understanding of written communications included avoidance of jargon and medical terms and translation of materials in commonly spoken languages other than English. IV. COMMON APPROACHES TO IMPROVING HEALTH LITERACY Through national surveys, outreach, and interviews with our member plans, we have identified eight common approaches that could serve as models to assist other entities in improving health literacy: • Assess the organization to determine if an infrastructure exists to provide clear, easy to use information. • Convene teams of professionals from all of the organization’s units that touch consumers via the written or spoken word to address health literacy. This allows infusion of health literacy across an organization. • Use tools such as the organizational assessment as a way to jump start a program, or as a planning and prioritization tool. • Adopted a targeted reading level. • Conduct inventories of jargon and acronyms used by the company and create lists of “words to avoid” and “words to use” as alterna- tives. These are generally company specific as companies tend to develop their “own language.” • Create checklists (or electronic tools) for evaluating written docu- ments to assure that they conform to principles of clear health communications. • Consider a company-wide policy that new documents and those being revised must conform to principles of clear health communication. • Provide training to a broad group of employees to increase aware- ness and enhance skills. 5 Gazmararian, J. A. 2009. America’s Health Insurance Plans’ response to health literacy. Power- Point presentation at the Institute of Medicine workshop on measures of health literacy. Washington, DC, February 26. 6 Health Literacy Innovations, LLC. 2007. National survey of Medicaid guidelines for health literacy. Bethesda, MD. http://www.healthliteracyinnovations.com/information.
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101 APPENDIX C Looking forward, the health plan community is intensely focused on improving communications to consumers, recognizing that clear written communications tend to be at a more advanced stage than clear verbal communications. Consumer testing of materials is an important priority for achieving further progress. While the costs associated with such test - ing and difficulty in getting consumer engagement have been limiting factors, health plans are creative in getting feedback on their materials, including obtaining this information through existing assessment tools or through employees who are engaged in activities unrelated to the materi - als being tested. V. CONCLUSION Thank you again for this opportunity to testify on this critically important issue. It is our hope that today’s IOM meeting will advance the ongoing dialogue about how to infuse health literacy into care deliv - ery and also pave the way for mechanisms that allow all entities to share information and tools across the health care system as the federal govern - ment, states, consumers, providers, and health plans gain experience in how to provide the structure and resources for consumers to use their health benefits and health information to their best advantage.
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