The American Journal of Managed Care July 2008
Language Disparities and Timely Care for Children in Managed Care Medicaid
Objective: To examine the relationship of race/ethnicity, language, communication with providers, and interpreter use with timeliness of illness and routine care for children in managed care Medicaid.
Study Design: Cross-sectional study using data from the Consumer Assessment of Health Plans Survey, which was administered to parents of children less than 15 years of age in Washington State managed care Medicaid in 2000.
Methods: Predictors of interest were child’s race/ethnicity, parent’s primary language at home, difficulty communicating with the child’s providers because of language, and need and use of interpreters. The primary outcomes were how often (always, usually, sometimes, or never) the child received illness and routine care as soon as wanted. Analyses used multivariate ordered logistic regression and model-based direct adjustment.
Results: A total of 5142 children were included. In adjusted analyses, children received illness and routine care significantly less often than wanted if the parent’s primary language at home was not English; the parent ever had difficulty communicating with the provider; and the parent needed but did not always get an interpreter.
Conclusion: Language barriers were associated with decreased timeliness of care for children in managed care Medicaid.
(Am J Manag Care. 2008;14(7):417-426)
This research suggests that language barriers are associated with delayed access to illness and routine care for children in managed care Medicaid.
Children received timely care less often if their parents’ primary language was not English or their parent reported language problems in communicating with providers. However, having access to interpreters was associated with getting timely care more often.
Racial/ethnic disparities in timeliness of care did not persist after controlling for language barriers.
Providers, health plans, and policymakers should consider steps to address language barriers in order to reduce disparities in the timeliness of children’s healthcare.Timeliness of care has been cited by the Institute of Medicine as a key component of quality healthcare.1 Delayed access to care is cause for concern because of its association with increased morbidity, longer hospital stays, increased costs, and increased emergency department (ED) use.2-6 Children from racial/ethnic minority families and those covered by Medicaid are at risk for suboptimal access to healthcare7-10 and may be at risk for less timely care as well.8 Patient–provider racial/ethnic and language concordance appears to mitigate disparities in quality of care for adults,11-14 although less clearly for children.15-17
Language may play an important role in the existence of racial/ethnic disparities in access to timely care. In 2000, 18% of the US population over age 5 years spoke a language other than English at home, an increase over the previous 10 years.18 A number of studies have demonstrated the effect of language barriers on access to and use of healthcare. Children whose parents’ primary language is not English are less likely to have received the recommended number of preventive care visits.19 Adults who are limited in English proficiency (LEP) use physician services and preventive care less often, are less likely to have a regular source of care, and use the ED more often as the primary source of care20-22; children with LEP parents are less likely to be brought in for needed care.23 Lack of trained medical interpreters is common and is associated with decreased quality of care for adult populations.24-26 However, the relationship between race/ethnicity, language barriers, and delayed access to care for children has been less well elucidated. Prior studies of racial/ethnic disparities in timeliness of care for children have not adequately accounted for the confounding effects of language-related factors such as interpreter use and communication problems.20,21,27,28
Thus, the objective of this study was to examine the association of race/ ethnicity, parent’s primary language at home, difficulty communicating with providers, and use of interpreters with report of receiving illness care and routine care as soon as wanted for children covered by Medicaid.
This was a cross-sectional study using data from the Consumer Assessment of Health Plans Survey (CAHPS), conducted by the Washington State Medical Assistance Administration (MAA) (now called the Health and Recovery Services Administration) for children covered by the state’s Medicaid program. CAHPS was developed and validated by the Agency for Healthcare Quality and Research in 1995 for use in benchmarking performance and collecting information on consumers’ experiences of health services within different types of health plans. A version of CAHPS was designed specifically to assess children’s experiences of healthcare.29 The MAA administered a modified CAHPS 2.0H survey questionnaire to a sample of parents of children in managed care Medicaid between April and August 2000. Survey implementation used a mixed methodology, where an initial mail survey was supplemented with a phone interview for those not responding to the mailed survey. For parents of children whose enrollment data indicated Spanish as the primary language, both the English version and the official validated Spanish version of the CAHPS 2.0H were mailed and the parent could choose which to complete. Phone interviews also were available in Spanish.
Medicaid enrollment data were used to identify children meeting the following criteria: 14 years of age or younger; continuous enrollment in Medicaid from September 1999 through February 2000, with no more than a 1-month break; and English or Spanish listed as the primary language. One child per household was randomly selected as the reference child. Children between 3 and 48 months of age were not eligible if they had participated in a separate MAA survey on development that was conducted just prior to CAHPS. A total of 1050 eligible children were randomly selected from each of the 9 managed care plans participating in Washington State Medicaid during the study period, and surveys were sent to their parents. This study was approved by the Human Research Review Section of the Washington State Department of Social and Health Services.
The primary outcomes of the study were timeliness of both illness care and routine care. To measure timeliness of illness care, parents were first asked whether their child had an illness or injury that they believed needed immediate care from a doctor’s office, clinic, or ED in the previous 6 months. Those who responded affirmatively were asked “in the last 6 months, when your child needed care right away for an illness or injury, how often did your child get care as soon as you wanted?” Choices for responses were never, sometimes, usually, or always. The validity of this measure of delayed care has been demonstrated in previous work.5 To measure timeliness of routine care, parents were first asked whether they had made any appointments in the last 6 months for their child with a doctor or other health provider for regular or routine healthcare. If they had, they were asked “in the last 6 months, how often did your child get an appointment for regular or routine health care as soon as you wanted?” Choices for responses were never, sometimes, usually, or always.
The primary predictors of interest were measures of race/ethnicity and language barriers. Parents were asked whether or not their child was Hispanic/Latino and were asked to indicate whether their child’s race was 1 or more of the following: black/African American, Asian, native Hawaiian/other Pacific Islander, or American Indian/ Alaska native. Based on these parental responses, we then categorized race/ethnicity as white, non-Hispanic; black, non-Hispanic; Hispanic; or other/more than 1 race. Parents were asked to identify the primary language they spoke at home; as only 3.9% of parents reported a language other than English or Spanish, we categorized this variable into English or not English. Parents were asked how often in the last 6 months they had a hard time speaking with or understanding their child’s doctors or other health providers because they spoke different languages; this question was dichotomized into whether they ever (sometimes/usually/always) versus never had difficulty communicating with the provider because of language. Parents reported whether they needed an interpreter to help them speak with their child’s doctors or other health providers in the past 6 months; if they did, they were asked how often they got an interpreter when they needed one. These 2 questions were combined into 1 variable measuring interpreter use, with categories for those who did not always (ie, never/sometimes/usually) get an interpreter when needed, always got an interpreter when needed, or did not need an interpreter.
Other predictors of interest included child’s sex; health status as reported on a 5-point Likert scale; presence of a special healthcare need; age and highest education level of the person completing the survey (the child’s mother for 86% of children, and the father for 10%); and whether the child had a regular healthcare provider. Child age was derived from the date of birth on the enrollment records. Identification of children with special healthcare needs was done by asking questions from the Children with Special Health Care Needs Screener, which is based on the federal Maternal and Child Health Bureau definition of Children with Special Health Care Needs.30
Bivariate analyses were done using the χ2 test or Fisher exact test to assess the association between the predictor of interest and timeliness of care, categorized as always, usually, sometimes, or never getting care as soon as wanted. Multicollinearity of the key race/ethnicity and language predictor variables was tested using the Pearson correlation coefficient, and variables with r values less than 0.80 were included in the multivariate analyses. Data in the multivariate analyses were weighted to reflect the under-representation of children younger than age 48 months that occurred because of the exclusion of children who had participated in the earlier MAA survey on development. We used ordered logistic regression to determine the relationship between each predictor variable and whether the child always, usually, sometimes, or never received care as soon as the parent wanted. Ordered logistic regression maximizes statistical power and allows data from each distinct category of response to be analyzed as it was reported, rather than lumped together to create a binary outcome; this method has been used in other published literature assessing healthcare quality using CAHPS measures.31 Separate models were run for illness care and routine care. In addition to race/ethnicity and the language variables of interest, other variables in the model included child’s age, sex, health status, presence of a special healthcare need, parental age and education, and having a regular provider.
To make the results of the ordered logistic regression more easily interpretable, we performed simulations to derive the adjusted probabilities of always, usually, sometimes, or never getting care as soon as wanted for race/ethnicity and language predictors. To do this, we used model-based direct adjustment, using the entire study sample as the standard population.32 An overall P value for categorical predictor variables with more than 2 categories was calculated using the multivariate Wald test. All analyses were done using Stata 8.0 software (Stata Corporation, College Station, TX). A P value of <.05 was considered significant for all analyses.
Characteristics of the Study Sample
Of the 9450 children sampled, 319 were ineligible because of death, language barriers, undeliverable surveys, not being a member of the intended managed care plan, being in the plan less than 6 months, or not being a Washington state resident. Of the 9131 eligible children, the survey response rate was 56.3%, which yielded a sample size of 5142 children. Characteristics of the study sample are presented in Table 1, as well as characteristics of children in the analyses of timeliness of illness care (those with an illness or injury that needed care in the previous 6 months) and timeliness of routine care (those whose parent made an appointment for routine care in the previous 6 months). Fourteen percent of parents reported that they had ever (ie, sometimes, usually, or always) had a hard time speaking with or understanding their child’s provider because they spoke different languages. Six percent of parents reported that they needed an interpreter to speak with their child’s provider in that past 6 months; of these, more than half (52.7%) reported that they were not always able to get an interpreter if needed.