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2. Policy Development And
Research In Multicultural Health
2.1 Policy Development
One can not underestimate the power that policies requiring linguistically
and culturally appropriate services plays in persuading health care providers
to improve their services in a timely fashion. Hand-in-hand with community
advocacy and oversight, policymaking has a demonstrated impact in enhancing
access and quality of services for diverse populations.
There have been some excellent overviews of federal, state, and other
legal and regulatory measures that address linguistic and cultural competency
in health care (Perkins; Fortier/OMH; Ginsberg; Chicago Institute on
Urban Poverty; Association of Asian Pacific Community Health Care Organizations).
A brief summary of the best policies currently on the books includes:
- Federal laws: Title VI of the Civil Rights Act of 1964 especially
enforcement with respect to language access through consent decrees
between HHS and various health care providers, The guidance on this
topic issued in 1998 is being strengthen for re-release in 2000. HCFA
is developing cultural competence guidelines for Medicaid and Medicare
providers, and the Office of Minority health is publishing draft cultural
and linguistic competence standards in the Federal Register in 2000.
- State laws: California has a significant collection of statutory
language that addresses both linguistic and culturally appropriate behavior
by health providers, although most are rarely enforced.
- State regulation: again, California has the most comprehensive
regulatory requirements for Medicaid managed care providers and mental
health providers with respect to linguistic and cultural competence.
Oversight and enforcement will be a critical measure of success as implementation
progresses. Massachusetts is on its way to developing similar
requirements, and currently has a 'Determination of Need' criteria for
health care facility expansion that requires the availability of interpreter
services--a major factor in the widespread availability of interpreter
services in that state. Washington for many years had reimbursement
mechanisms for interpreter services costs incurred by health providers–these
were cut back drastically in 1997. And Minnesota includes a capitation
differential for Medicaid managed care providers who may incur extra
costs as a result of serving LEP clients.
- Accreditation requirements: JCAHO has extensive language on
culture and linguistic access in its standards, although enforcement
tends to vary greatly.
It must be stressed that what moves policymakers to act on these
issues is awareness, combined with persistent and vocal pressure from
constituencies. They must be able to support their actions with adequate
information and options. This has proven abundantly true in California
with Medicaid managed care, Illinois in the passage of a state law on
interpreter services, Maine with its recent awareness of Title VI violations,
and in the U.S. Congress in the development of requirements and programs
related to linguistically appropriate services (Fortier). Similarly, health
care providers are not inclined to respond vigorously to policy requirements
without awareness raising and government/community oversight. In turn,
these awareness raising and advocacy activities can not be successful
without validating research and community capacity building, which will
be discussed in the next sections.
2.2 Research and Evaluation
As policymakers, accreditation bodies, and health care providers come
under pressure to deliver health services that are linguistically and
culturally competent, questions inevitably arise about the intrinsic and
relative value of different approaches, methods, and programs. These questions
relate to:
- cost (for example, are medical interpreter services cost-effective?
Can they save our institution money and in what areas?)
- quality/risk management (can cultural competence training
improve provider-patient interactions?)
- clinical efficiency (does having an interpreter service
improve the way patients move through the institution?)
- comparative methodologies (is one approach to cultural competence
training or better than another? Does using face-to-face interpreters
lead to better encounters than telephone interpretation?)
The implied concern is that, right now, there is little to prove
that culturally competent activities are worth the effort of change or
expenditure of resources. While there are a few and perhaps increasing
number of individuals interested in these issues, most of the questions
outlined above and similar ones have not been of interest to the health
services research community.
There are two kinds of investigative work that providers and policymakers
can benefit from. First, and perhaps most straightforward, is the evaluative
work that would look at the factors that distinguish quality interventions
and would compare one approach with another. Comparing a simultaneous
remote interpretation technique with the more usual consecutive in-person
technique is one example. This evaluative study approach could be applied
to different interpreter approaches, cultural competence training, translation
methods, etc.
More challenging, but perhaps of more significant interest to those
who manage and pay for services, are the research questions related to
clinical efficiency, cost, effectiveness, and outcome. These questions
are considerably more complex to design research methodologies for, but
they are the questions providers and policymakers have the greatest stake
in answers to.
The tasks to promote the linguistic and cultural competence research
agenda are many. Funding must be made available for this research and
evaluation. A cadre of interested researchers needs to be cultivated and
networked. For example, several institutions with interpreter programs
have data that, in the most cursory analysis, supports the cost-effectiveness
of their programs and the impact on some clinical outcomes. However, they
have not had time or resources to investigate these questions more fully,
or have not been able to find researchers to do this for them.
Another important task, especially given the limited resources available
in this field for service delivery or research, is better information-sharing
about research projects to avoid duplication of effort. For instance,
right now there are at least five projects being conducted simultaneously
on the development of linguistic and cultural competence standards, and
two surveys of the linguistic and culturally appropriate practices of
managed care organizations.
Resources for Cross Cultural Health Care is currently developing
for the HHS Office of Minority Health a research agenda on linking cultural
competence to health care outcomes(Appendix 15).
Summary Recommendations for 2.1
- Educate policymakers and health care organization interest groups
about the need for policies that support culturally competent health
service delivery.
- Facilitate review, development, implementation, and oversight of government
policies, including those related to reimbursement of enabling services,
on health and social services issues that recognize and support the
needs of ethnic communities.
- Promote development of accreditation standards for provider organizations
and health professionals that support culturally competent health service
delivery.
- Support implementation of the California Medicaid managed care standards,
Department of Mental Health standards, and other policies related to
linguistic and cultural competence, especially with respect to:
- oversight/enforcement mechanisms
- provider implementation through dissemination of models and practices.
- Promote California Medicaid managed care standards as a national model
and support development of similar policies in other states, and by
federal agencies and national accrediting bodies.
- Enhance awareness of current policy regarding linguistic and cultural
competence among both providers and ethnic communities (especially civil
rights law, state laws and regulations, accreditation standards).
- Develop and promote model provider organizational policies and standards
and the practices needed to implement them. Promote management buy-in
through education and dissemination of information about models, costs,
and benefits.
- Promote with national organizations and local professional organizations:
- development of statewide, multicultural health professions education
initiatives
- adoption of training, and testing/certification on cultural competence.
Summary Recommendations for 2.2
- Support research methodology design and conduct of research on comparative
models of cultural competent services.
- Support research on clinical efficiency, cost, effectiveness, and
outcome of cultural competent services.
- Support development of a network of researchers interested in evaluation
and research on culturally competence in health care.
- Promote the need for this type of research and evaluation with a variety
of potential funders (e.g. foundations, government agencies, MCOs, etc).
- Promote findings of the research in various health care, policy, media,
and general community settings.
Contacts, Resources, References
2.1
HHS Office for Civil Rights
330 Independence Ave., S.W.
Washington, D.C. 20021
202-619-0585
http://www.hhs.gov/progorg/ocr/lepfinal.htm
David C. Clark
HCFA
7500 Security Blvd, S3-02-01
Baltimore, MD 21244
410-786-6843
Guadalupe Pacheco, Special Assistant
DHHS Office of Minority Health
5515 Security Lane, #1000
Rockville, MD 20852
301-443-3379
Jane Perkins, J.D.
National Health Law Project
211 N. Columbia Street
Chapel Hill, NC 27514
919-968-6308
Melba Rosa Hinojosa, RN, MA, Health Plan Adviser
CA Dept of Health Services
714 P Street, Room 650
Sacramento, CA 95814
916-654-0748
Iris Garcia
DMA-Office of Clinical Affairs
600 Washington St., 5th Flr.
Boston, MA 02111
617-210-5696
Shelby Dunster, Associate Director
Dept. of Standards
JCAHO
One Renaissance Blvd.
Oakbrook Terrace, IL 60181
630-792-5893
Request for Applications for Medi-Cal Managed Care Contractors. Sacramento:
State of California Department of Health Services, 1994.
Schmidt, R.E. et al. Limited English Proficiency as a Barrier to Health
and Social Services. Washington, D.C.:HHS Office for Civil Rights, 1995.
State Medicaid Managed Care: Requirements for Linguistically Appropriate
Health Care, Oakland: Association of Asian Pacific Community Health Organizations,
1996.
Impacts of Medicaid Managed Care on Immigrants and Refugees: A Best Practices
Review with Policy Recommendations. Chicago: Heartland Alliance for Human
Needs and Human Rights, 1996.
Contacts, Resources, References
2.2
Julia Puebla Fortier
Resources for Cross Cultural Health Care
8915 Sudbury Road
Silver Spring, MD 20901
301-588-6051
rcchc@aol.com
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2.
Policy Development and Research in Multicultural Health