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Appendix A: Numeracy and the Affordable Care Act: Opportunities and Challenges
Pages 91-136

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From page 91...
... Numeracy skills needed to select a health plan, choose treatments, and understand medication instructions include education-based skills and emergent decision-based abilities. We estimate that the skills needed to make many complex, informed health decisions (e.g., management of chronic diseases)
From page 92...
... Of particular importance will be numeracy skills needed to make informed choices about which health plan best meets individual needs, how to make informed treatment decisions (e.g., X treatment has a 5 percent greater risk than Y) , and understanding medication instructions.
From page 93...
... 2. What kinds of numeracy skills are needed to select a health plan, choose treatments, and understand medication instructions?
From page 94...
... are expected not to be able to perform this sample life insurance task. Results from the NAAL indicated that 22 percent of American adults are at the Below Basic level, 33 percent are at the Basic level, 33 percent are at the Intermediate level, and 13 percent are at the Proficient level of quantitative literacy.
From page 95...
... 101% 100.1% 100% Population or or 200,227,629 31,915,404 168,312,225 NOTE: Individuals at each level of quantitative literacy are thought to have the skills identified at that level, but are thought to not have the skills at levels above their own (e.g., an individual with Below Basic quantitative literacy should have the skills located in that row, but would not have the skills located in the rows for Basic, Intermediate, or Proficient literacy)
From page 96...
... The proportions of individuals at each quantitative literacy level are based on the overall U.S. population, however, and may not accurately reflect the numeracy abilities we should expect from previously uninsured adults who will now enter the health care system as the result of the Patient Protection and Affordable Care Act (ACA)
From page 97...
... QUESTION 2: WHAT KINDS OF NUMERACY SKILLS ARE NEEDED TO SELECT A HEALTH PLAN, CHOOSE TREATMENTS, AND UNDERSTAND MEDICATION INSTRUCTIONS? Education-Based Numeracy Skills Apter and colleagues (2008)
From page 98...
... When choosing a health plan from a health insurance exchange, for example, consumers must be able to read and understand basic fees and use simple arithmetic operations, such as adding costs together. Such understanding is a fundamental building block to deciding which health plans they prefer and can afford.
From page 99...
... Skill Categories Numeracy-Related Tasks Basic Reading numbers, counting, telling time Arithmetic operations Estimation of size, trend Computational Frequency Percentage Problem solving and inferring the mathematical Education-based concepts to be applied numeracy skills Logic Analytical Reading tables Reading graphs Reading maps Estimating error, uncertainty, variability Statistical Relative versus absolute Risk (cumulative, relative, conditional) Information Seeking numeric information rather than seeking avoiding it Willingness to perform computation Attention More likely to attend to numeric information in a complex display Able to disregard irrelevant information Emergent presented with numeric information decision-based Memory Recall numeric information from memory numeracy skills Information Sensitivity to numeric information sources sensitivity Sensitivity to non-numeric information sources when numeric sources are available Affective meaning Derive affective meaning (i.e., a sense of goodness or badness)
From page 100...
... . With respect to the NAAL quantitative literacy levels (Below Basic, Basic, Intermediate, and Proficient)
From page 101...
... . In the case of choosing a health plan, less numerate individuals might seek out, attend to, and be
From page 102...
... Proficient Calculate an Estimate total Basic; Computational; employee's share annual cost Analytical; Statistical (8.6% of of health insurance of the health uninsured costs for 1 year, plan, including Information Seeking; population) using a table that premiums, copays, Attention; Memory; shows how the and deductibles, Information Sensitivity employee's monthly based on expected cost varies with health care needs income and family (e.g., estimating size.
From page 103...
... Basic Perform a two-step Calculate the Basic; Computational; calculation to find difference in Analytical; Statistical (33.4% of the cost of three percentages uninsured baseball tickets, of patients Information Seeking; population) using an order who survive Attention form that gives the one treatment price of one ticket compared to and the postage another.
From page 104...
... should you order a refill to make sure that you do not run out of your prescription? Intermediate Determine what "The patient Basic; Analytical time a person can forgot to take this (29.3% of take a prescription medicine before Information Seeking; uninsured medication, based lunch at noon.
From page 105...
... In one study, for example, less numerate participants could usually understand which consumer-directed health plan had the lowest monthly premiums (we estimate this task to require Below Basic ability) , but only about a third of them were able to identify which health plan was better if the patient needed a lot of care (a more difficult task that likely requires at least Intermediate ability)
From page 106...
... The reason for this difference appeared to be that highly numerate individuals developed more precise feelings about the 9 percent chance of winning than the less numerate. Being able to derive affective meaning from numbers and number comparisons is important in a health environment to compare treatment effectiveness or health care costs.
From page 107...
... , the highly numerate may sometimes demonstrate worse judgments than the less numerate. Perhaps because of their greater abilities to attend to numeric information and draw affective meaning from it, highly numerate individuals tend to show a greater sensitivity to numeric information in health compared to the less numerate.
From page 108...
... The emergent decision-based abilities have not been linked explicitly with the four NAAL quantitative literacy levels. The extant research, however, supports these emergent abilities being present more among highly numerate individuals than the less numerate.
From page 109...
... . Selecting the health plan with the lowest cost based on the annual premium and deductible for a family is expected to be a Basic skill doable by about 71 percent of the uninsured population (everyone except those at the Below Basic level)
From page 110...
... . Beyond the difficulties posed in making the calculations to compare different health plans, individuals with Below Basic performance may be more prone than other individuals to focus on the most salient cost involved in health insurance, which, based on an analysis of Medicare Part D choices, is likely to be monthly premiums rather than out-of-pocket expenses (Abaluck and Gruber, 2011)
From page 111...
... With at least a Basic level of quantitative literacy (an estimated 71.2 percent of the uninsured population) , patients should be able to calculate the difference in survival rates between two treatment options when provided with the percentage of patients who survive.
From page 112...
... One NAAL task identified as at the Intermediate level of performance requires patients to understand medication information and infer, based on instructions, how to handle a missed dose, taking into consideration the time since their last meal. The management of chronic diseases such as diabetes and asthma pose particular challenges, even for those with Proficient quantitative literacy.
From page 113...
... ; • Provide evaluative meaning, particularly when numeric informa tion is unfamiliar; • Draw attention to important information; and • Set up appropriate systems to assist consumers and patients. Most strategies targeted toward the education-based numeracy skills from Table A-2 can be found in the section focused on reducing cognitive effort.
From page 114...
... Keep denominators and time spans constant Use numbers consistent with how people use the number line Do the math for them Use appropriate visuals Provide evaluative meaning, Carefully use evaluative labels and symbols particularly when numeric information Carefully use frequency versus percentage is unfamiliar formats Use other, more imaginable data formats Use emotion to persuade Draw attention to important Order information with the most important information information first or last Highlight the meaning of only the most important information Use a framework to provide an overview Use fonts that draw attention to important information Set up appropriate systems to assist Identify communication goals consumers and patients Choose information presentation formats strategically Consider the use of default options and other choice architecture Use computer-aided decision tools Use information intermediaries Provide Numeric Information (as Opposed to Not Providing It) In consumer domains such as purchases of homes and lottery tickets, numeric information (e.g., mortgage rates and likelihoods of winning)
From page 115...
... Reduce the Cognitive Effort Required from the Patient or Consumer and Require Fewer Inferences from Them (i.e., Do the Math for Them) Provide Fewer Options A breast cancer communication tool called "Adjuvant Online!
From page 116...
... The notion of providing fewer options may be particularly relevant to health plan selection. Numeracy effects have not been studied to the best of our knowledge, but it seems likely that providing fewer options would be especially helpful to the less numerate.
From page 117...
... To facilitate comparisons, use the same time frame when presenting risks and benefits (e.g., provide annual costs for all health plans rather than monthly costs for some and annual costs for others)
From page 118...
... Use Appropriate Visuals Presenting event rates with visual aids such as pictographs (also called icon arrays) , bar charts, or flow diagrams may aid accurate understanding of numeric information such as probabilities.
From page 119...
... . We can determine meaning through considerable effort in comparing and contrasting available information; this is especially true for the highly numerate (Peters et al., 2006a)
From page 120...
... . Less numerate participants (but not the highly numerate)
From page 121...
... . The choice of format will make little difference to the highly numerate, but will matter to the less numerate (see also Dieckmann et al., 2009; Peters et al., 2006b)
From page 122...
... (2002) , for example, found that ordering health plans by performance within premium cost strata resulted in more choices of higher performing plans compared with presenting the information unordered.
From page 123...
... With numeric information, this may be particularly true for less numerate consumers (see review of attention effects in the section on emergent decision-based numeracy skills)
From page 124...
... For each type of decision the previously uninsured population will need to make, effective communication will depend in part on identifying information that is more and less important and identifying options that are dominated and dominant. Doing so will allow communicators to take some of the recommended steps to reduce cognitive effort, highlight evaluative meaning, and draw attention to important information in ways that facilitate appropriate comprehension and use of numeric information.
From page 125...
... Such strategies may be quite important given the small proportion of the ACA population expected to have Proficient levels of quantitative literacy and to be able to perform such calculations (see Table A-3)
From page 126...
... and emergent decision-based numeracy skills (from seeking out numeric information to deriving affective meaning from it)
From page 127...
... 2012. New state insurance exchanges should follow the example of Massachusetts by simplifying choices among health plans.
From page 128...
... 2004. Literacy and numeracy skills and anticoagulation control.
From page 129...
... 2002. Strategies for reporting health plan performance information to consumers: Evidence from controlled studies.
From page 130...
... 2010. Breast cancer patients' treatment expectations after exposure to the decision aid program Adjuvant Online: The influence of numeracy.
From page 131...
... In National Library of Medicine cur rent bibliographies in medicine: Health literacy, edited by C
From page 132...
... U.S. Census Bureau.
From page 133...
... and 2009-2011 Census Bureau data, we calculated an estimate of the proportion of uninsured and insured American adults who fall into Below Basic, Basic, Intermediate, and Proficient quantitative literacy categories. The 2009-2011 Census Bureau provides data on the proportion of uninsured adults at each level of educational attainment (see Table Annex A-1)
From page 134...
... We first calculated the proportion of insured adults at each level of education by using Table TABLE ANNEX A-3 Proportion of Uninsured Adults at Each Quantitative Literacy Level Below Educational Attainment Basic Basic Intermediate Proficient Total Less than/some high 17.4% 6.8% 2.7% 0.3% school High school graduate 8.2% 14.3% 9.9% 1.7% Some college 2.7% 9.7% 11.6% 3.0% Bachelor's degree 0.5% 2.6% 5.1% 3.7% % uninsured adults 28.8% 33.4% 29.3% 8.6% 100.1% at each quantitative literacy level
From page 135...
... population for each education level, and then divided that number by the total number of insured adults. Next, we followed the same multiplication and summation computations previously described with the uninsured population, but used the insured proportions.


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