1. “Securing Health Rights for Those in Need” Making the Case for Language Access: Talking Points for Advocacy NLADA Annual Conference Denver, CO November 19, 2009 Doreena Wong 2639 S. La Cienega Blvd. Los Angeles, CA 90034 (310) 204-6010, ext. 107 (310) 204-0891 (fax) Email: wong@healthlaw.org www.healthlaw.org

2. NHeLP National non-profit law firm committed to improving healthcare access and quality for low-income individuals Coordinates the National Language Access Advocacy Project, funded by The California Endowment – Includes a national coalition of stakeholders on language access working to improve polices and resources at the federal level To switch from VOIP to a telephone connection, call 213-286-1201, access code 435-253-182

3. Overview Making the Case for Language Services – Business Case – Quality of Care/Quality Assurance – Pubic Health Objectives – Legal Mandates Funding Issues Advocacy Efforts & Next Steps

4. Business Case Changing demographics of consumers/ members Changing demographics of consumers/ members Marketing strategy: attract new consumers Marketing strategy: attract new consumers Need to meet consumer needs, increase consumer satisfaction Need to meet consumer needs, increase consumer satisfaction Risk management: indirect costs - increase patient compliance, reduce errors/malpractice Risk management: indirect costs - increase patient compliance, reduce errors/malpractice Cost reductions: measure cost effectiveness Cost reductions: measure cost effectiveness

5. Changing Demographics Individuals who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English Over 55 million people speak a language other than English at home (an increase of 8 million since 2000) and 19.7% of the population. Over 25 million (9 % of the population and an increase of 3 million from 2000) speak English less than “very well,” and may be considered LEP.

6. Marketing Strategy There is evidence that providing culturally and linguistically appropriate services (CLAS) can bring a return on investment (ROI) Alliance of Community Health Plans Foundation report (2007) showed that health plans providing CLAS increased enrollment and market share for plans The report found that “cultural competency attracted business and led to reduced cost of interpretation services, length of hospital stay, & increased patient and provider satisfaction

7. Patient Satisfaction Spanish-speaking patients less satisfied with care. – Morales et al. JGIM 1999; 14:409-417. LEP patients less satisfied with emergency care. – Baker et al. Med Care 1998; 36:1461-1470. LEP patients less satisfied with emergency care, less willing to return for future care. – Carrasquillo et al. JGIM 1999; 14:82-87.

8. Risk Management Medical History Taking Spanish-speaking pregnant woman suffered miscarriageur to lack of interpreter services. – Fortier et al. J Healthcare Poor Underserved 1998; 9:S81- 100. Non-English speaking man awarded $71 million for failure to diagnose stroke. – Harshan. Med Econ 1984; 289-292.

9. Risk Management Provider Communication Lao woman awarded $1.2 million for wrongful imprisonment for 10 months for noncompliance with tuberculosis treatment; it was never explained why she needed to take her medications. Hmong man had his leg amputated without realizing that was what he was agreeing to because no interpreter provided to explain consent form.

10. Cost of Care Emergency Room Costs Pediatric patients whose families were assessed to have a “language barrier” with the physician had higher charges ($38) and longer stays (20 minutes) than those without language barriers. – Hampers et al. Peds 1999; 103(6): 1253-1256. Non-interpreted LEP patients returned to the ER more frequently and followed-up in clinic less frequently than interpreted patients, who had the lowest 30-day post ER visit charges. – Bernstein J, et al. J Immigrant Health 2002; 171-176.

11. Quality of Care Patient Comprehension and Adherence LEP patients less likely to understand medication instructions, less likely to receive needed financial assistance, and less likely to return to the same hospital. – Andrulis et al. Access Project 2002, What a Difference an Interpreter Can Make. Spanish-speaking patients discharged from emergency room without interpreters less likely to understand diagnoses, prescribed medications, special instructions or plans for follow- up care. – Crane. J Emerg Med 1997; 15(1):1-7. Spanish-speaking patients more likely to miss appointments and be less adherent to asthma medication if physician did not speak Spanish. – Manson. Med Care 1988; 26(12):1119-1128.

12. Quality Assurance Language access questions included on Consumer Assessment of Health Plans Survey (CAHPS) Weech-Maldonado, et al. (2001) Health Services Research 36(3):575-594] Joint Commission will be establishing culturally and linguistic competency standards National Committee for Quality Assurance (NCQA) includes language access standards in HEDIS performance measures & proposing voluntary CLAS standards Monitoring by State Agencies – California example: Office of the Patient Advocate publishes its HMO Report Card at: http://wp.dmhc.ca.gov/report_card/

13. Public Health Objectives Healthy People 2010 acknowledged continuing health disparities based on racial/ethnic and other socioeconomic factors, including linguistic access Institute of Medicine (2002) health disparities report cited language access as challenge (www.nap.edu/books/030908265X/html)www.nap.edu/books/030908265X/html Administrative & Congresssional efforts to address

14. Federal Legal Mandates  Title VI of the 1964 Civil Rights Act  No person in the United States shall, on the ground of race, color, or national origin, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving Federal financial assistance.”  E.O. 13166-8/11/00 - prepare a plan to improve LEP access -draft a title VI LEP guidance for its recipients  DOJ (6/18/02) & DHHS OCR Guidance (8/8/03) -take reasonable steps to provide meaningful access -take into account the #/, % & freq. Of LEP persons; importance of the service; and available resources

15. Other Federal Guidelines Office of Minority Health CLAS Standards – 2000  First national standards for culturally and linguistically appropriate services (CLAS) in health care to help organizations provide culturally and linguistically accessible services or all (www.omhrc.gov/clas ).www.omhrc.gov/clas  All patients should receive fair and effective CLAS and treatment 14 Standards – mix of mandates, guidelines and recommendations: – Culturally Competent Care – Language Access Services – Organizational Supports fro Cultural Competency

16. State Guidelines All states and DC have at least two language access laws (http://www.healthlaw.org/library/item.174993)http://www.healthlaw.org/library/item.174993 – comprehensive – targeted (e.g. emergency room, hospital) 3 states require cultural competency continuing education for health professionals Some states moving towards interpreter certification Certification Commission for Healthcare Interpreters - A national, valid, credible, vendor-neutral certification program for healthcare interpreters (http://healthcareinterpretercertification.org)http://healthcareinterpretercertification.org

17. Funding Issues Medicaid Reimbursement – HCFA (CMS) “Dear State Medicaid Letter” (8/31/00) Recipients must comply with OCR LEP Guidance Federal matching funding available for reimbursement for language assistance services for CHIP and Medicaid recipients CHIPRA - included enhanced administrative funding for language assistance services = the higher of 75% or FMAP plus 5% for children in CHIP & Medicaid (2/2/09) – August 31, 2009 CMS letter – opportunity to explore ways to obtain increased FMAP

18. Medicaid Reimbursement Only a handful of states & DC have set up programs to provide direct reimbursement using federal matching funds to pay for language services: – CT, DC, HI, ID, IA, KS. MA*, ME, MN, MT, NH, UT, VA, VT, WA & WY Four models – – contract with language service brokers/agencies – reimburse providers for hiring interpreters – directly reimburse interpreters – contract for telephone interpreter services

19. Current State Reimbursements (2007) This information is current as of 3/07. 07. StateEnrollees Covered Providers Covered Who the State PaysReimbursement RateAdmin or Service DCFFSFFS < 15 emp.Lang. agency $135-$190/hour (in-person) $1.60/min (telephonic) Admin HIFFS Lang. agencies$36/hrService IDFFS Providers$12.16/hrService KSManaged Care EDS (fiscal agent)Spanish – $1.10/min. other languages – $2.04/min. Admin MEFFS ProvidersReasonable costsService MNFFS Providerslesser of $12.50/15 min or usual and customary fee Admin MTAll Interpreters$6.25/15 minutesAdmin NHFFS Interpreters$15/hr; $2.25/15 min after 1 st hourAdmin UTFFS Lang. agencies $28-35/hour (in-person) $1.10/minute (telephonic) Service VAFFS AHEC & 3 health depts.Reasonable costsAdmin VTAll Language agency$15/15 minAdmin WAFFSPublic entities 50% expensesAdmin WAFFS BrokersBrokers receive an admin. fee Language agencies – $33/hour Admin WYFFS Interpreters$45/hourAdmin

20. Advocacy Efforts to Obtain Funding Consider efforts within context of political environment, state budget, department policies, & Medicaid and SCHIP funding Work with interested stakeholders to develop & advocate for best proposed model to improve language access and funding, i.e., plan regional stakeholders meetings Develop an action plan with specific steps involving all interested stakeholders, including legislative and administrative strategies to promote reimbursement model Improve data collection systems, i.e. to determine actual costs and estimated cost savings & support advocacy for improved language access and funding

21. Next Steps Education – providers, clients/patients Advocacy – increased language assistance services & funding Increase pool of trained and available interpreters – coalition building w/ local CBOs, training/education Enforcement – file complaints with OCR, investigate state law possibilities

22. NHeLP Resources Available at: www.healthlaw.orgwww.healthlaw.org The California Endowment – “Ensuring Linguistic Access in Health Care Settings: An Overview of Current Legal Rights and Responsibilities” (Sept. 2003) Summary of State Law Requirements Addressing Language Needs in Health Care (March '08) NHeLP and Access Project – Language Services Action Kit: Interpreter Services in Health Care Settings for People with Limited English Proficiency” (August 2003 & December 2005 update) Commonwealth Fund – “Providing Language Services in Small Health Care Provider Settings: Examples From the Field” (April 2005) Commonwealth Fund – “Providing Language Services in State and Local Health-Related Benefits Offices : Examples From the Field” (Jan 2007) The National Council on Interpreting in Health Care/NHeLP/TCE – Language Services Resource Guide for Health Care Providers (Oct. 2006) NHeLP/Health Research and Educational Trust – “Hospitals Language Services for Patients with Limited English Proficiency: Results for a National Survey” (October 2006) NHeLP/Center on Budget and Policy Priorities – “Paying for Language Services in Medicare: Preliminary Options and Recommendations” (October 2006) Commonwealth Fund – “Interpretation Services in Health Care Settings: Examples From the Field” (May 2002)