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Archive for the ‘Health Literacy’ Category

Consumer info fact sheets  translated into WA’s threshold written languages   (Chinese, Lao, Khmer ( Cambodian), Korean, Russian,  Somali, Spanish, and Vietnamese) were posted on Dec. 16, just one week before the deadline to start an application for coverage to be effective Jan. 1, 2014. In an unrelated development, HBE  decided on this brief extension  for completing applications due to various  problems people have had in being able to use the online forms and or access phone customer services.  Regarding the translated fact sheets, it’s taken almost 6 months for their publication to replace the original problematic versions that were taken down from the site.
However, the new fact sheets are not easy to find as they are not posted on the consumer website,  but located exclusively on the HBE corporate website.  The corporate site features a line at top right-hand side of homepage entitled “Information in Other  Languages” which links to the fact sheets page, plus also links out to the consumer website.  In contrast, the consumer Healthplanfinder site (which is in both  English and Spanish) does not offer any such subject line, nor does it display a link to corporate site.  The Healthplanfinder site likewise does not contain any readily visible clear statement of consumer  language access or disability access rights, except for a message in tiny font on bottom of the homepage that says [sic] : If you need additional language or disability accomodations, you may call 1-855-WAFINDER (1-855-923-4633)  On the Spanish version of the website, this statement illustrates yet another example of  faulty translation, as the term “disability accomodation” is twice translated, and very ungrammatically, as  “discapacidad alojamiento”  which means disability lodging.  Sure enough, a quick check on Google Translate  English > Spanish reveals  “lodging” as the first  translation for “accommodation.”  Since 2012 advocates had been recommending the inclusion of multilingual tag lines and/or translated summaries sections for the website. Interpretersymbol

Information on some metrics for the Healthplanfinder call center became available last week with the release of the  November Healthplanfinder Data Report. On the language access side of things (p.10 of the report)  the numbers are not encouraging: the call center received almost 12,000 calls in Spanish, but handled only some 1600 of them. The call center in Spokane has bilingual Spanish-English staff (reported as 6 out of 80 employees at start-up) on site and routes calls in other languages to a telephonic interpreter service. For calls in all languages besides Spanish combined, 1045 were actually handled (answered)out of 3621 calls attempted. The report does not state if the multilingual calls are included in the totals for approximately 35,000 calls  handled in November or the almost  158,000 calls throttled (deflected from the system, i.e. not put into the queue to await a response).  While the HBE is said to be increasing staffing for the call center,  any increases planned for its language capacity are as yet unknown. Given the demand, it would seem that Spanish-speaking callers too could benefit from immediate access to interpreter services.

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The irony was not lost for me that while writing on the positive results of the FDA’s use of  translation services, that here in my state, once known as a national leader in language services, we are still struggling to get quality translations for our Health Benefits Exchange (HBE).  The efforts  to achieve this goal have been a major focus for the Washington State Coalition for Language Access, and its been a year now since we co-authored with Northwest Health Law Advocates the report Language Access in Washington under the Patient Protection & Affordable Care Act  expressly for the HBE efforts. Now with 175,000 enrollees, Washington State deserves the praise it’s getting for the record-breaking enrollment figures in the new health insurance  marketplace Washington Healthplanfinder, WA_Healthplanfinder_RGBespecially compared to the situation in neighboring Oregon and to the federal Healthcare.gov platform. But the picture is much less rosy regarding providing equal access for Washingtonians with limited English proficiency (LEP), who now number some 8% of state population or half-million residents, representing an increase of 210 % in the past decade . Demographic data on enrollees is said not to be available.

We are now less than 2 weeks away from the enrollment deadline for coverage to start Jan. 1, 2014, and the consumer fact sheets that were intended to inform the public of the options under the ACA have not yet been made available to Washington’s LEP population. Even though work began in July to replace the problematic original translations – errors brought to HBE’s attention by advocates- there are still no consumer fact sheets available in Washington’s  threshold languages ( in written form these are: Chinese, Lao, Khmer, Korean, Russian, Spanish, Somali, and Vietnamese).

In addition, the Spanish versions of the paper application for Healthplanfinder, while continuing to be publicly available, have contained horrific translation errors.  In the section  which inquires about the applicant’s citizenship status, the phrase ” Non-citizen legally present in the US”  was translated into Spanish to mean just the opposite,  i.e., the translation says “ non-citizen not legally present….”  ACA, complete with the  I-word in Spanish in version #1.  After the mistake was identified on Oct. 15 , again by advocates,  staff said they took immediate action to have the vendor correct it.  The screenshots included here show the sections containing the mistranslations.

Spanish version #1

And yet, advocates identified that the new translation contained the same error, just written with different wording.   Here is Spanish version #2, as it appeared on Nov. 14: Screen shot 2013-12-05 at 11.00.31 AM

This one particular error may now have been recently corrected  for a 3rd iteration, through volunteer  efforts of local language access advocates trying to beat the clock to help consumers. However, we hear anecdotally that more translation concerns persist and can’t be confident that there are not similar errors in the translations in the other languages.

What remains a mystery is how this sorry state of affairs has come about, and if there were ever robust quality assurance measures in the procurement chain for the translations. It is beyond comprehension how such blatant errors could be made given that the work was done by vendors holding official State contracts who must affirm that they use  qualified translators and proper translation procedures. And if this is happening in Spanish, the 2nd most used language in both our State and nationally,  and thus one for which there is an ample number of nationally-certified translators available to do the work, there is a real reason to fear that similar egregious errors may exist in other language translations.

Shortly before Thanksgiving, HBE staffers announced  at a meeting of its Health Equity Technical Advisory Committee, that work halted back in June to create a Language Access Plan  (LAP) for the HBE requested by the TAC , will resume in the new year.  LAPs are meant to serve as blueprints to guide the work of agencies and programs to comply with the laws requiring they provide language services, and  to help prevent the kind of  problems that we’ve being seeing here in the other Washington.  I’ll continue to report on the work in progress.

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I just learned that October is Health Literacy Month, via an article entitled  “Hospital discharge summaries are a health literacy issue” (a guest post by another physician) published on the KevinMD.com  blog.

(Background: this article had originally been posted on another blog called Engaging the Patient, sponsored by  Emmi Solutions, a healthcare communications firm which is promoting Health Literacy  Month.) 

The first paragraph described a patient as being a very elderly Filipino woman, and the article went on to explain how she had suffered some serious adverse effects because there was  a problem with how her Rx medicines had been prescribed.  Turned out that two of her meds had been combined into a single pill, a fact that was not apparent from the patient’s medication list.

But I was left wondering why the patient’s ethnicity was mentioned at all, since there was no discussion of any relevance to her health issues nor about if she had limited English skills, which also does not automatically track with ethnicity.  So I was surprised to read the following conclusion to the case study:

My hope is that this case illustrates the ways in which we might address health literacy issues using fail-proof systems-based approaches, rather than narrowly focusing our efforts on how we can build our patients’ capacity to interact with the health care system. Yes, teaching this patient to be a more fluent reader and to understand her prescription labels would have been ideal.

And we should have taught her to be more engaged and given her a phone number that she could call post-hospitalization to reach a Tagalog-speaking provider with questions about her discharge instructions or medications. But while we are working on engaging her with her care and teaching her to read prescription labels and providing enhanced communication support, let’s do what we can to “fix” the health literacy problem without involving Ms. Reyes at all.

Somehow the author made a non sequitur jump to depict the patient as  Limited English Proficient (LEP), but never once spoke of utilizing the services of  an interpreter at the hospital or if any  instructions had been translated for the patient.  It was likewise not mentioned that a pharmacist could have played an important role in the case. Seemingly this young physician knew nothing of the duties of the hospital to ensure communication between providers and patients, and is disseminating this scenario as typical.

So a response was in order.  I’m happy to say that my comments on the article were accepted for posting, and hope they will help make a dent.

My message for Health Literacy Month is that we need to seize the teachable moments.

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Several national health advocacy groups have put out an alert about some key changes to language access standards that have just been proposed for the communication responsibilities of certain federal agencies which regulate private health care plans. As we move forward towards the enactment of health care reform, it is critical that  everyone, including LEP individuals, have the same rights to get access to to plan information and help with insurance appeals.  Health insurance is of course a critical part of access to health care and thus of any individual’s health status. Communication is an essential part of health and health care.  Lack of communication access causes both personal harm and contributes to health inequalities between population groups, plus drives up health care costs for people and systems.  If the new proposed standards are enacted, they would roll back current rules which private insurance companies must follow to ensure language access for plan beneficiaries.

What you can do: there is a very short window of opportunity now available for  individuals and organizations to voice their concerns by submitting comments online to the federal government via a dedicated website.  The deadline for submissions  is 2 p.m, PDT, on Monday July 25 !

For details about this critical issue, and instructions on how to submit comments along with suggested language, please read the following memo from the National Senior Citizens Law Center (NSCLC), the Asian Pacific American Legal Center (APALC), and the National Health Law Program (NHeLP):

URGENT: Comments Needed on Important Language Access Standard

NSCLC, APALC and NHeLP asking advocates to submit by July 25

IMPORTANT: Please provide comments to the Centers for Medicare and Medicaid Services (CMS), Internal Revenue Service (IRS) and the Department of Labor (DOL) on proposed regulations governing private health care plans.  The regulations as proposed are a significant step backward from the version issued in 2010 and affect about 12 million individuals. They change the existing standards for oral interpretation and written translation in unprecedented ways. Please send in comments now and urge colleagues and networks to also take action.  

 The deadline for submitting comments to CMS on this proposed rule is 5 pm Eastern Time on Monday, July 25, 2011.

The National Senior Citizens Law Center (NSCLC), the Asian Pacific American Legal Center (APALC), and the National Health Law Program (NHeLP) urge you to submit comments using the guidelines below. Then, please spread the word to your listservs, networks, colleagues, and affected beneficiaries, near and far, who may care about language access issues!

Issue:  CMS, IRS and the DOL’s Employee Benefits Security Administration (EBSA) have jointly issued regulations governing the internal claims and appeals and external review processes for private group health plans and health insurance issuers (note: this does not directly impact Medicare and Medicaid plans).

These rules were first promulgated as interim final regulations in June 2010, and were relatively strong. After industry complaints, they were amended as of July 2011, and significantly watered down. The public has this opportunity to comment.

Here are the three major language access issues relating to internal claims and appeals and external review:

  1. Written translations for group health plans: The threshold for determining whether translation of vital documents is required is set at: 10% of county population for group health plans. Formerly this was at 10% of plan participants in a given language or 500 persons, whichever is less; where a group plan has less than 100 participants, 25% was used.
  2. Written translations for individual plans: The threshold for this group is also 10% of county population. This was set based on the Medicare Part C and D marketing regulation (a proposal that has since been changed as of 4/15/11 to 5%, as a result of many persons submitting comments against the 10%).  
  3. Oral interpretation: Although it has been well settled that civil rights law mandates that oral interpretation should be provided in the health and health insurance contexts for all languages, the proposed regulations set a new precedent and require oral interpretation ONLY in the languages that meet the 10% threshold.  This is a major issue that needs to be addressed.

The new proposed standards completely fail to recognize the needs of the approximately 12 million limited English proficient individuals in the United States that are estimated to be affected by these regulations. Many of these individuals may receive marketing materials and calls in their primary languages, but will not be able to access plan review and appeals under the new rules. Even Spanish speakers will be left out in most of the country, as only 172 counties meet the 10% county population threshold for Spanish (out of 3,143 counties in the United States). Besides Spanish, the new proposed translation threshold is met by Navajo in 3 counties (1 county each in AZ, NM, UT), Tagalog in 2 counties (both in AK), and Chinese in one county (CA). Only 177 counties would require translated materials. Only one county in the entire nation would have translations in more than one language: the Aleutians West Census Area (population of 5,505 total persons) would have Spanish and Tagalog translations.

We need everyone – even advocates that don’t usually work on private insurance issues and those who have never commented on a federal rule – to take action now.

What You Can Do: 

1. FILE COMMENTS:

a)   Go to   www.regulations.gov

b)   Enter keyword or ID as “group plan” and hit the “SEARCH” button

c)   Scroll down and choose “Group Health Plans and Health Insurance Issuers: Internal Claims and Appeals and External Review Processes” and click on “submit a comment” on right side

d)   Although the regulation is proposed by three agencies, you only need to submit once. The agencies will share the information.

e)   Paste in the comments below and edit them, or write your own, then “Submit.”

f)   You are not required to fill out other fields, although it may be helpful to provide your affiliation. If you wish, you may be anonymous.   Comments submitted are viewable online (after a processing period) by the general public.

SAMPLE COMMENT:

On behalf of [organization/myself], I wish to comment on the 10% threshold for translation and oral interpretation of private plan materials in the internal review and appeals contexts. I am… [add 1-2 sentences about yourself, organization or work with LEP individuals].  The 10% standard is far too high.  A more appropriate standard would be “5% of the plan’s population or 500 persons in plan’s service area, whichever is less” for large group plans, and 25% of population for small plans. Oral interpretation should be provided in all languages at all times. {Consider adding information about the impact on your clients when they cannot get documents in a language that they understand.}

2. Forward this email to all of your contacts – other advocates, providers, interpreters, beneficiaries affected, and urge them to also file comments.  The more comments filed, the more CMS/IRS/EBSA are likely to pay serious attention to this issue.

3. If you are bilingual or work with LEP populations, consider having them file comments in other languages as well as in English, for impact.

For more information about commenting and the proposed regulations, see www.nsclc.org and www.healthlaw.org .  Please feel free to submit detailed comments if you prefer.

Katharine Hsiao  khsiao@nsclc.org

Georgia Burke  gburke@nsclc.org

Kevin Prindiville kprindiville@nsclc.org

Mara Youdelman  youdelman@healthlaw.org

Doreena Wong dwong@apalc.org

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Can We Afford Personalized Medicine?

Special treatment for ‘high profile’ patients; exasperation for the rest of us

Health Insurers Making Record Profits as Many Postpone Care

People Who Donate Organs For Transplants Can Have Difficulty Getting Insurance

Foundations, Conflicts Of Interest And Drugmakers

Mission Crash: The Intolerable Policy Incoherence in US AIDS Policy, Global and Domestic

 Office of Minority Health Awards Major Project to Support
CCHI’s work on Healthcare Interpreter Certification

WA Governor signs precedent-setting healthcare worker safety laws

Washington is first state in nation to ban toxic pavement sealants

HHS awards $4.9 million to support families of children with special health care needs

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Urgent  messages  to the California State Board of Pharmacy asking them  approve regulations upholding the mandates of  SB 472, which was signed into law by Governor Schwarzenegger in 2008, are needed by close of business tomorrow,  Wednesday, March 10.

This law spoke to the need for readily-readable  (in minimum 12-point font) Rx labels, and required both translated labels and  use of interpreter services to offer personal  medication information to patients at pharmacies.   Advocacy groups  for senior citizens, consumer protection, health and safety, and immigrants, plus  pharmacy professionals, all supported the proposed  measures. all While the CSBoP ‘s original draft of regulations mandated these improvements, the version approved on Feb. 17 , reversed the changes and would  allow 10-point  font to be used, would not require use of translated labels, and would make pharmacy-level  interpreter services optional.  Reversal of the health-protective provisions of the law is attributed to intense lobbying  (and major gubernatorial campaign contributions)  by  national pharmacy chains and pharmaceutical companies. To make matters worse, the day before the Feb. 17 vote, Gov. Schwarzenegger appointed an executive from a major chain drug company to fill an open position on the CSBoP, and her vote swung the Board’s recommendations, as reported by the LA Times:

Drug executive cast key vote to kill labeling law

Pharmacy board was poised to OK measure opposed by one of the governor’s major donors until he named a CVS/Pharmacy official to the panel……

For more background on the issues, please visit the websites of the California Pan Ethnic Health Network,   Gray Panthers California, Consumer Union’s Safe Patient Project. The CSBoP website contains the text of the law and relevant materials on pending Patient-Centered Prescription Label regulations.

Send  your  by comments March 10 directly to Carolyn Klein, Manager, Legislation and Regulations for the CSBoP at:
carolyn_klein@dca.ca.gov

California residents can send comments  via the online form on Consumer Union’s Safe Patient Project .

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