He is a typical patient of our academic primary care internal medicine practice: elderly, frail, and with several complex conditions, including a history of a liver transplant requiring chronic immunosuppression, recurrent venous thrombosis requiring treatment with blood thinners, and type 2 diabetes. But in one very important way, he is different: our doctors don’t speak his language.
It is his fourth visit in the past six months, and, as usual, the allotted time is 20 minutes, the amount of time we are given for follow-ups. The last few months have been difficult for him. He was hospitalized for a respiratory illness, then later he had a fall requiring an emergency room visit. Today, his most pressing concern is worsening osteoarthritic knee pain, which is now limiting his ability to walk.
It is not uncommon for us to end up going substantially over the allotted time for his visits. Despite this, we can’t get to one of our main jobs: addressing his poorly controlled diabetes. We have spent all of our recent visits “putting out fires,” and, after our entire conversation gets translated, we just don’t have enough time for anything else. It’s hard not to wonder if he were an English-speaking patient, would this be the case?
Research demonstrates that language barriers impact multiple aspects of care quality. Federal law requires that the approximately 25 million patients in the U.S. with limited English proficiency (LEP), who do not speak English as their primary language, have “meaningful access” to programs and services receiving federal funding.
In the best scenario, patients with LEP are provided, free of charge, with a qualified interpreter for all health care interactions, as mandated but incompletely enforced. However, this does not go far enough to ensure equitable care for patients with LEP. For medical interpretation to be effective and result in meaningful access to high-quality care, more time is required to accommodate the need for interpretation. Unsurprisingly, 85 percent of community health centers reported that visits for patients with LEP require more time.
When everything must be said twice, it takes, roughly, twice as long to communicate with a patient through an interpreter. Additional preparation time is also needed to arrange for an interpreter, and often, extra time is needed to reconnect with a remote interpreter when a connection is lost. Time allotted for clinical encounters should reflect the additional needs of patients with LEP who require an interpreter to communicate with a language-discordant clinician.
However, extra time is not always allowed, likely due to a lack of adequate reimbursement for medical interpreter services, as well as health care financing structures that disincentivize longer office visit times. There is no legislation mandating extra time for interpretation during clinical encounters, and so it is up to the health system or independent practitioner to determine appointment length for visits requiring an interpreter.
Due to interpreter expenses, health care providers may be operating at a loss by seeing patients with LEP. As such, it might not be fiscally responsible to allow for the extra time needed for these visits, especially for providers seeing higher volumes of patients with LEP. Patients with LEP pay the same insurance co-pay for a primary care visit as an English-speaking patient with the same coverage, but they may very well be receiving essentially half the care, assuming doctors spend the amount of time allotted.
Clinicians are between a rock and a hard place; they can either provide equitable care by extending the visit time required for communicating with a patient via an interpreter, or they can stay on schedule and provide less care. Many times, clinicians will go above and beyond to make sure patients get the same care as English-speaking patients, but this is difficult to sustain. Such a system is inherently inequitable, as it does not foster the conditions necessary for the consistent delivery of high-quality care to everyone.
Meaningful access to health care services for patients with LEP requires not just the availability of a professional interpreter but also time for interpretation. As long as there is inadequate reimbursement for interpreter services and a lack of protection for the extra time medical interpretation takes, the care of patients with LEP will likely continue to be negatively impacted. Our nation of immigrants should do better to ensure equitable care for all.
Victoria Johnson and Maria Isabel Angulo are internal medicine physicians.
