Earlier this year Oregon lawmakers passed a controversial bill characterized by supporters as a major step in improving medical interpreter access around the state. But if you ask the state’s medical directors serving more than 1 million low-income people in the state, more needs to be done.
Medical directors serving more than 1 million low-income people who receive free care under the Oregon Health Plan have told the state its rules for health care interpreters are hurting equity and access — particularly the requirement that requires Oregon health care interpreters to receive 60 hours of training to be certified, not the 40 hours required elsewhere in the country.
Oregon Health Authority officials have balked at some of the directors' requests, causing rare public friction.
“The impression that we have … is that OHA is not going to change anything” when it comes to interpreter requirements, said Dr. Leona O’Keefe, the Jackson Care Connect medical director, in a meeting last month. “It sounds like there is zero intent to make any of the recommended changes.”
The criticism comes as the agency's new director, Sejal Hathi, is taking a close look at the agency's efforts as the state nears a goal of eliminating health inequities by 2030. It comes from the medical directors at the 16 insurer-like regional organizations that are contracted by the state to oversee services to low-income people, known as coordinated care organizations.
In March, the group of doctors sent a letter to the state raising concerns with how the state requires that their organizations track health care interpreter services to receive extra incentive funds under rules launched two years ago. While the organizations often use interpreters, those interpreters sometimes don’t meet Oregon’s elevated requirements to provide services, hurting incentive payments, they said.
The letter expressed support for improving medical interpreter access, saying “we are disheartened” that lack of access to language services “often results in lesser quality of care and even a complete lack of care.” But the letter said the state’s efforts to increase equity had, by increasing the training requirement from 40 hours to 60 hours, had the unintended effect of “inhibiting equity in some areas.”
Specifically, they wrote, “Oregon requires 60 hours of training to become an OHA certified/qualified healthcare interpreter. The rest of the nation requires 40 hours,” adding that “the additional 20 hours have now become a barrier to training, resulting in inadequate access to certified/qualified interpreters at the time needed, particularly in rural areas.” The letter added that the problem is even worse for languages “of lesser diffusion” that are not in widespread use in Oregon.
Because national companies are not willing to follow the state’s requirement that they check with each individual interpreter to verify whether they qualify for Oregon certification, “Oregon providers are faced with continuing to pay for national interpretation companies so that their patients have language access, yet being penalized by this measure if the individual interpreter provided is not certified/qualified per Oregon standards, clearly missing the intent of the measure.”
The letter urged administrative changes and that the state slightly lower the standard for required proficiency testing results, saying that the tests are written in such a way that even native speakers are not being rated as fluent in their languages.
“This is causing some to doubt the efficacy of the proficiency testing available in Oregon,” the letter said. “The current requirement has held back a lot of possible interpreters for our community that are fluent and capable.”
The letter was approved by every single medical director, O’Keefe said at the May meeting, adding that has “never happened before, never. That in itself should speak volumes.” She added that the concerns they raised are present “throughout Oregon.”
O'Keefe said the impression that the state had rejected the recommendations came from an unsigned letter agency officials had sent the medical directors in April responding to the concerns.
The unsigned state response letter defended the 60-hour requirement, noting that it was adopted to ensure quality because, to address equity concerns, Oregon had eliminated the requirement of passing a national test, saving each interpreter $2,000. The letter added that the number of certified interpreters in Oregon was growing by 100 a month. It also rejected the recommendation that the state slightly lower the requirement on test results to address seemingly flawed tests, saying doing so would amount to lowering standards, and “Doing so will not be supported by the state’s trained interpreters and their union.”
At the May meeting discussing medical directors' concerns, state employee, Derek Reinke, responded that state officials are working on improvements to the program but that the medical director’s recommendations “would really undercut a whole bunch of work” that agency officials had already done. He called it “a little bit of a nonstarter” to change requirements.
In a meeting on Monday, state officials laid out a number of changes they've been making to the Oregon Health Plan’s rules for its interpreter incentive program, but did not address the 60-hour requirement cited by the medical directors as a major issue.
At that meeting, Dr. Doug Carr, the medical director for Umpqua Health, called the state’s response “very thoughtful” and expressed the hope that the medical directors could continue working with the state to make improvements.
Asked by The Lund Report about the medical directors' concerns, a health authority spokesperson sent an email that was noncommittal about the 60-hour requirement issue they raised. It said the agency is open to making further changes in the overall rules and was committed to further discussion with the medical directors. Of the 16 regional care organizations serving Oregon Health Plan members, the statement said 10 of them had reported “renewed focus” on language access as a result of the program offering the organizations incentive payments for using Oregon-certified intepreters. The statement said the incentive is intended to result in data fueling further improvements.
This is not a new problem. CCOs expressed concern nearly a decade ago that meeting the requirement is impossible because a qualified healthcare interpreter workforce did not currently exist for all the languages spoken by OHP members. Of course, we would all like interpreter services to be provided only by certified professionals who have sufficient amounts of the best training not just in the language but also in healthcare terminology. That is the ideal. But CCOs knew then (and it is still the case today) that there are not enough qualified healthcare interpreters across Oregon to meet the need. They cannot contract with and utilize interpreters that don't exist in their communities.
A better balance (policy and contractual) needs to be found between moving the state's health system toward the currently required ideal that also acknowledges the workforce shortage, and without financial penalties. Policy changes could include paying the incentive and requiring CCOs to make local investments in the recruiting and training of more certified health interpreters. It would be best if this were to augment some new state investment in the development of sufficient capacity in certified healthcare interpreters.
This is a solvable problem. The incentive penalty alone will not solve it.