What is the “Language Barrier Premium,” and how does it impact healthcare?

The United States is more linguistically diverse than ever. As of 2015, there were at least 350 languages spoken in U.S. households. One in five people living in the U.S. speak a language other than English at home. Of those, approximately 41 percent are Limited English Proficient (LEP), which means they speak English less than “very well.”

When it comes to healthcare in the United States, a person’s ability to speak English plays a surprising role in their access to care and health outcomes. Research studies have shown that people with limited English proficiency face health disparities such as decreased access to healthcare, reduced quality of care, and decreased satisfaction with their care.

One way to decrease these disparities is to ensure patients have access to professional medical interpreters while they’re in the hospital. Interpreters can help medical professionals go over treatment plans such as wound care instructions, insulin regimens, and postpartum care, among other things. Unfortunately, language services are not reliably available in many hospitals. A 2016 survey done by the American Hospital Association showed that only 56 percent of hospitals offered language services to their non-English speaking patients.

A language barrier is a treatment barrier

This absence of language services not only increases disparities, but it also increases costs for patients and hospitals alike. A study reported in the Archives of Pediatrics and Adolescent Medicine found that when physicians encountered a language barrier, they tended to adopt a more costly treatment plan. Physicians “up-triaged” their patients – they ordered more diagnostic tests, more invasive treatments, and used a lower clinical threshold to admit LEP patients to the hospital. The authors coined this phenomenon as the “language barrier premium,” referring to the cost premium associated with an encounter when a language barrier existed.

This increase in costs is unsurprising to many healthcare workers. Without access to interpreters, patients and providers are essentially tongue-tied. Providers are forced to rely heavily on diagnostic tools to determine a treatment plan, while patients are unable to engage in their own care.

Dr. Francisco Javier Andrade, a resident physician at Atrium Health, says that when patients have a language barrier in the emergency department, he considers the challenges they are going to face when coordinating their care.

“There’s not only a language barrier when they are with you in the emergency department, but there’s also a language barrier for them outside of the hospital, which includes them trying to get any meds they need, arrange any transportation, trying to establish care with a primary care doctor. Their language barrier doesn’t only apply when we see them; it applies to all facets of their life.”

The price of admission

Studies have shown that the concern for proper follow-up often leads physicians to admit LEP patients more readily. Physicians understand that coordinating follow-up care is challenging for patients; add a language barrier, and it becomes an insurmountable task. Providers use this workaround to schedule follow-up appointments and coordinate care for patients that would otherwise face linguistic barriers doing so.

Because of this, admission costs are likely the most substantial part of the language barrier premium. Costs related to hospital admissions constitute the largest share of healthcare spending in the United States. In 2010, the average cost per hospital stay was $9,700. The aggregate cost for all hospital stays that year totaled $375.9 billion.

Additionally, hospital stays result in direct and indirect costs for families. Direct costs include healthcare costs and medications. Indirect costs include travel, accommodation, time off work, childcare, and food. A study published in the Journal of Pediatrics and Child Health aimed to measure the monetary effect that hospitalizations have on families. The study concluded that the total cost for families was estimated to be $458 per day. Consequently, higher admission rates in LEP patients may disproportionately burden them with the costs associated with admissions.

Reversing the trend

This reality has prompted some hospitals to adopt broad language access reform. A study done at the Children’s Hospital of Atlanta found that implementing access to language services reversed disparities that had been previously documented. Implementing these changes led to a decrease in factors that contribute to the language barrier premium, such as increased readmission rates and return-visit rates in their LEP patients.

One step healthcare systems can take to reduce the language barrier premium is ensuring the presence and utilization of qualified medical interpreters. One study examined the effect of providing interpreter services during an 8-month intervention period. In this case, paying for qualified interpreters actually lowered overall costs. They found a decrease in readmission rates and a monthly hospital savings of $161,404, after accounting for the costs of interpreter services.

Another step is filling the communication gaps that make it difficult to coordinate follow-up appointments. Providing patients with toll-free numbers that connect them directly with interpreters is a way to reduce these barriers. These services allow LEP patients to make follow-up appointments, find out test results and contact their physicians directly.

Equally important is increasing the presence of multilingual healthcare providers. This reduces the costs associated with the language barrier premium and is a crucial step in evolving the healthcare system into one that can provide linguistically equitable care.

In the last 30 years, the LEP population has increased by 80%. Since then we’ve learned more about the role language plays in health disparities. Failing to meet the language needs of patients has often resulted in increased costs and a decrease in desirable outcomes. Systemic changes to language services access are essential to a healthcare system that accounts for our linguistic diversity. Implementing these changes paves the way for 25.1 million people to have equal access to healthcare, and improves the long-term health of our communities.

Nicole Tavarez writes about the relationship between language and healthcare. She works at ALTA as a Language Access Advisor, collaborating with healthcare organizations to improve language access for patients that are Limited English Proficient.

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