Language Services: Patient Care in Any Language and How to Budget for It

May / June 2009
Language Services

Hundreds of Tongues:
Patient Care in Any Language and How to Budget for It

The demand for telephone interpreting (TI) services — and on-demand interpretation (ODI) in general — begins the moment a person enters a new language setting and cannot adequately communicate without outside support. Whether it is a patient trying to schedule an appointment with a doctor or an automobile accident victim dialing 9-1-1, interpreting services are critical to society, business, and government. As new arrivals pour into the United States, the influx of new languages fuels the demand for interpreting services.

Consider this fact: More than half the world’s immigrants reside in Europe and the United States. In 2006, the United Nations Population Fund estimated that there were 191 million immigrants worldwide resulting from transnational immigration over the past 50 years. Of these, approximately 20% (38 million) were living in the United States, 33% (63 million) in Europe, and 7% (13 million) in other developed countries. The remaining 40% were located in developing countries.

In part due to the rapidly growing population of non-English speakers in the United States, a number of government regulations mandate access to language services either via in-person or over-the-phone interpretation. At a federal level, Title VI of the Civil Rights Act prohibits discrimination on the basis of national origin, which includes language. Executive Order 13166 requires federal agencies to provide language access for individuals with limited English proficiency.

At the state level, a plethora of legislation exists to support language access. According to research from the National Health Law Program, the State of California alone has more than 150 laws on the books related to language access. California has passed new legislation requiring health plans — both commercial and public — to provide translated documents, interpreters, and other services in languages their members speak. A similar bill was introduced in the State of Washington in early 2009 to require health plans to boost their language access levels.

Hundreds of Tongues
In the United States, Spanish leads a litany of non-English languages. More than 10% of U.S. residents speak Spanish at home. As of 2000, the Census Bureau found that 31 million residents spoke Spanish as the primary language in their residences. The 2005 American Community Survey revealed that Spanish speakers in Texas, California, New Mexico, and Arizona now account for more than 20% of those states’ total populations. Nationwide, the Census showed that nearly one in five people spoke a language other than English in their residences — and that’s just among the people who were counted.

But, while Spanish tops the language list in the United States, the remaining languages vary as much as the landscapes of the states themselves. According to LanguageTrak, Language Line’s language tracking service, the company’s most requested languages in April 2008 varied substantially from one state to another. Mixteco was second in Alabama, Turkish was second in Idaho, Polish was second in Arkansas, Burmese was second in Indiana, Hmong was second in Alaska, and Bosnian was second in North Dakota.

For telephone interpreting, the notion of “less common” languages is relative. The 2007 Cyracom Language Index indicated that Somali ranked second in Kentucky, Burmese was fourth in North Carolina, and Nuer — a Sudanese language — came in fourth in Nebraska. In urban Washington D.C., Amharic was third, while Navajo was fourth in the Phoenix-Mesa area. Among the most needed languages nationwide, the Burmese language Karen moved from number 106 to 45 in a single year.

The variability spawns a major challenge — accurately forecasting language needs to ensure proper coverage and staffing. To help overcome this barrier, Language Services Associates carries out a customer-specific analysis to help forecast language needs. For example, the company can generate a client-specific map to indicate the fastest-growing languages in the areas where the customer has offices.

Budgeting for Interpreting Services — the Language Access Ratio (LAR)
In Common Sense Advisory’s recent sizing exercise for the worldwide interpreting market, we surveyed 17 U.S. hospitals to obtain information regarding annual spending on both outsourced and in-house interpreting services. Based on this research and experience with language and business-related measurements, Common Sense Advisory developed a tool — the language access ratio (LAR) — to enable hospitals to see how their spending compares to that of their peers.

How to Calculate the LAR
For the first iteration of this benchmarking tool, we took into account three key pieces of data:

  • 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.

Formula Example
People who speak another language at home / (individuals who speak English + individuals who speak other languages at home) = people who speak another language at home as a % of total population 3,164 / (21,604 + 3,164) = .0595
Number of beds x percentage of people who speak another language at home = # of LEP beds 592 x .0595 = 35.22
Total annual spending on interpreting services / # of LEP beds = Average annual spend per LEP bed $1,384,000 / 35.22 = $39,295.85
Average annual spend per LEP bed / Average daily spend per LEP bed 365 = $39,295 / 365 = $107.66
Table 1: Language Access Ratio Calculation
Source: Common Sense Advisory, Inc.

Nataly Kelly is a senior analyst at research firm Common Sense Advisory with a specialized interest in interpreting services. Her book, Telephone Interpreting: A Comprehensive Guide to the Profession, is the first full-length book ever published on the topic. She is an invited member of the National Project Advisory Committee for a web-based training program for culturally and linguistically appropriate disaster response offered through the U.S. Department of Health and Human Services Office of Minority Health. A former Fulbright scholar in sociolinguistics, she has served as an elected member of the board of directors of the National Council on Interpreting in Health Care and serves on the American Translators Association interpreter certification committee. Kelly may be contacted at 978-275-0500 or