Mark Hochhauser, Ph.D.

Managed care is complicated, so it's not surprising that "average" Americans have a hard time reading and understanding documents from their health plans. Yet it is possible to convey the information clearly.

The 1993 National Adult Literacy Survey studied prose literacy (skills needed to understand and use information from texts), document literacy (skills needed to find and use information in forms and schedules) and quantitative literacy (arithmetic skills).

On a scale from 0 to 500, high school graduates (about 75 percent of the population) had an average prose score of 270 (able to interpret instructions from an appliance warranty), a document score of 264 (able to identify and enter background information on an application for a Social Security card), and a quantitative score of 270 (able to calculate total purchase costs from an order form).

About 7 percent of the population can't read English very well; 10 percent can't write English very well; 9 percent get help with printed information from family or friends; 12 percent get help filling out forms, and 5 percent get help with basic arithmetic. Both literacy and educational level play an important, but often unrecognized, role when a managed care company attempts to communicate with enrollees.

'Understanding' emergency care

"We cover emergency care delivered in our network, if the care required is an eligible service set out in parts A, B, C, and J of this section, and if the situation is a medical emergency.... If you receive care in a nonparticipating facility for a condition which is not a medical emergency and you did not receive referral from our provider, there is no coverage for such care under this part." That second sentence, with one "non-participating," two "nots" and one "no," is probably incomprehensible to most readers.

A typical managed care booklet has more than 50 pages of instructions. One health plan says: "If you use a nonparticipating provider for certain nonemergency services, you or the provider must notify us 5 working days in advance," another that "We will not cover emergency care out of the network if you have left the service area and, in the judgment of your physician, the need for such care could have been foreseen before you left."

In adolescence, thinking changes from simple to complex, from concrete to abstract, from immediate to long-term consequences. Many adolescents will progress to a mature level of adult thinking — but some will not. Thus, some adults will think and behave more like adolescents than adults.

One explanation for adolescent risk-taking is that people of that age are not yet able to imagine the consequences of their behavior. In the same way, some adults have a hard time imagining the consequences of their health decisions. You're only young once, but you can be immature all your life.

Many HMO booklets assume that patients can think "in the future," but not all can do that.

One booklet italicizes words with special meanings and tells the reader to look them up in a "definitions" section. The sentence "To be eligible for coverage as Tier 1 benefits, you must obtain a referral recommendation from your primary care clinic or a preferred physician practicing in the specialty in which the nonpreferred provider from which you choose to receive services practices" has four words that should be looked up for their definition. Do readers look up one word at a time, or all four words at one time? Can they remember the definition when they return to the original sentence?

The definitions themselves have italicized words! To understand the concept of "deductible," the reader should look up "eligible ex-penses," "claims," "nonpreferred providers," "benefits" and "plan."

Short-term memories

While many italicized words are repeated, understanding the material still requires a good working memory, also called short-term memory. In this situation, working memory is the ability to remember the definition of the word that was looked up and to incorporate that meaning into the original sentence. Working memory tends to decline with age, so it shouldn't be surprising that older readers may find it impossible to understand a sentence that requires them to flip back and forth between the sentence and the definitions. This becomes even more of a problem when a patient changes health plans, since each plan has its own vocabulary. Is a "preferred provider" the same as a "participating provider"?

Legibility matters

Managed care information is often presented in too-small type — especially for readers with middle-aged eyes. Although legibility demands about 40 characters and spaces per line (maximum of 70) regardless of line length, the managed care booklets that I reviewed had twice as many. They averaged 18 per inch and 130 characters per seven-inch line, with one page of single-spaced text having 50 lines of text and 800 to 1,000 words. This combination of small type, long lines, single spacing and very little white space creates a booklet that is hard to read.

Health information should be readable by the average patient. A booklet at grade 17 suggests to many that the reader needs a graduate school education to read and understand the material. Grade 17 means the material is very complex — long sentences (30 words or more), words with three or more syllables, unfamiliar words.

But grade levels only estimate the complexity of the writing on the basis of words per sentence, syllables per word, percentage of big words in the text and similar calculations. Grade level should not be relied upon as the only measure of text complexity. Employing readability scores alone for a text diagnosis is like using a patient's temperature alone for a medical diagnosis. The information is necessary, but not sufficient.

Another complication is that average people read several grades lower than their highest educational achievement. Writing at the twelfth- grade level may be too demanding for someone who finished twelfth grade. For the public, writing should be at seventh- or eighth-grade level.

I evaluated the readability of membership booklets from three health care plans in Minnesota (see table) and found that they were at college or graduate school reading levels, and difficult or impossible for some readers to understand.

What to do?

Standardization would help. Couldn't managed care organizations work on a set of common terms, definitions, concepts and layouts to break up the Tower of Babel that has been built over the past decade? Take a tip from the securities industry, which realized that customers have a hard time reading and understanding stock prospectuses. The Securities and Exchange Commission has been working on a "Profile Prospectus" that includes basic investment information in legible type and readable format.

Test for readability. One way is to use readability software to make sure the target population can read the booklets. But writing at a lower grade level may not be more understandable if some of the other issues, such as type size and line length, aren't addressed. An even better route is to use consumer groups to help evaluate and rewrite the materials. Make sure that the materials are written in ways that are consistent with human behavior.

The cost of testing would probably be offset by having fewer customer service calls, fewer complaints and fewer medical and financial problems with patients who don't understand their coverage.

Use computer technology more effectively. Graphics programs offer many ways other than text to present information. Not only would better design help break up 50 pages of single-spaced text, but appropriate graphics would enhance understanding of the material.

Mark Hochhauser, Ph.D., a psychologist, is on the faculty at the Graduate School of America in Minneapolis. He has advised federal agencies, law firms, health care organizations and investment companies on readability issues.