Improving the Social Security Disability Decision Process Interim Report (2006) / Chapter Skim
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Interim Report
Interim Report
Pages 15-64
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From page 15... ...
Claimants file applications through one of 1,300 SSA field offices, over the telephone, by mail, or on the Internet. Interviewers in the field offices apply the nonmedical eligibility criteria to determine insured status and ask claimants to provide supporting 15
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From page 16... ...
. Among the initiatives proposed in the NPRM was the establishment of a Federal Expert Unit that would set up and administer a national network of medical, psychological, and vocational experts to support the disability decision process at the initial decision point and subsequent levels of appeal.
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Second, SSA asked IOM to recommend ways to improve the use of medical expertise in the disability determination process, including the appeals process. Subsequently, in the July 2005 NPRM, SSA announced it is looking to the IOM for advice on the qualifications of the medical and psychological experts to be recruited for the national network.
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From page 18... ...
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. These include the extent of knowledge about differences in decision outcomes depending on the qualifications of decision makers; research on inter-rater reliability of decision criteria; comparisons of evaluations of samples of cases by different groups of SSA adjudicators or by adjudicators compared with outside medical experts; results of long-term followups of applicants who were allowed and denied; evaluations of alternative decision making models, such as the single decision maker model; studies of sources of variation in allowance rates among DDSs and Office of Hearings and Appeals hearing offices; and in-depth analyses of program statistics about the outcomes of applications for benefits at different levels of decision making.
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From page 19... ...
This national network may include experts employed by or under contract with the State agencies; however, all experts affiliated with the national network must meet qualifications prescribed by the Commissioner. The Federal Expert Unit will organize and maintain this network com prised of medical, psychological, and vocational experts who will provide medi cal, psychological, and vocational expertise to State agencies, reviewing officials, administrative law judges, and the Decision Review Board.
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(SSA, 2005b:Appendix C) .6 Variability in Disability Decisions As noted above, the initial disability allowance rate is approximately 37 percent.
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.7 Allowance rates at the ALJ hearing level also vary widely from state to state. In FY 2002, the overall hearing allowance rate was about 66 percent but, at the state level, the rate varied from 35 percent to 86 percent (SSAB, 2001b:70)
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From page 22... ...
. 400 350 Processing time in days 300 250 200 150 100 50 0 Initial decision Reconsideration ALJ hearing Appeals Council Decision level Figure 1 Processing time for disability claims in days, CY 2004 SOURCE: SSA, 2005a:17.
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Implications of Trends for the Interim Report The increasing caseload makes it desirable to make the disability decision process as efficient as possible. One way to increase efficiency would be to find ways to make the Listings a more effective screening tool at step 3 of the sequential decision process, which will be addressed in the second phase of the study and the final report.
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From page 24... ...
Nevertheless, the committee believes that several factors significantly limit SSA's ability to make the correct decision early in the process, and these factors contribute to error, inconsistency, and delay in decision making. The development of a full record at the beginning of the disability decision process and evaluation of the record by appropriate experts, including medical experts, may not be essential for an accurate initial disability decision in every case.
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Number of SSA hearings processed; 3. Average processing time for initial disability claims; 4.
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The committee will address the role of balanced incentive systems in improving the disability decision process in its final report. ORGANIZATION OF MEDICAL EXPERTISE Task 9: "Advise on how best to provide medical expertise needed to support the entire disability adjudication process.
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From page 27... ...
An applicant's own medical providers, called treating sources by SSA, are the primary source of medical evidence throughout the entire disability decision making process. By regulation, DDSs must seek medical evidence and opinions from treating sources and, unless there are inconsistencies or ambiguities, give their evidence controlling weight.
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. SSA staff also expressed concern about state-to-state variation in the mix of different areas of medical expertise.
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35% 30% Share of Medical Consultants 25% Share of Initial Claims 20% 15% 10% 5% 0% e y y y y try e y gy s y og cs in og og og og ic tic og ic lo ia tri ed ol ol ol ac ol ol ed ol ro ch ia ch at rin ch op nc di Pr eu ed M sy um sy ar sy oc O rth N ily P P al P C P nd he O rn m ld R E te Fa hi In C FIGURE 4 Comparison of MC specialty mix with initial case mix NOTE: Each MC is classified by one primary specialty. SOURCE: Appendix Table 3.
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From page 30... ...
These would be "close call" cases in which the claimant is on the boundary of "able to work" and "not able to work" or the medical evidence is complex and could be interpreted either way. Medical Experts In June 2005, the OHA regional offices had blanket purchase agreements with 1,575 MEs representing 1,861 specialties (some MEs were specialists in more than one field of medicine)
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From page 31... ...
Such a model should also be effective for disability determinations in SSA, and it is quite similar to the way DDSs currently operate in relying on generalist specialists to evaluate the less complicated cases. 14 See, for example, Anfield, 2002, for a description of UnumProvident's use of "the appropriate level of medical expertise" for each case.
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From page 32... ...
Additional specialist MCs, such as cardiologists, oncologists, endocrinologists, ophthalmologists, and rheumatologists, who would be appropriate for more complex cases, could be accessed through the national network if the DDS does not have an MC with the needed specialty. Nevertheless, it is vital that all SSA adjudicators have a full range of medical expertise available.
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From page 33... ...
. The FEU would create and maintain a national network of medical, psychological, and vocational experts15 who would be available to adjudicators through the entire disability decision process, including DEs in DDSs and the administrative judges in OHA.16 These experts would be recruited and paid by SSA at rates to be established by the Commissioner.17 The Commissioner evidently intends to recruit members of the national network of experts from practitioners in private practice, who would agree to review medical evidence in case files and either consult to MCs in the DDS and ALJs in OHA or participate as an MC in the disability determination decision, depending on the case.
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Members of the national network would clearly serve as consultants when acting as expert witnesses at ALJ hearings or reviewing medical records in cases before the Appeals Council (or before reviewing officials and the Decision Review Board, if they are implemented as proposed in the NPRM)
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. Establishing a national network of experts who would play different roles at different points in the process (e.g., acting as agency adjudicators in initial decisions and providing expert opinions to ALJs in de novo proceedings)
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From page 36... ...
(See "Training of Medical Consultants," below, for additional discussion on this topic.) Currently, DDSs rely on state licensure or, in the case of psychologists and speech-language pathologists, certain alternative qualification requirements, to ensure a minimum level of medical expertise and competence.
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From page 37... ...
This will necessitate an increase in compensation in order to recruit and retain qualified physicians and psychologists as MCs and MEs or as members of the national network of experts, if it is established. SSA also should allow current MCs with qualified program experience who are not board certified to continue for a time period of five years.
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From page 38... ...
The committee recognizes that implementing a board certification requirement will pose practical problems but believes that it should be the standard for medical experts in SSA's disability decision process. In discussions with the committee, SSA staff also raised the issue of whether there should be a requirement that program physicians, psychologists, and others be currently (or recently)
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From page 39... ...
Currently, few if any DDSs make use of the wide range of medical expertise available beyond the currently acceptable medical sources that could both expedite case processing and improve the quality of the initial decisions. 24 Talmadge, 2003, discusses the contributions of physical therapists, occupational therapists, occupational nurses, and other disciplines make to the disability evaluation process.
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From page 40... ...
Expanding the range of expertise available in case adjudication would help DDSs implement the proposed "quick disability determination process" and make it more effective. The DDSs could triage cases more extensively, identifying not only the easy cases that can be expedited by the quick decision process, but also the hard cases that need more focused attention.
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From page 41... ...
SSA should consider developing demonstration projects with academic clinical research centers that focus on conditions that are difficult to evaluate. Academic research centers focus on improving diagnosis and treatment and few medical experts in them will be familiar with the SSA disability program or with evaluating the work capacities and limitations of patients.
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From page 42... ...
Involvement of Treating Physicians and Other Treating Sources Treating sources are an important component of SSA's disability decision process. Under its rules, SSA develops evidence from a claimant's own medical sources before evaluating evidence obtained on a consultative basis.
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Nevertheless, reliance on treating sources has limitations. Treating sources may unduly promote the interests of their patients, and SSA disability decision makers must take this into account in evaluating their opinions.
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For example, reimbursement for providing medical records is about $20. As will be discussed in the section on consultative examinations, below, reimbursement for performing a disability examination is also low, especially compared with comparable examinations performed for workers' compensation and for private disability insurance carriers.27 Qualifications of OHA Medical Experts At the hearing level of the disability claim process, ALJs are solely responsible for making the disability decision, including all medical, functional, and vocational aspects.
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who could support the disability decision-making process by providing expert assessment of impairment se
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Although the committee has recommended additional training for DDS MCs in disability evaluation and program requirements, it does not see a similar need for MEs, given that they are not directly involved in adjudication. If the national network proposed in the NPRM is established and network experts become the pool for MEs, then MEs will receive MC training, as called for in Recommendation 1-3.
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From page 47... ...
The committee was told that few CEs are purchased from sources who are not acceptable medical sources, which SSA refers to as "other sources," although these other sources are often in a better position to provide evidence about how well their patients function than are treating physicians who may see the patients infrequently (Talmadge, 2003)
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From page 48... ...
. The guide, which is available online as well as on paper, provides general information about the Social Security disability programs and how claims are adjudicated, including the role of CEs, how CE providers are selected, and what the DDSs look for in a report of a CE.
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From page 49... ...
Licensure and board certification do not necessarily ensure, however, that CE providers are expert in evaluating how a person's impairments limits their functioning in employment settings or that they know how to provide medical evidence in a form pertinent to evaluating whether someone meets Social Security's definition of disability. Physicians, with the exception of those trained in occupational medicine, usually do not learn how to evaluate work disability during medical school or residency or for board certification (Scheer, 2000:121)
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From page 50... ...
An additional option would be to use members of the national network of medical and psychological experts to supplement the pool of CEs, assuming that there are enough experts to accommodate this as well as advise DDS and OHA decision makers. The advantage of using national network experts is that they will have mastered the curriculum for MCs, which will focus on disability evaluation and on SSA program rules and practices (see Recommendation 1-3, above)
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From page 51... ...
An adequate CE examination should include the following:33 • Review of the claimant's medical records; • Taking of a medical history; • Examination of the patient, including the administration of any needed tests; • Interpretation of test results; • Preparation of a report detailing findings from the history, examination, and tests; • Diagnosis and prognosis; and • Medical source statement. A medical source statement is the CE provider's opinion of the claimant's ability to do work-related activities, such as sitting, standing, walking, lifting, carrying, handling objects, hearing, speaking, and traveling.
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From page 52... ...
Alternatively, SSA could use CPT codes 99455 and 99456, which are for "workrelated or medical disability evaluation services." Medicare does not use these services and therefore has not assigned a relative value to them, but the federal Office of Workers' Compensation Programs (OWCP) has assigned them RVUs of 6.96 and 9.16, respectively.36 This would mean fees up to $264 and $347, respectively, using the Medicare conversion factor, and up to $352 and $463 using the OWCP conversion factor.37 These fees are paid to treating physicians for an examination at the time of maximum medical 34 A recent study found that the relative value units (RVUs)
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From page 53... ...
Focused Requests for CEs Based on What Is Needed in Each Case Improving the quality of CEs depends not only on the skill and knowledge of the CE providers but also on whether they have been asked for the right information. DEs, in consultation with MCs, if needed, are supposed to develop a complete medical history for at least the preceding 12 months; evaluate the medical evidence to identify missing, inconsistent, or ambiguous information; and, if the treating physician does not supply the missing information or clarify inconsistencies and ambiguities, purchase a CE to obtain the information.
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From page 54... ...
eligibility requirements. SSA field offices are authorized only to make presumptive disability determinations for certain specified impairments.
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. Looking at field offices as a group, half of all presumptive disability decisions were in the two low-birth-weight categories (categories 9 and 11 in Table 1, Column 2)
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From page 56... ...
. Ultimately, 10.3 percent of the field office presumptive disability cases were not allowed at the initial decision level after going through the regular disability determination process (Table 1, column 3)
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40 Appendix Table 6 lists all 47 impairment codes for presumptive disability decisions that had reversal rates less than 5 percent in CY 2004.
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Although the number of presumptive disability decisions more than doubled, the overall rate of reversals fell from 13 percent to 9 percent. DDSs lowered their reversal rate from 12 percent to 9 percent and the field offices from 17 percent to 10 percent.
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From page 59... ...
At the end of 2003, the average SSI benefit for the blind and disabled under age 65 was $446.97. Taking this as the average cost of a presumptive disability decision and assuming that reversed presumptive disability cases were paid for the full 6 months, or $2,681.80 each, moving the reversal bar from 10 percent to 15 percent (thus adding 679 presumptive disability cases)
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From page 60... ...
However, the result of the current system is that claimants with the same condition may be treated differently, depending on if they do or do not have sufficient medical evidence or an established diagnosis. And as we have discussed above, it will result in claimants with an equally severe but not explicitly categorized presumptive disability impairment being ineligible for presumptive disability status, if their impairment cannot be easily observed or verified.
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From page 61... ...
In two states, however, field offices used only one of the 15 categories, accounting for two cases each. Some categories with high allowance rates overall (i.e., highly likely to be allowed)
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From page 62... ...
SSA should look at TERI procedures for les sons in making expedited decisions on cases that must meet specific medical criteria. These include uniform special procedures through out the decision process that promote consistency as well as speed.
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From page 63... ...
It also makes recommendations for improving the implementation of the presumptive disability policy. The committee is addressing other seven tasks in its next, and final, report, which is due in 2006.
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