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.

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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 Christen Brownlee, Contributing Writer

Not only is it safe for people with asthma to exercise, but doing so could reduce their risk of asthma symptoms or attacks, according to a new evidence review in The Cochrane Library.

Many people with asthma report avoiding exercise because they’re afraid it could trigger symptoms including shortness of breath, wheezing or a full-blown asthma attack, said review author Kristin V. Carson.

These fears might be encouraged from misreading their symptoms, their family’s beliefs about exercise and asthma, or even from their physicians.

Over time, Carson explains, patients can become out of shape, losing muscle mass and cardiovascular fitness. That makes any future attempts at physical activity significantly harder, increasing the chances that patients will become fatigued and breathless and further discouraging physical activity.

“This results in a spiraling cycle,” she says, in which patients are even more likely to avoid exercise.

To determine whether exercise was a danger to asthmatics, Carson and her colleagues reviewed previous studies that looked at the effects of physical training on people with asthma , comparing patients who received no or minimal physical activity to those who exercised for at least 20 minutes, twice a week, over the course of four weeks.

The researchers found that the patients who had exercised—using physical training as varied as running outdoors or on a treadmill, cycling, swimming or circuit training—were no more likely to have a serious asthma-related problem than those who weren’t exercising or who did light exercising such as yoga.

Additionally, Carson said, their findings showed that patients in exercise programs improved their cardiovascular fitness, which in turn could reduce asthma symptoms over time.

Some limited evidence from the included studies also suggested that exercise improved patients’ quality of life, she added, which could contribute to other health benefits and improved psychological well-being.

“We found no reason for people with stable asthma to refrain from regular exercise,” Carson said. “Physicians should encourage their patents with stable asthma to engage in physical training programs.”

Len Horowitz, M.D., a pulmonary specialist at Lenox Hill Hospital in New York City who wasn’t involved in this review, agrees that asthma patients shouldn’t shy away from exercise.

However, even though research suggests that exercise is safe for asthmatics, he says that many people will still use their asthma as a reason to avoid physical activity.

“Not everyone wants to exercise,” he said. “When patients think exercise makes them symptomatic or makes them risk an attack, it’s a good excuse not to do it.”

Horowitz notes that may professional athletes have asthma, which hasn’t negatively affected their careers.

However, he explains, some patients do have exercise-induced asthma, in which vigorous or prolonged exercise can trigger symptoms.

He advises patients in his practice to take precautions if they’re susceptible, including pre-treating themselves with an albuterol inhaler, avoiding exercise that exposes their lungs to cold, dry air (such as running outside in the winter) and building their activity levels gradually.

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

A new study suggests that refurbishing neighborhood parks may lead to improvements in community health. Increased visitors and higher rates of exercise were observed for more than one year when one community park provided new and varied amenities.

Study leader Jenny Veitch, Ph.D., of Deakin University in Burwood, Victoria, Australia, notes that it’s no secret that parks can be important places to spend leisure time and for physical activity.

However, she says, drawing more people to parks and having them get more exercise there is still largely an unmet public health goal.

It’s particularly important to encourage people in disadvantaged neighborhoods to exercise, she adds, where residents are at an increased risk of inactivity, which can lead to poor health.

For their study, Veitch and her colleagues took advantage of changes already scheduled to take place in a local disadvantaged neighborhood.

That neighborhood, containing two community parks, had one park scheduled for a significant refurbishment.

Before refurbishment, both parks were primarily open spaces, with few amenities. Afterward, the refurbished park would include a dog run, a playground, a 365-meter walking track, a barbeque area, new landscaping, and fencing to prevent motor vehicle access.

Veitch and her colleagues observed visitors at both parks three months before the changes took place, three months afterwards, and then a year later.

The researchers, reporting in the American Journal of Preventive Medicine, found that the number of visitors to the updated park more than quadrupled between the first observation and the last.

Moreover, the numbers of people walking or vigorously exercising in the refurbished park similarly grew.

While visitorship declined slightly in the other park, it wasn’t nearly enough to account for the number of newcomers to the refurbished park.

Investing in attractive and functional park features could pay off significantly in terms of increasing exercise, leading to positive health consequences for low-income communities, explains Veitch.

“Our previous research has shown parks in low socio-economic areas are of poorer quality compared with parks in higher socio-economic areas,” Veitch adds. “Modifying the built environment by improving park facilities and features is potentially a long term and sustainable way to increase population level physical activity.”

That exercise can improve health is an established fact that doesn’t need any additional research, adds John Librett, Ph.D., a former advisor on the effect of recreational activities on health for the Centers for Disease Control. However, he says, it’s still unclear whether park visitors continue to return after their initial visits and keep up their workout routines, a necessary step for maintaining health over the long haul.

“This study shows increased park usage, but what we don’t know is whether different people were visiting the park and not returning, or whether the same people were continually using the park every couple of days,” he says. “You have to keep exercising to maintain benefits.”

Health Behavior News Service is part of the Center for Advancing Health

The Health Behavior News Service disseminates news stories on the latest findings from peer-reviewed research journals. HBNS covers both new studies and systematic reviews of studies on (1) the effects of behavior on health, (2) health disparities data and (3) patient engagement research. The goal of HBNS stories is to present the facts for readers to understand and use for themselves to make informed choices about health and health care.

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.

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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.