The Talking Cure

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In a converted East Flatbush storefront, at the end of a row of fruit stands, about 50 people are packed into the waiting room of a community health clinic, chatting in a cacophony of languages. “Mondays are always heavy days,” explains Dr. David John, the medical director. “People get sick over the weekend and have to wait until we open.” Many are walk-ins: the clinic, run by Lutheran HealthCare, only books two-thirds of its appointment slots ahead of time, to leave room for those with sudden illnesses.

Patients who speak Creole have been assigned to one of three Creole-speaking doctors. Those who speak Spanish will see one of four part-time MDs who speak Spanish. English-speakers have a choice of all seven. “When we opened in 1998, that first year, we had 5,000 visits,” says Dr. John. “In 2003, we had 20,000.” To accommodate the burgeoning demand, Lutheran purchased the vacant restaurant next door and plans to use the space to offer more gynecological services and more free pregnancy and HIV testing. Meanwhile, Dr. John travels to his home country of Trinidad once a month to set up a $3.4 million, four-year program to train health care workers in anti-retroviral therapies. “We have a lot of immigrants who actually live here for six months and go back for six months,” Dr. John explains. “We see ourselves as taking care of them on this side and on that.”

The Caribbean-American Health Center is one of nine clinics that Lutheran runs in southwest Brooklyn. Founded in 1883 by a Norwegian nurse, Lutheran has seen its Sunset Park neighborhood change from Scandinavian to Puerto Rican to the mélange of ethnicities it is today: Arab and Russian to the southeast, Chinese in the south, and Latino all over. The health care system has picked up the languages of its clients along the way. “From a pure business point of view, Lutheran Medical Center had to respond to its community needs if it wanted to remain a health and social institution,” says Executive Vice-President Jim Stiles. “Our neighborhood was changing. We had to change.”

Lutheran expanded its geographic reach, too–satellite clinics stretch to Park Slope, Fort Hamilton, and East Flatbush. Some of Lutheran’s clinics tread on territory once claimed by other hospitals’ outpatient units. Yet Lutheran’s financial backers were confident it could attract patients–clients other health care providers were ignoring.

Brooklynites who don’t speak English were among those underserved groups. The number of inpatient and outpatient visits by Chinese, Arab, Latino and Russian patients doubled to 79,000 annually between 1999 and 2003. Somehow, Lutheran has made it all work: it speaks the local language, treats the poor and uninsured, and has run surpluses in each of the past four years.

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Health care institutions in New York City are finally beginning to speak to their patients in their own languages–something they’re supposed to have done all along. The mandate stretches back to the clause in the Civil Rights Act prohibiting discrimination because of national origin in programs receiving federal funds. An executive order by President Clinton in 2000 stipulated that the act guaranteed “meaningful access” to federal programs by people with limited English skills. Since then, the Department of Health and Human Services has drafted and redrafted its regulations three times, most recently stating that health institutions must extend language access for “critical services while not imposing undue burdens” on the institutions.

Immigrant advocates say a more rigorous mandate is needed. “The health care system is in denial,” says Adam Gurvitch, director of health policy at the New York Immigration Coalition. “If they needed a new CAT scan machine they would find the money. Language access is an essential service. Why can’t they find the money?”

Even as the regulators hash out the rules, local medical centers are making some important strides. At Gouverneur and Bellevue hospitals in Manhattan, the New York City Health and Hospitals Corporation is testing a high-tech audio network: A doctor and patient in the examination room are hooked up to an interpreter at a translation center elsewhere on campus.

But New York hospitals still lobby against new legal requirements for translation. Last November, the New York State Assembly held a hearing on a bill that would require hospitals to file an annual report documenting their patients’ language needs and what services are available. Susan Waltman, general counsel of the Greater New York Hospital Association called the legislation an unfunded mandate. Private medical centers, Waltman testified, “are simply unable to undertake additional efforts on any front without significant infusions of funding, not just for the specific purposes targeted but in order to keep them operating for the benefit of everyone.”

New York hospitals do already have a legal obligation to provide interpretation and translation of important forms and oral instructions. They don’t always comply with it. Last year, the state Attorney General’s office negotiated agreements with four hospitals that had been the subject of complaints they had failed to provide translation services, including Wyckoff Heights Medical Center and Woodhull Hospital, both in Bushwick. The Brooklyn agreements, which came about under pressure from the advocacy group Make the Road by Walking, required the hospitals to hire language coordinators and tap into the language skills of their entire staffs.

The problems identified at those hospitals don’t appear to be isolated. In a survey of patients from four hospitals last year, the New York Immigration Coalition found that two-fifths didn’t receive services in a language they knew, and one-fifth did not understand their diagnosis or treatment. One in 10 said they had medical decisions made without their consent.

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It is hard to say just how well Lutheran HealthCare meets patients’ language needs compared with other health systems in the city, but local leaders in Sunset Park say they are satisfied with what they’re getting. “Our perception is that it’s a real community hospital,” says Elizabeth Yeampierre, executive director of the United Puerto Rican Organization of Sunset Park. “It has a culturally sensitive bilingual staff.” More than half of Lutheran’s 3,000 employees speak a second language.

Lutheran’s policy, established three years ago, is to start by asking new patients their language preferences. A patient is assigned a staff member, usually one trained in medical translation at the New York University Center for Immigrant Health, to act as interpreter. A patient’s child cannot serve as translator–a traumatic event should the parent be diagnosed with serious illness. Nor can an adult relative.

Each day, a staff of 10 bilingual patient representatives–speaking Spanish, Arabic, Russian, Cantonese and Mandarin–receives a list of patients who are scheduled to come in the following day. They call each one and ask, in their own language: Do you know how to get here, and where to enter? Any questions? The rep then greets the patients when they arrive for their appointments. The patient representatives spend about three-quarters of their time interpreting and the rest giving patients general assistance.

Outlying clinics are able to serve language needs even more directly. The entire medical staff at the Brooklyn Chinese Center speaks Mandarin and Cantonese. One doctor at the Park Ridge Center speaks Arabic, two Spanish, three Hindu and Urdu and another Mandarin. A last resort is a commercial telephone link that connects doctor and patient through medical interpreters located off campus.

Virginia Tong, Lutheran’s vice president for cultural competence, acknowledges that the system can appear confusing, since each patient is accommodated in different ways depending on the circumstance. The only Arabic-speaking patient representative serves both clinic and hospital, which keeps her running back and forth. But Tong says the bottom line is that the hospital can guarantee that all patients are served in their own languages. “Communication is the crux of health care,” says Tong, who knows three Chinese dialects, understands a fourth and speaks some Spanish. “Even if you are bilingual, when you are talking about health care, when you are talking about your body, only in your native tongue do you really feel comfortable.”

Still, more than half of all immigrants in New York City don’t have health insurance. How does Lutheran provide these translation services and still survive financially? The answer lies in savvy grant-seeking and prescient decisions about managed care. Almost four decades ago, the hospital opened a community health center–now one of 26 federally certified centers in New York City and the only one allied with a hospital. The center must serve uninsured patients and charge a sliding fee based on income. Health centers’ mission to serve their communities also encompasses language services–from translators to multilingual signage–monitored through site visits by HHS personnel. Lutheran receives an annual grant to reimburse the cost of those services–$7.7 million this year, out of the health center network’s $100 million budget.

The experience that the federal grant gave Lutheran among the underserved also gave it a track record attractive to foundations, which, together with competitive federal grants, contribute about $17 million annually. “We would go out and get grants that would help us take care of the at-risk and uninsured,” recounts Stiles. “Very few hospitals have gone after grants for this purpose. They go after grants for medical research.”

The medical center began to set up satellite clinics, by teaming up with local community organizations. These clinics have a distinct competitive advantage. Medicaid reimburses at generous rates for hospital inpatient care and services at federally certified clinics. By contrast, satellite clinics run by Lutheran’s competitors are considered outpatient arms of hospitals and therefore are stuck under a punishing reimbursement rate set during the 1980s.

In addition, Lutheran had the foresight in 1984 to set up a Medicaid managed care program of its own, Health Plus. Many poor immigrants qualify for government-sponsored health care coverage, including all children and pregnant women, regardless of legal status. Undocumented adult immigrants can at the very least get emergency room bills paid. Medicaid brought in $115 million a year to the entire system in 2001, which, counting the hospital, had a budget of $280 million. The Lutheran health system thus has an incentive to enroll as many of its own patients as possible in HealthPlus, including those who don’t speak English.

Lutheran does not break out a budget for how much it spends on interpretation, but analysts elsewhere have sought to come up with estimates of what it costs a hospital to translate. The federal Office of Management and Budget found it would add 0.5 percent to the cost of treating a patient. Immigrant advocates and health care experts agree that substantial pools of public and private money have yet to be tapped. “It is probably not enough to cover all language services all over the country at this time,” says Mara Youdelman, staff attorney at the National Health Law Project, “but there are sources of money out there.”

Two are Medicaid and the State Children’s Health Insurance Program, through which the federal government can match each state dollar spent on interpretive services for enrolled patients with between 50 and 65 cents of its own. Ten states are doing this. But with the governor and state legislature hustling to slash rising state and local Medicaid costs, New York is unlikely to join them. New York administers other grant programs that hospitals could draw on, among them the $250-milllion-a-year Community Healthcare Conversion Demonstration Project.

The cost of offering language access also has to be balanced with the cost of not providing it. Five years ago, a county health official in California asked a Laotian woman with tuberculosis why she had stopped taking her medication. A Hmong man tried to interpret, but since he spoke no Lao, she thought he was asking if she felt like she was going to die. She did–the side effects were what made her stop taking the medication. But the interpreter thought the woman was threatening to kill herself, and the patient was put in jail for 10 months on suicide watch. The county paid $1.2 million in damages. An interpreter costs about $40 an hour.

Matthew Schuerman is a Brooklyn-based freelance writer.