We explore how health plans and health systems can help members and patients overcome health equity barriers and bridge the language gap.
Given the specialized lingo of healthcare, it’s not rare for a patient to feel as if the doctor is speaking a different language. Consider how it must feel to face that literal reality―to be, for example, a non-English speaker trying to navigate the American healthcare system.
All too often, this patient encounters not only barriers of access but also disparities in outcome and satisfaction.
A study published in Health Affairs in 2021 found that Spanish-speaking Americans received about one-third less care (based on spending) than patients whose primary language is English. The report suggests that language barriers may lead to significant inequities in healthcare delivery. Hispanic populations experience multiple health disparities and often have worse outcomes than English-speaking populations.
How can health plans and health systems help members and patients overcome health equity barriers and bridge the language gap? As with most significant challenges, there’s no simple answer. But solutions begin with awareness, and we aim to foster productive conversations while also providing practical suggestions and proven guidelines.
A Key Social Determinant
A recurring topic in this blog is social determinants of health (SDOH): conditions in the environments where people live, learn, work and play that can drive health outcomes. We tend to associate SDOH with factors such as education, job opportunities, safe housing, access to nutritious foods, transportation and social support systems. But, as a 2021 article in PatientEngagementHIT makes clear, English language proficiency is also a key determinant. “Patients for whom English is not their first language and who have limited English language proficiency may experience stunted patient-provider communication and unequal opportunity for strong patient engagement and education,” it says.
Limited English proficiency (LEP) also exacerbates other SDOH, a 2021 commentary in the AMA Journal of Ethics says, leading to access barriers, lower-quality care and worse outcomes.
In the United States, whose 60.5 million Hispanic residents make up 18.4% of the total population according to 2019 census estimates, this is cause for concern. More than 71% of U.S. Hispanics speak a language other than English at home, says the Office of Minority Health, part of the U.S. Department of Health and Human Services. Today, the Health Affairs study says, 1 in 7 U.S. residents speak Spanish at home, and 25 million have LEP.
According to that study, mean annual per capita spending during 2014–2018 was $1,463 (35%) lower for Hispanic adults with LEP than for Hispanic adults who were proficient in English. Those with LEP “also made fewer outpatient and emergency department visits, had fewer inpatient days, and received fewer prescription medications than Hispanic adults who were English proficient.” Such spending gaps grew wider between 1999 and 2018, prompting concerns that language barriers might be impeding access to care.
Miscommunication between providers and patients based on language barriers can have serious consequences, as detailed in a 2020 article published in the Oman Medical Journal. These include misdiagnosis and incorrect medications, along with patient difficulty understanding their situation, physician instructions or medication directions, all of which can potentially lead to harmful health events. Patients struggling with language barriers also are more likely to miss medical appointments or have difficulty arranging them.
Citing research from SCAN Health Plan, one of the nation’s largest not-for-profit Medicare Advantage plans, PatientEngagementHIT reported that members whose provider spoke the same language faced fewer obstacles to primary care access, such as challenges interacting with front office staff, medical personnel and organization representatives, in person and by phone. They were more likely to visit their primary care physician for preventive and follow-up care; have a stronger, more trusting relationship with their provider; and make fewer visits to the emergency department (ED). Conversely, members whose provider spoke a different language “were less likely to regularly access primary care but had higher specialty care and ED utilization patterns.”
Language barriers can erode patients’ trust and cause them to disengage from the medical institution, forgoing primary and preventive care and ultimately requiring more expensive care. A common patient-provider language, on the other hand, can build trust and engagement, encouraging patients to take a more active role in their own well-being and leading to better outcomes and significant cost savings.
A Legal and Moral Imperative
According to the Centers for Disease Control and Prevention (CDC), “health equity is achieved when every person has the opportunity to attain his or her full health potential and no one is disadvantaged from achieving this potential because of social position or socially determined circumstances.”
There are multiple barriers to achieving this, however, some of them highly visible among Spanish speakers. For example, The Commonwealth Fund says: “The very heterogeneity of the Hispanic population—they come from more than 20 countries, with widely differing experiences and social circumstances, including immigration status—makes it hard to pinpoint problems, including high rates of diabetes, liver disease, and certain cancers and poor birth outcomes among some Hispanic groups.”
Under federal and state regulations, healthcare organizations must provide trained interpreters for patients with LEP. When dealing with Medicaid populations, they also must ensure that patients are educated in their terms (including preferred language and education level) about privacy and information access issues and how to understand medical codes. But inadequate interpreter staffing, inaccurate interpretation and technological limitations have hindered communication, according to the AMA Journal of Ethics commentary, which stresses: “Health care organizations and clinicians have a moral imperative to reduce and ultimately eliminate the injustice experienced by patients with LEP in this country.”
Despite the clear need for reliable translation services—and laws requiring them—patients and providers have reported poor access to such services, the Oman Medical Journal article says.
In an article published in the April 2018 issue of Nursing Management, Allison Squires, Ph.D., RN, FAAN, offers “practice-based strategies to improve outcomes and reduce readmissions” when dealing with language barriers.
- Using the organization’s interpreter resources
- Getting staff members who are fluent in other languages certified for their skills and trained as medical interpreters
- Using care when other staff members provide interpretation
- Documenting the use of medical interpreter services
- Strategically timing the use of interpreters―use during admission, patient teaching and discharge decreases the risks of medical errors and hospital readmissions
- Prioritizing hiring staff members who speak your patients’ languages
SCAN has used Spanish-speaking care navigators and Spanish-language “teletalks” to increase flu vaccination rates among Spanish-speaking members. It employs bilingual pharmacists who regularly reach out to members who fail to adhere to their medication regimens. It also distributes printed materials in Spanish and Korean to emphasize the importance of adherence among speakers of those languages.
One downside of professional translation services is the cost; the Oman Medical Journal report estimates the cost of such services for Medicaid recipients at $4.7 million a year. The use of free online translation tools such as Google Translate and MediBabble can significantly increase provider and patient satisfaction, healthcare quality and patient safety at a much lower cost, it says.
For the long term, healthcare organizations should invest in diversifying their medical workforces, making it easier to connect patients with clinicians with a shared language and background, the PatientEngagementHIT article suggests.
More Than Words
Communication is about more than words, though. The Commonwealth Fund cautions that “focusing on language alone can fall short, especially if the translation doesn’t take into account cultural differences.” It relates the story of a rural California clinic serving a large population of women from El Salvador, only half of whom were showing up for postpartum visits three to eight weeks after delivery. Interviews revealed a traditional practice of self-quarantine after delivery; the women felt clinicians were not acknowledging their cultural practices.
Effective communication is built on trust and sensitivity, and the education that helps to forge those is a two-way street. That means physicians and other clinicians, as well as office staff, social workers and others involved in patients’ care need to “meet them where they are”—whether that means physically or figuratively.
“Not all communities seek healthcare at the same rate. Whether we’re talking about vaccinations, blood pressure monitoring or anything else, we have to take healthcare where the people are,” says Dr. Terri Steinberg, Medecision’s chief medical officer and chief strategy officer, in a May 2021 blog post. “Targeted outreach is a must. … If your goal is to provide health services for people whose first language is not English, go to the community centers that attract those populations.”
Tips for identifying and addressing health disparities among Hispanics, suggested by The Commonwealth Fund, include:
- Harness quality, claims and other data to identify disparities. Then have conversations with patients and clinicians to pinpoint root causes, which often lie in cultural differences.
- Combine interpretation, health education, case management and advocacy. Such cultural mediation can be a boon for patients and their families. Cultural mediators can attend doctor’s appointments with patients, visit them at home, and connect them with resources. They can also help patients understand their treatment options.
- Be sensitive to cultural differences. Religious beliefs and traditions, as well as factors such as immigration-related stressors, might be deterring someone from seeking care.
- Use community health workers. This can be particularly useful for campaigns targeting a particular disparity, such as cervical cancer.
- Integrate behavioral health into primary care. This can help overcome access issues as well as cultural stigmas attached to behavioral health problems.
- Take advantage of healthcare opportunities. During pregnancy, for example, women may be more open to making life changes.