Physicians hesitate to treat patients with disabilities, Health Affairs finds

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Physicians are feeling overwhelmed by the demands of practicing medicine, generally, but in particular, by the demands of the Americans With Disabilities Act of 1990, leading many to experience hesitation when treating people with disabilities, finds a new survey published by Health Affairs.

Some physicians feel they were inadequately reimbursed for accommodations. A few reported that because of these concerns they attempted to discharge people with disabilities from their practices.

Increasing access for those with disabilities will require increasing the accessibility of space and the availability of proper equipment, improving the education of clinicians about the care of people with disabilities, and removing structural barriers in the healthcare delivery system, authors said.

These are the challenges facing providers – and some of the reasons they may balk at treating such patients.

WHAT'S THE IMPACT?

The data is based on a focus group that included 22 participants, with a mean age of about 51. They identified several barriers to providing care for people with disabilities: physical accommodations; communication accommodations; knowledge, experience, and skills; structural barriers; and attitudes toward people with disabilities, including the inclination to discharge them or deny them medical care.

All participants reported physical barriers to providing healthcare for people with disabilities, including inaccessible buildings and equipment. Many were forthcoming about the lack of accessibility in their clinics. For example, one rural primary care physician said, "I know for a fact our building is not accessible."

Some respondents reported using workarounds for physical accommodations, such as low exam tables. Participants responded to the question, "If a wheelchair user comes and cannot stand on a weight scale, what is your approach to taking a weight?" Some physicians reported sending patients to a supermarket, grain elevator, zoo or cattle processing plant to obtain their weight.

Participants also discussed various approaches to communicating with people with vision or hearing impairments and those with intellectual disabilities or mental illness as part of clinical care. None of the participants were able to provide patients with written materials in Braille, and only a few offered print materials in large type.

Respondents answered the question, "Do you have approaches for ensuring you are communicating effectively with patients with intellectual disability or serious mental illness?" One primary care physician said, "I'm fortunate that my patients who use sign language usually bring someone with them. … But also, we use pen, paper, and a whiteboard." Referring to patients with hearing loss, another primary care physician said, "A lot of times, the caregivers are able to give us a lot more information without communicating with the patient directly. So that's how we get the information that we need: from the caregivers."

Physicians described both financial and time-related challenges of accommodating communication needs. One non-rural primary care physician said, "I took it upon myself to actually hire an outside service to do [sign language interpretation]. They billed the office. … Their bill was higher than what we were making, so it was a losing venture. … It cost me $30 per visit for that patient, out of pocket."

Most physicians noted the lack of sufficient knowledge, experience and skills among themselves and clinic staff concerning care for people with disabilities. Patient transfer skills were mentioned often – specifically, a fear of hurting themselves or their patients.

Structural barriers, meanwhile, were divided into three categories: procedural, policy, and financial or allocation of resources. Subthemes included lack of time with patients, the burden of documentation and paperwork, difficulties with coordination of care, lack of awareness that a patient requiring accommodations is scheduled, and lack of communication about the needs of people with disabilities.

Some revealed negative attitudes about people with disabilities and commonly used outdated language (for example, "mentally retarded"). Many participants implied that providing accommodations to care for people with disabilities was burdensome. One specialist said about people with disabilities, "They can create a big thing out of nothing." Another said that people with disabilities "are an entitled population."

Multiple participants indicated that people with disabilities make up a small portion of their caseloads. One said, "You're only going to have a certain percentage of patients that are going to require [accommodations] – maybe 10%, 15% – so how much can you do?" Similar comments were repeated across groups, suggesting limited recognition and a deprioritization of people with disabilities.

A handful described denying care to people with disabilities or attempting to discharge them from their practices. These refusals were varied in their rationale. Some physicians described care they would have provided if a patient did not have a disability. "We have had patients where the level of disability is too high, and it is such a very delicate procedure and delicate part of the human anatomy, and we felt we couldn't control the situation enough to do it properly," one specialist said.

Some acknowledged they were aware of requirements that prevented them from denying care because of disability. As one specialist put it, "I think the problem is that you cannot refuse them straight. We have to give them an appointment. You have to come up with a solution that this is a small facility, [and] we are not doing justice to you; it is better [if] you would be taken care of in a special facility."

When asked about their knowledge of the ADA, nearly all the physicians reported having little or no training on the law and its implications for their practices. A participant who is a specialist, said, "I know they offer conferences and lectures, but this is a personal choice if you want to take it or not." In general, attitudes about the ADA were apathetic and even adversarial. For example, one specialist physician described feeling as if the legislation works "against physicians" and thereby, does not help people with disabilities.

THE LARGER TREND

More than 61 million Americans had a disability as of 2016, Health Affairs said. Disparities in healthcare access and quality have been observed across many groups of people with disabilities and in a variety of clinical environments. Such people also have been found to be less likely to report satisfaction with their care compared with people without disabilities.

Disparities in access to healthcare, and the quality of that care, have been associated with worse physical health and greater burden of chronic disease for people with disabilities compared with their nondisabled peers, research found.
 

Twitter: @JELagasse
Email the writer: jeff.lagasse@himssmedia.com