CrossingTheLanguageChasmAnin-depthanalysisofwhatlanguage-assistancepro - PDF document

CrossingTheLanguageChasmAnin-depthanalysisofwhatlanguage-assistanceprogramslooklikeinpractice.byCindy Brach, Irene Fraser, and Kathy PaezABSTRACT:Thequalityofcommunicationbetweenpatientsandclinicianscanhaveamajorimpactonhealthoutcomes,andlimitedEnglishproficiencycaninterferewitheffective March/April2005 InsurersResponse DOI 10.1377/hlthaff.24.2.424©2005 Project HOPE…The People-to-People Health Foundation, Inc. CindyBrach(cbrach@ahrq.gov)isaseniorpolicyresearcher,CenterforDelivery,Organization,andMarkets, proficientEnglishspeakers,peoplewithlimitedEnglishproficiency(LEP)arelesslikelytoseekcareandtoreceiveneededserviceswhentheydo.Theyhavefewerphysicianvisitsandreceivefewerpreventiveservices,evenaftersuchfactorsasliteracy,healthstatus,healthinsurance,regularsourceofcare,economicindicators,orethnicityarecontrolledfor.Languagebarriersareassociatedwithpoorqualityofcareinemergencydepartments(EDs);inadequatecommunicationofdiagnosis,treatment,andprescribedmedication;andmedicalerrors.Patientswithlanguagebarriershavelowersatisfactionwithcare,evenwhencomparedwithpatientsofthesameethnicitywhohavegoodEnglishskills.Languagebarrierscanalsocreateadditionalcosts,calledbyLouHampersandJenniferMcNultylanguagebarrierpremiums.ŽLEPpatientshavemorediagnostictests,presumablybecauseofphysiciansattemptstocompensateforcommunicationdifficulties,andaremorelikelytobeadmittedtothehospitalfromtheED.Furthermore,failuretoaddresslanguagebarrierscanresultinothercosts,includinglossofbusinessfromminorityconsumersandfromtheprivatepurchasersthatbuyhealthcoverageforthem,andlossofbusinessfrompublicpurchasersthatincreasinglyimposelinguisticcompetencerequirements.Which Strategies Work?Althoughmanygapsremainintheliterature,evidenceismountingthatuseoflanguageassistancecanimprovecare.Bilingualphysicians.Spanish-speakingpatientsattendedbynativeSpanish…speakingphysicianshavereportedbetterwell-beingandfunctioning,improvedad-herencetomedicalregimens,andlowerEDusethantheirpeerswhowerenotat-tendedbybilingualphysicians.StudiesalsoshowthatLEPpatientswithinterpreterserviceshavemorephysicianofficevisitsandprescriptions,usemorepreventiveservices,andhavehighersatisfactionwithcarethancomparablepatientswithoutinterpreters.OnestudyevenfoundthatLEPdiabeticpatientswhousedinterpretersachievedsimilarhealthoutcomestothosewhohadnoneedofinterpreters„aneliminationoflanguagebarrierdisparities.Theeffectofinterpreterservicesonhealthcarecostsislessclear.Interpreterserviceshavebeenfoundtolowercostsbydecreasingtheuseofdiagnostictesting,loweringtheprobabilityofhospitaladmissionandreceiptofIVfluids,andreducingpost…EDvisitcharges.Ontheotherhand,professionalinterpreterservicesarenotfree,anduseofinterpreterservicesorothereffortstoreducelanguagebarrierscanalsoaddcostsintheshorttermbyincreasinguseofprimaryandpreventiveservices.Thoseincreases,however,mayleadtolowerhealthcarecostsinthelongrun.Insum,theresearchsuggeststhatuseofinterpretersandprovidersskilledinapatientslanguagecanimprovehealthcarequalityandsatisfactionwithcare.However,asisoftenthecase,thereisagapbetweenwhattheresearchshowscan LanguageChasm HEALTHAFFAIRS~ Volume24,Number2 425 workandwhatgetsimplemented.Asanextstepinourinquiry,therefore,weidentifywhatsomemodelsoflanguage-assistancestrategiesmightlooklikeinpractice.Directprovidersofservices,suchashospitalsandphysicianpractices,havetraditionallyassumedresponsibilityforprovidinglanguageassistancetotheirpatients.Ashealthplanshavedevelopedlanguage-assistanceprograms,theyalsohavebeguntoassumeagreaterroleinfacilitating,organizing,andfinancinglanguageassistanceinclinicalsettings.Todescribethecutting-edgeapproachestakenbyhealthplans,weidentifiedandinterviewedtrailblazersintheareaoflinguisticcompetence.Tobeconsideredforinclusioninourstudy,ahealthplanhadtoengageinactivitiesdesignedtopromotebothculturallyandlinguisticallyappropriateservices.Purposefulsamplingwasusedtoselectplansthatwereleadersinthefield.Thesamplewasstratifiedonseveralcharacteristics,showninExhibit1.Thefirstwaveofdatacollection(semistructuredtelephoneinterviewsandcollectionofsupportingmaterials)tookplacein2000and2001,followedbyasec-ondwavein2002,whichobtainedupdatedinformationandexpandedthenum-berofplansincludedinthestudy.Althougheachoftheplansoperatedinasomewhatdifferentway,mostper- 426 March/April2005 InsurersResponse EXHIBIT1CharacteristicsOfSampledHealthPlans,StudyOfLanguageAssistanceInHealthPlans,2000…2002statusModel type formedfourcriticalfunctions:collectingdataonmemberslanguages,recruitingandidentifyingbilingualstaffandphysicians,organizingandfinancinginterpreterservices,andeducatingmembersandphysiciansaboutinterpreterservices.TheexperiencesoftheseplanleadersillustratethepotentialforaddressingtheneedsofplanmemberswithlimitedEnglishproficiency.Collectingdataonmemberslanguages.Thefirststepindevelopingalanguage-assistanceprogramisusuallytoassessmemberslanguageneeds.Incontrasttohealthplansgenerally,mostoftheplansinourstudypossesseddataonmemberslanguages.Theseplanseitherreceiveddatafromthestatespublicinsuranceprogramsorcollectedthedatathemselvesfrommembers.Theplansgenerallyusedthesedatafortwopurposes:(1)aggregateplanning(forexample,assessingthelanguageadequacyofstaffandthephysiciannetworkorplanningforinterpreterservices),and(2)conductingplanbusinesswiththatmember(forexample,makingwelcomecallsintheappropriatelanguageorassigningmemberswhodidnotmakeaselectionofaprimarycareprovidertoabilingualprovider).Languagedatacouldalsobeusedforplanningclinicalvisits,butfewplansthatpossessedlanguagedatasharedthemwithphysicians.Plansreportedthatmemberssometimesquestionedtheplanscollectionoflan-guagedata.Oneofthestudyplansrespondedbytrainingstaffonhowtoexplaintomemberswhylanguageinformationisneeded.Thisplancollectedthreedis-tinctdataelements:preferredlanguageforwrittencommunications,preferredlanguagefororalcommunications,andtheneedforinterpreterservices.Recruitingandidentifyingbilingualstaffandphysicians.TocommunicatewithLEPmembers,mostplanshadbilingualstaffinpositionsthatinteractedex-tensivelywithmembers,suchascustomerservicerepresentativesandhealtheduca-tors.Useofbilingualstaffwaslimitedtothemostcommonlyspokenlanguages.Fewplansactivelyrecruitedbilingualphysicians.Manyplans,however,surveyedphysicianofficesontheirlanguagecapabilities,toreportlanguagecapabilitiesinproviderdirectories(toaidmembersinselectingtheirphysicians)andtoassesstheplanscomplementofbilingualphysiciansandtheneedforinterpreterservices.Planshavebecomemoresophisticatedinconductingtheirassessmentsinrecentyears.Increasinglytheyaskaboutthelanguagecapabilitiesofclinicalstaffratherthanaskingaboutthelanguagecapabilitiesofthephysiciansofficesoverall,andaskphysicianstoratetheirproficiencyintheforeignlanguage.Organizingandfinancinginterpreterservices.NoplanhadsufficientbilingualstafforphysicianstoadequatelyserveitsLEPmembership,soallhadsomeneedofinterpreterservices.Usingexistinginterpreterservices.Manyoftheplansrelied,foratleastsomeoftheirlanguage-assistanceservices,onphysicianswhoseofficeshistoricallyservedLEPpopulationsandhadinterpreterservicesprogramsinplace.Thispolicyrequiredcontractingwithhealthclinicsorsolopractitionerswhoareoftenleftoutofcommercialnetworks.Thiswassomeplansonlyapproachtoprovidingmembers LanguageChasm HEALTHAFFAIRS~ Volume24,Number2 427 withaccesstointerpreterservices.Facilitatingprovisionofinterpreterservices.Healthplansstrategiesincluded(1)compilingresourcedirectoriesofinterpretersintheareaanddistributingthedirectorytotheirphysiciannetwork;(2)negotiatingadiscountfortelephoneinterpreterservicesforphysiciansintheirnetworks;(3)schedulinginterpreterstoappearatphysiciansofficesforpatientsappointments;(4)andtrainingpeople,includingnetworkphysicianssupportstaffs,asmedicalinterpreters,toincreasethesupplyofmedicalinterpretersinthearea.Providingandpayingforinterpreterservices.Inthemostactivistapproach,sometimesusedincombinationwithotherstrategiesidentifiedabove,plansprovidedandpaidforinterpreterservices.ThisstrategywasusedprimarilybyplansthatservedMedicaidparticipants.TheapproachesrangedfromthegoldstandardŽofusingprofessionalmedicalinterpreterstousingtelephoneinterpretersandadhocstaffarrangements.Noneoftheplansreliedheavilyonpatientsfamilyandfriendstointerpret.Plansthatfinancedin-personprofessionalinterpreterservicestendedtoactivelydiscouragephysiciansuseoffamilyandfriendsasadhocinter-preters.Whenusingprofessionalinterpreters,mostplansusedlanguagebanksorfree-lanceinterpreters.Healthplansgenerallyrequiredthatinterpretersbetrainedandcredentialed,eitherbytheplanitselforbythelanguagebankwithwhichtheplancontracted.Becauseofthedifficultyinverifyingquality,useoffreelancein-terpreterswasgenerallylesspopularthanusingalanguagebank.UseofadhocstaffinterpreterswasnotuncommonforconductingnonclinicalplanbusinesswithLEPmembers.Planssurveyedtheirstaffonlanguagecapabilitiesandthencirculatedalistofstaffwhocouldserveasinterpreters.Thesestaffmemberswereusuallynottrainedasinterpreters,andonlytwooftheplansweinterviewedtestedadhocinterpretersfortheirproficiencyinthelanguageandinmedicalterminology.Plansusingthisapproachexpressedsomeconcernswiththequalityofadhocinterpretation.Plansalsoreportedorganizationaldifficultiesinrunningadhocinterpreterservicesprograms,suchasunavailabilityofstaffmemberswhentheirinterpreterservicesareneeded.Plansdidnotcollectdataontheuseofadhocinterpretersbyphysiciansintheirnetworks,butthepracticewasbelievedtobewidespread.Plansalsoreportedthattelephoneinterpreterserviceswerearelativelyinexpensivewaytoprovidecoverageforawidearrayoflanguages.Butimplementationproblems,suchasexaminingroomsnotbeingwiredfortelephoneuse,longwaitingtimes,andlackofproficiencywithmedicalterminology,werecommon.Althoughafewplansusedtelephoneinterpreterservicesastheirsolemethodofin 428 March/April2005 InsurersResponse Somephysiciansarenotawareoftheneedforaninterpreter,believingthattheirownlanguageskillsaresufficient.Ž terpreterservices,othersusedtelephonelanguagelinesforrarelyspokenlanguagesandasabackupwhentheneedforinterpreterserviceswasnotanticipatedorinterpreterswerenotavailable.Althoughhealthplansviewedinterpreterservicesaskeytoprovidinghigh-qualityhealthservicestotheirLEPmembers,fewplansformallyevaluatedtheimpactofinterpreterservices.Interpreterservicesevaluationsconductedbythreeplansfoundthatafteraninterpreterservicesprogramwasimplemented,LEPmembersweremoresatisfiedwiththeircare,anddisparitiesbetweenEnglish-speakingandLEPmembersinthereceiptofpreventiveservicesweregreatlyreduced.Educatingmembersandphysicians.Threemethodsweremostcommonlyusedtonotifymembersandphysiciansoftheavailabilityoflanguageassistanceandprovidethemwithinstructionsforaccessinginterpreterservices:newsletters,providermanuals/memberhandbooks,andorientations.Innovativemethodsweresometimesused,suchasoneplansgivingphysiciansaRolodexcardwiththetoll-freenumbertoobtaininterpreterservicesprintedonit,andanIspeak[language]Žcardwiththesameinformationforpatientstopresenttophysicians.Plansthatdidnotfinanceorprovideinterpreterservicesstilltriedtoeducatephysiciansaboutprofessionalinterpreterservicesandtheplansfacilitationstrategies.Severalplansconductedtraining,eitheraspartofproviderorientationsessionsorasastand-alonecourse,toteachphysicianshowtoworkwithtelephoneandin-personinterpreters.However,mostplansbelievedthatmorephysicianeducationaboutin-terpreterservicesisneeded.Moreover,educationmaynotbeenough.Physiciansaresometimesreluctanttouseinterpreterservices.Forexample,physiciansvetoedoneplansproposaltoprovideinterpreterservicesandhavenotavailedthemselvesofanotherplansofferofextrapaywhentheyuseaninterpreter.Anexplorationofwhyphysicianswerenotusingplan-providedinterpreterservicesrevealedthatphysicianshavemanyknowledgegapsandmisperceptionsaboutinterpreterservices.Itfoundthatsomephysiciansarenotawareoftheneedforaninterpreter,believingthattheirownlanguageskillsaresufficientorthatuseoffamilyorfriendsasinterpretersisappropriate.Otherphysiciansdidrecognizeaneedbutdidnotknowhowtouseinterpreterservicesorthattheplanpaidforthem.Ourliteraturereviewanddiscussionswiththeplanssuggestthathealthplans,providers,policymakers,andresearcherscantakestepstofacilitate,expand,andbuildonearlyeffortstocrossthelanguagechasm.Whatcanhealthplansdo?Evidencefromthefourteentrailblazerplanssuggestssixpriorityactivitiesthatplanscaninitiatetoimprovelinguisticcompetence.Developalanguage-assistanceplan.Plansoftenbeginprovidinglanguageassistanceadhocwithouthavingdevelopedaconsistent,comprehensiveapproach.Plans HEALTHAFFAIRS~ Volume24,Number2 429 LanguageChasm thatwanttotakeasystematicapproachtolanguageassistancecanfollowthestep-by-stepprocessoutlinedinProvidingOralLinguisticServices,whichisbasedontheexperiencesofplansinthisstudy.Collectanduselanguagedata.Tocreatealanguage-assistanceplan,healthplansneedtoknowthenumberofLEPmembersandwhichlanguagestheyspeak.Althoughsomedatamaybeavailableforpubliclyinsuredmembersandcommunitydatacanalsoprovidevaluableinformation,thesedataarenotsubstitutesforplanscollectionofmember-specificdata.Forlanguagedatatohelpattheclinicallevel,thedatamustalsobetransmittedtophysiciansandtheirstaff„astepthatmostplansomit.DontrelyexclusivelyonphysicianswhohistoricallyhaveservedLEPpopulations.Theavailabilityofbilingualphysiciansandphysicianswithlanguage-assistanceprogramsinplacecanbeatremendousassettoaplan.Nothavinginterpreterservicestoaugmentthesetraditionalproviders,however,confinesmemberswithlimitedEnglishproficiencytotheseproviders.Withsomeevidencedemonstratingthatprovidersservingminoritycommunitiesdeliverpoorer-qualityhealthcare,plansfailuretopayforinterpreterserviceswouldallowhealthcaredisparitiesthatre-sultfromcurrentmarketsegmentationtopersist.Educatephysiciansandholdthemaccountable.Theexperienceofmostofthefourteenplanswestudiedisthatphysicianshavenotbeenembracingplanslanguage-assistanceinitiatives,evenwhenplanshavepaidforinterpreterservices.Plansthatpayfortheseservicescanfollowtheexampleofonestudyplanbynotonlyeducatingphysiciansaboutthebenefitsofinterpreterservicesandhowtoaccessthem,butalsorequiringphysicianstodocumentpatientsrefusalofinterpreterservices.Plansthatdonotpayforinterpreterservicescanalsoeducatephysiciansandusesomeofthefacilitationstrategiesdescribedearliertoencouragetheuseofinterpreterservices.Recognizelanguageassistanceasanintegralpartofquality.Healthplansinterviewedforthisstudyoverwhelminglyfeltthataccesstointerpreterservicesisanimportantcomponentofprovidinghigh-qualityservicestoLEPplanmembers,butsomehadconcernsaboutcostsandmaintainingcompetitivenesswithotherhealthplansthatmadethemreluctanttoinvestinlanguage-assistanceprograms.Itisimportanttorecognizethatprovidinglanguageassistancecarriesnomoreriskthatreturnsoninvestmentswillberealizedbyothersthanotherqualityimprovementefforts.Negotiatewithpurchasers.PurchasershaveaninterestinincreasingprimaryandpreventivecaretoLEPpeopleandreducingunnecessarytestingthatcanresultfromcommunicationfailures.Bydevelopingcostestimates„usingdataonthe March/April2005 InsurersResponse Bydevelopingcostestimates,planscandemonstratetopurchasersthattheshort-runcostsofinterpreterservicesarenotexorbitant.Ž numberofLEPmembers,theprojectednumberofinterpretedencounters,andtheaveragecostofinterpreterservices„planscandemonstratetopurchasersthattheshort-runcostsofinterpreterservices,evenwithoutcostoffsets,arenotexorbitant.Whatcanpurchasersdo?Publicandprivatepurchasersalsocanhaveamajorimpactontheavailabilityoflanguageassistancebecausetheylargelycontrolthebusinesscase.ŽWhilemanyplansandprovidershaveaninterestinprovidinglanguageassistancetohelpthemmeetbothpatientsneedsandlegalrequirements,manyarealsostrugglingtocopeinverycompetitivemarkets.Atleastintheshortrun,investinginlanguageassistancecanraisecosts.Butpurchaserscandoseveralthingstomakeplansandproviderswillingtoincursuchcosts.Payforinterpreterservices.Publicandprivatepurchaserscaninstructtheiractuariestoincludethecostofinterpreterservicesinconstructingcapitationpaymentandallowforreimbursementofinterpreterservicesinfee-for-servicearrangements.StatescanamendtheirstateMedicaidplanstoaccessthefederalmatchingfundsforinterpreterservicesforMedicaidandStateChildrensHealthInsuranceProgram(SCHIP)participants.Todate,tenstateshavedoneso.Makeexpectationsexplicit.Purchasersareoftenvagueaboutwhattheyexpectfromhealthplansintermsofculturalandlinguisticcompetence.Communi-catingrequirementsclearly,asCaliforniahasdoneinitsMedicaidandSCHIPprograms,canpromoteextensivehealthplanlinguisticcompetenceactivity.Pri-vatepurchaserscanalsoaffectplanservicesforLEPmembers.Onehealthplaninthisstudyhadcultivatedsmallemployers,manywithSpanish-speakingLEPem-ployees,asitsmarketniche.Employersdesireforeffectivecommunicationbe-tweenemployeesandhealthcareproviderspromptedtheplantoprovidelan-guageassistanceevenbeforepublicpurchaserswererequiringsuchservices.Requirereportingonlanguageassistance.Informationonplanslanguage-assistanceprogramsnotonlycanbeusedasafactorinselectingplanstocontractwith,butalsocanbesharedwithconsumerstoinformtheirplanForexample,CaliforniasHMOReportCard,createdbytheOfficeofthePatientAdvocate,listshealthmaintenanceorganization(HMO)servicesrelevanttoLEPanddeafpatients,suchastheavailabilityoffreeinterpreterservices,translatedlistsofbilingualphysicians,andmonitoringthesatisfactionwithcareofnon-Englishspeakers.Whatcanpolicymakersdo?FederalandstatelawsandregulationsrequiringthatplansandprovidersaddressthelanguageneedsofLEPpopulationshaveprovidedmuchoftheimpetusforlinguisticcompetenceefforts.Continuedattentionbypolicymakersandaccreditingorganizationscouldspeedthetrajectoryandsuccessoftheseefforts.Encourageandsupporthealthplancollectionoflanguagedata.Amajorrolethefederalgovernmentcanplayistoincreaseawarenessthatcollectionofrace,ethnicity,andlanguagedataisnotonlylegal,butalsovitalforenforcingnondiscriminationrequirementsandaddressinghealthcaredisparities.TheNationalCommitteeon LanguageChasm HEALTHAFFAIRS~ Volume24,Number2 431 VitalandHealthStatistics(NCVHS)hasrecommendedthattheU.S.DepartmentofHealthandHumanServices(HHS)stronglyencourageandprovidesupportforaccurateandcompletecollectionofsuchdatabyhealthplans,andthatHHSimproveitscollectionofdataonlanguageandLEPpopulations.MedicareandMedicaidhaveaparticularlygreatpotentialtoaffectlanguagedatacollection.Medicarecollectsandshareswithhealthplansdataonraceandethnicitybutnotlanguage.ProposedMedicaidmanagedcareregulationsrequirestatestoprovidelanguagedatatomanagedcareplans.Thesefederalprogramscanalsopromotelinguisticcompetenceaspartoftheirrequiredqualityimprovementactivities.Forexample,improvementofculturallyandlinguisticallyappropriateserviceswasoneoftwochoicesforMedicaremandatoryqualityassessmentandperformanceimprovementprojectsin2003.Statesalsohavemajorrolestoplayinencouraginghealthplanstocollectlanguagedata.Thiscanrangefromimprovingtheaccuracyoflanguagedataonpubliclyinsuredmembersthattheycollectandsharewithhealthplans,torequiringthathealthplanscollectlanguagedata,asdoesTexas.Developnationalmeasuresandstandards.Therearenonationalmeasuresoftheade-quacyoflanguageassistanceforhealthplans.In2004theNationalCommitteeforQualityAssurance(NCQA)retireditsmeasure,AvailabilityofLanguageInter-pretationServices,Žandisnowconductingafeasibilitystudytodeterminehowtoassesshealthplansprovisionofculturallyandlinguisticallyappropriateservices.TheJointCommissiononAccreditationofHealthcareOrganizations(JCAHO)isalsoexploringstandardsandmeasuresthataddresshospitalscapabilitytoad-dresslanguageandculturalissues.Healthplansinourstudyalsoreflectedthatthereisaneedfornationalstandardsforcertifyingmedicalinterpreters.Onlytwostatescredentialmedicalinterpreters,andstandardshavebeendevelopedintwootherstates.Whatcanresearchersdo?Asnotedearlier,thereisagrowingbodyofevidencetoshowthatbettercommunicationmeansbettercareandthatlanguageassistancecanimprovesuchcommunication.Ontheotherhand,theevidenceislessclearonthetypesofinterventionsthatcanbemosteffectiveandcost-effectiveandhowtoimplementtheminvarioussettings.TheOfficeofMinorityHealthandtheAgencyforHealthcareResearchandQualityrecentlypublishedSettingtheAgendaforResearchonCulturalCompetenceinHealthCare,whichidentifiesunansweredquestionsontheimpactofculturalandlinguisticcompetenceonhealthcaredeliveryandhealthoutcomes.Researcherscanpartnerwithhealthcareproviderstoproducerigorousanswerstothesequestions.rovidinglinguisticallycompetenthealthcareisacomplexundertaking.Fortunately,theactivityofplanssuchasthoseinterviewedforthisstudycanprovideguidance,andmanyresourcesandtoolsareavailabletothose who pursue linguistic competence. March/April2005 InsurersResponse Thanksareduetonumeroushealthplanofficialswhogavegenerouslyoftheirtimetobeinterviewed.CarolynWangsexcellentresearchassistanceinselectingstudyparticipantsanddevelopingtheinterviewprotocolisgreatlyappreciated,asisMarcChowsassistanceinidentifyingexpertsandcontactsinhealthplans.TheauthorsalsoacknowledgeDennisTolsmaandJodyHickmanofKaiserPermanenteGeorgiafortheirparticipationinconductinginterviews.TheviewsexpressedinthispaperarethoseoftheauthorsanddonotnecessarilyreflecttheviewsofAgencyforHealthcareResearchandQualityorLovelaceClinicFoundation.1.K.S.Collinsetal.,DiverseCommunities,CommonConcerns:AssessingHealthCareQualityforMinorityAmericans(NewYork:CommonwealthFund,2002).2.CalculatedfromU.S.BureauoftheCensus,Census2000SupplementarySurvey,P035,AgebyLanguageSpokenatHomebyAbilitytoSpeakEnglishforthePopulationFiveYearsandOver,ŽinCensus2000SupplementarySurveySummaryTables(Washington:U.S.BureauoftheCensus,2002).AlthoughthesefigurespresumablyincludethosewhospeakAmericanSignLanguage(ASL),andmanyofthefindingsofthispapermayberelevanttoASLspeakers,thisresearchfocusedonspeakersofforeignlanguagesanddoesnotspecificallyaddressdeafnessorotherdisabilitiesasasourceoflanguagebarriers.3.M.A.Stewart,EffectivePhysician-PatientCommunicationandHealthOutcomes:AReview,ŽJournaloftheCanadianMedicalAssociation152,no.9(1995):1423…1433.4.Forextensivereviewsoftheliterature,seeJ.P.FortierandD.Bishop,SettingtheAgendaforResearchinCulturalCompetenceinHealthCare,ed.C.Brach(Rockville,Md.:OfficeofMinorityHealthandAgencyforHealthcareResearchandQuality,2004);E.A.Jacobsetal.,LanguageBarriersinHealthCareSettings:AnAnnotatedBibliographyoftheResearchLiterature(WoodlandHills,Calif.:CaliforniaEndowment,2003);andC.BrachandI.Fraser,CanCulturalCompetencyReduceRacialandEthnicHealthDisparities?AReviewandConcep-tualModel,ŽMedicalCareResearchandReview57,Supp.1(2000):181…217.5.L.HampersandJ.McNulty,ProfessionalInterpretersandBilingualPhysiciansinaPediatricEmergencyDepartment:EffectonResourceUtilization,ŽArchivesofPediatricsandAdolescentMedicine156,no.11(2002):1108…1113.6.Ibid.;L.C.Hampersetal.,LanguageBarriersandResourceUtilizationinaPediatricEmergencyDepart-ment,ŽPediatrics103,no.6,Part1(1999):1253…1256;andE.D.Leeetal.,DoesaPhysician-PatientLanguageDifferenceIncreasetheProbabilityofHospitalAdmission?ŽAcademicEmergencyMedicine5,no.1(1998):86…89.7.C.BrachandI.Fraser,ReducingDisparitiesthroughCulturallyCompetentHealthCare:AnAnalysisoftheBusinessCase,ŽQualityManagementinHealthCare10,no.4(2002):15…28.8.HampersandMcNulty,ProfessionalInterpretersŽ;andA.Manson,LanguageConcordanceasaDeterminantofPatientComplianceandEmergencyRoomUseinPatientswithAsthma,ŽMedicalCare26,no.12(1988):1119…1128.9.E.A.Jacobsetal.,TheImpactofInterpreterServicesonDeliveryofCaretoLimited-English-ProficientPatients,ŽJournalofGeneralInternalMedicine16,no.7(2001):468…474;E.A.Jacobsetal.,OvercomingLanguageBarriersinHealthCare:CostsandBenefitsofInterpreterServices,ŽAmericanJournalofPublicHealth94,no.5(2004):866…869;R.Rivadeneyraetal.,PatientCenterednessinMedicalEncountersRequiringanInterpreter,ŽAmericanJournalofMedicine108,no.6(2000):470…474;andD.W.Baker,R.Hayes,andJ.P.Fortier,InterpreterUseandSatisfactionwithInterpersonalAspectsofCareforSpanish-SpeakingPatients,ŽMedicalCare36,no.10(1998):1461…1470.10.T.M.TocherandE.Larson,QualityofDiabetesCareforNon-English-SpeakingPatients:AComparativeStudy,ŽWesternJournalofMedicine168,no.6(1998):504…511.11.HampersandMcNulty,ProfessionalInterpretersŽ;andJ.Bernsteinetal.,TrainedMedicalInterpretersintheEmergencyDepartment:EffectsonServices,SubsequentCharges,andFollow-up,ŽJournalofImmigrantHealth4,no.4(2002):171…176.12.Jacobsetal.,OvercomingLanguageBarriers.Ž13.M.Q.Patton,QualitativeEvaluationandResearchMethods(NewburyPark,Calif.:Sage,1990).BecauseCaliforniaisalargeanddiversestatethat,intermsoflinguisticculturalandcompetence,isaheadofmuchofthecountry,adisproportionateshareofstudyhealthplanswaslocatedinCalifornia.14.COSMOSCorporation,NationalStudyofCulturallyandLinguisticallyAppropriateServicesinManagedCareOrganizations(CLASinMCOsStudy):FinalReport,ExecutiveSummary(Rockville,Md.:OMH,2003). LanguageChasm HEALTHAFFAIRS~ Volume24,Number2 433 15.K.Quan,AssessingtheImpactofPhysician-PatientCommunicationBarriersonHealthCareCostsandQuality,ŽPresentedtotheOMHExpertPanel,Rockville,Md.,16October2003.16.K.Paez,ProvidingOralLinguisticServices:AGuideforManagedCarePlans(Baltimore:CentersforMedicareandMedicaidServices,2002).17.P.B.Bachetal.,PrimaryCarePhysiciansWhoTreatBlacksandWhites,ŽNewEnglandJournalofMedicineno.6(2004):575…584;andA.M.Epstein,HealthCareinAmerica„StillTooSeparate,NotYetEqual,ŽNewEnglandJournalofMedicine351,no.6(2004):603…605.18.Forexample,theaveragenumberofinterpretedvisitsinonestudywas2.95peryear.Jacobsetal.,OvercomingLanguageBarriers.ŽWhilethecostofinterpreterservicesvaries,theOfficeofManagementandBudget(OMB)estimatesthatin-personprofessionalinterpreterservicescost$20…$26perhour.TheOMBalsocitesdecreasesinnumberandseverityofmisdiagnosesorothermedicalerrorsthatarecostlytoprovidersandinsurancecompaniesandobtainingtrueinformedconsentthatcanleadtolegalandotherproblemsaspossiblecostoffsets.OfficeofManagementandBudget,ReporttoCongress:AssessmentoftheTotalBenefitsandCostsofImplementingExecutiveOrderNo.13166:ImprovingAccessforPersonswithLimitedEnglishProficiency(Washington:OMB,2002).19.MaraYoudelman,staffattorney,NationalHealthLawProgram,personalcommunication,23September2004.20.S.RosenbaumandJ.Teitelbaum,CulturalCompetenceinMedicaidManagedCarePurchasing:GeneralandBehavioralHealthServicesforPersonswithMentalandAddiction-RelatedIllnessesandDisorders(Washington:GeorgeWashingtonUniversityMedicalCenter,1999).21.CaliforniaOfficeofthePatientAdvocate,HMOServicesinOtherLanguages(Sacramento:CaliforniaOPA,22.BrachandFraser,ReducingDisparitiesthroughCulturallyCompetentHealthCare.Ž23.NationalCommitteeonVitalandHealthStatistics,LettertoHHSSecretaryThompsononracialandeth-nicdisparitiesinhealthcare,26September2003,www.ncvhs.hhs.gov/030926ltb.htm(13December2004);andNationalCommitteeonVitalandHealthStatistics,LettertoHHSSecretaryThompsononim-provingpopulation-baseddataforracialandethnicminorities,27March2003,www.ncvhs.hhs.gov/030327lt.htm(14December2004).24.CentersforMedicareandMedicaidServices,Medicare+ChoiceOrganizations(M+CO)NationalQual-ityAssessmentandPerformanceImprovement(QAPI)fortheYears2002and2003,ŽJuly2001,www.cms.hhs.gov/healthplans/opl/opl133.pdf(25January2005).25.NationalHealthLawProgram,AssessmentofStateLaws,RegulationsandPracticesAffectingtheCol-lectionandReportingofRacialandEthnicDatabyHealthInsurersandManagedCarePlans,Ž7January2004,www.omhrc.gov/omh/sidebar/datastats13.htm(13December2004).26.JointCommissiononAccreditationofHealthcareOrganizations,Hospitals,Language,andCulture:ASnapshotoftheNation,ŽJanuary2004,www.jcaho.org/about+us/hlc/home.htm(30November2004).27.FortierandBishop,SettingtheAgenda.28.Forexample,seeOMH,APracticalGuideforImplementingtheRecommendedNationalStandardsforCulturallyandLinguisticallyAppropriateServicesinHealthCare,Žwww.omhrc.gov/clas/guide2a.asp(14December2004);FederalInteragencyWorkingGrouponLimitedEnglishProficiency,LanguageAssistanceSelf-AssessmentandPlanningToolforRecipientsofFederalFinancialAssistance,Žwww.lep.gov/selfassesstool.htm(30November2004);andM.YoudelmanandJ.Perkins,ProvidingLanguageInterpretationServicesinHealthCareSettings:ExamplesfromtheField,May2002,www.healthlaw.org/pubs/cmwfreport0502.pdf(14December2004). March/April2005 InsurersResponse