9

Overall Conclusions¹

This chapter presents overall conclusions derived from the chapter-specific findings and conclusions detailed throughout the report.

OVERALL CONCLUSIONS

The committee’s chapter-specific findings and conclusions (summarized in the next section) served as the basis for the following nine overall conclusions.

The Promise of Assistive Products and Technologies

The committee’s review of the literature and the expert opinions of its members and others who provided input for this study made clear that appropriate-quality assistive products and technologies in all four categories examined may mitigate the impact of impairments sufficiently to allow people with disabilities to work. In some cases, however, environmental and personal factors create barriers to employment despite the impairment-mitigating effects of these products and technologies. For instance, work settings that are not accessible to wheeled and seated mobility devices (WSMDs) for entry and exit and maneuverability create barriers to employment. Likewise, the fit and function of a prosthesis and thus its impairment-mitigating effects may be impacted by such environmental factors

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¹ This chapter does not include references. Citations to support the text and conclusions herein are provided in prior chapters of the report.

as exposure to moisture, heat, and dirt. And working in a noisy office with cubicles can create barriers to effective use of a hearing aid.

Maximal user performance requires that individuals receive the appropriate devices for their needs, proper fitting of and training in the use of the devices, and appropriate follow-up care. Even if these conditions are met, moreover, and even given relevant technological advances, assistive products and technologies may not fully mitigate the effects of impairments or associated activity limitations. The committee emphasizes that environmental, societal, and personal factors are as important in determining individuals’ overall functioning with respect to employment. Even for people who are able to obtain upper-extremity prostheses (UEPs), for example, rejection rates are high, in part because of discomfort with wearing the devices, limited ability of the devices to meet individual needs, a lack of training in their use, and limited durability. For these reasons, the committee drew the following conclusions:

1. Assistive products and technologies hold promise for partially or completely mitigating the impacts of impairments and enhancing work participation when appropriate products and technologies are available, when they are properly prescribed and fitted, when the user receives proper training in their use and appropriate follow-up, and when societal and environmental barriers are limited.
2. When matching individuals with appropriate assistive products and technologies, it is important to understand the complexity of factors that must be optimized to enhance function. Selecting, designing, or modifying the correct device for an individual and providing training in its use, as well as appropriate follow-up, are complex but necessary elements for maximizing function among users of assistive products and technologies.

Access to and Coverage of Assistive Products and Technologies

Financial access to appropriate assistive products and technologies as well as qualified providers varies significantly across reimbursement and funding sources in the United States. Numerous pathways exist for accessing these assistive products and technologies and related services, but different coverage sources vary in their missions, their eligibility requirements, and the types of products and technologies and related services they cover. As discussed in Chapter 7, differences in funding policies among various programs affect access to these devices and services for some individuals. In addition, the provision of UEPs is contingent largely on reimbursement

policy rather than patient need. The variation among reimbursement and funding sources in the United States also has a significant impact on the types of WSMDs individuals receive. Coverage of hearing aids varies by funding source as well; Medicare and some private health insurers, for example, do not cover hearing aids at all. In some cases, a mismatch exists between the products and technologies covered and those that would best meet the needs of users to enhance their participation in work and other life roles.

In some cases, there also exists a shortage or geographic imbalance of qualified providers and clinics with the knowledge, skill, and expertise to properly evaluate, fit, and train people in the use of assistive products and technologies. As discussed in Chapters 3 and 5, the distribution of providers and clinics with appropriate expertise to evaluate, prescribe, and train people in the use of WSMDs and hearing devices varies greatly throughout the United States. In addition, there is a need for more qualified providers (including physicians, prosthetists, and therapists) and clinics with expertise in the use of UEPs. Similarly, access to speech-language pathologists and other professional members of an augmentative and alternative communication (AAC) team with relevant knowledge, skills, and expertise is necessary and currently limited.

In addition, socioeconomic status and education levels may affect access to coverage for assistive products and technologies and related services. Health literacy is associated with a variety of factors, including educational level. Acquisition of assistive devices may be promoted by people’s knowledge of their needs, device and coverage options, and means to pursue the device(s) they need. Moreover, loss of access and coverage among youth of transition age is a significant impediment to their independent living, transition to work, vocational readiness, or further education. The committee drew the following conclusions with respect to access and coverage:

3. Access to appropriate assistive products and technologies and to qualified providers and teams with the knowledge, skill, and expertise necessary to properly evaluate, fit, train, and monitor people in the use of those products and technologies is frequently limited and varies considerably from case to case, state to state, district to district, urban to rural and frontier areas, and funding source to funding source.
4. The variability of coverage for assistive products, technologies, and related services is an important impediment to optimizing function and maintaining gainful employment among transitioning youth and adults with impairments.

Information and Policy Concerning Assistive Products and Technologies

Individuals’ knowledge about assistive product and technology options, their needs, their coverage options, and the means available to them to pursue the products and technologies they need will either promote or hinder their acquisition of the devices. The committee found, for example, that representation by an attorney or advocate who is experienced in health law could help individuals secure Medicaid or Medicare coverage and approval of various medical supplies, equipment, and assistive devices. However, the distribution of knowledge about available assistive products and technologies varies greatly. Socioeconomic status, education level, and a variety of personal factors—including ethnic, cultural, and language barriers—may affect access to assistive products and technologies and related services even when they are covered. The committee therefore drew the following conclusion:

5. Education regarding the availability of assistive products and technologies and knowledge and training that empower users to self-advocate or have a significant other (e.g., family member, friend, or professional) advocate for them are important elements in achieving successful access to appropriate assistive products and technologies and related services.

The provision of assistive products and technologies such as WSMDs, UEPs, and AAC devices is contingent largely on reimbursement policy rather than patient need. In some cases, the products and technologies that are covered by Medicare and other insurers as medically necessary are not those that would best meet the needs of users to enhance their participation in life roles. Medicare and other insurers may reject payment for devices and components that are new technologies or that they do not consider medically necessary even if prescribed by a trained professional. For example, Medicare’s policy limiting coverage of WSMDs to those needed for home use is an impediment to achieving gainful employment. The variability in reimbursement for UEPs and related rehabilitation services also creates unequal access, particularly for new technologies. Similar limitations exist for users of hearing aids and communication devices. In addition, the relatively small numbers and/or variable distribution of providers and clinics qualified to provide relevant assistive technology services limit access to those services independently of funding or reimbursement considerations. Accordingly, the committee drew the following conclusion:

6. Assistive products and technologies are advancing at a much faster rate relative to clinician education, regulations, and reimbursement systems, which may limit access to these devices and/or access to training in their use.

The mission of funding sources and benefit programs affects the extent to which they provide, or help beneficiaries to obtain, appropriate assistive products and technologies and related services designed to facilitate their ability to work. Some private disability insurers provide certain assistive products and technologies in support of occupational functioning and return to work. Unum, for example, utilizes assistive products and technologies in support of occupational functioning in its private insurance disability determinations. Prudential Financial is another private disability insurer that supports assistive products and technologies used primarily for return-to-work purposes, most commonly musculoskeletal aids such as modified workstations, chairs, or mobility devices. State vocational rehabilitation agencies may provide or facilitate the acquisition of assistive products and technologies and related services to enable eligible individuals to prepare for, retain, or regain work based on their personal vocational goals. The Veterans Health Administration is an integrated health care system that provides high-quality, comprehensive, interdisciplinary care and assistive products and technologies to veterans. In addition, a few private health insurers provide integrated health care plans through which covered individuals receive clinical care, prescription drugs, and assistive products and technologies. Based on its review of selected monetary disability benefit programs and funding sources for assistive products and technologies, the committee drew the following conclusion:

7. Some coverage and disability benefit models, such as those of the Veterans Health Administration, state vocational rehabilitation agencies, some private disability insurance carriers, and a few private health insurers, are more holistic than others, providing access to a greater range of assistive products and technologies and related services that can be appropriate to meeting individuals’ needs and facilitating their ability to work.

Evaluation of Ability to Work

The concept of disability has evolved to reflect a biopsychosocial model in which disability is perceived as the interaction between an individual’s functional capacity and relevant social and physical environmental and

personal factors. Although assistive products and technologies may mitigate the impacts of impairments sufficiently to allow a person to work, personal factors such as gender, race/ethnicity, age, socioeconomic status, insurance coverage, education, and previous work experience can influence how an individual experiences disability. In addition, the individual experience of disability is influenced by such environmental factors as the job market, workplace attitudes, geographic location, and the built environment. Although the committee found that a complete evaluation of a person’s functioning would include the assistive products and technologies he or she normally uses, that finding needs to be tempered by the following conclusion:

8. Professionals involved in disability determinations cannot assume that because an individual uses a particular assistive product or technology, this device is always effective for that person, that it mitigates the impact of the person’s impairment, or that it enables the person to work. Environmental, societal, and personal factors also must be taken into account.

Data on the Use and Effectiveness of Assistive Products and Technologies

The committee found that data on the prevalence of use of the assistive products and technologies discussed in this report and the extent to which they mitigate the impacts of impairments are fragmented and limited. At this time, it is difficult to quantify the impact of assistive products and technologies and related services on impairment mitigation and employability because of contextual/environmental, societal, and personal factors that affect device use and job function; the lack of data on occupational success; and unequal access to relevant products and technologies and training. The committee recognizes that limited or lack of evidence about the impact of assistive products and technologies and related rehabilitative services on activity and participation may affect decisions by funding sources about which devices and services to cover. Information from outcomes research could contribute to studies on the effectiveness or cost-effectiveness of various assistive products and technologies and thereby help to inform the development of rational resource utilization, including coverage decisions by insurers and other funding sources. Accordingly, the committee drew the following conclusion:

9. Additional research is needed to understand how the specifications for and use of assistive technologies and products and related services impact inclusion in society and work participation for individuals with disabilities. Such research may not

SUPPORTING EVIDENCE FOR THE COMMITTEE’S OVERALL CONCLUSIONS

Box 9-1 shows the links between the overall conclusions presented above and the most relevant chapter-specific findings and conclusions that support them.²

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² The committee’s chapter-specific findings and conclusions are numbered according to the chapter in which they appear.

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