The American Medical Association is aggressively promoting medical literacy at the same time it's battling to overturn federal rules that require doctors to hire interpreters for patients who don't understand the English language.
It may seem like a cultural contradiction, but the messages in those seemingly paradoxical policies are consistent, according to top officials with the Chicago-based doctors' group.
Asked about that apparent incongruity, Richard Corlin, M.D., a gastroenterologist from Santa Monica, Calif., and the incoming president of the AMA, says, "No, not all, it's like saying everyone should be on a high-fiber diet. But that doesn't mean you should eat 12 pounds of oat bran every day.
"We're strongly pushing medical literacy and better communications," he adds. "But there are foolish and stupid ways to improve that communication. And the government has managed to find one."
In fact, one of Corlin's goals for his yearlong presidency is to overturn or modify what the AMA has long described as a "well-intended but unfunded mandate" requiring doctors who accept Medicaid funds to hire interpreters for patients who are not proficient in English.
Those guidelines were announced last August by the HHS' Office of Civil Rights after President Clinton signed an executive order directing federal agencies to ensure equal access in all areas to non-English speakers. Rep. Bob Stump, a Republican from Arizona, has introduced legislation that would repeal that order. It has more than 50 co-sponsors.
Joined by all 50 state medical associations, the AMA argued against the guidelines in an April letter to HHS Secretary Tommy Thompson, claiming that the cost would be prohibitive and could lead to a reduction in services to many poor patients.
The letter cited one specific instance in which a physician was required to pay $237 to hire an interpreter for a non-English-speaking patient. The Medicaid payment for the office visit: $38. This kind of a disparity would be common if these guidelines are enforced, Corlin says.
"This is going to actually decrease the number of (physicians) who will see these patients," Corlin says. "If you have a small office, and you're in a situation where you're having to pay four or five times (the amount of reimbursement), it doesn't even pass the laugh test."
The AMA's letter was countered by a coalition of health organizations, led by the National Alliance for Hispanic Health, which appealed to Thompson to enforce the rules included in Title VI of the Civil Rights Act of 1964. The coalition includes such heavyweights as the American Cancer Society, the American Heart Association, the March of Dimes and Easter Seals.
A media advisory on the coalition's effort was headlined "Doctors put money first, patient second."
Jane Delgado, president of the Hispanic health group, blasted the AMA and doctors in general for caring more about the size of their pocketbooks than the well-being of their patients. "Communicating with patients, unless you are a veterinarian, is the first step in clinical intervention," she says. "I guess some providers really do not want to listen to patients."
Physicians are among the most vocal foes of the guidelines, says Delgado, who suggested that they are simply clinging to the status quo against all evidence to the contrary.
"They're physicians-and they're used to being in control," she says. "They don't want to change their behavior. Physicians are used to being the top dog. And now they're out in the compound, and they have to deal with a lot of other dogs."
She and other supporters of the civil rights rules believe that the added cost for interpreters will be more than offset by savings from the "significant" medical costs attributed to errors resulting from a language barrier.
Diversity issue on agenda
AMA officials, advocating a voluntary effort for translation services, have created a 460-page "Cultural Competence Compendium" to help physicians deal with diverse populations. Last year, the AMA pledged support for HHS' "Healthy People 2010 Initiative," which, among other goals, is aimed at eliminating ethnic and racial disparities in care.
The issue is on the agenda for the AMA's five-day annual meeting, which began Sunday in Chicago.
Noting that the AMA has "gone to great lengths to find mechanisms to increase access to healthcare for the poor and disadvantaged," the District of Columbia's contingent to the AMA meeting called for an "immediate request to HHS to delay implementation of this rule."
In a two-page resolution, Peter Lavine, M.D., an orthopedic surgeon with offices in the District of Columbia and Virginia, says physicians "should not bear the responsibility for providing interpreter services," and advocates a policy encouraging patients "to find someone from their community or family member to translate."
He already has encountered problems trying to find interpreters for a diverse patient population that includes Nigerians, Laotians and Vietnamese.
The AMA, the nation's largest doctors' group with about 290,000 dues-paying members, has been a leader for years in promoting medical literacy, maintaining that physicians must play a vital role in addressing the problem. One study several years ago by the AMA's Council on Scientific Affairs showed that 42% of patients were unable to comprehend the directions for taking medicine on an empty stomach and 26% couldn't understand the information on an appointment slip.