arbitrarily defined ''medical necessity" requirement that does not permit reimbursement for many types of preventive and rehabilitative services and assistive technologies. Insurance policies tend to mirror the acute care orientation of the U.S. medical system and generally fail to recognize the importance and value of longitudinal care and of secondary and tertiary prevention in slowing, halting, or reversing deterioration in function. The presumption, which has never been thoroughly evaluated, is that rehabilitative and attendant services, assistive technology, and other components of longitudinal care are too costly or not cost-effective.

Access to health care, particularly primary care, is a major problem for persons with disabilities. Many report that they have great difficulty finding a physician who is knowledgeable about their ongoing health care needs. They also have problems obtaining timely medical care and assistive technology that can help prevent minor health problems from becoming significant complications. National data indicate that, relative to the general population, person with disabilities, regardless of age, have high rates of use of health care services such as hospital care.

The problem of access to care for persons with disabilities transcends the availability of insurance of a regular relationship with a health professional (although for many large gaps exist in both these areas). More important is that the person have access to appropriate care during the full course of a disabling condition. Such care should be provided in a way that prevents secondary conditions and maximizes the person's ability to function in everyday social roles. It must have continuity and not be restricted by arbitrary rules that limit services necessary for effective rehabilitation and participation in society. Persons with disabilities often face enormous impediments to obtaining the coordinated services they need to prevent secondary conditions and improve their opportunity for successful lives. Such impediments include (1) lack of support from insurance and other funding agencies, (2) lack of locally available services, and (3) absence of local coordinating mechanisms.

RECOMMENDATION 18: Develop new health service delivery strategies for people with disabilities

New health service delivery strategies should be developed that will facilitate access to services and meet the primary health care, health education, and health promotion needs of people with disabling conditions. These strategies should include assistive technologies and attendant services that facilitate independent living.

Access to Vocational Services

Vocational services are crucial to ensure that return-to-work goals are achieved. These services may include counseling and work readiness evaluations,



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