As healthcare continues its digital transformation, ensuring clear, accessible communication with patients remains crucial. This is especially important for a diverse population with varying language needs and accessibility requirements. The recent Centers for Medicare & Medicaid Services (CMS) Final Rule reflects this commitment to inclusivity by establishing stricter guidelines for Medicare Advantage and Part D payers regarding patient communication accessibility and language requirements.
Communications that are static for a period, such as a year, and do not have personal health information (PHI) in them are now required to be provided in all of the formats and online versions needed to be compliant with Section 508 of the Rehabilitation Act. Section 508 specifies compliance with Web Content Accessibility Guidelines (WCAG), which is a set of guidelines created by the World Wide Web Consortium (W3C) to help make web content more accessible to people with disabilities. While requiring additional work and time to create the different formats, they should not be problematic for the plans. Where the challenges arise are in the documents that are transactional in nature, such as Explanations of Benefits (EOB), which contain PHI and need to be sent to members in a timely manner.
The mandate for accessibility and timely delivery
Gone are the days when patients relying on alternative formats like braille, large print or foreign languages would wait weeks to receive critical healthcare communications. The new CMS Final Rule mandates a significant shift, requiring turnaround times measured in hours, often within the same business day. This is a positive step forward, ensuring timely access to vital information for all patients, regardless of their abilities.
These turnaround requirements create major challenges for the plans, as their current processes and suppliers are geared to taking weeks to deliver braille, large print, audio and documents translated to various languages. And in some cases, the plans do not currently deliver some of these formats. They will need to put systems and processes in place to create all of these formats; to be compliant with CMS rules, they must deliver whatever format the member requests and they must remember the member’s requested format to always deliver all of their critical communications in that format. This requires a good preference management database and delivery process to be in place.
If a plan does not currently create WCAG compliant accessible PDF, then they will be required to adopt technology that can create the proper format. Next, they will need to set up templates to create the required accessible PDF files. Finally, they will need to modify their processes to either create and store the new format or implement solutions to create them dynamically on demand.
Beyond accessible documents
The scope of the Rule extends beyond turnaround times. Healthcare communications, including enrollment kits, letters, Annual Notice of Change (ANOC), Evidence of Coverage (EOC), EOB and Summary Benefits documents, must now be readily available in foreign languages if the population relying on a specific language exceeds 5% in a given geographical area.
The challenge: complexity and time constraints
While the intent of the CMS Final Rule is clear, implementing it can present real challenges. Developing complex healthcare communications in additional languages is a time-consuming and resource-intensive process due in part to complex legacy processes that have been used in the past.
- Composition Templates
The document composition solutions that create these complex documents and customize each one for the intended recipient require commands that drive the process, called templates. The traditional approach to creating translated documents is to create a new template for the target language. This process can take a significant amount of time and resources to do, especially with each target language requiring a new template. Many people are needed to create one of these. For a moderately complex document, like an EOB, this can require six months of elapsed time, document designers, language translators, testers, project managers and others—and this needs to be done for each target language. The other major problem with this approach is that it doesn’t handle dynamic content, such as notes entered by doctors and nurses.
- Manual Translation
Each document can be translated manually by certified language interpreters. This approach will normally be needed for each document, followed by a desktop publishing step to format the translated documents correctly. This approach can create complete, accurate documents. However, for large plans, the volume of documents that need to be translated every day greatly exceeds the capacity of the language translators, causing the CMS timelines to be missed. The other disadvantage of this approach is that, at $100 to $200 per page, it is very expensive.
- Automated Document Translation
Using a combination of glossaries, translation memory, machine translation engines and formatting software in conjunction with human translators, all driven by intelligent automation software, this option can achieve all of the CMS requirements at a reasonable cost. The ideal approach is one that is language agnostic so adding new language documents can be done easily.
The additional challenge of alternate formats
Beyond these core challenges, the sheer volume and complexity of healthcare documents add to the time constraints. But the complexities don’t stop there. The CMS Final Rule mandates providing critical healthcare information in alternate formats as well, further increasing the challenges.
- Braille
Converting documents into braille requires specialized software, hardware, supplies and expertise. Without all of these, this process can be error-prone and slow, delaying delivery to the members beyond the timeframes specified by CMS.
- Large print
Converting documents into large print requires specialized software and expertise. Without the needed experience and tools, this process can be time-consuming for lengthy documents, especially when dealing with complex layouts or tables. One consideration is the paper bloat it creates. Typically, the large print document should require twice the page count as the original, increasing printing and mailing costs.
- Audio files
Creating high-quality audio recordings of healthcare documents necessitates professional voice talent and editing capabilities or good text-to-voice software. Additionally, ensuring audio clarity and proper pacing for visually impaired audiences can add another layer of complexity. In addition, delivery equipment such as DVD-ROM writers may be needed.
The time crunch
The combined challenges of language translation and alternate format creation significantly extend the time to market for these crucial communications. Imagine the effort required to translate and convert an enrollment kit, packed with dense information and legal jargon, into Spanish or French, while simultaneously ensuring its accessibility in braille and large print. The task becomes even more daunting for languages with complex writing systems or those with limited resources for creating accessible formats.
Finding qualified translators and specialists skilled in crafting accessible formats can be a significant hurdle. This time-consuming process can potentially delay critical communication with patients who rely on these alternative formats. As a result, the time to market for accessible and translated documents can be extensive. This is where innovative technology solutions and strategic partnerships become critical for payers to meet the CMS Final Rule’s requirements effectively.
Considerations for payers to ensure compliance
For payers grappling with meeting the demands of the new Rule, here are some key considerations:
- Technology solutions
Leverage technology platforms equipped with robust language translation and alternate format capabilities. Look for solutions that offer machine translation models specifically trained in healthcare terminology for improved accuracy.
- Vendor partnerships
Partner with experienced vendors who specialize in healthcare communication accessibility. These partners can provide invaluable expertise in content creation, translation and alternate format conversion.
- Internal processes
Streamline internal processes for content creation, review and approval in multiple languages. This includes training staff on the new regulations and establishing clear communication protocols with language service providers.
- Proactive planning
Don’t wait until the last minute to translate documents. Develop a proactive strategy for identifying high-demand languages and prioritizing translations.
Embracing inclusivity beyond compliance
The CMS Final Rule goes beyond compliance; it represents a shift toward a more inclusive healthcare system. Empowering individuals to make informed decisions about their health by ensuring timely access to critical information in a patient’s preferred language and format is crucial. This not only fosters better patient engagement but also improves overall health outcomes.
About Ernie Crawford
A digital document industry pioneer, Ernie Crawford is President/CEO and founder of Crawford Technologies. One of only a small number of people worldwide withan M-EDP (Master Electronic Document Professional) designation, Ernie has more than 30 years of senior marketing and management experience in the high-volume digital printing market.
