HARVARD MEDICAL SCHOOL PRIMARY CARE REVIEW

Wi! Si! Yes! We Can Provide More Equitable Care When Interpretation is Required

May 4th, 2022

Imagine you’re a primary care provider at our clinic in Malden, Massachusetts. A patient quickly rattles off a list of concerns during your latest telehealth visit with her. Before you can ask any clarifying questions, you wait for the Brazilian Portuguese medical interpreter to interpret her concerns into English. You ask some questions, then wait again for the interpreter to relay this to the patient in her native language.

You go through this dance, between English to Portuguese and Portuguese to English. You’re 15 minutes into the conversation. She is scheduled for a 20-minute visit. By the time you finish collecting a history, and before you even come up with an assessment and plan, you’re already at 25 minutes. The total amount of time you spent in the visit is 30 minutes. You’re already 10 minutes behind.

Many of us face this impossible conundrum as health care providers. The ability to provide equitable care to patients is harmed when there’s a language barrier, yet we’ve not been able to address this issue appropriately. Research has shown that patients who require an interpreter have decreased access to care, poorer understanding of their diagnoses and treatment options, decreased satisfaction, poorer adherence to treatment, and more adverse medication events when compared to patients who don’t require an interpreter.

In these visits, the medical interpreter—the key to having a productive visit—has become a barrier to care. The time-language discrepancy now leads to inequities as clinical visits must be finished in half the time it takes for congruous language visits. Research demonstrates that the average visit with an interpreter takes four times longer than a visit without an interpreter.

How did we get here? Well, this archaic formula dates back to the American Medical Association (AMA) coding manual from 1992, which designated physicians’ time in RVUs (Relative Value Units). This formula designated that a primary care visit should be 1.3 RVUs, which works out to be 15 minutes. This 30-year-old regulation does not reflect the needs of patients today. As the late poet, Maya Angelou, once stated, “When you know better, do better.”

So, what can we do? The following are a few recommendations:

  • Recruit and compensate providers who speak the languages of the communities you work in. When providers take the time to learn the languages of their communities, they should be paid as they would for any part of their expertise. This may also incentivize more providers to learn the languages of their communities.
  • Offer interpreting services that have been certified through appropriate testing. In fact, organizations that receive federal funding are required by Title VI of the Civil Rights Act of 1964 to provide language concordant services.
  • Acknowledge that clinical visits with interpreters require additional time, and build this time into providers’ schedules. Twenty-minute visits are not enough.
  • Bill accordingly. Longer visits involving incongruous languages should be billed at higher rates to reflect the added complexity.
  • Increase access to in-person interpreters whenever possible. Not only does this reduce lost time and inefficiency from technology-related phone-interpreting services, but it also allows the patient to form a connection with an interpreter. And, providing the same interpreter at each visit further develops the patient-interpreter relationship, which enhances quality of care.

We have the opportunity to provide more equitable care to patients, which results in improved health outcomes for patients and more sustainable work for clinicians. We hope our mission-driven health care organizations will hear this call to action!

**Feature photo obtained by standard license on Shutterstock.

 

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Tia Tucker, MD, MPH, is a Family Medicine Physician at Cambridge Health Alliance and Director of Health Equity at the Tufts Family Medicine Residency Program. She received her MD from the Latin American School of Medicine in Havana, Cuba, and her MPH from the Tulane School of Public Health & Tropical Medicine. Tia enjoys designing educational opportunities for residents, as well as speaking to medical students and working with community partners to advocate for health for all.

 

MalanaGeraldine-DO_OriginalGeraldine Malana, DO, MPH, is a Family Medicine Physician at Cambridge Health Alliance, Faculty of the Tufts Family Medicine Residency Program, Clinical Instructor at Tufts University School of Medicine, and Lecturer at Harvard Medical School. She received her DO/MPH from A.T. Still University in Arizona and completed her residency at Northwestern McGaw Family Medicine Residency at Humboldt Park in Chicago. Geraldine's professional interests include health equity and research.

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