By Michelle Andrews

A visit to the emergency department or a physician’s office can be confusing and even frightening when you’re trying to digest complicated medical information, perhaps while you’re feeling pain or discomfort.

For the 25 million people in the United States with limited English proficiency, the potential for medical mishaps is multiplied.A trained medical interpreter can make all the difference. Too often, however, interpreter services at hospitals and other medical settings are inadequate.

Family members, including children, often step in, or the task falls to medical staff members who speak the required language with varying degrees of fluency.

According to a study published in March, such ad hoc interpreters make nearly twice as many potentially clinically significant interpreting errors as do trained interpreters.

The study, published online in the Annals of Emergency Medicine, examined 57 interactions at two large pediatric emergency departments in Massachusetts. These encounters involved patients who spoke Spanish at home and had limited proficiency in English.

Researchers analyzed audiotapes of the visits, looking for five types of errors, including word omissions, additions and substitutions as well as editorial comments and instances of false fluency (making up a term, such as calling an ear an “ear-o” instead of an “oreja”)

They recorded 1,884 errors, of which 18 percent had potential clinical consequences.

For professionally trained interpreters with at least 100 hours of training, the proportion of errors with potential clinical significance was 2 percent. For professional interpreters with less training, the figure was 12 percent.

Ad hoc interpreter errors were potentially clinically significant in nearly twice as many instances — 22 percent. The figure was actually slightly lower — 20 percent — for people with no interpreter at all.

A Civil Rights Issue

It makes sense that trained interpreters, especially those with more experience, would make fewer errors, says Glenn Flores, a professor and director of the division of general pediatrics at UT Southwestern Medical Center and Children’s Medical Center of Dallas, who was the study’s lead author.

Experienced interpreters “know the medical terminology, ethics, and have experience in key situations where you need a knowledge base to draw on,” he says.

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Title VI of the Civil Rights Act of 1964 prohibits discrimination based on race, color or national origin. Courts have interpreted that to mean that all health-care providers that accept federal funds — because they serve Medicare and Medicaid recipients, for example — must take steps to ensure that their services are accessible to people who don’t speak English well, according to the National Health Law Program, a nonprofit that advocates for low-income and underserved people. (Doctors whose only federal payments are through Medicare Part B are exempt from this requirement, however.)

The Census Bureau estimates that nearly 9 percent of the population age 5 or older has limited English proficiency, which the bureau defines as people who describe themselves as speaking English less than “very well.”

Hospitals and other medical providers are in a tough spot, say experts. The law prohibits them from asking patients to pay for translation services, and they may not receive adequate or in some cases any other reimbursement.

“It’s a civil rights law, not a funding law,” says Mara Youdelman, managing attorney in the Washington office of the National Health Law Program.

A dozen states and the District reimburse hospitals, doctors and other providers for giving language services to enrollees in Medicaid, the joint federal-state program for low income people, and in CHIP, a federal-state health program for children, according to Youdelman.

A 2008 survey by America’s Health Insurance Plans, an industry trade group, found that 98 percent of health insurers provide access to interpreter services, but providers and policy experts question that figure. According to a survey by the Health Research and Educational Trust, in partnership with the American Hospital Association, 3 percent of hospitals received direct reimbursement for interpreter services, most of that from the Medicaid program.

“Most hospitals that make this a priority make it a budget item,” says Youdelman.

Lost In Translation

Hospitals and other providers realize that providing competent interpreter services can help ensure that they don’t miss or misdiagnose a condition that results in serious injury or death, say experts. Trained interpreters can also help providers save money by avoiding unnecessary tests and procedures.

Youdelman cites the example of a Russian-speaking patient in Upstate New York who arrived at an emergency department saying a word that sounded like “angina.” The emergency staff ran thousands of dollars’ worth of tests, thinking he might be having a heart attack. The real reason for his visit: a bad sore throat.

Like many hospitals, Children’s Medical Center of Dallas provides interpreter services around the clock via varying modes of communication — face-to-face, telephone and video — delivered by a mix of trained staff interpreters and outside contractors.

When Nadia Compean, 23, was six months pregnant, her doctor in Odessa, Texas, told her that her baby had spina bifida, a condition in which the spinal cord doesn’t close properly, leading to permanent nerve and other damage.

The local hospital wasn’t equipped to handle the birth and subsequent surgery that her daughter would require, so Nadia and the child’s father traveled to Dallas, about 350 miles away.

Neither speaks much English, but at Children’s Medical Center of Dallas, interpreters helped them understand what to expect, Nadia said (through an interpreter).

Nadia says she learned that her daughter, Eva, would be born with a lump on her back and would require immediate surgery. She also learned about problems that Eva may experience walking and using the toilet, she says.

Eva was born on March 6. Because of her medical needs and the lack of adequate interpreter services in Odessa, the couple is considering relocating to Dallas, where the father hopes he can find construction work.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

KHN wants to hear from you: Contact Kaiser Health News

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Up to half of the people who are treated at hospital emergency departments and trauma centers are under the influence of alcohol, experts say.

That may be a sobering statistic, yet a recent study found that emergency departments can capitalize on this “teachable moment” to discourage problem drinking in the future.

But laws in more than half the states permit insurers to deny payment for medical services related to alcohol or drug use and that can derail hospitals’ best intentions, experts say.

Faced with the prospect of not getting paid for care, some emergency department personnel may sidestep the problem by simply not testing patients’ blood or urine for alcohol.

In the study, published online in the Annals of Emergency Medicine in March, nearly 600 emergency department patients who were identified as hazardous or harmful drinkers (defined for men as drinking more than 14 drinks per week or more than four on any single occasion, and for women as more than seven weekly drinks or three on any one occasion) took part in a seven-minute interview.

During the interview, an emergency department staff member discussed the link between a patient’s injuries and alcohol, as well as guidelines for low-risk drinking, and encouraged the patient to discuss what was stopping him from drinking less and to set a drinking goal.

Compared with those who received standard care, patients who took part in the sessions reduced their average number of weekly drinks significantly as well as their episodes of binge drinking and drinking and driving over the next 12 months.

“In the emergency department on a weekend, all the cases may be drug or alcohol related, and yet we don’t do” screening and intervention, says Gail D’Onofrio, the study’s lead author who is chair of emergency medicine at Yale University School of Medicine. ”Our goal is to normalize this in the emergency department.”

Although some of the nearly 4,000 emergency departments screen patients for drug or alcohol use, it’s not required. Level 1 and 2 trauma centers, however, which are typically equipped to handle emergency patients suffering from serious injuries sustained, for example, in major car accidents, must screen for problem drinkers. Level 1 trauma centers must also be able to provide counseling.

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Such screening and counseling can be effective, says Larry Gentilello, a trauma surgeon who has published studies on injury prevention and substance abuse.

“Most of the people who are injured don’t need to go into treatment,” he says. “They aren’t alcoholics or alcohol dependent. That’s why one counseling session can help them by talking about the risks of drinking.”

The extent to which so-called alcohol-exclusion laws deter emergency medical personnel from screening and counseling patients for alcohol or drugs is unknown.

The laws have a long history. Since 1947, more than 40 states have passed measures allowing health plans to refuse to pay for care if the patient’s injuries occurred while he was under the influence of alcohol or, in some states, drugs, say experts.

As people came to understand alcohol addiction and the possibility of treatment, however, it became clear that the laws were counterproductive. In 2001, the National Association of Insurance Commissioners recommended against them.

Since then, at least 15 states have repealed or amended their laws and now prohibit exclusions of coverage for drinking or drugs, according to data from the National Institute on Alcohol Abuse and Alcoholism. Maryland and the District of Columbia are among them; Virginia’s law remains in place.

Regardless of state law, self-insured companies that pay their employees’ health care costs directly can refuse to cover employees for alcohol-related claims.

The laws have ensnared both problem and occasional drinkers.

In Washington state a law, RCW 48.20.385, specifically bars insurers from denying coverage solely because an injury was sustained as a result of the insured being intoxicated or under the influence of a narcotic. http://apps.leg.wa.gov/rcw/default.aspx?cite=48.20.385.

Gentilello describes the case of a Seattle woman who was celebrating her 25^th wedding anniversary and had a few glasses of champagne at dinner with her family.

It was a rainy night and she was dressed up and wearing high heels. As she and her husband tried to hail a cab, she tripped on a curb, fell and broke her ankle. In the emergency department, her chart noted that she had a few drinks.

Her insurer refused to pay. Washington subsequently adopted a prohibition on alcohol-related claims exclusions in 2004.

It’s unclear how frequently insurers continue to apply such laws to avoid paying claims. Susan Pisano, a spokeswoman for America’s Health Insurance Plans, a trade organization, says the group doesn’t know what member practice is.

Cynthia Michener, a spokeswoman for Aetna, says that “to our knowledge” the company doesn’t apply such exclusions. Other insurers, including UnitedHealthcare and Humana, didn’t provide information about their practices.

But a professor who has written about such laws says there are indications that health plans continue to use them to deny payment.

“There are tons of these cases,” says Sara Rosenbaum, a professor of health law and policy at George Washington University’s School of Public Health and Health Services.  ”The only evidence we have suggests that these cases go on.”

“There’s no reason to think that insurers, eager to hold down costs, wouldn’t continue” to deny payment based on such exclusions, she adds.

Please send comments or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

KHN wants to hear from you: Contact Kaiser Health News

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

By Michelle Andrews
Insuring Your Health

“Insurance is for pessimists” seems to be the attitude of many people planning a vacation overseas. No one wants to dwell on the mishaps that might land you in a foreign hospital or, worse, require an emergency air evacuation from your dream vacation.

Travel insurance is worth considering, however. For a relatively modest outlay, you can buy coverage that protects you if you have to cancel before or during your trip because you, your traveling companions or even a family member not traveling with you becomes ill and requires care.

(These policies also cover cancellations for non-health-related reasons, such as a weather-caused flight delay that makes you miss a cruise launch.)

The policies cover prepaid, nonrefundable trip expenses that an airline, hotel, cruise line or other travel vendor doesn’t refund if you must cancel.

Photo courtesy of Steve Woods.

They typically also provide emergency medical/evacuation coverage in case you get seriously ill while traveling, and a hotline to English-speaking physicians and facilities that can best handle your medical problem.

Coverage is usually available either for a set annual fee or on a per-trip basis, generally about 5 to 7 percent of the price of a trip.

“The driving force of a [comprehensive] plan is the cancellation coverage,” says Damian Tysdal, a travel insurance agent in Hingham, Mass. “You can get a good travel medical plan for $2 to $4 per day.”

Although it’s highly unlikely that you’ll need to be airlifted out of a country and returned home, it can be a devastating expense, often running $50,000 or more, say experts.

Less-dramatic emergencies that don’t require evacuation can still send you to the hospital and ruin your trip. In 2009 Robert Brucato took one misstep in the ancient town of Egmort, in southern France, and ended up in a local hospital with a broken thigh bone.

Following surgery and five days in the hospital, he and his wife, Margaret, were flown home to Tucson first class by way of Montpellier, Paris and Dallas.

Their travel insurance company, HTH Worldwide, oversaw all the medical and travel details.

When Margaret, now 60, had questions, she called the customer service representative assigned to their case.

“They knew more about Robert’s status than I did,” she says.

Robert, 71, needed a wheelchair to get through the airports. A company representative met them at each stop and escorted them to the gate.

Is it worth it? Robert can’t say how much they might have had to pay out of pocket for his medical care and their flights home if they hadn’t had travel insurance because, he says, “we never got a bill for any of this.”

Many people think that their regular health insurance policy will cover them if they get into medical trouble overseas. Don’t bet on it.

Some plans, such as those under the Blue Cross Blue Shield umbrella, give their members access to networks of hospitals and physicians around the world, but a domestic health insurance plan generally covers only emergency care overseas, say experts. In addition, members often have to pay upfront if the local medical provider doesn’t recognize their plan.

Traditional Medicare doesn’t cover care overseas, either, though some Medicare supplemental plans do. People in private Medicare Advantage plans may have access to some services outside the United States; it depends on the plan.

Before you travel or buy travel insurance, find out what you can expect from your existing plan if you need medical care on a trip.

Although travel insurance can fill many of the gaps in coverage left by domestic health plans, there’s one big problem area that is the source of many complaints: preexisting medical conditions.

Travel insurance plans typically don’t cover care or reimburse expenses for a canceled trip if the problem is related to a medical condition you or your family members already suffer from. However, you can sidestep this problem, if you’re on your toes.

The time frame varies. Travelers who buy one of Travel Guard’s core retail plans, for example, are eligible for coverage of preexisting conditions if they buy insurance within 15 days of making their initial trip deposit, says Carol Mueller, a vice president at the company.

The preexisting condition coverage applies not only to the traveler but also to family members at home who might become ill and need care.

For example, let’s say a traveler’s mother has heart trouble and suffers a heart attack while her son is on vacation: A travel insurance policy would cover trip cancellation costs so he could go home and care for her if he had purchased the preexisting condition coverage in the designated time frame. If not, the traveler would have to absorb any lost deposits and additional airfare charges.

When in doubt, call the insurer or a broker before you buy a plan and discuss your concerns.

Please send questions or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Photo: Willi Heidelbach

By Michelle Andrews

Financially, it’s always been risky to get health care from a hospital or doctor that’s outside your health plan’s network.

Without the protection of guaranteed rates negotiated by your health plan, you may end up owing much more, including any billed amounts not paid by your plan.

Out-of-network cost sharing is usually higher, too.

Some recent developments put consumers in a slightly stronger position if they go out of network: A new database lets consumers learn the prevailing rates for medical procedures in their area, and the 2010 health-care overhaul provides better protection when people receive out-of-network emergency care.

But it’s still often an expensive proposition, and that trend is accelerating. Consider these findings from the annual survey of employer-sponsored health plans by the human resources consultant Mercer:

• The average annual deductible for individual coverage in network rose 17.2 percent between 2008 and 2011, to $587, according to Mercer. For family coverage, the average increased 12.4 percent, to $1,317

Deductibles for out-of-network care increased much more during those years. For individuals, the average rose to $1,084, a 27.5 percent increase, while the average for family coverage jumped 30.9 percent, to $2,591.

• A similar pattern emerged for provider services. In network, the median co-payment stayed steady at $20 for physician services, while the median coinsurance for hospital stays remained at 20 percent.

Out-of-network, plan members’ share of the tab for physician visits rose from a median of 30 percent to 40 percent, while it rose from 35 percent to 40 percent for hospital stays.

“Plan sponsors want to give members a bigger incentive to use in-network providers,” says Tracy Watts, a partner in Mercer’s health and benefits business. “If they can shift costs [to employees], some employers are trying to do that.”

Within networks, insurers and providers agree on reimbursements. When consumers go out of network, insurers may reimburse the providers based on so-called “usual and customary rates,” or increasingly, on what Medicare would pay for the same service, which is often significantly less than the usual and customary amount.

In 2010, only nine states restricted balance billing of members in private plans for out-of-network services, according to an analysis by the Georgetown Health Policy Institute for the Kaiser Family Foundation (KHN is an editorially independent program of the foundation.)

Although out-of-network charges can be a problem with any medical service, they’re particularly vexing in emergencies, when patients need care urgently and generally can’t pick their providers.

The 2010 law prohibits health plans from charging consumers higher co-payments or coinsurance for emergency care that they receive out of network than they would owe if they had used their plan’s provider network.

The law doesn’t prohibit providers from balance-billing patients, but it sets standards for how much they can charge. The new provisions apply to new health plans and those that have changed their benefits enough to lose their grandfathered status.

Gael Drew of Decatur, Ga., used the law to her advantage last year when she broke three fingers in a fall at a gas station in Greenville, S.C. The ambulance that took her to the hospital was outside her health plan’s network (a not uncommon problem, even near home).

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The bill was $1,082, of which her health plan paid $472, or 44 percent of the total, based on usual and customary rates in the area. Drew, 57, was left with a bill for $610. She successfully appealed to her health plan to pay the entire bill by arguing that the new law requires insurers to cover out-of-network emergency care at in-network rates.

“From a financial perspective, it’s satisfactory,” she says. “But I look at what it took for me in personal time and calls and online researching. A lot of people don’t have the ability to do that.”

In some cases, people use an out-of-network provider because they think they’ll get better care or they want a certain expertise that they don’t believe they can get in network.

Now it’s easier to get an idea of how much such care might cost through Fair Health, a nonprofit group operating a free Web site that allows consumers to investigate costs for out-of-network care. The site contains continually updated claims data from insurers and third-party administrators covering 126 million people, says Robin Gelburd, Fair Health’s president.

Consumers can learn reasonable and customary rates for services in their area as well as the rates that Medicare pays. The site also has an online calculator that provides comprehensive out-of-network estimates for more than 30 common procedures and includes related services such as anesthesia.

Sometimes, people find themselves using an out-of-network provider despite their best efforts. Earlier this year, New York Attorney General Eric Schneiderman announced a settlement with eight large insurers that had failed to keep their provider directories up-to-date.

Consumers went to physicians listed in their provider directories as in network, only to discover later that the doctor had left the network. As part of the settlement, insurers agreed to refund consumers for any overpayments and keep their directories current.

The lesson for consumers: Don’t believe what you read. To ensure a physician is in your network, call his office and ask.

Please send questions or ideas for future topics for the Insuring Your Health column to questions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.

Bette Davis in The Little Foxes

By Michelle Andrews

Bette Davis, who had breast cancer and suffered a series of strokes before her death in 1989 at age 81, famously remarked that old age is not for sissies.

Many people assume that as health problems multiply and loved ones die, it’s inevitable that the elderly become depressed.

Not true, say experts. Older people have lower rates of depression than younger groups.

But depression often goes undiagnosed in the elderly, who feel the stigma of mental illness more acutely than younger people and are often less likely to seek help.

At the same time, older people are more likely to have multiple chronic conditions that consume their primary-care provider’s attention in the limited time available during a typical office visit.

The situation may be changing. In October, Medicare began to cover annual depression screening in primary-care settings with no cost sharing for beneficiaries.

Paying doctors to screen for depression — Medicare’s going rate is $17.36 per person — may well increase how often they do it, say experts.

“Doctors are trying to do the right thing, but how do you prioritize what to do in 21 minutes with a complex person?” asks Ken Duckworth, medical director for the National Alliance on Mental Illness, [www.nami.org] an advocacy group. “If they get paid for it, they structure it into their practices.”

Medicare covers 60 percent of the treatment for mental health problems, including depression. (Under a 2008 law, that figure is scheduled to rise to 80 percent in 2014.)

A Rapid Test

Most primary-care practices that screen for depression use a tool called the patient health questionnaire. The PHQ-9, as it’s called, asks people to describe how frequently during the past two weeks they have felt down or hopeless or taken little interest or pleasure in doing things. It also asks about sleep patterns, appetite and concentration, among other things. Although the test can be taken in just a few minutes, a 2001 study indicated it identifies depression and pinpoints its severity nearly 90 percent of the time.

Nearly 17 percent of people will have a major depressive disorder during their lifetimes, according to 2007 data from the National Comorbidity Survey of mental health disorders. For people 60 and older, however, the lifetime prevalence is much lower, 10.7 percent. “It’s the survivor factor,” says Michael Friedman, an adjunct associate professor at Columbia University’s schools of social work and public health. “You’re more likely to die young if you have depression.”

The lower figures don’t tell the whole story, say experts. Older people are much more likely to suffer from chronic conditions such as diabetes and heart disease, which can complicate diagnosis and treatment of both depression and other medical problems.

“Depression worsens the effect of other illnesses,” says Charles Nemeroff, a geriatric psychiatrist at the University of Miami. “People with depression are more vulnerable to [disease], and once it happens, it’s worse.”

People with depression often don’t take very good care of themselves. They don’t exercise or eat right. They don’t take their medications or get their blood work done to make sure their blood pressure, blood sugar and cholesterol levels are under control. And people with multiple chronic conditions probably take multiple medications that may interact with each other.

In addition, diabetes and heart disease can actually cause a late-life form of depression called vascular depression, which may occur when blood vessels harden, reducing blood flow to the brain.

All of these factors present a challenge for primary-care providers. There’s no point in screening for depression, after all, if you don’t have the resources to help people get the treatment they need.

An Encouraging Trial

Mental health experts point to a model called collaborative care as one that has shown good results. In one trial conducted at 14 primary-care clinics in Washington state, patients who had poorly controlled diabetes and/or heart disease as well as depression received help from a nurse to improve their efforts to control their diseases over a 12-month period.

The nurse worked closely with a psychiatrist, primary-care physician and psychologist to track patient progress and adjust medications as necessary.

Patients who received the intensive team approach showed significantly more improvement in both their depression and other medical conditions compared with patients who received usual care, according to a study published in the New England Journal of Medicine in December 2010 about the trial. Lead author Wayne Katon, a professor of psychiatry at the University of Washington School of Medicine, said the clinics saved an average of $600 per patient over a two-year period.

Most primary-care practices don’t provide that kind of comprehensive, coordinated care, Katon says.

But as policymakers and insurers increasingly offer incentives to primary care physicians to transform their practices into medical homes for their patients and reward providers for better disease control rather than simply running tests and doing procedures, the landscape should change.

Depressed people are more likely to receive diagnoses and be treated in primary-care settings than elsewhere. Research shows that elderly people, in fact, prefer to deal with their primary-care provider on mental health issues. In that context, coverage of depression screening may help more Medicare beneficiaries get the help they need.

Please send questions or ideas for future topics for the Insuring Your Health column toquestions@kaiserhealthnews.org.

This article was reprinted from kaiserhealthnews.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.