Interpreter rule still costly: Doctors with non-English-speaking patients bear burden

Changes to federal rules for treating patients with limited English skills could help doctors, but the government fails to lift the financial burden.

Editorial. Nov. 10, 2003.

All doctors want to be able to communicate easily and effectively with their patients. That holds true for all patients, including those who have limited English language skills.

A recent revision of strict federal requirements on physicians' interactions with such patients could help doctors reach this goal while working within the practical realities of most medical offices. But the government's failure to remove physicians' responsibility for carrying the cost of this unfunded mandate means that good communication will continue to be a hardship.

The rules require physicians who accept even one patient in Medicaid or the State Children's Health Insurance Program to provide interpreter services to all patients who need help with English -- at the physician's expense.

That is not only unfair to physicians but a good way to discourage doctors from taking Medicaid and SCHIP patients.

The federal guidance, first issued by the Dept. of Health and Human Services Office of Civil Rights in 2000, lumped physician practices, even the smallest ones, in the same category as hospitals and other institutions that have much greater resources to provide interpreter services. Given that Medicaid rates often do not cover the cost of medical services, let alone an interpreter, physicians understandably regarded the rule as a burden.

Since the guidance was issued, the AMA and other physician groups have steadfastly argued for modifications. It seems as if the federal government got some of the message. In August, an update of the guidance was released in an effort to bring HHS standards in line with those of other government agencies. In some respects, it appears to give physicians some much needed flexibility.

Doctors are required to consider four factors when developing a plan for treating non-English speakers: the number of patients with language difficulties, the frequency of their visits, the importance of the service and the available resources. The government says small practices are not required to provide the same level of language services as bigger offices and institutions. The guidance goes on to add that steps to help limited-English speakers may cease to be reasonable when the cost substantially exceeds the benefit.

The gist of these changes is that physicians may now be better able to tailor their plans to their practices' needs. A small practice that rarely sees a non-English speaker will not be required to provide the same level of interpreter services, for example, as a hospital in an inner-city neighborhood where the majority of people speak Spanish.

Physicians welcomed this nod to the cost and resources involved in providing medical interpreters.

Other parts of the new guidance also could prove to be helpful. For example, the document appears to allow physicians to utilize patients' family members as interpreters in some cases, as long as doctors give patients the choice between a family member and a professional interpreter. The earlier version said family members were not viewed as competent interpreters, leaving doctors vulnerable to liability.

The guidance also says that, in certain circumstances, physicians may use telephone language lines or commercially available telephonic interpretation services, rather than having an interpreter on site.

While the changes could help, they don't eliminate the biggest burden on physicians -- the bottom-line cost of providing these services. The economic losses to physicians are difficult to sustain.

The AMA has called for the elimination of physicians' financial responsibility for interpreter services. It is also urging HHS to create a separate Medicare payment category, with ample funding, that would allow interpreters to separately bill the program for their services. This would defray physicians' costs for some patients.

Taking these steps would let physicians ensure this fundamental aspect of the office visit -- communication -- for their patients who have limited English skills, without doing so at a loss.

ADDITIONAL INFORMATION:

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Information on the rules for patients with limited English proficiency from the Dept. of Health and Human Services Office of Civil Rights (www.hhs.gov/ocr/lep)

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