Transcript Measuring the Cost of Language Barriers in

The Cost and Effectiveness of
Meeting Patients’ Language Needs
Elizabeth A. Jacobs, MD MPP
Associate Professor of Medicine
John H. Stroger, Jr. Hospital of Cook County &
Rush University Medical Center
Welsh Language in Health Care Conference
Cardiff, Wales
March 27, 2010
Language Barriers to Access to
Health Care
• 21 million US residents speak English less
than “very well”1
• Many health care organizations do not
provide adequate linguistic access services2,3
• A commonly cited reason is cost4,5
1 2000
US Census; 2 Wirthlin Worldwide 2001, 3Vandervort and Melkus
2003; 4 Graham 2001; Radcliffe 2001; 5Gadon, Balch, and Jacobs
What do We Know About Costs?
• The cost of language barriers
• The cost of language access services
• The cost-benefits of providing language
access services
The Cost of Language Barriers
• Potential Costs:
– Opportunity costs
– Increased resource utilization
– Societal costs
– Malpractice risk
Opportunity Costs
• Documented interpreter use in psychiatric
hospital in South Africa6
• 67% nursing staff
• 10% janitors
• The authors calculated the cost of lost
staff productivity and found the cost to be
twice that needed to employ interpreters
6 Drennan,
1996
Increased Resource Utilization
• Language barriers between physicians
and parents accounted for increased
diagnostic testing and length of stay in a
pediatric emergency department (ED)7
• Encounters in which a language barrier
was present had significantly higher test
costs: $145 vs. $104
7 Hampers,
et al, 1999
Societal Costs
• Language barriers have been linked to
numerous disparities in health and health
care
• These disparities are linked to increased
morbidity, mortality, and loss of productivity
Malpractice
• Misinterpretation of a single Spanish word
led to a $71 million dollar malpractice
settlement associated with a potentially
preventable case of quadriplegia.8
• Intoxicado was misunderstood in this case
to mean "intoxicated" instead of its
intended meaning of "feeling sick to the
stomach."
The Cost of Language Services
• Potential Costs:
– Provision of language access services
– Increased health care utilization
Provision of Language Services
• Office of Management and Budget:
– Estimated the cost of language access
services represents 1.5-2% of all health care
costs4
• Cost of providing interpreter interventions:
– Outpatient costs-$279 per person per year9
– Inpatient costs-$234 per person/ 6 months10
– Average HCIN encounter $20.19 - $25.29
4 Graham
J, 2001; 9Jacobs et al. 2004; 10Jacobs, Sadowski, Rathouz, 2007
Increased Health Care Utilization
• Provision of adequate interpreter services
increased use of 11:
– Office visits
– Prescription refills
– Preventive care
• Cost estimated to be $45 per person
receiving the intervention9
11Jacobs
et al. 2001; 9Jacobs et al. 2004
Increased Visit Time
• Use of interpreters has been shown to
increase primary care encounter time for
resident physicians, increasing visit costs
by 15-25%12
• Other studies have found no increase in
mean visit encounter time, and therefore
costs, in interpreted encounters13,14
12
Kravitz, et al. 2000; 13Fagan et al. 2003; 14Tocher and Larson, 1999
Cost-benefits of Providing
Language Services
• Does provision of services reduce costs?
• Does provision of services reduce
malpractice risk?
Language Services Reduce ED
Visit Costs
• Use of trained interpreters in an adult ED
did not change visit costs15 and:
•
•
•
•
increased intensity of services
reduced ED return rate
increased clinic utilization
Lowered 30-day charges
• Use of trained interpreters in a pediatric ED
reduced costs incurred when a language
barrier is present16
15Bernstein
J et al. 2002; 16Hampers & McNulty. 2002
Language Services and Hospital
Costs-I
• An interpreter service intervention did not
significantly impact:
•
•
•
•
•
•
Hospital length of stay
Consultations
Diagnostic radiology tests
Adherence to outpatient follow-up
Post-discharge hospitalizations
Post-discharge ED visits
• And therefore costs for adult inpatients10
10Jacobs,
Sadowski, Rathouz, 2007
Language Services and Hospital
Costs-II
• Spanish-speaking patients who had an
attending physician fluent in Spanish
significantly reduced post-discharge ED
visits, reducing costs by $92 per Spanishspeaking patient over the study period.10
10Jacobs,
Sadowski, Rathouz, 2007
What do We Know About Costs?
• The cost of language barriers
•
•
•
•
Opportunity costs
Increased resource utilization
Societal costs
Malpractice risk
• The cost of language access services
• Provision of language access services
• Increased health care utilization
• The cost-benefits of providing language
access services
• Does provision of services reduce costs?
• Does provision of services reduce malpractice risk?
What about Other Benefits?
• What benefits are important? Those to
• Patients
• Providers
• Society
• All of the above?
• Are costs all that matter?
“I wanted to ask them about my
illness. I couldn’t because there was
no one to help me [communicate].”
[email protected]
References
1.
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3.
4.
5.
6.
7.
8.
9.
10.
2000 US Census
Wirthlin Worldwide. New Survey Shows Language Barriers Causing Many
Spanish-speaking Latinos to Skip Care. 2001. Robert Wood Johnson Foundation.
Vandervort EB, Melkus GD. Linguistic Services in Ambulatory Clinics. Journal of
Transcultural Nursing. 2003;14(4): 358-366.
Graham, J. Assessment of Cost and Benefits Associated with the Implementation
of Executive Order 13166. Federal Register. 2001;66(231); 59824-25.
Gadon M, Balch G, Jacobs E. Private Practice Perspectives on Caring for Rapidly
Growing Limited English Proficient Populations. In press, Journal of General
Internal Medicine.
Drennan G. Counting the Costs of Language Services in Psychiatry. South African
Medical Journal. 1996; 86(4): 343-45.
Hampers LC, Cha S, Gutglass DJ, Binns HJ, Krug SE. Language Barriers and
Resource Utilization in a Pediatric Emergency Department. Pediatrics.
1999;103(6):1253-56.
Harsham P. A Misinterpreted Word Worth $71 Million. Medical Economics.
1984;61(5):289-292.
Jacobs EA, Shepard DS, Suaya JA, Stone EL. Overcoming Language Barriers in
Health Care: Costs and Benefits of Interpreter Services. American Journal of
Public Health. 2004;94(5): 866-9.
Jacobs EA, Sadowski L, Rathouz PJ. The Impact of an Enhanced Interpreter
Service Intervention on Hospital Costs and Patient Satisfaction. Journal of General
Internal Medicine. 2007
References (cont)
11.
12.
13.
14.
15.
16.
Jacobs EA, Lauderdale DS, Meltzer DO, Shorey JM, Levinson W , Thisted R.
Impact of Interpreter Services on Delivery of Health Care to Limited-EnglishProficient Patients. Journal of General Internal Medicine. 2001;16: 468-474.
Kravitz RL, Helms LJ, Azari R, Antonius D, Melnikow J. Comparing the Use of
Physician Time and Health Care Resources among Patients Speaking English,
Spanish, and Russian. Medical Care. 2000;38(7): 728-738.
Fagan MJ, Diaz JA, Reinart SE, Sciamanna CN, Fagan DM. Impact of
Interpretation Method on Visit Length. Journal of General Internal Medicine.
2003;14: 303-309
Tocher TM, Larson EB. Do Physicians Spend More Time with Non-EnglishSpeaking Patients? Journal of General Internal Medicine.1999;18: 634-38.
Bernstein J, Bernstein E, Dave A, Hardt E, James T, Linden J, Mitchell P, Oishi T,
Safi C. Trained Medical Interpreters in the Emergency Department: Effects on
Services, Subsequent Charges, and Follow-up. Journal of Immigrant Health.
2002;4:171-76.
Hampers LC, McNulty JE. Professional Interpreters and Bilingual Physicians in a
Pediatric Emergency Department. Archives of Pediatric Adolescent Medicine.
2002;156:1108-13.