Special E-Mail Bulletin
October 2003
Paying for Interpreters?

Special E-Mail Bulletin

Hi, everyone.

Here's an interesting story about possible changes and clarifications in the regulations regarding when health care providers must provide (and cover the cost of) translators for their non-English proficient patients. This appeared in the October 13 issue of AM News.

Gil Weber

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GOVERNMENT & MEDICINE

HHS eases interpreter mandate but doctors must pay the bills New guidance on serving patients with limited English skills grants physicians more flexibility.

By Markian Hawryluk, AMNews staff. Oct. 13, 2003.

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Washington -- When it comes to the burden of providing medical interpreters, the Bush administration is beginning to speak physicians' language.

In a revision of its previously published guidance, the Dept. of Health and Human Services described requirements for accommodating patients with limited English language skills. The document provides greater flexibility for physician practices than ever before. But doctors remain worried about how they will pay for interpreter services.

Under the guidance, physicians would be required to create a plan for serving non-English speakers after considering four factors -- the number of patients with language difficulties, the frequency of their visits, the importance of the service provided and the available resources.

"We must ensure that federally assisted programs aimed at the American public do not leave some behind simply because they face challenges communicating in English," HHS said in the guidance.

The requirements apply to any individual or group that receives federal assistance. HHS clarified that Medicare Part B payments do not trigger language service obligations. But physicians who receive federal dollars, such as Medicaid or State Children's Health Insurance Program reimbursement, are required to comply with the guidance for all of their patients with limited English proficiency, including Medicare beneficiaries.

For the first time, however, the guidance says that while who the requirements apply to is a black-and-white issue, the reasonable steps a physician, practice or institution may be required to take are somewhat gray.

"Smaller recipients with more limited budgets are not expected to provide the same level of language services as larger recipients with larger budgets," HHS stated. "Reasonable steps may cease to be reasonable where the costs imposed substantially exceed the benefits."

More would be required of practices or facilities that score higher on the four factors. For example, a hospital emergency department in a city with a significant Hmong population may need immediately available oral interpreters and may want to hire bilingual staff, HHS said.

On the other hand, a physician's practice that encounters one Hmong patient per month on a walk-in basis could use a telephone interpreter. A dentist in a predominantly English-speaking community who has rarely encountered a patient who didn't speak English may not need to provide language services for a Hmong individual who comes in for a cleaning, the agency said.

Cost still a problem

Physician groups, including the American Medical Association, welcomed the softer stance but remained concerned about the bottom-line costs the guidance imposes.

"When physicians are required to fund written and oral interpretation services for limited English proficiency patients in their practices, as remains the case under the new guidance, this can impose severe economic losses that are difficult to sustain, especially when the cost of providing the services far exceeds the payment for treating the patient," said AMA Trustee Edward L. Langston, MD.

HHS plans to provide additional education for physicians and health practitioners on how best to provide interpreter services. The guidance cited a number of options, including using telephoneor video interpreting, training bilingual staff, pooling community resources, and referring patients to physicians with specific language capabilities.

The guidance also indicated that family members may be used in certain cases, although no patient could be forced to use a family member as an interpreter.

The Medical Group Management Assn. said the latest guidance addressed most of its concerns about language service rules, other than the financing issue. A widespread concern is that unless funds can be found to pay for interpreter services, the requirements may become one more administrative hassle that drives physicians away from Medicaid.

"Just accepting one Medicaid patient requires you to offer limited English proficiency services to all patients who have a deficiency in the English language," said Jennifer Miller, government affairs representative for MGMA. "It comes down to a financial burden, especially for large practices, which seem under this guidance not to have that much flexibility."

Miller said HHS needs to direct education toward physician and patient communities so that both understand what is required of them. "Providers aren't sure where limited English proficiency and defensive medicine begin and end," Miller said. "They would rather be safer than sorry."

But medical interpreters viewed the guidance as a step backward.

"We consider that it is weaker," said Cynthia Roat, co-chair of the National Council for Interpreting in Health Care. "It will make it easier for providers who are not aware of what they're risking in not providing the language access." She said providing the services would keep doctors' costs down in the long run and guarantee the quality care that patients deserve.

Roat said the interpreter group was disappointed that HHS was required to pattern its new guidance after the Dept. of Justice model for the entire federal government. While broad, flexible standards may be appropriate for other sectors, health care quality depends on accurate communications, she said.

"There are many providers and institutions that understand this is not just a legal requirement, this is an issue of providing good care. And for those people, this won't matter one way or another," Roat said. "For those people for whom the previous guidance was a little bit of a motivation, we're afraid that the new guidance will be a lesser motivation."

But medical interpreters and doctor groups agree that federal funding would help ensure access to interpreter services. The AMA has called for creating a new provider category under Medicare with adequate funding so interpreters could bill Medicare separately for their services.

ADDITIONAL INFORMATION:

Talk isn't cheap

The Bush administration last year estimated that the bulk of costs for medical interpreter services falls on physicians.

Source: Office of Management and Budget

Things to think about

Doctors who treat Medicaid or SCHIP patients should consider four factors in determining how best to accommodate those with limited English proficiency.

• Number or proportion of patients with limited English proficiency
• Frequency of encountering individuals with limited English proficiency
• Importance of the service provided
• Resources available

Source: U.S. Dept. of Health and Human Services

Weblink

U.S. Dept. of Health and Human Services guidance for accommodating people with limited English proficiency: http://www.hhs.gov/ocr/lep/revisedlep.html

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