Public Policy Principles for Improving
Cultural Proficiency & Care to Minority
& Medically Underserved Communities

: :  Adopted November 2005  : :  Document Updated May 29, 2007

1. Introduction: Importance of Improving Cultural Proficiency in the Delivery of Health Services

• The organizations that comprise The California Endowment's Medical Leadership Council on Cultural Proficiency are committed to promoting access for limited English proficient (LEP) patients, cultural proficiency, expanded health workforce diversity, and reduced health disparities in the provision of medical care to California's Limited English Proficient and racial/ethnic medically-underserved populations. All persons, regardless of race, ethnicity or primary language deserve access to high quality health services.
• Cultural proficiency is defined as a set of congruent behaviors, attitudes and policies that come together in a system, agency or among health professionals that enables work in cross-cultural situations. A culturally proficient organization values diversity; conducts cultural self-assessments; is conscious of and manages the dynamics of difference; institutionalizes cultural knowledge; and adapts services to fit the cultural diversity of the community served.

2. Organizing Principles

Provider Education

• Medical societies and provider associations should work with their members to educate them about cultural proficiency, health disparities among racial and ethnic medically-underserved populations, and the impact on health outcomes of limited English proficiency. These organizations should make available information, trainings, and other resources so that physicians and other health care providers may continually improve access to quality care and reduce health disparities.
• Health professionals should be aware of, and sensitive to, the cultural and ethnic diversity of patients they serve so they can develop and implement best practices such as providing interpreter services and culturally proficient care in their offices. Health professionals should be aware of the connection between good cross-cultural communication and ensuring patient safety.
• The Office for Civil Rights should disseminate information and provide technical assistance about best practices in the provision of culturally, ethnically, and linguistically sensitive care delivery.

Workforce Issues

• The State of California should encourage the racial, ethnic, religious, and linguistic diversity of its health care workforce to reflect the needs of the population it serves.
• Medical and other health professional schools should increase efforts to recruit and retain minority faculty and promote minority faculty into leadership positions.
• Cultural proficiency training should be incorporated into residency programs in every specialty and should be available as part of the continuing professional development of health professionals.
• To meet the needs of LEP patients, the State of California should provide incentives for the development of a trained interpreter workforce.
• Medical school admissions policies should reflect the importance of increasing the representation of under-represented minority students.

Language Access

• Language assistance services, including, but not limited to, bilingual providers and staff, dedicated staff interpreters, contract interpreters, telephonic and video language services, translated written materials, and translated signage, are an essential element of delivering culturally proficient care, particularly to LEP, racial and ethnic medically-underserved communities.
• Any language access requirements placed on physicians and other health care providers must recognize the logistical difficulties in the provision of interpreter services for unusual/rarely encountered languages and in urgent/emergent situations, and provide exemptions and additional assistance for these situations, as appropriate.
• State, regional and local systems of language assistance service should take into account the limited capabilities and resources of health plans, hospitals, clinics, health departments, medical groups, physician practices and other health professionals. To the extent possible, there should be efforts to collaborate, coordinate and centralize the provision of language assistance services to increase efficiencies and minimize costs and administrative burdens to health professionals.
• Payment for interpreter services in both publicly- and privately-funded health care systems must be the responsibility of the insuring or purchasing entity.

Research and Data Collection

• Health insurers and health care plans should be required to collect and/or report socio-cultural health information (e.g., patient’s race and ethnicity, including subpopulations, primary language, etc.) to assist physician offices, while respecting the individual privacy of patients. This data collection shall not be delegated to the treating physician without an explicit paid, contractual agreement.
• Culturally and ethnically diverse populations must be fully represented in clinical studies supported by both private and public sector funds. Researchers from minority communities must be trained to conduct research and clinical trials.
• Diseases and conditions disproportionately affecting LEP, racial and ethnic medically- underserved populations should be adequately investigated. Research on specific populations should be conducted to document health issues and successful interventions.

Health Care Financing

• The availability of, and access to, quality, affordable health insurance is integral to eliminating disparities among LEP, racial and ethnic medically-underserved populations.
• Public insurance programs should promote access for beneficiaries by advertising availability, providing applications and other documents in other languages, and reviewing application processes to see what barriers may exist for eligible populations.

Written Resources

• The state and other interested stakeholders should examine the feasibility of statewide or local clearinghouses for translated or in-language materials that could increase access to quality health education, medication information, and other health-related information.

Quality Assessment

• Quality indicators that measure cultural proficiency should be developed.
• A review of current quality assessment measures should be conducted to identify areas for integration of cultural proficiency measures and make appropriate recommendations.

Payment

• Payment for interpreter services in both publicly- and privately-funded health care systems must be the responsibility of the insuring or purchasing entity.
• The primary financial entity (state, insurance company, or managed care company) should contract with and pay interpreters directly unless medical groups or physicians explicitly choose to accept risk for such services in their contracts. Health professionals, including medical groups, shouldn’t unwillingly bearing the burden or expense of providing interpreter services.
• There should be consideration of reimbursement of physician office bilingual staff who serve as interpreters, as long as they have been trained and assessed for linguistic competency. There should be consideration of compensation for bilingual physicians who would otherwise require an interpreter, provided they have been assessed for linguistic competency.

3. Policy Options

Medi-Cal/SCHIP/Medicare

• The State of California should work with the Centers for Medicare and Medicaid Services (CMS) and the State Health Insurance Program (SHIP) to ensure the cultural and linguistic proficiency of their respective staffs. Materials used to detail Medicare services, in particular Medicare-covered preventive care, should meet the language and health literacy levels of the beneficiaries they serve. CMS should evaluate the materials and strategies used by SHIPs to reach the LEP, racial and ethnic populations they serve.
• The State of California should work with CMS to ensure that reliable and comprehensive data are collected and reported with regard to beneficiaries' race, ethnicity, and primary language, while respecting the individual privacy rights of beneficiaries.
• The State of California should work with CMS to ensure that any program developed by CMS that bases a payment, bonus or reward on quality measures, includes quality measures of care for minority beneficiaries.
• The State of California should seek federal matching funds for the provision of interpreter services for patients in the Medi-Cal and Healthy Families programs; the State should also address funding issues within the Workers' Compensation program.
• The State of California and Council members should work with federal policy makers to ensure that language services are a covered benefit under the Medicare program.
• Ideally, the State or federal government would organize a centralized service for interpretation that can be accessed easily by physicians. Models with significant promise include that in place in Washington state and the national telephonic interpreting service in Australia. The State of California should support a regional pilot project to test delivery models for such a service.

Managed Care/Health Plans

• Managed care/health plan organizations, including public and private HMO's, should work with physician and other health provider organizations to ensure the development, evaluation, and diffusion of curricula, training, and education programs that address cultural proficiency, medically underserved communities, and health disparities.
• Managed care organizations/health plans should use cultural proficiency as an indicator of access and quality.
• Both public and private HMOs and health plans should be asked to take explicit responsibility for paying and arranging for interpreter services as a covered benefit for members with the caveat that such services are the responsibility of the primary financial entity (HMO or purchaser) and are not to be born by fiscal intermediaries such as local medical groups or physicians and other providers, unless physicians/groups/other providers have explicitly contracted for the provision of such interpreter services.
• Managed care organizations/health plan organizations should negotiate with both public and private payors for adequate reimbursement to cover the expenses of interpreter services so that they can establish services without burdening physicians.

Private Industry

• Private industry should be engaged by medical organizations and patient advocacy groups to consider innovative ways to provide interpreter services to both employees and the medically underserved.