State policies and language access in California's commercial HMOs: Public reporting and regulation of HMOs' language services

Background: Language barriers contribute to disparities in access to health care services among limited English proficient (LEP) Californians. Of Californian health maintenance organization (HMO) members in 2007, more than 1 million were LEP. Professional interpretation can improve access to care, quality of care, patient satisfaction, clinical outcomes, and health services utilization. One previous qualitative study explored health plans' language services, but no quantitative study has previously described such services.

Study design: We conducted a retrospective, descriptive analysis of voluntary HMO responses to the California Office of the Patient Advocate's annual survey, administered from 2003 through 2008. Responses were stratified by product line and/or language.

Population studied: California's nine largest full-service HMOs and other HMOs that serve the state's Medicaid (Medi-Cal) population. Combined, these groups represent over 90% of Californian HMO members.

Results: From 2003 to 2008, during California's voluntary public reporting of HMO language services and before implementation of state-mandated reporting in 2009, the percentage of HMOs providing in-person interpretation at medical points of contact free of charge to consumers increased to over 80% across all product lines. From 2006 to 2008, the percentage of commercial product lines providing in-person medical interpretation in threshold languages (for which such services became mandatory in 2009) increased from 64% to 94%. From 2004 to 2008, the percentage of commercial HMO product lines matching new LEP members to providers by language increased from 50% to 71%. In 2005, 64% of commercial product lines and 56% of Medicare product lines provided telephone interpretation services in all seven surveyed languages, compared with 79% and 83%, respectively, in 2008. Throughout the reporting period, Medi-Cal and Healthy Families product lines provided nearly all language services due to state contract requirements.

Conclusions: HMOs increasingly provided language access services in varying forms for LEP Californians from 2003 to 2008 during a period of voluntary public reporting but before implementation of state regulations. Such changes within commercial product lines appear more pronounced than those within state-contracted product lines.

Implications: Voluntary public reporting of HMO language access services may have been effective in encouraging such services, particularly within commercial product lines. It is too early to assess the additional effects of the regulatory mandate implemented in 2009. Expanding language services may lead to improved access to care and health outcomes for the LEP, although future research should explore the LEP health consumer's experience of such services.