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LEP HMO Enrollees Communication Barriers

LEP HMO Enrollees Communication Barriers

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Health Policy Brie 
February 2013
Limited English Profcient HMOEnrollees Remain Vulnerable toCommunication Barriers DespiteLanguage Assistance Regulations
Max W. Hadler, Xiao Chen, Erik Gonzalez and Dylan H. Roby
SUMMARY:
HMO enrollees with limitedEnglish profciency, and particularly those inpoorer health, ace communication barriersdespite language assistance regulations. Morethan 1.3 million Caliornia HMO enrollees ages18 to 64 do not speak English well enough tocommunicate with medical providers and mayexperience reduced access to high-quality healthcare i they do not receive appropriate languageassistance services. Based on analysis o the 2007and 2009 Caliornia Health Interview Surveys(CHIS), commercial HMO enrollees with limitedEnglish profciency (LEP) in poorer health aremore likely to have difculty understandingtheir doctors, placing this already vulnerablepopulation at even greater risk. The analysis alsouses CHIS to examine the potential impact o health plan monitoring starting in 2009 (due to a2003 amendment to the Knox-Keene Health CareServices Act) requiring health plans to provideree qualifed interpretation and translationservices to HMO enrollees. The authorsrecommend that Caliornia’s health planscontinue to incorporate trained interpreters intotheir contracted networks and delivery systems,paying special attention to enrollees in poorerhealth. The results may serve as a planning toolor health plans, providing a detailed snapshoto enrollee characteristics that will help designeective programs now and prepare or a likelyincrease in insured LEP populations in theuture, as ull implementation o the AordableCare Act takes place over the next decade.
A
lmost two-thirds o limited Englishprocient commercial HMOenrollees who reported communicationbarriers were in air or poor health. Therecent implementation o regulations toimprove commercial HMO provision o language assistance services may eventuallyhelp increase understanding, but in therst year o implementation, it does notappear that HMO policies ensuring accessto language-appropriate services have led toimmediate improvements in communicationor the sickest enrollees.
Requirements or HMOs to ProvideLanguage Access Services
In response to the passage o the Knox-Keene amendment in 2003, languageaccess regulations were established in 2007or all health plans covered by Caliornia’sDepartment o Managed Health Care (DMHC)and select plans covered by the CaliorniaDepartment o Insurance (CDI). The newregulations require insurers to assess theirmembers’ languages o preerence and provideverbal interpretation in all languages, andwritten translation in threshold languages.Threshold languages generally include Spanishand Chinese and, or some health plans,
HMO enrolleesin poorer healthexperience thebiggest languagebarriers.
Funded by the Caliornia Ofceo the Patient Advocate
 
UCLA CENTER FOR HEALTH POLICY RESEARCH
2
Vietnamese, Russian, Korean, Tagalog, Khmer,Armenian, Arabic, and/or Hmong.
2
DMHCbegan monitoring health plan compliance in January 2009, when all HMOs were requiredto have ully implemented language accesspolicies and procedures.The law is particularly important in the currenthealth policy environment as LEP populationswill make up a signicant portion o the newlyinsured ater implementation o the AordableCare Act, including via the state’s healthbenets exchange, Covered Caliornia. A recentUC Berkeley and UCLA analysis estimated that29% to 36% o non-elderly adults who take-upsubsidized coverage in Covered Caliornia willbe LEP.
3
 In this study, we examine the LEP HMOenrollee population and attempt to measurecommunication barriers and early progresssince the Knox-Keene amendment wentinto eect. A limiting actor is that datarom 2009 may reer to language barriersthat existed as early as September 2007 andas late as April 2010 since respondents are
This publication containsdata rom the CaliorniaHealth Interview Survey(CHIS), the nation’s largeststate health survey.Conducted by the UCLACenter or Health PolicyResearch, CHIS data givea detailed picture o thehealth and health careneeds o Caliornia’s largeand diverse population.Learn more at:
www.chis.ucla.edu
 LEPCaliornianswill make up a signifcant  portion o thenewly insured under healthcare reorm.
Defnitions
Threshold languages
Determined by the demographic makeupo a health plan’s membership, these arelanguages or which plans must providetranslated vital documents, includingapplications, consent orms, letters abouteligibility or participation criteria, andnotices advising changes in benets andavailability o ree language assistance.
1
Knox-Keene Health Care Services Act
 Caliornia law established in 1975 thatregulates managed care plans. The law hasbeen amended multiple times since itsinception, including in 2003 to addresslanguage access issues as a result o SenateBill 853.
Limited English Profciency (LEP)
 Individuals who reported speaking Englishnot well or not at all.
Fee-or-Service (FFS)
A method o payment in which health careproviders are paid per service rendered.In Caliornia, most ee-or-service care isdelivered to Medicare beneciaries andMedicaid enrollees living in rural areas.
Preerred Provider Organization (PPO)
 A health insurance plan that encouragesmembers to seek care through contractedproviders by requiring patients to pay alarger share or services delivered outsideo its contracted network o providers. Forexample, a patient can see an in-networkprovider and pay 20% o the provider’s ee,or see an out-o-network provider and pay40% o that provider’s ee.
Health Maintenance Organization (HMO)
A health plan that requires members toseek care in a contracted network. HMOstypically use primary care physicians andother protocols to authorize specialty careand medical procedures. Care deliveredout-o-network is not covered except inemergency situations.
 
UCLA CENTER FOR HEALTH POLICY RESEARCH
3
Percent o Enrollees Who Are Limited English Profcient by Type o Insurance, Ages 18-64,Caliornia, 2007-2009Exhibit 1
35%30%25%20%15%10%5%0%Commercial HMO Commercial PPO Public HMO Public FFS8.3% 9.0%4.4%4.8%23.9%27.2%23.8%27.2%2007 2009
Note: Based on chi-square test o proportions or each insurancecategory between 2007 and 2009. See Appendix 1 orurther details.Sources: 2007 and 2009 Caliornia Health Interview Surveys
 LEP enrolleesrepresent a substantial  portion o membershipin manyHMO plans.
asked about experiences up to two yearsprior to being surveyed. Although theregulations were published in early 2007,some o the results reported here preceded theimplementation deadline in 2009. These dataare an intermediate measure o progress towardimproved language access ater 2009.
Limited English Profcient a SubstantialProportion o HMO Membership
In 2009, nearly one in eight HMO enrolleesin Caliornia was LEP. A much largerproportion o enrollees in public programssuch as Medicare and Medicaid (27.2%) wereLEP when compared to those in commercialplans (9.5%), but the total number o LEPenrollees in commercial HMOs (842,000)was substantially larger than in public HMOs(460,000) given the greater number o peoplewith commercial coverage (Exhibit 1 andAppendix 1). Examining large commercialinsurers individually, LEP enrollees representeda substantial proportion o membership inmany HMO plans (Exhibit 2 and Appendix 2).The change in LEP as a percentage o allenrollees did not change signicantly rom2007 to 2009 or commercial or publicHMOs. This suggests that the plans have arelatively consistent membership prole togauge demand and plan or language assistanceservices or language concordance with healthcare providers.

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