Potential Health Literacy Resources for Health Plans: A Narrative Review

ABSTRACT

Objectives: Numerous health literacy (HL) resources exist for hospital, provider, and pharmacy settings, but they are limited in health plans, which are a common touchpoint for patients. The objective of this study was to identify evidence-based resources that exist or may be adopted by health plans to increase patient HL.

Study Design: Narrative review.

Methods: We first described efforts in the US addressing HL and best practices for detecting limited HL that could potentially serve as evidence-based resources for use in health plan settings. Next, identified resources were examined for an evidence base by reviewing existing peer-reviewed literature (limited to 1999 to 2023).

Results: Core initiatives reflective of current HL strategies included the National Action Plan to Increase Health Literacy, Healthy People 2030 Initiative, and the Ten Attributes of Health Literate Health Care Organizations. From these efforts, 31 potential resources were identified, of which 11 (35%) had an evidence base. From these 11 resources, the teach-back method, the Patient Education Materials Assessment Tool (PEMAT), and the CDC Clear Communication Index (CCI) may have high yield in health plan settings, whereas the Health Literate Health Care Organization 10-Item Questionnaire (HLHO-10) and Consumer Assessment of Healthcare Providers and Systems Health Literacy Item Sets (CAHPS-HL) may be emerging.

Conclusions: Although HL resources designed specifically for health plans are sparse, several exist in other settings that can potentially be adapted to improve patient HL and advance health equity. Specifically, resources focusing on both personal (teach-back method) and organizational (PEMAT, CCI, HLHO-10, CAHPS-HL) HL may improve communications and make health plan materials more accessible and easier for patients to understand.

Am J Manag Care. 2025;31(Spec. No. 6):SP351-SP363. https://doi.org/10.37765/ajmc.2025.89759

Health literacy (HL) encompasses the interpersonal and intrapersonal challenges experienced when navigating the complex systems of health care. Although the burden of limited HL on the US economy may be $106 billion to $238 billion annually, future estimated annual costs range between $1.6 trillion and $3.6 trillion.¹ HL can be categorized into 2 domains: (1) personal HL (PHL), “the degree to which individuals have the ability to find, understand, and use information and services to inform health-related decisions and actions for themselves and others,” and (2) organizational HL (OHL), “the degree to which organizations equitably enable individuals to find, understand, and use information and services to inform health-related decisions and actions for themselves and others.”² OHL contextualizes PHL by acknowledging the responsibility of the producers of health information and services to address HL.

Health Plan Motivations for Improving HL

Improving PHL and OHL is critical for a health plan’s ability to help patients achieve their best health. Individuals with limited HL experience reduced uptake of preventive services, lower patient satisfaction, more frequent emergency department visits and inpatient admissions, higher mortality rates, and increased health care expenditures.^3-6 Health plans are often accountable for performance on such utilization, experience, and health outcomes measures through Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, Healthcare Effectiveness Data and Information Set (HEDIS) measures, and CMS Star Ratings. Additionally, disparate levels of limited HL have been observed among older and non–native-English-speaking populations in the US, as well as racial/ethnic minority groups and individuals with chronic conditions, low income, limited social capital, and limited education, thereby contributing to health inequities.^7-10 This relationship may have implications for Medicare Advantage plans with the new CMS Health Equity Index reward that is scheduled to take effect for the 2027 Star Ratings.¹¹

Health Plans Can Be a Conduit for Improving HL

Although numerous resources to improve HL exist, they are typically designed (1) for direct patient care interactions such as in hospital, primary care provider, or pharmacy settings and (2) to assess PHL via screening instruments. There is a paucity of literature specific to health plans regarding HL resources, such as screening instruments, educational resources, and interventions, that can be translated into practical applications. Health plans are distinct in that they have broader population-level engagement and are a common touchpoint with patients for a wide range of nonclinical and clinical reasons, furthering the need to expand beyond only health insurance literacy. Examples of these reasons include assisting patients with care management, answering questions about plans and benefits; finding doctors; making appointments; and connecting members to unique programming or care models through provider arrangements, community-based organizations, or community wellness programs. Health plan content, such as utilization management communication or benefit and coverage summaries, is highly regulated. Health plans have a unique role in several of the CMS-identified HL barriers to health equity related to (1) confusing terms in health coverage; (2) changes to plans, provider directories, or formularies; (3) being new to health care services or not regular consumers; (4) language or cultural differences; and (5) hard-to-understand materials. Increasingly, however, many health plans are also playing dual roles in insurance and care delivery, adding further complexity and immediacy for having resources to address PHL and OHL across the health care ecosystem.

As numerous PHL screening assessments have been extensively validated (Table 1), the objective of this narrative review was to identify additional evidence-based OHL and PHL resources that may be adapted for use in US health plan settings. Therefore, this review’s scope encompasses all literature within and outside health plan settings to maximize translation. Identification and adaptation of resources may help to improve HL of patients (including highly vulnerable populations) enrolled in public or private health plans by improving clear communication and making information easier to find, understand, and use within health plan organizations.

METHODS

Setting

Humana Inc. is a large national health plan across the US covering 17 million patients through Medicare Advantage, Medicaid, and TRICARE programs. Humana also offers primary care, home health, and pharmacy services. Humana’s health equity strategic plan is focused on reducing health disparities by improving access to care, improving quality of care, and addressing barriers to healthy living. Given the critical importance of HL across these health equity priorities, Humana launched a body of work in 2021 to create compassionate, evidence-based solutions for its members with limited HL. Subsequently, Humana collaborated with The Ohio State University College of Public Health Center for Health Outcomes and Policy Evaluation Studies (HOPES) to scope resources that health plans could potentially adopt to address limited HL. We leveraged and summarized recommendations and best practices from leading HL efforts and coalitions to guide our search for potential resources.

Study Design

This review of gray and peer-reviewed literature was performed between January 2023 and May 2023 by 2 authors (K.A.H. and M.E.L.). Reviewers performed an extensive iterative search of (1) websites, including those of US government agencies, organizations, and associations, to identify recommended resources, and (2) recommended resources in electronic databases to examine the evidence base or their use and testing in various settings. Evidence base was then discussed with the entire team for potential applications in health plan settings.

Search strategy. To identify potential gray literature sources, an initial Google search was performed to understand and describe the current landscape of HL in the US and best practices of detecting limited HL. Search terms included health literacy, health literacy policy or policies, health literacy guidelines, health literacy initiatives, health literacy and health plan, health literacy and health insurance, and limited health literacy. Notably, the US National Action Plan to Improve Health Literacy¹² and the Healthy People 2030² effort were identified as major HL initiatives in the US, and using a universal precautions approach is recommended by the National Academy of Medicine¹³ (eAppendix 1
[eAppendices available at ajmc.com]). A timeline of primarily national US efforts addressing HL is shown in Figure 1.^12-20 From these identified efforts, websites of government agencies, states, organizations, and associations that developed or supported these initiatives were searched (eAppendix 2) for recommended HL resources using the search term health literacy, resulting in a total of 31 potential HL resources identified (eAppendices 3 and 4). An HL resource was defined as any material for OHL screening, other assessments related to HL principles, educational resources, interventions such as guidance or direct actions that could be implemented, or training that could be deployed that may impact PHL or OHL in any setting. These 31 resources were examined for evidence base²¹ (Figure 2) by searching for peer-reviewed literature in electronic databases including PubMed, Google Scholar, and the Cochrane Library using the search terms listed in eAppendices 3 and 4.Records related to the identified resources were included and exported to Excel if they were published between January 1999 (the year HL efforts began to gain traction in the US)¹⁴ and May 2023. Reports were excluded if they were duplicated, not within that date range, not available, or not in English; did not use the resource; were not a systematic review; were not peer reviewed; or were a protocol, a dissertation, or a book chapter/brief. Resources were excluded from further examination if they were based on expert opinion (not peer reviewed), likely not translatable to health plans (confirmed by discussions with Humana staff), or untested as of May 2023 (eAppendix 4).

Examination of potentially translatable HL resources. The HOPES team (K.A.H., K.J.M., M.E.L.) was blinded and reviewed the 11 identified resources with an evidence base(eAppendix 3). Agreement was achieved if 2 of the 3 reviewer responses matched. These resources were first examined for resource type (screening assessment, intervention, or educational resource), HL domain (PHL or OHL), uptake (defined as number of studies that utilized the resource categorized by study type [observational or randomized]), and study findings. Next, quality of evidence was determined using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) guidelines²² and categorized as high, moderate, low, very low, or not applicable (if resource was used as an outcome metric). Finally, recommendation for potential health plan use (high, low, very low, emerging) was categorized based on resource uptake (number of peer-reviewed articles utilizing resource), quality of evidence, and findings (positive or negative effect). Uptake thresholds were set to a cutoff of 10 studies arbitrarily before recommendations to help with categorization. To make the recommendation for potential health plan use, recommendations for use were categorized as high if uptake was 10 or more studies with consistent certain positive effects, low if uptake was less than 10 studies and/or uncertainty of positive effects, and very low if uptake was less than 5 studies with uncertainty of positive effects. Additionally, emerging status was also designated for those that were categorized as low uptake (< 10 studies) but relatively recent within the past 10 years. This was a semistructured approach to categorize the recommendations. We opted for this approach over the standard GRADE strength of recommendations to give a broader context and to be inclusive of resources that were not specifically designed for health plans but may still be useful. This approach may limit the reliability and validity of the conclusions drawn.

RESULTS

From the 31 potential resources identified, 20 were excluded from further review as they were based on expert opinion, likely not translatable to health plan settings, or untested (eAppendix 4). The remaining 11 HL resources are reported in Table 2.^23-73 As the Health Literacy Universal Precautions (HLUP) Toolkit (third edition) is comprised of 21 items called tools, we were also interested in examining them individually. The choice was made to report individual HLUP tools with uptake greater than 5 in Table 2 to highlight those with a stronger evidence base, and we report the remaining individual HLUP tools in eAppendix 5.

Of the overall resources listed in Table 2, those with high recommendation for use or low but likely emerging are described in further detail as follows.

HLUP Toolkit’s Teach-Back Method

The Agency for Healthcare Research and Quality (AHRQ) developed the HLUP Toolkit to help primary care practices reduce the complexity of health care, increase patient understanding of information, and enhance support for their patients with varied HL levels.^23,31 Its goal is to improve organizational readiness, spoken communication, written communication, self-management and empowerment, and supportive systems. This tool kit was designed to be used adaptively according to needs; hence, its true effects are difficult to determine. However, the teach-back method has been tested across multiple environments and recommended by both the American Diabetes Association and the American Heart Association.^74,75 The teach-back method is a strategy to have patients tell you what they need to know or do in their own words. This strategy is used to confirm both that the information was clear and that the patient understands. In health care settings, including primary care, outpatient clinics, and hospitals, the teach-back method has been shown to improve disease-specific knowledge, medication adherence, self-efficacy, self-management, and readmission rates.^37-41

CAHPS Health Literacy Item Sets

CAHPScore surveys are considered the national standard for measuring and reporting patient experiences with health care services under different settings and conditions, including for health plans,⁷⁶ and are tied to value-based payments to CMS providers. CAHPSsurveys can inform providers on how to modify services to provide equitable care,⁷⁷ be associated with better patient outcomes,⁷⁸ and enable patients to choose higher-quality health plans.⁷⁹ Numerous supplemental surveys exist, including the Health Literacy Item Sets (CAHPS-HL). This item set was designed to offer a valuable metric of how well organizations are performing at meeting their HL demands from the consumer’s perspective.⁸⁰ Although there were no studies directly pertaining to the Health Literacy Item Set specific to the Health Plan Survey, it is likely emerging, as this set was released in 2017.⁸¹ The CAHPS-HL Health Plan Survey questions typically center around being able to easily find health plan information such as coverage and benefits and whether the information is understandable or confusing. Of all the evidence-based resources reviewed, this is the only resource that has established content specifically for health plans.

Patient Education Material Assessment Tool

The Patient Education Material Assessment Tool (PEMAT) is a systematic assessment of the understandability and actionability of patient education materials.²⁶ Two versions exist: one for print materials (PEMAT-P), consisting of 26 items, and one for audiovisual materials (PEMAT-A/V), consisting of 25 items to score. Topics for understandability are subcategorized as content, word choice and style, use of numbers, organization, layout and design, and use of visual aids. The higher the scores, the better the understandability/actionability of the materials. The PEMAT has been widely utilized to evaluate materials relating to a variety of medical contexts and media. Examples include evaluation of print materials such as emergency department discharge instructions and over-the-counter medication package inserts,^82,83 online educational materials and decision aids regarding medical condition,^42,84 videos for fall prevention,⁸⁵ and mobile apps for parents of newborns in neonatal intensive care units.⁸⁶ PEMAT has also been used in conjunction with other assessments such as the Simple Measure of Gobbledygook or Flesch-Kincaid scores to evaluate the readability of materials.^42-48

CDC Clear Communication Index

The CDC Clear Communication Index (CCI) is similar to PEMAT in that it also assesses public health communication materials, but its focus is more on clarity of information.²⁷ It is a widget comprised of 20 scored items split into 4 sections: (1) core items: main message and call to action, language, information design, and state of science; (2) behavioral recommendations; (3) numbers; and (4) risk. If the total score is 90 or higher, the materials are easy to understand and use. This widget has been used to measure the HL levels of a patient portal for primary care,⁴⁹ educational materials for those with chronic disease,⁵⁰ COVID-19 information communicated by health departments,⁴⁸ and web-based materials.⁵¹ It has also been used in conjunction with the PEMAT and Flesch-Kincaid scores.^48,51

Health Literate Health Care Organization 10-Item Questionnaire

The 10 attributes of health literate health care organizations were developed in 2012 by the Institute of Medicine (now the National Academy of Medicine) to establish a framework for health care organizations to create an environment that enables people to access and optimize benefits from the range of health care services.¹³ The Health Literate Health Care Organization 10-Item Questionnaire (HLHO-10) was subsequently developed in 2015 in response to this framework to objectively measure these 10 attributes.²⁹ The HLHO-10 survey can help assess OHL and the degree to which organizations help patients navigate, understand, and use information and services. Although this questionnaire was initially developed in Germany,²⁹ it has been tested among a sample of US hospitals, and its use is continuing to emerge across health care facilities.⁵² Preliminary works reveal that high HLHO-10 scores may be associated with higher patient satisfaction and perceived quality.^53,54

DISCUSSION

Summary

As HL resources specific to health plans are limited, the purpose of this narrative review was to identify HL evidence-based resources that could potentially be adapted in US health plan settings. From the 11 evidence-based HL resources identified, high-yield evidence-based translatable resources may include the teach-back method, PEMAT, and CCI, whereas CAHPS-HL and HLHO-10 may be emerging(Table 2).Notably, the CAHPS-HL is the only resource that was specific to health plans. Further testing and review of these resources are needed in health plans.

Potential Implications for Health Plans

HL resources may be adapted for practical use in health plans with the goal of improving OHL and PHL as well as patient outcomes. Potential implications for the identified HL resources are described as follows.

Overall. Practically, health plans can utilize one or many of the identified resources to isolate areas of improvement or evaluate PHL and OHL interventions or initiatives depending on the HL goal, team, and scope. Given the scale and administratively complex nature of health plan organizations, implementation feasibility of each resource in its own setting must be taken into consideration. The majority of communications from health plans to patients occur asynchronously through different mediums, including mail, robocalling, digital communications, and sometimes via phone conversations rather than face-to-face interactions. These communications tend to focus on ensuring patient understanding of benefits, accessing provider networks, delivering preventive service reminders, and offering more intensive care management for patients with complex needs. We anticipate that improving OHL and PHL will improve the clarity and simplicity of communications, resulting in improved member understanding, better self-management and adherence, improved patient outcomes, and decreased health care resource utilization such as emergency department visits, hospitalizations, and costs due to better patient management and preventive care.

Using a universal precautions approach. Screening every patient for their PHL may not be pragmatic for a health plan, so understanding administrative burden is essential in evaluating feasibility. Additionally, certain health care consumers may have some level of mistrust in health plans, so asking individuals about their PHL may not be appropriate for data collection or risk analysis purposes only. Having solutions, resources, or relevant assistance may be necessary when individuals self-identify as having limited HL through one of the PHL surveys. A compounding challenge is the low quality of evidence for PHL resources. The exception to this is the teach-back method, which can be applied in any spoken communication setting regardless of the identification of PHL as it is a part of the universal precautions approach. Therefore, practical applications may include (1) using a universal precautions approach, which assumes all members may have difficulty understanding health information and need support for all health plan communications, and (2) PHL screening for members when possible, which can measure PHL baseline and changes. It is anticipated that using a universal precautions approach will simplify communications to improve patient understanding and self-management, whereas PHL screeners may identify those who need additional support to better manage their chronic diseases and decrease health care resource utilization.

Improving OHL. With OHL’s role in helping patients navigate care and creating content that is used by consumers for health care decision-making and self-management, health plans may be able to improve an individual’s health insurance literacy and PHL by improving their own OHL. Both the HLHO-10 and the CAHPS-HL items can be used for identifying opportunities for improving OHL. HLHO-10 may have less off-the-shelf utility for a health plan, as each questionnaire that correlates with an attribute of a health-literate organization is designed specifically for hospitals. Practically, a health plan–modified version of the HLHO-10 questionnaire may require further tailoring to specific teams within the health plans, as the question assessing communication standards may be different for a care manager than it is for the team developing benefit education material. We anticipate that deployment of a health plan–adapted HLHO-10 has the potential to increase OHL, and thus member and employee PHL. CAHPS-HL items offer consumer input into OHL performance but have the same logistical limitations as PHL assessment surveys. CAHPS survey responses are typically shared back to a health plan in aggregate form, so the ability to analyze trends, patient touchpoints, or patient journeys becomes limited. However, we anticipate that incorporating CAHPS-HL item sets into member surveys may predict performance of health plans and member satisfaction while also improving health equity. It is important to note, however, that a large majority of the CAHPS-HL questions are focused on experiences with doctors, so questions would need to be adapted for the health plan setting.

Improving communications. Health plans may benefit from leveraging the teach-back tool for spoken communications or interactions by phone, whereas the PEMAT or CCI may improve its written communications. The PEMAT was designed to help health care professionals select patient education material that is easier to understand and act on. Although the questions within the PEMAT and CCI could remain the same, their user guides may need to be modified to explain use in health plan settings. Health plans might leverage using the PEMAT in the review phase for any type of patient-facing material, whereas the CCI may be more relevant for health education or clinical material. We anticipate that utilization of the PEMAT and/or CCI, along with the universal precautions approach, will significantly improve a health plan’s spoken and written communications, resulting in improved patient outcomes, self-management, and resource utilization.

Limitations and Future Directions

Several methodological limitations exist. At the time of this narrative review, very few HL resources existed specific to health plans, and we did not want to rule out potentially viable resources or insights for practitioners. Therefore, a nonstandard approach to categorize recommendations was used based on resource uptake, GRADE quality of evidence, and positive effects. This approach may limit reliability and validity of the findings. The proposed practical applications and anticipated outcomes will need to be rigorously tested in health plan settings. This review was specific to discussions with one health plan, so it may not be generalizable to all health plans. Resources should not be observed as an exhaustive list but rather for general reference as there is the risk that potential resources were missed and newer information will be developed. Although some of the resources can identify deficits in workforce capabilities, they do not offer specific guidance in HL educational content, cost-effectiveness, training programs, or insight into culturally and linguistically tailored interventions to meet population-specific needs, so there is still room for organizations to design and interpret actions differently. Although the focus of this review was to identify potential evidence-based resources to improve HL, HL is a broad concept influenced by numerous factors including social determinants of health and a person’s other literacy levels (general/basic, digital, or insurance/health system). Therefore, application of these resources will likely need to be included with other efforts to improve health equity, such as improved health care access and addressing other barriers to care. Additionally, further studies are needed to adapt and test these resources in health plan settings and better understand their reliability and effects on OHL, PHL, health outcomes, and patient experience.

CONCLUSIONS

This narrative review identified several evidence-based HL resources (teach-back, PEMAT, CCI, HLHO-10, CAHPS-HL) for potential adaptation/implementation in US health plan settings. If adapted in environments where health plans can test and learn to understand impact and outcomes and evolve the applicability for patients and employees, these resources can potentially be leveraged to improve HL at both the organizational and patient levels, but they need further evaluation regarding their impacts on validity, generalizability, and reliability of findings in health plan settings. Health plans focused on health equity may want to deepen their understanding of the role HL plays in their patient populations and how improving HL can serve as a powerful lever for health equity.

Author Affiliations: Center for Health Outcomes and Policy Evaluation Studies (HOPES), The Ohio State University College of Public Health (SN, KAH, MEL, KJM, AT), Columbus, OH; PATH USA (SN), Seattle, WA; Humana Inc (CM, AR, SH, FO, JNO), Louisville, KY; ; now with Aledade, Inc (CM), Bethesda, MD; now with Advocate Health (JNO), Charlotte, NC, and Milwaukee, WI.

Source of Funding: Humana Inc.

Author Disclosures: The Ohio State University Center for Health Outcomes and Policy Evaluation Studies, which employed Dr Nawaz, Ms Hasenstab, Ms Lewie, Mr Moon, and Ms Trinh, received development/gift support from Humana to conduct an evaluation of health literacy activities. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (SN, CM, KAH, MEL, AR, SH, KJM, JNO); acquisition of data (KAH, MEL); analysis and interpretation of data (SN, KAH, MEL, JNO); drafting of the manuscript (SN, CM, KAH, MEL, AR, SH, KJM, AT, FO); critical revision of the manuscript for important intellectual content (SN, CM, KAH, MEL, AR, SH, KJM, AT, FO, JNO); provision of study materials (KAH); obtaining funding (SN, JNO); administrative, technical, or logistic support (CM, KAH, KJM, AT, FO, JNO); and supervision (SN, AT, JNO).

Send Correspondence to: Saira Nawaz, PhD, PATH USA, 455 Massachusetts Ave NW, Washington, DC 20001. Email: snawaz@path.org.

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