Low Health Literacy Hits Physicians Where it Hurts

What’s driving the rise in healthcare costs? That’s a lengthy list, but when you start to configure that list, make sure to include low health literacy. It may not get the coverage that heart disease or diabetes receive, but its influence on rising healthcare costs cannot be denied.

Consider that fewer than 1 in 6 adults—and only 1 in 3 seniors, have proficient health literacy. In addition, most Americans read at a 5th grade reading level while most healthcare information is written at a 10th grade level. The result is that rising healthcare costs from low health literacy are now, by some estimates, $236 billion annually.

“The diseases that kill, like heart disease, have sufficient data recorded in hospitals as to the cause of death,” explains Aracely Rosales, who runs her own consultation business, Plain Language and Culture. “However, low health literacy could be the lead issue why people are not taking care of themselves; why they present in the first place.”

That’s a challenge for healthcare providers at all levels.

Lost patients, lost revenue

Terry Davis, Ph.D., professor of Medicine & Pediatrics at Louisiana State University, works with patients and providers to develop and test the efficacy of patient-centered education materials. She was involved in a 2006 study published in the Annals of Internal Medicine that found, among other things, that two-thirds of the people surveyed did not understand that “take two tablets by mouth twice daily” means take a total of four pills a day.

“Most doctors don’t write the prescription precisely enough,” Davis explains. “So, two pills twice a day, well, when do you take it? Do you take it with food or not? These are questions that people have when they get home that doctors are sort of unaware of. The only way to confirm understanding is to ask the patient to tell you back how they’re going to take the medication. And some studies found that when the doctors did this, it didn’t really slow them down. But, doctors perceive that it will slow them down if they do the teach-back, so it’s rarely done.”

Compounding the problem is that it’s extremely difficult to tell which patients have low health literacy. In fact, because we tend to assume that everyone can read, an individual may be presumed to be noncompliant with treatment recommendations when low health literacy is really the issue. And patients hide their problem well.

“Patients may not ask questions due to the fear of appearing dumb,” explains Rosales. “Doctors need to improve their communication skills and speak at the level of the patient. In fact, studies have shown that the majority of malpractice lawsuits over medical errors are the result of poor patient-provider communication.”

New tools can help

The medical community is beginning to catch on to the importance of combating low health literacy. Affinity Health Plan, a New York City-based not-for-profit managed care company, recently signed an agreement with Health Literacy Innovations to license the Health Literacy Advisor, an interactive health literacy software tool. Medical Mutual, a professional liability company owned and operated by North Carolina physicians, has already experienced the benefits of the Health Literacy Advisor.

“When I joined Medical Mutual, I looked at the informed consent process that was in place,” recalls Marsha Hughes, vice president for risk management. “I’m a nurse by background, and I actually struggled with a fair amount of the terminology.” Hughes and her staff talked to health literacy experts, then began revamping the informed consent forms by shortening sentences and multi-syllabic words. “We would spend 45 minutes to an hour making changes we believed would bring the literacy level down, and then find that there was little or no change.”

Then they came across the Health Literacy Advisor, a software tool that links to Microsoft Word and contains a database of more than 10,000 medical words, disease names, and health plan and insurance vocabulary that has been simplified into plain English. Think of it as a spelling and grammar checker for the medical community. After a demo, they were convinced of its effectiveness.

“We’re in the risk management department, and one of our objectives is to do everything we can to help our insured stay out of the courtroom,” Hughes explains. “[The Health Literacy Advisor] has really been, to me, one of the best things we could have purchased to help us meet our objective.”

Doctors at the forefront

Healthcare providers are huge stakeholders on the low health literacy battleground. “We’re asking patients to become more engaged in their own care, but they feel intimidated because they don’t understand what doctors are telling them,” says Rosales. “But if they get a document that is written in plain language, they’ll feel more confident, they’ll ask questions, and they’ll keep coming back and referring more people, which is good for business.”

Ed Rabinowitz is a veteran healthcare reporter and writer. He welcomes comments at

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edwardr@ptd.net