Coverage Is Confusing for Non-English Speakers

Understanding the U.S. healthcare system is hard enough for those who speak English. For those who don’t, grasping the nuances is an even bigger challenge – especially when you throw culture into the mix. Enter North Hollywood-based ConsejoSano, founded three years ago as a solution for employers, health plans and insurance providers to communicate with non-English-speaking patients. ConsejoSano – which means “healthy advice” in Spanish – has developed a software-as-a-service platform that sends messages about doctors’ appointments and other health matters to patients in their native tongues, said Abner Mason, chief executive at ConsejoSano. The messages are written to be consistent with the values of a patient’s culture so as to maximize the chance of influencing behavior. “It’s about building trust and doing it in a language that the patient understands, but even deeper than language is culture,” Mason said. “Culture is what resonates with people.” Culture as related to health care includes concepts about the human body, the importance of keeping appointments and lifestyle habits. “The issues of language are not simply issues with medical translation and interpretation, but rather with … the meanings of the patients’ behaviors that comes from understanding cultural idioms and norms,” Rosana Bravo, a researcher at the UCLA Center for Health Policy Research explained. A lack of trust of the medical profession is a barrier to access, too, she said. Care challenges About 21 percent of U.S. residents over the age of 5 speak a language other than English at home, according to a 2013 report from the U.S. Census Bureau. Spanish is the largest contingent, followed by Chinese, Tagalog and Vietnamese. “America has changed over the last 30 to 40 years, and that change is accelerating,” Mason said. “It has become a much more multicultural country.” California already reflects the demographic make-up the country as a whole can expect to hit within the next three decades. Most of the state’s residents are minorities: A full 40 percent are Hispanic, while another 15 percent are Asian, according to the Census. “You have this growing disconnect between people who the health care system is supposed to serve and the health care system itself,” Mason said. “The health care system in the U.S. is still fundamentally English-focused – it hasn’t kept up with the demographic change.” Language is only one part of the problem. Cultural barriers, too, can make it difficult for insurers and providers to connect with patients in a way that drives behavioral outcomes. For instance, the necessity of certain procedures – such as prostate exams – must be conveyed in a very sensitive manner to patients of certain cultures. “No one wants to (go in for a prostate exam), and in certain cultures it’s really hard to convince men who are of a certain age where they’re at risk for prostate cancer that they should go in and get a prostate screening,” Mason said. “So you’ve got to understand the culture – if you’re an Arabic man, it’s different from a Hispanic man, and even within the Hispanic community, it’s different whether you’re from Mexico or Puerto Rico or Argentina.” The most effective way to convince patients to keep doctors’ appointments seems to differ between Hispanic and white populations. Hispanic patients respond better to messages that convey that they can trust the provider they are going to see, while white patients are more likely to follow through if they are told that the appointment will not take too much time, Manson explained. The issues are compounded by poverty. Even with Medicaid coverage, low-income individuals may not engage with the healthcare system due to lack of resources, such as transportation. They may also find it harder to take off work in order to keep doctor’s appointments, causing them to delay care until they are very sick, Bravo said. That has consequences not only for patients, but also for the taxpayers who subsidize their healthcare costs. “Prevention is always cheaper than treatment,” Bravo noted. “When vulnerable populations, such as immigrants and non-English speaking communities, lack access to healthcare, the impact on the greater economy is greater.” Tackling the issue is a matter of reaching the patients who are kept out of the system by both poverty and linguistic or cultural barriers, Mason explained. “It’s the worst of all combinations – really poor outcomes for people and really high costs for society,” Mason said. “We’ve got to find a way to solve that.” Connecting through culture ConsejoSano’s solution is software that serves as a conduit between managed care providers and patients. Health care plans that are contracted with Medicaid, along with some employers and physicians’ groups, pay ConsejoSano a monthly per-patient fee to help them communicate with members, Mason explained. “If you’re a large health plan, you might have 10 different languages and cultures you have to serve,” he said. “The plan has a hard time connecting with those people, both culturally and linguistically.” The firm has a team of employees responsible for designing direct messages and other forms of content that help a patient keep up with appointments, encourage them to visit their primary care provider and answer questions – all in a way that is consistent with the patient’s culture. “We’ve found that these patient populations are really comfortable with SMS texting,” Mason said. “The key is to text them in their language and in a culturally appropriate away.” By improving appointment adherence and patient satisfaction, ConsejoSano’s platform provides an incentive for Medicaid-contracted insurance companies to use its services. Insurers are required to meet certain performance metrics on the Healthcare Effectiveness Data and Information Set; failing to do so could result in the loss of a Medicaid contract, while exceeding the standards can offer financial rewards. Long road Mason started ConsejoSano with investments from family and friends along with money out of his own pocket, he said. The company closed a $4.9 million Series A funding round last February, which was led by Chicago venture capital firm 7Wire Ventures and included contributions from Tufts Health Ventures, a health plan, along with a number of social enterprise investors. The firm used the money to scale up its team and build out the platform’s analytical suite; in the time since, it has expanded the number of patients it serves from 30,000 to more than 300,000. “In the last year we’ve really seen dramatic growth because of the capital infusion,” Mason said. Looking ahead, ConsejoSano is considering moving to a “risk-share” business model, which entails contracting with clients for lower monthly and per capita fees than it already demands in exchange for an agreement that the fees will rise in accordance with performance. Giving patients access to health care is only one part of the puzzle, Dr. Jose Arévalo, chair of the Latino Physicians of California, said. Fewer than 20 percent of California’s physicians speak Spanish and only around 4.5 percent of California’s physicians are Latino, according to the organization. While a physician does not have to be Latino to understand the community, she does need to be well-versed in both the language and culture to adequately care for patients within that population. “We need to be able to have those providers who can mesh with the population that they’re serving,” Arévalo said. While Mason acknowledges that his firm cannot solve all of the system’s problems, he believes that building a bridge between low-income, non-English speaking populations and health care providers is a key first step. “People have different cultures – they are who they are,” he said. “We’ve got to accept that people are different and that we can’t expect them to change in order to get good health care.”