• the total number of hospital beds;
  
  
• the percentage of individuals who speak a language other than English at home according to the primary ZIP code where the hospital is located, based on the 2000 U.S. Census data; and
  
  
• the amount spent on interpreting services in the most recent fiscal year.

Then, multiply the percentage of individuals who speak another language at home by the total number of hospital beds in order to calculate the number of spaces for patients that are likely to correspond to the portion of the hospital's coverage area with limited English proficiency (LEP) — what Common Sense Advisory refers to as "LEP beds." For example, if 10% of the population residing within the hospital's ZIP code speaks a language other than English at home and the hospital has 100 beds, the number of LEP beds is 10.

Next, take the total amount spent annually on interpreting services and divide it by the number of LEP beds. If the hospital in the above example spent $200,000 annually on interpretation services, the average annual spend per LEP bed would equate to $20,000.

From there, divide this number by 365 to determine the amount spent per day on each LEP bed. This allows for the computation of the average daily spend per LEP bed — or rather, the language access ratio (LAR). In this example, that number would be $55 after rounding up to the nearest dollar. The formula and an anonymized example are shown on page 38 (Table 1).

Limited English Proficiency Versus Speaking Another Language at Home
It is important to note that the number of individuals who speak a language other than English at home does not equal the number of people with LEP. However, there is a likely strong correlation between these two numbers. Also, for purposes of its application within healthcare settings, the difference between the two numbers may be offset by three important facts:

• Language access issues often relate to impaired health status. Individuals with LEP or who speak another language at home often have a lower likelihood of having a regular source of medical care and are more likely to be in poor health than individuals with full English proficiency and who speak English at home.
  
  
• Many people are not included in the Census. The number of individuals tracked via Census data is not representative of unauthorized migrants, estimated to be in ranges from 7 million to 20 million.
  
  
• LEP population rates are growing exponentially. The numbers of individuals with limited English proficiency are increasing at staggering rates. This number more than doubled in the period between 1980 and 2000, and the number stands to continue to grow — LEP children represented one in every 15 schoolchildren in the year 2000.

Findings from Survey of U.S. Hospitals
Common Sense Advisory's survey of hospitals across the United States included six large hospitals in the Midwest, six on the East Coast, three on the West Coast, and two in the South. The results yielded a wide range of language access ratios. However, many hospitals had similar LARs, meaning that they were spending approximately the same amount each day per LEP bed. On average, the 17 hospitals spent $56 per day for every LEP bed; the majority of hospitals spent more than $25. The sample of these 17 U.S. hospitals yielded some interesting findings:

• Language access ratios vary widely. LARs spanned a large range. One Midwest hospital with a mature interpreting program spent $308 per day per LEP bed, while the lowest-scoring hospital — in a southern state with a relatively recent influx of immigrants and a brand-new program — spent just $5 per day.
  
  
• East Coast and Midwestern hospitals spend most. The median for hospitals based on the east coast of the United States was slightly higher — at $37 per day spent on each LEP bed — than that of their counterparts in Midwestern states, $33. Southern states, largely new to immigration, had less sophisticated programs in place, often relying almost exclusively on third-party companies such as telephonic providers and on-site interpreting agencies.
  
  
• Mature programs bring more services in-house. The longer an interpreting department has been in operation, the greater the percentage of services provided internally versus the use of outsourced interpreters. Hospital interpreting coordinators seek to provide services through more cost-effective methods, and employing staff directly is usually less expensive — for most high-demand languages, that is — than going through outside agencies.

Potential Uses for the Language Access Ratio
Calculating the average daily spend per LEP bed will prove helpful — not just for benchmarking, but for planning and pleading the case for greater language access with the hospital's budgetary decision-makers. However, spending more doesn't guarantee quality. An organization's LAR does not necessarily mean that its program is "better" or "worse" than another — the quality of the program depends upon many factors beyond the amount of money spent. Some hospitals have invested their dollars wisely and realized cost efficiencies. Tools such as the LAR provide a much-needed starting point based on uniform data related to language needs, giving hospitals a solid basis for comparison.