Sep 27 2013
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Professional Interpreters are Costly, But Crucial

Lisa Ross DeCamp, MD, MSPH, is an alumna of the Robert Wood Johnson Foundation Clinical Scholars program. She is an assistant professor of pediatrics at Johns Hopkins University School of Medicine and a researcher with the Center for Child and Community Health Research.

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Good communication is critical for development of an effective partnership between patient and provider.  However, for the more than 25 million people in the United States who report speaking English less than very well and are classified as having limited English proficiency (LEP), access to the most basic aspect of communication—a common language with the provider—may be limited.

It is easy to imagine how language barriers may compromise the quality and safety of health care. Research consistently demonstrates that physicians falter in many aspects of communication, compromising health care quality and lowering patient satisfaction even when they speak the same language.  Quality and satisfaction gaps stemming from poor communication are only magnified when a language barrier is present. Health care safety requires understanding instructions, again an impossible task if the patient and provider do not share a common language. 

When a language barrier is present between patient and provider, the provider has several options for overcoming this barrier. The provider may choose to use a family member who speaks English or a staff member with other responsibilities who speaks the patient’s language to provide interpretation during the visit. These so-called ad hoc interpreters are not recommended as they have been shown to commit errors in translation or censor information because of discomfort or unfamiliarity with the topic.  Ideally, a patient would be able to find a provider that speaks their language.

The next best option is to use a professionally trained interpreter, either by phone or in-person. Given the fundamental importance of overcoming language barriers to high quality and safe health care, we completed a studying examining how pediatricians communicated with LEP patients in their practice. A similar study was completed in 2004 and found that pediatricians faced challenges using appropriate language services to overcome language barriers. Since that time there has been an increase in education about the importance of using either a bilingual provider or interpreter to manage language barriers between patient and provider and an increased focus on improving the quality and safety of health care. We wanted to know if this culture shift during the interval between studies resulted in an increase in use of appropriate language services.

We found, however, that there was little improvement in the use of language services. More than 80 percent of pediatricians who responded to this American Academy of Pediatrics (AAP) survey (administered only to AAP members) reported they had LEP patients. The majority reported using family members to communicate with some of their LEP patients, though there was a small decrease from the prior study. There was modest improvement in professional interpreter use, but still our findings suggest many LEP parents do not have the opportunity to communicate well with their child’s pediatrician.

When we examined factors associated with interpreter use, we found that pediatricians in states that provided reimbursement for use of language services through the state Medicaid program were twice as likely to report use of professional interpreters than pediatricians in states that did not provide this reimbursement.  This is not surprising. Providing interpretation can be costly. For many pediatric practices, providing a professional interpreter eats away at their bottom line in already tight fiscal times. Pediatricians who work in hospital-based practices or practices affiliated with an academic medical center may be able to offset interpretation costs through federal payments for hospitals that bear a disproportionate share of care for the underserved. However, this payment structure likely will change under full implementation of the Affordable Care Act.

The clear relationship between providing reimbursement for a costly service and use of interpreters we found in our study underscores the need to pay attention in these changing health care times, so as to not exacerbate already concerning disparities for LEP patients and families.

Tags: Clinical Scholars, Patient-Centered Care, Research & Analysis