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7 Findings and Recommendations
Pages 89-112

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From page 89...
... By relying heavily on diagnostic and clinical criteria in the Listings, SSA also ensures that disability decisions based on the Listings have a medical basis, as required by the law. By using identical and specific Listings criteria for all applicants, SSA provides equal treatment for all.
From page 90...
... The goal of the overall decision process is to distinguish individuals who meet the Social Security definition of disability from those who do not, so that the people who should be awarded benefits (i.e., true positives) are allowed benefits and people who should not receive benefits (i.e., false positives)
From page 91...
... . Because the political costs of denying benefits to applicants who meet the SSA disability standard are high, while the political and economic costs of awarding benefits to applicants who do not meet the standard are also high, SSA is willing to spend a substantial amount of time and resources to increase the sensitivity and specificity of the decision process.
From page 92...
... SSA should support research and perform analyses of its own program data to approximate a gold standard and better evaluate how well the Listings (and the entire decision process) work.
From page 93...
... Calibrating the Listings to a higher degree of impairment severity will tend to decrease the number of undesirable false positives -- but at the cost of also decreasing the desirable true positives. (SSA already does the latter to some extent by deliberately trying to set the Listings criteria to a severity level higher than the disability standard, i.e., inability to engage in any gainful activity, instead of inability to engage in any substantial gainful activity.)
From page 94...
... A decade ago, SSA asked the Institute of Medicine (IOM) to conduct an independent review of SSA's plans to redesign its disability decision process, a project that SSA had begun in 1994.
From page 95...
... 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.
From page 96...
... On the other hand, the QDD process picks cases to expedite using factors in addition to medical criteria and looks for quick denials as well as quick allowances, which may slow the adjudication of cases meeting the Listings. Ultimately, the correct rate at which allowances are made at the listings step has to be determined by carefully analyzing the actual outcomes of the disability determination process.
From page 97...
... . NOTE: Based on initial state agency determinations for SSDI-only and concurrent claims (excludes Supplemental Security Income [SSI]
From page 98...
... RECOMMENDATION 1. SSA should continue to use the current Listings as a screening test in its disability decision process, but should increase their value and utility by closely examining and monitoring their performance, conducting research to evaluate and improve their effectiveness in expediting awards in obvious cases, and making timely changes in response to these evaluations.
From page 99...
... With functional equivalence, SSA performs an overall functional assessment of the child using six broad domains.3 The domains are: acquiring and using information, attending and completing tests, interacting and relating with others, moving about and manipulating objects, caring for yourself, and health and physical well-being. Each domain is scored by an SSA pediatrician on a four-point scale: no limitation, less than marked, marked, or extreme.
From page 100...
... These are all helpful sources of input to the listing revision process. However, SSA does not appear to make full use of its extensive program data in revising the Listings.
From page 101...
... SSA provided the committee with an extensive amount of highly detailed program data that could be used to assess some aspects of the performance of the current Listings, and to identify circumstances in which new listings might be appropriate. For example, these data indicated that there are impairments that are very frequently found to be disabling, but for which no listings exist.
From page 102...
... These include changes in disease patterns, advances in scientific knowledge and medical practice, advances in assistive technologies, and changes in the workplace affecting workers in terms of job requirements and potential sources of injury. The most common devices that government agencies use to ensure that evidence-based regulations are kept current are: • feedback from the regulatory process • staff research • external advisory committees SSA has expanded regulatory feedback in recent years by sponsoring policy conferences and using advanced notices of proposed rulemaking (ANPRMs)
From page 103...
... . The use of medical advisory groups was stopped when the Federal Advisory Committee Act (FACA)
From page 104...
... RECOMMENDATION 5. SSA should re-establish a medical advisory committee under the Federal Advisory Committee Act to advise the com missioner on when scientifically based regulations, especially the Listings, should be revised to keep them up to date.
From page 105...
... [a] daptability of the listings, including methods to account for variable access to health care services (including diagnostics and pharmaceuticals)
From page 106...
... The fact that all applicants may not be able to document impairment severity this way does not make it any less valuable as a method to assess impairment severity in those who can, especially given that the Listings are only a screening tool to identify obvious allowances. Ideally, individuals applying for disability benefits would be evaluated and receive the medical, vocational rehabilitation, and employment services that would enable them to resume working gainfully.
From page 107...
... Despite the difficulty assessing medical severity of multiple impairments, it is possible that, given a sufficiently comprehensive study of common comorbidities (which might include, for example, putting a sample of cases through medical equivalency evaluations at step 3 and residual functional capacity evaluations at steps 4 and 5 and comparing the results) , some recurring patterns might occur showing frequently occurring combinations of impairments that could be described in listings that addresses those combinations.
From page 108...
... INTEGRATING FUNCTIONAL ASSESSMENT IN THE LISTINGS Task 7 Statement: ".
From page 109...
... The 2002 revision introduced a standardized approach to considering the functional consequences of musculoskeletal disorders, using two broad criteria, each representing the same degree of functional deficit -- "inability to ambulate effectively on a sustained basis for any reason" and "inability to perform fine and gross movements effectively on a sustained basis for any reason" -- as the ultimate criteria for meeting the Listings for disorders of the spine and joints, fractures of the extremities, amputation, and soft tissue injuries such as burns. As SSA noted in response to public comments expressing concern about these new functional criteria, the intent was to establish a clearer and more consistent functional standard that would "promote greater consistency in decision making."6 The question remains whether it is possible to identify valid functional Listings criteria that correlate highly with inability to work.
From page 110...
... SSA could also the test the effects on decision making of using functional assessment tools validated for use in particular conditions or body systems. Such testing would support the effort called for in Recommendation 9 to integrate function in the Listings to the extent functional assessments are found to be predictive of inability to engage in substantial gainful activity.
From page 111...
... This might be done by supplementing existing surveys. The results would be useful for program planning and for evaluating the effectiveness of the Listings and other aspects of the disability decision process.
From page 112...
... 1991. Determining disability due to mental impairment: APA's evaluation of Social Security Administration guidelines.


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