Sp 2. Rita Stanley: on policy making, role of reimbursement codes for assistive technologies, and how to make AT more accessible.

Hi everybody, this is Gears of Progress, a perfectly stellar and admired research in Rehab Engineering and Assistive Tech. I'm your host, Sasha, a postdoc at the University of Washington, and this is special episode number two. Today in my postdoc studio, we have Rita Stanley, who is currently a vice president of government relations at Rx Function Incorporated. She also serves on the board of directors for Resna, the rehabilitation engineering and assistive technology society of North America. And she's also served as a founding chair of the regulatory committee of the National Coalition for Assistive and Rehab Tech. So welcome in Rita. Thank you. This is going to be great. I'm really excited to talk about the role of policy making in the space of Rehab Engineering and Assistive Tech, and I'm glad we got someone with a vast background and experience in that as you. So the first question I like to ask is, I saw that your very first bachelor major was in polycyan psychology. So my question that I like to ask in the beginning is, what compelled you to start doing policy work specifically for the space of assistive technology and rehab engineering? How did you get into that? Yeah, interesting story. And I will say it has absolutely nothing to do with what I thought I was going to do when I was in school. Actually, when I got out of school, I started in sales. And I did sales for a number of years, five years to be specific. And then I went into sales management. And while I was doing sales management, there was a change in how Medicare handled processing of claims. It went from a whole lot of physical intermediaries to four regional carriers, contractors. And something just said to me, you know, if you're going to be out here selling or even managing people that are selling, it might kind of important to know the people that are paying for the product. And so I made it a point to start to get to know the medical directors within the new, at that time they were called demarks. They're now called demimax. But I started trying to get to know them, tried to understand new policies, new coding. They didn't know product. So I worked with a couple of organizations to go in and start educating the medical directors and the claims review staff to make sure they understood what they were paying for. And who used these products? And why did they use these products? So that they could do a better job on their end, but we could also do a better job on hours. And as time went on, I just became incredibly intrigued in policy development, how you might be able to influence policy development in a meaningful sort of way. And after a while it became a second job, and then after about four years of doing two jobs, I was given the option. You know, you either need to, you got to pick one. They're both full-time jobs. You can't, you know, you just can't do both. And so I was told I needed to make a choice and I made the choice to stay in the policy work. And I've just been doing that for so many years now. It's like second nature, but that's really kind of what led me into it. And then the more you learn and the more you understand the processes, the more I'm pulled into it, I'm just like, yeah, I've just got to try to find ways. It's one thing to say, manufacturers need to develop product, innovate product that meets on that medical need. Well, what good is it if there's not access to that product once it's been developed? So that's really been kind of the pull for me. The, you know, hit your heart, got to stay in it, got to keep doing it sort of thing is that concept that that's where access really begins. Interesting. And you mentioned that you were kind of doing the sales work from the beginning. What, what type of devices were you selling? Everything from walkers and crutches and canes to bedside lifts to power wheelchairs, manual wheelchairs. I mean, I just went through the whole gamut. When I started, it was mostly what people today would call standard, durable medical equipment or home medical equipment. Not too long after that sunrise medical, which is where I was employed them acquired J medical and quickie designs and some of the more what today would be called complex rehab technology. And I said, ooh, that's where I want to go focus my time. And so that's, I moved over and ended that's where I remained until I hit that, you know, 40, some year mark. And now at our exhibition. I see. So you mentioned the complex rehab tech CRT. How much have you seen the technology that comes out that needs that a little bit of help with the policy making and becoming accessible? How much has a change in the past? Many decades that you've done the work with it. Wow, it's a lot. I can point back, I think the one policy change that probably was the most impactful to me personally was when I worked with a group and we got Medicare to cover speech generating devices. And that was back in the, you know, at the end of the 90s and into 2000. But then what I've observed is unfortunately fraud or abuse of particular programs tends to be a high motivator for the payers. And when they start to see, you know, this particular device category seems to really be increasing in utilization and can't really explain why very often it will get the attention that we need to go in and understand what the drivers are. We need to check and make sure that the documentation is adequate. Let's look at who the patient population is and is that really supported by scientific evidence. And so I've seen whether it was power wheelchairs, whether it was seeding systems, whether it was wheelchair cushions. We've seen that sort of thing, either they either a decision that we think we're paying too much or a decision that we're paying for too many and it's not justified. But that very often has led to pretty dramatic change in terms of policy. Sometimes that's good. A lot of times it ends up where people used to have access to technology and they can't get it anymore. And I'll give you an example of that before Medicare made dramatic changes in coding, coverage and payment for power wheelchairs. It was relatively easy for a wheelchair user to obtain a chair that could function in all the environments they encountered in a day. So in the home, outside the home, in the community, at work, at school, whatever. When they went to change from essentially four-hit pit codes to 64-hit pit codes, but they weren't all power wheelchairs, some of them were scooters and things. But a lot of codes, I mean you're talking really peel-in-the-union skin so to speak relative to the technology. And they ended up making a decision that chairs that had features and function that was primarily useful outside the home would not be covered. And so all of a sudden you've just got access to chairs and I'm not saying that the chairs aren't good. I mean they're good, quality, whatever. But in a lot of situations, depending on where a person lives and what they do every day and their environment, it's not enough. And so what has occurred over the last few years, and there's been a lot of activity in the disability community, as chairs are breaking down at a faster rate than they had historically. There's a lot of evidence that people have trapped or around why that is and what that means and a lot of ideas about what to do about it. But at the end of the day, I feel like a lot of it is therapists have lost a little bit of that control over how they recommend technology. Instead of feeling like I can really go in and ask a person, "What do you do every day?" And what are the most important activities and what's really important to you that this chair be able to do for you on a daily basis? Instead it's kind of like, "Well, Medicare and maybe even your private payer or maybe commercial plans, whatever, are only going to cover what you need inside your home." So this is really all that's going to be paid for on your behalf and anything else is going to have to be out of your pocket. And I'm not even sure that much of the conversation ever takes place. It's led to maybe the technologies there, but not necessarily available. There's not equity in that across the board. That is crazy. That is actually not the answer. I was expecting. Right? I was expecting it. I mean, it's better now than it was before. Well, at least that was my assumption, especially the pre-ADA to post-ADA era, but it sounds like it took a complete 180 turn in the access to the stack really. Just got so much reduced, which adds more job on your plate, obviously, as a policy maker or policy influencer in a way, right? So if I understand correctly, your job is to convince the government that the technology that's out there should be more accessible. And through that, you end up reading a lot of scientific papers, even as someone outside of the hard sciences fields. Is that correct? Oh, absolutely. I really tell people a lot. If I had known, when I was 17, when I know today, I think I probably would have considered research as a career. I find it incredibly intriguing how the hypothesis and how you can go about proving different things and how significant it is to improving access today. There was a legislation actually passed a few years ago that requires the medical directors to establish policy based on evidence. And there's just not a ton that's even available. I mean, if you talk about doing research around will mobility and seeding, most people are like, "Henry that all been done already?" But in reality, there's so much we don't know. I mean, there's just not enough money. There's not, in my understanding is, I'm not the researcher, so I can't speak with a level of certainty on this, but what I understand is that it's very difficult to do a really strong study because of the fact that there's so many different diagnoses that present in different ways. And since the policymakers here look more at diagnosis than they do function, if we could say, "Well, we're going to group people maybe the diagnoses are different, but their functional levels are the same." That would certainly make some of the research easier. But one of the challenges is how do you control things enough that you can really prove the outcome of a particular technology? And then the other problem that really kind of comes into that is if you're trying to test different technologies, but they happen to fall into the same billing code, which was referred to as a HIPPIT code, if they're in the same HIPPIT code, then you would literally be going through and test each product against every other product as opposed to, I can group similar products within this code and test them against similar products in this code, but there's a wide array of technologies that fit into the same billing code. So the system of how products are grouped and classified and paid for is not set up well to facilitate the kind of studies that are necessary to influence access the way I want to like to influence access. So it's kind of like trying to influence with your hands tied behind your back, because it's just not as simple as, you know, change policy, by the way, here's all the research you need to support what I'm asking for. You really do have to build the story a little bit at the time and it's a bit complicated. And as you can imagine, you know, the cost of it, the finances of it is all kind of stacked against you at the same time. Yeah, well, I was going to say that although you do have a dream of maybe going back in time and becoming a researcher, I think what you do is extremely important to those of us in research as you become that kind of the important bridge between the access to the tech that is being developed. And that leads perfectly into the question I wanted to ask you, what do you wish as someone on the side that does policy work about this technology? What do you wish us on the research side in 80 and rehab engineering would know about codes, about policies when we're actually developing the technology or doing the research? Oh, man, you have hit the jackpot with me on those two questions. All right, I'm going to answer the first one. What do I wish policymakers knew? What it's like every day for the person who needs the technology? What I've always looked at, technologies being what levels the playing field, you know, it's what allows the person's real talent and capacity to be utilized. The technology allows that to come through and allows that to happen. If you're just looking at it purely from, hey, a wheelchair is a wheelchair is a wheelchair. What difference does it make? Well, if you haven't spent time around people with totally different needs and capacities, then you're not going to understand that. I can put all the research in the world in front of you and you're never going to get that story. So if there was anything I would hope for, it's like, go spend a day, just one day in the field of the person, in a manual chair or a power chair or a speech engineering device, whatever the technology is, spend one day with them and just realize how much harder they have to work to do what they want to do and can do should be able to do every day. Just go watch that. That would be my one wish on that side. And I'd probably have another wish. And it was an opportunity for all the stakeholders to be at the table together to find a reasonable solution. Because I really think you have to be able to whether it's a technology user who can't imagine why an employer or a policymaker might not agree to cover something. All the way down to the manufacturer supplier that says, why are they not willing to pay enough? I mean, everybody needs to be around the table talking about how to resolve those problems. So that's my point for the day wish on that side. On the researcher side, if I could read one article that doesn't end with, but more research is needed. I'm just like, what? Can you just give me a clear, this is what we learned, this is what this shows instead of? It might show, it could show, it may be shows. So I understand that when research can't necessarily be that black and white, and I'm sure more research is needed, I did a presentation quite a few years ago at the State of the Science. And I said, you know, if you're going to close with, but more research is needed, could you at least say what it is that still needs to be studied because it sounds like to the, you know, the kind of innocent reader that, well, we think we showed something that we're not quite sure. we should study it again. Or we prove, you know, kind of showed this in this study of 300 people, but we need a thousand people for it to really prove anything. Because then I can't really use that, you know, it's not very convincing for the policymakers if that's how that's perceived. That's really interesting. I was going to say this sounds like such a big discrepancy. Because I personally, I think I know why we always end every paper like that. From a research standpoint, we cover all of our bases on a research level because A, you're most likely are going to continue doing more research into the similar topic because that's what you do in research. You dedicate the entire life to a very specific thing. You cover your bases with potential reviewers that are kind of like, well, you shouldn't be very definite with this results that you're showing. And especially, you know, when we're talking about designing something for a population that is just very hard to recruit in general for participation, you know, you can have like, if you have an N of 10, it's already like a wow. Most of these studies are N of 3 and a 5. And from there, you know, as a scientist in you, it's very hard for you to be like, this is definite from my N of 5 results. But I hear you that once you present this paper to a policymakers, all they think of is kind of like, well, if they're not sure, why should I be sure? Exactly. And I'm not sure. Here's my other wish in the research area. And it's big. There needs to be the bar that's set for pharmaceuticals is different in my mind. You know, it's like, okay, I get it. You're putting a drug into human bodies and you have no idea what what the impact is going to be. You don't know what it's going to do in terms of medical outcome. You don't know what it's going to do in terms of symptoms and side effects or whatever. But with most assistive technology, not all, but with a lot of it, some of the results are observable. I mean, literally, you put a person in a wheelchair with a particular seating system, you can see how that changes their posture, how that impacts breathing, how that potentially impacts a lot of things, swallowing, eating. I feel like to have a bar that says, well, we need a randomized clinical trial that has 150 in each arm. You know, you kind of go, what? Can we just sit down and say, help us figure out design methodologies and questions that are achievable, affordable, and are going to provide you a level of assurance that if you use this information to establish policy, then it's fair and equitable for you as the payer, the person who's receiving the technology, and the clinicians and physicians that are trying to, you know, improve their health, their well-being, that sort of thing. I mean, it's kind of like, can we just agree on what that looks like when it comes to assistive technology because we're held to the same standard, as, you know, pharmaceuticals in a certain sense, not completely, but to a huge extent. So, I would love to see a stakeholder conference, the consensus conference around research, where all the players can come together, and I would love to see, I mean, there's a lot of conversation about equity and healthcare, and, you know, ADA, all that's happened with the ADA, and with Section 504, you kind of look at that and go, "Think should be getting better for people with disabilities." And in reality, I'm not seeing that. And as I worked with several small innovators in the past, over the last, you know, two or three years, great technology that people are designing that are answering on that medical need, and they call me and they go, "I'm in cell and this seems like crazy in Europe. I've been cell and this seems like crazy in, you know, wherever, New Zealand, whatever. Why can I not get it into the US market?" Well, how much research has been done on your product? How much evidence is there about what your product does? And because it's just, it's all kind of intertwined. If you can't, you've got to get a benefit category within Medicare if you want to reach the Medicare population, but if you don't have Medicare first, it's really hard to get Medicaid. It's really hard to get commercial plans because they want you to be accredited to Medicare standards. So there's just like lots of meshing together of these different policies that kind of says, "If you don't go knock on the door at CMS and go through the benefit category coding and payment processes, it's really hard to get your product to the people that you designed it for." So it's, you know, people ask me because HIPIP coding has been my kind of the passion that has driven me for many, many years because you got to have a code, not once they did HIPAA back in '96 or whenever it was. And it made HIPIP coding the uniform code set for all payers. If you can't get your product placed appropriately from a coding perspective, it equals payment, it equals coverage. It just, everything is based off that foundation. So it's, there's a lot of work that still needs to be done for innovation to actually get into the hands of the people that need it. This is really interesting. So going back to that example of someone mentioning, you know, I've been selling these like crazy in Europe or in New Zealand, do you think this is mainly because of the way our medical system is set up where everyone, even the commercial insurance plans are looking up to your Medicaid, Medicare, first of all, and yeah, totally. And I would say the other piece of that, which is different in some countries than here, is the coverage is like a continuum where it's the same, you know, that's following the person, the money is there out of the same bucket, whether you're being cared for at home or in a hospital or in a assisted living or a nursing home or whatever. It's all one big continuum wherein the US market, you essentially have buckets, whether you're talking about physician, lab, equipment versus hospital stays, nursing home stays, that sort of thing. And so there's no, there's no incentive to look at, gosh, could we look at all the cost? And maybe some of the technology costs would reduce the cost of the nursing home, maybe prevent people from even having to go into nursing homes, but that kind of connectivity of where who all's paying for what just does it come together here in the States, like it does in other countries. You see, that's interesting. Yeah, that kind of brings me back the memory of the episode I did was Maureen Linton. And we, she mentioned, you know how she's trying to push the study on just kind of identifying if you provide some aid for a person with a disability to return to work, the cost on the government to work for the government to provide aid to that person is ends up being much lower if they just provide that piece of technology for them to return to to the workforce instead of, you know, just kind of finding them in a home and then providing a separate kind of aid there. So, well, yeah, that's incredible. You mentioned codes a lot. How, how do they get developed? Have you ever seen how, you know, a government comes in and as you mentioned that time when there were just this few codes and then now there are these many codes. Happened in both ways. It happens both ways actually. Sometimes, sometimes they'll look at a small group of codes and decide to blow them up into a lot and sometimes it's well, we really don't think we need that many codes, we'll just consolidate it down to one. I really feel like that there needs to be evidence, this piece of it, because in order to go in, let's just say, "Well, chair cushions." There's some codes that have literally hundreds of products that have been code verified into that one code. And they're very different. I mean, very different. And you could try one code. It may be, let's say it's a fluid or air. And let's say that product for some reason just doesn't work for that client. You can't get another product in that code for five years. Unless you have a medical need to move to a different product, or you know, you've had a change in your condition or whatever, you're not going to be able to get another product. And so for a long time, I've looked at, considered the cushion codes. I've actually, Georgia Tech has done an awful lot of research around skin protection and wheelchair cushions. I feel like until there's comparative research that's done that can really, without question, show different outcome with this cushion, then this cushion. And I don't know how you do that because you're dealing with the technology plus nutritional, you know, for the client, what's their nutrition like, what's their skin like, where do they live? Do they have a lot of heat, a lot of moisture? And there's a million things that are going to influence that. And so until a lot of brains that are a lot better at that than me can figure out, how do you go about comparing this product? You know, I just kind of look at that and say unless I can, this is the quote out of the policy, you have to be able to show superior clinical outcome. How do I do that? How do I do that with certain products? I mean, certainly with some, that would be probably fairly simple to do, but in the world of will mobility and seeding not so much. And of course, Medicare only covers in the home. So when you're talking about mobility, you know, flat level surfaces inside, you don't need nearly as much as if you're out in the community. So that kind of makes that hard to. I see. How can us folks in research influence policy making and that kind of goes back to I saw you have presented and rest in this conference in 2012. The topic was how science influences policy. So maybe if you could give a little spiel from that. From that. Yeah. But because for me, I think what would be really, really helpful is when you look at, where's the money for research coming from? Because that's how, I mean, you've got to figure out how to stay alive. If you're alive as research, right, you've got to have the money to do the research and it's either maybe coming from manufacturers to a certain extent, but not a lot because it's just so expensive to do research. But if you look at NIH, for example, and you look at grant money that might come that way, how are you going to get grant money to study wheelchair cushions again? It's not exciting. It's not new. It's not whatever. I think again, I love the idea of community coming together. But if the disability community could, and clinicians, because they're the ones that are seeing the problems, they're the ones that are saying, I can't really provide or recommend the equipment that I really believe could help this person. If those two groups could come together and identify a need, and then the research community comes with that and says, what's the hypothesis? What's the research hypothesis? What's the methodology? How many people do we need? What do those people need to look like? What's the inclusion and exclusion criteria? And then get all this support, maybe, behind a grant, and maybe an opportunity even to approach funding agencies to say, there's this huge need, and here's what it's doing to the people who need this technology and can't get it. And I know it's not as sexy as something else that we might do. It's not as, it's not new. It's not as maybe as exciting, but at the end of the day, it's critical to leveling that playing field. And to me, that's what it's got to be all about. And if we can blaze a path that says, here's how research needs to be done to influence policy makers appropriately. And these are the processes that innovators have to go through in order to get their products to market. Then it becomes predictable and achievable and hopefully affordable so that there's an incentive for innovators and existing manufacturers to develop new technology. I think that's not only is that invest interest of the healthcare system in general. I think it provides better health and well-being for people who need the technology. But I also think it does great things for the U.S. economy that people have an incentive to do it here. I guess I'll have to go to Europe or I'll have to go to Canada or I have to go somewhere else to distribute my product. I think it's an all-round-good thing. I just don't know how we make it where it doesn't feel to people trying to make product here available in the States. It seems like it's as they refer to it to me. It's like a black hole. It's this thing that I don't know how to navigate through. Even after 40-some-odd years of doing this, there's only so much advice that I can give people and top of my list is usually you better make sure you've got evidence, better make sure you've had some research done. I'll tell people you don't necessarily have to start with 200 people or 300 people. Start with 20. But try to get 20 that are similar people that you can really narrow the focus of that research to say something meaningful about your device. To me, that's like the one thing that's standing in the way is how do we get that research designed that is repeatable, achievable and affordable at the end of the day? Absolutely. I think there should be a much higher importance put on the need-based research. That's kind of what I was taught since my undergraduate years when I was doing research. We tend to get carried away by some cool, exciting things that oftentimes do not even have any potential viability in the community. I think that's especially where us engineers get the pitfall of us all. But I think I have a clear need-based research is very important. I was thinking back to the day that, as an undergrad from the University of Washington, I was invited to participate in a conference that was called posters on the hill. And that was when a bunch of undergrad researchers got invited to present their research to actual policy makers, to congressmen, congresswoman, actual at the Capitol Hill. So those were the closest I've ever been to a policy maker. But I've been in research for almost a decade. I feel like that was the only interaction I've ever had with policy makers. Are there any other opportunities for researchers to get closer to those making policy? I think we have to create those. I really do. And that is a passion of mine. Not only when you talk about policy makers as legislators, and they're very important, but then there's also those policy makers at Medicare. you know, and within the different Medicaid programs, there's actually programs around the country that try to assist with what they call evidence-based policy development. I'm not sure that in all cases, there are even aware of all the research that's out there. I think that they would be an ideal group to help identify where there's holes in the research. There's just, there's like these almost like barriers between the payer and the consumer and the researchers and the engineers. It's like, can we all just get on the same page? So the focus and the money is being spent where the most people are going to benefit versus always spent, you know, a million dollars on this device that ten people have been able to access and we did all this research and in that wasn't that lovely and fun, but how many people did that really help? You'll hear me say it a lot for the rest of my career. How do we bring the stakeholders together to develop meaningful mechanisms to establish policy that, again, levels the playing field? That's all I'm advocating for is let's just level the playing field so that people have the tools they need to live the best life they possibly can. I don't think that's too much to ask. So I think we've got to create, I think we've got to create that. So I don't think it exists anywhere really. Just to wrap things up, what are you most excited about and looking for in the next couple of decades of continuing kind of bridging the gap between research and policy making in the fields of AT&T and rehab engineering? Yeah, I have had so much fun in my current job. The device that ARX function has addresses the loss of sensation in the bottom of the foot, which causes a lot of difficulty with balance and, you know, walking a lot of falls and a lot of risk associated with that. And as we've gone through this process with Medicare of trying to get a benefit category, trying to get a code, trying to get adequate payment, trying, you know, getting accredited and all the things that you have to do, I have absolutely loved the conversation around the research, the research questions. There's so many things that you can learn about a device beyond what does this device do and does that have a meaningful outcome for the individual it's intended for. There's so many things and I guess this is where my curiosity comes in. It's like, I want to know everything. If the person that needs this device gets it, how does that impact their life? How does that impact the rest of their health? What does that mean for, you know, you could go on and on and on. I mean, I could sit and write just sheets of questions that I would like to ask somebody. If I, if I had, if, you know, I won't be around for two more decades doing this, I'm sure I'm going to be off having grandchildren and having fun. But if I, if I could lay the foundation for anything, it would be to lay a foundation that establishes meaningful criteria for research that needs to be done. I mean, there can still be all the fun, new, exciting research that people do. It can be all the fun, you know, papers and scientific papers and fun things that can be done on the engineering side and on the research side. But from the government's perspective, in particular, I think that there has to be a focus on not just what does this piece of equipment do, but how does all of this work together within the system, whether it's home care, hospital care, nursing care, whatever, or no care, you know, a lot of people with disabilities, they're not sick. They just need a face of equipment to be able to function. I would just like to see a plan that says, this is really important for us to do to advance health, well-being, for people with disabilities that, that is going to improve the overall system that we're going to look at, how they get to live their lives and what the equipment does for them. And we're going to establish funding for research to make that happen. I mean, that would be my preference. That would require Congress, that would require an awful lot. And that's going to be, I'm sure, quite challenging over the next four plus years. But I mean, I just feel like that's going to be critical. That's great. This was a great conversation. Thanks so much, Rita. I learned a lot about policy-making and the challenges we're facing. It really surprised me by kind of the status of accessibility to technology from the government standpoint in the past 30 plus years. But thanks for sharing. Thank you for this opportunity. I love chatting with you. I just wish I had that much, if it was as easy to talk to the end of the policy makers and get them to listen to me and be awesome. Yeah, such a, no, sometimes I wonder, you know, the policies that come out, I wonder if they even have any experts on the policies they're creating. Yeah, they do. I mean, Medicare does and, you know, I have to have to at least go out and say Medicare is most recent approval of coverage for C-DEL, power C-delivation was huge. And I think when we look at those kinds of decisions, now there was a lot of work in gathering, find the science to support it. But it can happen, but it just, it just takes a huge lift, a huge lift. So did you end up participating in pushing the Medicaid to towards approving that? That was, well, Medicaid is really good in terms of Medicaid doesn't have the same limitations and the legislation that established Medicaid has more about community access than Medicare does. And so in a lot of situations, you'll see Medicaid pay for things that Medicare doesn't. But in a lot of other situations, you'll see them just follow Medicare, you know, where they can. So it makes it really complicated. I know. That is very complicated. It's really difficult because people call me with questions, I'm like, it depends. I mean, there's never a black and white answer. It's like, it depends. Who's the primary? Who's the secretary? You know, it depends. But I think, I think the answer to it is less about trying to change them and more about how do we provide what they need in order to establish proper policy. And it just, it's a he is a herculean lift in some situations, but the more, the more stakeholders come together, that's my mantra, the more that we can get people to work together, I think the better our chances are. And togetherness, there's power. That's right. That's right. Thank you. Those are pleasure. This episode was powered by Create, the Center for Research and Education on Accessible Technology and Experiences at the University of Washington and Resna, the Rehabilitation Engineering and Assistive Technology Society of North America. Thanks for listening to Gears of Progress. I hope you enjoyed learning more about policy making and assistive technology. 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