How does the cost of interpreting show up in hospitals? Let’s take a look at the quality programs that impact hospitals and how language access services affect the bottom line.
MIPS (Merit-based incentive payment system) and Payments
While there are several quality programs under CMS (Centers for Medicare and Medicaid Services), MIPS has the largest potential impact on providers that see patients with Medicaid and Medicare plans. Under MIPS, providers can lose up to 9% of their CMS payments based on their performance in four areas — Quality, Improvement Activities (measuring improvements in the quality category compared to the previous year), Promoting Interoperability (related to the use of electronic health records), and Cost. LEP patients experience disparities that can affect all of these areas, and the provision of language access services can mitigate those disparities
Quality encompasses several types of measures:
- Process measures (health maintenance/preventive services)
- Outcome measures (impact of services or interventions on patient health)
- Structural measures (capacity, systems, and processes for providing high-quality care)
- Patient engagement and patient experience measures (feedback from patients regarding their experience, including communication)
- Intermediate outcome measures (control over short-term factors that could have an impact on long-term outcomes)
- Efficiency measures (affordability of health care)
- Patient-reported outcome measures (self-reported health status)
(48, 49, 50)
LEP patients experience disparities that could affect all of the areas above:
Quality
- “Lower rates of physician visits and preventive services” (1,6).
- “Lower rates of mammograms, pap smears, and other preventive services (Marks et al. 1987; Woloshin et al. 1997)” (8).
- “Greater risk of line infections, surgical infections, falls, and pressure ulcers” (35)
- Worse interpersonal care (30)
- Higher rates of poorly-controlled diabetes and hypertension (27, 28)
- “Suboptimal disease-specific outcomes in mental health, asthma, diabetes mellitus, and heart failure” (31)
- Higher risk of having an impaired health status (8).
- “Poorer adherence to treatment and follow-up for chronic illnesses” (6)
- “Higher resource utilization for diagnostic testing” (8), and “more frequent and more expensive testing” (1)
- Higher ER utilization; according to a study, 60% more likely to visit the ER “after adjusting for age, sex, medical complexity, residency and outpatient health care utilization” (31)
When overall quality of care is affected negatively without an interpreter or translator, the increase of care needed proves to be more expensive than the cost of interpreting services.
Interoperability
Electronic health records systems that are inaccessible to LEP patients may discourage this population from engaging with the EHR system (48).
Cost
- 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)
Language access services mitigate the disparities LEP patients face:
Quality
- According to OMH, “the use of clinical and preventive services has increased when professional interpretation services were provided.” (1)
- Implementation of language access services can increase quality of care (1).
- Patients with access to trained interpreters experienced higher levels of satisfaction compared to those who were provided with no interpreters and compared to those who relied on untrained/ad hoc interpreters (1)
- Access to professional interpreters resulted in “increased patient and clinician satisfaction with care” (3)
- Compared to ad hoc interpreters, trained interpreters were linked to higher satisfaction with clinical care (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).
- Patients who work with trained healthcare interpreters have better health outcomes than those who work with untrained/ad hoc interpreters (6-9)
- Patients with access to professional interpreters experienced “improved clinical outcomes” (3)
- When working with interpreters, providers are better able to make an accurate diagnosis the first time, and are less likely to resort to superfluous diagnostic testing (1).
Cost
- “When language barriers are reduced and health insurance coverage is the same, LEP patients show ambulatory health care utilization associated with lower cost and more access to preventive care through establishing a primary care home.” (32)
- Patients who are provided with language access services are more likely to get an accurate diagnosis the first time (1)
- Compared to ad hoc interpreters, qualified interpreters were linked to better “utilization of clinical care” (6)
- Patients with access to professional interpreters experienced “increased appropriate health care utilization” (3)
- Use of language access services in the pediatric ED setting was shown to reduce costs (31).
- According to the AMA, interpreters “improve quality of care and outcomes, thereby generating revenue rather than adding cost” (2).
- “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).
- When provided with full access to professional interpreters, LEP patients on Medicaid “were 94% more likely [than English proficient patients] to use primary care and 78% less likely to use the emergency department. Specialty visits and hospitalization did not differ” (32).
- When working with interpreters, providers are better able to make an accurate diagnosis the first time, and are less likely to resort to superfluous diagnostic testing (1).
Does a provider actually benefit from seeing the LEP patient? How much?
Because Medicare and Medicaid cover the cost of interpreting services, providers presumably benefit financially from seeing LEP patients just as much as they would benefit from seeing their English-proficient counterparts.
That said, when LEP patients face health disparities due to language barriers, they increase the likelihood that providers will have to pay CMS penalties.
What does a longer hospital stay actually mean to the bottom-line hospital revenue?
The average cost for a patient to stay in the hospital for one day is as follows:
State/local government hospitals — $2,052 per day
Nonprofit hospitals — $2,488 per day
For-profit hospitals — $1,889 per day
(51)
Of course, the overall impact on the bottom line depends on the patient’s insurance coverage.
How much do hospitals lose by seeing Medicare/Medicaid patients?
On average, Medicaid payments covered 93 percent of the costs of patient care in 2014; Medicare payments covered 88 percent of the costs. That means that, on average, hospitals do not recoup their costs through Medicaid/Medicare payments.
However, hospitals that accept Medicaid and Medicare and see many low-income patients may also receive supplemental Disproportionate Share Hospital Payments (DSH Payments) and other supplemental payments. After DSH payments, hospitals received an average of 107% of costs.
That said, hospitals received payments equivalent to 144% of costs from private insurers in 2014, so even if they do profit from seeing Medicare/Medicaid patients, they certainly profit more from seeing patients with private insurance.
(41)
Why do hospitals see patients who are not profitable?
On average, hospitals do make a profit when seeing Medicare/Medicaid patients after supplemental payments.
However, even in the event that they are not profiting monetarily from seeing these patients, the alternative in the absence of these programs (seeing uninsured patients and providing them emergency care) costs hospitals substantially more money, so they benefit from the existence of these programs.
Legally, hospitals cannot turn away patients who need lifesaving treatment under the Emergency Medical Treatment and Labor Act (EMTALA), so even for-profit hospitals must see patients who are not “profitable” monetarily. Public hospitals cannot turn away patients even for non-emergency care.
Likewise, many clinics are obligated to have a policy of seeing patients regardless of their ability to pay as a condition of grant funding or membership in particular programs. This includes Federally Qualified Health Centers (FQHCs), for example.
Providers also cannot discriminate against patients due to their national origin; turning away patients with Limited English Proficiency or refusing to provide language access services for them would be considered national origin discrimination and would be a violation of Title VI of the Civil Rights Act. So even if these patients are not “profitable,” they must be seen.
How do hospitals make money?
● Grants
● Donations
● Payments
○ Patients
○ CMS
○ Private insurance
At Linguava, we are dedicated to reducing communication barriers and providing equity to all members of our community through language access services.
If you are interested in learning more about incorporating interpreting or translating services into your organization or would like to book a training session, contact us today.
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
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
