BILL ANALYSIS Ó
AB 2392
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Date of Hearing: May 9, 2012
ASSEMBLY COMMITTEE ON APPROPRIATIONS
Felipe Fuentes, Chair
AB 2392 (John A. Pérez) - As Amended: April 24, 2012
Policy Committee: HealthVote:14-5
Urgency: No State Mandated Local Program:
No Reimbursable: No
SUMMARY
This bill establishes a program to provide medical interpreter
services to limited English proficient (LEP) Medi-Cal
beneficiaries. Specifically, this bill:
1)States the intent of the Legislature to create a program to
provide reliable access to language interpretation for LEP
Medi-Cal beneficiaries, and to enable trained and qualified
interpreters to meet the demand for language services among
LEP Medi-Cal beneficiaries.
2)Requires the Department of Health Care Services (DHCS) to seek
federal funding to establish a program to provide and
reimburse for medical interpreter services.
3)Requires the program to serve Medi-Cal beneficiaries in either
fee-for-service or managed care.
4)Allows a health care provider or entity entering into a
provider agreement or a managed care contract with DHCS,
including Medi-Cal managed care organizations (MMCOs) and
their subcontracting plans, and fee-for-service providers, to
use the program.
5)Requires MMCOs contracts and their subcontractors, including
health providers and other health plans, to include provisions
describing access to medical interpreter services under this
program.
6)Requires DHCS to pursue all available sources of federal
funding to establish and administer the program and seek any
federal approvals necessary to implement this article.
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FISCAL EFFECT
1)Costs for a number of activities are noted below. All costs
would be at a 50% GF, 50% federal funds matching rate except
for costs associated with services used by children, subject
to federal approval. Pursuant to the Children's Health
Insurance Program Reauthorization Act of 2010 (CHIPRA) and
subsequent federal guidance, language services for children
can be claimed at a 25% GF, 75% federal funds matching rate.
Children comprise approximately half of the Medi-Cal
population.
2)An exact estimate of the cost of language services is
difficult given a lack of accurate projections about how, by
whom, and with what frequency a centralized system would be
used. Assuming 1.5 million LEP individuals receive one
additional office visit annually with interpretive services
provided through this program at a cost of $20 per visit,
additional costs of $30 million annually.
3)One-time administrative costs in the range of $1 million to
DHCS to seek federal approvals, create system protocols,
develop an IT infrastructure, design communications and
guidance, promulgate regulations, and other initial program
development activities.
4)Ongoing DHCS costs, potentially in the range of several
million dollars, to administer a centralized medical
interpreter program. Costs would depend on the volume of
services and how billing and payment for these services was
structured.
5)If DHCS establishes an accreditation system for qualifying
language providers as stated in the intent language of this
bill, one-time costs of $100,000 to develop standards and
promulgate regulations, as well as $50,000 or more ongoing to
credential these providers.
6)Potential impact on medical services used is also difficult to
estimate, but improved access to high-quality interpretive
services is likely to improve access to care and increase
overall medical costs to the Medi-Cal program for LEP
beneficiaries. It would also likely result in some offsetting
cost savings associated with the provision of higher-quality
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care and fewer medical errors. The magnitude of savings as
compared to costs is unknown, but evidence suggests that, on
balance, the Medi-Cal program would experience increased
medical costs if centralized, high-quality interpretive
services were available.
COMMENTS
1)Rationale . The author states there is no provision in current
law that requires DHCS to maximize federal funding for these
services. While the state does use some federal dollars for
these purposes, the author indicates there may be other
opportunities to draw down additional federal funds.
2)Background . It is well-documented that limited proficiency in
English is a risk factor for reduced access to health
services, decreased satisfaction with care, poor understanding
of instructions, longer hospital stays, and increased risk of
medical errors and misdiagnoses. A recent study found LEP
hospital patients are more likely than their English-speaking
counterparts to experience adverse events that result in harm,
and the severity of that harm is often greater.
Title VI of the federal Civil Rights Act of 1964 requires that
any health care provider accepting federal funds must provide
linguistically accessible services to all patients. Linguistic
accessibility standards have been upheld and further clarified
through a number of related court decisions, regulations,
guidance, and executive orders. However, these standards
appear flexible and do not appear adequate to ensure
high-quality services are available everywhere. For example,
HHS guidance indicates smaller recipients with more limited
budgets are not expected to provide the same level of language
services as larger recipients with larger budgets. The
provision of language services in current practice appears to
be highly variable across the state, varying based on the
proportion of LEP persons served, health care
provider/facility priorities, and available resources.
This bill intends to establish medical interpreter services as
a separate program that would be made uniformly available to
all LEP Medi-Cal beneficiaries.
3)Medi-Cal Language Access Services Task Force Study . In 2009,
the Medi-Cal Language Access Services Taskforce released a
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report detailing their findings based on three years of work.
This group was comprised of stakeholders including advocates
for minority rights and health access, LEP consumers,
facilities, provider groups, and state government
representatives. This effort was intended to design a system
that could accommodate large numbers of persons whose primary
language was other than English. One of the effort's guiding
principles was that federal and state governments should
establish and fund mechanisms through which language access
was available to Medi-Cal beneficiaries.
The Taskforce Report included a recommendation to DHCS
described as a hybrid Brokerage/Direct Provider Reimbursement
model to finance the provision of language services within the
Medi-Cal FFS program. The Taskforce proposed a two-year pilot
project in 10 counties to sufficiently test the model.
Subsequently, DHCS undertook a planning effort for a pilot in
collaboration with community based organizations. However,
due to lack of funds, no pilot ensued.
This study was specific to the Medi-Cal FFS program; the
report notes that language services in Medi-Cal managed care
are negotiated between the state and managed care plans. At
the time of the study, more than half of the Medi-Cal
population was receiving benefits through FFS. Now the
majority is enrolled in managed care, and the proportion
enrolled in managed care is likely to grow, suggesting the
recommendations of this study are more relevant to the program
as it existed in 2009 than they are today.
4)Medi-Cal Managed Care Contracts Require Language Access . MCMC
contractors must also follow cultural and linguistic
competency requirements outlined in the contract and a series
of policy letters issued by DHCS. The contract contains strong
provisions related to linguistic access, including a
requirement that plans to provide no-cost, 24-hour access to
interpreter services for all monolingual,
non-English-speaking, or LEP Medi-Cal beneficiaries at all key
points of contact either through interpreters or telephone
language services. Advocates state there is often limited
access at the provider level in spite of these contractual
requirements.
5)Medical Interpreters . There is currently no universal
certification required of interpreters and translators.
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However, workers can pursue voluntary certification to show
proficiency, and there are short training courses available
that are specific to medical translation.
6)Fiscal Comments .
a) Potential Cost Shift . The program envisioned in this
bill may increase the availability and improve the quality
of language services to Medi-Cal enrollees, but it also
would encourage a significant cost shift from private
providers, who are currently required to provide these
under federal law and/or managed care plan contracts, to
the state.
In addition, some of the providers that do offer quality
interpretive services already receive indirect
reimbursement for these services. For example, public
hospitals have well-established interpretive networks.
These hospitals have unique funding arrangements whereby
they do not receive direct reimbursement from the state,
but instead certify their own expenditures for language
services as eligible for federal matching dollars. Many
federally qualified health centers (FQHCs) also provide
interpretive services, and receive reimbursement for these
services as part of an all-inclusive per-visit rate that is
based on the FQHC's total costs.
b) Increased Access = More Medical Costs . LEP patients
commonly cite language barriers as the single greatest
barrier to care. There is widespread agreement that
accessible, appropriate, linguistically competent care is a
laudable goal for the Medi-Cal program. However, improved
access to care generally means an increase in the use of
medical services, which increases costs. It is certain that
in some instances, inefficient care as a result of language
barriers results in extra procedures or higher costs, and
that improved access to language services could have
prevented such costs. However, if high-quality language
services were reliably available and communication was no
longer a barrier, it is likely that this increased access
would result in greater use of health care services. To
illustrate this point, a recent study attributes at least
part of a wide disparity in total health care costs to the
lack of language access. It found average medical spending
is far greater for insured White, non-Hispanics ($2,325 per
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year) than for insured Latinos ($1,840) and Asians
($1,471).
Another study identified significant disparities in
preventative health care utilization between
English-speaking and non-English speaking Latinos after
adjusting for demographic and socioeconomic
characteristics, health status, and access to care. 54% of
Hispanics who spoke English at home received recommended
preventative services, compared to 45% for Hispanics who
did not speak English at home but who were comfortable
speaking English, and 35% for Hispanics who did not speak
English at home and were uncomfortable speaking English.
The study suggested that increased access to interpreters
and bilingual health care providers would be expected to
reduce disparities caused by difficulties with English in
the LEP population.
Although certain preventative services are cost-neutral or
cost-saving, it is well-documented that many are not. A
letter from the Congressional Budget Office U.S.
Representative Nathan Deal on the CBO's analysis of the
prevention funding in the federal health care reform bill
states, "Although different types of preventive care have
different effects on spending, the evidence suggests that
for most preventive services, expanded utilization leads to
higher, not lower, medical spending overall." This is
because, in general, a large number of people need
preventative services, such as cancer screening, to detect
or prevent a small number of cases.
In sum, increasing access to high-quality language services
in the Medi-Cal program would be likely to reduce health
disparities, improve LEP patient satisfaction, improve the
quality of care provided to LEP patients, and increase the
use of preventative care. However, it is also likely to
increase total medical expenditures for LEP patients.
Analysis Prepared by : Lisa Murawski / APPR. / (916) 319-2081