Helen: Welcome to Health Literacy Out Loud. I’m Helen Obsorne, President of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud.

In these podcasts, you get to listen in on my conversations with some truly remarkable people. You will hear what health literacy is, why it matters and ways we all can help improve health understanding.

Today I’m talking with Dr. Howard K. Koh who serves as the 14^th Assistant Secretary for Health for the US Department of Health and Human Services.

Dr. Koh is dedicated to the mission of creating better public health systems for prevention and care so that all people can reach their highest attainable standard of health. Health literacy is key to accomplishing this goal.

Welcome, Dr. Koh.

Dr. Koh: Thank you very much.

Helen: Thank you for being such a prominent health literacy champion. I read a recent health literacy article that you co-authored with many other leaders in health and health literacy. The article is called “New Federal Policy Initiatives to Boost Health Literacy Can Help the Nation Move Beyond the Cycle of Costly Crisis Care.” It was published in the January, 2012 edition of Health Affairs.

Even before I knew I was going to interview you, I had flagged this article as one that I thought was really important because it gives such a vivid overview of what’s happening in healthcare today. You raised so many important points. I’m hoping we can address a few of them.

Dr. Koh: That’s great.

Helen: In the article, you say that health literacy is a dynamic systems issue. Can you explain that a little bit more?

Dr. Koh: This area of health literacy is such an important public health challenge, and for years it has been portrayed as an issue of individual deficits that people individually need to learn more about the health system and be better advocates for themselves.

Helen: With the skills they can and cannot do, like reading, literacy and all of that?

Dr. Koh: That’s right. It’s basic skills in understanding oral communication from their providers and written instructions, understanding how to take medications properly with the proper doses, and those sorts of issues.

Over time we’re understanding that this is really a systems issue and that organizations and complex health systems should take responsibility for making health literacy come alive.

Helen: When you talk about systems, are you talking about that system of one provider and one patient, or are you talking about great big health systems and organizations?

Dr. Koh: We’re moving in this period of health reform to greater emphasis on team approaches to patient care where everybody involved in the team helps the patient achieve greater health, and it’s a patient-centered approach. Health literacy is really an effort that involves providers, doctors, hospital leaders, and everybody who helps the patient navigate the system and get good care at the end.

Helen: I am just delighted that the definition is moving in that direction. I’ve long been uncomfortable with the fact that it seemed to be just about them, the other person, and what he or she cannot do. I am just thrilled that it’s coming together at that intersection of what the providers can do, what the systems can do, even what the Federal government is doing, and what patients can do. We’re all in this one together.

Dr. Koh: Absolutely. I am a physician, but I am a patient as well. Very few people can understand the system now and navigate it easily. It has become so complex. It’s really up to everyone to take responsibility for it to make it easier for the patient to reach their true health potential.

Helen: Thank you. You also talk about healthcare reform. Is this equation changing a little bit?

Dr. Koh: Yes. Health reform was one of the three major federal policy initiatives in 2010 that I think are moving this conversation of health literacy past the possible tipping point.

The Affordable Care Act of health reform passed in March of 2010. We have the National Action Plan to Improve Health Literacy that came out of our department the same year.

Finally, the President signed the so-called Plain Writing Act of 2010 that instructs people across federal government to write more simply about issues, including health, so that people can understand.

These are three policy initiatives that have all come together and I think bode well for the health literacy movement.

Helen: It’s actually even more perfect that I’m interviewing you now because I’ve done a podcast on the health literacy action plan with Cynthia Baur, and I did one on the Plain Writing Act with Annetta Cheek. We’re putting all these parts together and really moving forward with this. It’s very exciting.

In the article, you talk about this tipping point and the fact that health literacy might be going from the margins to the mainstream. Can you make that come alive for us?

Dr. Koh: Particularly with the Affordable Care Act where we’re using the patient-centered theme very squarely, we’re stressing the team approach to healthcare as I mentioned already. We have new organizations such as accountable care organizations that really stress helping the patient achieve quality outcomes and achieve good health outcomes. That responsibility lies with everyone.

Helen: Our listeners are at all levels across the United States and around the world. I wonder if you could frame this for people so that those who may not have heard of accountable care organizations might have a greater understanding about that.

Dr. Koh: Previously, the model was that the patient was sick and came in to see a doctor or provider. There was some interaction, and that person left. It was one-on-one, and there wasn’t attention to whether the care given was high-quality care, whether anybody followed up with the patient, and where the patient understood directions in how to take medications or take next steps.

With accountable care organizations, there is a team approach. We measure the quality of the interaction with the patient. We want to make sure the patient is satisfied with the care they’re getting. Most of important of all, payment is tied to those outcomes. This is really about a patient-centered approach, which is very important.

Helen: That’s terrific. I don’t think I’ve ever heard it put as succinctly together. I hear payment, I hear teams, I hear quality, and I hadn’t seen all of those parts merging. Thank you for explaining it clearly to me.

When you talk about the team approach, we all know that doctors are really busy. Everybody is busy. Who might be involved in the team when somebody is sick or going for a routine exam?

Dr. Koh: It’s not just the doctor. It’s the nurse, the nursing assistant, the clerk at the front desk, and the person who is responsible for scheduling follow-up. We also want patients to be able to access their team on off hours and weekends, be able to get prescriptions filled easily and have the directions be understandable, for example.

A really important concept with the teach-back method is something that I embrace as a physician myself. I’ve cared for patients for over 30 years in the specialty of cancer. Over my career, I’ve had literally thousands of patients referred to me for cancer-related issues.

At the beginning of my career, I would start in on a little overview of what that cancer was all about and the implications. Over time I came to realize that the most important question to any new patient was, “What is your understanding of the condition you have and of the actions for the future?”

It was amazing to me as a provider and physician the range of responses I got. Some people had a very clear, scientific understanding of their condition, particularly cancer. Others would go on the internet and read information that was either of high quality or not and come in absolutely terrified.

I came to respect that each person is different. Each patient situation is different, and the patient’s level of understanding about their options differs greatly as well.

This is at the heart of health literacy in my view as a clinician, starting where the patient is and going from there.

Helen: Thank you for coming to terms with that. When you spoke in the beginning, you said that you’re also a patient. Your story brings out some patient experiences that I’ve had too. When you hear a serious diagnosis or a word like “cancer,” for at least a little while nothing else matters. Nothing else gets through.

Whatever our learning needs, skills and abilities are, for at least a little while they’re all blocked right there.

Dr. Koh:Absolutely. I know exactly what you’re describing. To make it even more complex, I’m of Asian-American background, so I’ve often been the navigator on behalf of my extended family, many of whom are born overseas. When you talk about the cultural and racial-ethnic dimensions to all of this, it makes the health literacy issues even more important.

Those are areas I’m very sensitive to as an everyday citizen, as a physician and also as the Assistant Secretary for Health.

Helen: That’s interesting. In other times, would you be the one to go in with a family member and help interpret that message?

Dr. Koh:Absolutely. When you’re the physician of the family, everyone asks you to advise and, if you will, interpret and navigate, which I’ve been happy to do my whole career. You get to see the health system from the eyes of your family members. Again, this is where the Affordable Care Act is very important.

There’s an emphasis on patient navigators, especially as new health exchanges come online for every state in 2014. Just understanding the various insurance coverage options is very challenging, but there are provisions in health reform to require that the insurance plans make these options as simple as possible so people understand the coverage options before them.

Helen: That’s if we’re all not lucky enough to have a prominent physician at HHS in our family. Thank you for bringing that forward.

Dr. Koh: We want to make the system work for everybody whether you have a physician in the family or not.

Helen: Thank you for enacting it for everybody out there. You talked about the role of teach-back. I think you’re talking about that from your physician hat.

Do you see that really working? Can physicians and others really put that into practice? I know that’s a recommendation that I and everybody else seems to be making. “Use the teach-back.” Do people use it, and what’s the receptivity to others to use this?

Dr. Koh: I think this is essential to quality care. It has to be taught to physicians from the earliest days of training. You could be the most informed clinician, physician and provider, but if your patients don’t understand what you’re trying to convey and there’s a big gap, then they won’t get better. They will be frustrated and lose trust in you as well.

It’s really critical that not just providers but their staff and the system have ways to check with the patient and say, “Please tell us what your understanding is. Let’s make sure that we’re on the same page here.” That’s a really critical part of health literacy.

Helen: What do you say or what would you recommend I and others say when we sometimes get a little pushback and people say, “But I don’t have any time?”

Dr. Koh: You have to take a long view here. You may feel like you’re saving a minute or two in the short run, but in the long run if there’s confusion about simple directions about your care, how to take a medication, or about which tests to pursue before coming back for the next appointment and information falls through the cracks, you’re not having good health outcomes and quality outcomes for your patient.

This becomes a systems issue for everyone. We really need to take the long view and take on that responsibility that belongs to everybody.

Helen: Thank you very much. It sounds like this is very much tied into the other part you were talking about that’s affecting that quality care, and that’s all tied into reimbursement.

Dr. Koh: That’s right. You may know that another major theme in the Affordable Care Act, particularly through our Centers for Medicare and Medicaid services is to move from what’s been called volume-based purchasing to value-based purchasing.

What the Centers for Medicare and Medicaid services has stressed in the past is to just pay for patient visits and not really pay attention to whether the patient was satisfied or that there was a quality visit. In the future we’re going to reward providers who are doing their job well and have the patient be a satisfied patient who understands exactly how to take care of themselves.

Central to that is understanding what is being conveyed in terms of health communication. We’re moving toward a value-based system slowly but surely in this country.

Helen: That’s terrific. In the article, you have two diagrams. I love these diagrams. I have highlights all over them because I love them so much. They are diagrams about the patient’s experience in a health situation. One of them is labeled with some version of a crisis of care. The other one is labeled “health-literate care.”

In one it seems to make the spiraling loop of the patient coming back, and there are more tests and expenses. That circle never seems to end. In the one with health literacy, it seems like there is relief from it. People get better and people understand. Can you talk more about those diagrams?

Dr. Koh: I’m very grateful to my colleagues at the department to help co-author this article, for generating many of the ideas that are central to the article, and then to create these two diagrams.

We just wanted to show very simply at the individual patient level what the challenges are, what the cycle of crisis care consists of right now, and how with some attention to building a better system we could have an end result with a healthier patient and one who understands what the provider is trying to convey.

Helen: You conveyed that visually and I’m very much a visual learner, so that met my needs. For our Health Literacy Out Loud listeners, we will have a link on the web page to this article that is in Health Affairs Journal. It will include all of your many other esteemed coauthors.

Dr. Koh:I’m very grateful to them. Thank you for your appreciation of these two figures.

Helen: Ithink they’re terrific. The article is also filled with a lot of resources. There are federal resources, federal initiatives, tools to help and ways people can learn more. Could you address some of what the federal government is doing to help the person dealing with day-to-day care in health communications?

Dr. Koh:I’m glad to. Again, I’m very grateful to so many colleagues at the department who have been committed to this issue for many years. In fact, we have a dedicated health literacy working group that promotes these new tools for the general public.

First and foremost, we have a new website called www.Healthcare.gov that was launched in July, 2010. It provides the public with basic information about health reform and health coverage. There’s a related site called www.HealthFinder.gov that is focused on prevention.

If you are interested as an individual about learning how best to take care of yourself and keep yourself healthy, going to www.HealthFinder.gov and looking at the interactive consumer tool My Health Finder, it will be very important to you. www.Healthcare.gov has had over 10 million visitors so far. It’s a very popular site that we’re very proud of.

The department has also put out a couple of very basic tool kits that deliver the patient-centered theme. One of them is a Health Literacy Universal Precautions Tool Kit. It encourages patients to bring all of their medications to an office visit to make reviewing those medications with the doctor easier.

There are many other websites that have been crafted by the department to help promote the theme of health literacy.

Helen: I see so much going on out there, and I applaud everybody bringing this to attention at a federal level. I’ve been focused on health literacy for 15, 16 or 17 years now. I remember that way back then I’d say, “What are we going to do about health literacy?” That was back in my hospital days. People might say, “What? Is that teaching people to read?”

Fast forward to now. I’m talking to you about all that’s happening at a federal level. This is astounding to me. If we take that long view that you were talking about, about all that has been accomplished, and have such a big platform to share, that is very exciting that we are making a difference.

Dr. Koh:Helen, thank you for your commitment. It’s a great privilege to be a part of this and see so many colleagues of the department and so many leaders around the country like yourself who care about this. This is just essential for good health, quality and breaking that cycle of crisis care. We really appreciate your leadership and partnership.

Helen:Thank you for talking with us at Health Literacy Out Loud. Keep going. We need you as a champion.

Dr. Koh:Thank you very much.

Helen: I learned a lot from Dr. Howard Koh and hope that you did too. But health literacy isn’t always easy. For help clearly communicating your health message please visit my healthy literacy consulting website at www.HealthLiteracy.com. While you are there sign up for the free e-newsletter, What’s New in Health Literacy Consulting.

New Health Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find us on iTunes, on the app Stitcher Radio, and on the Health Literacy Out Loud website,www.HealthLiteracyOutLoud.com.

Did you like this podcast? Even more, did you learn something new? If so, tell your colleagues and friends. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.