Why is there a U.S. Annual Excess of $200 Billion in Healthcare Expenditures?

By John W. Lacey, III, MD with input from Tennessee’s previous First Lady Crissy Haslam

Ninety million U.S. adults, including 36% of adult Tennesseans, have basic or below basic ability to obtain, process, and understand the fundamental health information and services needed to make appropriate health decisions— the Institute of Medicine’s definition of health literacy.

The financial impact of low health literacy is an astounding $200 billion in annual excess U.S. healthcare expenditures, of which $3.8 billion is attributable to low population health literacy in Tennessee (International Journal of Health Policy and Management, 2015). If the costs and the underlying health problems are to be mitigated, physicians and other key stakeholders must begin to actuate impactful interventions through leadership, advocacy, and role modeling.

A fully health-literate person is able to access healthcare services, analyze relative risks and benefits from recommended treatment plans, and calculate dosages and health insurance cost options. Such patients are able to communicate with healthcare providers by articulating their health concerns, accurately describing symptoms, asking pertinent health questions, and understanding spoken medical instruction. Full health literacy enhances test result interpretation and facilitates locating health information from a variety of sources.

The consequences of low health literacy affect people across all demographics but especially those of lower socioeconomic and minority groups, limited educational attainment and lower cognitive ability, as well as those at the poles of age and those for whom English is a second language. Only 13% of English-speaking adult Americans have fully proficient health literacy skills according to the United States Department of Education. Tennessee is not statistically different.

What makes improving health literacy so critical in Tennessee is reflected in our overall health ranking in 2017— an all too consistent 45th among states in “America’s Health Rankings.” The imperative to engage fully any malleable factors that can bend Tennessee’s health curve in a positive direction is clear. Literacy/health literacy are such factors.

Where then should we begin? Health literacy begins with literacy, so a logical point of embarkation is at the earliest steps in our children’s journey toward literacy—a set of reading, writing, basic math, speech, and comprehension skills. These building blocks of literacy are first laid in early childhood. Eighty percent of brain development occurs by age three, and 90% of synapses are formed by kindergarten. Tennessee children who haven’t developed some basic literacy skills by the time they begin school or are not reading proficiently by end of the third grade have a fourfold increased risk of not completing high school. Two-thirds of children who don’t read proficiently by the end of the fourth grade will be on welfare or experience incarceration at some point in their future. Having Tennessee’s children prepared for success in education and health matters because of the direct impact on the future of all Tennesseans— our workforce, economy, and the kind of place where we will live, work, and raise families. The reality we face in 2018 is that only 34% of Tennessee’s third graders are reading proficiently (Tennessee Department of Education).

Development of literacy/health literacy is affected by multiple factors including age, language, culture, health status and experiences, as well as cognitive and psychosocial abilities that evolve from early childhood forward. However, some of the most powerful influences emanate from adult caregivers—parents, grandparents, teachers, coaches, other adults in the home. As illuminated by research that directly measures literacy levels, childhood health literacy is shaped to a significant degree by parents’ health literacy, knowledge, health system experiences, attitudes, and behavior. These ultimately affect both childhood health literacy development and health outcomes. Examples of such health outcomes include the impact of maternal literacy on child glycemic control. Low maternal literacy portends compromised control. Children are much more likely to manifest symptoms of depression and withdrawal when their mothers have depressive symptoms and low health literacy, as opposed to the scenario when mothers have depression and proficient health literacy. Low health literacy is implicated in reduced prenatal screening, lower immunization rates, poor dental health, improper medication dosing and diminished understanding of consent forms and process management of diseases, including asthma and diabetes. Low parental health literacy is associated with the child experiencing an increase in all-cause hospitalization and total health service usage, substance abuse, pre-teen alcohol use, and behavior such as gun carrying and fighting. If the family environment is one of abuse or household dysfunction resulting in exposure of the child to adverse childhood events (ACE), the risk of chronic disease and disability is compounded.

A home environment that fosters health literacy helps pediatric patients reach the achievement-guided independence to co-manage their health. This transition most often emerges between 11 and 15 years of age. Data gathered by the Tennessee Office of Coordinated School Health gives urgency to defining and deploying interventions that support this transitional advancement of childhood health literacy. More than 233,000 or 23% of Tennessee public school students (K-12) have a chronic condition or disability diagnosis—the most common being asthma (30%), ADHD/ADD (21%), and severe allergies (14%). Some 3,700 children or 1.5% have a diagnosis of diabetes. Chronic illness and disability diagnoses have increased by 209% since the 2004-2005 school year. More than 12,000 students receive a daily health procedure by a licensed healthcare provider while at school (such as blood glucose monitoring) with another 4,300 performing their own monitoring without assistance.

Tennessee has established excellent health education and lifetime wellness standards for K-12, divided into three grade bands (K-5; 6-8; 9-12). The standards define developmentally appropriate learning experiences and knowledge that support our children’s journey toward health literacy, with skills for self-care participation and a framework for life-long health learning and wellbeing—if these standards are fully implemented and resourced. This school year only 40% of school districts are providing comprehensive health education for all students (K-12). This underachievement, in conjunction with our low rate of reading at grade level, augurs poorly for enhancing health literacy—much less health outcomes—for Tennessee’s children. Now is as late as we dare wait to pursue meaningful course corrections if we are to reach the health targets we desire and our children deserve.

Tennessee ranked 42nd for the health of women and children in 2017, 40th in immunizations for children 19 to 35 months, 37th in adolescent immunizations and 38th in infant mortality. Seeds sown in childhood for poor health literacy bear the expected fruit. Tennessee ranks 44th for senior health and premature death (years lost before age 75 per 100,000 population). While we rank 9th in high school graduation, estimates suggest more than 60% of graduates have basic or below-basic health literacy.

A compendium of research on health outcomes for adults afflicted by low health literacy includes lower general health status, reduced participation in health insurance, higher rates of hospitalization and hospital readmission, lower use of preventive health services, more unnecessary ER visits, higher morbidity and mortality for heart failure, less effective self-care for chronic conditions, more medication adverse effects and improper use including opioids, and decreased understanding of nutritional labels and informed consent. The Knoxville Academy of Medicine’s Project Access Program has found low health literacy second only to transportation among the frequency of socioeconomic barriers hindering optimum health care coordination.

So at a time of rapidly advancing medical knowledge and technology as well as the possibility of bringing these to bear on our most intransigent health challenges, low health literacy remains a sinister stumbling block: Too many around us are unable to seize the moment of improving their own or their children’s health.

Since publication of the “National Action Plan to Improve Health Literacy” (U.S. Department of Health and Human Services 2010) and “Healthy People 2020” (U.S. Office of Disease Prevention and Health Promotion 2010), focus has intensified on the role and responsibility of practitioners and other components of our healthcare system in addressing low health literacy. Evolving payment methodologies (including Medicare and TennCare); growing racial, ethnic and cultural diversity; and broadening definitions of healthcare quality have contributed as well. For hospitals, new imperatives to define and inculcate countermeasures have arrived via the Joint Commission’s linking health literacy to patient safety and the introduction of the concept

of health-literate organizations by the Institute of Medicine.

Multiple organizations representing physician interests such as the AMA, the American Academy of Pediatrics, the Academy of Family Physicians, the American College of Emergency Physicians and others have published research, reviews, or recommendations to guide physician practices regarding approaches to the low health literacy challenge.

So where should Tennessee physicians begin? Which practical tactics are supported by research of acceptable methodological strength to consider in your practice? Consider beginning at home. As adult caregivers—parents, grandparents and volunteer mentors— reading to children daily from birth is meaningful in fostering and reinforcing brain development and literacy. Supplement school health offerings with grade-appropriate “home use” friendly programs that take advantage of your knowledge to fill in gaps in progression toward health literacy. The OrganWiseGuys materials (organwiseguys.com) have been thoroughly vetted with good outcome p-values and are reasonably priced.

In your practice, consider employing the 2017 AHRQ Health Literacy Universal Precautions Tool Kit (ahrq.gov/literacy). The information includes approaches to improve spoken and written communication as well as patient self-management tactics. This tool kit includes 21 realistic, evidence-based interventions ranging from a “brown bag” review of medications to effective implementation of teach-back methodology. These practices move from assuming that all patients understand what we communicate to embracing that they often don’t understand essential information when they leave the office. The AHRQ kit tools can help physician practices meet Patient Medical Home certification/recognition standards for NCQA, the Joint Commission, and URAC. A crosswalk between the tools and related standards is available. Support and lead the deployment of similar tactics at your hospital.

At community and school district levels, leverage your authority and credibility in health matters to advocate for full implementation of Tennessee’s robust health education and lifetime wellness standards for grades K-12—including the developing focus on opioid misuse. Also, use your credibility to encourage young parents to support development of health literacy in their children and to enhance their own acumen/proficiency.

Seek allies such as the Office of Coordinated School Health, The Institute of Agriculture at The University of Tennessee, and local libraries. The Executive Director of Healthy Schools, Lori Paisley, reports that, “Tennessee is the only state in the nation that funds a Coordinated School Health presence in every school district. This program is an effective approach designed to connect health with learning. It encourages healthy lifestyles, provides needed supports to at-risk students and helps to reduce the prevalence of health problems that impair academic success.” This represents an important step, but more steps must follow. The Extension at The University of Tennessee’s Institute of Agriculture has agents across the state in each county providing programs aimed at equipping parents of young children and child care providers with tools to enhance reading capabilities for Tennessee’s children. These agents will welcome your input, support, and participation.

As we look around our communities and understand the lost opportunities for health and wellbeing for many of our neighbors and recognize the challenges that many of our children face in achieving and sustaining wellness, we must recommit ourselves to bending the health-outcome curve toward enhanced lives for all Tennesseans. Physicians wielding accelerating advances in knowledge and technologies while simultaneously improving the basics like effective communication and health literacy can and must be among those leading the way.