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Health Disparities Caused by Limited English Proficiency

By Jefferine Li

Limited English Proficiency (LEP) individuals are those who do not speak English as their primary language and demonstrate a limited ability to read, speak, write, and understand English. As the U.S. grows increasingly diverse, issues that affect those that speak another language and those that have LEP will become magnified. According to the Agency for Healthcare Research & Quality, around 20% of the U.S. population (57 million people) speak a non-English language at home.1 The LEP population represents a significant 8.6% of the total US population (25 million people).1 This signifies that at least 8.6% of the U.S. population is subject to unfavorable outcomes due to language barriers.

Specifically, language barriers when seeking to access healthcare tend to lead to health disparities: patients encountering language barriers are less satisfied with their care, have less access to and utilization of health care, and face higher costs and lower quality of care. For example, LEP patients tend to have longer hospital stays when professional interpreters are not used during admission and discharge.1 Studies also found that racial and ethnic minorities have a greater chance of readmission than white patients, most likely due to misunderstandings about medication instructions, discharge instructions, and follow up.1 Physicians also may opt to “make do” with their own limited foreign language skills; in their attempt to increase efficiency, however, they risk misdiagnosis and mistreatment.1 Other sources of LEP-caused health disparities include inaccurate and/or incomplete documentation of medical history and insufficient informed consent.1 In one such case of inadequate consent, a LEP pancreatic cancer patient’s metastatic ovaries were surgically removed to relieve her constipation. However, the patient did not understand the operation to which she was consenting and was devastated to learn that she was sterile and would never have children (Karen Kim). Therefore, good communication between LEP patients and physicians is necessary and can improve understanding of exam results, increase satisfaction, increase quality of care, lower anxiety, and increase chances of appropriate follow-up. To better communication and understanding between physicians and patients, professional medical interpreters are crucial.

Research confirms that healthcare providers often use ad hoc interpreters for LEP patients. For example, friends and family members are often asked to help interpret, even though they may not understand the medical terminology used in the conversation and are not trained to catch the nuances of the language.1 Professional interpreters are therefore crucial in improving care for LEP patients because ad hoc interpreters are likely to exhibit false fluency. False fluency occurs when people with no formal training in translation try to interpret for a patient and end up omitting, substituting, or making up words; these mistranslations, inevitably, lead to clinically significant errors. False fluency can be especially dangerous because it creates the illusion of mutual understanding between doctor and patient. Professional interpreters, however, are trained to have a better knowledge of medical terminology and the medical field. Thus, they can translate patient’s symptoms and questions to physicians and in turn convey physicians’ rationale for treatment to the patient. It has been found that using trained professional interpreters leads to lower interpretation errors, lower chances of health disparities, and better patient understanding.3 A 2012 study done by the American College of Emergency Physicians found that the error rate for ad hoc interpreters was 22%, while the error rate for professional interpreters was 12%.4 Specifically, professional interpreters with more than 100 hours of training had an error rate of 2%.4 Clearly, professional interpreters with adequate training and certification are vital in improving communication between physicians and LEP patients.

Professional interpreters, however, may not be as accessible for certain LEP patients based on where LEP patients live. While every state has laws mandating access to language resources in healthcare situations, one of the most significant barriers to language access for LEP patients is the absence of uniform nationwide reimbursement for healthcare interpreting services.5 Each state can decide how their respective Medicaid program will give reimbursement for interpreting services. If a state does not provide reimbursement, none of the providers in that state will be paid for providing such translation services.5 Currently, only 13 states and the District of Columbia provide reimbursement for hospitals providing language services for Medicaid, and State Children’s Health Insurance Program (SCHIP) patients.6 Hospitals that that do not receive federal funding face the additional financial burden associated with providing adequate language services for patients. Even the states that do provide reimbursement are not uniform in their reimbursement rates, affecting the incentive for providing language access for LEP patients.5 It is especially notable that the states that do provide reimbursement are the states with the smallest LEP populations, the only exception being Hawaii.5 There is clearly a disparity between the need for language assistance and the ability of hospitals in certain states to provide them.

Furthermore, due to the large number of languages in the world, it can be difficult to find on-site professional interpreters of medical care for rarer languages. Many hospitals, therefore, opt to use a phone service to meet federal requirements; however, the people behind these phone services are often not certified medical interpreters and may not be able to understand medical terminology and catch nonverbal cues made by the patient about how they are feeling and where their symptoms are occurring.4 Furthermore, patients who have hearing issues or dementia will not be able to understand interpreters over the phone as well as they would in person.4

Since there has been little movement to improve language access on the federal front, most of the legislative action done to bridge language barriers in healthcare has occurred on the state front. For example, California has broadened the requirement of providing language services to privately insured individuals.5 A notable way that states have addressed language barriers in healthcare is by requiring continued education in language access and cultural competency for health professionals. California, New Jersey, and Washington are three states that have initiated these requirements.5 Such legislature is made with the hope that physicians and health professionals will continue their practice with increased awareness and support for the use of language resources for LEP patients. Furthermore, some states have begun to develop certification standards for healthcare interpreters to ensure the quality of interpretation. Washington was the first state to implement a comprehensive certification program Language Interpreter Services and Translations (LIST) that regulates testing and certification of bilingual healthcare interpreters and translators.5

While the U.S. has come a long way in improving LEP patients’ access to language services, there is much more to be done to ensure that efficiency of healthcare does not occur at the expense of the quality of care LEP patients receive. All patients should have the right to effectively communicate with their physicians.

References

  1. “Improving Patient Safety Systems for Patients with Limited English Proficiency: Executive Summary.” Agency for Healthcare Research and Quality. Last modified September 2012. https://www.ahrq.gov/professionals/systems/hospital/lepguide/lepguidesumm.html#what
  2. Kim, Karen E. “Patient centered communication.” Presentation at Health Disparities in Breast Cancer Class, University of Chicago, Chicago, IL, January 9, 2017.
  3. Karliner, Leah S., Jacobs, Elizabeth A., Chen, Alice Hm, and Mutha, Sunita. “Do Professional Interpreters Improve Clinical Care for Patients with Limited English Proficiency? A Systematic Review of the Literature.” Health Services Research 42, no. 2 (2007): 727-754.
  4. Foden-Vencil, Kristian. “In The Hospital, A Bad Translation Can Destroy A Life.” NPR. Last modified October 27, 2014. http://www.npr.org/sections/health-shots/2014/10/27/358055673/in-the-hospital-a-bad-translation-can-destroy-a-life
  5. Chen, Alice Hm, Youdelman, Mara K., and Brooks, Jamie. “The Legal Framework for Language Access in Healthcare Settings: Title VI and Beyond.” Journal of General Internal Medicine 22, no. 2 (2007): 362-367.
  6. Rice, Sabriya. “Hospitals often ignore policies on using qualified medical interpreters.” Modern Healthcare. Last modified August 30, 2014. http://www.modernhealthcare.com/article/20140830/MAGAZINE/308309945
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