Barriers to Disability-Competent Care

Adults with disabilities face tremendous barriers (literally and figuratively) to effective, accessible, patient-centered, and efficient care in our current health care system: dysfunctional systems, poor care, and inefficient financing mechanisms perpetuate these barriers. In addition to the competence and knowledge needed to serve this population, there are a variety of more practical barriers, including physical space/accommodations, and time, along with financing methodologies that are insufficiently risk-adjusted to reflect the needs of individuals with disabilities.While the population of adults with physical disabilities is growing rapidly, the number of disability-competent providers is woefully few in number.  Non-disability-competent providers tend to see only the disability and not the person as a whole who wants what all other patients want: respectful, collaborative care with an emphasis on prevention.

Accessibility & Access

Accessibility and access barriers are both physical and procedural.  The physical barriers include entry doorways and waiting rooms, room size and maneuverability (for transfers and equipment).  Procedural barriers are primarily a matter of time allotted for clinical visits, as well as flexibility on the part of the provider.  It is important to differentiate between barriers of inconvenience and those that prevent the delivery of the service.

It is anticipated that most of the members in the existing DCPs will be wheelchair users. Wheelchairs and other mobility aids require an accessible entrance, wider hallways and doorways, and special equipment (such as lifts for transferring from chair to table in some cases) to enable physical examination.  For individuals in wheelchairs, merely navigating from the reception area to the exam room and appropriately positioning within the room can easily take twenty minutes, the time normally allotted for an entire visit.  In addition, some individuals have great difficulty being understood and therefore require the use of special communications devices (such as keyboards to type out speech).  These are examples of the many dynamics involved in a clinical encounter (especially outside of the member’s residence), which require clinicians to dedicate significantly more time when serving this population, and thus are barriers to disability-competent care.

Current State of Disability-Specific Risk-Adjustment

The lack of a sensitive and viable risk-adjusted rate-setting methodology presents several challenges to the goal of creating and supporting integrated care programs for adults with physical disabilities. Currently, Medicaid and Medicare are using Hierarchical Condition Categories (HCCs), Diagnostic Costs Groups (DxCGs), and the Chronic Disability Payment System (CDPS).  These have been based and tested on a broader population (elderly, disabled of all ages) and have consistently proven to be insufficiently predictive of both the actual costs and unique issues relating to adults with physical disabilities.  As experience has shown that the Medicare HCC payment model (currently being used as the basis of Medicare Advantage / Special Needs Plan financing) has been of varying sensitivity, the ACA has mandated a study of the model to refine it for Medicare beneficiary subpopulations such as people with disabilities.

Similarly, the transition to Medicare Part D and bidding and payment methodology has underfunded plan liability pharmacy costs. Although further analysis is needed, this underpayment appears to be primarily related to the use of drugs to (attempt to) retard progression of disease for persons with Multiple Sclerosis (MS), as well as higher incidence of prescriptions for insulin-dependent diabetes mellitus (DM) and anti-psychotic medications.  These two criteria alone – among many others involved in caring for people with the most medically and behaviorally complex conditions—are emblematic of the unique financial risk-adjustment challenges that need to be addressed as payment models are developed and refined.

There are many reasons for the lack of disability-competent providers: As stated earlier, caring for adults with disabilities is often time-intensive, depending on the consumer’s functional limitations and the availability of appropriate adaptive equipment.  Payment mechanisms are at best ineffective: traditional payments for primary care services are based on complexity, without consideration of the time-consuming factors involved in serving individuals with physical disabilities. Even with adjustments to primary care payments, the payment methodology is unable to reflect the additional time and accommodations needed to appropriately serve adults with disabilities.