Helen: Welcome to Health Literacy Out Loud. I’m Helen Osborne, 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 Lynn Quincy who is a Senior Health Policy Analyst for Consumers Union, the policy and advocacy division of Consumer Reports. Lynn works on a wide variety of health policy issues, often focusing on consumer protections, consumers’ health insurance literacy, and health insurance reform at the federal and state levels. Welcome, Lynn.

Lynn: Thank you for having me.

Helen: I know you’re working on so many aspects of health insurance as it relates to the US Affordable Care Act, otherwise known as Healthcare Reform. Some of your work specifically looks at helping consumers choose the health plans that are right for them. Let’s take it from the top.

In the US Affordable Care Act, what’s the role of consumers and choice when it comes to health plans?

Lynn: The Affordable Care Act has a lot of goals, and it is attempting to accomplish a wide variety of things. One of its goals is to improve the consumers’ health insurance shopping experience, and it does that in a number of ways.

Helen: It improves health consumer’s shopping experience when it comes to health insurance?

Lynn: That’s right. We know from testing that we’ve done here at Consumers Union that it’s really hard for consumers to choose among health plans. They find the plans confusing, and they’re often very intimidated by the process. It’s not surprising because these are actually very complex products with a lot of terms imbedded in them.

The Affordable Care Act does a couple of things. It is introducing a new Health Insurance Disclosure Form that presents that health insurance information in a standard way so consumers can line them up and compare things apples to apples and side by side.

It is also standardizing the products themselves a little bit so there are fewer moving parts and it becomes a little easier for them to compare.

Helen: Does that mean that different health plans at the core are similar?

Lynn: Yes. Here’s an example of that. As of right now, certain preventative services are always offered with no cost sharing, so when it comes to those types of medical services, you don’t have to wonder how it’s covered by any given plan. You know that these are now available with no cost sharing.

Helen: When you say “cost sharing,” what do you mean?

Lynn: I mean what the consumer has to pay when they go to the doctor. You see this is similar to a co-pay, or you might be charged a deductible. You might be charged co-insurance. Those are all things that control how much of the doctor’s bill you pay and how much that health plan pays.

Helen: You are bringing in a whole other vocabulary. I’ll bet that’s part of the problem, isn’t it?

Lynn: It is. These terms, like “co-insurance,” that actually govern how much coverage you’re getting for your premium dollars are pretty hard for consumers. It makes it hard for them to figure out which plan offers more health coverage. The Affordable Care Act is trying to make it a lot clearer as to how much coverage you’re getting from a given health plan with the major reforms happening late next year.

Helen: Is that in 2013 and 2014?

Lynn: That’s right.

Helen: Really, you have been working with a lot of people to help make it clearer which health plans offer what coverage at what price and what benefit. Is that correct?

Lynn: It is correct. Here at Consumers Union, I’m primarily working with regulators at the federal and state level who are busy figuring out the rules that are going to govern how insurers operate in this new health insurance world. I want to make sure those rules are consumer-friendly so it becomes easier for consumers to compare their health plan choices.

Helen: Let’s make a real example because like probably just about everybody in this country, I hate choosing insurance, and I live in Massachusetts, a state where we’ve been doing this for a while. You’re advocating making it more consumer-friendly. Go, Lynn! What would a more consumer-friendly choice look like when it comes to health insurance plans?

Lynn: There are two things that we’re doing. One is that for any individual plan, what kind of information can you see about that plan? As an example, the disclosure form that I mentioned earlier has something brand-new that consumers have never seen before. It’s called a coverage example.

It shows what that plan would pay for two medical scenarios, having a baby and treating diabetes. Instead of the consumer having to figure out, “If I add together the co-pays and account for the deductible and work in the out-of-pocket maximum, what does that cost me as a bottom line?” the health plan now has to tell you what that consumer bottom line is for the two medical scenarios.

Helen: Those scenarios are just examples, so it’s not just that a health plan covers having a baby or having diabetes. Is this where you actually do the math? Do you say, “You’ll pay this, we’ll pay that and this is what you’ll get?”

Lynn: Yes. It’s a new requirement where the math is done for the consumer. Now the health plan says, “In this scenario, as an example, this is how much we would pay.” Consumers can compare that information across plans to see how they differ. This is really handy because the math has been done for the consumer. We did testing around this, and it was a huge help. They really like it.

Helen: It’s just like telling a story.

Lynn: Yes, it’s illustrating those discrete health plan provisions, like the co-pay and deductible that we talked about before. It’s illustrating how they’re used to factor into a bottom line for consumers.

Helen: That’s great. You talked about some other changes you’re working with regulators on to make it consumer friendly. Are there other aspects of this that we, as people making a choice, would be seeing?

Lynn: There’s another very important dimension, and that is when you’re looking at comparative health plan information. Maybe you’ve got six, seven or 10 health plans. You’re looking at them online and it’s a side-by-side. We’re looking at whether the way it’s displayed affects consumer’s ultimate selection. The way that information is displayed has a name, and it’s called choice architecture.

Helen: What a neat term.

Lynn: Yes, it is. It turns out that it’s an amazingly powerful concept. The way your choices are arrayed has a profound influence on which plan you select.

To take a simple example, the way those health plan choices are sorted—meaning which one comes to the top and  which one is at the bottom, or maybe it’s actually off the screen and you won’t see it unless you scroll down—is a very important dimension of choice architecture.

We did a study, and we can talk about the link later. We looked across health plan chooser tools that are out on the market today to see how they made these design decisions for how these choices are arrayed.

As a specific example, it seems that sorting by premium is probably not the most helpful thing for consumers. Sometimes, if you have a plan with a low premium, it has very high out-of-pocket costs when you’re going to see the doctor.

Helen: A premium is what you pay out of your pocket for the plan before you ever see anybody for anything.

Lynn: That’s correct.

Helen: Sorting it by what you’re going to pay every month even if you never go to the doctor is the way they used to sort it, but that’s not the most helpful. Is that correct?

Lynn: That’s correct. We looked at some tools that are out there today, like the tool that a lot of federal workers use to select from among their options.

Federal workers tend to have a lot of health plan choices at work, and one of these tools uses a concept called total estimated costs. They take the premium, but they add to it an estimate of what you might have to pay next year for when you do go to the doctor. They add in those costs, so it’s another example of doing the math for the consumer.

When you sort by that, you’re taking into account not only the premium but this other dimension of what you have to pay when you go to the doctor.

Helen: That’s interesting. I’m actually thinking of when you buy airline tickets and you buy just by the price of the ticket or if you add in the baggage fee and everything else. It’s almost the same where you’re doing the math.

Lynn: Yes, that’s a similar idea. Let’s take into account all of the fees. It’s a tiny bit different with medical care. You can’t perfectly predict that whereas when you go on the airline you may have a very good idea of how many bags you’re going to check, but it’s the same general idea.

Helen: Is part of this choice architecture deciding what goes at the top or what goes at the bottom? Do you do the most expensive and the least expensive? Where do you start?

Lynn: I personally like the idea of this total estimate cost, so somewhere on the screen you would see what the premium is and what some of these cost-sharing dimensions are that we talked about before, things like deductible. You also see that combined number so that you have a good sense of, “How much am I going to have to pay all together?”

By showing that, you help consumers not make the mistake of only looking at premium.

Helen: I’m just looking at how you would sort them. I think many of us listening as health literacy advocate fans probably write materials, and I know that I’m often faced with what comes first. Do I start with something that’s least expensive, most expensive, most common or least common? When they sort your total estimated cost, which one would come first?

Lynn: This is a great question. This is getting at the heart of choice architecture. What I would put first is that plan with the lowest total estimate cost, which might not be the same as the lowest premium.

Helen: You would start with the lowest. Is that standard practice for choice architecture, or is it all just being figured out right now?

Lynn: It’s both. In many states, as they think about how to implement the new law, they’re thinking about how to do their choice architecture. However, when we did our study and looked at six tools that are in the market today, we found that four of them use this. I think it is the coming thing. This is what we will be seeing more of. It’s a well-regarded way to present choices to consumers.

Helen: I’m fascinated by this, and I’m thinking of so many options I see to make choices out there. Can you translate this to general health information? What lessons can those of us who write for consumers every day take from this concept of choice architecture?

Lynn: If you’ll allow me a lot of generalization, I think there are two key things.

One is that I believe health insurance literacy is significantly different from more general health literacy. There are a whole bunch of concepts that consumers need to know to be effective and confident, health insurance shoppers, and we may need to get better as a community about thinking about health insurance literacy quite distinctly.

Helen: Tell us more about that because that’s new to me. Of course, I know health literacy, but I’m not well versed in health insurance literacy.

Lynn: Health literacy is an amazing field because it has had such a large impact on how we think about consumers. Primarily, it impacts how we think about them engaging with their providers.

A lot of the studies out there are trying to answer questions like, “How can we make prescriptions more understandable for consumers? How can we activate a consumer when they’re talking to the physician? How can we make sure they understood the physician’s instructions, etc.?” It’s taking place in this realm of, “I’m consuming medical services.”

Over here in the realm of, “I’m trying to buy health insurance coverage,” I think that we haven’t dug deep enough to understand what barriers facing consumers are there.

As a single example, when we did consumer testing having to do with health plan shopping, we found out that there are three distinct things that are hard for consumers about the concept of co-insurance.

That’s the nuance to understanding that I think we need to cultivate if we’re going to improve their ability to function in the marketplace. It’s very specific to these insurance concepts that you really need to have mastered or simplified for them to be good, activated shoppers.

Helen: I agree with you. There are a lot of distinctions in there. You also use the word “shopping.” Shopping and getting healthcare is nothing I’ve ever quite put together in a way, but you’re bringing up so many concepts that I can see in my life in both fields where there’s health insurance or active healthcare that are filled with nuances.

What else would you like us to consider? Translate for us from the world of health insurance to the world of care. What else would you like us to consider when we present choices to people?

Lynn: I would be so happy if, as the result of your podcast, there was widespread recognition that we even have to pay attention to choice architecture and that not all decisions about how to array choices are alike. There are important differences. Some are consumer friendly and some aren’t, so just that basic message would be wonderful.

The natural follow-up question is, “Which are the consumer-friendly ones?” We talked about providing total estimated cost for consumers. Another thing that consumers are very interested in is the ability to filter their health plan choices by whether or not their doctor participates with that health plan. That’s changing your choice set by this dimension. Is your doctor in the health plan? That’s something consumers are very interested in.

Helen: If I can translate that to acute care perhaps, it’s that issue of personal relevance. Does this matter to me rather than does this just basically matter? Is that a correct translation?

Lynn: That’s a dimension of it. Another dimension is that there are so many things that vary across health plans that consumers need a way to narrow down the options so it becomes a manageable set for them to look at.

Whether or not their doctor participates is very important to them, so it just appeals to them as a way of narrowing down the different things they have to consider before they make a decision.

Helen: That would apply in other situations as well. If I go to an ice cream store that has 42 flavors, that’s about 40 too many choices for me.

Lynn: There’s a famous experiment where the researchers were in the supermarket. In one case they had about 30 jars of jam and in the other case they had six.

The result of the experiment is that although you would have thought consumers faced with 30 choices would have said, “That’s good. I like having so many choices,” in reality they came to a decision less often and were less satisfied with their selection. They were worried they had left a good choice on the table. When they only had six choices, they purchased more often. They actually made a decision and were more satisfied with their decision.

Helen: That’s really interesting. What do you see as a magic number when it comes to either choosing health plans or choosing a treatment or something? Is there a magic number?

Lynn: That is a great question. When it comes to choosing treatment, my research doesn’t speak to that. When it comes to looking at health plans, there are some tradeoffs that policymakers need to consider.

If the underlying health insurance product has been greatly simplified, which is something they did in Massachusetts, then you can have more choices because there are fewer moving parts that you have to look at.

If the underlying products are still very complex like they are on today’s market where the number of services covered can change and there are so many aspects to cost sharing that it’s really hard to figure out and compare it, and then there are exceptions, you probably want fewer choices to make it easier to account for all of those moving parts.

A third dimension is how good is the tool that allows you to compare your choices and maybe does things like we talked about, such as total estimated cost and doing the math for the consumers? If those shortcuts exist, you can have a few more choices because the cognitive burden of comparing them has been eased by the tools.

Helen: Thank you. You’re talking about doing the math. Earlier you spoke about the stories or scenarios that make it very real, limiting the choice and thinking through what order your choices go. What about visuals in this? The visual I’m thinking about is some kind of a table. Does that work or not work in comparing A, B and C all on the same line going across?

Lynn: Consumers definitely have a preference for being able to line up their choices and look at them side by side. The research varies in terms of how many they want to see at one time. Some people would really prefer to see only three at once, and others would like to see quite a bit more, but the visual that you’re talking about is very important.

If you’re very good with design and you provide visual clues to the consumer, by showing them what they have to do next and visual clues that lead them through the display, you can have more information in that display. I’ll give you one example.

Coming back to this tool that federal workers see, you’ll see many health plans and about six or seven attributes about the health plans all on a big table. The attribute which was used to sort the list of health plans is highlighted yellow so it pops right out to you. You know exactly how they’re sorted. If that’s not what you intended, you can change that sort order. That’s an example of a fantastic visual clue.

Helen: It seems like, in ways, you’re using the principles we’ve known in health literacy for good communication. You’re applying it in those extraordinarily complicated, financially heavy situations. I have a feeling you’re just giving us a tiny taste of all that’s involved here. I’ve got about a zillion questions, but we don’t have unlimited time. How can people learn more about this?

Lynn: Thank you for asking. We have a report.

Helen: We, being who?

Lynn: Consumers Union and me, specifically. There are two that I think would be of greatest interest to your listeners.

One is titled “The Choice Architecture,” the concept we’ve been talking about. The other one is “What’s Behind the Door: Consumers’ Difficulty Selecting Health Plans.” The second report goes over our research in terms of what we uncovered about what’s hard and what some possible solutions might be. They’re both available at www.ConsumersUnion.org/health.

Helen: That’s great. Let’s put that link on the Health Literacy Out Loud website too. If people go there, they can click on your reports as well.

Lynn: That’s perfect.

Helen: Thank you, Lynn. I also have this book. I think I read a presentation that you gave called Facilitating State Health Exchange Communication Through the Use of Health Literate Practices. It’s a workshop summary from the Institute of Medicine. They have a round table on health literacy.

I found that to be a fascinating book looking at the many complexities, nuances and dimensions to communicating health plan information clearly. We’ll have a link to that on the website too.

Lynn: That’s wonderful.

Helen: For my last question, think ahead. If all goes well, what would this role of choice for health insurance look like in five years?

Lynn: I think that we will have made tremendous progress. Starting today, where very few consumers have a robust consumer-friendly method of choosing from among health plans, to where that’s available to almost all consumers and this role of choice architecture is widely understood, I feel very confident that we will be there in five years.

Helen: That’s wonderful. Thank you so much for playing such an important role along the way and making this happen. Thank you so much for sharing your expertise, wisdom and lessons learned with listeners of Health Literacy Out Loud.

Lynn: You are very welcome. Thank you for having me.

Helen: I learned so much from Lynn Quincy, and I hope that you did too, but Health Literacy isn’t always easy. For help clearly communicating your health message, please visit my health literacy consulting website at www.HealthLiteracy.com. While you are there, sign up for the free enewsletter, 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 mobile 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.