Reviewed by Dr. Eddie Hackler III
Rasu RS, et al. Int J Health Policy Manag. 2015 Aug 17;4(11):747-55

Health literacy is associated with healthcare utilization and expenditures and is an essential aspect of patient care. It is defined as “the degree to which an individual has the capacity to obtain, communicate, process and understand basic health information and services to make appropriate health decisions.”1 Health literacy presents a challenge in the delivery of effective healthcare and quality outcomes. The National Assessment of Adult Literacy (NAAL) from 2003 found that only 12% of U.S. adults had a proficient health literacy level (HLL), while 75% had an intermediate or basic HLL and 14% had a below basic HLL. In 2011, U.S. healthcare costs reached 2.7 trillion dollars, which is about $8680 per person, and poor health literacy is thought to play a significant role in healthcare costs.

This study used multivariate regression analysis to evaluate the effect of health literacy on the utilization and cost of healthcare. Data was analyzed from the MEPS (Medical Expenditure Panel Survey Household Component), which surveys U.S. families and individuals regarding the use of medical services, medications, and medical expenditures. The health literacy variable was derived using a validated, predictive model2 based on patient demographic and socioeconomic factors from U.S. census data, incorporating community level predictors of health literacy. The model provided a health literacy score (HLS) which is a continuous variable on a 0 to 500 point scale (mean = 245 and standard deviation (SD) = 55), with a higher score reflecting higher health literacy. Then, two categories of HLL were created: below basic or basic HLL (HLS <226) and above basic HLL (HLS ≥ 226).

A total of 22,599 samples representing approximately 503,000,000 U.S. adults from 2005-2008 were analyzed. The mean HLS was 247.5 with a SD of ±28.3, and 22.4% of the cohort had basic or below basic health literacy. Individuals with a below basic or basic HLL had statistically significantly (p < 0.05) more healthcare utilization in all categories compared to individuals with above basic HLL: 5.8 vs 4.5 annual physician visits, 4.1 vs 2.7 annual non-physician provider visits, and 0.2 vs 0.1 annual emergency room (ER) visits. The annual healthcare expenditures were also statistically significantly (p < 0.05) higher in the below basic or basic HLL group compared to the above basic HLL group: $1862 vs $1027 in annual prescription drugs and $1121 vs $871 in total annual healthcare visits. These trends remained statistically significant after adjusting for health insurance.

These findings may be explained by many factors. Two specific reasons may be a greater prominence of preventative services and self-management in those with higher HLL. Furthermore, increased expenditures in those with lower HLL may result from decreased understanding of disease and improper medication use. As providers in inpatient and outpatient settings, we have the opportunity to mitigate these disparities. In our outpatient clinics, taking time to explain disease processes at the level of understanding of each patient is essential. Providing our patients with warning signs that warrant ER visits and encouraging close follow up with primary care providers may decrease unnecessary ER visits. Furthermore, explaining proper use of medications can improve administration, which could decrease the need for additional medications to be purchased. Tools such as the AHRQ Health Literacy Universal Precautions Toolkit can help us to understand and address the unique health literacy needs of each patient we encounter. (The toolkit is available at

1. Centers for Disease Control and Prevention (CDC). Health Literacy. html. Accessed January 19, 2018.
2. Martin LT, Ruder T, Escarce JJ, et al. Developing predictive models of health literacy. J Gen Intern Med. 2009;24(11):1211-1216.