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# An Overview of Health Insurance Literacy

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This presentation discusses:
-Research on the readability of health insurance forms
-Reading level assessment tools
-Best practices for lowering the reading level of materials

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• Adults at the Below Basic level range from being nonliterate in English to having the abilities listed below:■ locating easily identifiable information in short, commonplace prose texts■ locating easily identifiable information and following written instructions in simple documents (e.g., charts or forms)■ locating numbers and using them to perform simple quantitative operations (primarily addition) when the mathematical information is very concrete and FamiliarBasic indicates skills necessary to perform simple and everyday literacy activities.■ reading and understanding information in short, commonplace prose texts■ reading and understanding information in simple documents■ locating easily identifiable quantitative information and using it to solve simple, one-step problems when the arithmetic operation is specified or easily inferredIntermediate indicates skills necessary to perform moderately challenging literacy activities.■ reading and understanding moderately dense, less commonplace prose texts as well as summarizing, making simple inferences, determining cause and effect, and recognizing the author’s purpose■ locating information in dense, complex documents and making simple inferences about the information■ locating less familiar quantitative information and using it to solve problems when the arithmetic operation is not specified or easily inferredProficient indicates skills necessary to perform more complex and challenging literacy activities.■ reading lengthy, complex, abstract prose texts as well as synthesizing information and making complex inferences ■ integrating, synthesizing, and analyzing multiple pieces of information located in complex documents■ locating more abstract quantitative information and using it to solve multistep problems when the arithmetic operations are not easily inferred and the problems are more complex
• The 150 million Americans with private health insurance must select their preferred coverage level each year using summary of benefits forms from their insurance providers. However, these forms can be difficult to comprehend and assess. Only 14% of individuals with employer-provided have proficient health literacy levels. The majority (62% have intermediate), while 24% have basic or below basic health literacy levels.
• While grade reading level is not an equivalent for health literacy skills (National Center for Education Statistics, 2013), grade level is most often used to assess readability of health materials. Words are unfamiliar if they do not appear on a list of 3,000 common words that are known to most 4th-grade students. (New Dale-Chall)The Flesch-Kincaid (Kincaid 14) readability formula was designed for technical documents and is best suited for manuals and forms, rather than primary-age schoolbooks or literary works. This test calculates the grade level of a document based on sentence length and syllable count.
• The 200 million Americans with private health insurance must select their preferred coverage level each year using summary of benefits forms from their insurance providers. However, with 36% of Americans with basic or below basic health literacy skills, these forms can be difficult to comprehend and assess.
• The 200 million Americans with private health insurance must select their preferred coverage level each year using summary of benefits forms from their insurance providers. However, with 36% of Americans with basic or below basic health literacy skills, these forms can be difficult to comprehend and assess.
• FORCAST - only test not designed for running narrative, grade level based on number of monosyllabic wordsCommon insurance words removed: deductible,formulary, coinsurance,generic, precertification
• The 200 million Americans with private health insurance must select their preferred coverage level each year using summary of benefits forms from their insurance providers. However, with 36% of Americans with basic or below basic health literacy skills, these forms can be difficult to comprehend and assess.
• In developing these recommendations, the draft SBC template, including the coverage examples, and the draft uniform glossary underwent consumer testing, sponsored by both consumer and insurance industry groups. These tests were intended to assist in determiningnecessary adjustments to ensure the final product was consumer friendlyThe NAIC consulted readability experts and conducted consumer testing. The SBC format wasdesigned to enhance to consumer understanding and usability. For example, use of vocabulary, such as ‘‘don’t’’ verses ‘‘do not’’ reflects intentional design based on feedback from consumer testing. These format choices reflect in part, the NAIC’s efforts to address the statutory requirement that the form be ‘‘culturally and linguistically appropriate.’’
• FORCAST - only test not designed for running narrative, grade level based on number of monosyllabic wordsCommon insurance words removed: deductible,formulary, coinsurance,generic, precertification
• Used in Pati article
• Used in Pati article
• Used in Pati article
• The tests are categorized by subject. You can select to only use the health-related tests when assessing your materials. That way the information is targeted to what you’re looking for.
• Guide those seeking to create reader-friendly materials
• Guide those seeking to create reader-friendly materials
• Guide those seeking to create reader-friendly materials
• Guide those seeking to create reader-friendly materials
• Guide those seeking to create reader-friendly materials
• Guide those seeking to create reader-friendly materials
• Guide those seeking to create reader-friendly materials
• As a reminder, we’ll turn to an explanation of the different readability tests.Words are unfamiliar if they do not appear on a list of 3,000 common words that are known to most 4th-grade students. (New Dale-Chall)The Flesch-Kincaid (Kincaid 14) readability formula was designed for technical documents and is best suited for manuals and forms, rather than primary-age schoolbooks or literary works. This test calculates the grade level of a document based on sentence length and syllable count.
• From that, we can build our documents so that they’ll follow the prescriptions outlined by the tests.
• ### An Overview of Health Insurance Literacy

1. 1. An Overview of Health Insurance Literacy Emily Vardell, MLS PhD Student and Teaching Fellow School of Information and Library Science UNC Chapel Hill February 20, 2014
2. 2. In today’s session, we’ll discuss o An overview of health insurance literacy o Commonly used readability tests o Research on the reading levels of health insurance forms o The tools that can be used (by librarians and others) to assess reading levels o What can be done to lower the reading level of materials
3. 3. 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” Ratzen, S. C., & Parker, R. M. (2000). Introduction. In: Selden, C. R., Zovn, M., Ratzen, S. C., & Parker, R. H. (Eds.), National Library of Medicine current bibliographies in medicine: Health literacy. NLM Pub N. CBM 2000-1. Bethesda, MD.
4. 4. Health Literacy Categories • Below Basic indicates no more than the most simple and concrete literacy skills. • Basic indicates skills necessary to perform simple and everyday literacy activities. • Intermediate indicates skills necessary to perform moderately challenging literacy activities. • Proficient indicates skills necessary to perform more complex and challenging literacy activities. Kutner, M., Greenburg, E., Jin, Y., & Paulsen, C. (2006). The health literacy of America's adults: Results from the 2003 National Assessment of Adult Literacy. NCES 2006-
5. 5. Text Kutner, M., Greenburg, E., Jin, Y., & Paulsen, C. (2006). The health literacy of America's adults: Results from the 2003 National Assessment of Adult Literacy. NCES 2006-
6. 6. Health Literacy Level by Health Insurance Coverage Kutner, M., Greenburg, E., Jin, Y., & Paulsen, C. (2006). The health literacy of America's adults: Results from the 2003 National Assessment of Adult Literacy. NCES 2006-
7. 7. Health Insurance Literacy “a new concept that addresses the extent to which consumers can make informed purchase and use decisions” “knowledge, ability, and confidence to effectively choose and use health insurance” Kim, J., Braun, B., & Williams, A. D. (2013). Understanding Health Insurance Literacy: A Literature Review. Family and Consumer Sciences Research Journal, 42(1), 3-13.
8. 8. Does this look familiar?
9. 9. Readability Tests • FORCAST - only test not designed for running narrative, grade level based on number of monosyllabic words • Flesch-Kincaid - grade level based on sentence length and syllable count • Gunning Fog – grade level based on number of sentences and complex words • New Dale-Chall - grade level based on sentence length and number of unfamiliar words Readability Studio [computer program]. Version 1.2.0.0.
10. 10. Reading level of Medicaid renewal applications • 45 states had reading level guidelines • 24 (52.2%) of the states failed to meet their own guidelines • 41 states (89.1%) failed the Flesch-Kincaid Grade Level Index • None (0%) of the assessments passed the FORCAST Pati, S., Kavanagh, J. E., Bhatt, S. K., Wong, A. T., Noonan, K., & Cnaan, A. (2012). Reading level of Medicaid renewal applications. Academic pediatrics, 12(4), 297–301.
11. 11. Assessment of Children’s Public Health Insurance Program enrollment applications • A more holistic assessment of CHIP applications that assessed reading demands, layout characteristics, and document complexity through: – Lexile Analyzer (to assess reading demands) • Reading Level = sentence length and word frequency – The User-Friendliness Tool (to assess layout) • Font size; avoidance of capital letters, italics, and specialty fonts; use of ample white space; short paragraph lengths – The PMOSE/IKIRSCH scale (to assess document complexity) • Complexity of structure (use of lists) and density (number of labels and items on the list) Wallace, L. S., DeVoe, J. E., & Hansen, J. S. (2011). Assessment of Children’s Public Health Insurance Program enrollment applications: a health literacy perspective. Journal of pediatric health
12. 12. Examples
13. 13. Examples
14. 14. Affordable Care Act (ACA/Obamacare) Readability FORCAST 11.1 Gunning Fog 9 New DaleChall 7-8
15. 15. Company Administering Insurance Company Number of Pages FORCAST Test FORCAST Test (grade level) (without common ins. words) Aerostructures Manufacturer Architecture Firm Aetna 4 13.4 13.0 UnitedHealthCare Midwestern regional health system Self-administered 2 2 13.9 10.9 13.1 9.9 Large, Southern public university BlueCross/ BlueShield North Carolina 8 13.4 13.2 Large, Midwestern public university Medica 4 13.6 13.4 Large, Mid-Atlantic public university Self-administered 5 12.5 12.4 National cable company UnitedHealthCare and BlueCross/BlueShield 11 12.6 12.2 National pharmacy chain BlueCross/ BlueShield Illinois ½ 11.8 11.2 1 12.6 12.3 National, natural foods UnitedHealthCare supermarket chain
16. 16. Oleander Readability Studio Readability Studio [computer program]. Version 1.2.0.0.
17. 17. Oleander Readability Studio http://www.oleandersolutions.com/readabili tystudioorder.html Readability Studio [computer program]. Version 1.2.0.0.
18. 18. Oleander Readability Studio (with Language Options) http://www.oleandersolutions.com/ReadabilityStudioL Readability Studio anguagePackOrder.html [computer program]. Version 1.2.0.0.
19. 19. Oleander Readability Studio http://www.oleandersolutions.com/Readabil ityStudioFeatures.html Readability Studio [computer program]. Version 1.2.0.0.
20. 20. Readability Studio: Difficult Words
21. 21. Read-able.com
22. 22. Testing MedlinePlus
23. 23. Read-able.com
24. 24. ReadabilityFormulas.com http://www.readabilityformulas.com/
25. 25. Microsoft Word (2010) 1. Click the File tab, and then click Options. 2. Click Proofing. 3. Under When correcting spelling and grammar in Word, make sure the Check grammar with spelling check box is selected. 4. Select Show readability statistics. After you enable this feature, open a file that you want to check, and check the spelling. When Outlook or Word finishes checking the spelling and grammar, it displays information about the reading level of the document. http://office.microsoft.com/en-us/word-help/test-your-document-s-readabilityHP010354286.aspx#_Toc342546555
26. 26. Microsoft Word (2010)
27. 27. How to Adapt Your Materials • FORCAST - only test not designed for running narrative, grade level based on number of monosyllabic words • Flesch-Kincaid - grade level based on sentence length and syllable count • Gunning Fog – grade level based on number of sentences and complex words • New Dale-Chall - grade level based on sentence length and number of unfamiliar words Readability Studio [computer program]. Version 1.2.0.0.
28. 28. How to Adapt Your Materials  Monosyllabic words  Short sentence length  Minimum number of sentences and complex words  Lessen number of unfamiliar words Perhaps add:  Increase the amount of white space  Use clear fonts; avoid italics and other hard to read features Readability Studio [computer program]. Version 1.2.0.0.
29. 29. In today’s session, we’ve discussed An overview of health insurance literacy Commonly used readability tests Research on the reading levels of health insurance forms The tools that can be used (by librarians and others) to assess reading levels What can be done to lower the reading level of materials
30. 30. Questions? Emily Vardell, MLS evardell@unc.edu