The Dynamics of Disability Measuring and Monitoring Disability for Social Security Programs (2002) / Chapter Skim
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6. Improving the Disability Decision Process
6. Improving the Disability Decision Process
Pages 113-139
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From page 113... ...
, and the subsequent decision by SSA to terminate this redesign effort and explore ways to incrementally improve the current process. The chapter then discusses and makes recommendations on the research needed to bring about fundamental improvements in the current disability decision process.
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From page 114... ...
Finally the disability decision process requires a means for comparing those capacities with He capacities demanded by work roles in all jobs in the national economy that provide substantial gainful activity (SGA) earnings level.
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From page 115... ...
~ 4. in the fourth decision step, clannants who have impairments that are severe, but not severe enough to meet or equal those in the Listings, are evaluated to determine if the person has residual functional capacity to perform past relevant work.
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From page 116... ...
The new disability decision process, as envisioned by SSA, would assess a person's functional ability once, relying on objective, standardized, functional assessment instruments. SSA believed that focusing decisions on the functional consequences of a person's medical impairments would permit physicians and others who provide medical evidence, as well as decision makers, to use a consistent frame of reference for determiIiing disability, regardless of the diagnosis and would facilitate evidence collection by reducing the need for developing extensive medical records (SSA, 1994a)
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From page 117... ...
on . functional assessment instruments; · occupational classification systems; · disability determination processes used in other disability programs in the United States and other countries; and · the effects of age, education, and work experience (vocational factors)
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From page 118... ...
other work / \ / \ \~es ( Denial ) no / \ yes FIGURE 6-1 The Social Security Administration's current and proposed redesigned disability decision process.
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From page 119... ...
In summary, SSA's research plan aimed at developing and testing the functional assessment instruments in the disability decision process, examining the effect of vocational factors on decisions, exploring what is being done in other disability programs, and developing a prototype for a revised disability decision process. Committee's Review of the Research Plan Early in the study, the committee conducted a preliminary review of SSA's workplan and individual research projects completed and under way.
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From page 120... ...
The committee commended SSA for initiating the major task of redesigriing to improve the disability decision process and undertaking a range of research activities related to the functional consequences of medical impairments and for recogruzing the need to assess the feasibility, validity, and reliability of a proposed redesigned decision process. Nevertheless, the committee concluded in its second interim report (IOM, 1998)
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From page 121... ...
Field evaluation · Laboratory research and pilot studies and demonstrations · Field tests · Focus groups · Process engineering assessments · National surveys 3. Will the proposed Program evaluation · Clinical trials disability decision and transition to · Simulation process be workable, implementation · Evaluation studies of the and will it alleviate proposed decision process using the problems?
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From page 122... ...
This review relates directly to one of the key elements in the proposed redesigned disability decision process, namely, assessing baseline work. The purpose of the review is to determine if a standard exists, and if not, whether it is feasible to develop one to describe basic physical and mental demands of a baseline of work.
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From page 123... ...
, SSA undertook an internal reevaluation of its disability decision process redesign irutiatives. SSA concurred with several of the committee's conclusions and some of the recommendations.
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Updating the Listings SSA states that although it is no longer focusing on development of the new decision process described in the disability redesign plan, it is continuing to explore the potential in some of those ideas. However, it is now devoting most of its resources to needed improvements to the current evaluation process (SSA, l999b)
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From page 125... ...
Several of the key issues that the committee had identified earlier in the study in the context of the problems associated win SSA's research plan for redesigning the disability decision process still have to be addressed with respect to the activities undertaken to improve the current process. Therefore, they bear emphasizing again in this report.
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From page 126... ...
It presumes analysis of baseline information from the current decision process to assess the effectiveness of the current decision process and compare it with similar analysis of changes in the new decision process. However, based on the information provided by SSA, the committee assumes that the agency has not conducted such baseline analysis with predetermined criteria for evaluating the components of the sequential disability decision process leading to the decision to redesign.
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From page 127... ...
Throughout the documents reviewed by the committee relating to the redesign research, including the scope of work for the research contracts and in presentations before the committee, SSA has recognized the need to test the new disability decision process by applying standards of validity, reliability, sensitivity, specificity, credibility, and flexibility. In addition, the stated objectives of the redesign also include requirements such as simplicity in administration, consistency, accuracy, timeliness, equity of decisions at all levels, and fairness.
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From page 128... ...
For example, although the word "disability" is used by SSA, the actual phenomenon focuses on an attribute more narrowly defined than the inability to perform the usual activities of daily living. It refers to the inability to engage in substantial gainful activity because of a medically determinable physical or mental impairment leading to death or expected to last for at least 12 continuous months.
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From page 129... ...
Many of the Listings have since evolved into complex and highly detailed diagnostic requirements, demanding specialized medical evidence that may not be readily available from treating sources. Some, but not all, of the Listings consider the functional consequences of an impairment; however functional considerations vary significantly among the Listings" (SSA, 1994a, p.
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From page 130... ...
As SSA moves forward to incrementally revise and reform the current decision process, it must be able to determine whether or not changes are improving the accuracy of the process. Indeed, it has to be able to make these determinations prior to the time that changes are implemented on a national basis.
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From page 131... ...
to undertake research for developing a process of validation of the Listings in order to assess them and to ensure that changes made actually result in improvements in the disability decisions. This research will (1)
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From page 132... ...
First, it operates an ongoing program that requires continuous incremental adjustment in order to make appropriate decisions. Second, the environment of disability decision making is constantly shifting in ways that have unanticipated consequences for the current process and that generate movements for substantial reorientation of the entire disability benefit programs.
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From page 133... ...
Clearly, a great deal more careful research and experimentation is required to evaluate what functional capacity to work really means and exactly how it would be applied to persons with disabilities. When the committee reviewed SSA's redesign research plan, there were no indications in the plan that the gaps in OWNED will be carefully considered and no specific research to fill those gaps was identified.
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From page 134... ...
NET's descriptor data may not be as precise as they seem, resulting in measurement errors as well as improper interpretation of the severity of claimants' impairments (AIR, 2000~. Without an appropriate characterization of job requirements that can be matched to the vocational characteristics of disability claimants, SSA might be cast back into the era in which it relied extensively on the testimony of "vocational experts,/' or their written evaluations, as the way to integrate claimants' functional capacities, vocational factors, and the demands of work into an objective determination of their capacity to engage in substantial gainful employment.
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From page 135... ...
As part of the initiative to redesign the decision process, SSA included in its research plan the evaluation of the effect of vocational factors age, education, and work experience on the ability to work or adapt to work in the presence of functional impairment. To assist in deciding an appropriate way to incorporate into the redesigned disability decision process the specific statutory requirement to consider an individual's vocational factors in deterrrurung ability to work, SSA entered into a reimbursable agreement with the Federal Research Division of the Library of Congress to review and evaluate published literature and any other research pertaining to the subject.
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From page 136... ...
Existing knowledge concerning vocational factors and their impact on the ability to perform jobs in the national economy raises challenging questions about the continuing validity of the approach taken by SSA's existing grid rules. It suggested a critical need for a program of research designed to validate or reform the use of vocational factors in SSA's disability decision process.
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From page 137... ...
ALTERNATIVE APPROACHES TO THE CURRENT DECISION PROCESS The objectives of the current disability decision process appear to be an attempt to make accurate decisions about the capacity to engage in substantial gainful employment consistent with the statutory definition of disability as consistently, expeditiously, and cost-effectively as possible within a system that is hierarchically accountable and makes determinations at a relatively low cost. Mashaw (1983)
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From page 138... ...
Workers' compensation and unemployment compensation systems provide other examples of adversary models of benefits adjudication. Another, radically different approach would conceive of disability benefits designed to assist claimants in receiving appropriate medical attention and vocational rehabilitation as well as appropriate income supports.
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From page 139... ...
thy IMPROVING THE DISABILITY DECISION PROCESS 139 In conclusion, although SSA has deferred a major redesign of the disability decision process, the committee believes that it is paramount that the determination of disability not only be timely, understandable, straightforward, and feasible, but also provide accurate and consistent decisions that are fair to the claimant and to the government. To this end the committee believes Mat SSA should undertake a systematic, longterm program of research intramural and extramural- Mat provides baseline information on all key aspects of the current disability decision process and subsequent evaluative data on all future change aimed at improving the effectiveness and efficiency of the work disability determination process currently in use in the United States.
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