A sign at Bellevue Hospital Center (Photo by Karen Pennar for Voices of NY)
Since doctors told him last year that he was developing stomach cancer, Yee Pak Lee, 63, a Manhattan resident originally from China, needs to get frequent checkups at Bellevue Hospital Center. One thing that makes his visits less burdensome is that he can speak in his native Cantonese.
“Every time I go to see the doctor, they always ask, ‘What do you speak? Do you need a translator?’” said Lee, who is able to communicate in English and doesn’t need help with basic conversation, but said he always asks for an interpreter when discussing anything serious.
“When you’re asking [the doctors] to tell you why your body is hurting, you need to understand what is wrong with your body and how to fix it,” said Lee. “[When] speaking [in] English, sometimes the doctor doesn’t understand [me] or I don’t understand [him]. That’s why I ask for a translator. When it’s important, I always ask for translation.”
Lee’s experience is shared by thousands of Limited English Proficient (LEP) New Yorkers who enjoy access to free translation and interpretation services at the biggest public health system in the country, serving roughly 1.4 million city residents. Last year, NYC Health + Hospitals (formerly NYC Health and Hospitals Corp.) handled over 900,000 requests for interpretation, around 60 percent more than five years ago.
Those translation services – provided either by staff members or through remote systems via video or phone – have been an intrinsic feature of the city’s hospitals for the past decade. However, things have not always been like that, and it took vigorous action from advocates to break language barriers in health care.
In 2001, the New York Lawyers for the Public Interest filed a civil rights complaint against two Brooklyn hospitals alleging that Spanish-speaking New Yorkers were being forced to navigate city hospitals in a language they didn’t understand.
“Patients couldn’t understand their diagnosis, they were confused about their medical care and didn’t know when to return to the hospital and clinic,” said Rose Cusion-Villazor, now a professor of immigration and citizenship law at the University of California, Davis, who helped prepare the complaint on behalf of Bushwick-based community group Make the Road New York.
The complaint resulted in an agreement between the state attorney general’s office and the two hospitals, Woodhull and Wyckoff Heights. In the following years, subsequent civil rights complaints detailed similar experiences from across the city, and demands for better services were answered with more legal agreements and government mandates, including the 2006 Hospital Language Assistance Law and Executive Order 120 passed in 2008.
(Photo by Karen Pennar for Voices of NY)
The changes are visible today at Bellevue Hospital Center, where there are not only translators but also a diverse staff to address the patients. A pregnant woman who only gave her name as Joanna, said that she only speaks a little English but that wasn’t a problem at the Manhattan health center. “Everyone spoke Spanish,” she said. “The doctor, the nurse, the people at reception. Everybody.”
Some New York hospitals had started addressing those language concerns well before local regulations were adopted, especially in areas with strong immigrant populations, like Queens. Jayne Maerker, director of the Elmhurst Hospital Volunteer Office, said that when she started working there 27 years ago, the need for translators was so urgent that non-English-speaking patients would bring their children to translate what the doctors said.
“For a long time we knew that [the situation was not] ideal. Our policy is that no one under 18 should be interpreting unless it’s a life-or-death situation,” explained Maerker. “It is also against our policy for patients to bring interpreters along.”
Today, Maerker oversees a team of over 20 people – including professional translators, bilingual doctors and on-site trained volunteers and staff members – that has served as a model for the rest of the city health system. Also, “you can dial 1500 from any phone in the hospital and either get a face-to-face interpreter or an over-the-phone interpreter,” added Maerker. “Last year, the entire interpretation system recorded nearly 11 million minutes of phone services. Our percentage was probably 25 percent of that.”
Anecdotally, there are still instances of individuals bringing friends or relatives to help with interpretation because they are uncomfortable relying solely on the available telephonic interpretation. But there is no question that the availability of translation and interpretation services to patients is being made clearer.
Even once-critical advocacy groups are reporting that more patients are being informed of their right to free language access services. In a 2014 report, the New York Immigration Coalition (NYIC) found that the number of patients that said they were told about translation services rose from 8 percent in 2004 to 65 percent in 2014.
“That’s a pretty astronomical difference,” said Max Hadler, a health advocacy specialist with the NYIC who previously worked as a hospital medical interpreter himself. “The distance that has been covered in improving language access for limited English proficient people in the health care setting is pretty amazing,” he added. “No matter what time frame you put on it, we’ve come a long way.”
Costs and gaps
NYC Health + Hospitals is a historically big spender when it comes to providing translation services. A report by the city’s Independent Budget Office (IBO) estimated that in 2009 the agency spent close to $11 million in Language Access services, almost three times as much as the next highest budget (Department of Education, with $4 million), and more than a third of the city’s total cost (almost $27 million).
Available spending and utilization data shows how services have expanded rapidly to accommodate a sharp rise in demand. The agency spent nearly $7 million on over-the-phone interpretation (OPI) services in 2012, compared to more than $4 million in 2008 and almost $5 million in 2010. Increased spending costs came as requests for interpretation services rose from 563,000 in 2010 to almost 700,000 in 2012.
However, as the agency is now facing a billion-dollar budget deficit, officials were prompted to hold back costs by renegotiating contracts with translation vendors.
In 2013, NYC Health + Hospitals renegotiated contracts with vendors CyraCom International, Language Line Services and Pacific Interpreters. Board meeting minutes detail how the agency was able to lower a rate change from 90 to 75 cents a minute, with a cap of roughly $31 million over five years – an average of just over $6 million a year.
Meanwhile, a recent report by the Mayor’s Task Force on Immigrant Health Care Access highlighted that gaps in language services still exist. One issue, according to Hadler, is that hospitals rely heavily on bilingual employees to act as interpreters for patients.
Max Hadler (Photo by Gustavo Martínez Contreras for Voices of NY)
“Relying only on people who already have a full-time job in that same place is a bit risky without some very careful measures in place,” said Hadler. “If they’re supposed to be doing everything that they were hired to do and also interpreting, that needs to be something that health care facilities are taking into consideration.”
However, standards for bilingual staff members have improved considerably, explained Silvina De La Iglesia, the Language Assistance Program Administrator at MediSys Health Network at Jamaica Hospital.
“If we go back 20 years, anybody was an interpreter; there was no difference between translator, interpreter and the janitor,” said De La Iglesia. “Anybody could be called: ‘You speak Spanish? You’re an interpreter.’”
The drive for professionalization has not been without roadblocks. “It’s not easy to educate the staff, it requires a lot of training and some rowing against the tide,” she said, pointing to some resistance on the part of doctors. “We have a mandate to fulfill but also a staff that, well, they are in a rush, they want to do things their way, you have patients waiting, and calling an interpreter takes more time.” Also, she added, “some doctors somehow think that they speak Spanish very well and they go: Duele? Mucho? Poquito? They think that they are communicating well, but that’s not enough.”
Training bilingual staff
Matilde Roman, senior director of the NYC Health + Hospitals’ Office of Culturally and Linguistically Appropriate Services/Limited English Proficiency, acknowledged the potential problems of relying on bilingual staff, but stressed that the agency has protections in place.
“We can ensure that individuals are tested for fluency in a target language and English, trained in interpretation skills and also tested for competency,” said Roman, who pointed out that the use of bilingual employees plays on the agency’s already diverse staff.
“We’re lucky in the fact that many of those providers can communicate directly with the patient – and that we don’t have to use interpreters as frequently as we would need,” she said, adding that the agency is currently working on plans to change the way it uses staff members for language access services, including setting up a classroom at city facilities to make it more convenient for bilingual staff members to receive training.
However, according to Hadler, the budget-strapped agency will need more resources to hire additional full-time interpreters and effectively train bilingual staff. “Anything that’s going to happen to professionalize the health interpreter core will require money,” he said. “It’s critically important to fund the services – to hire people, to train people.”
Hadler said that increased funding could come from the city’s budget or from raising the Medicaid rates; a change that the New York Immigration Coalition is pushing for at the state level.
“The Medicaid reimbursement rate for language assistance services doesn’t make health care providers whole for the services that they do provide,” said Hadler, who explained that the NYIC is proposing a statewide task force to seek for ways to improve language access.
Roman said that the increased reimbursements would be helpful but stressed that the agency would continue providing and improving their language access services regardless of expense.
“Despite the cost this is a necessity,” said Roman. “The main goal for us is to ensure that our patients experience the best patient experience that they can have.”
Carlos Rodríguez Martorell contributed reporting to this story.