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Understanding National Patient Language Proficiency, Barriers

Eight percent of Medicare beneficiaries have limited English proficiency, introducing a major communication barrier.

Clinicians must understand communication barriers such as limited English proficiency.

Source: Thinkstock

- Clear and open patient-provider communication is integral to any healthcare encounter, especially as clinicians look to drive value and patient engagement. To ensure communication is up to par for all patients, clinicians must be mindful of language proficiency, visual, and auditory barriers keeping patients from fully participating in their own health.

The CMS Office of Minority Health (OMH) has published an issue brief pertaining to English proficiency and other communication barriers among Medicare beneficiaries.

The agency used data from the 2014 American Community Survey (ACS) Public Use Microdata Sample (PUMS) to determine how many Medicare beneficiaries face communication barriers, in which populations barriers were most prevalent, and in which regions.

Language barriers affect metropolitan areas, minority patients

Overall, 8 percent of the 52 million Medicare beneficiaries across the country have limited English proficiency, the data showed. Beneficiaries living in urban areas are nearly four times as likely as those in rural areas to be limited in English proficiency. Eight percent of urban dwellers have limited English proficiency versus 2 percent of rural dwellers.

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Limited English proficiency was most prevalent in Asian (57 percent) and Hispanic (49 percent) patients. Other minority populations also have high levels of limited English proficiency, including 27 percent of Native Hawaiian and Pacific Islanders and 11 percent of Native American/Alaska Natives. Five percent of white beneficiaries and three percent of black beneficiaries also have limited English proficiency.

Overwhelmingly, the most commonly spoken language outside of English is Spanish, with 52 percent of limited English proficient patients speaking it.

Spanish is the most common language among limited English proficient patients.

Source: CMS

Vision impairment more prevalent in racial minorities

Just under 8 percent of Medicare beneficiaries are blind or have vision impairment, the data revealed. The concentration of visually impaired beneficiaries does not differ in rural (8.7 percent) versus urban (7.6 percent) regions.

Different patient populations are affected by vision impairment at varying rates. Fifteen percent of American Indian/Alaska Native beneficiaries suffer from vision impairment, versus 7 percent of white and Asian beneficiaries.

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The prevalence of vision impairments also decreases with educational attainment. Thirteen percent of beneficiaries with high school diplomas have vision impairments, compared to 7 percent of those with a high level of education.

Little demographic difference in hearing barriers

Fifteen percent of the total Medicare beneficiary population is considered deaf or hard of hearing, and there is little to no difference among varying demographics.

About 14 percent of urban dwellers are hard of hearing, compared to 17 percent of rural dwellers. Thirteen percent of Hispanic versus 15 percent of non-Hispanic beneficiaries also have auditory barriers.

Hearing issues were most prevalent in a number of racial ethnicities, including American Indian/Alaska Natives, whites, and Native Hawaiians and Pacific Islanders.

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Females are also more likely than males to be deaf or hard of hearing.

Communication barriers differ by state, region

By state, there is a wide range in all communication barriers. However, CMS does not offer an explanation for this variance.

Limited English proficiency was far more prevalent in urban areas than in rural areas. In West Virginia, a mere 0.25 percent of Medicare beneficiaries are limited English proficient. In California that percentage jumps to 22 percent.

Among the states with the highest concentration of limited English proficiency, there is wide variance, CMS found.​

There is great national variation in English proficiency.

Source: CMS

The state-to-state variation is less pronounced for vision impairments, CMS found when inspecting the states with the most beneficiaries with visual impairments. West Virginia had the highest population of beneficiaries with visual impairments at 12 percent. New Hampshire had the smallest, with 5 percent of its patients having visual impairments.​

There was little variation in visual impairment across the country.

Source: CMS

This pattern continued for beneficiaries who were deaf or hard of hearing. In Alaska, 21 percent of patients have hearing complications, while 9 percent do in the District of Columbia.​

CMS investigated these three communication barriers to help clinicians identify vulnerable patients and overcome limitations, ideally leading to higher quality care.

“Communication and language barriers are associated with decreased quality of care and poor clinical outcomes, longer hospital stays, and higher rates of hospital readmissions,” CMS reported.

Understanding how many patients need assistance will help clinicians offer better support to patients with language, visual, and auditory barriers. Clinicians offering this support will ultimately lead to better communication and eventually stronger patient engagement.

“Persons with limited English proficiency and those who are deaf or hard of hearing may need an interpreter to communicate effectively, and persons who are blind or who have low vision may need materials or signage presented in alternative formats during their receipt of health care,” CMS explained.

“Evidence suggests that access to communication and language assistance for patients and consumers is important to the delivery of high-quality care for all populations,” the agency continued.

Breaking down language, visual, and auditory barriers by state and region will help clinicians better serve specific patient populations. Knowing the national average of limited English proficiency will mean something different for a clinician practicing in California than for one practicing in West Virginia.

“State level needs are not always the same as local level needs,” CMS explained. “Organizations, such as hospitals and health plans, may need to examine language and communication data at the most local level possible to ensure they are best positioned to meet the needs of patients and consumers they are most likely to encounter and to enhance their overall efforts to deliver high quality care.”

Ultimately, supporting clinicians and patients in overcoming these communication barriers is a part of CMS’s mission to improve healthcare quality. And by understanding where these barriers are located, CMS hopes to drive health equity and close gaps in communication support.

“Communication and language barriers are associated with decreased quality of care and poor clinical outcomes,” the agency concluded. “Understanding and working to address communication and language needs of Medicare beneficiaries is a critical part of ensuring high quality care for this group. This work is related to an overall CMS commitment to quality and health equity, as well as to regulations and initiatives.”