1. 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

2. 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 services 2,3 A commonly cited reason is cost 4,5 1 2000 US Census; 2 Wirthlin Worldwide 2001, 3 Vandervort and Melkus 2003; 4 Graham 2001; Radcliffe 2001; 5 Gadon, Balch, and Jacobs

3. 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

4. The Cost of Language Barriers Potential Costs: –Opportunity costs –Increased resource utilization –Societal costs –Malpractice risk

5. Opportunity Costs Documented interpreter use in psychiatric hospital in South Africa 6 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

6. 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

7. 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

8. 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."

9. The Cost of Language Services Potential Costs: –Provision of language access services –Increased health care utilization

10. Provision of Language Services Office of Management and Budget: – Estimated the cost of language access services represents 1.5-2% of all health care costs 4 Cost of providing interpreter interventions: – Outpatient costs-$279 per person per year 9 – Inpatient costs-$234 per person/ 6 months 10 – Average HCIN encounter $20.19 - $25.29 4 Graham J, 2001; 9 Jacobs et al. 2004; 10 Jacobs, Sadowski, Rathouz, 2007

11. 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 intervention 9 11 Jacobs et al. 2001; 9 Jacobs et al. 2004

12. 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 encounters 13,14 12 Kravitz, et al. 2000; 13 Fagan et al. 2003; 14 Tocher and Larson, 1999

13. Cost-benefits of Providing Language Services Does provision of services reduce costs? Does provision of services reduce malpractice risk?

14. Language Services Reduce ED Visit Costs Use of trained interpreters in an adult ED did not change visit costs 15 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 present 16 15 Bernstein J et al. 2002; 16 Hampers & McNulty. 2002

15. 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 inpatients 10 10 Jacobs, Sadowski, Rathouz, 2007

16. 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 Spanish- speaking patient over the study period. 10 10 Jacobs, Sadowski, Rathouz, 2007

17. 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?

18. What about Other Benefits? What benefits are important? Those to Patients Providers Society All of the above? Are costs all that matter?

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

20. ejacobs@rush.edu

21. References 1.2000 US Census 2.Wirthlin Worldwide. New Survey Shows Language Barriers Causing Many Spanish-speaking Latinos to Skip Care. 2001. Robert Wood Johnson Foundation. 3.Vandervort EB, Melkus GD. Linguistic Services in Ambulatory Clinics. Journal of Transcultural Nursing. 2003;14(4): 358-366. 4.Graham, J. Assessment of Cost and Benefits Associated with the Implementation of Executive Order 13166. Federal Register. 2001;66(231); 59824-25. 5.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. 6.Drennan G. Counting the Costs of Language Services in Psychiatry. South African Medical Journal. 1996; 86(4): 343-45. 7.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. 8.Harsham P. A Misinterpreted Word Worth $71 Million. Medical Economics. 1984;61(5):289-292. 9.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. 10.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

22. References (cont) 11.Jacobs EA, Lauderdale DS, Meltzer DO, Shorey JM, Levinson W, Thisted R. Impact of Interpreter Services on Delivery of Health Care to Limited-English- Proficient Patients. Journal of General Internal Medicine. 2001;16: 468-474. 12.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. 13.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 14.Tocher TM, Larson EB. Do Physicians Spend More Time with Non-English- Speaking Patients? Journal of General Internal Medicine.1999;18: 634-38. 15.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. 16.Hampers LC, McNulty JE. Professional Interpreters and Bilingual Physicians in a Pediatric Emergency Department. Archives of Pediatric Adolescent Medicine. 2002;156:1108-13.