Literacy and Health Literacy: Prerequisites to Effective Health Care Decision Making National Coalition for Literacy December 5, 2007 Washington, DC Presented by Joyce Dubow, AARP

Presentation Overview Profile of the Medicare population Information burden and the importance of patient engagement Implications of poor health literacy skills on ability to navigate Medicare Strategies to meet needs Policy implications

Source: People on Medicare: Age, 2005

Education Source: MedPAC analysis of the Medicare Current Beneficiary Survey, Cost and Use file, 2004 People on Medicare:

Todays Medicare Program Medicare The Original Medicare Plan Part D Coordinated Care Plans HMOs POS PPOsPSO Private FFS Part D MSADemos

What is expected of Medicare beneficiaries Recognize differences among Medicare coverage options Decide whether to buy Rx coverage Identify differences among similar plans Choose best doctors and hospitals Navigate within a plan Choose most appropriate treatment options Understand rights and responsibilities

Numeracy

Source: Kripalani and Jacobson, www/ahrq.gov/qual/pharmlit/pharmtrain2.htm

Health Literacy The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. IOM, Health Literacy: a Prescription to End Confusion

Source: Kripalani and Jacobson m

Average Health Literacy Scores of Adults by Age, 2003 Age Average Score Source: Results from the 2003 NAAL

Source: Literacy in Everyday Life: Results from the 2003 NAAL

Source Kripalani and Jacobson,

Consequences of Inadequate Health Literacy Poor health outcomes Low health literacy is an independent risk factor for hospital admission among Medicare managed care enrollees. Risk of non-compliance Errors Poor decisions Anxiety Inertia

People with Chronic Conditions Report Getting Conflicting Advice Source: Jane Horvath, Partnership for Solutions (Chronic Illness and Caregiving, a survey conducted by Harris Interactive, Inc., 2000.)

Engagement Fosters Desirable Patient Behaviors (Hibbard) Informed choice role using performance information to validate choice of provider Co-producer role having skills and confidence to partner with providers and to be vigilant in ensuring that ones own care is safe Evaluator role understanding and acting on information on performance and understanding how such information affects ones life.

Health Literacy Level and Decision Making Health literacy influences decision making confidence to make decisions ability to use comparative information (Patient activation influences engagement in self-management behaviors )

Challenges Cognitive overload Need to help people take into account multiple variables in making decisions Statistical concepts not well understood (e.g., absolute vs. relative performance; average/percentage; benchmarks; statistical uncertainty. Lack of Interest? Adequacy and timeliness of relevant and meaningful information

What Works? Symbols vs. numbers Simplifying Focus on key messages Present recommended actions steps clearly Rank ordering by performance vs. alphabetical ordering Summarizing Teach Back

What Works? Evaluable formats (can be as important as content) Framing makes a difference. Use of alternative media (e.g., interactive data bases)

Other Strategies Test materials with diverse groups for comprehension and appeal Use simple language, (e.g., plain English) white space, large fonts culturally sensitive; age- appropriate colors; avoid fancy graphics

Policy Challenges Medicare must address needs of a very diverse beneficiary population: diverse skills diverse preferences diverse needs diverse SES Advance health literacy as a policy issue

Summary: Help Beneficiaries Use Information Lower cognitive effort required to use information Reduce amount of information Computer-aided decision tools Evaluable displays Highlight meaning and significance Framing; Provide information that helps consumers understand the implications of their choices Give a better idea of what the actual experience of a choice might be like. Narratives Design information displays to highlight the meaning of important information that might otherwise be overlooked

Conclusions Emphasis on private plans/market competition and consumerism in Medicare requires an informed consumer Adequate funding for information and education programs, including counseling programs, is required to address diverse beneficiary needs