M. Fordyce MD1 ADDRESSING THE CHALLENGE: EMERGING POLICY AND ETHICS AND ASSISTIVE TECHNOLOGY

M. Fordyce MD 1

ADDRESSING THE CHALLENGE: EMERGING POLICY AND ETHICS AND ASSISTIVE TECHNOLOGY

ADDRESSING THE CHALLENGE: EMERGING POLICY AND ETHICS AND ASSISTIVE TECHNOLOGY

M. Fordyce MD 2

Moira Fordyce MD, MB ChB, FRCPE, AGSF

[email protected] Moira Fordyce MD, MB ChB, FRCPE, AGSF

[email protected]

• Geriatrician• California Coalition for Caregivers• Vice-chair AGS Public Education Committee• Member CA AT Coalition• Teaching• Writing• Public Speaking• Educational TV Program

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1. Policy and AT1. Policy and AT

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1. Policy and AT1. Policy and AT

a) Lip service paidb) Health Care Reform Billc) CLASS Actd) Older Americans Acte) Americans with Disabilities Actf) Funding for ATg) DME benefith) IOM recommendsi) A model program

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a) Lip Service Paid to ATa) Lip Service Paid to AT

• 2009 President Obama - value of home-based care

• DHHS Healthy People 2020 included:• Increase the proportion of adults with disabilities

who participate in social, recreational, community, and civic activities to the degree that they wish

• Reduce the number of people with disabilities who report unmet need for assistive devices, service animals, technology services, and accessible technologies they need

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b) Health Care Reform Bill and AT

(HR 3590)

Patient Protection and Affordable Care Act

Signed into law March 23, 2010 www.healthcareandyou.org

b) Health Care Reform Bill and AT

(HR 3590)

Patient Protection and Affordable Care Act

Signed into law March 23, 2010 www.healthcareandyou.org

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Health Care Reform Bill and ATHealth Care Reform Bill and AT

1. Certified EHR Grant Program for LTC Facilities - $67.5 million

2. Demonstration Project for Use of HIT in Nursing Homes to Improve Resident Care

3. Development of Medicare Part D Prescription Dispensing Techniques in LTC Facilities

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HCRB and ATHCRB and AT

4. New Models of Care Utilizing Technology

I. The “Community Living Assistance Services and Supports Act” - CLASS Act

II. Use of technology in new cost efficient payment models - Center for Medicare and Medicaid Innovation - CMI - November 2010

<innovations.cms.gov>

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HCRB and ATHCRB and AT

III. Use of HIT in Health Homes for

Enrollees with Chronic Conditions

IV. Use of technology in new state

options for LT Services and

Supports

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Sad but TrueSad but True

• Expansion of health care coverage does not necessarily mean access to care

• So, Medicaid and Chip Payment and Access Commission (MACPAC) set up under the Affordable Care Act (ACA) to review access and payment policies

• Dual eligibles and disabled children

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c) Community Living Assistance Services and Supports Act

c) Community Living Assistance Services and Supports Act

• CLASS Act will enable a new model of

funding for long-term services and

supports, including the use of aging

services technologies to meet care

needs

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CLASS Actwww.advanceclass.org

CLASS Actwww.advanceclass.org

• Cash benefits paid into a Life Independence Account of an eligible beneficiary shall be used to purchase non-medical services and supports that the beneficiary needs to maintain his or her independence at home or in another residential setting of their choice in the community

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CLASS Act Services and SupportsCLASS Act Services and Supports

Including (but not limited to)• Home modifications• Assistive technology• Accessible transportation• Homemaker services• Respite care• Personal assistance services• Home care aides• Nursing support

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CLASS ActCLASS Act

•January 5, 2011 - Kathleen Sebelius, the DHHS Secretary announced her intent to open the doors of the Office of CLASS within the Administration on Aging (AoA). This decision is the first step in helping millions of Americans overcome barriers to independence

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CLASS ActCLASS Act

• Kathy Greenlee (Assistant Secretary of

Aging) made administrator of this

program

• February 7, 2011 Secretary Kathleen

Sebelius reinforced the Administration's

commitment to moving forward with the

implementation of the CLASS Act.

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d) Older Americans Actd) Older Americans Act

Funds programs and services to keep

older adults independent including:•Meals On Wheels•Home and community-based care• Senior centers• Family caregiver support• Prevention of elder abuse•Older worker training and employment

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Older Americans ActOlder Americans Act

• Transportation

• Long-term care ombudsman program

• Legal services

• Services for Native Americans and Native

Hawaiians

•Research and training

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e) Americans with Disabilities Acte) Americans with Disabilities Act

• Defines a disability as a condition which limits a person’s ability to function in major life activities – including communication, walking, and self-care (such as feeding and dressing oneself) – and which is likely to continue indefinitely, resulting in the need for supportive services.

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Need for ATNeed for AT

As population ages, need for AT

increases, but -

• Economy in a mess

• Major cuts in all areas - feds and state

• Number in poverty increasing

• Much talk, little action so far

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f) Funding for ATf) Funding for AT

• Medicare - under DME benefit• Medicaid - under DME benefit• Department of Veteran’s Affairs• Not-for-profit organizations• Private organizations• Community resources• Grants• Self-funding

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Funding for ATFunding for AT

•Unpredictable

•Effect on developers?

•Could uncertainty about payment

inhibit new developments?

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g) Durable Medical Equipment Benefit

g) Durable Medical Equipment Benefit

• Definition of DME obsolete•Needs to change•Narrow focus on restorative care only

• Focus needs to shift to:• Preventing loss of function• Preventing illness and injury•Maintaining independence• Staying in community•Working at gainful employment

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DMEwww.durablemedicalequipment.org

DMEwww.durablemedicalequipment.org

• Review and redefine “medical

necessity”, perhaps re-name?

• Educate health professionals

• Educate lay people

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h) Institute of Medicine Recommends:

h) Institute of Medicine Recommends:

• A comprehensive disability monitoring system should be created to help monitor disability and inform policymakers. There should be more public funding for disability research programs.

• The Department of Justice should increase efforts to enhance the Americans with Disabilities Act, which will require health insurers to cover assistive technologies and devices.

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IOM Recommends:www.iom.edu

IOM Recommends:www.iom.edu

• Congress and administrative agencies

should eliminate long waiting periods for

disability insurance.

• Consumers and professionals alike

should be better educated about the

proper care for people with disabilities

and about they challenges they face.

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Low Tech in Action!Low Tech in Action!

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i) A Model Programi) A Model Program

The Department of Veterans’ Affairs (DVA):

•Purchases more assistive devices for individuals with disabilities than most other agencies

• It has a systematized structure to pay for its large volume of equipment

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DVADVA

• It provides widespread education for consumers and clinical personnel

• It also invests in R and D, evaluation, development of standards, and development of procurement guidelines for assistive devices.

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DVADVA

• The DVA program covers traditional

medical equipment such as artificial

limbs and wheelchairs, as well as

products that don’t fall under the

heading of medical necessity, such as

automobile and home modifications.

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Bottom Line - PolicyBottom Line - Policy

•Much talk

•Little action

•Keep pressure on legislators to, for

example, implement the CLASS

Act, build on the DVA program

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2. Ethics and AT2. Ethics and AT

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ETHICS AND ATETHICS AND AT

a) Four principles

b) Monitoring

c) Tested and True?

d) Needs and Resources

e) Possible Problems

f) New Hammer

g) Effects on Whole Society?

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a) Four Principlesa) Four Principles

•Non-maleficence simply means -

Do no harm. Are we in danger of doing

more harm than good?

•Beneficence means striving

consciously to be of benefit to the

person

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Four PrinciplesFour Principles

•Autonomy refers to respecting the person’s rights to things like self determination, privacy, freedom, and choice

•Justice means treating everyone fairly. For example providing equal access to technology, or taking into account diversity and individual differences.

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1984 - Big Brother!1984 - Big Brother!

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b) Monitoring in Different Settingsb) Monitoring in Different Settings

• At home• On computer• Place of work• Other buildings• In automobile• In nursing home• In hospital• ANYWHERE!

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Monitoring in Different SettingsMonitoring in Different Settings

• What data will be collected?•Medical?

• For safety?

• Financial?

•Other? For marketing?

• Why is it being collected?

• Are there “more protected” data?

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• Where is data stored?

• If data archived, how long will it stay

there?

• Does it follow you around?

• Can any information be deleted?

• Can any information be changed?

• If so by whom?

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• Who has access to it?

• How is access controlled?

• How easy is it to hack in?

• What scams could arise from covert

monitoring?

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• Can an individual’s data be combined

with others for prediction models?

• Can you be monitored against your will,

without your consent?

• What happens to privacy and freedom?

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c) Tested and True?c) Tested and True?

• Is it ethical to market and use technology that

has not yet been proven to be of benefit?

• Who will evaluate it?

• How to evaluate it?

• How reliable and safe is the AT?

• Can it be easily fixed/serviced?

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d) Needs and Resourcesd) Needs and Resources

•Resources are scarce and getting

scarcer:

•Who gets help/funding to have AT?

•Who decides this?

•How is the decision made?

•More need than resources

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Ethical AT Usee) Possible Problems

Ethical AT Usee) Possible Problems

•Learned helplessness?

•Loss of function?

•Loss of human contact/interaction?•AT used to cut back on this?

•Does AT help or hinder relationships?

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Possible ProblemsPossible Problems

• Does AT improve quality of life?

• Does AT focus on person’s problems

instead of strengths?

• Are there other options that would be as

good as or even better than AT?

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Possible ProblemsPossible Problems

•Some older adults do not want to

advertise the fact that they need

help, so avoid AT

•What scams could arise from AT

marketing claims?

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f) New HammerNails Everywhere?

f) New HammerNails Everywhere?

• What are the attitudes of health

professionals to AT?

• What are the attitudes of engineers and

other researchers to AT?

• Risk/benefit analysis essential:

• To do or not to do?

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New Hammer - Nails Everywhere?New Hammer - Nails Everywhere?

• AT can be good and bad at same time:

• Monitoring for safety invading privacy

• Should take a long term view rather than

quick fix

• Love small gains!

• Is need episodic or progressive?

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g) Effects of AT on our whole society?

g) Effects of AT on our whole society?

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AT and SocietyAT and Society

•Aging boomers and AT

•All of us affected, if we’re lucky!

•Depersonalization?

• Isaac Azimov

•Three Laws of Robotics

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Three Laws of RoboticsThree Laws of Robotics

1. A robot may not injure a human being or, through inaction, allow a human being to come to harm. (Humanity - fourth law)

2. A robot must obey any orders given to it by human beings, except where such orders would conflict with the First Law.

3. A robot must protect its own existence as long as such protection does not conflict with the First or Second Law.

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Web SitesWeb Sites

• www.aahsa.org/cast.aspx• www.aoa.gov• www.eskaton.org• www.advanceclass.org• www.house.gov• www.senate.gov • www.whitehouse.gov• www.toolsforindependence.org• www.goldviolin.com

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Documents

M. Fordyce MD1 ADDRESSING THE CHALLENGE: EMERGING POLICY AND ETHICS AND ASSISTIVE TECHNOLOGY