The American Journal of Managed Care September 2004 - Special Issue
Providing Linguistically Appropriate Services to Persons With Limited English Proficiency: A Needs and Resources Investigation
Increasing numbers of persons in the United States cannot speak, read, write, or understand the English language at a level that permits them to interact effectively. These limitations can hamper encounters between patients and healthcare providers, often leading to misunderstandings as to diagnosis and treatment, which in turn may result in poor patient compliance, unsatisfactory outcomes, and increased costs. A questionnaire was developed and distributed to clinical practice managers at the University of Maryland School of Medicine to assess the needs for language interpretation services and resources among clinical faculty providing healthcare to persons with limited English proficiency (LEP). Literature review, search of key Web sites, and consultation with national experts on issues pertaining to language access, health services, and reimbursement strategies also were done. Then, recommendations regarding the costs and benefits of language interpretation in healthcare settings were developed. Because recipients of federal financial assistance from the Department of Health and Human Services must provide meaningful access to persons with LEP at no cost to the client, there are clear benefits to providing language interpretation. Providers and managers should be made aware of interpretation service options and cost-saving strategies.
(Am J Manag Care. 2004;10:SP29-SP36)
Growing numbers of persons in the United States have limited English proficiency (LEP). These persons "do not speak English as their primary language andÖhave a limited ability to read, write, speak, or understand English."1 According to Census 2000, more than 31 million foreign-born residents live in the United States (11.1% of the total population),2 and 47 million residents speak a language other than English in the home (17.9% of the population over age 5 years).3 Furthermore, 21.3 million residents over age 5 years (8.1%) speak English less than "very well."4
In the state of Maryland, figures from Census 2000 indicate that more than 600 000 residents speak a language other than English in the home, with almost a quarter of a million of those speaking English less than "very well."5 A survey of state departments, boards, commissions, task forces, and independent agencies in Maryland, conducted in 2001 by the National Foreign Language Center at the University of Maryland,6 found Spanish to be the language most commonly encountered (reported by 62% of entities surveyed), with Russian (24%) and Korean (22%) the next most commonly encountered languages. A 2000 survey of service providers done for the Baltimore City Health Department found that the services for an ever-increasing population of Hispanic clients were culturally and linguistically inadequate.7
This paper has 2 purposes: (1) to review the literature and relevant national and state policies regarding provision of language interpretation services to LEP persons in healthcare settings; and (2) to describe a needs and resources assessment of language interpretation services for patients presenting to clinical faculty at a public medical school in the mid-Atlantic region.
The University of Maryland did not participate in the above-mentioned National Foreign Language Center survey of state agencies and programs nor in the Baltimore City Health Department survey of service providers. To fully assess the existing situation, we needed detailed data on the delivery of services to LEP persons presenting to the University of Maryland Medical School faculty. These data included an estimate of the number of LEP persons presenting to clinical faculty at the University of Maryland and their linguistic/cultural background. In addition, it was important to survey clinical practice managers at the University of Maryland School of Medicine to ascertain their perceived needs for providing language services to LEP persons presenting to them, discover what linguistic/cultural groups they encounter, and find out how the attendant cultural and linguistic issues are currently being dealt with. Reviews were needed of (1) intake and other registration forms for clients presenting to University of Maryland Medical School faculty to determine how and when data on race, ethnicity, and language are being collected; (2) the state of knowledge about the costs and benefits of language interpretation in healthcare settings; and (3) reimbursement policies of public health insurance programs for the provision of interpretation and translation services to LEP persons.
We developed a questionnaire to assess the need at the University of Maryland School of Medicine (in terms of LEP persons presenting to clinical faculty at the School of Medicine) as well as currently available resources to surmount the attendant cultural and linguistic barriers. The questionnaire was developed for practice managers, focusing on their knowledge of the numbers of LEP patients seen in the clinics and programs, what languages and cultures are represented, and how these patients are handled. The questionnaire was submitted to the institutional review board of the University of Maryland and received exempt status.
National experts on cultural competency, language access, and health services research were consulted regarding the draft materials, the project's approach, and relevant literature. Advice was solicited about locating literature on the costs and benefits of providing language services, locating gray literature (ie, foreign or domestic open source material that usually is available through specialized channels and may not enter normal channels or systems of publication, distribution, bibliographic control, or acquisition by booksellers or subscription agents) on cultural competency and language access, and how best to handle human-subject issues. After these consultations, the materials were revised and the institutional review board exemption request was finalized.
A computerized literature search was performed using MEDLINE, the Social Sciences Citation Index, the Science Citation Index, and Dissertation Abstracts with the keywords and phrases "culture," "multicultural issues in medical school curriculum/education," "cross-cultural communication," and "translators/interpreters in medical settings." A list of 167 possibly pertinent abstracts was developed. Further searching using 16 key articles and looking for others that cited those articles resulted in another 218 abstracts. In addition, 14 potentially pertinent dissertation abstracts were identified.
Out of the initial 385 abstracts, we obtained full-text articles for the abstracts that were identified as potentially the most useful. We primarily focused on cost-benefit and liability issues, as these are generally key factors that must be taken into account when any kind of institutional change is under consideration. We also sought studies conducted using objective outcome measures.
The literature review included a review of realistic options for improving language access in healthcare facilities; these are described on the Office for Civil Rights Web site (http://www.hhs.gov/ocr/lep/). Various articles also have been published occasionally in medical management journals regarding medical liability cases related to LEP, for which we sought the full text.
Finally, full text of 2 dissertations was obtained. The first details the organizational change and decision making that led to the creation of interpreter services at selected healthcare organizations in the United States and Canada.8The second offers a cost-benefit analysis of providing interpreter services in healthcare settings.9
The Benefits of Medical Interpretation
It is difficult to communicate effectively when there are linguistic or cultural barriers between clients and providers. Limitations in spoken and written language comprehension hamper encounters between patients and healthcare providers, often leading to misunderstandings concerning diagnosis and treatment, which in turn may result in poor patient compliance and unsatisfactory outcomes.
Studies have shown that overcoming language discordance between patients and providers leads to increased compliance with medications10 and appointments,10,11 fewer emergency department (ED) visits,10,11 better recall of information discussed during the encounter,12,13 and more questions being asked.12 In addition, there is evidence that using interpreters increases the delivery of healthcare services (office visits, prescriptions written and filled, rectal examinations, fecal occult blood testing, and influenza immunizations).14
Patient surveys conducted after ED visits have revealed increased satisfaction associated with language-concordant encounters15,16; better-informed patients are more satisfied, and may also be more compliant.12 In a study of physical and psychological well-being in patients with hypertension or diabetes, P√©rez-Stable et al found that having a language-concordant physician was significantly associated with better functioning on all 4 overall health-status scales and on 6 of 10 subscales.17
Barriers in communication affect healthcare providers as well. Some physicians who cannot fully understand their patients appear to compensate for the unaccustomed lack of information by altering their management to a more cautious, conservative style. Some studies have shown that when language barriers are present, more tests are ordered18,19; in addition, more intravenous hydration is ordered and there are more frequent hospital admissions.19 This phenomenon has been termed a "language-barrier premium."19
Informed consent also must be considered in the context of barriers to communication. In Western medical practice, it is believed that patients have a right to be fully informed about their condition and treatment options to participate in the decision-making process regarding their care. In the case of LEP patients, of course, this consent will not be truly "informed" unless appropriate interpretation services are available to them. Informed consent is an ethical obligation fundamental to the physician-patient relationship,20 and has potential legal ramifications as well.
The risk of medical malpractice occurring due to language discordance between providers and patients is almost certainly reduced when competent medical interpretation is provided, and should be taken into consideration when weighing the costs and benefits of interpreter services, as the costs of malpractice can be quite high when an adverse event occurs. Although medical liability lawsuits are most commonly settled out of court and the terms of the settlements are not revealed, a few published reports detail the circumstances leading to a medical mishap related to the presence of language barriers and the amount awarded to the plaintiff. One such case hinged on a single word, intoxicado, the misinterpretation of which by nonóSpanish-speaking care providers led to a sequence of events that culminated in quadriplegia for the patient and, subsequently, a settlement totaling $71 million.21 In another case, a patient's eye injury was inappropriately treated due to inadequate interpretation (via telephone, and the patient never spoke directly to the interpreter). The patient suffered a permanent impairment of vision in that eye, and the case went to trial with an ultimate verdict for the plaintiff of $350,000.22