Talk is Not Always Cheap

The conclusion of a recent study concerning the affordability, availability and acceptability barriers to healthcare for the chronically ill seems to say it all:

“In strengthening the public sector, it is important not only to improve drug supply chains, ambulance services, referral systems and clinical capacity at public clinics, and to address the financial constraints faced by the socially disadvantaged, but also to think through how providers can engage with patients in a way that strengthens the therapeutic alliance.”

In this survey of 1446 individuals from low to middle income areas, 74% of reported health problems were chronic and only 35% were receiving regular treatment.  To quote the results of the study:

“Poor provider-patient interaction led to inadequate understanding of illness, inappropriate treatment action, ‘healer shopping’, and at times, a break down in cooperation, with the patient ‘giving up’ on the public health system.”

The study found, however, “productive patient-provider interactions not only facilitated appropriate treatment action, but enabled patients to justify their need for financial assistance to family and neighbors. In addition, patients and their families with understanding of a disease became a community resource drawn on to assist others.”

The conclusion of the study was that providers communicating effectively with their patients results in better care for everyone.  Communication is the key to good healthcare.

Did we mention this study was done in rural South Africa?

Now, before you discount the above as not pertaining to the United States, consider the plight of roughly 72 million Americans (about 27% of US residents) who speak a language other than English or have limited English proficiency.  These patients receive “poor provider-patient interaction” and flounder in our healthcare system, similar to care in third world countries.

According to a recent article by the New England Journal of Medicine, “Patients who face such (language) barriers are less likely than others to have ausual source of medical care; they receive preventive servicesat reduced rates; and they have an increased risk of non-adherenceto medication.”

“Such patients are lesslikely than others to return for follow-up appointments aftervisits to the emergency room, and they have higher rates ofhospitalization and drug complications. Greater resources areused in their care, but they have lower levels of patient satisfaction.”

How do help millions of people overcome the language barriers to healthcare in our industrialized nation?  The obvious solution is to teach them English.  Most people are willing to learn, but it takes time to become fluent (and their appendix may be bursting today.)  It also takes resources that some do not have.  In the meantime, we can provide them with medical interpreters.

The 1964 Civil Rights Acts forbids discrimination based on national origin.  Healthcare providers receiving federal funds are required to offer interpreting services to patients with limited English skills.  Forty-three states have passed laws that address language access in healthcare, but few enforce them.  The enforcing agency, the Office of Civil Rights (OCR) of the US Department of Health and Human Services is required to obtain “voluntary” compliance.  In short this means they wait for a complaint to be filed, investigate it, get an agreement from the offender to offer interpreting and go about their business.  They rarely return to see the problem has been resolved and in 40 years has not imposed a fine or withheld federal funds for non-compliance.  The OCR recommends telephone language lines for random languages that walk in the door but how does that work when a person is bleeding to death in the ER or in the middle of birthing a child?  In-person interpreting by a trained medical interpreter is the best option but it is also the most expensive.

That begs the next question:  Who should pay for this?  Hospitals?  States? Insurers?  The Federal Government?

In a burgeoning healthcare system that has many broken parts, some hospitals are barely able to function and keep their doors open.  As they put out fires, having medical interpreters handy is not on their list of priorities, nor is it something many can afford to provide.

Should insurers pay?  In California, legislation (SB853) became effective on January 1, 2009 requiring medical interpreting and translation services for insured individuals.  Unfortunately there is no way to enforce this requirement.  Physician and advocacy groups claim the large chunks of change insurers pay out to shareholders and executives shows they could afford to pay for medical interpreting.  The fear that insurers will stop covering populations most in need of these services also comes with that claim.

Should the States have to foot the bill?  Indigent healthcare coverage by Medicaid is supposed to cover medical interpreting but it is up to the state to pay providers.  Medicaid reimburses providers for claims (at rates lower than those charged by professional interpreters) but only after the expense is incurred.  As such, providers consider medical interpreting an “unfunded mandate” and refuse to pay for it up front.

In 2000, before he left office, President Clinton signed an executive order requiring all recipients of federal funds, including government agencies, to provide free verbal interpreting and written translation services for non-English speaking clients.  The Association of American Physicians and Surgeons (AAPS) sued to overturn this order.  They felt it was wrong to expect doctors to pay for the service and thought the federal government should pony up the dollars.  When the Bush administration was elected, they kept the “mandate” in place but softened the language and gave it a more voluntary tone.

There is a federal program currently in place through the Center for Medicare and Medicaid Services (CMS) which offers states federal matching funds for medical interpreting services for Medicaid patients and low income children who are receiving federal assistance funds.  It has not been well advertised over the years and, especially in this economic downturn, many states are unable to raise their half of the cash.

In 2002, the federal Office of Management and Budget estimated an annual cost of 268 million dollars to provide professional medical interpreting service in the US.

As “the buck” continues to be passed around, the question remains:  Who should pay for medical interpreting services for non-English speaking patients?

Regardless of who should pay, the bottom line here is pay for it now, or wait and pay later at a compounded cost.  The truth is that many of the non-English populations in need of interpreting services are at a higher prevalence for many common diseases than most Americans.  Educating them now in their native tongue and providing them with equitable healthcare based on good provider-patient communications means paying less for preventable procedures and hospitalizations, medical errors and lawsuits down the road.

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