Legal and Financial Parameters& Promising Practices

for Language Access in Healthcare Settings

Mara YoudelmanNational Health Law ProgramYoudelman@healthlaw.org

April 25, 2007

National Health Law Program

• NHeLP is a national, non-profit law firm working on health care access and quality

• With the generous support of The California Endowment, NHeLP began the National Language Access Advocacy Project in 2003

• With the generous support of The Commonwealth Fund, NHeLP has issued three “promising practices” reports on language services in healthcare settings

Federal Civil Rights Law

• Title VI has been in existence since 1964 “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.” 42 U.S.C. § 2000d

• “National origin” includes individuals with limited English proficiency (LEP)

What Has Recently Focused Attention on Linguistic Access?

• August 11, 2000 – Executive Order 13166

• August 31, 2000 – Letter from Department of Health & Human Services re: funds available

• August 2003 – HHS Office for Civil Rights guidance on language access

• Recent federal legislation – Patient Navigator Outreach and Chronic Disease Prevention Act of

2005 Ryan White HIV/AIDS Treatment Modernization Act Homeland Security Appropriations Bill – FEMA

The States – a Better Stage

• 43 states have language access laws comprehensive targeted (e.g. emergency room, hospital)

• More and more states are enacting laws/policies to expand language access

• Not necessarily needed b/c of Title VI’s scope but appropriate given limitations of enforcement

• The carrot rather than the stick – little appetite for enforcement by individuals but other deterrents

Statewide Medicaid/SCHIP Programs

• Only a handful of states have set up programs to provide direct reimbursement using federal matching funds to pay for language services

DC, HI, ID, KS, ME, MN, MT, NH, UT, VA, VT, WA, WY

TX to start pilot program NC initiating credentialing prior to reimbursement CA – Medi-Cal Language Access Taskforce MA – previously had reimbursement for hospitals

Medicaid Reimbursement for Language Services

• Four models – contract with language service agencies

(DC, HI, UT, VA, WA) reimburse providers for hiring interpreters

(ID, ME, MN, VT) reimburse interpreters (MT, NH, WY) provide access to language line (KS)

Current State Reimbursements (2007)State Enrollees

CoveredProviders Covered

Who the State Pays Reimbursement Rate Admin or Service

DC FFS FFS < 15 emp. Lang. agency $135-$190/hour (in-person)$1.60/min (telephonic)

Admin

HI FFS FFS Lang. agencies $36/hr Service

ID FFS FFS Providers $12.16/hr Service

KS Managed Care

Managed Care EDS (fiscal agent) Spanish – $1.10/min.

other languages – $2.04/min.

Admin

ME FFS FFS Providers Reasonable costs Service

MN FFS FFS Providers lesser of $12.50/15 min or usual and customary fee

Admin

MT All All Interpreters $6.25/15 minutes Admin

NH FFS FFS Interpreters $15/hr; $2.25/15 min after 1st hour Admin

UT FFS FFS Lang. agencies $28-35/hour (in-person)$1.10/minute (telephonic)

Service

VA FFS FFS AHEC & 3 health depts. Reasonable costs Admin

VT All All Language agency $15/15 min Admin

WA FFS Public entities Public entities 50% expenses Admin

WA FFS FFS Brokers Brokers receive an admin. fee

Language agencies – $33/hour

Admin

WY FFS FFS Interpreters $45/hour Admin

CME requirements

• NJ – each medical school must educate students on cultural competency; CME must include cultural competency for physician relicensure

• CA – requires all clinically oriented CME for physicians and surgeons to include cultural and linguistic competency

• WA – each health professions training program must integrate issues of multicultural health into its curriculum; authority for continuing ed

Other State Activities

• NHeLP 50-state survey

• CA – private insurers, C&L data collection

• RI & MA – hospital requirements

• Information from “Promising Practices” reports

Measuring Nature/Frequency of Contacts

• Important to identify individuals being served and eligible to be served

• Determining language needs at first points of contact –notations in schedule/patient records; language notification flyers; “I Speak” cards/posters

• Recording language needs L.A. Care Health Plan – color-coded stickers designate language

needs Women’s Health and Education Center – notes language needs in

schedule and computer data system

Identifying Language Needs

• WA Department of Social and Health Services – requires noting the client’s primary language in its computer system

• KY Cabinet for Health and Family Services collects language information and specifics on each encounter using language services

Arizona• Department of Economic

Security – database does not proceed past certain fields without noting the client’s language needsclients are asked their

primary language at initial and renewal interviews

includes 68 language choices plus an open-ended option

Los Angeles County• Department of Public Social

Services collects language information at initial eligibility and renewals

• County compiles a report to show the number of LEP individuals in the Medicaid caseload, by language spoken, served by each eligibility office during the month

Washington D.C.• Medical Assistance

Administration worked with community advocates to develop its “I Speak” poster and cards and a “Know Your Rights” pamphlet

Identifying Available Resources

• Need to identify both internal and external resources

• NHeLP’s Language Services Resource Guide for Healthcare Providers helps identify external resources including interpreter/translator associations and providers; training programs; translated materials; symbols; etc.

Training

• Neponset Health Center (MA) – employs native Vietnamese speakers trained as medical interpreters through the MMIA or Mass. DPH

• L.A. Care Health Plan – offers medical interpreter training for bilingual staff of

participating clinics and medical groups training for health care providers (for continuing

medical education credit) on how to work with interpreters

Testing and Certification

• No federal standards for interpreter certification

• NCIHC has National Code of Ethics and Standards of Practice

• WA – has had state-based certification since early 1990’s

• State laws – state-wide (OR)

• Other states starting the discussion – IN, MA, CA

Testing and Certification

• WA has the only statewide interpreter assessment program – candidates who want to work as DSHS interpreters (staff and contract) must pass the state certification test

• KY Cabinet for Health and Family Services worked with a consortium of local colleges and universities to develop an assessment program only those who pass are “deemed qualified” to provide

services in languages other than English or act as interpreters

Testing and Certification

• NE Health and Human Services System plans to develop an assessment test for new hires – only those who pass will be allowed to use their non-English language skills on the job; also plans to develop an assessment test for outside interpreters

• NC Department of Health and Human Services is working with other agencies to develop system-wide standards and payment rates for interpreters and establishing credentialing as pre-cursor to Medicaid reimbursement

Assessing Competency

• St. Joseph Health System Community Health Programs (CA) – requires assessment of staff providing services in non-English language or as interpreter

• North DeKalb Health Center (GA) – requires all bilingual staff to attend training sessions and pass test

Bilingual Staff• KY Cabinet for Health and Family Services –

designated Language Access Section with four trained interpreters

• LA Cty. DPSS – human resources division certifies language skills of bilingual staff

• WA DSHS – bilingual employees can provide interpretation only if certified as interpreters and documented in the employee’s classification questionnaire

Bilingual Staff – Compensation

• AZ Department of Economic Security offers a stipend of $1,000 a year

• NC Department of Health and Human Services – pays bilingual employees at a higher grade level

• LA Cty. Department of Public Social Services gives $100 monthly to certified bilingual workers

• KY Cabinet for Health and Family Services plans to pay qualified bilingual employees at a higher pay level

Contract interpreters

• KY Cabinet for Health and Family Service – qualifies community partners (both individual interpreters and language agencies) to interpret for the agency

• WA DSHS – comprehensive process to certify contract employees and only those who pass certification (in the state’s seven most common languages) or assessment (for other languages) may provide services to the agency

Community Resources

• ID Department of Health and Welfare contracts with local community organizations

• NC Division of Public Health is working with the United Hmong Association to translate its fact sheets

• IL Department of Human Services funds the IL Coalition on Immigrant and Refugee Rights

Community Resources

• PPPBTC – La Promesa and Los Promotoras program

• St. Joseph Health System – promotoras and promotoritas

• Cooley-Dickinson Hospital – interpreters in affiliated providers’ offices

• L.A. Care Health Plan – training for bilingual staff and providers; medical glossaries

Translation of Written Materials

• NE – uses designated translators with a degree from translation program

• ID Department of Health and Welfare – works with the Idaho Migrant Council and the Hispanic Commission to review benefits forms for appropriate Spanish translation

Where do we go from here?

• Explore potential for new state and federal laws and policies, inc. expectations for non-hospital settings (private insurance, nursing homes, etc.), Medicaid reimbursement, funding for workforce/training, training/certification standards

• Link to quality of care to change the debate – healthcare is different

• The demographic changes won’t stop so change is likely inevitable