Roadmap to Providing the Best Assistive to the Technology for Community
Participation For People with Disabilities Educational Conference
September 28, Dinner Presentation
St. Louis, MO
Plaza Hotel
"The President’s New Freedom Initiative – Accomplishments and Future Steps in Assistive Technology Throughout the Federal Government and a Look at CMS Payment Provisions"
Good evening. Thank you David for inviting me to be a part of this important conference. For those of you who know David, you know he has worked tirelessly over the course of nearly a year to make this meeting happen – to bring together key parties to get REAL answers to the REAL problems faced by consumers and -- to find ways to improve upon getting assistive technology into the hands of the people who need it – quickly, effectively, and cost effectively – and matching the right technology with the right person. Thank you, David, for your passion, for your commitment, and for your nonstop efforts to improve upon the present state of affairs and to provide a roadmap for a better tomorrow.
As healthcare professionals in the 21st century, we are witnessing advances in medicine, rehabilitation, research, development and technology that would appear to be miracles to our forefathers in healthcare. We live in an age in which telehealth is no longer a dream of the future, but a reality of the present. We live in an age in which “smart homes” enable aging persons and those with disabilities to live in the comfort of their own homes, surrounded by friends and family. We live in an age in which it is not only possible for persons with disabilities to enter the workforce, but we live in an age, where – by law – the Federal Government must make accommodations necessary to facilitate persons with disabilities to achieve their full potential in the workforce.
We live in an age in which our Federal Government – in partnership with our state and local governments, the medical community, service providers, engineers and manufacturers, private industry, and academia, are WORKING TOGETHER TO TEAR DOWN BARRIERS CONFRONTING PERSONS WITH DISABILITIES.
Yet, with all the progress we’ve made, we CONTINUE to come together because we know we have not come far enough. We come together to learn from each other, to gather and exchange information and ideas, and to find ways to COLLECTIVELY solve the problems of getting the assistive technology into the hands of the people who need it because we realize NO ONE OF US CAN ACCOMPLISH THIS TASK ALONE.
Tonight I will speak about President Bush’s Government-wide “New Freedom Initiative,” and what has been accomplished in the area of Assistive Technology. At the conclusion of my remarks, I will provide a synopsis of information that was supplied to me by the Centers for Medicare and Medicaid Services with regards to payment provisions.
We are now in the third year of the President’s “New Freedom Initiative,” which as you may know is an Executive Order signed by the President to tear down barriers facing the 54 million Americans with disabilities. I am here tonight because I was appointed by the President and the Secretary of the Department of Health and Human Services Tommy Thompson to serve as the Director of the first HHS Office on Disability.
HHS was asked to take the lead in the New Freedom Initiative and the Office on Disability is responsible for coordinating the development of policies and programs within the Department and throughout the Federal Government.
When the President announced the NFI, he articulated six goals – one specifically stated: “INCREASING ACCESS TO ASSITIVE AND UNIVERSALLY DESIGNED TECHNOLOGY.” The other goals include:
• Integrating Americans with disabilities into the workforce;
• Promoting a comprehensive array of community-based services and supports;
• Promoting safe, decent house and home ownership;
• Promoting integration into and sustained participation in the workforce;
• Expanding transportation options; and
• Promoting full access to community life.
These goals, as you know, in reality ALL rely heavily upon the one I mentioned first, and that is “INCREASING ACCESS TO ASSISTIVE AND UNIVERSALLY DESIGNED TECHNOLOGY.” This conference and what has been accomplished and needs to be accomplished in all areas of assistive technology is of paramount importance in ensuring the full community integration of persons with disabilities.
Three years into the Initiative, what have we – spanning the entire Federal Government -- accomplished and what are some of the future steps planned with regards to assistive technology?
In addition to promoting the development of new assistive and universally designed technologies, the New Freedom Initiative is charged with putting assistive technology into the hands of more individuals with disabilities through policies that reduce barriers associated with cost.
As part of the NFI, the President secured $37 million for loan programs for individuals with disabilities to purchase assistive technologies under Title III of the Assistive Technology Act of 1998. The program, as you may know, matches state dollars with Federal dollars to create alternative financing mechanisms, such as low interest, long-term loans.
The President has continued to fund one of our most critical agencies with respect to assistive technology – the National Institute on Disability and Rehabilitation Research, and there are new Rehabilitation and Engineering Research Centers springing up as a result of the NFI to promote research and development on assistive and universally designed technology. There is a RERC designed to focus on workplace accommodations; another to enhance mobility and function for individuals with spinal cord injuries; another to study accessible medical instrumentation; there is a RERC on tele-manipulation machines assisting recovery from stroke; and a RERC dedicated specifically to recreational technologies and exercise physiology benefiting persons with disabilities.
There are new RERCs which focus on technology transfer; on prosthetics and orthotics; on wheeled mobility; on public transportation; and on universal interface and information technology accessibility.
Additionally, through the NFI, new Small Business Innovation Projects have been funded at NIDRR to fill such specific needs as career guidance for students with disabilities; to focus on automated systems to help integrate individuals with memory disabilities into places of employment and independent living settings; and hand-arm rehabilitation interfaces for training the hand following paralysis. These are just a few of the exciting efforts underway.
Additionally, President Bush established, funded and continues to fund the Interagency Committee on Disability Research (ICDR). The President established this Committee, of which I serve as co-chair, specifically to improve the coordination of Federal Assistive Technology Research Programs and to serve as a basis for further activities designed to increase access to assistive and universally designed technologies. The committee identified six technology research priority areas for technology research and development, which include: sensory function; mobility enhancement; manipulation ability; cognitive function; accessibility of information and communications; and accessibility to and mobility within the physical environment.
As you know, mobility limitations make up the largest area of disability in the American population and we know ambulation can be restored through the use of leg prostheses and orthoses, internal joint replacement, surgical procedures, special shoe inserts, canes, crutches, Functional Electrical or neuromuscular Simulation, and walkers. As you may know, some government-funded research projects in this area include computer-aided design and manufacture of sockets for prosthetic limbs; intelligent knees with computer chips programmed to respond to changes in walking speed; and ultrasound 3-D imaging of residual limbs for better fitting of the socket. Still, the President has charged the ICDR this year to place even a stronger emphasis on assistive technology mobility devices in future activities for research and development and federal funding. This is a direct result of another Presidential Executive Memorandum, in which he created the Interagency Working Group on Assistive Technology Mobility Devices, which I will detail for you in just a bit.
With respect to Section 508 of the Rehabilitation Act, we’ve been VERY aggressive in implementing Section 508. The Administration has taken a number of steps to ensure compliance with Section 508, and although the law’s requirements apply only to the Federal Government, initiatives are also being undertaken to promote better accessibility in the private sector and through state and local governments.
To create a robust assistive technology industry domestically and internationally, the Department of Commerce Secretary developed an 8-point initiative to support the development of assistive technologies and to promote the U.S. assistive technology industry. The initiative was based on recommendations from a 2-year survey of the assistive technology industry.
The initiative seeks to speed new technologies to individuals with disabilities, to expand the U.S. assistive technology industry, and to boost exports of our products and services. The development of a robust U.S. assistive technology industry will lead to greater assistive technology development and advancement.
The Department of Commerce will continue to reach out to industry via both technical forums and roundtables to engage representatives from industry and trade associations to share manufacturing information, discuss regulatory and trade impacts, and to gain a greater understanding of new methods to improve the capabilities and success of U.S. assistive technology providers.
Additionally Commerce will facilitate measurement and private sector standards development for assistive technology devices, in coordination with standards organizations, government agencies, industry, and user groups so that new technologies can be faster commercialized into the marketplace.
Other Activities throughout the Government which might interest you include, for example:
• The Department of Labor’s Employment and Training Administration has been funding grantees that are providing innovative strategies to address the high rate of unemployment and underemployment of persons with disabilities by focusing on training in the high-skill, high-demand information technology sector. More than 625 individuals with disabilities have been trained, with the majority entering employment at averages of $14.75 per hour;
• And the National Highway Traffic Safety Administration’s Research Program is focused on further developing and validating a safety test procedure for electronic steering and brake controllers that are used by persons with disabilities.
At HHS, we have been very aggressive in implementing Section 508 of the Rehabilitation Act as well as ensuring full implementation of the Help America Vote Act. Additionally, the Administration for Children and Families (ACF) has some interesting collaborative state efforts underway that facilitate putting assistive technology devices into the hands of the persons who need them.
In FY 2003, The Kentucky Assistive Technology Loan Corporation (KATLC), in partnership with Fifth Third Bank of Kentucky, made 106 loans for assistive technology ($956,885). These loans were used to purchase augmentative communication devices, hearing aids, mobility aids, computers, modified vans, and home modifications. KATLC received an average of 15 applications per month, and approved nearly 60% of those applications. In FY 2004 – 2005, with two large grants from the Kentucky Council on Developmental Disabilities, 2 substantial grants from NIDRR, and a significant contribution of state general funds, KATLC now has $1.8 million on deposit, which will make it possible to make loans in excess of $2.5 million. The goal of KATLC Board of Directors is to make at least 10 loans per month. This is a good example of working together across the Federal and State governments to solve the problem of coverage for assistive technology.
ACF has also been working with the State of North Carolina’s Protection and Advocacy, which provides on-going technical assistance and advocacy services to those having difficulty with assistive technology. Outreach efforts have targeted students with disabilities in community colleges and universities, which we have identified as a very important “target group.” As you may know, in October, 2002, the General Assembly of North Carolina passed Senate Bill 866, “Changes to Persons with Disabilities Protection Law.” This GUARANTEES people with disabilities the right to access electronic information, including websites, ATMs, computers in public libraries, and other public facilities.
Electronic access provisions of this law apply to information technology placed into service on or after January 1, 2004. The law requires compliance by municipalities, counties, community colleges, universities, and any agencies in State government. The State will continue its efforts to provide technical assistance and advocacy services to those having difficulty with assistive technology in 2004 and 2005.
Those are some of the highlights of what has been accomplished throughout many agencies of the Federal Government with regards to assistive technology and the NFI. The NFI has been the most dramatic undertaking to remove barriers facing persons with disabilities since the ADA was signed.
Yet, the President still saw a need to fill, and it is my pleasure to report on President Bush’s April 2003, Executive Memorandum, in which he Established an Interagency Working Group on Assistive Technology Mobility Devices. I had the great honor to participate in that working group. The Secretary of Education Chaired the Work Group, which included representatives from the Department of Education, Health and Human Services, Labor, Veterans Affairs, and the Social Security Administration, along with other federal agencies. The President charged the group with identifying existing federal government programs and resources designed to help individuals with disabilities obtain the assistive technology mobility devices that they needed for education and employment.
As you may know, the Assistive Technology Devices that the work group looked at included: attendant-controlled wheelchairs, manual wheelchairs, lever-driven wheelchairs, single side-driven non-powered wheelchairs, foot-driven wheelchairs, combustion-powered wheelchairs, travel wheelchairs and scooters, sport wheelchairs, standing wheelchairs, and wheelchair accessories.
The group was charged with:
• identifying existing federal government programs and resources designed to help individuals with disabilities obtain the assistive technology mobility devices that they need for education and employment; and
• working with State, local and tribal programs that are designed to help individuals with disabilities obtain assistive technology mobility devices for education and employment.
We submitted a report to the President with our recommendations to improve coordination among existing programs and to train vocational rehabilitation counselors, other service providers and individuals with disabilities as provided by law and to inform individuals with disabilities about these opportunities. The report included a description of how individuals with disabilities can pool funding from existing resources to obtain the assistive technology mobility devices that they need to pursue their educational and employment goals. Additionally, as you may know, we invited public comment on improving access to Assistive Technology Mobility Devices (ATMDs) and invited parties to testify at a pubic forum in May 2003. We received 42 written comments and 23 individuals testified at the public hearing. Many of these suggestions were included in the activities that the Federal Agencies are taking in response to the Executive Memorandum.
I will highlight for you some of the recommendations made in the report and where we are with some of those recommendations.
State, Local and Tribal Government Programs
The Interagency Working Group (IWG), through NIDRR, set aside approximately $100,000 to commission a report to identify State, local and tribal programs that are designed to help individuals with disabilities obtain ATMDs for education and employment. These include Temporary Assistance for Needy Families (TANF) and State Workers’ Compensation Programs. The report is organized by State, and includes all State and local and tribal programs, including eligibility criteria as well as descriptions of benefits and payment policies. The report will be disseminated through various disability organizations, Centers for Independent Living, Indian tribes, and other interested parties. It has been completed and is now in clearance at NIDRR and will be available shortly.
The Social Security Administration
As you may know, in 2002, Social Security and the Department of Labor signed an agreement to establish, train, and evaluate a new position – the DISABILITY PROGRAM NAVIGATOR. This position will be located in One-Stop Career Centers in selected States. Social Security is providing funding for a 2-year pilot of the new position. The first Navigators were in place the latter part of 2003. Among their many duties, some include:
• to help people with disabilities, including SSDI and SSI beneficiaries, access and “navigate” the complex provisions under various programs that impact their ability to gain, return to, or retain employment;
• to serve as One-Stop resources on Social Security employment support programs and policies;
• to develop linkages with employers and employer organizations to promote the hiring of people with disabilities and to facilitate their job placement; and
• to serve as a resource to area workforce investment staff to ensure the availability of comprehensive information on Federal, State, local and private programs and to link persons with disabilities to employers through the local workforce investment boards.
• Additionally, Social Security is working with several States (California, Colorado, Iowa, Mississippi, Maryland, and New York) to develop better transition strategies of youth with disabilities. The goal of this initiative is to help youth with disabilities maximize their economic self-sufficiency and Social Security will coordinate with the States involved in the demonstration to ensure that these youth receive the ATMDs they need;
• The Department of Education’s Office of Special Education Programs will fund a new center on technology implementation that will include a focus on interagency coordination relative to provision of AT devices and services, including AT mobility devices;
* The Rehabilitation Services Administration will produce a Policy Directive for Vocational Rehabilitation Counselors and other service providers, as well as for persons with disabilities, describing the findings and recommendations of the working group on ATMDs as well as information about ATMDs on choosing and obtaining appropriate ATMDs and resources and information for individuals with disabilities to become better informed consumers;
* The Family Center on Technology and Disability will collect and develop information resources relevant to AT mobility devices, including funding strategies. This OSEP Center is funded to improve the availability and quality of technology-related information and support to families of children with disabilities; and
* NIDRR will request that all of its grantees that address issues regarding ATMDs disseminate information on accessing funds for ATMDs, particularly strategies for pooling funds.
• The Department of Veterans Affairs is conducting quarterly meetings concerning provision of prosthetic appliances, including ATMDs, and invites the Veterans Service Organizations to participate. These meetings provide panels to discuss veterans’ access to ATMDs, and the VA is extending the same invitation to other government agencies to participate.
• HHS’s Health Resources and Services Administration (HRSA) is providing block grants to States to assist them in ensuring the health of mothers and children, including children and youth with special health care needs. Although Medicaid funds are typically used to pay for mobility devices, approximately 18 States indicate that under these HRSA black grants, they often pay for durable medical equipment, rehabilitation equipment, motorized and manual wheelchairs, AT and/or adaptive equipment.
• The NFI Ticket to Work Program is designed to give disability beneficiaries access to a wider range of providers of vocational rehabilitation services, employment services, and other support services. Under this program, a SSDI or SSI disability beneficiary may directly select a service provider, known as an Employment Network to help him or her return to work. The Employment Network may provide a beneficiary with services, including access to an ATMD as part of the employment plan.
Moving on to CMS, I will provide you a brief status of where CMS is in determining eligibility for wheelchairs and payment provisions.
First, as you may know, an Interagency Wheelchair Work Group (IWWG) was established to examine clinical guidance/eligibility for wheelchairs.
The group met this past July, and they will have ongoing meetings, October 4 and December 6. CMS commissioned a technology assessment from the Agency for Health Research Quality, which was contracted to ECRI (formerly Emergency Care Research Institute—now goes by acronym). Responding directly to public comments received in their June “Open Door Forum,” the working group is considering a functionality-based interpretation of “bed or chair confined,” the VA’s practice for determining eligibility for wheelchairs, the State of Pennsylvania experience with wheelchairs, and the SSA definition of “ambulatory.”
In September, the Working Group reviewed the technology assessment, noting the paucity of robust published clinical data. The group reached consensus on the adoption of functionalty-based format for clinical guidance.
Dr. Louis Jacques, a chair of the group, reports that in the first meeting, the group reached consensus on the clinical context for addressing the Medicare coverage of assisted mobility – a patient who is unable, in spite of the use of assistive devices to independently ambulate with sufficient safety to adequately perform activities of daily living in a domestic environment. They felt this step was necessary as a means to focus the technology assessment and state that the context clearly is based on a patient’s functional status. In the second meeting, the work group reviewed the technology assessment and discussed possible interpretive/guidance language.
The third meeting, scheduled for October 4, will focus on reviewing draft interpretive/guidance language and reaching consensus on the text. CMS WILL THEN MAKE CHANGES AS INDICATED BY THE WORKING GROUP AND POST THE DRAFT FOR PUBLIC COMMENT. And the fourth meeting, schedule for December 6, will focus on discussing public comments on the draft, reaching consensus on the final text and then posting the final document. For further information on this group, I would suggest contacting either Dr. Sean Tunis, at 410-786-6841; or Dr. Louis Jacques at 410-786-4512.
Issues Surrounding Power Wheelchair Coding and Payment
CMS tells me that issues surrounding power wheelchair coding and payment, specifically CMS’s proposed new code categories were recently discussed at an “Open Door Forum,” held September 1, which was announced in the Federal Register. Their time frame for implementing revised codes, medical review policy, and payment amounts for power wheelchairs was covered at this meeting. CMS is planning to implement the new codes, policies, and payment amounts by July 2005. They are tentatively planning a follow-up “open door session” at some point at the end of this year or the beginning of next year to summarize these changes. I would encourage you to participate in this forum.
Although the coverage and medical policy issues are still being addressed internally, the tentative direction CMS is heading, they say, was presented at the September 1 meeting. The CMS coding proposal presented at this meeting and one presented by the National Coalition for Assistive and Rehab Technology (NCART) are posted on CMS’s Health Care Common Procedure Coding System (HCPCS) coding website at www.cms.hhs.gov/medicare/hcpcs/default.asp. A summary of the September 1 meeting will be posted shortly on that website.
Additionally, CMS tells me that relative to provisions in the Medicare Modernization Act of 2003 (MMS), the Program Advisory and Oversight Committee on competitive bidding will be assembled and will hold its first meeting later this year. The committee will be comprised of members selected by the Secretary to provide advice on implementation of competitive bidding and quality standards for durable medical equipment and other devices mandated by the MMA Proposed Rule on competitive bidding, with a 60-day comment period, expected to be published in Spring or Summer of 2005.
In the short term, CMS says the MMA also mandates payment reductions for standard manual and power wheelchairs effective January 1, 2005. The reductions are based, they say, on the percentage difference between the 2002 Medicare payment amounts for these items and the median price paid in 2002 under the Federal Employee Health Benefit (FEHB) plans. Although the reductions will vary by State, most State’s fees will be reduced by 7% or less for standard manual chairs (monthly rental fee ceiling will drop from approximately $54 to $50) and 3% or less for standard power chairs (purchases fee will drop from approximately $5,270 to $5, 112).
So unfortunately, at a time when we would hope coverage would be going up, it appears that it is going down. This is a complex area, and one in which I encourage you to become involved. I would encourage you to stay apprised of public forums and open door forums and to let your suggestions be put forth. Certainly, wheelchairs are not something a person aspires to have – they are a necessity that one finds him or herself in need of. When that need arises, it should be available, without a maze of paperwork, and it should be available quickly, cost-effectively, and to ensure the full safety of the consumer.
In closing, I encourage all of you in this room who share my continued, life-long passion for tearing down all the needless barriers that confront persons with disabilities to continue to work to live to see the day when full community integration is something we no longer talk about, but something we enjoy. That is possible only through continued research and development and access to assistive technology that meets the consumer’s needs.
Let your voices be heard. Continue to be strong advocates. You can see that we have made great advances throughout and across the federal government in many areas of Assistive Technology since the inception of the New Freedom Initiative. The bottom line, and where the rubber meets the road, however, is getting the right technology into the hands of the people that need it. We must remain vigilant in our efforts to ensure that all persons in need of assistive technology -- the poor, those in rural areas, the disadvantaged, and persons across the entire lifespan -- receive the accommodations they need. This is not a luxury – this is, indeed, a basic human right. I know this is something all of us agree is worth fighting for, and I encourage you to join me. Let us never give up the good fight. I am not telling you it’s going to be easy, only that it’s going to be worth it. In the words of Albert Einstein, “in the middle of every difficulty lies opportunity.” We must take the opportunity to change things NOW, to ensure a better life for those with disabilities both now and in the future.
Thank you very much.
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