Healthcare reform is on our collective mind right now, and quality of care is at the forefront of this topic. It is certainly a massive subject to tackle and a multifaceted approach is needed to address quality issues, but how do translation and interpreting fit into this? Is there a way that linguistic services can lead to better-quality care for patients and a better bottom line for providers?
The ACA, reimbursement, and the importance of communication
Medical providers receive reimbursement from three main sources, of which federal programs contribute approximately 40%. The Affordable Care Act will affect this source of revenue by linking federal payments to the quality of care through Value-Based Purchasing requirements. The goal is to transform Medicare/Medicaid from a passive payer to an active purchaser of higher-quality, more efficient healthcare. For example, hospitals will receive less reimbursement if they have high rates of patient readmission, so proper discharge instructions and patient adherence are important. Consequently, being able to provide well-translated discharge documents may potentially help a hospital avoid the readmission of limited English-proficient (LEP) patients, and subsequent penalties.
Patient satisfaction is also an integral part of healthcare quality. Value-Based Purchasing uses two systems to assess satisfaction (HCAHPS for hospitals, and PQRS for practices). For each, the majority of measures relate to communication:
• Communication with nurses
• Communication with doctors
• Communication about medicines
• Discharge information
Providers that are rated poorly in these areas will see a reduction in their reimbursement rates, with the cut reaching up to 2% for low scores by 2017. With a typical profit margin of 1–5%, this is not a small amount. As a result, we can begin to see that it is in the providers’ best interests to ensure effective communication with their patients in order to boost satisfaction rates.
The language barrier
A simple fact: most LEP patients in the US do not have access to providers who share their native language.1 Until the medical workforce becomes more linguistically diverse, many LEP patients will continue to see providers who speak only English. A growing body of research suggests that this language barrier may compromise the quality of care. In recent studies, LEP respondents with language-discordant physicians were significantly more likely to have trouble understanding a medical situation (9.4x), have problems understanding medication labels (4.2x), and have a bad reaction to medications (4.1x) than English-proficient respondents.2 In addition to impaired comprehension and decreased adherence, patients with language-discordant providers also reported worse interpersonal care, and were more likely to give low ratings to their providers.2
Enter the interpreter
For these language-discordant encounters, some type of interpreter service is often used. Without this service, it is unlikely that much health education can take place; an interpreter is essential to overcome the language barrier and allow meaningful communication. However, while the use of untrained, ad hoc interpreters is common, it can often result in miscommunication.2 Conversely, the use of trained professional medical interpreter services can improve communication, satisfaction, and adherence among LEP patients.2 All of this adds up to a pretty healthy satisfaction rating for the provider. In addition, there is also evidence to suggest that having access to professional interpreters may simply be cost-saving overall, most especially in the context of emergency room visits.2
The current reality
Despite the benefits of medical interpreting, the majority of LEP patients in the US still lack access to interpreter services. The US Department of Health and Human Services recognizes this as an inequity, and developed a set of mandates and guidelines for culturally and linguistically appropriate services (CLAS).3 The CLAS standards require that providers offer and provide language assistance services to LEP patients, and exclude the use of friends/family as interpreters (unless requested by the patient). Yet most LEP patients with language-discordant providers still lack access to interpreters, and respond that they simply “do the best they can in English.”4 In a recent California study, only 9% had access to a professional interpreter, whereas the majority depended on family members or friends for translation.4
How we can help
While it is true that having an interpreter present facilitates communication, the quality of the interpreting may negatively affect patients’ opinions about the quality of their healthcare provider (it may surprise you to know that there is currently no national certification and no minimum requirements for medical interpreter training). Interpersonal care and satisfaction can be further improved by increasing the training for interpreters and providers. The National Council on Interpreting in Health Care recommends at least 40 hours of instruction on medical terminology, interpreting skills, ethical issues, role-playing, and cultural awareness.4 (All interpreters provided by River Linguistics hold Telelanguage Interpreter Certification, a national certificate program for telephonic and in-person interpreting. It meets CLAS standards and is the most comprehensive, in-depth program for interpreters who work across a broad spectrum of services, including healthcare.)
With improved communication come better satisfaction ratings, and these higher scores will increase quality for providers, help them to avoid financial penalties and achieve the maximum reimbursement rates. Healthier, happier patients; maximum reimbursements for providers.
1 New California Media (NCM). Bridging Language Barriers in Health Care: Public Opinion Survey of California Immigrants from Latin America, Asia and the Middle East: The California Endowment; 2003.
2 Wilson, E., Chen, A. H., Grumbach, K., Wang, F., & Fernandez, A. (2005). Effects of limited English proficiency and physician language on health care comprehension. Journal of General Internal Medicine, 20(9), 800-806.
3 CLAS & The CLAS Standards. Retrieved from https://www.thinkculturalhealth.hhs.gov/Content/clas.asp
4 Morales, L. S., Cunningham, W. E., Brown, J. A., Liu, H., & Hays, R. D. (1999). Are Latinos less satisfied with communication by health care providers?.Journal of General Internal Medicine, 14(7), 409-417.
5 Downing, B., & Roat, C. E. (2002). Models for the provision of language access in health care settings. California: National Council on Interpreting in Health Care and Hablamos Juntos.