A need for more interpreters in Valley [The Fresno Bee]

March 24--In the San Joaquin Valley, where roughly one in five people aren't fluent in English, providing health care interpreters is a challenge -- and could get worse under Obamacare.

About 170,000 limited-English speakers in the Valley will be newly eligible for insurance either from Medi-Cal or federally subsidized health plans on the state health-benefit exchange beginning in January. Statewide, about 1.5 million who lack fluency in English will qualify for insurance.

Many will need help communicating with health providers to get the most appropriate care. State and federal law mandate they get translating services.

Without it, "miscommunication can lead to inappropriate care, lack of follow-up care -- and medical jeopardy," said Dr. George Flores, program manager for prevention at The California Endowment, a private, statewide health foundation.

Managed-care health plans and state officials say they're prepared for more requests for translation. But critics say interpreter services in the state already are inadequate.

California is ill-prepared to train and provide competent interpreters for an influx of patients who don't speak English, they say. There are not enough people whose sole job is to provide face-to-face translation.

Right now, a patient has no guarantee that interpreting will be done by a trained professional in person, over the phone or on a computer, depending on whether the patient is in a hospital or doctor's office, or getting services from a healthcare insurer.

There's a lot at stake. A patient without access to an interpreter may be unable to provide feedback during a complicated medical procedure, or for something as simple as understanding why they are being taken for an X-ray and need to change into a gown.

Postponing care

Pang Thao, 59, of Fresno, cried as she recalled nurses removing her clothes during a 2009 overnight stay for stomach pains at Community Regional Medical Center.

"They just come in and take my clothes off, and I was so afraid," she said. "I didn't know what they were going to do to me."

Patient privacy laws prevented Community from commenting on the case.

Thao said after her discharge from the hospital, she found a Hmong-speaking family doctor. He told her that blood clots caused her stomach pains.

She continues to have pain off and on and said her doctor has told her she should go to the hospital when it's severe, but she won't -- she's too frightened.

Instead, she said, "I take a lot of pain medications."

Thao's story is among many that have been compiled by Interpreting for California, a group organized by the American Federation of State, County and Municipal Employees, one of the largest unions in the state. The Bee interviewed several of the women. Tom Vu and Macy Moua, volunteer interpreters, translated for them.

The union is pushing for more interpreters and for a requirement that interpreters pass a test and be certified to provide interpretation services for the state.

"It's in the interest of the state, particularly a state as diverse and multilingual as California, to have a work force of trained interpreters," said Amanda Ream, organizing director for Interpreting for California.

The union supports Assembly Bill 1263, introduced by Assembly Speaker John Perez, D-Los Angeles, which would require the state Department of Health Care Services to apply for federal matching funds to create a state-certified interpreter pool. The department oversees Medi-Cal, the state-federal insurance for the low-income and disabled.

The program would create a well-trained interpreter work force that managed care organizations, as well as small-group providers, could tap into, Ream said.

California has required commercial health plans to provide interpreting services since 2009. But providing interpreters has been common for much longer.

In 2000, federal guidelines made it clear the services had to be available at no charge to non-English speakers enrolled in Medi-Cal and Medicare, the federal insurance for the elderly and disabled.

California could take advantage of federal Affordable Care Act funds for interpreting services by providing an 11% match, Ream said. The state would need to allocate $250,000 from the general fund this year to start the program, which would be phased in over 10 years and cost millions of dollars, she said.

But the proposal could be a tough sell in the Legislature, especially for a state still digging its way out of budget deficits. A similar bill died in the Senate last year. Norman Williams, a spokesman for the Department of Health Care Services, said the department does not comment on pending legislation.

Meeting the need

It's difficult to gauge how many interpreters the state will need for face-to-face translation under health reform. It could depend on how effective outreach programs are at getting people with limited English fluency to apply for insurance.

About 110,000 limited-English speakers in the Valley will be eligible for coverage through the state health-benefit exchange, and about 60,000 will be eligible for Medi-Cal, said Ken Jacobs, chair of the University of California at Berkeley Center for Labor Research and Education. Jacobs has researched projected insurance eligibility in California for the state health benefit exchange.

Health reform could add more than 30,000 members -- a 15% growth -- to CalViva Health, the locally-governed Medi-Cal managed care plan for Fresno, Kings and Madera counties. It would increase interpretation requests by 138 a year, said Executive Director Gregory Hund. The health plan had 921 requests for interpreters in 2012.

Since health care interpreters are not an established occupation, it's hard to know how many are providing services now in the state.

John Capitman, executive director of the Central Valley Health Policy Institute at Fresno State, said the Valley could need 50 to 75 new professional interpreters in the next few years.

But it's unclear how quickly the state can train competent interpreters, who need to be fluent in English and another language and able to understand and translate complex medical terms, because the pipeline for training interpreters has shrunk over the past few years.

Community colleges that used to offer programs have cut them to tighten budgets. College of the Sequoias in Visalia dropped health care interpreting classes two years ago. Only one interpreter program, at Reedley College, provides a two-semester program in the Valley. The college offers classes for Spanish and Hmong interpreting.

"It's pretty obvious to me and others in our organization that there is just not enough basic training of health care interpreters going on out there," said Don Schinske, executive director of the California Healthcare Interpreting Association. The association has about 800 members.

The Hmong class at Reedley College has been very successful, said coordinator Rosie Carrillo. "A lot have jobs," she said.

But across the state, people coming out of programs with hundreds of hours of training can't find full-time jobs. Some hospitals prefer to train their own employees by providing eight to 40 hours of education, instead of hiring community college students who have 300 hours of training.

According to a March 2012 research brief of health care interpreters in California for community colleges, there were 289 job openings for interpreters statewide in 2011. Most were part-time and on-call jobs. Fresno County had 16 openings; Tulare and Merced counties had five each.

Companies and organizations that provide interpreting services to medical providers were the biggest employers of interpreters, the brief said. Other major employers were hospitals and medical centers.

Community Regional Medical Center, one of the busiest hospitals in the Valley, has five full-time Spanish interpreters and three who are hired on a day-by-day basis. It also has a Hmong and a Hindi/Punjabi interpreter who are employed on a daily basis, said spokeswoman Mary Lisa Russell. All of the interpreters have completed at least a 40-hour course, Russell said, and they also must pass a test that has been independently evaluated by a third party.

In 2012, the hospital had 48,879 interpreter interactions.

The hospital does in-house training and also contracts with Health Care Interpreter Network, a nonprofit organization, to provide 40 hours of online training, Russell said. Many of the interpreters have additional training beyond that, she said.

The regional medical center also uses the Health Care Interpreter Network for interpretive services by telephone or computer.

Translation by phone

Health care plans say they can handle more requests for interpreters under Obamacare -- but in many cases the service will be provided over the telephone.

Cal-Viva used telephone interpreters for 65% of the requests last year. Face-to-face interpretation was provided for 22% and sign language was provided for 13% of the requests.

Telephone-based interpreting services haven't always been widely accepted in the Valley. In 2002, California health officials pulled the plug on a translator-by-telephone pilot project when it couldn't persuade Fresno doctors to use the system. Doctors could dial up a toll-free number to reach interpreters in Spanish, Hmong and Vietnamese, but only 13 out of 150 Fresno physicians agreed to participate.

Doctors at the time said they had concerns the system would be cumbersome and time-consuming.

But telephone interpreting may be the only option in areas with diverse populations such as Fresno County.

According to the federal Centers for Disease Control and Prevention, 65 languages other than English are spoken in homes here. While Spanish and Hmong are the two most common non-English languages, Aztecan, Apache, Dutch, Ukrainian and Chinese are among the county's many languages spoken.

At Community Regional Medical Center, health providers have access to telephone interpreting through a phone they can take with them into patient rooms, Russell said.

The phones are at every nursing station and it's as easy as picking up the phone or any desktop phone and dialing a two-digit number to be immediately connected to a menu of language options, she said. Options included Spanish, Tagalog, Russian, Cantonese, Hmong, Mien, Punjabi and more, she said.

There are limitations, however, to using phones for interpreting, health educators said. Lou Vang, 25, of Fresno, began having seizures in 2007 and has had telephone and face-to-face interpreters at medical appointments. It wasn't until she had in-person interpreting that she felt comfortable and safe. Since 2010, her seizures have been under control, she said.

"You have questions to ask and also they listen to you," she said. "On the phone, you feel rushed to ask questions and they don't answer."

Doctors and clinics often use bilingual health care staff to interpret, but that can have downsides, said Nora Goodfriend-Koven, coordinator of the health care interpreter certificate program at City College of San Francisco, which began offering interpreting classes 15 years ago.

Small clinics may use bilingual staff who don't have medical interpreter training, she said. "That really does concern me." Workers may be unfamiliar with medical terms outside the specific medical area where they work, and they can be pulled away from their regular jobs to interpret, she said.

Goodfriend-Koven said she also sees a lot of adult family members acting as interpreters. Often patients choose to have relatives translate, but she finds this problematic. "Sometimes they do miss out on important information the patient needs to know," she said.

Family members often are called upon to interpret because people don't know they can ask for interpreters, said Ellen Wu, executive director of the California Pan-Ethnic Health Network, a statewide multicultural health advocacy organization. "They still think they have to bring their family members with them" to medical appointments.

The burden for requesting an interpreter is placed on the patient instead of health plans, Wu said. Health plans should be the patient's advocate, encouraging the use of trained professionals even when the patient has a family member with them to interpret, she said.

Fresno hospital officials, while unable to comment on specific cases because of patient privacy, said providing interpretation services is taken seriously.

Community has a cultural competency committee that believes "a patient's ability to understand and be understood is one of the most important patient rights," Russell said.

Not having access to those rights can make a scary hospital experience even more frightening.

Shang Yang, 55, of Fresno, is afraid to go to a hospital since spending a week at Community Regional Medical Center in 2010.

She was taken by ambulance to the hospital for shortness of breath. In the emergency department, her pastor came and translated for her. But after he left, she said, she couldn't understand the nurse who took her to a room and inserted an intravenous line into her arm.

Yang said an injection caused her heart to race, but she couldn't tell the nurse. Her daughter came to visit and got help, but until then, she said, "I thought I was going to die."

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MORE ONLINE

Centers for Disease Control and Prevention snapshots of populations: http://www.bt.cdc.gov/snaps/data/06/06019_lang.htm

California Simulation of Insurance Markets by UCLA Center for Health Policy Research and UC Berkeley Labor Center: http://www.healthexchange.ca.gov/BoardMeetings/Documents/UC%20Exchange%20Board%20Meeting%20Handouts%20for%203-22-12%20v5.pdf

California Pan-Ethnic Health Network: www.cpehn.org/democharts.php

California Health Benefit Exchange: www.healthexchange.ca.gov/Pages/ Default.aspx

California legislation: www.leginfo.ca.gov/

The reporter can be reached at (559) 441-6310, [email protected] or @beehealthwriter on Twitter.

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