DISCOVERING HIDDEN RESOURCES
Assistive Technology Recycling, Refurbishing, and Redistribution
Technical Assistance Project
To gain more support for existing recycling activities and to promote the development of new AT redistribution efforts, programs across the country must work together. Collectively, programs can shape solutions for common problems. Issues such as financing, transportation, marketing, technical assistance, and assuring program sustainability are themes that all programs share. Through the exchange of ideas and the development of national strategies in these critical issue areas, the effectiveness of all programs will be increased. A number of ideas that begin to address many of these issues are presented in this chapter.
Payment And Funding For Recycled Devices
Issue. Payment for redistributed devices, through third party and other funding sources, has been problematic.
Discussion. Only a small percentage of consumers who need and would benefit from assistive technology have the AT that they need. The inability of consumers to acquire appropriate funding is a major barrier to obtaining AT. The New Hampshire Assistive Technology Partnership analyzed the funding sources used to purchase its refurbished devices and found that 47% were purchased through private pay, 33% were purchased by DME vendors to restock their inventories, 7% of devices were funded with Medicaid dollars, and no devices were purchased through Medicare funding.
Historically, an AT redistribution program often has been looked upon as a type of "welfare" program, which tries to get needed equipment to those who cannot afford it. While well-intentioned, this idea has created a perception that redistribution is a last resort and is less desirable for mainstream users who also are trying to get their needs met. The welfare perception also has been fueled by the medical establishment, which promotes the purchase of new items as the best and only option. Those in the medical profession often do not examine the multifaceted needs of individuals. As a result, limited resources have been spent on certain items that are deemed "acceptable" and "essential" by the medical professions while other important items are considered luxuries or nonessential equipment.
With the work of Tech Act projects over the past 10 years, a much greater segment of the population has been exposed to the possibilities created by assistive technology, and perceptions have changed. Individuals of all ages and with many different types of disabilities are becoming more aware of technological solutions that can improve lives and increase options for work, school, and involvement with the community. Unfortunately, funding streams have held to a more conservative definition of medical necessity that does not look at the broader needs of an individual's life. Items ranging from complex augmentative and alternative communication (AAC) devices to simpler aids for independent living have been difficult to get funded through conventional funding streams.
The financial benefits of equipment redistribution programs can be tremendous. Providing refurbished devices at no cost or at a fraction of the cost of a new item will save the individual a large amount of money. Programs that allow trial use, leasing, or use for a temporary disability also can add immensely to the cost effectiveness of assistive technology purchases. Many insurance companies and managed care plans do not have restrictions on redistributed items, but because of the current system, these low cost options do not get favorable recognition. These systems can be changed.
Recommendations. A significant need exists for educating those who fund assistive technology about the financial and personal benefits of equipment redistribution programs. These funders include Medicaid, Medicare, private insurance companies, managed care plans, and vocational rehabilitation. Education also is needed to change the image of the redistribution program from that of a welfare program into one of a generally accepted option for meeting individual needs. The education component also should include information about the benefits of assistive technology in making possible certain essential activities of life, such as independent living and employment. The case for better funding for refurbished devices also would be furthered by the recognition that these less expensive devices can speed the recovery process. Additionally, refurbished devices can be a needed alternative to inappropriate or partial assistive technology solutions that can cause costly, secondary injuries.
Efforts to change regulations and procedures that do not allow the use of available refurbished devices must be encouraged. Not only should these efforts be allowed, but incentives also must be built into programs that allow redistribution of AT as these programs are more cost-effective.
Collaborative efforts with vendors, manufacturers, and other providers of technology related services also would be beneficial in improving the funding of redistribution programs. Demonstrating that these programs are not competing with existing distribution programs is vital to increasing support for redistribution efforts. Equally essential is encouraging programs to work together with vendors in meeting the needs of individuals who have no insurance or limited insurance, as well as those who have limited means and some insurance coverage.
Issue. Transferring a piece of assistive technology from one location to another can be a difficult task.
Discussion. Problems related to pickup and delivery of AT equipment are common in many programs, both large and small. Programs that have tried to operate on a statewide basis, especially in large states, have had to overcome major transportation issues to make a system work. Programs run in a small region or a large urban area have a great advantage in not having to move equipment over large distances.
Programs have used a number of means to address the transportation problem. Using the mail or other delivery companies is effective but is clearly costly. When items are large or delicate, delivery becomes more of a challenge and the costs become greater. When individual donors or users can provide their own transportation, costs are minimized and the breakage issues are reduced. The use of other third parties, such as independent living centers, public buses, or DME vendors, also has helped address transportation problems. But great barriers still exist when moving large numbers of items in redistribution programs at minimal cost over large geographic areas.
Recommendations. The key to the management of transportation issues is to use other existing resources to address the problem. Other resources can include the use of individuals who create a system to do their own pickup and delivery to support the program. Other forms of resources are those that can be achieved through collaborative efforts with other organizations. For example, recycling programs can receive help in transporting items to people who need them by working with independent living centers, Visiting Nurse organizations, or other community support agencies, which already have established some type of transportation system in their geographic areas.
Another way of addressing the transportation issue is to develop new resources, primarily through grant development or fundraising efforts that would directly address the issues of equipment delivery. Delivery vehicles could be purchased, drivers could be hired, or shipping could be paid with additional financial resources. One primary source of funds could be the shipping companies themselves. Most of the large shipping companies have foundations that support community activities. A community activity that focused on shipping would be a natural activity for a shipping based foundation to support. Essential to this effort would be creating a fund development message that generates a positive image for the company and the community-based program.
Issue. Developing an equipment redistribution program can be costly and maintaining it can be difficult.
Discussion. Many local, state, and national programs have been developed throughout the country, and operate equipment redistribution under many different models. Models range from purely voluntary programs that distribute equipment free to individuals to more complex vendor based models that involve sales and sophisticated distribution mechanisms. Programs have been developed with support through sources such as Tech Act projects with the intention of operating them on an ongoing basis. Some continue while others have not. All programs will say that more support would be helpful and many know that it is essential for continuing to meet consumer needs.
With varied needs by individuals with disabilities and with a vast amount of unused assistive technology available in many locations, it seems inevitable that these forces will continue to work toward complementing each other. Sustainability of programs will be promoted by continuing to create awareness of the need for recycling AT and to develop the ability of programs to find new resources that will support services.
Recommendations. One of the primary ways to sustain programs is to develop a national coordinated effort to promote equipment redistribution programs. There continues to be a lack of coordinated effort that could focus attention on these programs and allow support to come in greater amounts. A national effort could provide information on successful efforts as well as the less successful efforts. Sharing of resources also could help create better relationships with funders and change policies that are not supportive of equipment redistribution programs. In addition, there might be greater success in accessing support from foundations or other grant providing agencies if resources were shared.
Another benefit of a national effort would be to provide technical assistance to programs that were starting, or needed strengthening, or those that were looking for a change of direction. Technical assistance efforts could help coordinate international activities that could work collaboratively with national efforts.
The development of collaborative efforts with manufacturers, vendors, and other funders of assistive technology would enhance sustainability of programs. The National Cristina Foundation uses a model in which computers are collected from collaborating organizations and redistributed through affiliated organizations. A similar process could be started to coordinate and enhance local and regional distribution for a wide range of assistive technology.
Regionalization of efforts is another way of stretching limited resources. A number of small programs might pool efforts in a way that would keep functions from being duplicated while putting certain tasks such as equipment rehabilitation in the hands of a limited number of people trained to do the job. The ability to take in and store equipment also could be enhanced by the use of regional facilities. Regional efforts could be used to develop Web sites and other methods for marketing available equipment and programs.
Information About Federal Funding Sources
There are no national guidelines for Medicaid coverage of DME. Coverage varies from state to state. Provisions for paying for recycled equipment with Medicaid also vary in each state. There are some basic payment conditions to which states must adhere. For example, participants in the programs must provide appropriate, high quality services. In some instances, certain reused equipment may not meet the definitions of that standard. Consequently, those who are interested in changing Medicaid reimbursement policy must work with the state agencies that set the policies
Medicaid has funded demonstration centers that are looking at recycling. One involves an independent living center (ILC) that operates a lending library. Beneficiaries can borrow equipment to use while their equipment is being repaired or is being ordered. This same center also is exploring expedited payments, primarily through receiving prior authorization for purchases. Additionally, the ILC is trying out mass purchasing and being able to purchase non-covered items as long as they are within the price authorized for equipment. State Medicaid agencies can identify best practices for reused equipment purchase by conducting research on the effects of innovative reimbursement policies.
State agencies were provided some additional guidance from a recent court case. DaSario v. Thomas examined when a list of items may be used to determine coverage of medical equipment. State agencies may develop a list of equipment for pre-approval. However, a procedure must be in place for individual beneficiaries to request any item not on the list. Each determination has to be based on the needs of the specific beneficiary. Any process to evaluate equipment must be timely and employ reasonable and specific criteria to judge coverage. The state agency must have the pre-approved list available for beneficiaries to review and beneficiaries have the right to a fair hearing on any item not on the list.
Medicare was begun as a statutory benefit program 30 years ago. It functioned as an acute care program that has had a number of additions to it over time. Medicare does not have any restrictions related to payment for reused or recycled equipment. It does not address these issues. Individual contractors make coverage decisions, with guidance from Medicare. Generally contractors need Food and Drug Administration (FDA) approval clearance and any treatment must meet safety and efficacy standards, through literature and scientific evidence. If Medicare purchases the equipment, it belongs to the beneficiary. If Medicare rents the equipment, it belongs to the DME company.
Changing national policy on Medicare coverage for recycled AT equipment requires those requesting the change to go through a process. The Health Care Financing Administration (HCFA) will consider changes in coverage upon receipt of formal requests. HCFA's Medicare Coverage Advisory Committee (MCAC), which includes one consumer representative and one industry representative, is responsible for responding to these requests for change.
Policy Issues Concerning AT Payment by Public and Private Insurance Programs
The policies of public or private insurance programs should allow the purchase of reutilized/refurbished/recycled equipment. Policies also should allow used equipment to be donated to equipment reutilization efforts.
Some of the questions that need to be addressed by recycling programs include the following:
- What is the attitude of the funder toward the use and purchase of refurbished assistive devices?
- What are some incentives for funders to purchase reutilized or refurbished equipment?
- How can the attitude of the funders be affected with respect to reutilized equipment?
- How might the purchasing process be expedited?
Providing Guidance to Computer Recycling Programs
National Cristina Foundation
Since 1984 the National Cristina Foundation (NCF), a nonprofit public charity, has received donations of surplus and used computers from corporations and individuals. NCF directs these donations to grassroots partner organizations throughout the United States and abroad that provide training and support to people with disabilities and to economically disadvantaged persons. Additionally, based on its years of experience, NCF now provides guidance to organizations seeking to develop computer reutilization programs in their own communities. It has assisted programs in a number of states that created reutilization projects.
To assist programs in developing computer reutilization projects within their regions of the country, NCF has created the NCF Re-Utilization Model. This model provides a systems approach to the entire task of managing the acquisition of donations of computer technology, refurbishing the equipment, redistributing it, training users, and evaluating the process as a whole (see subsequent section listing the seven components of the NCF Re-Utilization Model). The model has been successful in diverse settings as it allows for variations among individual organizations. "If we were going to build a program that a local community would define and make its own, it would be based on the fact that they adapted the model to fit their local needs. We can only provide guidance about the roadway and support the sharing of practices and solutions," said Yvette Marrin, NCF's president.
The NCF model provides a systematic approach that can work on either a small or a large scale. The conceptual framework of the model enables programs to develop guidelines for using practical and logical approaches across a range of issues. These include planning for what are seen as acceptable equipment donations, how these might be acquired, and what mechanisms must be considered for getting equipment to new users. Most important, it presents the factors that can assess what resources may be available to a program to help achieve its objectives.
NCF has found that, based on how the model is applied, solutions will vary because of a variety of factors such as geography and organizational structures. It also has found that projects need to create their own knowledge base and support mechanisms to create and maintain momentum. If a program is to succeed, it needs a collaborative effort by groups of people who come together with a shared vision.
Seven Components of the NCF Re-Utilization Model
- Management - Establish and administer an efficient system to maintain a flow of usable, donated computer technology into targeted programs.
- Acquisition - Obtain, assess, and prepare (i.e., repair, configure, adapt as needed) donated computer technology.
- Deployment - Develop and maintain an efficient placement and distribution process.
- Training - Develop procedures for assuring the preparation of all concerned with supporting and/or using donated technology.
- Sharing -Provide/exchange/obtain information about project needs and solutions.
- Evaluation - Obtain and use information for ongoing decision-making, accountability, and validation of project implementation.
- Collaboration - Address issues related to the establishment of relationships that contribute to successful implementation of the NCF Re-Utilization Model.
National Cristina Foundation
Yvette Marrin, President
500 West Putnam Avenue
Greenwich, CT 06830
ELECTRONIC NETWORK CONNECTS NORTHEAST REGION
Northeast Assistive Technology Exchange
The Tech Act projects in Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont joined forces to support the Northeast Assistive Technology (NEAT) Exchange. The Exchange is a virtual entity with a presence on the Internet that allows residents of the northeastern states a common avenue to find recycled equipment throughout the region, regardless of state borders.
The Web page (http://www.neatexchange.org) allows users to list assistive technology items to sell, and identify items that others wish to sell or give away. It also allows people to contact participating partners and vendors. A database tracks the equipment and provides monthly statistics of exchange activity.
John Ficarro, Project Director of the Connecticut Assistive Technology Project, is a firm believer in collaborative efforts. The NEAT Exchange has brought the six states together for these efforts and provides a model for other regions of the country. "All of the northeastern states contributed financially to develop a database and worked together on the design of the database, " said Ficarro. "The result was a product that was better and less expensive than we might have produced if we had worked on it individually. Creatively looking for partners has benefits you don't even think of at the time the collaboration is being formed."
Connecticut Assistive Technology Project
John Ficarro, Project Director
Department of Social Services, BRS
25 Sigourney Street, 11th Floor
Hartford, CT 06106
RESNA Technical Assistance Project
1700 North Moore Street, Suite 1540
Arlington, VA 22209-1903
703-524-6686 (V), 703-524-6639 (TTY)
This publication is available in alternative formats.
The RESNA Technical Assistance Project, Grant #H224A50006, is an activity funded by the National Institute on Disability and Rehabilitation Research (NIDRR), U.S. Department of Education (ED), under the Technology-Related Assistance for Individuals with Disabilities Act of 1988, as amended. The information contained herein does not necessarily reflect the position or policy of NIDRR/ED or the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA), and no official endorsement of the materials should be inferred.
RESNA is an interdisciplinary association of people with a common interest in technology and disability. RESNA is the grantee funded under the Tech Act to provide technical assistance and information to the Tech Act projects.