Making the Case for Language Access: Talking
Points for Advocacy
NLADA Annual Conference
Denver, CO
November 19, 2009
Doreena Wong
2639 S. La Cienega Blvd.
Los Angeles, CA 90034
(310) 204-6010, ext. 107
(310) 204-0891 (fax)
Email: [email protected]
www.healthlaw.org
“Securing Health Rights for Those in Need”
NHeLP
• National non-profit law firm committed to
improving healthcare access and quality for
low-income individuals
• Coordinates the National Language Access
Advocacy Project, funded by The California
Endowment
– Includes a national coalition of stakeholders
on language access working to improve
polices and resources at the federal level
To switch from VOIP to a telephone connection, call 213-286-1201, access code 435-253-182
Overview
• Making the Case for Language Services
–Business Case
–Quality of Care/Quality Assurance
–Pubic Health Objectives
–Legal Mandates
• Funding Issues
• Advocacy Efforts & Next Steps
Business Case
• Changing demographics of consumers/
members
• Marketing strategy: attract new consumers
• Need to meet consumer needs, increase
consumer satisfaction
• Risk management: indirect costs - increase
patient compliance, reduce errors/malpractice
• Cost reductions: measure cost effectiveness
Changing Demographics
• Individuals who do not speak English as their
primary language and who have a limited
ability to read, write, speak, or understand
English
• Over 55 million people speak a language other
than English at home (an increase of 8 million
since 2000) and 19.7% of the population.
• Over 25 million (9 % of the population and an
increase of 3 million from 2000) speak English
less than “very well,” and may be considered
LEP.
Marketing Strategy
• There is evidence that providing culturally and
linguistically appropriate services (CLAS) can bring a
return on investment (ROI)
• Alliance of Community Health Plans Foundation
report (2007) showed that health plans providing
CLAS increased enrollment and market share for
plans
• The report found that “cultural competency attracted
business and led to reduced cost of interpretation
services, length of hospital stay, & increased patient
and provider satisfaction
Patient Satisfaction
• Spanish-speaking patients less satisfied with
care.
– Morales et al. JGIM 1999; 14:409-417.
• LEP patients less satisfied with emergency
care.
– Baker et al. Med Care 1998; 36:1461-1470.
• LEP patients less satisfied with emergency
care, less willing to return for future care.
– Carrasquillo et al. JGIM 1999; 14:82-87.
Risk Management
Medical History Taking
• Spanish-speaking pregnant woman
suffered miscarriageur to lack of
interpreter services.
– Fortier et al. J Healthcare Poor Underserved 1998; 9:S81100.
• Non-English speaking man awarded $71
million for failure to diagnose stroke.
– Harshan. Med Econ 1984; 289-292.
Risk Management
Provider Communication
• Lao woman awarded $1.2 million for
wrongful imprisonment for 10 months for
noncompliance with tuberculosis
treatment; it was never explained why she
needed to take her medications.
• Hmong man had his leg amputated
without realizing that was what he was
agreeing to because no interpreter
provided to explain consent form.
Cost of Care
Emergency Room Costs
• Pediatric patients whose families were assessed
to have a “language barrier” with the physician
had higher charges ($38) and longer stays (20
minutes) than those without language barriers.
– Hampers et al. Peds 1999; 103(6): 1253-1256.
• Non-interpreted LEP patients returned to the ER
more frequently and followed-up in clinic less
frequently than interpreted patients, who had
the lowest 30-day post ER visit charges.
– Bernstein J, et al. J Immigrant Health 2002; 171-176.
Quality of Care
Patient Comprehension and Adherence
• LEP patients less likely to understand medication instructions,
less likely to receive needed financial assistance, and less likely
to return to the same hospital.
– Andrulis et al. Access Project 2002, What a Difference an Interpreter Can Make.
• Spanish-speaking patients discharged from emergency room
without interpreters less likely to understand diagnoses,
prescribed medications, special instructions or plans for followup care.
– Crane. J Emerg Med 1997; 15(1):1-7.
• Spanish-speaking patients more likely to miss appointments and
be less adherent to asthma medication if physician did not speak
Spanish.
– Manson. Med Care 1988; 26(12):1119-1128.
Quality Assurance
• Language access questions included on Consumer
Assessment of Health Plans Survey (CAHPS)
Weech-Maldonado, et al. (2001) Health Services
Research 36(3):575-594]
• Joint Commission will be establishing culturally
and linguistic competency standards
• National Committee for Quality Assurance (NCQA)
includes language access standards in HEDIS
performance measures & proposing voluntary
CLAS standards
• Monitoring by State Agencies – California
example: Office of the Patient Advocate publishes
its HMO Report Card at:
http://wp.dmhc.ca.gov/report_card/
Public Health Objectives
• Healthy People 2010 acknowledged
continuing health disparities based on
racial/ethnic and other socioeconomic
factors, including linguistic access
• Institute of Medicine (2002) health
disparities report cited language access as
challenge (www.nap.edu/books/030908265X/html)
• Administrative & Congresssional efforts to
address
Federal Legal Mandates
 Title VI of the 1964 Civil Rights Act
 No person in the United States shall, on the ground of
race, color, or national origin, be excluded from
participation in, be denied the benefits of, or be subjected
to discrimination under any program or activity receiving
Federal financial assistance.”
 E.O. 13166-8/11/00
- prepare a plan to improve LEP access
- draft a title VI LEP guidance for its recipients
 DOJ (6/18/02) & DHHS OCR Guidance (8/8/03)
- take reasonable steps to provide meaningful access
- take into account the #/, % & freq. Of LEP persons;
importance of the service; and available resources
Other Federal Guidelines
• Office of Minority Health CLAS Standards – 2000


First national standards for culturally and linguistically
appropriate services (CLAS) in health care to help
organizations provide culturally and linguistically accessible
services or all (www.omhrc.gov/clas ).
All patients should receive fair and effective CLAS and
treatment
• 14 Standards – mix of mandates, guidelines and
recommendations:
– Culturally Competent Care
– Language Access Services
– Organizational Supports fro Cultural Competency
State Guidelines
• All states and DC have at least two language access
laws
(http://www.healthlaw.org/library/item.174993)
– comprehensive
– targeted (e.g. emergency room, hospital)
• 3 states require cultural competency continuing
education for health professionals
• Some states moving towards interpreter certification
• Certification Commission for Healthcare Interpreters
- A national, valid, credible, vendor-neutral
certification program for healthcare interpreters
(http://healthcareinterpretercertification.org)
Funding Issues
• Medicaid Reimbursement
– HCFA (CMS) “Dear State Medicaid Letter” (8/31/00)
• Recipients must comply with OCR LEP Guidance
• Federal matching funding available for
reimbursement for language assistance services for
CHIP and Medicaid recipients
• CHIPRA - included enhanced administrative funding
for language assistance services = the higher of 75%
or FMAP plus 5% for children in CHIP & Medicaid
(2/2/09)
– August 31, 2009 CMS letter – opportunity to explore ways
to obtain increased FMAP
Medicaid Reimbursement
• Only a handful of states & DC have set up programs
to provide direct reimbursement using federal
matching funds to pay for language services:
– CT, DC, HI, ID, IA, KS. MA*, ME, MN, MT, NH, UT,
VA, VT, WA & WY
• Four models –
– contract with language service brokers/agencies
– reimburse providers for hiring interpreters
– directly reimburse interpreters
– contract for telephone interpreter services
Current State Reimbursements (2007)
State
Enrollees
Covered
Providers
Covered
Who the State Pays
Reimbursement Rate
Admin or
Service
DC
FFS
FFS < 15 emp.
Lang. agency
$135-$190/hour (in-person)
$1.60/min (telephonic)
Admin
HI
FFS
FFS
Lang. agencies
$36/hr
Service
ID
FFS
FFS
Providers
$12.16/hr
Service
KS
Managed
Care
Managed Care
EDS (fiscal agent)
Spanish – $1.10/min.
other languages – $2.04/min.
Admin
ME
FFS
FFS
Providers
Reasonable costs
Service
MN
FFS
FFS
Providers
lesser of $12.50/15 min or usual and
customary fee
Admin
MT
All
All
Interpreters
$6.25/15 minutes
Admin
NH
FFS
FFS
Interpreters
$15/hr; $2.25/15 min after 1st hour
Admin
UT
FFS
FFS
Lang. agencies
$28-35/hour (in-person)
$1.10/minute (telephonic)
Service
VA
FFS
FFS
AHEC & 3 health depts.
Reasonable costs
Admin
VT
All
All
Language agency
$15/15 min
Admin
WA
FFS
Public entities
Public entities
50% expenses
Admin
WA
FFS
FFS
Brokers
Brokers receive an admin. fee
Language agencies – $33/hour
Admin
WY
FFS
FFS
Interpreters
$45/hour
Admin
This information is current as of 3/07.07.
Advocacy Efforts to Obtain Funding
• Consider efforts within context of political environment,
state budget, department policies, & Medicaid and SCHIP
funding
• Work with interested stakeholders to develop & advocate
for best proposed model to improve language access and
funding, i.e., plan regional stakeholders meetings
• Develop an action plan with specific steps involving all
interested stakeholders, including legislative and
administrative strategies to promote reimbursement
model
• Improve data collection systems, i.e. to determine actual
costs and estimated cost savings & support advocacy for
improved language access and funding
Next Steps
• Education – providers, clients/patients
• Advocacy – increased language assistance
services & funding
• Increase pool of trained and available
interpreters – coalition building w/ local CBOs,
training/education
• Enforcement – file complaints with OCR,
investigate state law possibilities
NHeLP Resources
Available at: www.healthlaw.org
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The California Endowment
– “Ensuring Linguistic Access in Health Care Settings: An Overview of Current Legal Rights and
Responsibilities” (Sept. 2003)
Summary of State Law Requirements Addressing Language Needs in Health Care (March '08)
NHeLP and Access Project
– Language Services Action Kit: Interpreter Services in Health Care Settings for People with Limited
English Proficiency” (August 2003 & December 2005 update)
Commonwealth Fund
– “Providing Language Services in Small Health Care Provider Settings: Examples From the Field”
(April 2005)
Commonwealth Fund
– “Providing Language Services in State and Local Health-Related Benefits Offices : Examples From
the Field” (Jan 2007)
The National Council on Interpreting in Health Care/NHeLP/TCE
– Language Services Resource Guide for Health Care Providers (Oct. 2006)
NHeLP/Health Research and Educational Trust
– “Hospitals Language Services for Patients with Limited English Proficiency: Results for a National
Survey” (October 2006)
NHeLP/Center on Budget and Policy Priorities
– “Paying for Language Services in Medicare: Preliminary Options and Recommendations” (October
2006)
Commonwealth Fund
– “Interpretation Services in Health Care Settings: Examples From the Field” (May 2002)
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