Jess Levy, MD.
Child and adolescent psychiatrist, Cleveland Clinic Foundation, OH.
Dr. Levy has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
According to US census data, 21.9% of the US population speaks a language other than English at home: chiefly Spanish, followed by Chinese (Center for Immigration Studies; www.tinyurl.com/s5e8s9q). Language barriers impair a child’s ability to receive appropriate, timely psychiatric treatment. Given these facts, as clinicians, we often need interpreters in our practices.
Interpreters provide meaning-for-meaning delivery of oral communication. This is different from translators, who provide word-for-word delivery of written communication. Accessing and appropriately utilizing interpreters can be difficult. Interpreters can cost as much as $150 per hour for in-person services or $3.50 per minute for video services (Jacobs B et al, Ann Fam Med 2018;16(1):70–76), and there are administrative and legal requirements to follow as well. Fortunately, clinicians can take steps to mitigate barriers and serve families.
Complying with requirements Providing interpreter services is important for good care and legally required. Section 1557 of the Affordable Care Act (ACA) codified guidelines that healthcare providers must follow to avoid patient discrimination. Every clinic with 15 or more employees must post a statement offering interpretation services in the 15 most common languages seen in the facility. This applies to practices who submit claims to Medicare, Medicaid, and CHIP (Jacobs B et al, 2018). Covered practices must provide accurate and timely, confidential language assistance programs free to patients and staffed by qualified interpreters.
Who is a “qualified interpreter”? According to the ACA’s requirements, an interpreter must:
Adhere to a code of ethics, including patient confidentiality
Be proficient in English and at least one other spoken language
Be able to accurately and impartially interpret using any necessary specialized vocabulary and phraseology (CyraCom Language Solutions; tinyurl.com/y9z7rcad)
Section 1557 does not mandate a particular certification or credentialing process. However, the best practice would be to utilize interpreters who have undergone formal training, testing, and certification.
The “qualified interpreter” requirement has important ramifications. Unless there is an emergency and time is of the essence, do not use family or friends to interpret, even when this seems convenient. In particular, do not use bilingual children as interpreters. Patients (and families) may decline interpreter services and want to use an adult family member or friend. However, we strongly recommend counseling families against this option. If you do use a layperson, have a low threshold for bringing in a professional interpreter if you feel that the designated individual cannot accurately interpret. If a layperson’s interpretation results in a medical error, the clinician will be held liable.
The ACA also discourages using bilingual physicians or coworkers. Unless a bilingual staff member or clinician meets the above description of a qualified interpreter, they should not interpret for patients. Even if they are qualified, they should only do so if language interpretation is part of their defined job duties.
Finally, despite progress in computer-assisted translation tools such as Google Translate, these technologies should never be used as a replacement for a qualified interpreter except in dire emergencies. One recent study of translated patient instructions found that 2% of the sentences that were translated from English to Spanish using Google Translate contained potentially harmful errors when back-translated using an interpreter (Khoong EC et al, JAMA Intern Med 2019;179(4):580–582).
Understanding interpreter options and controlling costs Telephonic or video interpreter services are great options for clinicians who have smaller practices or have few patients who are not proficient in English. Both options have pros and cons. Telephonic interpreter services have a low equipment cost, are easy to use, and offer access to a wider variety of languages than video services. However, this option may not work for patients or families who are hard of hearing, and the interpreter cannot rely on visual cues—which are especially important in pediatric mental health. Video interpreter services preserve those visual cues, but carry a higher technology overhead and must meet certain quality standards (see www.telehealth.hhs.gov), though these standards have been relaxed with the coronavirus pandemic. Staff also need to know how to use the technology and troubleshoot common problems.
Costs of in-person or telephonic interpreters range from about $1.50 to $2.50 per minute or up to $150 per hour. Because of the plethora of services and varying quality, we cannot offer names of specific companies. Check with your local hospital or other big clinics as well as attorneys to find good referrals, and vet them yourself too. State Medicaid and CHIP programs sometimes directly reimburse providers. Check your state’s programs to see if such reimbursement exists. Also, CPT codes, such as T1013 or the interactive complexity add-on code, might help.
Working with interpreters Professional interpreters are trained in relaying the meaning of your message to the patient and vice versa. You will often be working with an interpreter on sensitive issues (eg, abuse, suicide, or psychosis). Consider talking with the interpreter ahead of time and afterward to ensure accurate communication. Interpreters can often help you understand cultural aspects and help recognize if something is unusual or “off” about the patient’s presentation. Encourage the interpreter to access their own emotional supports should this become an issue in the course of their work. When seeing patients with an interpreter, allow 50%–100% longer times. Speak to the patient, not the interpreter. Have family members speak one at a time. Do not conduct private conversations in English in front of patients or families, and do not ask the interpreter not to interpret something. For more information, see the “Tips for Using Interpreters” box.
Counseling families about interpreters Some families are hesitant to use interpreter services. They may feel their English is adequate enough, underestimate the density of medical jargon, or fail to realize that subtleties of language can impact medical decision making. Some families worry about burdening the health care system, incurring extra costs, or giving up confidentiality. Explore their hesitation and provide reassurance. Emphasize that an interpreter helps you listen better. Inform patients that interpreter services cost them nothing, and that interpreters maintain confidentiality. You may also wish to keep an interpreter available during the appointment but agree to only use the interpreter if there is something that needs to be clarified. If a patient or family continues to decline interpreter services, then consider terminating care—though consult your legal team before doing so.
CCPR Verdict: Medical errors due to language barriers are considerably more costly than interpreter expenses. Find professional interpreters who can talk about medical and emotional concepts with children and teens. Put policies in place for their use, and avoid using family, friends, and especially children as interpreters. Using interpreters may seem daunting and costly. However, such service is essential for good patient care, prevents discrimination, and in most cases is legally mandated.
Tips for Using Interpreters
Clinicians must provide free, timely, and accurate language assistance from a qualified interpreter—not only is this good patient care, it’s the law.
Telephonic interpreters may be more accessible, cost less, and have more language options; video interpreter services may be more effective in conveying information.
Learn how to access interpreter services, including the technical aspects.
Do not use family (especially children) as interpreters or rely on computer-assisted translation tools such as Google Translate. Bilingual staff and clinicians should only interpret if they are specifically trained to do so and if it is part of their job duties.
Your state may offer funding and reimbursement support to offset the costs of interpreter services.
Budget more time for appointments when using interpreters, including time to talk with the interpreter before and after the actual clinical interaction.