Imagine that one day, a patient with limited English proficiency walks into your practice. Let’s say he speaks Spanish; you took a few Spanish classes in high school. With no interpreter readily available, you decide that you can rely on your long-dormant language skills to navigate the patient encounter.
As the patient begins to explain why he’s in your office, you grasp that he has pain. During follow-up questioning, you hear the phrase “a little bit.” What you miss, however, is that the patient is not telling you he has “a little bit of pain” but that his pain is “a little bit lower” than the spot indicated. Can you reliably diagnose and treat him if you fail to fully comprehend his presenting complaint?
For the approximately 56 million Americans who speak a language other than English at home (about 24 million are designated as limited in English proficiency [LEP]), such miscommunications are unfortunately common. In extreme cases, they can lead to dire consequences. (See “Interpreter Needed to Take Infant’s History,” below.) Adequate communication, regardless of language, is essential in the health care setting.
“If you don’t have good communication,” says Monica Fernandez, MMS, PA-C—who, as an interpreter, witnessed the encounter described in the opening—“you don’t have good patient care.”
If You Fund It, They Will Come
Title VI of the Civil Rights Act of 1964 actually requires recipients of federal funding (eg, through Medicaid and Medicare) to provide adequate language assistance to LEP patients. The denial or delay of medical care because of language barriers, the act states, “constitutes a form of discrimination.”
However, depending on their practice setting, health care providers may feel they don’t have adequate resources to provide language services to patients who need them. “They’re certainly right,” says Isabel Arocha, MEd, President of the International Medical Interpreters Association (IMIA), “because this is an almost completely unfunded mandate.”
The IMIA and other organizations are advocating for language reimbursement. Currently, 13 states and the District of Columbia receive reimbursement through Medicaid for language services, at a rate that varies from 50% to 75% of every dollar spent by the state. The current House version of the health care reform bill includes a provision that would require a federal match of 75%. “We’re hoping that will help some states that haven’t opted in at a 50% rate so they will [opt in] at a 75% rate,” Arocha says. “That should be very helpful, even to smaller venues.”
Health care providers can be “important advocates” if their state does not reimburse for interpreters, says Glenn Flores, MD, FAANP, Director of the Division of General Pediatrics at the University of Texas Southwestern Medical Center, Children’s Medical Center of Dallas. “It only requires a small change in the administrative handling of Medicaid to allow interpreter services to be classified as a covered service. And if your state is not doing that, it’s basically losing a source of revenue.”
For example, if Texas became the 14th state to reimburse for language services, the state would receive 61¢ for every Medicaid dollar spent and 72¢ for every state Children’s Health Insurance Program dollar spent. Every state has this option, which can go a long way toward providing essential services to LEP patients.
Arocha, too, encourages clinicians to support language-services reimbursement measures. “We really need providers to join with us in this fight,” she says. In addition to the House bill provision related to Medicaid reimbursement, she says, there is also a proposal for an Institute of Medicine study and demonstration project related to Medicare language services payment. Twenty-four grants would be available for projects “to demonstrate different ways of paying for language services,” Arocha explains. This is considered a first step toward “full-blown Medicare reform on language services payments.”
Available Services, Creative Strategies
With or without reimbursement, there is an expectation that clinicians will make a valiant effort to communicate effectively with their LEP patients. Bilingual providers are considered ideal, as long as they have been trained in interpretation; they would be familiar with medical terminology and in most cases with cultural contexts as well. Many providers strive to learn another language—medical Spanish courses are quite popular—but it can take years to achieve the level of fluency needed, and all the Spanish in the world will not help if a Ukrainian patient arrives in your office.
Clinicians, therefore, may be more likely to call upon the services of a medical interpreter. Arocha estimates that there are between 20,000 and 30,000 medical interpreters working in the United States. Even so, she notes, “we’re serving probably one out of the four or five patients who need our services. The demand is huge—much greater than the supply.”