Published Online: December 20, 2011
Elise H. Lawson, MD, MSHS; Rita Carreon, BS; German Veselovskiy, MPP; and Jose J. Escarce, MD, PhD
Objectives: Key stakeholders agree better data on patients’ language are needed to effectively address language-related barriers to timely, highquality healthcare. Our objective was to describe health plan efforts to collect language data from its members, provide language services, and improve the provision of culturally and linguistically appropriate services (CLAS).
Study Design: National surveys in 2003, 2006, and 2008.
Methods: Surveys were administered to health plans offering commercial, Medicaid, and/or Medicare Advantage products.
Results: 123 health plans responded to the 2008 survey (50% response rate), including 65 commercial (50%), 46 Medicaid (53%), and 12 Medicare plans (44%), representing a total enrollment of 133.8 million Americans. In 2008, 74.0% of health plans collected language data (commercial 60.0%, Medicaid 89.1%, Medicare 91.7%), which is an increase for each plan type since 2003. Health plans used direct and indirect collection methods. Nearly all health plans reported offering language services, the most common being telephonic interpreting, multilingual member materials, and access to bilingual providers. A variety of strategies for improving CLAS were cited by health plans, including improving health plan communication materials, health literacy initiatives for members, and targeted training for providers and staff.
Conclusions: Health plans have made substantial progress in the collection of language data and many are offering options for language services. With the rapid growth in Medicaid participation and newly insured individuals anticipated under the Affordable Care Act, health plans may be uniquely positioned to implement and test interventions that aim to improve appropriate utilization of language services by providers and patients.
(Am J Manag Care. 2011;17(12):e479-e487)
Key stakeholders agree that better data on patients’ language are needed to effectively address language-related barriers to timely, high-quality healthcare.
In 2008, 74.0% of health plans collected language data (commercial 60.0%, Medicaid 89.1%, Medicare 91.7%); an increase since 2003.
Health plans cited a variety of strategies for improving the provision of culturally and linguistically appropriate services and nearly all plans reported offering language services in 2008.
Health plans may be uniquely positioned to implement and test interventions that aim to improve appropriate utilization of language services.
Over the past several decades, the United States has experienced rapid growth in the racial and ethnic diversity of its population. By 2050, racial and ethnic minorities are estimated to comprise 54% of the nation’s population.1 Furthermore, in 2000, approximately 47 million Americans reported speaking a language other than English at home, and 21 million reported speaking English less than “very well.”2 Several studies have documented the negative impact of language barriers on patient-provider communication, patient safety, and the overall timeliness and quality of healthcare received.3-6
Although expanded insurance coverage is an important step in reducing gaps in care, it does not guarantee that patients, especially persons with limited English proficiency and low functional health literacy, can effectively navigate the healthcare system to access preventive services and obtain the care they need.7 Availability of a full range of culturally and linguistically appropriate healthcare services is essential for overcoming barriers and accessing timely care. To identify gaps in care for diverse populations, develop strategies to improve patient-provider communication, and allocate needed services and resources, key stakeholders agree that better data on patients’ language are needed.8
This article reports the results of 3 nationwide surveys of health plans regarding their efforts to improve the provision of culturally and linguistically appropriate services for their members.9-11 Specifically, we describe how health plans collect and use language data from their members, and what types of language access services are provided to members by plans. Our goal was to describe recent progress made by health plans and to identify areas needing further improvement.
The sources of data for this study were surveys of health plans conducted in 2003, 2006, and 2008 by America’s Health Insurance Plans Foundation (AHIPF), with support from the Robert Wood Johnson Foundation. Reported results are primarily from the most recent survey (2008), although selected questions from the prior 2 surveys were used to identify trends over time. The target population was defined as health plans offering commercial, Medicaid, and/or Medicare Advantage products.
We developed the 2008 survey using input from an advisory group of health plans with expertise in data collection. We pilot tested the survey with 5 health plans and made revisions based on their feedback. The final survey instrument, consisting of 50 questions, had several sections. For this article, we used information on whether health plans collected data on the “primary” or “preferred” language of their members and how they collected these data. “Primary” and “preferred” language was not explicitly defined in the survey, as plans may utilize different definitions. The questions regarding how plans collected data focused on whether each used direct methods, defined as collection by the plan of self-reported data from its members; indirect methods, defined as collection of data from sources other than members; or both. We also used information on the provision of language access services for members and strategies employed by health plans for improving the provision of culturally and linguistically appropriate services (CLAS). Of note, these questions were asked of all plans regardless of whether or not they collected language data.
America’s Health Insurance Plans Foundation used health plans’ listings in the Atlantic Information Service’s (AIS) Directory of Health Plans for 2007 to develop the sampling frame for the survey, and excluded leased preferred provider organization (PPO) networks, subsidiary companies, plans that were no longer in business or had merged; plans with unknown enrollment; and very small plans (defined as commercial plans with <6500 members, Medicaid plans with <20,000 members, and Medicare plans with <5000 members). This resulted in a final sampling frame consisting of 245 health plans, all of which were invited to participate in the survey. For each plan, AHIPF used AIS data to identify the product with the highest enrollment and asked that responses be specific to that product. Because the commercial product has the highest enrollment for most health plans, 11 multiproduct health plans were asked to respond for 1 additional product, Medicaid or Medicare, so that the distribution of product-specific enrollment in the overall sample would reflect the composition of the industry.
The Excel-based survey was fielded via e-mail between June and October 2008. Prior to e-mailing the survey, AHIPF utilized multiple internal and external contact lists (eg, health plan staff responsible for addressing disparities within individual companies, chief medical officers, directors of quality improvement, etc) to identify the appropriate health plan representative to complete the survey. America’s Health Insurance Plans Foundation staff made several attempts to reach nonresponding plans and contacted submitters to clarify incomplete or unclear responses. On average, health plans completed the survey in approximately 1 hour.
A total of 123 health plans responded to the 2008 survey (50% response rate), including 65 commercial (50%), 46 Medicaid (53%), and 12 Medicare plans (44%). Response rates varied by plan size: 76% for large plans (enrollment >500,000 for commercial and >300,000 for Medicaid and Medicare plans); 64% for medium plans (enrollment 200,000-499,999 for commercial and 100,000-299,999 for Medicaid and Medicare plans); and 37% for small plans. Responding health plans represented a total enrollment of 133.8 million members.
The main methodological differences between the 2008 survey and the earlier 2003 and 2006 surveys included:
• In 2003, 83% of the health plans in the sampling frame were included in the survey sample via random selection, while in 2006 and 2008, 100% of the plans in the sampling frame were surveyed.
• In 2003 and 2006, all health plans were asked to respond on only 1 product.
• In 2003 and 2006, the survey was conducted via an e-mail invitation to health plans with a link to an Internet-based questionnaire.
• The 2003 and 2006 surveys asked about collection of “primary” language only.
• Overall response rates in 2003 and 2006 were 40% and 60%, respectively. As in 2008, large- and medium-size health plans were more likely than small plans to respond to the surveys.
We calculated the proportions of health plans with various characteristics of interest. When appropriate, we weighted the proportions by plan enrollment. Because the responding health plans account for a large percentage of the sampling frame, we applied the finite population correction factor to obtain correct standard errors (SEs). In the Results section, all percentages are presented with the SE in parentheses.
Characteristics of Health Plans
The 2008 study sample included large, medium, and small health plans that were geographically distributed across all 4 US census regions, and that together represent a sizable percentage of the total US health plan enrollment (Table 1). Commercial plans that responded to the survey included health plans that offered health maintenance organization, PPO, and/or point of service products. Health plans in the study sample for 2003 and 2006 were similarly diverse in size, location, and product types.
Language Data Collection by Health Plans
Approximately 74.0% (SE, 2.8%) of health plans reported collecting language data (“primary” and/or “preferred”) for their members in 2008, including 60.0% (4.3%) commercial, 89.1% (3.2%) Medicaid, and 91.7% (6.3%) Medicare plans. This was an increase from 2003, when 38.5% (5.6%) of commercial, 84.6% (5.9%) of Medicaid, and 65.6% (6.5%) of Medicare health plans reported collecting primary language data (Figure). Most health plans that collected language data from their members also collected information on race and ethnicity.
Larger commercial and Medicaid plans were more likely to collect language data than medium or small health plans. For example, in 2008, 81.5% (4.0%) of large commercial plans collected these data, compared with 54.5% (10.1%) and 40.7% (7.8%) of medium and small plans, respectively. Similarly, 100% of large Medicaid plans reported collecting these data, compared with 93.3% (4.2%) and 83.3% (5.9%) of medium and small plans. When weighted by plan enrollment, 89.1% of commercial plan members, 96.8% of Medicaid plan members, and 95.3% of Medicare plan members were in health plans that collected some language data in 2008.
Health plans used both direct and indirect methods to obtain language data on their members. In 2008, the majority of commercial plans that collected language data relied on direct methods (66.7% [5.4%]) with only 2.6% (1.9%) reporting the sole use of indirect methods, and 30.8% (5.3%) reporting use of both data collection methods. By comparison, Medicaid and Medicare plans that collected language data used only direct methods less often (14.6% [3.9%] and 55.6% [13.4%], respectively), and only indirect data collection methods more often (24.4% [4.7%] and 22.2% [11.2%], respectively). Both methods were used by 61.0% (5.3%) of Medicaid plans and 22.2% (11.2%) of Medicare plans.
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