Many medical practices not ADA accessible despite incentives

More than two decades after President George H.W. Bush signed the Americans with Disabilities Act into law, many physician practices are not truly accessible for disabled patients.

Twenty-two percent of medical and surgical subspecialty practices indicated in a recent survey that they could not accommodate patients in wheelchairs, mostly because they couldn’t transfer them to an exam table. The report, in the March 19 Annals of Internal Medicine, found that the majority of practices that said they could accommodate patients with disabilities planned to manually transfer them onto an exam table, a method authors said is not always safe for the patient or those doing the lifting.

“The goal of the study was to increase awareness about the need for accessibility and to help doctors realize they may need to make some adjustments in their practice,” said Tara Lagu, MD, lead author of the Annals article and assistant professor at Tufts University School of Medicine in Boston. “I’d like to get a dialogue going about the next step to solve the problem.”

Dr. Lagu said a lack of awareness, liability issues, and time and cost concerns appeared to be the main reasons some medical practices don’t comply with the law, which states that all medical practices must provide “full and equal access to their health care services and facilities” for patients with mobility impairment. This includes building accessibility as well as transfer from a wheelchair to an exam table.

Experts say practices need to be fully accessible to people in wheelchairs to avoid fines from the U.S. Dept. of Justice. As the baby boomer generation ages, physicians will find a growing number of patients with disabilities. Tax deductions and tax credits could make the cost of accessibility less expensive than doctors might think.

Making the office meet ADA requirements could save money for physicians in the long run, consultants said. Doctors need to factor in the extra time it takes to handle patients with disabilities in a nonaccessible environment, especially if that results in delays in seeing other patients or scheduling longer appointments for patients with mobility impairment.

“There are 10,000 people every day going on Medicare,” said Owen Dahl, a member of the MGMA Health Care Consulting Group. “It’s a huge market, and it will get greater and greater. You’ll want to do as much as you can to accommodate them.”

The extent of inaccessibility

Dr. Lagu said the more than 3 million U.S. adults who use wheelchairs have difficulty gaining access to physicians and receive less preventive care than other adults.

She and several colleagues called 256 medical and surgical subspecialists in Boston, Dallas, Houston and Portland, Ore., attempting to make an appointment for a hypothetical patient who used a wheelchair and is unable to transfer without assistance from the chair to the exam table. Of the surveyed practices, 56, or 22%, reported that they could not accommodate the patient. Gynecology had the highest rate of inaccessible practices at 44%, and psychiatry had only 6% inaccessibility.

Nine practices cited inaccessibility to the building, and 47 cited inability to transfer the patient to an exam table.

Of 200 accessible practices, 67, or 33%, including practices such as otolaryngology and ophthalmology, said they had equipment that could adjust to the patient while he or she was sitting in a wheelchair. Psychiatry practices said they did not need to move the patient for an exam. An additional 103 practices, 51%, planned to transfer the patient manually from a wheelchair to a nonaccessible high table without using a lift. Twenty-two practices — 11% — use accessible tables or a lift for transfer.

“Many of the practices said why they wouldn’t see the patient,” Dr. Lagu said. “That degree of willingness to explain told us there is a lack of awareness about the law. Some thought if the building is accessible, they’re OK.”

A federal report lists adjustable-height exam tables that lower for patient transfer, different types of mechanical lifts, specialized mammography and gynecology tables and manual transfer of patients by trained staff as appropriate means of providing access.

Affordable options

An often-cited reason for practices not providing full accessibility to patients with disabilities is cost. For example, adjustable-height exam tables run about $5,000, twice as much as regular exam tables.

But practices can receive a tax credit equal to 50% of the eligible access expenditures in a year, up to $5,000 a year, and a maximum tax deduction of $15,000 a year for removing architectural and transportation barriers.

Manually lifting a patient is a common option employed by practices, but that should be used only if those doing the lifting are trained properly, said Lex Frieden, a professor of biomedical informatics at the University of Texas Health Science Center at Houston and an architect of the ADA. He said a local rehabilitation institute should be willing to train staff.

Frank Kelly, MD, an orthopedic surgeon in Macon, Ga., said that although he constructed his current building to accommodate people in wheelchairs in the 1980s, before the ADA was enacted, he sometimes needs physical therapists to transfer a patient onto an exam table.

“All are physical therapists, and they are trained in how to lift people. They are more attuned to these patients’ needs than anyone,” Dr. Kelly said.

Frieden said that if liability and workers’ compensation are concerns, practices can utilize a mechanical lift to transfer the patient, which he said is a relatively inexpensive option at $2,000 for a top-of-the-line model.

He said small practices need to be creative to accommodate patients in wheelchairs, such as entering into a cooperative agreement with large clinics or university clinics so their patients can access more expensive testing equipment and imaging devices. They also can share equipment with other small practices.

“You need to make it as easy for the patient as possible, but it doesn’t have to be in your office,” Frieden said.

Dahl said a practice may need to buy only one adjustable-height exam table, not one for each room. He said for some specialties, the exam could be conducted in a wheelchair.

Dr. Kelly said he doesn’t have any adjustable-height tables, but he does have two exam tables that are lower than a regular exam table and can accommodate people up to 600 pounds. He said they cost about 25% more than a regular table, but are worth the extra expense. He has an x-ray machine that can be lowered more than others, and he is considering purchasing a mechanical lift for performing x-rays.

“I’ve never turned away a patient because they might be obese or unable to ambulate,” Dr. Kelly said.

Although Dr. Lagu’s study points out the number of practices unable to accommodate people in wheelchairs, Frieden sees a more positive side.

“The study says to me that nearly 80% of medical practices are accessible,” he said. “I’m impressed there are so many providers eager to serve the whole population.”