The Economics of Language ServicesOr how to save Healthcare in Texas

Texas Association of Healthcare Interpreters and Translators 3rd Annual Symposium on Language Access and Healthcare

April 17th-18th, 2009 Austin, Texas

The Economics of Language ServicesTexas Has Been Historically Diverse

The Economics of Language Services

On average a 60-70% chance that a person you encounter on the street in a Metro area of Texas is of a different ethnic background.

*Census data 2000

Ethnic Diversity in Texas Today

The Economics of Language Services

Over 30% of Texas residents speak a language other than English in the home.

*Census data 2000

Texan Demography

The Economics of Language Services

Concentration in major urban areas, the Balcones Fault, and southern border area.

*MLA Map 2009

Distribution of Languages other than English in Texas

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-40000

-20000

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40000

60000

80000

Spanish

Vietnam

ese

Chinese

Germ

an

French

Tagalog

Korean

Urdu

Percent change

Quantitative change

The Economics of Language Services

*MLA data comparison between 2000 and 2005

Texas Non-English Speaking Population Change 2000/2005

Between 2000 and 2005 there was a 14% increase in the population that speaks a language other than English in Texas.

The Economics of Language Services

A cumulative change of 849,778 people which would make the difference equal to slightly less than the 11th largest city in the US.

Detroit 916,952 Jacksonville, 805,605

Over 30% of the population of Texas, 6.8 Million people, are forced into a Healthcare system that does not speak their language. This is a population that is slightly less than the size of New York

at 8M and 3x’s the official size of Houston.

Huge Increase of Individuals Who Speak a Language Other Than English in Texas 2000/05

The Economics of Language ServicesCost is a Perceived Barrier to Language Access

The Economics of Language Services

*Robert Woods Johnson Foundation, Hablamos Juntos, 2001

Cost is a Perceived Barrier to Language Access

The Economics of Language Services

$25 BILLION

The Economics of Language Services

Auto Bailout

Auto Bailout September 2008

The Economics of Language Services

$73 BILLION

The Economics of Language ServicesThe Economic Cost of Poor Communication in

Healthcare

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Lost in Healthcare*

Shoes

Jewelry & luggage

Lawn & garden

Office supplies

$73 BILLION is spent annually in unnecessary health care expenses due to the inability of patients to understand what

medical providers are communicating to them

*The Institute for Healthcare Advancement, July 29th, 2003

Size of Other IndustriesThe amount of waste due to poor communication in healthcare.

The Economics of Language Services

US Population 306,189,974

Waste due to poor communication in Healthcare $ 73,000,000,000.00

Per Person $ 238.41

US Population that speaks a language other than English in the home 58,176,095

Waste due to poor communication in Healthcare $ 73,000,000,000.00

Per Person $ 1,254.81

Cost Per Person of Poor Communication in Healthcare

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The Economics of Language ServicesThree Specific Areas to Address

System utilization

Inefficient LEP encounters

Liability

The Economics of Language ServicesThe Hidden Costs: Lack of Primary and Preventive Care

*Margaret O’Kane, NCQA Seattle, Washington October 18th, 2006

The Economics of Language ServicesThe Effect of Preventive and Primary Care

In 2000, an estimated 5 million hospital admissions may have been preventable with high quality primary care

1/3 to 1/2 of all Hospital ER Visits are treatable in primary care settings

Individuals with a primary care physician as their personal provider have 30-50% lower healthcare spending compared to those without a personal provider or with a

specialist as their personal provider

“Economic Argument for Increasing Preventive and Primary Care”, Charles Begley, February 12th, 2009 MALLF Conference on Health Disparities

The Economics of Language Services

*Robert Woods Johnson Foundation, Hablamos Juntos, 2001

Language is a Barrier to Primary and Preventive Care

The Economics of Language ServicesLEPs Less Likely to Use Primary and Preventive Care

Persons who have Limited English Proficiency are less likely to have a regular source of primary care and are less likely to

receive preventive care.

Elizabeth Jacobs, MD, MPP, Donald S. Shephard, Phd, MPP, Jose A. Suaya, MD, MBA, and Esta-Lee Stone, MS, OTR/L. Overcoming

Language Barriers in Healthcare: Costs and Benefits of Interpreter Services

Preventive Care Primary Care LEP

Non-LEP

“LEP Patients with professional medical interpreters were 94% more likely to use primary care and 78% less likely to use ED than English proficient patients, resulting in lower cost and more access to preventive care..”

Graham, EA., Jacobs, TA., Kwan-Gett, TS., Cover, J. (2008). Health Services Utilization by low-income limited English proficient adults. Journal of Immigrant Health, 10(3):207-17

The Economics of Language ServicesInterpreters Increase Primary and Preventive Care

“Use of trained interpreters was associated with reduced ED return rate, increased clinic utilization and lower 30-day charges without any increase in length of stay or cost of visit.”

Bernstein, J., Bernstein, E., Dave, A., Hardt,E., James, T., Linden, J., Mitchell P., Oishi, T., Safi C. (2002) Trained medical interpreters in the emergency department:

Effects on services, subsequent, charges, and follow-up

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Primary care

ED

30-day charges

The Economics of Language ServicesThe Effect of Preventive and Primary Care

“Economic Argument for Increasing Preventive and Primary Care”, Charles Begley, February 12th, 2009 MALLF Conference on Health Disparities

The disparity in preventive care for Latinos compared to whites is eliminated for those with a regular source of

primary care/medical home.

The disparity in preventive care for

Latinos compared to whites is

eliminated for those with a regular source of primary care/medical

home.

The Economics of Language ServicesThe Hidden Costs of Not Communicating With Over

30% of the Texas Population

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Liability

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The Economics of Language ServicesDual Role Staff Interpreters Lack Fluency

The Failure Rate of Dual Role Staff Interpreters

Moreno, M.R., Otero-Sabogal, R., Newman, J. (2007) Assessing Dual Role Staff-Interpreter Linguistic Competency in an Integrated Healthcare System. Journal of

Internal Medicine22 (Suppl2): 331-335

20-40% of dual role interpreters fail competency skills assessments.

The Economics of Language ServicesErrors by Untrained Staff

“Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters” by Dr. Glen Flores, Pediatrics

An average of 31 errors per encounter noted.

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All Modes Ad Hoc Interpreters Untrained Interpreters

Potential Clinical Consequence

Non Clinical Consequence

The Economics of Language ServicesTypes of Errors by Untrained Staff

“Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters” by Dr. Glen Flores, Pediatrics

The Economics of Language ServicesEconomic Impact of Errors

Head Catscan $ 592.00

Complete Blood Count $ 28.24

Chemistry 7 $ 164.78

Troptonin I Level $ 100.00

Portable Chest X-Ray $ 275.00

Oxygen $ 24.00

Cardiac Profile $ 21.00

Electrocardiogram (EKG) $ 54.00

IV Fluids $ 20.00

Costs for Tests $1,279.02

Interpreter Cost $ 1.00

Total Savings $1,278.02

“Comments to MA Health Care Committee”, April 9th, 1999 Carla Fogaren, Director of Interpreter Services at Good Samaritan Medical Center in

Brockton, Mass.

70 year old Portuguese speaking man. EMT’s suspect he might be suffering from a stroke or

heart attack. Interpreter was able to determine that it was only a head cold

and congestion.

The Economics of Language ServicesThe Hidden Costs: Associated Waste

“If one thinks of an interpreter-assisted history as a diagnostic test,

there are virtually no significant tests in medicine that are cheaper. Costs, in general compare to the costs of the

cheapest blood test that physicians order ($28 for complete blood count).”

“Comments to MA Health Care Committee”, April 9th, 1999 Eric Hardt, M.D., Clinical Director of Geriatrics and Medical Consultant to Interpreter Services

at Boston Medical Center

U.S. Office of Management and Budget estimated that it would cost, on

average, only $4.04 (0.5 percent) more per physician visit to provide all U.S. LEP patients with appropriate language services for ED,

inpatient, outpatient, and dental.

Flores, G. (2006). Language barriers to health care in the United States. New England Journal of Medicine, 355(2):229-231.

The Economics of Language ServicesThe Hidden Costs of Not Communicating With Over

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System utilization

Inefficient LEP encounters

Liability

The Economics of Language ServicesHow Much is a Word Worth?

Intoxicado

The Economics of Language ServicesHow Much is a Word Worth?

“Misinterpretation of a single Spanish word (Intoxicado misinterpreted in this case to mean “intoxicated” instead of its

intended meaning ‘of feeling sick to the stomach’) led to a

$71 million dollar malpractice settlement

associated with a potentially preventable case of quadriplegia.”

Harsham P. A Misinterpreted word worth $71 million. Med Econ. June 1984; 61:289-292.

The Economics of Language ServicesOther Examples of Risk

A resident’s misinterpretation of two Spanish words (se pego misinterpreted as ‘a girl was hit by someone else’ instead of ‘the

girl hit herself’ when she fell off the tricycle) resulted in a 2-year-old girl with a clavicular fracture and her sibling mistakenly being

placed in child protective custody for suspected abuse for 48 hours.

Flores G, Abreu M, Schwartz I, Hill M. The importance of language and culture in pediatric care: case studies from the Latino community. J Pediatr.

2000;137 842-848

The Economics of Language ServicesOther Examples of Risk

Lack of an interpreter for a 3-year-old girl presenting to the emergency department with abdominal pain resulted in several

hours’ delay in diagnosing appendicitis, which later perforated, resulting in peritonitis, a 30-day hospitalization,

and two wound site infections.

Flores G, Abreu M, Schwartz I, Hill M. The importance of language and culture in pediatric care: case studies from the Latino community. J Pediatr.

2000;137 842-848

The Economics of Language ServicesMediated Settlement Agreements and Language Access

• Resolution Agreement between the Office for Civil Rights (HHS) and Maine Medical Center (2001) • Revised NC Voluntary Compliance Agreement (2004)• Resolution Agreement between the New York Attorney General and Faxton St. Luke's Health Care (2004) • Resolution Agreement between the New York Attorney General and St. Elizabeth Medical Center (2004) • St. Vincents' Agreement with Attorney General re Language Assistance (2006)• Reyes v. Thompson Agreement of Settlement and Consent Order (1991) • Supreme Court Opinion in Sandoval Case (April 2001) • Supreme Court Dissent in Sandoval Case (April 2001)

http://www.healthlaw.org/library/topics.1333Cultural_and_Linguistic_Access_to_Health_Care

The Economics of Language ServicesMediated Settlement Agreements and Language Access

Today, details of dramatic legal settlements from the lack of medical interpreting make health industry rounds, but untold numbers of

lawsuits based on such interpreting errors settle out of court, away from public scrutiny. Most malpractice insurance

companies report that they don't track claims based on linguistic errors and prefer to offer seminars on language access to insured

health care providers rather than pressure them to offer medical interpreting (Abramson 2006).

Abramson, H (2006). Next great immigration hurdle—The right to a medical interpreter. New American Media investigative report

The Economics of Language ServicesModel for Justification of Language Services

A Case for Linguistic Competence

Corporate value Compliance concerns

Enhances provider ability to diagnose Medicaid Contract

Decreases medication errorsHealthy Families (SCHIP) Contract Requirement

Increases patient compliance & follow up Title VI Requirement

Decreases “no-show” appointments DHHS OMH CLAS Standards

May avoid costlier services later DHHS OCR Guidelines

Promotes quality care Federal Executive Guidelines

Improved patient satisfaction/member retention Tort Liability

Enhanced community perception in target markets State laws

Kelvin Quan offers a model that lists a number of compliance and liability concerns

Quan, K (2002). Financial models of language access. A PowerPoint presentation for the California Endowment Medical Leadership Council on

Language Access.

The Economics of Language ServicesThe Hidden Costs of Not Communicating With Over

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SUMMARY

The Economics of Language ServicesLanguage Services reduce costs and increase efficiency

1. Not ensuring proper language access costs more than not providing.

2. The provision of proper language services increases efficiencies resulting in less burden on the system.

3. Not providing services increases costs and liability.

The Economics of Language ServicesContact Information

Doug Green Director of Outreach TAHIT 713.817.1260 dougegreen@gmail.com http://www.tahit.us Facebook: TAHIT Twitter: @ninjadoug