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Experts Speak Out

Manny Ferris,
President and Chief Executive Officer, Harvard Pilgrim Health Care

This leader in managed care talks about the response to diversity in today's competitive marketplace.

Bruce Vladeck,
Adminstrator, U.S. Health Care Finance Adminstration

"Our vision for the future is to provide EQUAL access to the best health care. To help us fulfill our mission and strive for our vision, we've developed a set of simple, yet essential customer service standards..."

Mary Grayson,
Editor, Hospitals and Health Networks Magazine

"Ethnic diversity in the workplace and patient population is already a fact of life for many health care organizations. If it's not yet an issue at your hospital, you still have time to learn from the experience of others..."

Donna E. Shalala,
Secretary, U.S. Department of Health and Human Services

The top government health official speaks out on civil rights and access to health care for consumers with linguistic and cultural needs.

Manny Ferris
President and Chief Executive Officer, Harvard Pilgrim Health Care

"New England's demographics are shifting, which means we must continue to be responsive to a diverse membership and workforce. Our large business and government clients are interested in how we can care for their international, multilingual employees. Various community segments--women, seniors, ethnic minorities, lesbians, and gay men--ask for services sensitive to their personal experiences and needs. To satisfy today's market, we must work even harder to respect each other's differences.

Our need to embrace diversity comes from our commitment to the people with whom we work, the members we serve, and the customers with whom we do business. Learning to treat each other's differences with respect and sensitivity is the only right course. And it's critical if we want to stand out as a great employer and distinguish ourselves as the most responsive health care provider in New England."

Donna E. Shalala
Secretary, U.S. Department of Health and Human Services

"The truth is, a lot of communities have bad experiences with the health care system: they don't trust it to act in their best interests, and that attitude is based on genuine experience. At HHS, we are committed to breaking down the walls of misunderstanding and replacing them with a strong foundation of trust. And for that to happen, we're going to have to address all the interrelated areas and barriers to good health--such as cultural differences, transportation, language, discrimination, and a lack of culturally sensitive primary care providers.

First, let's talk about civil rights enforcement. We asked Dennis Hayashi, Director of our Office of Civil Rights, to put together a new strategy for the Department. And through that office we're reaching out to health care leaders and working with them to improve the quality of care and access to care. For the first time ever, we've teamed up with the Civil Rights Division at the Department of Justice to crack down on discrimination in the health care industry.

When we do get discrimination complaints, our first approach is to work with all the parties to see if we can reach quick, fair settlements, particularly ones that we can monitor. For example, in Boston, where the Latino population numbers more than ten percent, a complaint was filed against a hospital for not providing effective services to non-English-speaking patients. Our Regional Office helped the hospital work with the community to reach an agreement. When I visited that hospital recently, I saw interpreter services, signs posted in Spanish, documents translated into other languages, and a full-time coordinator for those efforts. This more thoughtful approach really can work. Our role is to make sure that there's been a real change a new system for preventing circumstances that lead to civil rights complaints.

We have to replicate these kind of successes on a national scale. That's why the HHS Office of Civil Rights has commissioned a landmark study to look at the complex issue of language barriers to services both acrcss the nation and across the Department's programs. We're talking to consumers, providers, insurance companies, and others--asking them what works effectively and efficiently, and what does not. And when we finish, we're going to take that study and turn it into a national blueprint for advising health care professionals of their obligations and how they can meet them.

The second thing that we're doing is to serve as a model for other health providers. We're breaking down the barriers of language in our own program and services, so that Americans can get what they need from the federal government in languages they understand. We're already providing Medicare information in Spanish, and we're increasing the number of other languages that Medicare utilizes. Our nationwide flu shots campaign for older Americans is being communicated in languages ranging from Spanish to Chinese to Polish. No longer are we simply saying that one language is enough. We are reaching much more deeply into all communities.

Third, in terms of expansion of services, we're doing more to bring information assistance and primary care to people where they live. We're supporting culturally-sensitive health centers around the country. We have teamed up with the Department of Housing and Urban Development to expand community health centers in public housing. We're looking at those communities that need mental health and substance abuse care, and we are trying either to start up new health centers to treat them or beef up the ones they already have."

Bruce Vladeck
Adminstrator, U.S. Health Care Finance Adminstration

"Our vision for the future is to provide EQUAL access to the best health care.

To help us fulfill our mission and strive for our vision, we've developed a set of simple, yet essential customer service standards -- none of which we can really meet without getting a better handle on language issues. Our work at HCFA and the work of our partners will be held accountable to these standards

And third, driven by our mission and by our vision -- and by the fiduciary and moral responsibility we have to the general public and to our beneficiaries --we have a number of projects underway to improve the way we communicate with people who have limited English proficiency.

When you consider that our country is a nation of immigrants, it's amazing that we have yet to learn how to effectively address the many language differences among our people. On the other hand, when we have some folks who truly believe that the best solution is to communicate in English or not communicate at all, maybe it's not so amazing. The hurdles are significant. From education to health care, language is an issue with which we continue to struggle.

For lots of different reasons, a patient's ability to communicate with both providers and payers of health care -- and vice versa -- is a crucial ingredient for access to high quality, effective, and appropriate health care.

For instance, individuals with limited English speaking ability may have profound difficulties getting access to care because it's harder for them to make and keep appointments, or request and receive appropriate care. Furthermore, non-English speaking beneficiaries may try to base their choice of provider on language and cultural similarities, exacerbating access problems since the health care workforce has yet to mirror the diversity of our population.

Of course language differences have quality implications as well -- most stemming from lack of communication, miscommunication, or misinterpretation. Inaccurate interpretation of symptoms could lead to misdiagnosis. Important preventive health measures may not be adequately understood and therefore not adhered to. Patient confidentiality could be breeched, particularly if interpreter services are provided by a family member or friend. And language barriers may stand in the way of patients receiving full information about treatment options.

Language barriers also have potential implications for research and cost effectiveness of treatment, since the accuracy of data collection depends on the accurate communication of patient information and the ability of a patient to communicate that they have already -- and perhaps just recently -- had the same series of tests performed that another clinician is about to prescribe. These are just a few examples, but I think they provide enough flavor to get my point across.

In addition, it is essential to consider cultural barriers to health care alongside language barriers -- the two are really inseparable. For example, in some cultures questioning authority -- the doctor, nurse, or other health care professional -- is considered very disrespectful. Providers and interpreters who don't take these cultural nuances into account aren't bridging the gap between the health care professional and the patient and therefore cannot facilitate an effective visit, potentially putting the patient's health at risk.

And from HCFA's point of view, although we don't set any fractures, heal any wounds, or comfort the ill, in order for Medicare and Medicaid to work for our beneficiaries, ALL beneficiaries and providers alike must understand our programs. Furthermore, we have a responsibility to make sure that our partners -- providers, our contractors, PROs, state Medicaid agencies, and others -- have information about our programs in a format that is useful to them and their patients or customers, and that we facilitate and require health care delivery in settings that are friendly to our beneficiaries' communication needs.

The customer service standards that we have developed for the new "mission" driven HCFA should serve as a driving force behind the improvement of HCFA's and our partners' response to language barriers in health care. By their very definition, these service standards require that our primary focus be on customer needs which we cannot determine unless we're effectively communicating with each other.

As part of this customer service equation, not only do beneficiaries come first, but in order to really put them first, we must listen to their needs. If we're not communicating with them in a language they can understand -- complete with cultural nuances -- we won't do a very good job of listening.

So we have standards related to written inquires, telephone communications, information needs, claims processing, customer satisfaction, health care choices, quality, program administration, and a special standard for Medicaid. We have these standards because they're integral to assuring that our beneficiaries have access to quality health care when they need it. If we do not -- and we includes HCFA and the agency's partners -- make sure that written and telephone inquiries, claims information, and information about health care choices are all available in a language that beneficiaries can understand, then our efforts to help certain vulnerable populations are really for naught. Similarly, if we do not solicit feedback from beneficiaries in their own language -- on their satisfaction with our programs and with the care they receive -- we won't be getting the kind of information we need to continually improve and meet the challenges of the future."

Mary Grayson
Editor, Hospitals and Health Networks Magazine

Ethnic diversity in the workplace and patient population is already a fact of life for many health care organizations. If it's not yet an issue at your hospital, you still have time to learn from the experience of others. But, regardless of where you live, it's just a matter of time before you must deal with multiculturalism.

By the year 2005--just 12 years from now--your senior management team, clinicians nurses, allied health professionals and patients are going to be considerably different from today's mix. The U.S. Bureau of Labor Statistics predicts an influx of Asians, Hispanics, blacks and women into the work force, followed by an exodus of white males. Current workers due to retire are likely to be male and almost half will be white, according to the bureau.

Many health care organizations have already demonstrated that they can learn about and handle multicultural patient populations. The reality of a multicultural future workplace poses different problems. Here, the real question is: Will this new work force be adequately educated and trained?

Certainly, ethnic background cannot be equated with substandard educational achievement. But multicultural school systems across America are encountering what seems like impossible odds: 60 different languages are spoken in the Los Angeles school system.

That's an extreme example, but other communities face lesser degrees of the same challenge. The April issue of American Demographics reports that 14 percent of those age 5 to 17 speak a language other than English at home, and almost one in five l 9- to 20-year-olds do not have a high school diploma.

Many hospitals have done an excellent job of working with local school systems to help them prepare students for health care careers--particularly in the inner cities--and their efforts should be commended. But a deeper level of involvement in the community education system is also needed. If the local school system fails in its mission, hospitals, as employers, will eventually be hindered in achieving their mission."

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