Health Literacy and Use of Outpatient Physician Services by Medicare Managed Care Enrollees


  • David W. Baker MD, MPH,

    Corresponding authorSearch for more papers by this author
  • Julie A. Gazmararian MPH, PhD,

  • Mark V. Williams MD,

  • Tracy Scott PhD,

  • Ruth M. Parker MD,

  • Diane Green PhD,

  • Junling Ren MEd,

  • Jennifer Peel MPH

  • Received from the Department of Medicine (DWB), Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill; Emory Center on Health Outcomes and Quality (JAG, TS, DG, JR, JP), Rollins School of Public Health, Atlanta, Ga; and Department of Medicine (MVW, RMP), Emory University School of Medicine, Atlanta, Ga.

 Address correspondence and reprint requests to Dr. Baker: Feinberg School of Medicine, Northwestern University, Suite 200, 676 N. St. Clair Street, Chicago, IL 60611 (e-mail:


OBJECTIVE:  To determine whether inadequate functional health literacy adversely affects use of physician outpatient services.

DESIGN:  Cohort study.

SETTING:  Community.

PARTICIPANTS:  New Medicare managed care enrollees age 65 or older in 4 U.S. cities (N = 3,260).

MEASUREMENTS AND MAIN RESULTS:  We measured functional health literacy using the Short Test of Functional Health Literacy in Adults. Administrative data were used to determine the time to first physician visit and the total number of visits during the 12 months after enrollment. The time until first visit, the proportion without any visit, and adjusted mean visits during the year after enrollment were unrelated to health literacy in crude and multivariate analyses. Participants with inadequate and marginal health literacy were more likely to have an emergency department (ED) visit than those with adequate health literacy (30.4%, 27.6%, and 21.8%, respectively; P = .01 and P < .001, respectively). In multivariate analysis, the adjusted relative risk of having 2 or more ED visits was 1.44 (95% confidence interval, 1.01 to 2.02) for enrollees with marginal health literacy and 1.34 (1.00 to 1.79) for those with inadequate health literacy compared to participants with adequate health literacy.

CONCLUSIONS:  Inadequate health literacy was not independently associated with the mean number of visits or the time to a first visit. This suggests that inadequate literacy is not a major barrier to accessing outpatient health care. Nevertheless, the higher rates of ED use by persons with low literacy may be caused by real or perceived barriers to using their usual source of outpatient care.