Health Literacy and the Misplaced Mantra, part 2 of 2

Health Literacy and the Misplaced Mantra, part 2 of 2

The Dilemma

Web-based decision support and concierge health services are on the rise, yet most people still believe (with considerable justification) that the most complete and objective advice remains reserved for the rich or well-connected. Meanwhile, system integrators believe that the best consumer is informed and would rather, for example, link her BMI to cash than evaluate plan designs. So, while incentives to “do the right thing” are coming into play, when/how to do it is still a very real issue for the consumer receiving constant, often contradictory, stimuli.

At the point of care, the patient, who still lacks access to much of her medical record, is told at one visit, "I can't decide for you," and acted for paternalistically the next, in both cases with the best of intentions, under a system that rewards speed, test orders and upcoding more than outcomes.

The Reality

The ability to limit health information stimuli to self-initiated searches no longer exists. What if you were as besieged with information about lawn mowers (which you may not even need) as you are with health information? How soon would you turn off and drop out? Now, what makes health information so compelling? At its root, it’s a catalog of ways to die. There are ways to dress it up, but charging ahead under the assumption that living’s easy is not the way. High utilizers are often the most likely to have at least one uncontrollable risk factor. How well are you illuminating what’s controllable and what’s not? And when you put together your health/disease education modules, shouldn’t you overlay all the content with incentive to actually use it?

We need to address the barriers to optimal decision-making head-on, rational or not. These include lack of self-efficacy, emotion/information overload and a perception that inputs relate poorly to outputs (everyone hears about the runner who dies of an early MI). P4P and CDHC designs in and of themselves cannot drive outcomes and may even make things worse. So we need to address the most pressing patient questions head-on:

• How important is making this decision? What are the risks and benefits of doing nothing vs. acting?
• How controllable is the risk of acting? Can the risks be spread out by making a series of decisions over time?
• What are the best and worst cases?
• How achievable is a positive outcome?
• How predictable are the positive and negative consequences?

In short, we can help deciders prioritize their decisions to optimize the achievable delta. Rather than agonize over which multivitamin to buy this month, what if I can spend that energy on overcoming my addiction to sweetened fruit drinks? The reason that so many people read Prevention, a monthly digest of often contradictory information, is that when its authors make a declarative statement, they are usually fairly good about telling readers how to implement it in their own lives. How well do your Web site, direct mail, brochures and e-mails do that? And no, “it’s easy to eat 5-7 vegetable servings per day” doesn’t count, because it’s not easy!

Imagine…

Today, tests for the extent of health literacy (e.g. the ability to read a product label) don’t measure the propensity to follow the label’s instructions, take it seriously, extrapolate it to other health decisions, etc. These are where motivation to spend time on the key decisions and wade through all the extraneous and repetitive information comes in.

Now imagine it’s 2017, and there are robust question batteries that reliably predict the capacity for and propensity to use health literacy. When rating or treating a group or individual, wouldn’t you want to combine this assay with medical underwriting and the patient’s past ratio of achieved to achievable health improvement, since the three together have a more direct effect on costs and outcomes?

So what is your organization putting into place today, to prepare you to develop, implement and/or integrate this algorithm in 2017? And underlying this entire fantasy has to be real-time access to claims and/or chart data, with the clinical and communication savvy to use these data intelligently. How close are you there?

Next…what self-administered risk assessments do and don’t do…and what might work better.