Andrew I. Batavia

Changing chairs: anticipating problems in prescribing wheelchairs.

Purpose: This article presents a framework for prescribing, ordering, and adapting a new wheelchair, focusing on individual, environmental and wheelchair factors that must be taken into consideration to ensure optimal function. Method: A review and analysis was conducted of all factors relevant to the transition to a new wheelchair. Without appropriate planning and implementation, this transition can result in unnecessary expenses, duplication of effort, and possibly even injury to the user and abandonment of the wheelchair. Results: Recommendations are provided to manufacturers, therapists, technicians, users, insurers and physicians, who must work together throughout this process. To the extent feasible, the authors suggest that major changes from the previous wheelchair should be avoided, particularly for people with substantial functional limitations. Therapists and technicians must measure the user accurately, and anticipate those factors that can impede a smooth transition. Insurers and other payors must recognize that changing wheelchairs will often require substantial professional assistance, including several fittings to adjust the new chair to the needs of the user. Conclusion: Additional research and case reporting on outcomes of adjusting to a new wheelchair appear warranted.PURPOSE This article presents a framework for prescribing, ordering, and adapting a new wheelchair, focusing on individual, environmental and wheelchair factors that must be taken into consideration to ensure optimal function. METHOD A review and analysis was conducted of all factors relevant to the transition to a new wheelchair. Without appropriate planning and implementation, this transition can result in unnecessary expenses, duplication of effort, and possibly even injury to the user and abandonment of the wheelchair. RESULTS Recommendations are provided to manufacturers, therapists, technicians, users, insurers and physicians, who must work together throughout this process. To the extent feasible, the authors suggest that major changes from the previous wheelchair should be avoided, particularly for people with substantial functional limitations. Therapists and technicians must measure the user accurately, and anticipate those factors that can impede a smooth transition. Insurers and other payors must recognize that changing wheelchairs will often require substantial professional assistance, including several fittings to adjust the new chair to the needs of the user. CONCLUSION Additional research and case reporting on outcomes of adjusting to a new wheelchair appear warranted.

Consumer Direction, Consumer Choice, and the Future of Long-Term Care

Traditionally, our long-term care system has had a strong institutional bias, with care directed by health care professionals and few options for consumers. There is now a growing trend toward consumer direction and consumer choice in long-term care. Some degree of consumer direction can be achieved under different models of long-term care, but many consumers prefer the independent living model in which they hire, train, and manage their own personal assistants. The Supreme Courts Olmstead decision supported the consumer-direction trend, finding that unjustified institutionalization is discriminatory and that Medicaid recipients with disabilities must receive their care in the most integrated setting appropriate. Initiatives by disability rights advocates, states, and the federal government to ensure the option of consumer-directed home- and community-based care, as well as innovative home-based programs in other countries, have further fueled the trend. The policy challenge will be to offer consumer-directed care on an equal basis with other long-term care options in a manner that meets the needs of people with different disabilities, and thereby to implement consumer choice in a manner that allows people with different disabilities to decide for themselves which option best meets their needs.

Disability, chronic condition, and iatrogenic illness

People with disabilities and chronic conditions are disadvantaged by the US health care system. Some people receive too few of the services they need; others receive too many services from practitioners who do not understand their disability-related needs and thus subject them to iatrogenic illnesses (health problems arising from the health care process). We explore this deprivation and excess and focus on 3 categories of iatrogenic illness that can harm this patient population and impede their ability to live independently. Empirical studies of iatrogenic illness in people with disabilities and chronic illnesses are needed. Physiatrists must play a central role in conducting such studies and in helping these persons access needed care while avoiding potential health problems associated with such care.

Independent living centers, medical rehabilitation centers, and managed care for people with disabilities

I NDEPENDENT LIVING centers are organizations that are intended to enhance the ability of people with disabilities to live independently in their communities.’ Traditionally, these community-based, consumer-directed service and advocacy centers have not been substantially involved in the health care issues of their consumers and have not established formal relationships with the health care industry. Recently, increases in health care cost pressures and the growth of managed care have raised the concerns of many people with disabilities about their ability to access quality care,2 increasing the imperative for independent living centers to become more involved in health care. This change in orientation could present valuable opportunities for medical rehabilitation providers.

Karaoke for quads: a new application of an old recreation with potential therapeutic benefits for people with disabilities

Purpose : Karaoke is a recreational activity whereby individuals sing into a microphone along with the melodies and lyrics provided both visually and auditorily by a machine. Methods : The potential therapeutic benefits of karaoke are explored in terms of increased respiratory strength, endurance, control, and capacity, as well as emotional and physical release for people with disabilities. Results : Although many individuals with disabilities could benefit from this activity, it is likely to be particularly beneficial to people with compromised respiratory systems, such as persons with high-level quadriplegia (tetraplegia). Conclusion : This article examines theoretical considerations and proposes a research agenda. Empirical research would be valuable to confirm the potential benefits of karaoke for people with disabilities.

Are People with Disabilities an Oppressed Minority, and Why Does This Matter?

consequences naturally follow, such as the right to certain entitlements, resources, or privileges in our society. Yet, there has been very little analysis of this contention of oppression or the validity of consequences claimed as a result of it. Whether people with disabilities are an oppressed minority is, to some extent, a question of semantics and political philosophy. What does it mean to be an oppressed person ? What does it mean to be a member of an oppressed minority? Are all people with disabilities oppressed if some are oppressed? What is autonomy, and are oppressed people with disabilities capable of autonomy? To what extent is the ideology of the disability rights/independent living movement consistent with the concept of people with disabilities as an oppressed minority? There are also basic empirical questions that must be an-

From Disability Rolls to Payrolls: A Proposal for Social Security Program Reform

Substantial growth in the Social Security disability programs, and the failure of work incentive legislation to curtail this growth, have demonstrated the need for structural reform. This proposal, based on a functional model of disability, would create four categories of benefits: a permanent disability pension, a temporary disability benefit providing cash payments to the vast majority of beneficiaries for a 3-year period (extendable under certain circumstances), an early retirement disability pension, and provision benefits providing devices and services to enable people with disabilities to function as fully as possible in the workplace. In addition, the proposal would eliminate the waiting period for eligibility, expedite the eligibility determination process, increase and improve the use of case mangement services, develop a new productive relationship between the beneficiary and the Social Security Administration (SSA), and eliminate remaining work disincentives. The objective is to fundamentally alter the expectations of all parties by adopting a realistic presumption of beneficiary employability.

Accounting for the health-care bill

As a health care attorney with quadriplegia who teaches health policy and law at a large university, my interactions with the health-care system are somewhat unique. However, I also have much in common with millions of other Americans who receive their care under the system. Like many of these people, I live in dread of opening a piece of mail from anyone who may be characterised as a health-care provider. The contents are likely to be a bill that is indiscernible to anyone, with the possible exception of the administrative person responsible for assembling and transmitting it. Actually, the bill is likely to be one of numerous interrelated mailings from several providers and one or more insurance entity, stating what they are and are not entitled to or responsible for. Inevitably, they are entitled to much and responsible for little. Having an extensive education and professional background is by no means a guarantee that one will be able to discern the rationale for the veritable table of random numbers that constitute the health-care bill. Knowledge of the system may prove to be a hindrance in trying to understand what cannot be understood. Of course, the complexity and duplicity of billing paperwork are no news to the millions of Americans who have been subject to these mailings. What is interesting and disturbing is not that it exists, but rather that it persists and appears to be getting worse after over two decades of the so-called “managed care revolution”. The financing and delivery of health-care services are now supposed to be integrated; costs are supposed to be getting under control. One recent experience shows that this is not always happening.