The initial presentation of the Economics of Language Access. For an updated version with new research please do not hesitate to contact Douglas Green through the website. Thank you.

1. The Economics of Language Services Or how to save Healthcare in Texas Texas Association of Healthcare Interpreters and Translators 3rd Annual Symposium on Language Access and Healthcare April 17 th -18 th , 2009 Austin, Texas

2. The Economics of Language Services Texas Has Been Historically Diverse

3. The Economics of Language Services On average a 60-70% chance that a person you encounter on the street in a Metro area of Texas is of a different ethnic background. *Census data 2000 Ethnic Diversity in Texas Today

4. The Economics of Language Services Over 30% of Texas residents speak a language other than English in the home. *Census data 2000 Texan Demography

5. The Economics of Language Services Concentration in major urban areas, the Balcones Fault, and southern border area. *MLA Map 2009 Distribution of Languages other than English in Texas

6. Percent change Quantitative change The Economics of Language Services *MLA data comparison between 2000 and 2005 Texas Non-English Speaking Population Change 2000/2005 Between 2000 and 2005 there was a 14% increase in the population that speaks a language other than English in Texas.

7. The Economics of Language Services A cumulative change of 849,778 people which would make the difference equal to slightly less than the 11 th largest city in the US. Detroit 916,952 Jacksonville, 805,605 Over 30% of the population of Texas, 6.8 Million people , are forced into a Healthcare system that does not speak their language. This is a population that is slightly less than the size of New York at 8M and 3x’s the official size of Houston . Huge Increase of Individuals Who Speak a Language Other Than English in Texas 2000/05

8. The Economics of Language Services Cost is a Perceived Barrier to Language Access

9. The Economics of Language Services *Robert Woods Johnson Foundation, Hablamos Juntos, 2001 Cost is a Perceived Barrier to Language Access

10. The Economics of Language Services $25 BILLION

11. The Economics of Language Services Auto Bailout Auto Bailout September 2008

12. The Economics of Language Services $73 BILLION

13. The Economics of Language Services The Economic Cost of Poor Communication in Healthcare $73 BILLION is spent annually in unnecessary health care expenses due to the inability of patients to understand what medical providers are communicating to them *The Institute for Healthcare Advancement, July 29 th , 2003 Size of Other Industries The amount of waste due to poor communication in healthcare.

14. The Economics of Language Services Cost Per Person of Poor Communication in Healthcare $ 1,254.81 Per Person $ 73,000,000,000.00 Waste due to poor communication in Healthcare 58,176,095 US Population that speaks a language other than English in the home $ 238.41 Per Person $ 73,000,000,000.00 Waste due to poor communication in Healthcare 306,189,974 US Population

16. The Economics of Language Services The Hidden Costs: Lack of Primary and Preventive Care *Margaret O’Kane, NCQA Seattle, Washington October 18 th , 2006

18. The Economics of Language Services *Robert Woods Johnson Foundation, Hablamos Juntos, 2001 Language is a Barrier to Primary and Preventive Care

19. The Economics of Language Services LEPs Less Likely to Use Primary and Preventive Care Persons who have Limited English Proficiency are less likely to have a regular source of primary care and are less likely to receive preventive care . Elizabeth Jacobs, MD, MPP, Donald S. Shephard, Phd, MPP, Jose A. Suaya, MD, MBA, and Esta-Lee Stone, MS, OTR/L. Overcoming Language Barriers in Healthcare: Costs and Benefits of Interpreter Services LEP Non-LEP

20. “ LEP Patients with professional medical interpreters were 94% more likely to use primary care and 78% less likely to use ED than English proficient patients , resulting in lower cost and more access to preventive care..” Graham, EA., Jacobs, TA., Kwan-Gett, TS., Cover, J. (2008). Health Services Utilization by low-income limited English proficient adults. Journal of Immigrant Health, 10(3):207-17 The Economics of Language Services Interpreters Increase Primary and Preventive Care “ Use of trained interpreters was associated with reduced ED return rate, increased clinic utilization and lower 30-day charges without any increase in length of stay or cost of visit.” Bernstein, J., Bernstein, E., Dave, A., Hardt,E., James, T., Linden, J., Mitchell P., Oishi, T., Safi C. (2002) Trained medical interpreters in the emergency department: Effects on services, subsequent, charges, and follow-up Primary care ED 30-day charges

21. The Economics of Language Services The Effect of Preventive and Primary Care “ Economic Argument for Increasing Preventive and Primary Care”, Charles Begley, February 12 th , 2009 MALLF Conference on Health Disparities The disparity in preventive care for Latinos compared to whites is eliminated for those with a regular source of primary care/medical home. The disparity in preventive care for Latinos compared to whites is eliminated for those with a regular source of primary care/medical home.

23. The Economics of Language Services Dual Role Staff Interpreters Lack Fluency The Failure Rate of Dual Role Staff Interpreters Moreno, M.R., Otero-Sabogal, R., Newman, J. (2007) Assessing Dual Role Staff-Interpreter Linguistic Competency in an Integrated Healthcare System. Journal of Internal Medicine22 (Suppl2): 331-335 20-40% of dual role interpreters fail competency skills assessments.

24. The Economics of Language Services Errors by Untrained Staff “ Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters” by Dr. Glen Flores, Pediatrics An average of 31 errors per encounter noted. Potential Clinical Consequence Non Clinical Consequence

25. The Economics of Language Services Types of Errors by Untrained Staff “ Errors in Medical Interpretation and Their Potential Clinical Consequences in Pediatric Encounters” by Dr. Glen Flores, Pediatrics

26. The Economics of Language Services Economic Impact of Errors “ Comments to MA Health Care Committee”, April 9th, 1999 Carla Fogaren, Director of Interpreter Services at Good Samaritan Medical Center in Brockton, Mass. 70 year old Portuguese speaking man. EMT’s suspect he might be suffering from a stroke or heart attack. Interpreter was able to determine that it was only a head cold and congestion. $1,278.02 Total Savings $ 1.00 Interpreter Cost $1,279.02 Costs for Tests $ 20.00 IV Fluids $ 54.00 Electrocardiogram (EKG) $ 21.00 Cardiac Profile $ 24.00 Oxygen $ 275.00 Portable Chest X-Ray $ 100.00 Troptonin I Level $ 164.78 Chemistry 7 $ 28.24 Complete Blood Count $ 592.00 Head Catscan

27. The Economics of Language Services The Hidden Costs: Associated Waste “ If one thinks of an interpreter-assisted history as a diagnostic test, there are virtually no significant tests in medicine that are cheaper. Costs, in general compare to the costs of the cheapest blood test that physicians order ($28 for complete blood count).” “ Comments to MA Health Care Committee”, April 9th, 1999 Eric Hardt, M.D., Clinical Director of Geriatrics and Medical Consultant to Interpreter Services at Boston Medical Center U.S. Office of Management and Budget estimated that it would cost, on average, only $4.04 (0.5 percent) more per physician visit to provide all U.S. LEP patients with appropriate language services for ED, inpatient, outpatient, and dental. Flores, G. (2006). Language barriers to health care in the United States. New England Journal of Medicine, 355(2):229-231.

29. The Economics of Language Services How Much is a Word Worth? Intoxicado

30. The Economics of Language Services How Much is a Word Worth? “ Misinterpretation of a single Spanish word (Intoxicado misinterpreted in this case to mean “intoxicated” instead of its intended meaning ‘of feeling sick to the stomach’) led to a $71 million dollar malpractice settlement associated with a potentially preventable case of quadriplegia.” Harsham P. A Misinterpreted word worth $71 million. Med Econ. June 1984; 61:289-292.

31. The Economics of Language Services Other Examples of Risk A resident’s misinterpretation of two Spanish words ( se pego misinterpreted as ‘a girl was hit by someone else’ instead of ‘the girl hit herself’ when she fell off the tricycle) resulted in a 2-year-old girl with a clavicular fracture and her sibling mistakenly being placed in child protective custody for suspected abuse for 48 hours. Flores G, Abreu M, Schwartz I, Hill M. The importance of language and culture in pediatric care: case studies from the Latino community. J Pediatr. 2000;137 842-848

32. The Economics of Language Services Other Examples of Risk Lack of an interpreter for a 3-year-old girl presenting to the emergency department with abdominal pain resulted in several hours’ delay in diagnosing appendicitis, which later perforated, resulting in peritonitis, a 30-day hospitalization, and two wound site infections. Flores G, Abreu M, Schwartz I, Hill M. The importance of language and culture in pediatric care: case studies from the Latino community. J Pediatr. 2000;137 842-848

34. The Economics of Language Services Mediated Settlement Agreements and Language Access Today, details of dramatic legal settlements from the lack of medical interpreting make health industry rounds, but untold numbers of lawsuits based on such interpreting errors settle out of court , away from public scrutiny. Most malpractice insurance companies report that they don't track claims based on linguistic errors and prefer to offer seminars on language access to insured health care providers rather than pressure them to offer medical interpreting (Abramson 2006). Abramson, H (2006). Next great immigration hurdle—The right to a medical interpreter. New American Media investigative report

35. The Economics of Language Services Model for Justification of Language Services Kelvin Quan offers a model that lists a number of compliance and liability concerns Quan, K (2002). Financial models of language access. A PowerPoint presentation for the California Endowment Medical Leadership Council on Language Access. State laws Enhanced community perception in target markets Tort Liability Improved patient satisfaction/member retention Federal Executive Guidelines Promotes quality care DHHS OCR Guidelines May avoid costlier services later DHHS OMH CLAS Standards Decreases “no-show” appointments Title VI Requirement Increases patient compliance & follow up Healthy Families (SCHIP) Contract Requirement Decreases medication errors Medicaid Contract Enhances provider ability to diagnose Compliance concerns Corporate value A Case for Linguistic Competence

38. The Economics of Language Services Contact Information Doug Green Director of Outreach TAHIT 713.817.1260 [email_address] http://www.tahit.us Facebook: TAHIT Twitter: @ninjadoug