Health-Literacy-White-Paper_February-2015

Tracking AmericanHealth Literacy andPrescribing ImprovementKey findings from an independent surveyFEBRUARY 2015

2 | Tracking American Health Literacy and Prescribing Improvement

Table of ContentsWhat Is Health Literacy and How Does It Affect Healthcare? ........ 1

Finding Out Where We Stand .............................................................. 2

The iTriage Health Literacy Index ...................................................... 3

Key Trends in Health Literacy ............................................................. 5

How Does Health Literacy Affect the Cost of Care? ........................ 7

Having a Primary Care Provider and Asking Questions .................. 9

Knowing Where to Get Medical Care ............................................... 11

Comprehending Health Insurance .................................................. 13

Understanding Medication and Preventive Health ........................ 16

A Prescription for Improvement ....................................................... 18

Tracking American Health Literacy and Prescribing Improvement | 1

What Is Health Literacy and How Does It Affect Healthcare?Health literacy is “the degree to which individuals can obtain, process, and understand the basic health information and services they need to make appropriate health decisions.”1

In 2003, the U.S. Department of Education conducted a study on the health literacy rates of the general U.S. population.2 It reported that only 12 percent of Americans had “Proficient” health literacy, while more than 75 million Americans displayed “Basic” and “Below-Basic” health literacy.

The notoriously poor health literacy rate in the U.S. means that many people often struggle to complete tasks essential to their health, such as understanding their care, navigating the healthcare system, and making informed health decisions.

Numerous studies have correlated low health literacy with serious consequences including:

+ Increased hospitalization + Greater unnecessary emergency care use + Increased risk of mortality for seniors

+ Lower utilization of preventive healthcare

+ Inability to take medications properly1

Low health literacy is estimated to cost the U.S. healthcare system between $106 and $238 billion annually.3 It also contributes to $395 billion—more than half—of the $765 billion of waste in the sys-tem through $210 billion in unnecessary services, $130 billion in preventable errors, and $55 billion in missed prevention opportunities.4

Ultimately low health literacy can largely be attributed to more pervasive issues within the healthcare industry:

+ A history of volume-based, rather than value-based, reimbursement

+ Lack of democratization, or shared decision making, between providers and patients

+ Limited public health training and education

+ Complicated insurance and benefit packages

+ Fragmented healthcare data and delivery systems

What will make a difference?Increasing Americans’ health literacy has strong potential to further the industry’s Triple Aim goals of improved care quality, reduced costs, and better health overall. Everyone in the U.S. healthcare industry can help educate consumers to reduce unnecessary health services and more effectively, safely, and efficiently use the system.

1. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, Holland A, Brasure M, Lohr KN, Harden E, Tant E, Wallace I, Viswanathan M. Health Literacy Interventions and Outcomes: An Updated Systematic Review. Evidence Report/Technology Assesment No. 199. (Prepared by RTI International–University of North Carolina Evidence-based Practice Center under contract No. 290-2007-10056-I. AHRQ Publication Number 11-E006. Rockville, MD. Agency for Healthcare Research and Quality. March 2011. http://www.ncbi.nlm.nih.gov/books/NBK82434/

2. U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy. http://nces.ed.gov/naal/health_results.asp 3. Vernon JA, Trujillo A, Rosenbaum S, DeBuono B. Low Health Literacy: Implications for National Health Policy, Oct. 2007. http://publichealth.gwu.edu/departments/healthpolicy/CHPR/downloads/

LowHealthLiteracyReport10_4_07.pdf 4. AARP Bulletin, November 2012, Volume 53, No. 9, http://pubs.aarp.org/aarpbulletin/201211?pg=4#pg4


Finding Out Where We StandGiven the improved access to information through technology and the industry’s education efforts in the years since the U.S. Department of Education evaluated health literacy, have we moved the needle?

Consumer healthcare technology company iTriage® commissioned an independent survey of 1,000 U.S. adults aged 18 and up to gauge individuals’ health literacy. The survey covered four key topics people are likely to encounter during their journey through the system:

1. Navigating and accessing the healthcare system2. Obtaining health information3. Comprehending health insurance4. Understanding medications and preventive health

This research provides a current measurement of health literacy and shines a spotlight on consumers’ experiences—throughout their healthcare journey—obtaining and interpreting health information, finding appropriate treatment and providers, and being actively involved in their treatment.

Research Methodology

Independent research firm Lawless Research conducted an online sur-vey of 1,000 anonymized U.S. adults 18 and older, matching U.S. Census data for sex, age and race. The survey was fielded August 5 through August 11, 2014. Results of the survey are accurate at the 95 percent confidence level plus or minus 3.1 percentage points.

Navigating and accessingthe healthcare system

• Treatment settings• Costs

Obtaininghealth information

• Patient/physician dialog• Credible print, digital

resources

Comprehendinghealth insurance

• Plan coverage• Industry terminology

Understandingmedications andpreventive health

• Medication adherence• Risks, benefits and

interactions


The iTriage Health Literacy IndexIn addition to uncovering the current state and key trends of health literacy in America, the research presented in this paper was also used to establish a Health Literacy Index. Based on responses to 17 questions falling within the survey’s four main topic areas, the Index presents a snapshot of respondents as Proficient, Intermediate, Basic, and Below-Basic in health literacy.

The ResultsThe iTriage Health Literacy Index is based on a point system in which respondents earn points for each of the 17 questions they answer correctly. The maximum number of literacy points a respondent could achieve is 42 and the minimum is 0. The point range for each literacy level is:

+ Below-Basic: 0–22+ Basic: 23–26+ Intermediate: 27–30+ Proficient: 31–42

17%

29%

36%

18%

Below-Basic0-22

Basic23-26

Intermediate27-30

Proficient31-42

Less than a quarter are proficient.


Who’s WhoAfter the Index established the percentage of people falling within each of the health literacy levels today, the researchers set out to identify the general attributes people with Proficient, Intermediate, Basic, and Below-Basic health literacy levels are likely to have—gender, age, educa-tion level, household income (HHI), and type of insurance (if any). Following is a snapshot:

Below-Basic: 17%+ Male (60% of those below basic are male)

+ Most likely aged 18-24

+ 56% with high school or some college

+ 30% with HHI under $25,000 + 32% uninsured or on Medicaid

Basic: 29%+ Male (53% of those basic are male)


+ 50% with high school or some college

+ $25-50K (53% with HHI under $50,000)

+ 41% have employer-provided health insurance

Intermediate: 36%+ Female (54%)


+ 45% with 4-year or advanced degree

+ 53% with HHI of $25-75K

+ 64% with employer-provided or private health insurance

Proficient: 18%+ Female (63%)


+ 54% with 4-year or advanced degree

+ 53% with HHI of $25-75K

+ 51% with employer-provided health insurance and 25% with Medicare

BASIC

INTERMEDIATE

BELOW-BASIC

PROFICIENT


37%

11%People aged

18-24

Adults45-64

10%

Adults65+

Key Trends in Health LiteracyOverall, the data revealed disparities in health literacy rates between respondents based on four key factors: gender, age, education, and insurance:

Women Uphold Their Reputation as “Household CEO”Women (Household Decision Makers) Score Higher in Health Literacy Proficiency Than Men

Young Adults Are UninformedMore Individuals 18-24 Have Below-Basic Health Literacy

More men than women have below- basic health literacy: 21% versus 14%

18-24 year-olds are 3x more likely to have the lowest level of health literacy than those 45 and up.

BELOW-BASIC


Degrees Make a DifferenceHealth Literacy Level Correlated to Education Level.

Insurance MattersType of Insurance Correlated with Health Literacy

Proficient adults are far more likely to have

employer-provided health insurance.

Adults with below-basic health literacy are

4x more likely to have Medicaid coverage.MED

ICAID

More than twice as many (27%) have a graduate or advanced degree.

Compared to the 11% who have a high school degree or less

PROFICIENT


How Does Health Literacy Affect the Cost of Care?With the current level of health literacy assessed and demographic disparities identified, researchers next analyzed how health literacy affects the cost of healthcare, both for the individual as well as the system.

Adults with Lower Health Literacy May Choose More Expensive Treatment Settings

Adults with Lower Incomes Are More Likely to Choose More Costly Care in Some Cases

59%People with below-basic literacy don’t know that treatment for a painful sore throat will cost most at a hospital emergency room.

ONLY

29% Correctly identified situations when using an urgent care center is appropriate.

More than one-quarter (28%) of adults with a house-hold income under $25,000 don’t know an out-of-network doctor will cost them more than one who’s in-network.

Only 55% of adults with below-basic health literacy know that treatment from an out-of-network care provider costs more; versus 98% of proficient.

ONLY

55%

BELOW-BASIC


Many Young Adults Don’t Know the Cost Implications of Their Healthcare Choices

42% of 18-24-year-olds don’t know out-of-network doctors will cost them more than in-network doctors, compared to less than 20% of all other groups.

Nearly half (48%) didn’t know the ER is the most costly choice.

EMERGENCY ROOM


Having a Primary Care Provider and Asking QuestionsHow many people have a primary care provider (PCP)? Would having one make a difference in a person’s health literacy? And, when people go to the doctor, how likely are they to ask questions to increase their understanding? Let’s find out:

Majority Have a Primary Care Provider

Rate of Health Literacy Increases with Having a PCPOf adults who have below-basic health literacy, 69% have a PCP. 81% of adults with basic health literacy have a PCP, versus 85% of adults with intermediate health literacy, and 92% of adults with proficient health literacy

8 in 10 adults (82%) have a PCP

81%

85%

92%

Basic

Intermediate

Proficient

69%

Below-Basic

% Who Have a PCP


Four in Ten May Not Ask Questions of Their Doctors + When people don’t understand what their doctors are telling them:

Women Are More Likely than Men to Ask Questions of

Their Care Providers+ 40% of women will “always ask questions” vs. 28% of men

40% 28%

? Almost half (42%) never or only sometimes ask questions of their care provider — even when they don’t understand what they are being told.

? ?


Knowing Where to Get Medical CareLower-cost care settings such as urgent care facilities may be equally, if not more, appropriate for certain healthcare scenarios. But people either don’t know they are available or don’t know what conditions can be treated there. In fact, people often make dangerous assumptions about where to get care—and these assumptions can lead to negative outcomes.

Many Are Confused About When to Use Urgent CareThere is some confusion about when getting medical care at an urgent care center is appropriate. Slightly more than half correctly chose when to go to an urgent care:

Percent who incorrectly think an urgent care center is the place to go when experiencing symptoms of a heart attack:

58% Knew that you go to an urgent care “When your doctor’s office is closed.”

54% Knew that you go to an urgent care “If you have an ear infection, but can’t get an appointment with your doctor.”

of men Almost half of allrespondents

52% ofmillenials

ü

ü


Women were correct more often than men in choosing the two appropriate situations for using an urgent care center:

+ 62% of women versus 53% of men chose “when their doctor’s office is closed”

+ 59% of women versus 49% of men chose “when they can’t get an appointment for an ear infection with their doctor”

Young adults had trouble knowing when to use an urgent care.

62% 53%

59% 49%

Only 38% of young adults, age 18-24, were correct in choosing an urgent care center as an appropriate place for treatment if their doctor’s office is closed.

ü

ü


Comprehending Health InsuranceIf a person has access to insurance, he or she is more likely to have access to health information through their insurance provider’s website or other educational resources. With that said, health insurance is often difficult to understand and navigate, even for those in the industry. How well does the general population understand it?

Access to InsuranceMajority Have Health Insurance Coverage

Understanding InsuranceHealth Insurance Terminology Confuses Many

36% Could not accurately define a deductible

39% Could not accurately define a copay

44% Are covered by an employer- sponsored health insurance plan

89% Of respondents have access to at least one form of health insurance

Proficient adults are far more likely to have employer-provided health insurance (51%) than those with a below-basic health literacy score (32%).

PROFICIENT

EXPLANATIONOF BENEFITS


Young Adults Have More Trouble Defining Insurance Terms

+ Only 34% of adults 18–24 correctly identified the definition of a deductible, compared with 65% of those 25–44 and 70% of adults 45 and older

Majority Know Meaning of In-Network vs. Out-of-Network Providers

+ The level of understanding is lower for:

- People who did not graduate from high school (50%)- People ages 18–24 (53%)- Those with a household income under $25,000 (63%)

18-24-year-olds have trouble correctly defining deductible, coinsurance and copay.

34%

65%

70%

Adults18-24

Adults25-44

Adults 45and older

% to Correctly Identify Definition of “Deductible”

Most people (71%) know that a doctor who accepts their health insurance plan is in-network and a doctor that does not is

out-of-networkIN-NETWORK


Many Adults with Lower Incomes Do Not Know the Cost Implications of Out-of-Network Care

Half of People with Low Health Literacy Know that Out-of-Network Care Costs More

55% of people with below-basic health literacy

know that out-of-network care is more expensive (vs. 98% adults who are proficient in health literacy)

More than one-quarter (28%) of adults with a

household income under $25,000 don’t know an out-of-network doctor will cost them more (versus 18% of all US adults)

OUT-OF-NETWORK


Understanding Medication and Preventive HealthMedications can be extremely dangerous if not taken correctly. Knowing how to read dosage instructions is a vital part of health literacy, as is knowing when to get a flu shot.

Reading a Pill Bottle Label

+ When reading this pill bottle label, 88% correctly determined that three capsules should be taken each day

+ But 36% of those with below-basic health literacy could not accurately determine how to take the medication based on the instructions on the pill bottle

+ 22% of 18-24-year-olds could not accurately read the instructions on the pill bottle

1234 WILMOT RDDEERFIELD IL 60015 PH (800) 555-5555

NO 0060023-08291DR D. INTERCOM

DATE 05/14/13

JOHN SMITH123 MAIN STREET ANYTOWN, US 111111

TAKE ONE CAPSULE BY MOUTHTHREE TIMES DAILY FOR 10 DAYS UNTIL ALL TAKENAMOXICILLIN 500 MG CAPSULES

QTY 30NO REFILLS - DR. AUTHORIZATION REQUIRED

MFC TEVA

USE BEFORE 05/30/13SLF/SLF


70% of people know that the recommended guideline

for how often adults should get a flu shot is once a year.

77% 63%

50%

76%

81%

Adults18-24

Adults45-64

Adults 65and older

% Correctly Answering How Often Adults ShouldGet a Flu Shot

Most Know the Recommended Guideline for Receiving a Flu Shot

+ More women (77%) than men (63%) are aware of the recommendation to get a flu shot annually

+ Only 50% of 18-24-year-olds know that adults should get a flu shot once a year versus 76% of those 45–64 and 81% of those 65 and older


A Prescription for ImprovementMain TakeawaysOnly 18% of Adults Are Proficient In Health LiteracyAnd, almost half (46%) of American adults have only a basic or below-basic level of health literacy compared with 35 percent in the 2003 U.S. Department of Education study.

Low Health Literacy May Result In Higher Healthcare CostsPeople with below-basic or basic health literacy have less understanding of where and when to get the most cost-effective care compared to people with higher health literacy levels.

Women Have Higher Health LiteracyWomen are more proficient in health literacy than men (22% versus 14%). Women are also more likely to ask care providers questions; know the most appropriate settings for receiving care; understand health insurance terms; know the guideline for receiving a flu shot; and recognize that name brand and generic drugs are usually equally effective.

Young Adults Need the Most Education to Improve Their Health LiteracyPeople aged 18 to 24 are less likely than other age groups to understand the cost implications of receiving care at an emergency room; know when it’s appropriate to use an urgent care center; know the guideline for receiving a flu shot; know the difference between an in-network and an out-of-network doctor; or understand that out-of-network care may be more expensive.

Now What? When it comes to educating Americans about the healthcare system—helping them to successfully obtain and interpret health information, find appropriate treatment and providers, and be actively involved in their treatment—the industry still has an extraordinarily long way to go. According to these findings, the nation has essentially made only a 6% improvement in proficiency over the last 11 years when compared to the findings of the 2003 U.S. Department of Education study.

If we can continue to move the needle by educating healthcare consumers, ensuring they have easy access to actionable information, and generally empowering them to make better healthcare decisions, we could dramatically change the industry for the better.

If each American’s health literacy improved by one level:

+ 17% of the population would have a Basic working knowledge of the system

+ 29% would benefit from an Intermediate literacy level, and

+ 54% of the population would be fully Proficient in health literacy


5. The Relationship Between Health Literacy and Medical Costs, David H. Howard, Ph,D. http://www.amjmed.com/article/S0002-9343%2805%2900011-2/abstract 6. https://ycharts.com/indicators/us_health_care_inflation_rate

For inspiration we can look to other public health education efforts about the dangers of smoking and the importance of wearing a seat belt. The CDC reports that 30 of the 50 biggest U.S. cities have enacted a smoking ban. This shows significant progress since in 2000 only one large U.S. city—San Jose, Calif.—had such a law. Seat belt usage has shown similar improvement: According to the American Public Health Association, “Seat belt use has gone from 11% in 1981 to about 85% in 2010 and saved hundreds of thousands of lives.” In both of these cases, change took time, but by promoting a consistent message, attitudes, knowledge and behavior all shifted.

More knowledgeable, activated and engaged consumers would help:

+ Decrease hospitalization

+ Reduce unnecessary use of emergency care

+ Increase use of primary care

+ Lower healthcare costs

+ Improve mortality rates for seniors

+ Decrease risk of improper medication use

+ Reduce use of unnecessary services

+ Improve overall health outcomes

+ Emphasize value of preventive care and health and wellness

Obviously, the benefits of better health literacy could help to drastically reduce the healthcare costs associated with low health literacy. In 2004, low health literacy was estimated to cost $928 per patient. Using the conservative estimate of a 5.47% rate of healthcare inflation, low health literacy now costs $974.40 per patient.

If we improve the population’s health literacy by just one level—meaning 83% would be at an intermediate or proficient level, leaving only 17% at a basic level—we could potentially save the industry $68 billion.

As healthcare spending continues to rise, as payment models increasingly move from volume to value, and as accountable care and population health management become more and more the norm, it’s easy to see how improving the nation’s health literacy quickly becomes priority number one.


Challenge to Consumers, Providers, Payers, and Employers: Take ActionSurveying current health literacy rates, we’ve learned where healthcare consumers continue to struggle with the health system. But consumers are not alone in their struggle to understand and manage their healthcare. Everyone involved in the healthcare system—consumers, providers, payers and employers—has a part to play in raising health literacy levels in order to achieve better health outcomes and reduced costs.

Consumers need to know how to obtain and understand health information to become more informed patients and make appropriate decisions; become stronger advocates for themselves and their families to receive the best care possible; and take a more active role in tracking and managing their own health history and preventive care.

Providers can use plain language in office visits and patient-facing materials; ensure consumers feel comfortable asking questions; solicit questions from their patients since the above research shows only one-third will always speak up; and use every patient interaction as an opportunity to educate.

Payers can work to simplify the processes of acquiring and using health insurance—eliminating difficult terminology and making insurance more of a consumer-oriented experience.

Employers can promote wellness and educate consumers about their health, healthcare, and insurance – not only during orientation and open enrollment, but year-round.

No matter what your role is in healthcare, we challenge you to do your part to move the needle on health literacy and create a better healthcare experience for consumers.

We all have the potential to raise national health literacy rates. All of us can help make the Triple Aim a reality: reduced cost, improved quality, and a better care experience for consumers.

Join usHelp Americans achieve better lifelong health at a lower cost by improving health literacy rates. Visit HealthAtHand.com, a new digital destination where people—even those in the industry—can test how much they really know about healthcare and find resources to help fill the knowledge gap and lead to better decisions. Encourage your peers, patients, members and employees to visit HealthAtHand.com. Together, we can create better healthcare consumers.

About iTriageiTriage is a healthcare technology company headquartered in Denver, Colorado.

Founded in 2008 by two emergency room doctors and acquired by Aetna, Inc. in 2011, iTriage connects patients, providers and health plans through smart technology providing decision support to help people navigate the healthcare system. Millions of consumers globally have downloaded the free and highly rated iTriage application to iPhone®, iPad® and AndroidTM mobile devices.

The company partners with hospitals and health systems, accountable care organizations, retail clinics, health plans, and employers to improve population health. Find more information about iTriage at http://about.itriagehealth.com.


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