Wellness Policy Study

Presenter Name: Simi Litvak

Institution: World Institute on Disability

Introduction

Available data suggest a number of disparities in health status related to disability, resulting from problems that include a lack of access to quality medical care and health promotion programs (Krahn, Sherry, Drum, & Culley, 2002). This report is based on information, analysis, and opinions about policy options and opportunities for improving access to quality medical care and health promotion programs from a variety of expert sources, including persons with disabilities who are experiencing health and wellness problems, and other primary and secondary sources.

Research/Training Objective

A number of federal and state statutes and regulations could be the locus of policy change and development to enhance the health and wellness of people with disabilities. The purpose of this report is to outline barriers and identify policy change strategies that are the most opportune and that would advance the health and wellness of people with disabilities. The most opportune policy directions are those that will enhance the lives of people with disabilities while at the same time streamline and improve programs, be cost neutral or even save federal and state dollars, and seem to be achievable. We are just beginning to accumulate the evidence to be able to assert that prevention and wellness approaches do indeed lower overall health care costs, particularly emergency and hospital care.

Methods

This study began with a literature search and a review of the findings from the Rehabilitation Research and Training Center (RRTC) on Health and Wellness for Persons with Long-Term Disabilities’ focus group and individual interview research on “Self-Definition of Health Practices, Opportunities and Barriers,” the foundation of the RRTC’s work. Using these primary and secondary sources, the World Institute on Disability explored how people with primary physical disabilities define health and wellness and what they see as facilitators and barriers to health and wellness in their experience with Medicaid and other health insurers. In particular, we were looking at the breadth of services that people with disabilities feel need to be covered, provider practices that enhance health and wellness, and health behaviors of people with disabilities that need supporting. We grouped these issues into a set of barriers that people with disabilities believe impede their ability to meet their health and wellness needs (Kaplan & Litvak, 2002).

Based on this work, we developed a preliminary set of recommendations to review with health and wellness policy experts for their comment. We added recommendations for potential policy change to eliminate identified barriers. These barriers and recommendations were presented to several panels of experts on health and disability policy. These included the RRTC National Advisory Council in June 2001; the principal investigators of the RRTC’s other projects; and the participants at the RRTC’s first policy conference. Applying this input, we pared down the list of barriers to six, added the desirable outcomes that could result from eliminating the barriers, and revised the recommendations. Using this revised document, we conducted individual phone interviews with a panel of disability policy experts to get their views on the recommendations, their ideas for policy change, and their knowledge of any innovative health and wellness projects for people with disabilities.

Results

Six barriers to improving the health and wellness of people with disabilities were identified: array of services; prevention and maintenance; access and accommodation; information on managing disabilities; procedures, finances, and transportation; and practitioner knowledge and expertise (see tables of each of the six barriers below). Policy change recommendations addressing a number of federal and state statutes and regulations were developed that combined the opinions of people with disabilities who are not working in disability-related fields as well as disability professionals, academics, advocates, and disability health policy experts with and without disabilities.

 

Barrier 1: Array of Services Table
Legislation Regulation Enforcement Policy R & D
 

Medicaid

  • Expand definition of medical necessity state-by-state
  • Equalize financial eligibility across Long Term Services

Medicare

  • Broaden law to cover medication, Durable Medical Equipment (DME) outside the home, dental care
  • Eliminate home-bound requirement for home health
  • Eliminate eligibility waiting period

Taxation

  • Create a refundable tax credit with a carry-over for disability related expenses
 

Medicaid

  • Expand service mix by continually changing regulations so that Medicaid stays current with the field and the state of the art.
 

Medicaid

  • Require states to implement Early and Periodic Screening, diagnosis and Treatment (EPSDT) for children
 Fund research that competently addresses “cost effectiveness” questions, so that cost-effective arguments used to advocate for services and research dollars are iron-clad and crystal clear.
Barrier 2: Prevention and Maintenance Table
Legislation Regulation Enforcement Policy R & D
 

Medicare

  • Mandate specific screening and prevention services

Medicaid

  • Increase number of waivers supporting health maintenance

Rehabilitation Act

  • Fund CILs for peer support of disability and health management

Private Insurance

  • States require insurers to cover prevention and maintenance
(No comments)  

Use ADA to improve access to fitness centers and ensure equitable treatment and better exercise protocols for people with disabilities

Expand demonstrations or pilot studies that would offer prevention and wellness services and monitor them to compare costs, define health necessity and document the cost saving of health necessity services.
Barrier 3: Access and Accommodations Table
Legislation Regulation Enforcement Policy R & D
(No comments)  

Taxation

  • Institute a universal design credit for manufacturers and designers of technology
  • Create broader private sector incentives in the form of tax credits and deductions for ADA compliance
  • Expand government negotiations and strengthen enforcement of disability-rights laws
  • Strengthen access requirements in health and social services accreditation mandates
  • Significantly increase community group resources for pursuing stronger enforcement of disability-rights laws.

Medicaid

  • Write enforceable contracts with providers that specify their ADA requirements
Assess the magnitude of barriers to health and wellness in various cultural and income groups and by gender and age
Barrier 4: Information on Managing Disabilities Table
Legislation Regulation Enforcement Policy R & D
Fund Independent Living Centers and other consumer / family run, controlled and focused organizations for peer support in disability, health management and self-advocacy.

Medicaid

  • Incorporate "self-empowerment" in Medicaid's case-management concept
(No comments) Assess the short and long term effectiveness and potential liability of CILs and other consumer run, controlled and focused organizations to deliver appropriate health related information, training and services and conduct health promotion workshops
Barrier 5: Procedures, Finances and Transportation Table
Legislation Regulation Enforcement Policy R & D
(No comments) Medicaid
  • Improve the process of replacing worn out DME by tightening up turn around, expanding the service provider base, and introducing more competition
  • Reinstate the Medicaid managed care regulations providing better consumer safeguards
(No comments)

Explore problems and solutions to payer-of-last-resort rules that allow Medicare, Medicaid, the schools and other providers to "pass the buck."

Medicare

  • Implement and expand consumer management pilots to evaluate consequences of direct consumer purchase of DME
Barrier 6: Practitioner Knowledge and Expertise Table
Legislation Regulation Enforcement Policy R & D
(No comments)
  • Establish minimum competency standards for serving people with disabilities.
  • States set Medicaid and Medicare Managed Care Organization (MCO) payment rates that reflect accurate risk adjustment and case mix, and set fee-for-service rates that are sufficient to attract direct care providers.
  • Enforce rules requiring care and services available under Medicaid be "available to the extent obtainable by the general population in the geographic area."
  • Use the ADA to compel higher fees as an equal access issue.
Develop and test new models that augment providers' ability to serve people with disabilities.

Conclusion

The methodology of this project culminated in a very rich set of recommendations of policy options and opportunities for health and wellness services for people with disabilities. There are ten recommendations that seem most feasible and have the possibility of a large impact on health and wellness of people with disabilities:

  1. Eliminate the inequities in Medicaid eligibility across programs.
  2. Continue expanding the Medicaid concept of medical necessity on the state level.
  3. Keep changing federal regulations so that Medicaid: stays current with the field and the state of the art for people with disabilities, improves the process of replacing worn out durable medical equipment, and includes self-empowerment in case management.
  4. Require the federal government to hold all states responsible for implementing EPSDT.
  5. Mandate Medicaid waiver-type services and expand Community Support waivers offering prevention and maintenance services.
  6. Develop Medicare prevention and wellness mandates for specific populations or specific services, shorten waiting periods for Medicare eligibility, broaden coverage, and eliminate the homebound requirement for services.
  7. Institute a universal design tax credit for manufacturers and designers of technology.
  8. Use ADA compliance as a standard for giving tax credits and awarding Medicaid contracts. Use ADA suits to open fitness centers to disabled people and to compel higher provider fees as an equal access issue.
  9. Recognize and reimburse Centers for Independent Living (and other organizations that are run by, controlled, and focused on consumers/family) as vendors for peer support in disability and health management and self-advocacy and as vendors for durable medical equipment with funding from Title VII of the Rehabilitation Act.
  10. Increase practitioner knowledge and expertise by establishing minimum competency standards for serving people with disabilities and/or make it economically feasible to serve people with disabilities.

Implications

In order to bolster policy changes to support health and wellness activities for people with disabilities, our panels of experts had several recommendations for needed research, which are:

  1. Conduct high quality cost-effectiveness research on outcomes of prevention and maintenance, PAS, alternative and complementary medicine, DME, health club membership, and models of intensive care management that augment providers’ capacities to provide quality service to people with disabilities.
  2. Assess magnitude of health and wellness barriers faced by disabled people from diverse backgrounds.
  3. Investigate and assess the short-and long-term effectiveness and potential liability of CILs and other consumer run, controlled and focused organizations to deliver appropriate health- related information, training, and services in a useful and cost-effective manner and conduct health promotion workshops for people with disabilities.
  4. Explore problems and solutions to payer-of-last-resort rules that allow Medicare, Medicaid, schools and other providers to “pass the buck.”
  5. Assess the benefits of disabled consumer control of health dollars for individual equipment needs under both Medicaid and Medicare services.

Though people with disabilities face many barriers to health and wellness, it is clear that there are a wealth of policy initiatives and research projects that could significantly improve disabled peoples’ health and wellness services. None of these policy changes will be easily achieved, but they provide a workable blue print for action.

References

Kaplan, D., & Litvak, S. (2002). Barriers to health and wellness from a disability perspective. Journal of Gender-specific Medicine, 5 (2), 9-12.

Krahn, G. L., Sherry, M., Drum, C. E., & Culley, C. (2002). Health disparities and disabilities: A brief report. Rehabilitation Research and Training Center on Health and Wellness for Persons with Long Term Disabilities, Oregon Health & Science University.