What happens when a person who speaks a language other than English enters a hospital? One who is fortunate enough to enter one of the one-quarter of American hospitals that offer professional interpreters or other language access services can expect to understand what is going on and to communicate comfortably with the care providers. For the approximately 75% of U.S. hospitals remaining, language access has become a common concern as increasing immigration levels expand ethnic groups.
Nearly 52 million people—one in 12—in the United States speak a language other than English at home. In fact, more than 300 languages are spoken in the United States. Basing their calculations on the 2000 census, demographers estimate that the number of people with limited English proficiency (LEP) ranges from 11 million (those who speak English “not well” or “not at all”) to more than 22 million (those who speak English less than “very well”). And those numbers are expected to continue to grow.
The Effects on Healthcare
The growing diversity of the United States population has a direct effect on healthcare providers. In order to provide appropriate and safe care, a provider must rely on accurate information from the patient. Simultaneously, the patient must be able to understand health instructions and treatment options in order to participate in his or her care. Language is the vital bridge in this process.
So what happens, for example, when an English-speaking emergency department physician faces a Spanish-speaking patient seeking medical care? Often, the hospital staff will turn to the patient’s family to act as interpreters. If that is not possible or advisable, the clinician may ask a bilingual staff member to help. This is commonly called dual-role or ad-hoc interpreting because the employee’s primary job in the healthcare organization (whether clinical or non-clinical) involves something other than interpreting.
While ad-hoc interpreters fulfill immediate needs by thoughtfully stepping in and helping out, many are asked to interpret outside their areas of expertise as they interrupt their own work. And an interpreter who has received no specialized training cannot be expected to achieve the same results as a professional interpreter. Simply being bilingual is not enough; professional medical interpreting is a learned skill.
Yet many healthcare organizations across the United States are not prepared to provide professional linguistic access for their patients. This is not to say that care providers would not like a professional interpreter program in the healthcare organization. Providers from a wide range of services have reported that language barriers and inadequate funding of language access services present major problems in ensuring both access to and quality of healthcare for LEP individuals. Funding, in particular, is one of the major reasons healthcare organizations hesitate to implement dedicated interpreter departments.
According to Cynthia Roat, MPH, a national consultant on language access in healthcare, the two major restrictions hindering the implementation of professional linguistic access programs in hospitals today are:
- Lack of funding and
- Lack of qualified interpreters.
“Fortunately the latter problem is being addressed,” she says. “We have established standards of practice for professional competence, and there are training programs for medical interpreters as well as for clinical staff who use interpreters.”
For example, the National Council on Interpreting in Health Care (NCIHC), a leading advocate of medical interpreting, has developed national standards to improve communication between the LEP patient and the healthcare provider. In addition, many technical and community colleges now offer medical interpreting classes, and some medical schools are beginning to offer seminars and courses designed to train clinical staff to work with interpreters. “Working with interpreters is a concrete, clinical skill,” says Roat.
Still, finding the money for this type of program can have a financial impact on healthcare organizations. Adding to that, accreditation agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the National Committee for Quality Assurance (NCQA) have set compliance standards for language access in terms of its contribution to quality care and patient safety. These compliance standards can also have a financial impact on healthcare organizations.
An even more significant effect may result from the federal government’s mandate to provide language services to LEP individuals. Specifically, Executive Order 13166, “Improving Access to Services for Persons with Limited English Proficiency,” stipulates that hospital and healthcare organizations receiving federal funds are required to provide interpretation services under Title VI of the Civil Rights Act of 1964. Denial of interpreter services to LEP patients is considered a form of discrimination.
In addition, the Office of Minority Health (OMH) within the U.S. Department of Health and Human Services has specified 14 National Standards for Culturally and Linguistically Appropriate Services in Health Care (CLAS) that direct healthcare organizations to make their practices more culturally and linguistically accessible. CLAS standards are organized by themes: Culturally Competent Care, Language Access, and Organizational Support for Cultural Competence. Within this framework, there are three types of obligation: mandates, guidelines, and recommendations. Mandates are current federal requirements for all recipients of federal funds; guidelines are activities recommended by OMH for adoption as mandates by accrediting agencies; and recommendations are standards suggested by OMH for voluntary adoption by healthcare organizations.
Despite its mandates, standards, and recommendations, however, the U.S. government has not included provisions for or suggestions about paying for compliance.
Benefits of a Language Access Program
Nevertheless, in addition to complying with governmental regulations and meeting accreditation standards, hospitals can derive benefits from an interpreter program. First and foremost, using interpreters with LEP individuals allows a hospital to fulfill one of its most important professional obligations: providing the best care possible to each patient. The clinician understands the patient’s symptoms, and the patient understands the doctor’s diagnosis and instructions. Together they can form a partnership to meet the physical, psychological, and cultural needs of the patient and to afford a sense of satisfaction to the caregiver.
Secondly, providing linguistic access can make hospital services more cost effective. Visits are fewer and shorter. There are not as many follow-up appointments or repeat admissions because patients understand their physicians’ instructions. Clinicians avoid unnecessary, inadvisable, or inappropriate tests because they understand the patients’ symptoms. Overuse of emergency department services for primary care decreases because patients are comfortable establishing a more conventional primary care relationship. And, as Roat points out, “if a hospital can develop an access program that does not rely on ad-hoc interpreters, the organization can avoid the hidden costs of lower productivity and higher turnover among those ad-hoc interpreters who are asked to interrupt their regular work to provide language access.”
Finally, there are benefits associated with legal and liability issues. Among them: fewer mistakes in diagnoses and treatment because the patients can communicate with their care providers. Also, patients are able to follow directions correctly and understand the need for follow-up or referrals, thus averting an unnecessary tragedy or potential lawsuit. Glenn Flores, MD, director of the Center for the Advancement of Urban Children and professor of pediatrics, epidemiology, and health at the Medical College of Wisconsin, can cite examples of medical errors attributable to language misunderstandings.
“Lack of language services can affect instructions about giving medications, such as the mother who thought she should apply a cortisone cream to the child’s entire body rather than just to the facial rash,” he says. “There is also the problem of possible overdoses. And a single misinterpreted word in one case led to a $71 million lawsuit in Florida a few years ago. This is a major patient safety issue.”
Another safety issue for hospitals is informed consent. Hospitals that provide language services are more likely to ensure that their LEP patients understand and agree to sign the informed consent form.
Paying for Language Access Services
The benefits of offering language access services may be self-evident, but who pays for them? Certainly not private insurers. At least not yet. But, as professionals in the field, both Roat and Dr. Flores see a need for private insurers to assume part of the financial cost. Although Roat believes the costs should be shared among hospitals/clinics, public financing, and commercial insurers, “Advocates of language access need to start a dialogue with commercial insurers and point to HMOs as examples of how these services are being covered,” she says.
Multiple approaches may be necessary to set up coverage from private insurers. Dr. Flores suggests that one possible course is insurance reimbursement for professional interpreters, paid for by the hour or by the visit. Another alternative might involve establishing contract services with outside agencies, community organizations, or video- or teleconferencing companies to recruit, train, and assign medical interpreters for healthcare organizations. These groups could provide services and bill the insurer directly.
“There are also ways to use public funding,” observes Roat, “and there should be more pressure on the federal government to pony up more money for this.”
Dr. Flores agrees. “Under Medicaid and the State Children’s Health Insurance Program (SCHIP), states may pay for interpreting services and receive federal matching funds of 50% or more,” he says. “Yet only 13 states are taking advantage of this. The other 37 states are missing out on this money.”
Like many of his colleagues, Dr. Flores is also mystified about the government’s reluctance to fully fund interpretation services, pointing out that “a federal report from the Office of Management and Budget (OMB) in 2002 estimated that it would cost an average of $4.04 per physician visit to provide all LEP patients with full language access services.”
Then why hasn’t this been allocated? Dr. Flores acknowledges that there is some recognition and awareness of the situation in Congress, and he thinks there may be some political will as well. He has testified before the Senate about the Hispanic Health Improvement Act, yet the bill has yet to pass. At the moment, there are immigration issues that are impeding political action in these areas.
In the meantime, Dr. Flores suggests that there are other steps that healthcare organizations can take to ease language access problems:
- Recruit bilingual providers in areas with large ethnic populations and offer hiring bonuses for qualified individuals;
- Encourage medical schools to require—and even teach—proficiency in languages other than English. “We should require, as other countries do, that children learn foreign languages,” he says; and
- Do a better job of helping LEP individuals learn English.
Begin the last step by directing LEP patients to the Web site of the National Institute for Literacy and Partners, which matches applicants to literacy and ESL programs within their geographical area.1
“We must debunk the oft-repeated story that professional medical interpreters are too expensive to use, that they charge $400 an hour,” says Roat. “That figure came from an incident in which an interpreter was supposedly working in a very remote area on a weekend and charged for the time, distance, and unusual circumstances. In reality, qualified medical interpreters earn $20 to $25 per hour and are worth every penny. Plus, they save money by reducing time and costs to the institution.” TH
Ann Kepler is based in the Chicago area.
- National Institute for Literacy, Literacy Directory. Available at: www.literacydirectory.org. Last accessed September 27,2006.