|
The following is a letter from the American
Medical Association to the Office of Management and Budget, explaining
the severe effects that Executive Order 13166 ("The Multilingual
Mandate") will have on the ability of medical doctors to treat and
care for patients with limited English proficiency ("LEP").
December 21, 2001 Ms. Brenda Aguilar Office of Information and Regulatory Affairs Office of Management and Budget Washington, DC 20503 Dear Ms. Aguilar: On behalf of the American Medical Association (AMA), we appreciate the opportunity to provide comments to the Office of Management and Budget (OMB) with respect to OMB's request for cost information associated with Executive Order 13166 which relates to access issues for individuals with limited English proficiency (LEP), 66 Fed Reg. 58,824 (November 30, 2001).As you know, pursuant to Executive Order 13166, on August 30, 2000, the Office of Civil Rights (OCR) of the Department of Health and Human Services (HHS) issued Policy Guidance on the Prohibition Against National Origin Discrimination As It Affects Persons with Limited English Proficiency, 65 Fed. Reg. 52,762 (August 30, 2000). Under the policy guidance, OCR establishes comprehensive standards (listed in Attachment A) that require all physicians who receive any federal financial assistance, including payments under the Medicaid program to provide, at their own expense, a trained clinical interpreter for all their LEP patients, regardless of whether the patient is insured by Medicaid, Medicare or a private payer. Physicians also must meet numerous other requirements, including (i) ensuring that interpreters are trained and demonstrate competency as interpreters, and (ii) providing the interpreter with orientation and training that includes skills and ethics of interpreting. The OCR policy guidance places Medicaid patients in a particularly vulnerable position with regard to access, since it may be very difficult to find a physician who can absorb the costs associated with these LEP requirements. Below we discuss the substantial problems with the OCR LEP requirements, including results of a state survey we conducted, which documents the extraordinary cost burden these requirements place on physicians. There is widespread concern in the physician community about the detrimental impact the OCR requirements may have on access for LEP patients. We have attached copies of letters (Attachment B) sent to the Secretary of HHS and signed jointly by the AMA and numerous specialty societies as well as by all state medical societies. Reduced Access for LEP Patient under OCR Requirements The AMA is fully committed to the importance of achieving greater access for LEP patients. Indeed, we strongly believe that clear, direct communication and understanding is the bedrock of the patient-physician relationship, and thus is a very important concern in providing quality medical care to all patients. Nevertheless, we are strongly opposed to allowing the burden of funding written and oral interpretation services for LEP patients to fall on physicians, as would occur under OCR's requirements. It is extremely inequitable to require physicians to fund written and oral interpretation services. The cost of hiring an interpreter, which our state survey shows can greatly vary between $30 and $400, is significantly higher than the payment for a Medicaid office visit, which in many states ranges between $30 and $50. Physicians would sustain severe economic losses if forced to cover the cost of interpretation services and thus may no longer be able to provide services to LEP patients. Indeed, AMA data shows that two-thirds of physician offices are small business. If a business, especially a small business, continues to lose revenue and begins to operate on a negative balance sheet, the business cannot be maintained. Accordingly, the OCR requirements could reduce, not strengthen access to health care services for LEP patients. Costs Associated with Implementation of OCR Requirements As discussed above, OCR's burdensome requirements are prohibitively expensive for physicians. In California, where many physicians have long-supported the Medi-Cal and Healthy Families programs despite extremely inadequate reimbursement, the costly OCR requirements likely will compel many of these physicians to terminate their participation in these programs. Medi-Cal pays only $24.00 for an established patient office visit and $57.20 for the less common new patient office visit. Clearly, Medicaid payment rates are already vastly insufficient to cover physicians' cost for the office visit. Thus, it is even more inequitable to expect this inadequate payment rate to also cover the cost of a certified interpreter. Although interpreter rates vary in California (and in many other states) accordingly to the level of difficulty of the language to be interpreted, the cost generally is $150 ($75 per hour, with a two hour minimum) and $180 for more difficult languages such as Hmong ($90 per hour, with a two hour minimum). In Minnesota, the Medicaid payment for an office visit is approximately $36.25 per visit. This rate is far less than interpreter fees in Minnesota, which range on average between $70 and $90. In Washington D.C., the Medicaid payment rate is $30, although interpreter rates on average range between $145 and $175 per hour, with a 2 hour minimum, or between and $275 and $400 for a half-day for European languages and $500 for other languages. The disparity between Medicaid payments and the cost of interpreter services exists in virtually every state. We have attached a chart (Attachment C) showing the results of a state survey we conducted, which details the cost of interpreter services in a number of states, as well as Medicaid payment rates and whether Medicaid makes a separate payment for interpreter services. Further, in many states, especially in rural areas, it is very difficult for physicians to obtain access to interpreters. For example, in Alaska, there is very limited availability of interpreters; Eskimos speak 8 different dialects and some do not translate into English. We understand from the states that availability of oral and written interpreter services is also extremely limited in states, such as, among others, Arkansas, Georgia, Indiana, Iowa, rural Kentucky, Minnesota and South Carolina. We have included in the attached chart specific comments from certain states discussing concerns about availability of interpreters. The lack of availability of interpreters is compounded by the fact that so many different languages are prevalent in many states, in both urban and rural areas. For example, there are 61 languages in Hamilton County, Indiana; Des Moines, Iowa has 37 languages, while there are 24 languages spoken in a very small rural community in Northeast Iowa; and in the Chicago public school system, more than 100 languages are spoken. Thus, it is often an extreme hardship to simply find an interpreter, and even if an interpreter speaks a particular language, that interpreter may have limited availability, especially in rural areas. Moreover, it would be extremely difficult, if not impossible, for a physician or health care institution to identify and have available bilingual staff or interpreter services for each of these languages. In addition, interpreters generally charge for travel costs, which become exorbitant in rural areas where interpreters could potentially travel up to 6 or 8 hours round-trip. Accordingly, as discussed above, the net result of the cost and feasibility issues associated with the OCR requirements is that some physicians may not be able to afford to treat LEP patients. This could create serious access problems for all Medicaid patients, which is already a very vulnerable patient population. Finally, the AMA is particularly concerned with the effects of such burden on minority physicians and their patients. Studies document that minority physicians are more likely to provide care to minority and/or underserved populations. The financial impact of such additional costs could further restrict community outreach and exacerbate minority health disparities. Other Problems Associated with Implementing the OCR Requirements Aside from the disparity in Medicaid payment rates and the cost of oral and written interpretations services, there are various other problems relating to implementation of the OCR requirements. For example, if a patient cancels an appointment, which is a common occurrence, who is required to pay the cost of the interpreter? As discussed above, in rural areas, the interpreter may have traveled several or more hours to attend the patient's appointment, which would involve substantial travel costs. Further, physicians already are besieged with overwhelming and burdensome regulatory requirements. Compliance with these requirements means less time spent on patient care, and the OCR requirements further reduce physician time spent with patients. In summary, we believe that the current OCR requirements, with their associated costs, as discussed above, will reduce - not improve - access to health care services for LEP patients. We appreciate the opportunity to provide the foregoing comments and stand ready to work with the OMB in further compiling information about the costs of developing Executive Order 13166 and the OCR policy guidelines in particular. Respectfully, Robert W. Gilmore, MD Executive Order 13166 Resources |
|||||
 |
||||||
|
|
       
|