1. Costs and Impact on Care of the Health Care Interpreting Network Elizabeth A. Jacobs, MD MPP John H. Stroger, Jr. Hospital of Cook County Health Care Interpreting Conference March 19, 2010 This research was funded by a grant from The California HealthCare Foundation

2. Language is a Major Barrier 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 services 2 A commonly cited reason is cost 3 1 2000 US Census; 2 Wirthlin Worldwide 2001, Vandervort and Melkus 2003; 3 Graham 2001; Radcliffe 2001

3. We Really Know Little About Cost

4. The Little We Know Use of health care workers as interpreters costs institutions lost staff time 1 Language barriers account for increased costs in a pediatric emergency department 2 The cost of interpreter services is relatively low and they can reduce the cost of care 3,4 1 Drennan, 1996 and Rader, 1988; 2 Hampers 1999; 3 Jacobs et al. 2004 & 2007; Hampers 2002; Bernstein et al. 2002

5. Study Objectives I.To provide high quality data on the cost of providing HCIN services II.To evaluate the impact of HCIN on care delivery in the Emergency Department

6. What is HCIN? Network of shared interpreter resources in 11 California public hospitals All linked by Video- voice interpretation service using an internet protocol Increases interpreter access

7. How Did We Calculate Costs Simple division using data from 8 HCIN hospitals –Costs Personnel & Overhead Telephone interpreting service HCIN fees Technology –Utilization Number of encounters Number of minutes

8. Costs Per Minute Average Encounter Time Cost with Technology Cost without Technology Overall (n=52,475) 10.6 minutes $2.28$2.11 Spanish (n=49,275) 10.5 minutes $1.83$1.65 Other Languages (n=3,197) 12.4 minutes $8.27$8.09

9. Costs Per Encounter Average Encounter Time Cost with Technology Cost without Technology Overall (n=52,475) 10.6 minutes $24.86$22.91 Spanish (n=49,275) 10.5 minutes $19.90$17.95 Other Languages (n=3,197) 12.4 minutes $101.31$99.36

10. How Do These Costs Compare?

11. Costs Per Minute HCIN Overall$2.11 HCIN Spanish$1.65 Video*$1.00 - $3.45 Telephonic*$1.00 - $3.45 In-person* **$0.25 - $1.45 *Estimates based on a variety of national sources **May require 2 hour minimum

12. Costs Per Encounter HCIN Overall$22.91 HCIN Spanish$17.49 Video*$10.60 - $36.57 Telephonic*$10.60 - $36.57 In-person* **$2.75 - $15.37 *Estimates based on a variety of national sources **May require 2 hour minimum

13. Why These Comparisons May be Misleading Does not reflect efficiency of interpreter utilization Does not include the value of increased access to interpreter services Other costs are estimates

14. Did HCIN Impact Care? Natural Experiment in 2 Emergency Departments Patients: English or Spanish speaking Diagnosis of abdominal or chest pain Care Measures: Length of stay Test ordering Admission to the hospital

15. Hospital A Spanish-speaking PatientsEnglish-speaking Patients No HCIN (n=1,727) After HCIN (n=2,454) No HCIN (n=2,850) After HCIN (n=3,957) ED Length of Stay (hours) 12.311.610.09.8 Radiology Tests/ Person 2.92.23.12.5 Laboratory Tests/ person 38.129.142.231.5 EKGs /person 3.02.63.52.9 Percent Admitted 50%39%59%44%

16. Hospital B Spanish-speaking PatientsEnglish-speaking Patients No HCIN (n=734) After HCIN (n=681) No HCIN (n=2,767) After HCIN (n=2,781) Length of Stay (Hours) 11.39.610.08.9 Radiology Tests/ Person 0.70.6 Laboratory Tests/ person 2.92.8 2.9 EKGs /person 0.30.20.3 Percent Admitted 15%16%19%17%

17. Limitations Narrow view of impact Strong systemic forces influence ED utilization Natural experiment 2 Emergency Departments

18. Conclusions Implementation of HCIN had no statistically significant impact on the outcomes we measured The cost of HCIN services compare favorably to other modalities

19. Implications HCIN increases efficiency and access to less frequently encountered languages at comparable cost Linguistic access services should also be viewed through the lens of the patient and physician, not just their cost and impact on outcomes

20. “I wanted to ask them about my illness. I couldn’t because there was no one to help me [communicate].”

21. Gratitude Co-Investigators: Paul Fu, Jr. MD MPH & Paul Rathouz, PhD Research Assistant: Ginelle Sanchez Paras and Associates: Melinda Paras HCIN: Frank Puglisi, HCIN hospital managers, Barbara Hill The California HealthCare Foundation: Dave O’Neill

22. Ejacobs@rush.edu