1. Tracking American
Health Literacy and
Prescribing Improvement
Key findings from an independent survey
FEBRUARY 2015

2. 2 | Tracking American Health Literacy and Prescribing Improvement
Table of Contents
What Is Health Literacy and How Does It Affect Healthcare?......... 1
Finding Out Where We Stand............................................................... 2
The iTriage Health Literacy Index....................................................... 3
Key Trends in Health Literacy.............................................................. 5
How Does Health Literacy Affect the Cost of Care?......................... 7
Having a Primary Care Provider and Asking Questions................... 9
Knowing Where to Get Medical Care................................................ 11
Comprehending Health Insurance ................................................... 13
Understanding Medication and Preventive Health......................... 16
A Prescription for Improvement........................................................ 18

3. Tracking American Health Literacy and Prescribing Improvement | 1
What Is Health Literacy and How
Does It Affect Healthcare?
Health literacy is “the degree to which individuals can obtain, process, and understand the
basic health information and services they need to make appropriate health decisions.”1
In 2003, the U.S. Department of Education conducted a study on the health literacy rates of the general
U.S. population.2
It reported that only 12 percent of Americans had “Proficient” health literacy, while
more than 75 million Americans displayed “Basic” and “Below-Basic” health literacy.
The notoriously poor health literacy rate in the U.S. means that many people often struggle to complete
tasks essential to their health, such as understanding their care, navigating the healthcare system, and
making informed health decisions.
Numerous studies have correlated low health literacy with serious consequences including:
+ Increased hospitalization
+ Greater unnecessary emergency care use
+ Increased risk of mortality for seniors
+ Lower utilization of preventive healthcare
+ Inability to take medications properly1
Low health literacy is estimated to cost the U.S. healthcare system between $106 and $238 billion
annually.3
It also contributes to $395 billion—more than half—of the $765 billion of waste in the sys-
tem through $210 billion in unnecessary services, $130 billion in preventable errors, and $55 billion in
missed prevention opportunities.4
Ultimately low health literacy can largely be attributed to more pervasive issues within the healthcare
industry:
+ A history of volume-based, rather than value-based, reimbursement
+ Lack of democratization, or shared decision making, between providers and patients
+ Limited public health training and education
+ Complicated insurance and benefit packages
+ Fragmented healthcare data and delivery systems
What will make a difference?
Increasing Americans’ health literacy has strong potential to further the industry’s Triple Aim goals of
improved care quality, reduced costs, and better health overall. Everyone in the U.S. healthcare industry
can help educate consumers to reduce unnecessary health services and more effectively, safely, and
efficiently use the system.
1. Berkman ND, Sheridan SL, Donahue KE, Halpern DJ, Viera A, Crotty K, Holland A, Brasure M, Lohr KN, Harden E, Tant E, Wallace I, Viswanathan M. Health Literacy Interventions and Outcomes: An
Updated Systematic Review. Evidence Report/Technology Assesment No. 199. (Prepared by RTI International–University of North Carolina Evidence-based Practice Center under contract No. 290-
2007-10056-I. AHRQ Publication Number 11-E006. Rockville, MD. Agency for Healthcare Research and Quality. March 2011. http://www.ncbi.nlm.nih.gov/books/NBK82434/
2. U.S. Department of Education, Institute of Education Sciences, National Center for Education Statistics, 2003 National Assessment of Adult Literacy. http://nces.ed.gov/naal/health_results.asp
3. Vernon JA, Trujillo A, Rosenbaum S, DeBuono B. Low Health Literacy: Implications for National Health Policy, Oct. 2007. http://publichealth.gwu.edu/departments/healthpolicy/CHPR/downloads/
LowHealthLiteracyReport10_4_07.pdf
4. AARP Bulletin, November 2012, Volume 53, No. 9, http://pubs.aarp.org/aarpbulletin/201211?pg=4#pg4

4. 2 | Tracking American Health Literacy and Prescribing Improvement
Finding Out Where We Stand
Given the improved access to information through technology and the industry’s education
efforts in the years since the U.S. Department of Education evaluated health literacy, have we
moved the needle?
Consumer healthcare technology company iTriage®
commissioned an independent survey of
1,000 U.S. adults aged 18 and up to gauge individuals’ health literacy. The survey covered four
key topics people are likely to encounter during their journey through the system:
1. Navigating and accessing the healthcare system
2. Obtaining health information
3. Comprehending health insurance
4. Understanding medications and preventive health
This research provides a current measurement of health literacy and shines a spotlight on
consumers’ experiences—throughout their healthcare journey—obtaining and interpreting
health information, finding appropriate treatment and providers, and being actively involved
in their treatment.
Research
Methodology
Independent research
firm Lawless Research
conducted an online sur-
vey of 1,000 anonymized
U.S. adults 18 and older,
matching U.S. Census
data for sex, age and race.
The survey was fielded
August 5 through August
11, 2014. Results of the
survey are accurate at the
95 percent confidence
level plus or minus 3.1
percentage points.
Navigating and accessing
the healthcare system
• Treatment settings
• Costs
Obtaining
health information
• Patient/physician dialog
• Credible print, digital
resources
Comprehending
health insurance
• Plan coverage
• Industry terminology
Understanding
medications and
preventive health
• Medication adherence
• Risks, benefits and
interactions

5. Tracking American Health Literacy and Prescribing Improvement | 3
The iTriage Health
Literacy Index
In addition to uncovering the current state and key trends of health literacy in America, the
research presented in this paper was also used to establish a Health Literacy Index. Based on
responses to 17 questions falling within the survey’s four main topic areas, the Index presents a
snapshot of respondents as Proficient, Intermediate, Basic, and Below-Basic in health literacy.
The Results
The iTriage Health Literacy Index is based on a point system in which respondents earn points
for each of the 17 questions they answer correctly. The maximum number of literacy points a
respondent could achieve is 42 and the minimum is 0. The point range for each literacy level is:
+ Below-Basic: 0–22
+ Basic: 23–26
+ Intermediate: 27–30
+ Proficient: 31–42
17%
29%
36%
18%
Below-Basic
0-22
Basic
23-26
Intermediate
27-30
Proficient
31-42
Less
than a
quarter
are
proficient.

6. 4 | Tracking American Health Literacy and Prescribing Improvement
Who’s Who
After the Index established the percentage of people falling within each of the health literacy
levels today, the researchers set out to identify the general attributes people with Proficient,
Intermediate, Basic, and Below-Basic health literacy levels are likely to have—gender, age, educa-
tion level, household income (HHI), and type of insurance (if any). Following is a snapshot:
Below-Basic: 17%
+ Male (60% of those below basic are male)
+ Most likely aged 18-24
+ 56% with high school or some college
+ 30% with HHI under $25,000
+ 32% uninsured or on Medicaid
Basic: 29%
+ Male (53% of those basic are male)
+ Most likely aged 25-44
+ 50% with high school or some college
+ $25-50K (53% with HHI under $50,000)
+ 41% have employer-provided health insurance
Intermediate: 36%
+ Female (54%)
+ Most likely aged 45-64
+ 45% with 4-year or advanced degree
+ 53% with HHI of $25-75K
+ 64% with employer-provided or private health insurance
Proficient: 18%
+ Female (63%)
+ Most likely aged 45-64
+ 54% with 4-year or advanced degree
+ 53% with HHI of $25-75K
+ 51% with employer-provided health insurance and 25% with Medicare
BASIC
INTERMEDIATE
BELOW-BASIC
PROFICIENT

7. Tracking American Health Literacy and Prescribing Improvement | 5
37%
11%
People aged
18-24
Adults
45-64
10%
Adults
65+
Key Trends in Health Literacy
Overall, the data revealed disparities in health literacy rates between respondents based on four
key factors: gender, age, education, and insurance:
Women Uphold Their Reputation as “Household CEO”
Women (Household Decision Makers) Score Higher in Health Literacy
Proficiency Than Men
Young Adults Are Uninformed
More Individuals 18-24 Have Below-Basic Health Literacy
More men than women have below-
basic health literacy: 21% versus 14%
18-24 year-olds are 3x more likely to have the lowest
level of health literacy than those 45 and up.
BELOW-BASIC

8. 6 | Tracking American Health Literacy and Prescribing Improvement
Degrees Make a Difference
Health Literacy Level Correlated to Education Level.
Insurance Matters
Type of Insurance Correlated with Health Literacy
Proficient adults are far more likely to have
employer-provided health insurance.
Adults with below-basic health literacy are
4x more likely to have Medicaid coverage.
MEDICAID
More than twice as many (27%) have
a graduate or advanced degree.
Compared to the 11% who have
a high school degree or less
PROFICIENT

9. Tracking American Health Literacy and Prescribing Improvement | 7
How Does Health Literacy
Affect the Cost of Care?
With the current level of health literacy assessed and demographic disparities identified,
researchers next analyzed how health literacy affects the cost of healthcare, both for the
individual as well as the system.
Adults with Lower Health Literacy May Choose More
Expensive Treatment Settings
Adults with Lower Incomes Are More Likely to Choose
More Costly Care in Some Cases
59%
People with below-basic literacy don’t
know that treatment for a painful sore
throat will cost most at a hospital
emergency room.
ONLY
29%
Correctly identified situations when using an
urgent care center is appropriate.
More than one-quarter (28%) of adults with a house-
hold income under $25,000 don’t know an out-
of-network doctor will cost them more
than one who’s in-network.
Only 55% of adults with below-basic health literacy
know that treatment from an out-of-
network care provider costs more; versus
98% of proficient.
ONLY
55%
BELOW-BASIC

10. 8 | Tracking American Health Literacy and Prescribing Improvement
Many Young Adults Don’t Know the Cost Implications
of Their Healthcare Choices
42% of 18-24-year-olds don’t know out-of-
network doctors will cost them more
than in-network doctors, compared to less than 20% of
all other groups.
Nearly half (48%) didn’t know the ER is the
most costly choice.
EMERGENCY ROOM

11. Tracking American Health Literacy and Prescribing Improvement | 9
Having a Primary Care Provider
and Asking Questions
How many people have a primary care provider (PCP)? Would having one make a difference in a
person’s health literacy? And, when people go to the doctor, how likely are they to ask questions
to increase their understanding? Let’s find out:
Majority Have a Primary Care Provider
Rate of Health Literacy Increases with Having a PCP
Of adults who have below-basic health literacy, 69% have a PCP.
81% of adults with basic health literacy have a PCP, versus 85% of adults
with intermediate health literacy, and 92% of adults with proficient
health literacy
8 in 10 adults (82%) have a PCP
81%
85%
92%
Basic
Intermediate
Proficient
69%
Below-Basic
% Who Have a PCP

12. 10 | Tracking American Health Literacy and Prescribing Improvement
Four in Ten May Not Ask Questions of Their Doctors
+ When people don’t understand what their doctors are telling them:
Women Are More Likely than Men to Ask Questions of
Their Care Providers
+ 40% of women will “always ask questions” vs. 28% of men
40% 28%
?
Almost half (42%) never or only sometimes
ask questions of their care provider — even when they
don’t understand what they are being told.
? ?

13. Tracking American Health Literacy and Prescribing Improvement | 11
Knowing Where to Get
Medical Care
Lower-cost care settings such as urgent care facilities may be equally, if not more, appropriate
for certain healthcare scenarios. But people either don’t know they are available or don’t know
what conditions can be treated there. In fact, people often make dangerous assumptions about
where to get care—and these assumptions can lead to negative outcomes.
Many Are Confused About When to Use Urgent Care
There is some confusion about when getting medical care at an urgent care center is
appropriate. Slightly more than half correctly chose when to go to an urgent care:
Percent who incorrectly think an urgent care center
is the place to go when experiencing symptoms of
a heart attack:
58% Knew that you go to an urgent care
“When your doctor’s office is closed.”
54%
Knew that you go to an urgent care
“If you have an ear infection, but can’t
get an appointment with your doctor.”
of menAlmost half of all
respondents
52% of
millenials
ü
ü

14. 12 | Tracking American Health Literacy and Prescribing Improvement
Women were correct more often than men in choosing the two appropriate situations
for using an urgent care center:
+ 62% of women versus 53% of men chose “when their doctor’s office is closed”
+ 59% of women versus 49% of men chose “when they can’t get an appointment for
an ear infection with their doctor”
Young adults had trouble knowing when to use an urgent care.
62% 53%
59% 49%
Only 38% of young adults, age 18-24,
were correct in choosing an urgent care center
as an appropriate place for treatment if their doctor’s
office is closed.
ü
ü

15. Tracking American Health Literacy and Prescribing Improvement | 13
Comprehending Health
Insurance
If a person has access to insurance, he or she is more likely to have access to health information
through their insurance provider’s website or other educational resources. With that said, health
insurance is often difficult to understand and navigate, even for those in the industry. How well
does the general population understand it?
Access to Insurance
Majority Have Health Insurance Coverage
Understanding Insurance
Health Insurance Terminology Confuses Many
36% Could not accurately define a deductible
39% Could not accurately define a copay
44% Are covered by an employer-
sponsored health insurance plan
89% Of respondents have access to at
least one form of health insurance
Proficient adults are far more likely to have employer-
provided health insurance (51%) than those with a below-
basic health literacy score (32%).
PROFICIENT
EXPLANATION
OF BENEFITS

16. 14 | Tracking American Health Literacy and Prescribing Improvement
Young Adults Have More Trouble Defining Insurance Terms
+ Only 34% of adults 18–24 correctly identified the definition of a deductible, compared with
65% of those 25–44 and 70% of adults 45 and older
Majority Know Meaning of In-Network vs. Out-of-Network Providers
+ The level of understanding is lower for:
- People who did not graduate from high school (50%)
- People ages 18–24 (53%)
- Those with a household income under $25,000 (63%)
18-24-year-olds have trouble correctly defining
deductible, coinsurance and copay.
34%
65%
70%
Adults
18-24
Adults
25-44
Adults 45
and older
% to Correctly Identify Definition of “Deductible”
Most people (71%) know that a doctor
who accepts their health insurance plan
is in-network and a doctor that does not is
out-of-networkIN-NETWORK

17. Tracking American Health Literacy and Prescribing Improvement | 15
Many Adults with Lower Incomes Do Not Know the Cost Implications of
Out-of-Network Care
Half of People with Low Health Literacy Know that Out-of-Network Care Costs More
55% of people with below-basic health literacy
know that out-of-network care is more
expensive (vs. 98% adults who are proficient in
health literacy)
More than one-quarter (28%) of adults with a
household income under $25,000 don’t know an
out-of-network doctor will cost them
more (versus 18% of all US adults)
OUT-OF-NETWORK

18. 16 | Tracking American Health Literacy and Prescribing Improvement
Understanding Medication and
Preventive Health
Medications can be extremely dangerous if not taken correctly. Knowing how to read dosage
instructions is a vital part of health literacy, as is knowing when to get a flu shot.
Reading a Pill Bottle Label
+ When reading this pill bottle label, 88% correctly determined that three capsules should be
taken each day
+ But 36% of those with below-basic health literacy could not accurately determine how to
take the medication based on the instructions on the pill bottle
+ 22% of 18-24-year-olds could not accurately read the instructions on the pill bottle
1234 WILMOT RD
DEERFIELD IL 60015 PH (800) 555-5555
NO 0060023-08291
DR D. INTERCOM
DATE 05/14/13
JOHN SMITH
123 MAIN STREET ANYTOWN, US 111111
TAKE ONE CAPSULE BY MOUTH
THREE TIMES DAILY FOR
10 DAYS UNTIL ALL TAKEN
AMOXICILLIN 500 MG CAPSULES
QTY 30
NO REFILLS - DR. AUTHORIZATION REQUIRED
MFC TEVA
USE BEFORE 05/30/13
SLF/SLF

19. Tracking American Health Literacy and Prescribing Improvement | 17
70% of people know that the recommended guideline
for how often adults should get a flu shot
is once a year.
77% 63%
50%
76%
81%
Adults
18-24
Adults
45-64
Adults 65
and older
% Correctly Answering How Often Adults Should
Get a Flu Shot
Most Know the Recommended Guideline for Receiving a Flu Shot
+ More women (77%) than men (63%) are aware of the recommendation to get a flu shot
annually
+ Only 50% of 18-24-year-olds know that adults should get a flu shot once a year versus 76% of
those 45–64 and 81% of those 65 and older

20. 18 | Tracking American Health Literacy and Prescribing Improvement
A Prescription for Improvement
Main Takeaways
Only 18% of Adults Are Proficient In Health Literacy
And, almost half (46%) of American adults have only a basic or below-basic level of health
literacy compared with 35 percent in the 2003 U.S. Department of Education study.
Low Health Literacy May Result In Higher Healthcare Costs
People with below-basic or basic health literacy have less understanding of where and when to
get the most cost-effective care compared to people with higher health literacy levels.
Women Have Higher Health Literacy
Women are more proficient in health literacy than men (22% versus 14%). Women are also more
likely to ask care providers questions; know the most appropriate settings for receiving care;
understand health insurance terms; know the guideline for receiving a flu shot; and recognize
that name brand and generic drugs are usually equally effective.
Young Adults Need the Most Education to Improve Their Health Literacy
People aged 18 to 24 are less likely than other age groups to understand the cost implications of
receiving care at an emergency room; know when it’s appropriate to use an urgent care center;
know the guideline for receiving a flu shot; know the difference between an in-network and an
out-of-network doctor; or understand that out-of-network care may be more expensive.
Now What?
When it comes to educating Americans about the healthcare system—helping them to
successfully obtain and interpret health information, find appropriate treatment and providers,
and be actively involved in their treatment—the industry still has an extraordinarily long way to
go.
According to these findings, the nation has essentially made only a 6% improvement in
proficiency over the last 11 years when compared to the findings of the 2003 U.S. Department
of Education study.
If we can continue to move the needle by educating healthcare consumers, ensuring they
have easy access to actionable information, and generally empowering them to make better
healthcare decisions, we could dramatically change the industry for the better.
If each American’s health literacy improved by one level:
+ 17% of the population would have a Basic working knowledge of the system
+ 29% would benefit from an Intermediate literacy level, and
+ 54% of the population would be fully Proficient in health literacy

21. Tracking American Health Literacy and Prescribing Improvement | 19
5. The Relationship Between Health Literacy and Medical Costs, David H. Howard, Ph,D. http://www.amjmed.com/article/S0002-9343%2805%2900011-2/abstract
6. https://ycharts.com/indicators/us_health_care_inflation_rate
For inspiration we can look to other public health education efforts about the dangers of
smoking and the importance of wearing a seat belt. The CDC reports that 30 of the 50 biggest
U.S. cities have enacted a smoking ban. This shows significant progress since in 2000 only
one large U.S. city—San Jose, Calif.—had such a law. Seat belt usage has shown similar
improvement: According to the American Public Health Association, “Seat belt use has gone
from 11% in 1981 to about 85% in 2010 and saved hundreds of thousands of lives.” In both of
these cases, change took time, but by promoting a consistent message, attitudes, knowledge
and behavior all shifted.
More knowledgeable, activated and engaged consumers would help:
+ Decrease hospitalization
+ Reduce unnecessary use of emergency care
+ Increase use of primary care
+ Lower healthcare costs
+ Improve mortality rates for seniors
+ Decrease risk of improper medication use
+ Reduce use of unnecessary services
+ Improve overall health outcomes
+ Emphasize value of preventive care and health and wellness
Obviously, the benefits of better health literacy could help to drastically reduce the healthcare
costs associated with low health literacy. In 2004, low health literacy was estimated to cost
$928 per patient. Using the conservative estimate of a 5.47% rate of healthcare inflation, low
health literacy now costs $974.40 per patient.
If we improve the population’s health literacy by just
one level—meaning 83% would be at an intermediate
or proficient level, leaving only 17% at a basic level—we
could potentially save the industry $68 billion.
As healthcare spending continues to rise, as payment models increasingly move from volume
to value, and as accountable care and population health management become more and more
the norm, it’s easy to see how improving the nation’s health literacy quickly becomes priority
number one.

22. 20 | Tracking American Health Literacy and Prescribing Improvement
Challenge to Consumers, Providers, Payers,
and Employers: Take Action
Surveying current health literacy rates, we’ve learned where healthcare consumers continue to
struggle with the health system. But consumers are not alone in their struggle to understand
and manage their healthcare. Everyone involved in the healthcare system—consumers,
providers, payers and employers—has a part to play in raising health literacy levels in order to
achieve better health outcomes and reduced costs.
Consumers need to know how to obtain and understand health information to become more
informed patients and make appropriate decisions; become stronger advocates for themselves
and their families to receive the best care possible; and take a more active role in tracking and
managing their own health history and preventive care.
Providers can use plain language in office visits and patient-facing materials; ensure consumers
feel comfortable asking questions; solicit questions from their patients since the above research
shows only one-third will always speak up; and use every patient interaction as an opportunity
to educate.
Payers can work to simplify the processes of acquiring and using health insurance—eliminating
difficult terminology and making insurance more of a consumer-oriented experience.
Employers can promote wellness and educate consumers about their health, healthcare, and
insurance – not only during orientation and open enrollment, but year-round.
No matter what your role is in healthcare, we challenge you to do your part to move the needle
on health literacy and create a better healthcare experience for consumers.
We all have the potential to raise national health literacy rates. All of us can help make the Triple
Aim a reality: reduced cost, improved quality, and a better care experience for consumers.
Join us
Help Americans achieve better lifelong health at a lower cost by improving health literacy
rates. Visit HealthAtHand.com, a new digital destination where people—even those in the
industry—can test how much they really know about healthcare and find resources to help fill
the knowledge gap and lead to better decisions. Encourage your peers, patients, members and
employees to visit HealthAtHand.com. Together, we can create better healthcare consumers.

23. About iTriage
iTriage is a healthcare technology company headquartered in Denver, Colorado.
Founded in 2008 by two emergency room doctors and acquired by Aetna, Inc. in 2011,
iTriage connects patients, providers and health plans through smart technology providing
decision support to help people navigate the healthcare system. Millions of consumers
globally have downloaded the free and highly rated iTriage application to iPhone®
, iPad®
and AndroidTM
mobile devices.
The company partners with hospitals and health systems, accountable care organizations,
retail clinics, health plans, and employers to improve population health. Find more
information about iTriage at http://about.itriagehealth.com.

24. 22 | Tracking American Health Literacy and Prescribing Improvement