Patients with physical or mental disabilities present special challenges, but you can take steps to meet their needs and avoid liability.
An Oklahoma internist will never forget the wheelchair-bound patient who came in carrying pictures of the pressure sore on her buttock.
The pictures alone, the internist knew, were insufficient to make a diagnosis. But without extra help or a lift, she was unable to place the woman on the exam table to see the lesion firsthand. Frustrated, the physician suggested that the patient return with family members to help with the transfer. The patient balked, however, and eventually filed a complaint against the doctor for violating the Americans with Disabilities Act of 1990, the landmark law forbidding discrimination based on disability.
"My office manager had to go to an arbitration meeting, where we agreed either to invest in a lift, which wasn't economically feasible, or to transport future wheelchair patients to the nearby ED," says the internist, who requested anonymity.
Noncompliance costs money
Violations of the law can be costly-up to $100,000 per incident for repeat offenses. But the ADA is not the only legal concern associated with this population. Physicians may also face a greater malpractice risk when something goes awry with a disabled patient.
"We refer to such people as 'eggshell patients,' " says Kevin Quinley, a risk management specialist in Fairfax, VA, and author of Bulletproofing Your Medical Practice (SEAK, 2000). "For them, a complication or adverse outcome might be far more devastating than for someone without a physical or mental encumbrance. That fact not only affects whether an incident is litigated, but also the potential damages involved."
Being extra careful to fulfill your obligation to provide genuine access and equal treatment not only constitutes good risk management, but also good medicine.
Barrier removal and beyond
Physicians who own their own buildings or are responsible for design changes have generally succeeded in making their offices more accessible to people with disabilities, especially those with mobility impairments.
They've added disabled-only parking spots, installed ramps in places where stairs interrupt a travel route, retrofitted entrances and doorways, and, in some cases, built or redesigned rest rooms and installed accessible drinking fountains and public telephones. In general, such modifications are considered "readily achievable"-able to be completed without undue difficulty or expense. (See the box to learn more about specifications. You can also find a checklist of modifications at http://www.usdoj.gov/crt/ada/checkweb.htm.)
But physicians have done less well in instituting changes that exceed these minimal requirements for physical accessibility, says Margaret A. Nosek, executive director of the Center for Research on Women with Disabilities, at Baylor College of Medicine, in Houston.
"A doctor's office may have a ramp and designated parking spaces for the disabled, but still be turning away patients because it isn't equipped to handle them once they get inside," Nosek says. The Center can document "hundreds and hundreds" of such cases, which violate the ADA's nondiscrimination provisions. The most prevalent "accessibility" issues in medical settings are "lack of effective communication, lack of accessible equipment and services, and refusal of care," according to a Department of Justice document on ADA enforcement.
If your office isn't equipped to treat disabled patients, you can lower your risk of incurring an ADA violation and improve patient care by making certain practical changes. Installing an adjustable-height exam table is the most important accommodation a physician's office can make, Nosek says.
Such tables can be lowered to as little as 16 to 18 inches above the floor, making it easy to transfer patients who can't move themselves. Experts recommend a table that can support a minimum of 300 pounds, although most models easily exceed that weight capacity. Tables should also have strong, adjustable handrails, adjustable foot-leg supports, and adequate cushioning to protect the feet.
Depending on the additional features you select, count on spending anywhere from $3,500 to $5,000 for a well-designed adjustable-height exam table. Small businesses, however, are eligible for up to a $5,000 nonrefundable tax credit for costs incurred in complying with ADA access requirements.
Additional accommodations depend on specialty. To allow women unable to stand for a mammogram to undergo this screening, for example, radiologists might consider purchasing equipment that can accommodate patients in wheelchairs. For FPs, internists, and ob/gyns, the ability to weigh patients while they sit in a wheelchair can significantly improve access to care for this patient population.