HCFA wants to improve readability, increase comprehension levels of Medicaid materials

The Health Care Financing Administration (HCFA) has awarded two contracts to Maximus, a company with corporate headquarters in Reston, VA, that performs Medicaid outreach in many states. Maximus will be involved in an effort to improve the readability of applications and notices used by states with applicants for Medicaid and the Children’s Health Insurance Program (CHIP).

The contracts, worth more than $567,000, will be administered by Maximus’ Center for Health Literacy and Communication Technologies.

John Boyer, president of the Maximus Health Management Services Division, tells State Health Watch that the Center opened at the beginning of 2000 with a mission to advance an understanding of the relationship between health literacy and health.

"As a result of our work in providing enrollment assistance, we became concerned about the ability of some populations to grasp the written word. Because of our widespread presence in Medicaid and other programs, we saw an opportunity for us to have an impact on health communications," he says.

Christina Zarcadoolas, the center’s executive director, says the need for materials to be revised is clear; 60% to 80% of the Medicaid population read below an eighth-grade level, and many may be reading below a fifth-grade level. "Because of their reading level, people are unable to understand and access some very basic information."

She says a national assessment in 1993 showed that 49% of Americans could not read above an eighth-grade level. "We’re talking about a profound problem. It’s not just an educational problem because it also affects many aspects of day-to-day living."

The new Maximus center works to improve the company’s own materials, Ms. Zarcadoolas says, but also competes for contracts in programs where literacy plays an important role.

Under the first HCFA contract, Maximus will look at application forms used by individuals seeking to qualify for Medicaid and state CHIP programs. Center staff will collect applications currently used by the states, evaluate them for simplicity, literacy, and cultural appropriateness, and develop and field-test more user-friendly forms in both English and Spanish. Maximus has already received a 29-page application in use by one state. Some staff at the center with graduate degrees have been unable to categorize some of the Medicaid notices. In some cases, it is difficult to determine what information the notices are requesting.

Don’t answer that question!

Ms. Zarcadoolas says one problem identified by HCFA is that states are including items in the application forms that are not required by HCFA regulations, such as asking for the Social Security numbers for all family members, when the requirements only call for a number for the applicant. She says the agency is trying to get word to state Medicaid officials about what is required. Guidelines to be issued as a result of the Maximus study will address the question of required and prohibited information as well.

"Whatever questions are asked," she says, "it’s important to look at how the form is designed and the words that are used. If it were easy to do, we’d all be doing it already. We still don’t have all the answers."

A key element of the contracts is qualitative field-testing of revised forms. Ms. Zarcadoolas says they will be relying less on focus groups and more on in-depth interviews with individuals and observing people attempting to complete the forms.

Testing will be held at several sites and will go on until the Center staff determine additional interviews will not yield any additional insights. They intend to use community-based organizations to identify and recruit evaluation subjects. Those who participate will be paid for their time and will have travel and child care assistance available.

The second contract requires Maximus to assess and make improvements in the official notices used by state agencies to formally communicate case actions to applicants and beneficiaries.

The center will collect notices commonly used in states, determine the degree to which individuals comprehend them, and develop and field-test new English and Spanish models. Ms. Zarcadoolas says they have found there are many more notices than application forms, but they will apply the same basic methodology and evaluation to the notices as to the applications.

The results of the work will be brought together as guidelines that HCFA will publish and disseminate to state Medicaid directors. The agency already has written to Medicaid directors to tell them of the project and ask them to submit their materials and consider possible evaluation sites. To help ensure that its recommendations will be considered, Maximus says it will not issue a final report that can be placed on a shelf and ignored. It expects that operations staff in the various states will refer regularly to the guidebook.

The contract also provides for the center’s assistance in making Spanish-language documents available. Senior manager Mercedes Blanco tells SHW that the center will be working to adapt documents instead of doing a word-for-word translation. Rather than waiting to translate the documents until after they are completed in English, the writers and researchers in both languages work together so they can share insights and better understand what the forms are intended to communicate.

Asked whether opposition to Maximus’ enrollment activities in some states could have an adverse impact on the project, Mr. Boyer says he thinks his company often is blamed when people really are opposed to mandatory managed care for Medicaid.

"In virtually every place that we operate, we collaborate with community-based organizations and that has worked very effectively. I think our best work is done in face-to-face relationships over time in which trust can be built."

Texas state Medicaid director Linda Wertz, who also is president of the National Association of State Medicaid Directors, tells SHW that states are "willing to participate in any process that will make things more beneficial for clients. . . . It’s hard to tell at this stage if Maximus’ work will be fruitful, but states will give their best practice recommendations due consideration."

Ms. Wertz says states would prefer that Maximus’ recommendations come to them as guidelines rather than as mandates from HCFA.

[For more information, contact the Maximus staff through Rachel Rowland at (888) 941-9549.]