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Learning from George Costanza

Les Masterson, for Health Plan Insider, August 27, 2008

Seinfeld fans will remember the episode when Jerry and sidekick George Costanza filmed their pilot for NBC. As a writer of a new television show, it looked like sad-sack George was finally going to make something of himself.

But then fate handed George yet another blow. He discovered a white growth on his lip, and worried that it was cancer.

A doctor performed a biopsy and told George the results were "negative." The news sent George into hysterics. How could he be struck down just when he was ready to enjoy success, he lamented. His mood quickly changed, though, when he realized the doctor was telling him good news—he did not have cancer.

If George Costanza has trouble understanding a diagnosis, think about the 60% of Medicare enrollees who are at either a basic or below-basic literacy level. Will they know that negative is actually positive?

Low health literacy costs the country between $106 billion to $236 billion annually, according to a 2007 University of Connecticut study, yet many in healthcare continue to ignore the problem.

This issue can lead patients to avoid the doctor or simply not follow directions. Just think of the barrier if a patient can't follow a doctor's instructions, and the potential impact that has on health.

Health literacy's impact was evident in two articles that recently appeared in the Washington Post and The Boston Globe.

Both of these articles show how a person's literacy (both health literacy and general literacy) can erect barriers.

In the first article, a study showed that a majority of seniors who visited the Medicare Web site was frustrated by the experience (anyone who visits CMS' site could surely relate. I often feel like I'm in that maze in "The Shining" when I'm on that site.)

A study by the University of Miami reported that Medicare beneficiaries found the Medicare site difficult to navigate and they were not able to gain the information they wanted. They also told researchers that some of the language was too complex.

Then, there's the news from Massachusetts. The state's healthcare program has experienced highs (more insured residents) and lows (skyrocketing costs), but news this past week showed that tens of thousands of previously uninsured residents who enrolled in the state's Commonwealth Care were bounced out of the program because of errors on member forms and mistakes by the state.

Advocates say the state's eligibility documents are too complex, and that complexity is confusing residents who are losing their insurance.

This has led some patients to pay for medical bills while not getting reimbursed. There is no data as to whether patients have put off care because of being removed from the program, but that could be another problem.

Barbara Anthony, executive director of Health Law Advocates, a nonprofit that has sued the state on behalf of some Commonwealth Care members who were mistakenly terminated, told The Boston Globe that there has been a "steady stream" of people dropped by accident.

Anthony was quoted in the paper sounding like a health insurer: "I think there would be a huge outcry by state government if a private insurance plan behaved that way." These cases show how health literacy plays a role in healthcare. Medicare's Web site is not user-friendly enough to provide useful information and Massachusetts' forms are not easy enough to follow.

So, what can a health insurer, managed care company, or anyone in healthcare do to remove these barriers? I recently moderated an audio conference on the topic of health literacy.

One of the leaders on the health literacy issue is Gloria Mayer, EdD, RN, FAAN, president and CEO of the Institute for Healthcare Advancement, a nonprofit that works to improve health literacy.

Mayer provided two ways that healthcare providers and payers could connect with patients and members:

  • Avoid medical jargon. For this tip, think back to George Costanza's dilemma. Think about how terms like terminal, immunization, and contraception sound to a patient, and whether there is a more basic way to say it. Mayer said rather than using medical terms, healthcare should use "living room language" to connect with patients. For instance, rather than saying "insomnia," say "can't sleep," and rather than "benign," say "no cancer."
  • Use the teach back technique. Rather than simply informing a patient or member about what needs to be done and asking if he understands, Mayer said the healthcare representative should ask the person to actually relay what he is going to do.

As we transfer more healthcare decisions onto the individual, properly reaching members with understandable communication will play a larger role in healthcare. Health insurers may puff out their chests and brag about the latest personal health record or their outreach efforts, but if literacy levels are not taken into account, insurers are wasting their money and just placing barriers to healthier living.


Les Masterson is senior editor of Health Plan Insider. He can be reached at lmasterson@healthleadersmedia.com .
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