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Suggested Citation:"Front Matter." Institute of Medicine. 2007. Improving the Social Security Disability Decision Process. Washington, DC: The National Academies Press. doi: 10.17226/11859.
×

IMPROVING THE SOCIAL SECURITY DISABILITY DECISION PROCESS

Committee on Improving the Disability Decision Process: SSA’s Listing of Impairments and Agency Access to Medical Expertise

Board on Military and Veterans Health

John D. Stobo, Michael McGeary, and David K. Barnes, Editors

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.
www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Improving the Social Security Disability Decision Process. Washington, DC: The National Academies Press. doi: 10.17226/11859.
×

THE NATIONAL ACADEMIES PRESS

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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

This study was supported by Contract No. 08820000 between the National Academy of Sciences and the Social Security Administration. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.

International Standard Book Number-13: 978-0-309-10381-7

International Standard Book Number-10: 0-309-10381-9

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Copyright 2007 by the National Academy of Sciences. All rights reserved.

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The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

Suggested citation: IOM (Institute of Medicine). 2007. Improving the Social Security disability decision process. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Improving the Social Security Disability Decision Process. Washington, DC: The National Academies Press. doi: 10.17226/11859.
×

“Knowing is not enough; we must apply.

Willing is not enough; we must do.”

—Goethe

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Improving the Social Security Disability Decision Process. Washington, DC: The National Academies Press. doi: 10.17226/11859.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine


The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.


The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering.


The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.


The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council.


www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Improving the Social Security Disability Decision Process. Washington, DC: The National Academies Press. doi: 10.17226/11859.
×

COMMITTEE ON IMPROVING THE DISABILITY DECISION PROCESS: SSA’S LISTING OF IMPAIRMENTS AND AGENCY ACCESS TO MEDICAL EXPERTISE

JOHN D. STOBO (Chair), President,

University of Texas Medical Branch at Galveston, University of Texas

FRANK S. BLOCH (Vice Chair), Professor of Law,

Vanderbilt University Law School, Nashville, Tennessee

GUNNAR B. J. ANDERSSON, Professor and Chairman,

Department of Orthopedic Surgery, Rush University Medicine Center

RICHARD V. BURKHAUSER, Sarah Gibson Blanding Professor of Policy Analysis,

Department of Policy Analysis and Management, Cornell University

DIANA D. CARDENAS, Professor and Chair,

Department of Rehabilitation Medicine, University of Miami Miller School of Medicine

SHEILA T. FITZGERALD, Associate Professor,

Division of Occupational Health, Bloomberg School of Public Health and School of Nursing, Johns Hopkins University

ARTHUR GARSON, Jr., Dean, School of Medicine, Vice President,

University of Virginia

KRISTOFER J. HAGGLUND, Associate Dean and Professor of Health Psychology,

School of Health Professions, University of Missouri, Columbia

ALLEN W. HEINEMANN, Professor,

Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University

RONALD LEOPOLD, National Medical Director and Vice President,

MetLife, Alpharetta, Georgia

LARRY G. MASSANARI, Former Acting Commissioner, Social Security Administration,

Exton, Pennsylvania

STEPHEN G. PAUKER, Professor, Department of Medicine, Tufts University School of Medicine; and Associate Physician-in-Chief, Vice Chairman for Clinical Affairs,

Tufts-New England Medical Center Department of Medicine,

LINDA A. RANDOLPH, President and CEO,

Developing Families Center, Inc., Washington, DC

BRIAN M. SCHULMAN, Private Practice in Occupational Psychiatry,

Bethesda, Maryland

PETER W. THOMAS, Principal,

Powers Pyles Sutter & Verville, PC, Washington, DC

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Improving the Social Security Disability Decision Process. Washington, DC: The National Academies Press. doi: 10.17226/11859.
×

CRAIG A. VELOZO, Associate Professor and Associate Chair,

Department of Occupational Therapy, College of Public Health and Health Professions, University of Florida; Research Health Scientist, Rehabilitation Outcomes Research Center, North Florida/South Georgia Veterans Health System

Project Staff

MICHAEL McGEARY, Study Director

MORGAN A. FORD, Program Officer

SUSAN R. McCUTCHEN, Research Associate

REINE Y. HOMAWOO, Senior Program Assistant

RICK ERDTMANN, Director, Medical Follow-up Agency

PAMELA RAMEY-McCRAY, Administrative Assistant

ANDREA COHEN, Financial Associate

DAVID K. BARNES, Consultant

PETER M. SLAVIN, Editor

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Improving the Social Security Disability Decision Process. Washington, DC: The National Academies Press. doi: 10.17226/11859.
×

Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:


Barbara de Lateur, Johns Hopkins School of Medicine, Johns Hopkins Bloomberg School of Public Health and Johns Hopkins Bayview Medical Center

Robert E. Drake, Psychiatric Research Center, Dartmouth Medical School

Susan L. Garber, Department of Physical Medicine and Rehabilitation, Baylor College of Medicine

Katie Maslow, Initiative on Alzheimer’s and Managed Care and Quality Care Advocacy, Alzeimer’s Association Public Policy Division

Michael Msall, Department of Pediatrics, University of Chicago

Susan A. Randolph, Occupational Health Nursing Program, University of North Carolina at Chapel Hill

Virginia Reno, National Academy of Social Insurance

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2007. Improving the Social Security Disability Decision Process. Washington, DC: The National Academies Press. doi: 10.17226/11859.
×

Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Joseph P. Newhouse, Department of Healthcare Policy, Harvard University, and M. Donald Whorton, WorkCare, Inc., Alameda, California. Appointed by the National Research Council and Institute of Medicine, respectively, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Improving the Social Security Disability Decision Process. Washington, DC: The National Academies Press. doi: 10.17226/11859.
×

Preface

I would like to thank the committee members (see Appendix A), staff, consultants, and others who contributed to this report by providing their views of and information about the Social Security disability determination process. It was a very interesting and important endeavor that we hope will be of service to the Social Security Administration (SSA) and to those individuals with disabilities who are unable to engage in substantial work activities and need public support.

SSA asked the committee to address 10 tasks (see Appendix B). It further asked the committee to address three of the tasks on an urgent basis and report its findings and recommendations in an interim report. The committee began its work by addressing the three tasks, which concern the professional training and qualifications of medical personnel involved in the disability decision process. The interim report was issued in December 2005. It is reproduced in its entirety in Appendix C.

The committee has reviewed and affirmed the 13 recommendations in the interim report, except for the same revision in two recommendations. In Recommendations 1-2 and 1-7, the committee recommended that SSA require board certification of physicians and psychologists who serve as medical consultants for the state disability determination services agencies and medical experts who appear at appeals hearings held by administrative law judges. We noted in the interim report that, “board certification is rapidly becoming the standard credential for the practice of medicine or psychology.” The committee realizes that almost all physicians become board certified, but board certification is not yet routine for psychologists. Implementing a board certification requirement for psychologists in the

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Improving the Social Security Disability Decision Process. Washington, DC: The National Academies Press. doi: 10.17226/11859.
×

near term could seriously limit SSA’s ability to obtain enough qualified experts in psychology. The committee has, therefore, modified its position. We recommend that SSA continue the current requirements for psychologists participating as medical consultants or medical experts but establish a long-term goal requiring that psychologists be board certified.

The body of the present report contains our findings and recommendations concerning the remaining tasks that SSA asked us to address. These seven tasks concerned the Listing of Impairments, a screening tool that SSA developed to expedite the approval of claims from obviously disabled individuals who have a high probability of being approved for benefits if they went through the full disability determination process. The Listings, as they are called, are not only useful for SSA as an administrative tool to reduce the time and resources needed for the disability determination process, they are also of great benefit for individuals with disabilities in having their claims decided more quickly. This report treats the Listings as a diagnostic test with properties such as sensitivity, specificity, and predictive values. The report recommends ways to improve the performance of the Listings as a quick screen to identify truly disabled applicants for Social Security disability benefits. It also discusses what can be expected from using the Listings and ways to keep the Listings up to date in the face of advances in medical practice and assistive technologies, demographic trends, and economic trends affecting the workplace.

During the second phase of the study, the committee was greatly helped by presentations at several meetings from SSA’s Office of Disability Programs (ODP), which maintains and oversees the Listings and provides guidance on how to apply them. The committee would like to thank (in alphabetical order) Dr. Bernard Arseneau, medical officer, ODP; Dr. Ethan Balk, Agency for Healthcare Research and Quality Evidence-Based Practice Center, Tufts-New England Medical Center; Donna Sue Bongardt, Office of the Deputy Commissioner for Disability and Income Security Programs, SSA; Dale Cox, Office of Medical and Vocational Expertise, SSA; Robin Doyle, Office of Medical Policy, ODP; Dr. Terrence Dunlop, medical officer, ODP; Katherine Edwards, Disability Evaluation Services, University of Massachusetts Medical School; Barry Eigen, executive program policy officer, ODP; Dr. Christine Hartel, National Research Council (NRC); Dr. Monte Hetland, medical officer, ODP; Kristin Johnson, Disability Evaluation Services, University of Massachusetts Medical School; Jim Julian, director, Office of Medical Policy, ODP; Robin Kaplan, Office of the General Counsel, SSA; Barbara Kocher, Information Technology support staff, SSA; Cathy Lively, team leader, ODP; Patricia Owens, Consultation in Health and Disability Programs, Minisink, Pennsylvania; Dr. Marquita Rand, medical officer, ODP; Nancy Schoenberg, ODP; Dr. Frank Schuster, medical officer, ODP; Joshua Silverman, Office of Regulations, SSA; Glenn

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Improving the Social Security Disability Decision Process. Washington, DC: The National Academies Press. doi: 10.17226/11859.
×

Sklar, Associate Commissioner for Disability Programs; Dr. Charles Sweet, Disability Evaluation Services, University of Massachusetts Medical School; and Dr. Susan Van Hemel, NRC.

The names of the many people who assisted the committee and staff in preparing the interim report are listed in Appendix C.

We would also like to express our appreciation to Jo Anne B. Barnhart, then-Commissioner of Social Security, and Martin H. Gerry, then-Deputy Commissioner for Disability and Income Security Programs, who met with the committee at its October 2005 meeting to outline their goals for improving the disability decision-making process.

The committee also requested and was provided with a great deal of data on the disability determination process, which were analyzed by staff and are used throughout this report. Staff would like to thank those at SSA’s Office of Disability Policy who helped provide the data—Nancy Schoenberg, the project officer for the study; Susan David; and Bob L. Appleton—and those who helped fact-check the descriptive parts of the report—Barry Eigen, Joe Herendeen, Nancy Schoenberg, and Glenn Sklar.

The committee also wants to acknowledge the expert support of the Institute of Medicine staff and consultants: Michael McGeary, David K. Barnes, Rick Erdtmann, Morgan A. Ford, Susan R. McCutchen, Reine Y. Homawoo, Andrea Cohen, Pamela Ramey-McCray, and Peter M. Slavin.


John D. Stobo, M.D.

Chair

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Suggested Citation:"Front Matter." Institute of Medicine. 2007. Improving the Social Security Disability Decision Process. Washington, DC: The National Academies Press. doi: 10.17226/11859.
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Tables, Figures, and Boxes

TABLES

2-1

 

Comparison of Components of Models of Disablement,

 

20

3-1

 

Number and Prevalence of Individuals Ages 25-61 with and without Disabilities and Number and Percentage of Those Employed, by Disability Category and by Survey,

 

32

3-2

 

Initial Allowance Rate for Claims by Program Segment, 2004,

 

40

6-1

 

Comparison of Mental Impairment Severity Measures,

 

84

FIGURES

3-1

 

Distribution of applications for Social Security disability benefits among program and selected diagnostic groups, 2004 (percentage of all applications),

 

39

3-2

 

Distribution of initial awards of Social Security disability benefits among program and selected diagnostic groups, 2004 (percentage of all awards),

 

40

3-3

 

Distribution of annual disabled worker (DI) awards among selected diagnostic groups, 1961-2003 (percentage of all awards),

 

42

3-4

 

Distribution of annual SSI adult awards among selected diagnostic groups, 1985-2003 (percentage of all awards),

 

43

3-5

 

Distribution of annual SSI child awards among selected diagnostic groups, 1985-2003 (percentage of all awards),

 

44

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Improving the Social Security Disability Decision Process. Washington, DC: The National Academies Press. doi: 10.17226/11859.
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4-1

 

Percentages of allowances and denials at each stage of the claims process,

 

52

4-2

 

SSA’s five-step sequential disability evaluation process,

 

53

4-3

 

Bases for allowances and denials, by program segment, 2003,

 

56

4-4

 

Percentage of allowances made on the basis of meeting or equaling the Listings, by selected impairment codes, 2004,

 

57

4-5

 

Percentages of allowances for malignant neoplasms meeting or equaling the Listings, 2004,

 

59

4-6

 

Percentages of allowances for mental disorders meeting or equaling the Listings, 2004,

 

60

6-1

 

Basis for allowances at initial decision level, FY 1994 - FY 2004,

 

81

7-1

 

SSDI allowances meeting/equaling the Listings: 1975-2004 (percentages),

 

97

BOX

5-1

 

How SSA Uses the Listings: Listings Example—Peripheral Arterial Disease,

 

69

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Suggested Citation:"Front Matter." Institute of Medicine. 2007. Improving the Social Security Disability Decision Process. Washington, DC: The National Academies Press. doi: 10.17226/11859.
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Abbreviations and Acronyms

AAJ administrative appeals judge

AC Appeals Council

ACS American Community Survey

ADA Americans with Disabilities Act

ADLs activities of daily living

ALJ administrative law judge

ANPRM Advance Notice of Public Rulemaking

APA Administrative Procedures Act

BRFSS Behavioral Risk Factor Surveillance Survey

CWB Civilian War Benefit

DDS Disability Determination Service

DES Disability Evaluation Study (renamed National Study of Health and Activity)

DRB Decision Review Board

DRI Disability Research Institute

DSI Disability Service Improvement

DSM Diagnostic and Statistical Manual of Mental Disorders

FACA Federal Advisory Committee Act

FR Federal Register

FRO federal reviewing official

Page xviii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2007. Improving the Social Security Disability Decision Process. Washington, DC: The National Academies Press. doi: 10.17226/11859.
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GAO Government Accountability Office

GDP gross domestic product

IADLs instrumental activities of daily living

ICD International Classification of Diseases

ICF International Classification of Functioning, Disability and Health

ICIDH International Classification of Impairment, Disability and Handicap

IOM Institute of Medicine

IQ intelligence quotient

Listings Listing of Impairments

MAC Medical Advisory Committee

MC medical consultant

ME medical expert

MET metabolic equivalents of task

MVES medical and vocational expert system

MVEU medical and vocational expert unit

NASI National Academy of Social Insurance

NCDDD National Council of Disability Determination Directors

NCMRR National Center for Medical Rehabilitation Research

NHANES National Health and Nutrition Examination Survey

NHIS National Health Interview Survey

NPRM Notice of Public Rulemaking

NRC National Research Council

ODISP Office of Disability and Income Security Programs

ODP Office of Disability Programs

OHA Office of Hearings and Appeals

OMP Office of Medical Policy

OQA Office of Quality Assurance

POMS Program Operations Manual System

PSID Panel Study of Income Dynamics

QA quality assurance

QDD quick disability determination

SGA substantial gainful employment

SIPP Survey of Income and Program Participation

Suggested Citation:"Front Matter." Institute of Medicine. 2007. Improving the Social Security Disability Decision Process. Washington, DC: The National Academies Press. doi: 10.17226/11859.
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SSA Social Security Administration

SSAB Social Security Advisory Board

SSDI Social Security Disability Insurance

SSI Supplemental Security Income

SSR Social Security Ruling

TERI terminal illness

VA Department of Veterans Affairs

VBA Veterans Benefits Administration

WHO World Health Organization

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The Social Security Administration (SSA) provides Social Security Disability Insurance (SSDI) benefits to disabled persons of less than full retirement age and to their dependents. SSA also provides Supplemental Security Income (SSI) payments to disabled persons who are under age 65. For both programs, disability is defined as a "medically determinable physical or mental impairment" that prevents an individual from engaging in any substantial gainful activity and is expected to last at least 12 months or result in death.

Assuming that an applicant meets the nonmedical requirements for eligibility (e.g., quarters of covered employment for SSDI; income and asset limits for SSI), the file is sent to the Disability Determination Services (DDS) agency operated by the state in which he or she lives for a determination of medical eligibility. SSA reimburses the states for the full costs of the DDSs.

The DDSs apply a sequential decision process specified by SSA to make an initial decision whether a claim should be allowed or denied. If the claim is denied, the decision can be appealed through several levels of administrative and judicial review. On average, the DDSs allow 37 percent of the claims they adjudicate through the five-step process. A third of those denied decide to appeal, and three-quarters of the appeals result in allowances. Nearly 30 percent of the allowances made each year are made during the appeals process after an initial denial.

In 2003, the Commissioner of Social Security announced her intent to develop a "new approach" to disability determination. In late 2004, SSA asked the Institute of Medicine (IOM) to help in two areas related to its initiatives to improve the disability decision process: 1) Improvements in the criteria for determining the severity of impairments, and 2) Improvements in the use of medical expertise in the disability decision process.

This interim report provides preliminary recommendations addressing the three tasks that relate to medical expertise issues, with a special focus on the appropriate qualifications of medical and psychological experts involved in disability decision making. After further information gathering and analyses of the effectiveness of the disability decision process in identifying those who qualify for benefits and those who do not, the committee may refine its recommendations concerning medical and psychological expertise in the final report. The final report will address a number of issues with potential implications for the qualifications of the medical experts involved in the disability decision process.

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