california’s hmo enrollees: diversity in language and education...

California’s HMO Enrollees: Diversity in Languageand Education Poses Challenges for Health PlansGERALD F. KOMINSKI, DEBORAH GLIK, AND CORI REIFMAN

A Publication of the UCLA Center for Health Policy Research

California’s health maintenanceorganizations (HMOs) face seriouschallenges in meeting the needs of their

members who have diverse languageproficiency and educational attainment. Thispolicy brief summarizes findings from a reportthat is the most comprehensive profile of thestate’s entire HMO membership available todate, including commercial, Medicare, Medi-Cal, and Healthy Families members. Alsoincluded are an assessment of the readability ofHMO member materials and the availability oflinguistic services for limited English-proficiency members, who represent almost5% of HMO members statewide (see Exhibit 1).

Language Proficiency and EducationalAttainment of HMO Members StatewideHMO plans strive to ensure the best possibleaccess to health care for California’s HMOenrollees. Access to important health servicessuch as cancer screenings and treatment forchronic conditions is determined not only bywhether these services are covered by a healthplan, but by the extent to which the plan assistsits diverse membership in understanding theseand other benefits. As shown in Exhibits 1 and2, California’s HMOs face serious challenges inmeeting the needs of their membershipbecause of limited English proficiency andlevels of education.

This policy brief covers:

• Comprehensive Profile of State’s HMO Membership

• Readability of HMO Member Materials

• Availability of Linguistic Services

• Policy Recommendations

More than one-third (35%) of California’snonelderly HMO members have a high schooleducation or less (see Exhibit 2)—yet, the vastmajority (94%) of the material describingtheir benefits is written at the college orgraduate school level (see Exhibit 3) andpresented in a format that may be difficult formost consumers to use. In addition, although34% of the state’s HMO populationcommunicates at home in a language otherthan English, not all HMO plans ensure thesame linguistic services to all of their limitedEnglish-proficiency members.

P O L I C Ybr ief

May 2003

Los AngelesSan Francisco

Santa ClaraOrange

Central ruralStatewide

Southern ruralSanta Cruz

OaklandRiverside

SonomaNapa

San DiegoSacramento

Northern ruralVentura

0 1 2 3 4 5 6 7Percent

Exhibit 1: Percentage of HMOMembers with LimitedEnglish Proficiency.All Ages, by Region.

Source: 2001 CaliforniaHealth Interview Survey

continued on page 3

Note: Limited language proficiency is defined as HMO members who report that they speakEnglish “not well” or “not at all.” Ventura County has too few observations to report.

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Exhibit 2: Educational Attainment and Language Proficiencyof California’s Adult HMO Enrollees

Source: 2001 California Health Interview Survey

California’s HMO Enrollees: Diversity in Language and Education Poses Challenges for Health Plans

HMO Member Profile Paints a Diverse PictureMore than half (54%) of California’spopulation is enrolled in an HMO—approximately 17.7 million children and adultsin 5.5 million households.1 This HMOpopulation is extremely diverse. Six in 10enrollees (59%) are white, two in 10 (19%) areLatino, 12% are Asian American and PacificIslander, 7% are African American, and 3%comprise several smaller racial groups,including American Indians and Alaska Natives.

More than one-fourth (27%) areimmigrants; 15% are naturalized citizens and12% are noncitizens. Twelve percent of HMOenrollees were not born in the United States buthave lived in this country for 20 or more years;approximately 3% are new immigrants (havinglived in the U.S. less than five years).

Because so many people in California haveimmigrated from other countries, effectivecommunication is an important concern forthe state’s health-care providers. One in three(34%) HMO members in California speaks alanguage other than English at home (24% arebilingual and 10% speak solely anotherlanguage). A total of 4% of HMO enrolleesstatewide report limited English proficiency(see Exhibit 1). In Los Angeles and Santa Claracounties, nearly half of the populationcommunicates at home in a language otherthan, or in addition to, English.

One in three (35%) HMO members ages18-64 and almost half (45%) of enrollees ages65 and over have no education beyond highschool. Among 18-64 year olds, the proportionwith a high school education or less rangesfrom 20% in the San Francisco area to 46% inthe Central Rural region (see Exhibit 2).


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Materials Not Readable to ManyHMOs regularly send their membershandbooks, flyers, newsletters, and brochuresintended to educate them about their plancoverage, benefits, rights, and type and locationof available services. However, these materialsare often written at a level not easilyunderstood by most members.

Ninety-four percent of HMO consumer-education materials are written at the college orgraduate school level, while only 6% werewritten at the high school level (see Exhibit 3).

Among the general public, half of all adultsread at an eighth-grade level or lower, whileamong adult HMO enrollees, 37% have a highschool education or less. Thus, there is amismatch between the reading level required tounderstand the information communicatedand the literacy levels of a large portion of thetarget audience.

Systematic content analysis of these writtenmaterials from the eleven largest HMOs inCalifornia showed a number of factors thatcontribute to high readability levels. There wasexcessive use of polysyllabic words, lengthysentences, and complex paragraphs withobscure grammatical constructions, as well asdifficult-to-read font sizes and types. Only half(51%) have either introductory or summarystatements for sections of text. Just one in seven(14%) has clear pronoun references and only3% highlight new words. One in six (17%)provides definitions or synonyms for key terms

49% 45%

6%

High School

College

Graduate School

Exhibit 3: Reading Level ofHMO Materials

Source: Health and MediaResearch Group (HMRG),UCLA School of PublicHealth, 2002.

One in three(34%) HMOmembers inCalifornia speaksa language otherthan English athome…A total of 4% ofHMO enrolleesstatewide reportlimited Englishproficiency…

1 According to reports filed by health plans with the stateDepartment of Managed Health Care, there are over 20 millionhealth plan members in the state. However, this figure includesmembership in two large PPOs and double counts individualswho are members of plans that subcontract with other plans.When these are factored out, the number of health planmembers reported to the state is similar to the number derivedfrom the 2001 California Health Interview Survey.

Ninety-fourpercent of HMOconsumer-educationmaterials arewritten at the college or graduateschool level…

that are not widely understood, and slightlymore than half (55%) have relevantillustrations. Therefore, many of thesematerials are difficult to read, especially for theless-educated consumer.

While HMOs have put some thought andeffort into making their documents more user-friendly, such efforts are often hampered by alack of coordination among multiplecontributors and by use of overly sophisticatedlanguage that conforms to legal oraccreditation standards.

Linguistic Services May Vary Dependingon Coverage TypeThe diversity of California’s HMO membershipincreases the importance of providinglinguistic services for members with limitedEnglish proficiency (LEP). These servicesinclude telephone and face-to-face interpretersand written materials translated into otherlanguages. Health plans also collect memberlanguage information and monitor language-barrier grievances. Such efforts play a role inensuring that LEP members receive the samequality health care as non-LEP members.

Although many health plans provideappropriate linguistic services for theirmembers, there is variability in how membersare informed about available services as well ashow to access services. Additionally, thelinguistic services offered may vary based onthe member’s type of coverage.2

Many HMOs provide certain interpreterand translation services for their Medi-Cal,Medicare, and Healthy Families members tomeet federal and state contract requirements,but do not routinely offer the same services totheir commercial members, who are notcovered by these requirements.

Across all types of coverage (commercial,Medi-Cal, Healthy Families, Medicare), 90% ofplans report that they ask some members toindicate their preferred language at the timethey enroll. But only 30% ensure that amember’s primary language is documented in

his or her medical records; 70% shift thatresponsibility to the delegated medical group,independent practice association (IPA), orindividual provider.

When asked, HMOs report that they track“predominant” languages of their members,where predominant is defined as at least 3% ofthe member base of the health plan. All HMOsparticipating in the Medi-Cal and HealthyFamilies programs report that Spanish is apredominant non-English language ofmembers. Spanish is also a predominant non-English language in approximately 83% ofHMOs with commercial coverage and 90%with Medicare coverage. Chinese ispredominant in approximately 40% of planswith Medi-Cal and Healthy Families coverage,25% of plans with commercial coverage, and33% of plans with Medicare coverage.

Across all types of coverage, 85% of plansreport that they have a procedure in place tomonitor their non-English speaking memberpopulation and to adjust or target providercontracting accordingly.

All plans report that they providetelephone interpreter services for LEPmembers at no cost and have bilingual staffmembers who speak a language other thanEnglish. Eighty-five percent of plans report thatthey contract for language line services.3 Eightypercent of plans report that they providetelephone interpreters at medical points ofcontact for at least one line of business.Similarly, 80% offer access to face-to-faceinterpreters for some LEP members at medicalpoints of contact. Ninety percent of plans thatoffer face-to-face interpreter services do so atno cost to the member.

Across all types of coverage, only 65% ofplans report that they directly arrange and payfor telephone or face-to-face interpreter servicesfor at least one line of business. Another 30%delegate this responsibility to their contractedmedical group or provider, and 5% report thatthey provide access information to commercialHMO enrollees, who are then responsible for


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2 HMOs may offer several types of coverage, known as lines ofbusiness, including commercial, Medicare, Medi-Cal, orHealthy Families, based on the source of payment.

3 Language line services are provided by a company oftelephone interpreters contracted by a health plan to speakwith members when an appropriate bilingual staff memberis not available.

Although manyhealth plans

provideappropriate

linguisticservices for their

members, thereis variability in

how membersare informed

about availableservices…


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65%

5%

Plan

Delegated IPAor Provider

HMO Member

30%

arranging their own telephone interpreterservices (see Exhibit 4).

Twenty percent of HMOs across all lines ofbusiness report that they use a standardizedmeasure to evaluate the language proficiency oftheir health-care providers. Approximately60% report that information on providerlanguage proficiency is self-reported by theprovider, while a smaller proportion of HMOsreport having no such evaluation process inplace. Regarding member service staffs, 85% ofHMOs report that they evaluate bilinguallanguage proficiency while 10% conduct suchstaff assessment via self-report, and 5% reporthaving no such evaluation process.

Policy Recommendations California continues to be at the forefront ofthe HMO field, as evidenced by theestablishment of the California Office of thePatient Advocate (OPA), which distinguishesCalifornia as the first state with an officededicated to assisting HMO members to attainthe highest quality of care and services.California also has the nation’s most diversepopulation, adding to the challenge OPA andindividual health plans face in ensuring thatthis goal is met. The ability of HMO enrolleesto understand membership benefit materialsprovided by their plans and to access linguisticservices when needed are essential forincreasing HMO public accountability andassuring that HMOs are responsive tomember needs.

The comprehensive demographic profile ofCalifornia’s entire HMO populationsummarized in this Policy Brief suggests thateffective HMO outreach and communicationrequires recognition of the diversity inethnicity, English proficiency, and educationalattainment of the membership. The ethnicdiversity, variety of languages spoken, andvaried literacy levels among California’s HMOpopulation point to potential barriers forHMO members in understanding their plan’spolicies and programs and obtaining access to

services. Thus, when preparing materials fordistribution and outreach, HMOs need toprovide information in different languages thatare adapted for the cultural variations in theirmember populations.

Because the educational attainment ofHMO enrollees varies within the state, theOffice of the Patient Advocate has anopportunity to establish guidelines for thedevelopment of materials written by HMOsso that respective policies and benefits areclearly communicated to all enrollees,particularly those with high schooleducations or less. OPA and individual healthplans also need to recognize the diversity ofCalifornia’s HMO membership in their effortsto educate enrollees regarding their health-carebenefits, rights, and needs.

The discrepancy between the educationalattainment of HMO enrollees and thereadability level of the materials designed toeducate them about their benefits—compounded by the fact that these materialsare often presented in ways that are confusingeven to highly educated members—is cause forserious concern. When consumers receivedifficult-to-understand materials, they arelikely to put them aside without reading them.While HMOs may be motivated to producemore readable documents, they have clearlynot always been successful. OPA can take anactive role in supporting efforts to improve thereadability of member materials.

Exhibit 4: Who Is Responsible for ProvidingInterpreter Services?

Source: California Office ofthe Patient Advocate, 2002.

A strong benefitspackage may beof little use tomembers whohave troubleunderstandingwhat thosebenefits actuallyare and how togain access to them…

The use of overly complex language shouldbe examined and recommendations made forthe translation of these materials into text thatis easy to understand. HMOs should also beencouraged to improve coordination in thedevelopment of these materials. More critically,the Office of the Patient Advocate needs toestablish a service to provide technicalassistance to HMOs in testing for readabilityand in revising materials accordingly.

Clearly, obtaining high quality care andservices depends greatly on the ability of anHMO member to communicate with his or herhealth-care provider and health planrepresentative. HMOs should be responsiblefor assessing their members’ language needsand tailoring services to meet those needs. Thisinvolves not only collecting member-languageinformation, but also providing appropriatelinguistic services at medical points of contact.It also means offering the same linguisticservices to all members, regardless of type of coverage.

Many HMOs are providing certaininterpreter and translation services for theirMedi-Cal, Medicare, and Healthy Familiesmembers to meet federal and staterequirements, but they are not consistentlyoffering the same services to their commercialmembers who are not covered by theserequirements. Such distinctions createconfusion and may unnecessarily limit accessto entitled benefits among commercial LEPmembers. All health plans need to adoptstandardized procedures to inform LEPmembers about the availability of interpreterand translation services as well as how toobtain them.

In the past decade, a number ofperformance-reporting measures have beenimplemented to improve the ability of HMOconsumers to assess the quality of servicesprovided by plans, including those reported bythe Health Plan Employer Data andInformation Set (HEDIS) and the ConsumerAssessment of Health Plans (CAHPS). These


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measures, however, may not capture all thedimensions of health plan performance thataffect a diverse population. A strong benefitspackage may be of little use to members whohave trouble understanding what those benefitsactually are and how to gain access to them, orif the benefits are not explained in themember’s language of choice.

Data SourcesThis Policy Brief reports the findings of three separatestudies, two conducted by the UCLA Center for HealthPolicy Research under contract with the CaliforniaOffice of the Patient Advocate (OPA), and the thirdconducted by OPA staff.

The first study was headed by Gerald Kominskiand has been published as a separate UCLA Center forHealth Policy Research report (January 2003).4 Thatstudy analyzed information describing thedemographic profile of California’s HMO enrolleepopulation using data from the 2001 CaliforniaHealth Interview Survey (CHIS), the largest statehealth survey conducted in the United States. Thedemographic profile was developed using the random-digit dial (RDD) telephone sample from CHIS 2001,which collected information from 55,428 households(55,428 adults, 5,801 adolescents ages 12-17, and12,592 parents about a child in their home ages 0-11).For full information on the data and methods used todevelop the demographic profile, see Kominski et al.,referenced below, p. 53. Additional informationregarding CHIS 2001 is available atwww.chis.ucla.edu.

The second UCLA Center for Health PolicyResearch study was headed by Deborah Glik andassessed the readability of consumer educationmaterials provided by eleven of California’s largestHMOs by applying two well-known readabilityscoring tools: the Simple Measure of Gobbledegook(SMOG) test, which assigns a grade level of difficultyto written material based on the number ofpolysyllabic words and the length of sentences; and theReadability Assessment Instrument, which looks atgrammatical and organizational characteristics ofwritten material, including the logical structure of thedocument, the coherence in meaning from onesentence to the next, the adequacy of definitions, and

4 GF Kominski, PL Davidson, CL Keeler, N Razack, LMBecerra, R Sen, Profile of California’s HMO Enrollees: Findingsfrom the 2001 California Health Interview Survey. A Reportfor the California Office of the Patient Advocate. Los Angeles:UCLA Center for Health Policy Research, January 2003. Forcopies of this report, visit www.healthpolicy.ucla.edu.


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the general appearance of the materials presented(presence and relevance of illustrations and font sizeand type), among other measures. This approachconsiders the fact that longer, more complexparagraphs with obscure grammatical constructionsare hard to understand, especially for persons withlower levels of literacy.

The data on linguistic services in CaliforniaHMOs is a summary of information from a surveydeveloped by the Office of the Patient Advocate withassistance and input from the ad hoc OPA Culturaland Linguistic Services Work Group. The survey wasmailed to health plan CEOs and sent as an electronicdocument to key contacts in 20 HMOs in May 2002.Nine commercial HMOs (consisting of more than95% of commercial enrollees in the state) and elevencounty-based local-initiative health plans and theirplan partners participating in the Medi-Cal programreceived the survey. The information is based onvoluntary self-reports. The survey and more detailedinformation are available from the OPA in acomprehensive report.5 OPA also provides a summaryof the linguistic services information for consumers onthe 2002 HMO Report Card, available atwww.opa.ca.gov.

The California HealthInterview Survey (CHIS) isa collaboration of theUCLA Center for Health

Policy Research, the California Department of HealthServices, and the Public Health Institute. Funding forCHIS 2001 was provided by the CaliforniaDepartment of Health Services, The CaliforniaEndowment, the National Cancer Institute, theCalifornia Children and Families Commission, theCenters for Disease Control and Prevention (CDC),and the Indian Health Service. For more informationon CHIS, visit www.chis.ucla.edu.

Author InformationGerald F. Kominski, PhD, is an Associate Director ofthe UCLA Center for Health Policy Research,Professor in the Department of Health Services, andAssociate Dean for Academic Programs, UCLA Schoolof Public Health. Deborah Glik, ScD, is Professor inthe Department of Community Health Sciences, andDirector of the Health and Media Research Group(HMRG), UCLA School of Public Health. CoriReifman, MPH, is Project Coordinator in the Policyand Program Support Division of the CaliforniaOffice of the Patient Advocate (OPA).

AcknowledgementsThe authors wish to acknowledge the followingindividuals who contributed to the production of thisPolicy Brief: Paula Y. Bagasao, Clodagh Harvey, andKaren Markus from the UCLA Center for Health PolicyResearch; Cheri Agonia from the California Office ofthe Patient Advocate; and Dan Gordon, UCLA. StevenWallace and Nadereh Pourat of the UCLA Center forHealth Policy Research provided valuable criticalreviews of this policy brief.

CitationGF Kominski, D Glik, C Reifman. California’s HMOEnrollees: Diversity in Language and Education PosesChallenges for Health Plans. Los Angeles: UCLACenter for Health Policy Research, 2003.

FunderThe California Office of the Patient Advocate (OPA)funded the research for and the development of thisPolicy Brief.

5 State of California, Office of the Patient Advocate, HMOServices in Other Languages: A Portrait of California HealthPlans and Linguistic Services for Limited English ProficientMembers, April 2003. For copies, contact OPA at 1-866-HMO-8900.

PHONE: 310-794-0909 • FAX: 310-794-2686 • EMAIL: [email protected] • WEB SITE: www.healthpolicy.ucla.edu


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The views expressed in this report are those of the authors and donot necessarily represent the UCLA Center for Health PolicyResearch, the Regents of the University of California, theCalifornia Office of the Patient Advocate.

PB2003-2Copyright © 2003 by the Regents of the University of California

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The UCLA Center for Health Policy Research is based in the UCLA School of Public Health

and is also affiliated with the UCLA School of Public Policy and Social Research

The California Office ofthe Patient Advocate

(OPA) funded theresearch for and thedevelopment of this

Policy Brief.

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