CMS quality programs were designed with the intention of improving the quality and standard of healthcare available to the public. These programs work to encourage healthcare providers to improve their services through payment incentives, payment reductions, and by reporting information on healthcare quality on government websites.
MIPS (the Merit-Based Incentive Payment System) has the largest potential impact on hospitals’ bottom line, but there are many other CMS (Center for Medicare and Medicaid Services) programs that adjust payments to hospitals based on quality measures.
HRRP and the cost of readmissions
The Hospital Readmissions Reduction Program (HRRP) charges hospitals a penalty of up to 3% of the total amount they receive in Medicare and Medicaid payments when they have a high number of readmissions (42, 46).
LEP patients have higher rates of readmission to the emergency department, and “the increased risk of a return visit for LEP patients remained significant after controlling for age, emergency severity index, and time of day.” (34)
Language access services reduce this problem; “use of trained professional interpreters was associated with a decrease in utilization disparities; this was true for outpatient preventive services, intensity of ED services, ED return and referral rates, and admission rates from the ED” (6).
What about the HAC?
The Hospital Acquired Condition (HAC) Reduction Program reduces CMS payments to hospitals by 1% if they are in the worst-performing quartile in terms of patient safety index (PSI). PSI measures rates of pressure ulcers, falls and fractures, sepsis, and other conditions patients might acquire during a hospital stay (45).
LEP patients:
- Have a “greater risk of line infections, surgical infections, falls, and pressure ulcers” (35).
- Have an increased risk of drug/medication complications (6,8)
- Are more likely to experience a medical error resulting in physical harm (4).
- Experience more medication errors (30)
With language access services, LEP patients fare better:
- Patients with access to professional interpreters experienced “decreased communication errors of clinical consequence” (3).
- Working with “qualified, trained medical interpreters,” rather than untrained/ad hoc interpreters, can aid in “reducing medical errors and improving the quality of medical care” (8)
What about HVBP?
The Hospital Value-Based Purchasing (VBP) Program encourages hospitals to improve the quality, efficiency, patient experience and safety of care that Medicare beneficiaries receive during acute care inpatient stays. Hospitals are evaluated on several domains related to the care they provide.
Hospital Scoring Factors:
- Clinical care
- Person and community engagement
- Safety
- Efficiency and cost reduction
2% of each hospital’s CMS payment is deducted, and hospitals are awarded incentive payments depending on their performance on the above criteria (47).
LEP patients experience health disparities that affect all of these areas. According to the Office of Minority Health (OMH), the disparities between English-proficient and LEP patients exist “even after considering factors such as literacy, health status, health insurance, regular source of care, and economic indicators” (1). Language access services can reduce these disparities, helping hospitals avoid penalties.
Clinical Care:
- LEP patients “have been consistently shown to receive lower quality care than English-proficient patients on various measures: understanding of treatment plans and disease processes, satisfaction, and incidence of medical errors resulting in physical harm” (4).
- Patients with access to professional interpreters experienced “decreased communication errors of clinical consequence” (3).
- Working with “qualified, trained medical interpreters,” rather than untrained/ad hoc interpreters, can aid in “reducing medical errors and improving the quality of medical care” (8)
Person and Community Engagement:
- LEP patients “have been consistently shown to receive lower quality care than English-proficient patients on various measures: understanding of treatment plans and disease processes, satisfaction, and incidence of medical errors resulting in physical harm” (4).
- They experience communication issues, which leads to “poor decision making on the part of both providers and patients, or ethical compromises” (1)
- Studies have shown that patients who work with trained healthcare interpreters have better understanding compared to those who rely on ad hoc interpreters, such as family, friends, and bilingual staff who are not trained as interpreters (6-9).
- Compared to ad hoc interpreters, qualified interpreters were linked to better communication, fewer errors and improved comprehension (6 )
- A study conducted by The International Customer Management Institute (ICMI) found that the provision of language access services “improves satisfaction with customer support by 72%” and “increases customer loyalty by 58%” (30).
Safety:
- LEP patients have an increased risk of drug/medication complications (6,8)
- LEP patients are more likely to experience a medical error resulting in physical harm (4)
- They experience more medication errors (30)
- Patients with access to professional interpreters experienced “decreased communication errors of clinical consequence” (3).
Efficiency and Cost Reduction:
- Lower likelihood of having a usual source of medical care (i.e. a “primary care home”) (6,8).
- More follow-up visits with physicians (32)
- “Lower rates of physician visits and preventive services” (1,6), including “lower rates of mammograms, pap smears, and other preventive services (Marks et al. 1987; Woloshin et al. 1997)” (8)
- Have longer stays in the hospital, even when compared to patients with the same conditions (31, 35)
- “Use of trained professional interpreters was associated with a decrease in utilization disparities; this was true for outpatient preventive services, intensity of ED services, ED return and referral rates, and admission rates from the ED” (6).
- Compared to ad hoc interpreters, qualified interpreters were linked to better “utilization of clinical care” (6) and “increased appropriate health care utilization” (3)
Language access services influence performance in each of these CMS quality programs, which means they have a significant impact on hospitals’ bottom lines. Additionally, patients covered by Medicare and Medicaid plans will also have the cost of language access services covered by their insurance plans, so it’s no extra cost to the hospital to provide these services to their Medicare and Medicaid patients.
If you are interested in learning more about implementing a language access plan in your organization please contact us today for more information.
Sources
1 https://minorityhealth.hhs.gov/Assets/pdf/Checked/HC-LSIG.pdf
2 https://journalofethics.ama-assn.org/article/language-based-inequity-health-care-who-poor-historian/2017-03
3 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5798672/pdf/10.1177_0046958017739981.pdf
4 https://www.ncbi.nlm.nih.gov/pubmed/15368768
5 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3937896/
6 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1955368/pdf/hesr0042-0727.pdf
7 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1855271/pdf/11606_2007_Article_136.pdf
8 http://mighealth.net/eu/images/3/3b/Flores2.pdf
9 http://www.mighealth.net/eu/images/6/61/Flores1.pdf
10 https://9kqpw4dcaw91s37kozm5jx17-wpengine.netdna-ssl.com/wp-content/uploads/2018/09/LanguageAccess-and-Malpractice.pdf
11 https://www.imiaweb.org/resources/legal.asp
12 https://academic.oup.com/intqhc/article/19/2/60/1803865
13 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5091811/
14 CLAS Standards https://minorityhealth.hhs.gov/assets/pdf/checked/finalreport.pdf
15 Executive Order 13166 https://www.gpo.gov/fdsys/pkg/FR-2000-08-16/pdf/00-20938.pdf
16 Title VI Guidance (2000) https://www.gpo.gov/fdsys/pkg/FR-2000-08-30/pdf/00-22140.pdf
17 Title VI Guidance (2003) https://www.gpo.gov/fdsys/pkg/FR-2003-08-08/pdf/03-20179.pdf
18 HHS Language Access Plan https://www.hhs.gov/sites/default/files/open/pres-actions/2013-hhs-language-access-plan.pdf
19 ORS 413.550-558 https://www.oregonlegislature.gov/bills_laws/ors/ors413.html
20 DOJ https://www.hhs.gov/civil-rights/for-individuals/special-topics/limited-english-proficiency/guidance-federal-financial-assistance-recipients-title-vi/index.html
21 ACA 1557 https://www.govinfo.gov/content/pkg/FR-2016-05-18/pdf/2016-11458.pdf
22 LEP.gov https://www.lep.gov/faqs/faqs.html#OneQ6
23 Joint Commission https://www.jointcommission.org/standards_information/jcfaq.aspx?ProgramId=0&ChapterId=0&IsFeatured=False&IsNew=False&Keyword=Language%20Access
24 https://www.smithsonianmag.com/innovation/millions-americans-are-getting-lost-translation-during-hospital-visits-180956760/
25 https://journalofethics.ama-assn.org/article/legal-risks-ineffective-communication/2007-08
26 https://journals.lww.com/academicmedicine/fulltext/2017/01000/Through_the_Veil_of_Language__Exploring_the_Hidden.30.aspx
27 https://link.springer.com/content/pdf/10.1007%2Fs11606-017-3999-9.pdf
28 https://www.ncbi.nlm.nih.gov/pubmed/29256089
29 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4737649/
30 http://blog.cyracom.com/could-improving-lep-patient-outcomes-boost-hcahps-scores?utm_source=hs_email&utm_medium=email&utm_content=70916307&_hsenc=p2ANqtz–Nj23ccJacd_GxYfMf-rpjoO5cpefBWhVsAyXK3LaP5ZlQXrS6_TQbA7WkTj_yaRwQtTcEUD_Oo7UJrN9TeUXj2nfK0g&_hsmi=70916307
31 https://bmchealthservres.biomedcentral.com/articles/10.1186/s12913-015-0874-4
32 https://journals.lww.com/lww-medicalcare/Abstract/2000/07000/Comparing_the_Use_of_Physician_Time_and_Health.5.aspx
33 https://www.ncbi.nlm.nih.gov/pubmed/17687651
34 https://journals.lww.com/pec-online/Abstract/2013/05000/Unscheduled_Return_Visits_to_the_Emergency.5.aspx
35 https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/lepguide/lepguide.pdf
36 https://www.ncbi.nlm.nih.gov/pubmed/17687651
37 https://www.beckershospitalreview.com/finance/average-hospital-expenses-per-inpatient-day-across-50-states.html/
38 https://www.kff.org/medicaid/state-indicator/federal-dsh-allotments/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
39 https://www.macpac.gov/wp-content/uploads/2018/06/Medicaid-Base-and-Supplemental-Payments-to-Hospitals.pdf
40 https://www.medicaid.gov/medicaid/finance/
41 https://www.kff.org/report-section/understanding-medicaid-hospital-payments-and-the-impact-ofrecent-policy-changes-issue-brief/
42 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Readmissions-Reduction-Program
43 https://www.medicaid.gov/medicaid/finance/
44 https://qpp.cms.gov/docs/QPP_quality_measure_specifications/CQM-Measures/2019_Measure_416_MIPSCQM.pdf
45 https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HAC/Hospital-Acquired-Conditions
46 https://www.qualitynet.org/inpatient/hrrp/payment
47 https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/HVBP/Hospital-Value-Based-Purchasing
48 https://qpp.cms.gov/resource/2019%20Promoting%20Interoperability%20Information%20Blocking%20Fact%20Sheet
49 https://qpp.cms.gov/mips/overview
50 https://qpp.cms.gov/resource/2019%20MIPS%20Quality%20Performance%20Category%20Fact%20Sheet
51 https://www.beckershospitalreview.com/finance/average-hospital-expenses-per-inpatient-day-across-50-states.htm
