They say everything is bigger in Texas. That is certainly true about the volume of healthcare interpreting.

Dallas-based Parkland Memorial Hospital is an 882-bed facility that handles more than one million outpatient visits each year. Its interpretation and translation needs are not just high, but also symbolic of the demographic changes in the US: 41% of Parkland’s patients speak a language other than English; 39% speak Spanish.

Of the approximately 11,000 Parkland employees, only 458 are qualified bilingual staff  — not enough to meet demand, even with 80 onsite interpreters.

As Parkland’s Language Services Director Meredith Stegall explained to the audience at SlatorCon San Francisco 2019, a unique in-house call center model turned this challenge into an opportunity for both the hospital and the local community.

Providing language access for patients has been legislated and regulated at different levels in the US.

Some states have specific requirements for providers, but these do not apply to Parkland because Texas has not expanded Medicaid.

Most meaningful, according to Stegall, are the Joint Commission standards, because the Joint Commission (whose rules have traditionally been the strictest) is the certifying body for hospitals. As such, it has the power to terminate programs.

On top of these are the requirements introduced by ACA 1557, the nondiscrimination provision of the Affordable Care Act (Obamacare), which has had a ripple effect on the healthcare and language industries since its enactment in 2010.

ACA 1557 requires providers to ensure that individual patients, not just patient populations, have access to language services. This compels hospitals to collect extensive data on individual patient experiences and follow up with clinicians who have decided not to use interpreters in specific instances.

For an institution of Parkland’s size, Stegall said, “the data-collection burden becomes quite onerous.” At the same time, there is also pushback from much smaller, over-extended rural facilities that are struggling to stay open, let alone meet the standards demanded of larger hospitals.

ACA 1557 has also left healthcare providers vulnerable by creating another reason for patients to sue. Prior to ACA 1557, Stegall explained, language access violations could prompt a lawsuit through tort or through Office for Civil Rights violations and related fines. With ACA 1557, patients could also sue under the Act itself, putting institutions with high populations of limited English proficiency (LEP) patients at risk from expensive litigation.

Going Big AND Going Home

Back in Dallas, Parkland’s in-house interpreters were simply unable to keep up with the growing demand for their services. In response, Parkland outsourced 70% of its interpretation to third-party vendors for USD 9m in 2017, using technology integrated into patient rooms to deliver VRI at the click of a button.

While troubleshooting technical difficulties, Stegall realized that taxpayer-funded outsourcing was costly and often relied on interpreters working outside the US who, unlike in-house staff, had not been trained internally.

Stegall approached Parkland’s board with an idea: “I can do this better, smarter, faster, cheaper,” she promised. Her solution? “Insourcing,” to create Parkland’s own call center.

By June 2018, Parkland was hiring and training interpreters for its call center, which began operating in November 2018. The center now employs over 80 interpreters, and Parkland, as well as Dallas County, are spending less. Interpreting through the Parkland call center costs USD 0.55 per minute compared to third-party vendors at USD 0.74 per minute. This adds up to USD 1.5m in annual savings.

“You absolutely have to have intensity to drive the capital expenses that come with insourcing. I’ve seen smaller hospitals try to do it. I wouldn’t suggest it.”

Interpreters employed in the call center receive not only benefits, but also educational and professional opportunities. Parkland provides 8 to 12 weeks of training for new interpreters, depending on the individual’s skill level. The call center’s goal is to put itself out of business, Stegall emphasized, adding that 25% of current call center interpreters are in nursing school. Onboarding those interpreters-turned-nurses in the future will allow the hospital to match the clinician to a patient’s needs while bringing down staffing costs.

Stegall doubts that the model is appropriate for facilities operating on a smaller scale. She said you “absolutely have to have intensity to drive the capital expenses that come with insourcing. I’ve seen smaller hospitals try to do it. I wouldn’t suggest it.”

Parkland has also benefited from already having a fully operational call center as part of the hospital’s existing telehealth services. “Part of scale [is] having that available to you,” Stegall said.

Unfazed by Changes to ACA 1557

The call center has already become a “Parkland profit center” by selling its capacity to pre-hospital and hospital clients, and anticipates future savings thanks to the built-in career paths for interpreters.

Proposed changes to ACA 1557 are already making waves in the language industry, but Stegall pointed out several ways in which a rollback could benefit Parkland, and, ultimately, patients.

Lifting the requirement for providers to send pages of “tagline” translation notices in at least 15 languages to inform patients of the availability of interpreting services could save millions, according to a May 2019 statement from the Department of Health and Human Services (HHS).

Placing certain limits on ACA 1557 may also open up avenues for experimenting with new tools like speech-to-text technology, which clashes with the legal definition of adequate translation or interpreting as being produced by a human. Stegall also cited chatbots as an option for enhancing the patient experience in lower-stakes administrative and financial interactions.

Other opportunities might include helping to improve electronic medical records (EMR) used across the US, which were originally built around homogeneous populations.

Stegall asserted that Parkland’s commitment to language access will stay strong regardless of any changes to ACA 1557.

“We truly feel this will have a minimal impact on our patients,” she said, noting that Parkland will continue to meet the Joint Commission’s higher standards, and that hospitals have trained physicians and nursing staff about the expectation to use interpreters.

According to Stegall, “the likelihood that this will change, in my opinion, is next to nothing.”