KABVI NEWS - Volume 47, Spring 2004

DIFFERING AGENDAS ON VISION REHAB

By Michael Byington

KABVI’s agenda differs from Envision’s regarding Medicare coverage of vision rehabilitation. KABVI, and its cooperating national organization, the American Council of the Blind (ACB) have long supported the idea that Medicare and Medicaid should cover vision rehabilitation. ACB in fact began supporting some Legislation which is moving through the federal Congress dealing with this issue. ACB later withdrew its support for this specific legislation because it became clear that some of the wealthier, medical model based, not-for-profit service providers around the Country were moving evolving versions of the legislation in directions which are not acceptable to many blind and low vision consumers.

Envision, the largest, and wealthiest not-for-profit organization in Kansas serving people who are blind and low vision, has invested considerable effort and money in lobbying for some provisions in the pending legislation which KABVI finds to be unacceptable. In the winter 2004 edition of “InTouch” Magazine, Envision’s CEO, Linda Merrill, published n editorial supporting provisions of pending legislation on Medicare coverage for vision rehabilitation.

Merrill states, “One of the key areas of concern is that vision rehabilitation professionals be properly licensed. While there are certifications for different specialties in vision rehabilitation, licensing is not handled by the States.”

Merrill’s statement shows some misunderstanding of human service credentialing processes. It is true that the State of Kansas, and most other States, have chosen not to license Orientation and Mobility Specialists, Rehabilitation Teachers for the Blind, and Vision Therapists. As the potential for third party payment from Medicare and other third party sources nears, States may consider licensure or other credentialing refinement for professionals who work with people who are blind or who have low vision. There is, however, no federally operated credentialing entity in existence which is empowered to confer Nation-wide licensure. Credentialing issues, for purposes of receiving third party payment through Medicare and other sources, are either handled by the States, or by private credentialing boards recognized by third party payers. Often both State and private credentialing are involved. In the case of Medicare, private credentialing entities are sometimes recognized in law or federal regulation. There is nothing, however, magical about the word “license.” Many professionals who receive Medicare and other third party payments are referred to instead as “registered” or “certified.” In fact, the meaning of each of these terms is defined by the individual States, and varies from State to State. What would be licensure in one State might be registration or certification in another.

The Kansas Credentialing Act defines licensure as requiring an exclusive scope of practice. A licensed profession in Kansas can be practiced ONLY by practitioners who have achieved a defined set of qualifications. For licensure to be granted under Kansas law, it must be documented that harm would result to the public if a person not having the required qualifications were to do any of the activities defined as being a part of the licensed profession.

If we look at credentialing by national, private organizations, the process may not be called licensure. The wealthier not for profit groups working on the pending legislation, however, have identified national groups whom they feel should be recognized to credential vision rehabilitation professionals. They have largely arrived at standards which they feel should be in place for credentialing. Lets look in general terms at the world such standards might create.

Many Kansans who are blind or low vision received their initial training in blindness and low vision skills from a State-employed rehabilitation teacher for the blind. These individuals are now not formally credentialed. Their funding does not come through Medicare or private insurance. Traditionally, the Kansas rehabilitation teachers for the blind are people who are blind or visually impaired themselves, and who know a great deal about living independently with less vision than most people have. Most of the people filling the rehabilitation teaching positions are highly successful at the work they do, and have helped many blind and low vision Kansans. But few of them would qualify to meet nationally established credentialing standards. Licensure of Rehabilitation Teachers for the Blind is quite clearly an attempt to put practitioners such as State rehabilitation teachers out of business. It makes the assertion that someone with professional training, even a sighted individual with no personal experience with blindness, would do a better job than one highly experienced blind person showing another less experienced blind person how to perform tasks. This is an assertion that many blind Kansans who have been taught skills by other blind Kansans might oppose.

Credentialing of Orientation and Mobility instructors is also a controversial subject. The vast majority of credentialed orientation and mobility professionals are sighted. In some States, most persons employed to teach travel skills to people who are blind and low vision are blind and low vision professionals who are expert travelers, and who have demonstrated the ability to teach the techniques they use to other blind and low vision individuals. Kansas now employs only sighted orientation and mobility instructors who are credentialed, or who are in the process of completing their credentials. Historically, Kansas has employed both blind and sighted persons to teach travel skills to people who are blind and low vision. Many blind and low vision Kansans have expressed the view that the training provided was as competent, or more so, when some of the travel trainers were blind and/or low vision.

The way Envision wants to implement Medicare coverage for vision rehabilitation appears to make several changes likely in terms of overall service delivery. Under the Envision scenario, it would be likely that less and less professionals working with people who are blind and low vision would be blind and low vision themselves. College trained sighted folks would become the vast majority of those available to provide services. The goal seems to be that private, not-for-profits, who provide medical model services, such as Envision does, want to put the State rehabilitation for the blind programs out of business.

This intent is further documented by the fact that Envision is currently circulating petitions to all of its older clients, attempting to get them to suggest to Governor Sebelius, and the head of the Kansas Department of Social and Rehabilitation Services (SRS) that Envision should completely take over, and assume control of the Kansas Seniors Achieving Independent Living (KanSAIL) program. KABVI published a position paper opposing this hostile takeover, not because we have any objection to Envision’s working with older blind Kansans, but rather because there is not sufficient programming to adequately cover the State now, and we believe Envision should continue developing its own efforts rather than attempt to subsume federally funded, State operated programming which is also providing many good services. It almost appears that Envision wants to run KanSAIL so that it can be used as a vehicle to get more referrals for Envision’s new low vision clinic, which is already able to receive considerable third party payment under Medicare.

An environment where the not-for-profit sector attempts to put State Services for the Blind out of business, or visa-versa, is shameful. We who are blind need all of the services and service options possible. The State cannot provide all of the needed services for blind and low vision Kansans. Neither can Envision. Blind Kansans would suffer if they had to do without either entity. It is sad when either the governmental sectors of services for the blind, or the private, not-for-profit sectors, become this petty and greedy. Such actions are not in the best interests of blind and low vision Kansans overall.

If State services for the blind are moved under the Envision umbrella, the very fact of this change gives Kansans who are blind and low vision les control of the former State services. The State has a Kansas Services for the Blind Advisory Committee. The input of this body is taken very seriously. If a blind or low vision Kansan is not pleased with services offered to the blind by the State, they have the option to go up line to their Legislators, the Governor, or other elected officials. Envision is operated by a sighted CEO and a Board of Directors, the vast majority of whom are successful, sighted, business leaders. KABVI has long taken the position that the blind and low vision of Kansas should control what State Blind Services does and how it does it. Currently, blind and low vision Kansans have some modicum of control, but not nearly enough. The blind and low vision of Kansas, however, have absolutely no control over what Envision does or how it does it. To support Envision’s taking over State programs is to support the disempowerment of blind Kansans.

Other issues exist with regard to Medicare coverage of vision rehabilitation, and the currently pending legislation, which must be considered. The term “vision rehabilitation” suggests that the emphasis will be skewed toward low vision techniques, not blindness techniques. Because the majority of people who are legally blind have some residual vision, this is not surprising. Low vision is where the money is located. The current Medicare and vision rehabilitation legislation covers low vision examinations and evaluations, but in no way covers the teaching of blindness techniques in situations where such techniques would work better for the individual than low vision techniques. KABVI and ACB can not fully embrace Medicare coverage of blindness and low vision related treatment until the provisions of legislation to bring about payment for such treatment stop blatantly discriminating against people who are totally blind or who do not have enough vision to use low vision techniques more efficiently than blindness techniques.

Also, the current legislation would in fact lower the expertise of some of the people who would be providing rehabilitation training for people who are losing vision, and receiving third party payment for doing so. Occupational Therapists are recognized service providers under the provisions of the pending legislation. They are trained in general techniques of medical rehabilitation. Many occupational therapy preparation programs feature no specific training in blindness or visual impairment whatsoever.

One last point about the pending legislation: The current proposal would pay considerable Medicare monies to Envision and similar medical model providers to diagnose and evaluate an individual’s vision loss. It would, however, pay nothing toward the visual aids, equipment, Braille adaptations, or other prosthetic devices or durable equipment the person might need to then improve their functioning. The current legislation would help the big time medical model providers get more sources of money, but it would not really contribute to recovery of function for the blind or low vision citizen.

KABVI respects and applauds the work in rehabilitation of people who are blind and low vision being done by Envision, and similar not-for-profit agencies around the country. We are glad Envision is in Kansas and is providing the services they make available to blind and low vision Kansans. But the pending legislation is geared toward increasing the profitability of low vision rehabilitation at the expense of rehabilitation of those who are totally blind, and at the expense of non-medical rehabilitation approaches provided by governmental entities or by people who are blind and visually impaired on a peer-to-peer basis.