A Third of Docs Uninformed of ADA Laws, Health Inequity Requirements

January 05, 2022 - Nearly a third of physicians admit they don’t have a great understanding of their legal responsibilities under the Americans with Disabilities Act (ADA), leaving them liable to both legal infractions and perpetuating the health inequity and disparities experienced by individuals with disabilities.

What’s more, nearly seven in 10 physicians incorrectly identified who determines ADA accommodations, according to Harvard Medical School and Massachusetts General Hospital data published in Health Affairs.

Passed in July 1990, ADA requires healthcare providers and organizations to make reasonable accommodations for individuals with disabilities to help them access and engage with their medical care. Whether a provider falls under ADA Title II (a public entity) or ADA Title III (a private entity serving the public), the researchers said they are required to not only practice non-discrimination but also make reasonable accommodations to enable healthcare access to all.

Particularly, organizations must provide equal access, must accommodate disability-related needs, and must make accommodation decisions with both physicians and patients in a collaborative manner. Healthcare organizations, not patients, must pay for disability accommodations, the law states.

Despite those legal requirements intended to promote equity, including health equity, for individuals with disabilities, the researchers said health disparities still exist.

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“Despite broad civil rights protections, which encompass health care, many people with disability experience health care disparities, as documented in federal reports, including Healthy People, and numerous studies,” the researchers wrote in the study. “Research suggests that failures to receive accommodations contribute to inequitable care for people with disability.”

Through a survey of more than 700 family medicine, general internal medicine, rheumatology, neurology, ophthalmology, orthopedic surgery, and OBGYN physicians, the researchers determined these disparities could be due to lack of knowledge.

Overall, 35.8 percent of the physician respondents self-reported that they had limited knowledge about ADA and their own legal responsibilities to fulfill the law. More than half of respondents said they knew “some” of their legal responsibilities per ADA, and physicians who said they own or co-own their practice were more likely to say they knew more about the law.

“The daily demands of running a practice may bolster physicians’ knowledge of regulatory requirements, such as accommodations and other responsibilities under the ADA,” the researchers posited.

But when asked specific questions about ADA, the researchers found a sizeable portion of physician respondents were unsure or had inaccurate information. Overall, 71.2 percent of physicians incorrectly answered who makes decisions about reasonable accommodations under ADA.

This is a serious shortcoming that can raise quality of care and health equity issues, the researchers said. Previous studies have found patients with disabilities report substandard accommodations, which can in turn lead to patient-reported poor clinical quality and healthcare experience.

For example, a patient in a wheelchair may not be transferred to an exam table, or a patient who is deaf or hard of hearing may not receive reasonable access to a sign language medical interpreter.

Healthcare organizations can access recommendations for reasonable accommodations for certain disabilities, but they should also be considering patient input. ADA Title II organizations are legally requires to prioritize patient preferences, whereas ADA Title III organizations are encouraged to consider patient preferences. For both organization types, strong patient-provider communication and decision-making will be key.

The survey also revealed one in five physician respondents provided incorrect answers about who bears the financial responsibility to provide reasonable accommodations. White physicians and those who practiced in safety-net clinics were more likely to answer these questions correctly.

Survey results did suggest physicians were somewhat self-aware about these ADA knowledge shortcomings; 68.4 percent said they believed they were at risk for an ADA lawsuit because of poor accommodations. Physicians who had a serious functional limitation or a family member with a disability were more likely to identify a perceived risk for an ADA lawsuit.

Additionally, physicians who practiced in very small practices, who reported limited education or training for ADA accommodations, or who said they were not confident in their ability to provide equal clinical quality to individuals with disabilities were also more likely to identify a perceived risk for lawsuit.

These findings raise serious medical education curriculum questions, the researchers said. Physicians who reported limited education and training about ADA accommodations were more likely to say they were not confident in treating a patient with a disability and more likely to say they are liable for an ADA lawsuit.

Many medical schools are beginning to incorporate more health equity and disability topics into their curricula, which the researchers cautioned should not reflect the implicit biases of instructors.

But those efforts also need to account for the long-term, the researchers added.

“Implementing disability competence into educational curricula is an important step, but a long lead time elapses before trainees become practitioners,” they wrote in the study’s discussion. “Continuing medical education offers opportunities for training the current physician workforce about caring for patients with disability.”

That continuing medical education will be essential as the nation likely faces a growing population of individuals with a disability.

“Because of demographic and other factors, the population of Americans with disability will grow substantially in coming decades. Most practicing physicians can therefore expect to see increasing numbers of patients with disability in their practices,” the research team concluded.

“Our survey findings suggest that there is considerable work to do in educating physicians and making health care delivery systems more accessible and accommodating to achieve equitable care and social justice for patients with disability.”