Physicians' Understanding of Disability Law Lacking

Kerry Dooley Young

April 01, 2019

Many physicians may have an incorrect or only superficial understanding of their legal responsibilities for accommodating patients with disabilities, a population that's poised to grow with the aging of baby boomers, according to the authors of a newly published study.

In an article published online today in Health Affairs, Nicole D. Agaronnik, BS, a research assistant in the Mongan Institute Health Policy Center, Massachusetts General Hospital, Boston, and colleagues report on a qualitative study to determine how well physicians understand the mandates of laws such as the Americans With Disabilities Act (ADA).

They found that most physicians understand that they cannot refuse a patient because he or she has a disability, but they are not always clear on how to fulfill their responsibilities to these patients.

For example, of 20 physicians interviewed for the study, 16 believed that a practice cannot refuse a patient because of a disability. But three indicated that a practice may do so, and one was unsure.

All of the physicians seemed to broadly understand that charging a patient for accommodations is prohibited under the ADA, but they expressed this belief "with varying levels of certainty," according to Agaronnik and colleagues.

"Despite a common understanding that refusing a patient would be wrong and that practices should not impose accommodation costs upon patients, physicians voiced concern and frustration with the challenges of accommodating patients with disability, the additional time required to see these patients, and the lack of financial compensation for that additional time," Agaronnik and colleagues write.

In their article, the authors urge that physicians be better educated not only about their legal obligations but also about approaches they can use to accommodate disability. For example, many physicians are not aware of assistance available to them to better equip their clinics, Agaronnik and colleagues say. Such assistance includes tax incentives to offset the costs of acquiring equipment.

Physicians should keep the needs of people with disabilities in mind as they plan and renovate their offices, said senior author Lisa I. Iezzoni, MD, professor in the Department of Medicine, Harvard Medical School, who is based at the Mongan Institute Health Policy Center.

"They need to realize that the baby boomers are coming — with bad backs and bad knees," she told Medscape Medical News. "It will be easier for everybody" if practices were well equipped to meet their needs.

Disabilities are common in the United States. In an article published last year, the US Census Bureau estimated that in 2014, 27.2% of the people living in the United States — 85.3 million — had at least one disability. The majority of this group — 55.2 million people — had a severe disability.

In 2015, researchers at the Schaeffer Center for Health Policy and Economics, the University of Southern California (USC), reported that in the near future, people will be living longer with disabilities.

"The good news — life expectancy for people at age 65 will grow by almost a year from 19.3 years in 2010 to 20.1 years in 2030," the USC researchers say in their article. "The bad news — their expected years of life with a disability at age 65 will increase even more, rising from 7.4 years in 2010 to 8.6 years in 2030."

Billing and Reimbursement Common Issues

In the current study, Agaronnik and colleagues used telephone interviews to gauge physicians' knowledge about their obligations to patients with disabilities. Physicians were offered $100 for participation in the project; four of the interviewees refused this payment. Iezzoni conducted all of the interviews, which averaged 41 minutes in length.

Initially, the researchers intended to include in their survey 25 physicians practicing in Massachusetts. They sought representatives of five specialities in which patients frequently require some accommodation for disabilities: general internal medicine and family practice, rheumatology, orthopedics, neurology, and obstetrics/gynecology.

"We stopped recruitment after twenty interviews because we had reached data saturation — that is, no new qualitative information was emerging from the interviews," Agaronnik and colleagues write.

Several participants in the study suggested that insurers could help physicians by compensating them for the additional time needed to help patients with disabilities.

"An orthopedist urged 'recognizing how labor-intensive and resource-intensive it is at every level,' suggesting that this was essential to ensure that future providers would be willing to care for patients with disability," the authors write. "A general internist observed, 'Sometimes the E&M [evaluation and E&M] coding system doesn't always reflect the extra work that's involved.' "

Iezzoni said that for years, she's had an ongoing research interest in the healthcare experiences and outcomes of people with disabilities. One of the continuing concerns in this field is having the right equipment to perform examinations. In a 2013 editorial in the Annals of Internal Medicine, Iezzoni wrote: "If barbers found simple ways to lift and lower their customer eons ago, why haven't physicians done the same with patients and examination tables?"

Iezzoni said she knows of recent cases in which women with disabilities were not weighed while receiving prenatal care because they could not stand on the scale.

Iezzoni told Medscape Medical News about her own experience as someone who uses a wheelchair because of multiple sclerosis. An internist whom Iezzoni saw as a patient didn't have the needed equipment in her office.

"She would do breast exams with me sitting in my wheelchair," Iezzoni said. "That is not optimal."

The study was partially funded through the Executive Committee on Research, Massachusetts General Hospital, and by the Eunice Kennedy Shriver National Institute of Child Health and Human Development. The authors have disclosed no relevant financial relationships.

Health Aff. 2019;38:545–553. Abstract

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