Despite the progress that many hospitals have made to improve their financial communications, much work remains to be done. "It's safe to say that a majority of people do not understand their medical bills the first time they pick them up and read them," says Joanne Locke, a member of the executive board for the Center for Plain Language.

Plain Language Basics

The Center for Plain Language offers these criteria for determining whether language is working well:

  • Can the people who are the audience for the material quickly and easily find what they need?
  • Can they understand what they find?
  • Can they act appropriately on that understanding?

Plain language may mean short words and short sentences-or it may not. What it always means is language that works well for the intended audience.

Jessica Ridpath, research communications coordinator, Group Health Research Institute, identifies four basic tenets of plain language.

Use language your audience can easily understand

For instance, choose common everyday words instead of medical or financial jargon. If you need to use a hard-to-understand term, define it using simple language. You can also get a rough estimate of how easy a document is to read by using automated "readability tests."

Write in a conversational style, as if you were speaking

For example, use active rather than passive voice and personal pronouns (i.e., "I," "we," and "you").

Organize and filter content with your readers' needs in mind

For instance, use short sentences, and limit paragraphs to one main topic. Consider your audience-their literacy level, age, culture, ethnicity, or health conditions. Also, ask someone unfamiliar with your project to read your materials. Or better yet, conduct a field test with your target audience.

Format your document so that it looks easy to read

Use ample white space and margins. Break up chunks of dense copy. Give your readers "road signs" to help them identify topic areas. And emphasize key information using bold, color, or large type.

(These tenets are pulled from Ridpath's Powerpoint presentation "Introduction to Health Literacy and Plain Language." Access the entire presentation.)

A History of Plain Language

The plain language movement started in the federal government in the 1970s with the recognition that government regulations were too difficult to understand. Locke says work to simplify language in government documents was sporadic until the late 1990s, when a Presidential Memorandum mandated that new regulations and documents explaining benefits or services be written using plain language.

Every federal agency assigned a senior official to implement the use of plain language. A web site ( was set up to support the movement, and the "No Gobbledygook" awards were established to recognize plain language overhauls. Meanwhile, a few states-notably, Washington and Florida-and segments of private industry picked up on the plain language concept in various ways.

The Focus on Health Literacy

In the healthcare sector, a focus on health literacy has been building in lockstep with the plain language movement. Health literacy is the ability to understand the health information you need at the time you need it. 

Research shows that healthcare materials are typically written above the 10th grade level. Yet 20 percent of American adults read at the 5th grade level or below, and the average American reading level is at the 8th or 9th grade level. (Doak C.C., Doak L.G., Root J.H., "The Literacy Problem," In: Teaching Patients with Low Literacy Skills. 2nd ed., Philadelphia: J.B. Lippincott Co, 1996, 1-9.)

The difficulty of understanding health communications has been recognized in high places. The Institute of Medicine published a report on health literacy in 2004, and in 2007, the Joint Commission initiated a project to improve health literacy as a way of improving patient safety.

The idea that health literacy is an issue only for people with low general literacy is a misconception, says Locke. "You get up in the middle of the night, your two-year-old is screaming, and it's really hard to find the dosage on a bottle of medicine," she says. "Or you have just been diagnosed with breast cancer, and it's hard to understand what the physician is telling you. Or you get papers from the hospital or the insurance companies that you can't understand."

Plain language helps solves these types of literacy problems by presenting information in a clear, forthright manner and using words that are easy to understand.

Plain Language for Healthcare Financial Documents

A 2003 U.S. Department of Education literacy survey asked questions about health financial literacy. "Roughly 90 percent of the people couldn't compare health insurance policies to figure out what was best for them," says Locke.

Using plain language approaches to create clear, easy-to-understand patient financial communications can translate into increases in efficiency for hospital billing departments. Locke cites a cable company that used plain language principles to rework its customer bills. The number of customer calls with questions about their bills declined by 15 percent; the length of the calls received fell by 8 percent; and the use of on-line self-help increased by 17 percent. 

"Just think about how much time the hospital billing office will save if patients get their bills and actually know what on earth they are supposed to do," she says.

Publication Date: Thursday, November 05, 2009