Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month, and author of the book Health Literacy from A to Z. I also produce and host this Health Literacy Out Loud podcast series that focuses on many aspects of health communication, patient education, and health literacy.

Today, I’m welcoming two guests to the conversation. Rex Wallace is founder and CEO of Rex Wallace Consulting, a firm that helps health plans improve quality. A key way they accomplish this is by helping organizations improve the experience of their members.

Jennifer Nguyen is a quality improvement consultant with Rex Wallace Consulting. Building on her background in public health and health education, Jennifer approaches quality as a genuine lever for health equity and health outcomes.

Quality improvement and health literacy intersect in many important ways. Rex, Jennifer, and I first discussed this when I was a guest on their podcast series, Beyond Quality. I’m delighted that we’re now continuing this conversation on Health Literacy Out Loud. Jennifer, Rex, welcome!

Jennifer Nguyen: Thanks so much, Helen. So happy to be here. Such a pleasure.

Rex Wallace: Yes, thank you so much Helen. It was great having you on our podcast and we’re really excited to be here today.

Helen Osborne:  Our worlds really are intersecting and you’re helping me understand that a little bit more clearly. Our audience who may be clinicians, public health folks, people involved in community organizations, and health students going into the health careers, or people just interested in these topics. We all want to know how to communicate more clearly.

Let’s communicate more clearly ourselves. What does the term, “quality improvement,” mean?

Jennifer Nguyen: I feel like what we do is just a tiny bubble in our work with a lot of health plans. We help them move forward on whatever it is that they’re working on. Let me take a step back. A lot of the plans that we work with are either Medicare Advantage or Medicaid. Some of them also provide health insurance to commercial members, members that are buying health insurance on the commercial market.

Helen Osborne: To listeners who might be anywhere in the world, this is an underpinning of the U.S. health care system. It’s a complicated system. I’m glad you’re dealing with a piece of this. Please go on from there, Jennifer.

Jennifer Nguyen: Let’s talk about Medicare today. The U.S. federal government has department called CMS (Centers for Medicare & Medicaid Services). A part of this is a program called CMS Star Ratings. We can think about that like a report card for health insurance plans. They’re measured on a whole slew of measures, 30 to 40 of them, around clinical measures such as whether members are getting their cancer screenings and flu shots.

They’re measuring how we care for our members. For instance, are members with diabetes getting their diabetes managed well. That includes a whole slew of things including the member experience–how they interact with their providers, with the plan, with their pharmacy, things like that.

When we’re talking about quality improvement, we’re talking about all those measures that are being scored on this report card and how are they doing on a scale of one to five overall.

Helen Osborne: Thank you. So it’s a one to five scale on 40 measures.

Jennifer Nguyen: Yeah, roughly so. The program changes from year to year because the government likes to keep it fun.

Helen Osborne: Ha ha! I can see you smiling and laughing. I’m glad you’re doing this work.

Jennifer Nguyen: Anything to add, Rex?

Rex Wallace: When most people think of quality or healthcare quality, they think of clinical measures, H-E-D-I-S, “Healthcare Effectiveness Data and Information Set.”

It’s a set of 200 or 300 clinical measures like breast cancer screening. Like did members get their mammogram when they were supposed to? Is their blood sugar under control if they’re a diabetic? It’s a host of measures like that. Most people historically think of healthcare quality as those measures.

CMS, the Centers for Medicare and Medicaid Services, like Jennifer said was within the federal government when they created this Medicare Star Ratings Program. They think of an expansion of the definition of quality to where now this program specifically assesses health plans on other things, too. That expands the definition of quality.

Member experience measures are evaluated from a survey that members take. It includes operational excellence measures like how quickly the plan process an appeal that the member submitted. Things like that to really assess not just the clinical quality but sort of an expanded definition of quality. I think that’s important to understand, too.

Helen Osborne: Thank you. I come at this from a health literacy lens of patient education. I’ve been involved with this for over 30 years, trying to figure out what is the definition of health literacy and how to measure it.

You’re talking about the insurance side of this, whether it’s public insurance or private payers or some variation of those. It’s very specific on a one to five scale of perhaps 40 measures here and 100 measures there. It sounds the opposite of what we’re doing. From your perspective, because I know you care about health literacy too, how do our worlds interact in that way? Please make it clear for all of us.

Jennifer Nguyen: Happy to take that. Rex and I, and actually our firm, are unique in the sense that we have all spent time on the health plan side trying to move quality improvement within these health plan organizations. What that really means is we are looking at these 40-some measures and really thinking – Where are the gaps? How do we help close them?

What I mean by that is that you have to work on all those measures. For example, in the breast cancer screening measure that Rex mentioned, we would look at our population and say, who are the ones that are overdue for their mammogram? How do we encourage them to go get this? Why is it important? How do we make that connection with them and their provider? And then making sure that they get the appointment that they need. The whole gamut is a patient journey. How do we help them navigate the health system which is overly complex.

Helen Osborne: I want you to give some examples of that intersection of quality improvements, star ratings, all these different objectives, and health literacy.

Jennifer Nguyen: The breast cancer one is kind of an easy example. If I’m looking at everyone in my population, I can look at medical claims and see who hasn’t and who has gotten a claim. Maybe I’d send them a mailer. How do I design that mailer so that members can read it, they can understand it, they know where to go, they know why this is important and why they should go get this appointment.

In our recent podcast conversation, Helen, you brought up great points about when we design a communication. We can think that it’s beautiful and that it checks the box in terms of reading levels. But who’s on the receiving end of it and what do they bring? And are we really speaking to them in a way that meets their needs and understands any challenges that they may have, social risk factors and things like that?

What about when they get to their doctor’s appointment? Are there any challenges that they have in that specific setting? How are we supporting members at those junctions?

Helen Osborne: It’s wonderful to hear from people who are looking at data, like both of you, that you’re considering the people side of this. Rex, this firm has your name on it. Tell us another example. Maybe what’s hard because Jennifer said this is a straightforward example. Please give us something that’s hard about the interaction of health literacy and these quality improvement and star ratings.

Rex Wallace: In the measure about breast cancer screening that Jennifer gave, none of those measures are easy.But you know, and I’m doing air quotes here, like the member just has to get a mammogram, right?

Helen Osborne: It’s a binary, yes or no?

Rex Wallace: Yes or no closes the gap. If the member gets a mammogram, the plan gets the credit.There are other measures within star ratings that are weighted differently. Some are more important from a math standpoint in calculating your overall score than others. Breast cancer screening is a weight of one, it’s the one of the lowest weighted measures.

In contrast, medication adherence for diabetes. That’s a heavy weight measure because it is not binary.If a member is diabetic and they’re on an oral diabetes medication, they have to refill it throughout the year. It’s measured throughout the year and to essentially make sure it’s filled 80% of all the days that should have been covered that year.

There’s this constant need to engage with the member, like every month, to remind them to refill their medication and take it for a lot of reasons. One, because it should improve their diabetic condition if they take their medication. So health literacy is actually one of the highest predictors of non-adherence in these medication measures. It’s kind of like we talked about the expansion of the definition of quality in the Star Ratings Program.

Helen, since I’ve met you, you’ve helped me expand the definition of health literacy.

Helen Osborne: Oh, thank you.

Rex Wallace: So many factors in there that go beyond just being able to read at a certain level, which is what I kind of always associated with health literacy.

Helen Osborne: Yeah! You’re a health literacy convert.

Rex Wallace: Some of the factors in there like language and culture and geography and a host of other things. Imagine a member, if they’re unable to understand for various reasons, they can’t understand the doctor or the clinician or they can’t read or whatever the case may be. If they don’t understand why they should take the medication or how to even access the medication or what happens if they skip the medication, you know, one or two days, then, you know, that impacts their likelihood of taking it and whether they’re taking it and how often they’re taking it, which is going to affect their clinical outcome as well. It not only affects that one measure. Let’s say they don’t pick up their medication for a couple of months because they didn’t understand how or something.

They’re all of a sudden non-adherent in the measure itself. Their diabetic condition is probably going to decline maybe significantly, so there are other diabetic measures that the plan will be negatively impacted on as well. Most importantly, that member is going to suffer needlessly because of these literacy challenges. So that’s another example.

Helen Osborne: Thank you. Listening to you, I’m thinking of a term I don’t know if we’ve ever discussed, the continuum of care. I often talk about how health literacy can matter all along the continuum of care.

Let me tell you how I frame that, thought it may not be in any official definition. To me, the continuum of care includes wellness and that includes screening and prevention of disease. In the example you gave, Jennifer, about breast cancer screening, that might be part of it. Someone decides to have it or not.

Then I think of the next part of the continuum, though it’s not in any specific order, access to care. Access is not just walking down the street or taking your wheelchair to a place and knowing what door to go in. It also has to do with accessing the U.S. health care system including at what point you enter whether that is a hospital, a local clinic, or a phone call. How in the world do you manage this and how do you pay for it?

Health literacy in the United States, and that’s pretty much where it got its roots more than 30 years ago, dealt with the clinical encounter. This has to do with disease management including diagnosis and making important decisions about treatment.

Rex, your example about someone who has diabetes is part of it. It’s talking about what this disease is and how medication can help.

The other really important component, the largest component is self-care. How much of our time is interacting with the healthcare system? A teeny, teeny, tiny amount. We’re responsible for our own care, or our families are, and managing all the transitions of care.

In my view, and I would expect in yours, health literacy matters in each of those. The examples you gave support that. You’re talking about different components of care. But our system may be fragmented. We might be seeing different people at different time for different body parts. How do the pieces come together?

It sounds as though we both are approaching this, whether it’s looking at more subjective or objective measures, things you can count and assign a number to, or how you’re feeling and doing that day.

In my world, I’ve had to face this. In the early days, I’ve had to address why health literacy matters. Sometimes people would say that they’ve got other more important things to do like blood tests and surgery. That’s all important, of course. I don’t see happening as much now, but it might still be scoffed at it a little bit. You’re coming from more of a number cruncher part. You ever deal with any pushback on this?

Rex Wallace: I’ve had some conversations even recently when we think about the patient and member experience and how little plans, I think, focus on this. Maybe because they do consider it as a soft thing. We have a lot of clients and health plans who invest time in training physicians, training provider offices on how to capture codes, how to close these gaps, maybe even how to communicate with patients and members in a better way.

What we don’t do, because I think a lot of what you just said, Helen, makes me also think that. Being able to advocate for yourself, whether you have literacy challenges or not. It’s such an important role of being a patient, right?

Helen Osborne: Being a person and a patient.

Rex Wallace: 100%, yeah. I think health plans should do more to train members on how to be a patient. Being aware of the of these challenges that we’re talking about. You know gave examples when you were on our show about a patient who was Spanish speaking who was taking medication. The label said, “take once per day.” He was not feeling well. The clinicians were wondering what’s going on. They finally figured out he was taking the medicine 11 times per day as “once” in Spanish means 11.

If you can recognize those things and help patients be aware of those literacy issues and opportunities to help them advocate for themselves. I don’t know exactly how to do that, but I feel like it’s a huge need and would play such a big role in helping patients have a better experience and clinical outcome and everything else.

Helen Osborne: And that’s why you’re doing the work you’re doing?

Rex Wallace: it’s a big part of why we do what we do. We talk a lot about the member experience, the patient experience, especially as most of our clients are in, like Jennifer said, the Medicare Advantage space. Our clients are serving elderly and disabled people.

We talk a lot about human connection, improving the member experience for people who are a vulnerable population.We also do some work in the Medicaid space, which are all low-income members and with real challenges and lots of barriers to care. If we can help plans serve those people better, we definitely will feel like we’ve done something right.

Helen Osborne: Thank you. Jennifer, I see you have a background in public health and health education. You’re seeing the combination of all these measures as a genuine lever for health equity. Tell us more about your perspective.

Jennifer Nguyen: I agree with what Rex said, it’s really about helping members, helping patients, right? Before diving into the health insurance and quality improvement world, I worked a little bit in nonprofit world, in patient advocacy world.

I really do think that it’s about supporting members and patients getting the care that they need, getting it when they should be getting it. One of the core things that we do at our firm is work toward changing the culture within health plans so that health plans understand that it’s not about just the measures. It’s about how an organization thinks about taking care of their member population. It’s ingraining organizations with that health equity lens. The bigger picture is moving these measures forward, performing better in quality improvement.

Everyone wants to get straight A’s on their report card, right? The reason why CMS and the federal government put this program in place is because they want to improve health outcomes for the population, like getting your breast cancer screening.

We want to get members in for their screening before it’s due so that we’re catching cancer screening early, they’re getting treatment early, there are better health outcomes. The root of all of it is really helping. On our podcast, you talked about Healthy People 2030. This is one of the ways that the government is trying to push health outcomes. They go about it by measuring in a very strange and complicated way.

That’s the lens we bring. How do we get these outcomes? For health plans, how do we help our clients understand that health equity is one of the factors that we need to solve? If organizations are approaching quality improvement without that health equity lens, without that health literacy lens. they’re never going to be a straight A student. They might be able to improve one thing really well. But the overarching picture is, are you managing your population well? Are you meeting them where they are? Quality improvement is built on the assumption that when we are communicating with members, they can understand it. They know what to do, they know where to go, and then they kind of do what we’ve asked them to, right?

But health literacy, as you said earlier, is not a soft skill. It’s the underpinning to everything that we do in terms of quality, whether it’s engaging with members and helping them to advocate for themselves as a patient in those medical encounters.

It underpins how we’re talking to our provider partners on the healthcare delivery side. Are they meeting their patients in that encounter the way that their patients need? It’s this whole wraparound thing. The organizations that really see health equity see health literacy driving all these things. They’re the ones that are doing it well. We’re just the cheerleader helping them to see it, helping them act on it, and really driving those changes. Not just measure by measure, but from this holistic perspective.

Helen Osborne: Thank you both. It seems like a worldview coming together. I think we’ve both been doing learning.

We’re going to have a link on the webpage for Health Literacy Out Loud to that interview we did together so people can see that conversation that took a slightly different approach. I think that these come together as a whole. That’s my overriding message of our conversation now.

We have a complicated system. You understand that system and see its inherent value. I am a true believer in health literacy. We’re coming together and watching our worlds interact.

Our listeners come from many frames of references, too. I hope that for everybody, there is a place for you in this conversation towards making health information and healthcare, more functional and understandable by everyone.

Jennifer, Rex, thank you so much for being guests on Health Literacy Out Loud.

Jennifer Nguyen: Thank you so much for having us.

Rex Wallace: ‘Thank you so much, Helen.

Helen Osborne: As we just heard from Rex Wallace and Jennifer Nguyen, it’s important to consider health literacy from many perspectives. That includes quality improvement and star ratings. But thinking in that big holistic way is not always easy. For help clearly communicating your health message, please take a look at my book, Health Literacy from A to Z. Feel free to explore my website, www.healthliteracy.com, or contact me directly at helen@healthliteracy.com. New Health Literacy Out Loud interviews come out the first of every month. You can get them all for free by subscribing at www.healthliteracyoutloud.com or wherever you get your podcasts. Please help spread the word about Health Literacy Out Loud. Together, let’s let the whole world know why health literacy matters. Until next time, I’m Helen Osborne.

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