MLC News

In a state where one in five residents report they speak English less than �very well,� California health care leaders called for making language access services immediately available when they convened at the seventh meeting of the Medical Leadership Council on Language Access May 2 in Los Angeles.

�Since we began meeting in 2002, we have learned of the great need for these services among our patients,� said Leonard Fromer, MD, past president of the California Academy of Family Physicians. �We have learned effective ways to provide these services, and the great need to find more ways to pay for them. Now it�s time to act.�

Bolstered by funding and encouragement from The California Endowment�s President and CEO, Robert K. Ross, who offered to fund two more years of Council work, the presidents and executive directors of medical societies and other organizations formed a task force to draft next steps for the group�s work to be discussed this summer and fall, and agreed upon by all 30 Council organizations at their next meeting November 17.

�Given the current state and federal budgets, it�s no surprise we can�t get immediate large-scale funding for language access services,� said Endowment Program Director Ignatius Bau. �It�s important, though, that we put all the building blocks in place now so when the political and economic climates are more positive, we can move forward quickly.�

Presentations at the May 2 meeting focused on current training materials and methods available for health care providers and available ways to provide language access services to patients. A summary is provided below.

The AMA has launched several projects within its Health Disparities Initiative with the goals of increasing physician awareness of health disparities among various racial and ethnic groups, promoting physician behavior change and system change through physician action, increasing workforce diversity, and addressing language access.

�The AMA believes the government should pay for language access,� Gadon said, �but we shouldn�t let patients languish while payment gets worked out.�

The Health Disparities Initiative focuses on five areas:

Physician awareness and education: The AMA is launching �EPoCH,� which will offer public health information for physicians in a Web-streaming format. Health disparities information is included in education as a public health issue, along with issues such as immunizations, obesity, and violence prevention.

The AMA also will distribute a speaker�s kit with print and video materials being developed by the Commission to End Health Disparities (see below). The kit will include fact sheets, how-to information, resource lists, and background information.

Language access: Through both focus group study and a population study of physicians, the AMA is identifying barriers to the implementation of language access services, identifying strategies to overcome them, and testing the replicability of strategies (e.g., bulk purchasing of tools). The AMA also is developing an informational brochure on options for clinicians.

The Commission to End Health Care Disparities: In January, the AMA, the National Medical Association, and the National Hispanic Medical Association announced the creation of the commission, comprised of leaders from the nation's largest physicians' organizations and more than 30 other medical specialty and health-related groups.

Two current projects are:

The AMA Institute on Ethics conducted a survey of 1,800 physicians on behalf of the Commission to examine how many physicians are ready, willing and able to address health care disparities by focusing on these issues in their own practices and communities. The AMA reports on its Web site that:

The study consisted of a nationally representative sample of primary care physicians with an oversampling of those practicing in communities with a high proportion of racial and ethnic minorities. Early results indicate that many physicians now perceive health care disparities to be a problem and have become actively engaged in attempting to address them. Overall, more than half (55%) of physicians agreed that �minority patients generally receive lower quality care than white patients�, while 21% were unsure of this claim and about the same number (24%) disagreed with it. Nearly two-thirds of the nation�s physicians (62%) report they have witnessed a patient receive poor quality health care because of the patient's race or ethnicity.

These findings are in contrast to those of a 2001 physician survey by the Kaiser Family Foundation which found that �the majority of physicians believe disparities in how people are treated within the healthcare system �rarely� or �never� happen based on factors such as income, fluency in English, educational status, or racial or ethnic background.�

Many physicians expressed an interest or were actively participating in educational or community activities to help address health care disparities. For example, within the past month, 32% percent had spoken with colleagues about ways to address specific health care needs of their minority patients and 44% had spoken with a community health worker about the health needs of patients in their practice community. Within the last six months, many had attended an educational event (19%) or read a journal article (54%) on improving the health of minority patients.

Nearly nine out of ten physicians (89%) believed that it is possible to provide high quality of care to all of their patients, and three out of four (75%) reported they are in a position to make a difference in the quality of care that minority patients receive.

Despite the encouraging findings of the current study, several barriers to decreasing disparities remain, highlighting the importance of collaboration between individual physicians, their professional organizations, and the communities in which they practice. Among the barriers identified that hinder physicians from participating more actively in efforts to improve the health and health care of minorities were difficulty accessing hospitals for non-emergency care (13%), poverty in the communities in which their minority patients live (20%), financial problems (21%), and time constraints (41%).

Community partnerships: The AMA is encouraging physician offices to link with their local public health systems and communities to work in interdisciplinary ways, including making community and public health information more widely available in physicians� offices.

The AMA also would like to work with the EQUIP Project on electronic health records to collect data on issues such as literacy and acculturation processes to determine whether these influence health disparities, and work to eliminate these and other barriers.

Governmental advocacy: The AMA is continuing its work at the federal level to influence legislative and regulatory work to improve public health, including finding ways to fund language access services.

For more information: www.ama-assn.org/go/healthdisparities.

The Ethical Force Program at the AMA is a collaborative effort to develop health care system-wide performance measures for ethics. �Because patients who need health care are often vulnerable and unable to protect their own interests, high ethical standards must exist throughout the entire health care system,� says a statement on the AMA Web site. �Every participant in health care must share fundamental ethical obligations.

�The Institute for Ethics believes that if specific shared expectations for ethical action can be developed, it should be possible to develop performance measures for these expectations,� the statement says. �The Ethical Force Program is built on the belief that performance measurement in health care ethics would be valuable to improving the quality of health care delivery.�

The program is run by a diverse group of leaders from all aspects of health care delivery including clinicians, researchers, ethicists, managed care executives, public health and patient advocates, business owners, and union representatives.

The Ethical Force Program�s current topic areas are privacy and confidentiality, fair health care coverage, and patient-centered communication. Wynia and others are proposing a new ethical domain for assessment � patient-centered communication for populations who are vulnerable within the health care system as a result of difficulties in communication.

The goal would be to encourage health care organizations to perform self-assessment of their performance in meeting the needs of limited-English-proficient and other vulnerable patients, using a quality-improvement model. Steps would include collecting data on performance, engaging communities, evaluating the workforce and engaging patients, to fully evaluating and then improve an organization�s performance.

The Ethical Force Program has compiled existing expectations on patient-centered communications in health care (e.g., JCAHO and NCQA standards), is developing a consensus report on the organizational factors that influence such communication, and then - with partial funding from The California Endowment � is creating and piloting self-assessment toolkits for hospitals and other stakeholders.

For more information and to volunteer to review the toolkits as an end-user: www.ethicalforce.org.

Dr. Betancourt presented a new educational product, an two-hour CME/CEU e-learning program, �Quality Interactions,� a patient-based approach to cross-cultural care. Highly interactive and informative and using actual case studies, the program is designed to:

�This problem-based, interactive case study method focuses on sentinel events that link to health outcomes and teachable moments,� Betancourt said. �The events track to Institute of Medicine reports, literature, and evidence-based guidelines.�

Developed by Manhattan Cross Cultural Group and Critical Measures, LLC, the current learning modules are geared to internists, family practitioners, cardiologists, oncologists, and surgeons. The companies are building cases for pediatrics, obstetrics and gynecology, psychiatry, orthopedics, and ophthalmology.

Some 1,000 physicians and 800 nurses have completed the trainings to date, with pre-test mean scores of 37 points and post-test mean scores of 83 points. The e-learning modules have received strongly positive reviews from users.

For more information and demonstration, see: www.criticalmeasures.net .

Perkins provided information from NHLP�s April 2005 report, �Providing Language Services in Small Health Provider Settings: Examples from the Field.� They conducted 11 site visits and seven phone interviews in settings with 10 or fewer clinicians.

The report outlines the many ways in which these practices coordinate language access activities, determine language needs at first points of contact, hire bilingual mid-level practitioners, use staff and contract interpreters, assess interpreter competency, and otherwise provide language assistance services.

The report suggests that small practices should follow eight steps in providing language access services:

For a full copy of the 80-page report, see:
www.cmwf.org/usr_doc/810_Youdelman_providing_language_services.pdf or www.healthlaw.org.

Program Director Ignatius Bau highlighted some of the many ways The Endowment continues to fund critical work on language access, including projects at Sutter Health, St. Joseph�s Health, Catholic Healthcare West, Kaiser Permanente and the California Association of Public Hospitals Safety Net Institute. In addition, Medical Leadership Council organizations such as the California Academy of Family Physicians, the California Latino Medical Association, the American College of Emergency Physicians, California Chapter and the American College of Obstetricians and Gynecologists, Region IX, are continuing their CME activities on language access issues for their members. Advocacy efforts are being continued by the California Pan Ethnic Network and the National Health Law Program, among others. The Endowment also recently commissioned an analysis by health financing experts at George Washington University to examine what California would have to do to draw down federal matching funds for language assistance services. The California Primary Care Association and the Asian and Pacific Islander American Health Forum are completing a guide for physicians� offices listing whom to call at all the MediCal and Healthy Families health plans in the state for interpreter services, to be paid by the health plan. A companion guide will be available for patients in several languages.

In addition, The Endowment has published two new reports: The Interpreter�s World Tour: An Environmental Scan of Standards of Practice for Interpreters by Marjory Bancroft, MA and Giving Voice to the Voiceless: Language Barriers & health Access Issues of Black Immigrants of African Descent by Summit Health Institute for Research and Education. These and other publications on language access, cultural competence, health disparities and other topics can be downloaded from The Endowment�s Web site: www.calendow.org/reference/publications/cultural_competence.stm.