When English becomes a barrier to care: Demand for medical interpreters booming as demographics shift
Thursday, November 05, 2009
- Organization: MarketWatch
SAN FRANCISCO (MarketWatch) -- Gayle Tang remembers the time she thought she was speaking English but only realized she had lapsed into Cantonese when one of her doctors spoke it back to her.
That was 14 years ago, but she recalls the uneasy feeling of not knowing what was wrong with her and undergoing tests for heart palpitations. The doctor's words in the language she needed to hear and speak at that sensitive time moved her, she said.
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"It was very natural, very comforting," Tang said. "I was able to express myself and it was emotional. I felt, wow this person really cared about me."
The experience gave Tang insight into what patients who speak languages other than English may face when they're frightened and in the throes of medical treatment.
"It's very exhausting to try to communicate your most personal information in a language you may not be as comfortable in when you're under stress," said Tang, director of national linguistic & cultural programs for Kaiser Permanente in Oakland.
"When people are under duress, they may lose their language skills," she said. "It's not like going to the bank and making a banking transaction or going to the grocery store and buying food."
Kaiser Permanente has been on the forefront of a movement toward greater linguistic and cultural competence in health care. Kaiser routinely asks patients which language they prefer to speak, and developed a voluntary physician assessment tool that lets health-care organizations determine if doctors have enough foreign-language proficiency to speak with patients in that language independent of an interpreter. About 1,000 doctors have taken the test so far.
As the nation's population grows and ages, the demand for language services in hospitals, doctor's offices and other health-care arenas is booming, experts say.
Federal law mandates that any entity that receives federal funding, whether it's Medicare reimbursement or research grants, must provide a patient with limited English proficiency an interpreter at no cost to the patient. In early 2009, California enacted a language-services law requiring all health plans and insurers to provide an interpreter for limited-English speaking patients at no cost to the patients.
The House of Representatives' health-reform bill calls for a study into how the Medicare program makes use of language services for beneficiaries who have limited English proficiency. If a health-care overhaul expands coverage as promised, an influx of newly insured people into the Medicaid program also may increase demand for medical interpreters. Health-care reform: See our complete coverage.
An estimated 15,000 to 17,000 people perform medical interpreting work in the U.S., according to Common Sense Advisory, a Boston-based research firm. Interpreters typically earn $15 to $30 an hour.
Driven to standardize
As hospitals look to boost patient safety and limit their exposure to potential lawsuits if a crucial detail gets lost in translation during a fast-paced medical response, some are open to a new national certification standard for the people they hire to provide medical interpretation.
In October, a nonprofit group launched a first-of-its-kind national interpreting standard that will allow interpreters working in the medical field to be tested and credentialed as certified medical interpreters, or CMIs. The CMI designation first will be available to Spanish language interpreters, with national certification for several other languages starting next year.
At M.D. Anderson Cancer Center in Houston, interpreters have to have at least one year of experience doing medical interpretation. They then go through three months of in-house training including medical and oncological terminology and technical aspects of interpretation, said Cesar Palacio, manager of the language assistance department.
"Right now when we hire someone we have to take a very good look at their credentials and verify that they really know what they're doing," he said. "If we have national or state certification, at least we'll have a benchmark for establishing credentials."
The field of medical interpretation has come a long way from when patients would rely solely on their minor children or when hospital staff would comb their ranks for candidates or ask if anyone in the waiting room spoke Polish, for example, said Dr. Eric Hardt, medical consultant to interpreter services at Boston Medical Center.
"They would tap these people completely untrained," he said. "Today we would think of it as an instant [health-care privacy] violation. That standard has long been gone."
"Now the issue is what about your secretary who's fully bilingual? If she's not been evaluated, had some training, I don't think it's safe for you to use her to interpret" for low-English proficiency patients, Hardt said. "If something went wrong, you're increasingly likely to be liable."
Of course, such services don't come cheap. At M.D. Anderson, the annual price tag comes to $2 million, Palacio said. The cancer-treatment center has 25 staff interpreters covering nine languages, but it provides services in about 30 languages by tapping a phone-based medical interpreting agency.
About 60% of M.D. Anderson's non-English business is Spanish; another 28% is Arabic. Turkish, Vietnamese and Mandarin Chinese round out the top five languages it hears.
"Providing these services is a very good risk-management tool," Palacio said. "There have been settlements for language-related problems amounting to tens of millions of dollars because of one word or phrase used incorrectly."
Offering interpreters also pays off in public-relations gains.
"We have many patients who were not even expecting to find this kind of service here," he said, "but they find the service very useful, very rewarding."
Health care makes up about a third of the business at Language Line Services, which provides telephone-based interpreting services for $1.50 a minute on average. Its president, Louis Provenzano, said the company serves more than 170 languages by staffing interpreters in 18 time zones who are available to customers by phone or sometimes video at all hours. More than half its staff is based in the U.S.
Despite the recession, the company continues to grow, Provenzano said. Spanish drives 70% of the U.S. business volume, and Mandarin Chinese is the second most in-demand language. It's not just acute-care facilities and emergency rooms that are calling for help. New customers are coming on board in the area of preventive care, disease management and needs related to the pandemic H1N1 flu virus, he said.
"No matter which side of the fence you sit on immigration, there's a fundamental complexity in terms of the demographics of this country," Provenzano said. "One of every five citizens speaks another language other than English."
Still, doctors often balk at providing medical interpreters because that often means they pay more in interpreter's fees than they are reimbursed for the patient's office visit. The American Medical Association says it understands the need for good patient-doctor communication but objects to the "unfunded mandate" that leaves doctors on the hook for the cost of providing interpreters.
Many patients whose native language isn't English often choose doctors who speak their first language, said Dr. Anmol S. Mahal, a gastroenterologist in Fremont, Calif., and past president of the California Medical Association. Others count on trusted loved ones who accompany them to the visit.
"The largest volume of interpreters are loving family members and neighbors and transporters who come with patients and help," said Mahal, who speaks Hindi and Punjabi.
Doctors should be able to determine when a family member is appropriate vs. when a professional interpreter is needed, he said.
"If I have someone with a minor illness -- a bronchitis or a cold -- and a family member is interpreting for the patient, I would think the communication level that visit requires could be adequately covered and the quality of care would not be affected," he said.
"On other hand, if I had a patient with a malignancy that was quite complicated and I had to describe the extent of the malignancy and options for treatment to determine what further course of action to take, I think it would be more important in that circumstance to have a professional interpreter who could ascertain the patient's understanding."
Studies show that people who don't speak English generally receive a lower standard of care, Hardt said.
"Our hypothesis is the amount of money that's wasted on language barriers would be enough to cover the cost of good interpretive services," he said, noting that appropriate services could reduce health-care disparities and inefficiencies such as the number of patients who make repeat trips to the emergency room because their original problem wasn't handled properly.
"These are all big-ticket items," Hardt said.
But that doesn't mean medical interpreting is an easy sell, he noted. "It's the old problem of when you save someone else's money, how can you convince them to pay you back?"