In many of the discussions about creating empowered, engaged patients, I hear a common theme: that improving the general health literacy of Americans will largely solve the problem. It’s a view that, in hindsight, I’ve generally agreed with. If only health consumers understood the problems, challenges and tradeoffs of healthcare more fully we would stop bad behavior and when injury or illness occurred, we would make better decisions.
I have come to the conclusion that I’ve been wrong.
This idea has been percolating for a few weeks in the back of my mind after listening to a podcast debating a similar question for financial products. The always thought provoking Freakonomics podcast, an extension of the successful books of the same name, looked at the question of financial literacy as a way to prevent the next financial crisis.
We know the recent financial crisis had many causes, but at the bottom of the food chain were a lot of individual consumers who took out loans they couldn’t afford. Some of those loans couldn’t be afforded because the monthly payments were simply outside what’s reasonable for that individual’s income while others were very complex instruments in which payments ramped up dramatically over the course of the loan and, in some instances, included expensive penalties which made refinancing all but impossible.
So the argument which follows states that a consumer with greater financial literacy would have understood the intricacies of these instruments and never would have agreed to the preposterous terms of the loan. This argument appeals to my laissez-faire streak. After all, I was presented with adjustable rate mortgage options when I refinanced in that same timeframe, realized immediately that the loans were ridiculous, and rejected them outright. If we gave the consumer my level of financial literacy, then we’d have no crisis – right?
But the counter-argument recognizes the impracticability of this answer. I have an MBA with a lot of finance courses under my belt. If that’s what it takes for consumers to make bad decisions then the process is fundamentally broken.
The counter-argument states that financial products are complex. The contracts explaining them are complex. Building a base of knowledge in the general population that would allow them to work through all of that and understand the implications is far too expensive given that this is the sort of transaction that they’ll deal with only a few times in their lives.
Implications for healthcare.
Now look at healthcare. The same assumptions underlying the financial products problem certainly hold true. Healthcare is complex. Building an understanding that would allow for general good decision making in those relatively few occasions in an average consumer’s lifetime is difficult if not impossible. Certainly, it’s a very expensive undertaking and probably prohibitively so.
In the field of usability design, for both online usability and usability of real-world products, there is a general rule that you should design so consumers aren’t able to make bad decisions. In the Web world, for example, you shouldn’t allow a search form to allow for combinations of options that return no results.
Could we structure the financial services problem to prevent consumers from making poor choices? Absolutely. Today, most of us need to opt-in to our employer’s retirement plans. When I worked at an academic medical center, the opposite was true and they automatically made my contribution high enough to max-out my employer’s match. This seems like a simple concept, but when employees need to opt-in to such plans, millions don’t contribute at this level – resulting in money being left on the table.
Likewise, as we speak about health, making good choices is often more difficult than making poor choices.
Blue Zones and making better choices.
The closing keynote speaker at HIMSS this year was Dan Buettner, the author of Blue Zones. Over the past several years, Dan has been looking at a few distinct communities around the world that live far longer than the rest of us with fewer health complications. This work spawned a few articles for National Geographic, a book titled Blue Zones, and an experiment in deploying his findings in an actual community in the U.S.
The test site for the Blue Zones concept was Albert Lea, MN. In this community, they have been able to create an environment where good choices for health and longevity are easier. It’s a holistic attack on the problem, building sidewalks and green space to encourage physical activity, growing the variety and prominence of good food choices, and building support structures between members of the community.
The approach recognizes that we don’t all want to be unhealthy. It’s simply that unhealthy choices have become the path of least resistance. Our communities are so spread out, we never walk anywhere. Our jobs keep us at desks, so we get very little routine physical activity. Fast food and junk food are easily available any time day or night, and they’re marketed and presented to be more appealing manner than healthy alternatives.
More information isn’t necessarily better.
This is not to say that some degree of education isn’t necessary. Within the realm of good options, there are choices to be made, and with a lack of any understanding of the concepts, there is simply no way to facilitate that decision making process. For example, in financial services, many Americans don’t understand interest compounding, so it is very difficult to have any discussion about the pros and cons of investment options.
Given a basic level of understanding, these decisions can be facilitated if the relevant information is presented transparently and clearly. Handing a consumer a loan contract is certainly complete information, but it requires that person to be able to interpret a lot of detail and understand implications. A more effective approach is to be clear when explaining the relevant implications directly.
Another HIMSS speaker, Dr. Neil Izenberg, CEO of pediatric health content provider, KidsHealth, addressed this question in the context of medical diagrams. Such diagrams, he explained, aren’t typically designed for consumer use. They show too much detail, and leave it to the reader to extrapolate the implications. More detail doesn’t help the casual health consumer’s understanding.
Health literacy also falls short because many of the challenges health consumers face relate to accessing and navigating the healthcare system rather than the intricacies of their specific healthcare condition. Programs such as cancer navigators are designed to help patients access care and navigate barriers, but such programs exist only for a small number of conditions and at a limited number of organizations. These programs are labor intensive, making their ability to scale to many common or chronic health challenges such as diabetes more difficult. Doing so is critically important, however, which is why this is incorporated as a key piece of new healthcare delivery models such as medical homes.
The goal, therefore, must be to simplify the healthcare system, at least from the patient’s perspective, and provide better tools for health consumers as they deal with healthcare challenges. As we look to the demands on the healthcare system with more patients using more healthcare services and little in the way of additional resources to work with, it’s clear that technology will need to step in and facilitate changes to healthcare in the way that it has for other industries. There’s no doubt that it’s an exciting time to be working in healthcare!