Cover Image

Not for Sale



View/Hide Left Panel

Improving the Social Security Disability Decision Process

Interim Report

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

Medical Follow-up Agency

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES
Washington, D.C.
www.nap.edu



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page R1
Improving the Social Security Disability Decision Process: Interim Report Improving the Social Security Disability Decision Process Interim Report Committee on Improving the Disability Decision Process: SSA’s Listing of Impairments and Agency Access to Medical Expertise Medical Follow-up Agency INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES Washington, D.C. www.nap.edu

OCR for page R1
Improving the Social Security Disability Decision Process: Interim Report THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 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. SS00–04–60083 between the National Academy of Sciences and 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. ISBN 0-309-10094-1 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624–6242 or (202) 334–3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. 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.

OCR for page R1
Improving the Social Security Disability Decision Process: Interim Report “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.

OCR for page R1
Improving the Social Security Disability Decision Process: Interim Report 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

OCR for page R1
Improving the Social Security Disability Decision Process: Interim Report 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 Medical Center, Chicago, IL RICHARD V.BURKHAUSER, Professor and Chairman, Department of Policy Analysis and Management, Cornell University, Ithaca, NY DIANA D.CARDENAS, Professor and Chief, Department of Rehabilitation Medicine, University of Washington Medical Center, Seattle, WA SHEILA T.FITZGERALD, Associate Professor, Division of Occupational Health, School of Hygiene and Public Health, Johns Hopkins University School of Nursing, Baltimore, MD ARTHUR GARSON, Dean, School of Medicine, Vice President, University of Virginia, Charlottesville, VA KRISTOFER J.HAGGLUND, Associate Dean for Health Policy and Professor of Health Psychology, School of Health Professions, University of Missouri, Columbia, MO ALLEN W.HEINEMANN, Professor, Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Director, Center for Rehabilitation Outcomes Research, Rehabilitation Institute of Chicago RONALD LEOPOLD, Vice President, MetLife, Alpharetta, GA LARRY G.MASSANARI, Exton, PA STEPHEN G.PAUKER, Professor, Tufts University School of Medicine, Vice Chairman for Clinical Affairs, Department of Medicine, Associate Physician-In-Chief, Tufts-New England Medical Center, Boston, MA LINDA A.RANDOLPH, President and CEO, DC Developing Families Center, Washington, DC BRIAN M.SCHULMAN, Private Practice in Occupational Psychiatry, Bethesda, MD PETER W.THOMAS, Principal, Powers Pyles Sutter & Verville, PC, Washington, DC CRAIG A.VELOZO, Research Health Scientist, Rehabilitation Outcomes Research Center, North Florida/South Georgia Veterans Health System, 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, Gainesville, FL Project Staff MICHAEL McGEARY, Study Director MORGAN FORD, Program Officer SUSAN 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

OCR for page R1
Improving the Social Security Disability Decision Process: Interim Report 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 NRC’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: Veronica D.Feeg, George Mason University School of Nursing, Fairfax, VA Claude Earl Fox, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD Linda P.Fried, Johns Hopkins University Center on Aging and Health, Baltimore, MD Patricia M.Owens, Consultation in Health & Disability Programs, Brooklyn, NY James M.Perrin, Massachusetts General Hospital, Boston, MA Harold A.Pincus, University of Pittsburgh Medical Center, Pittsburgh, PA Glenn S.Pransky, Liberty Mutual Research Institute for Safety, Hopkinton, MA Stephen T.Wegener, Johns Hopkins University School of Medicine, Baltimore, MD 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, Harvard University, and Lee Goldman, University of California, San Francisco. 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.

OCR for page R1
Improving the Social Security Disability Decision Process: Interim Report Preface The Institute of Medicine (IOM) Committee on Improving the Disability Decision Process has been working since it first met in January 2005 to develop recommendations to the Social Security Administration (SSA) on how to improve the medical aspects of its disability determination process. By law, Social Security can only pay benefits to those unable to engage in substantial gainful activity because of a “medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months (emphasis added).” Medical and psychological expertise is critical both in developing the criteria for measuring the severity and functional impact of an impairment or impairments on an applicant’s ability to work and in applying the criteria to individual cases where the medical evidence does not clearly meet the criteria in the eyes of a nonmedical disability examiner. The committee’s final report is due in 2006, but SSA asked the committee to focus first on the expertise issues and provide early recommendations on the qualifications of the medical and psychological experts involved in the disability decision process in a short interim report. SSA is currently in the process of revamping its disability decision process and, according to a Notice of Proposed Rulemaking published in the Federal Register in July 2005, plans to establish a national network of medical and psychological experts who meet qualification standards set by the Commissioner of Social Security. The NPRM did not specify the qualification standards but noted that they would be promulgated within six months of the effective date of the final rule and that the Commissioner would consider the advice of the IOM in setting the standards. The committee is continuing to address the remaining tasks in its charge, which focus on the medical criteria for assessing if an applicant qualifies for disability benefits. In this phase of the study, the committee is assessing the overall effectiveness of the Listing of Impairments (Listings) in the disability decision process, especially the use of the Listings as a screening tool for determining disability based on medical

OCR for page R1
Improving the Social Security Disability Decision Process: Interim Report considerations alone. The committee’s findings and recommendations concerning the screening criteria may have further implications for the expertise needed to apply the medical criteria. If so, the committee may have further recommendations about medical expertise in the final report. In developing this interim report, the committee received input from many sources, in the form of presentations at meetings and written statements submitted for the record. Many others responded to requests for information from the committee staff. On behalf of the committee, I would like to thank those who provided information. At the fist meeting on January 31-February 1, 2005, these included directors of three state Disability Determination Services (DDS) agencies—Andrew Marioni, Jr. (Delaware DDS); Tommy Warren (Alabama DDS); and Walter Roers (Minnesota DDS)—and four judges from the SSA Office of Hearings and Appeals—David B.Washington, Chief Administrative Law Judge (ALJ); Nancy Griswold, Chief ALJ, Region I, Boston; William Taylor, Executive Director, Office of Appellate Operations; and Robert Johnson, Appeals Council. For the second meeting, in April 2005, the committee notified more than 100 organizations of the opportunity to make presentations or provide written statements at the meeting. The public forum part of the meeting was held in the Barbara Jordan Conference Center of the Kaiser Family Foundation, a very accessible facility provided for free by the Foundation. Presenters at the public forum were Eileen Sweeney, Center on Budget and Policy Priorities; Marty Ford, Disability Policy Collaboration of The Arc and United Cerebral Palsy; Ethel Zelenske, National Organization of Social Security Claimants’ Representatives; Andrew Marioni, Jr., National Council of Disability Determination Directors, and Director, Delaware Disability Determination Services; David Randolph, American Academy of Disability Evaluating Physicians; and James McCarthy, National Federation of the Blind. The National Association of Disability Examiners submitted a written statement. At the second meeting, the committee also heard from panels of experts on training and certification requirements that might improve the level of medical expertise in the disability decision process. The panelists and their organizations were Robert Robertson, Shelia Drake, Beverly Crawford and Carol Dawn Petersen, Government Accountability Office; John Pro, American Board of Independent Medical Examiners; Douglas Martin, American Academy of Disability Evaluation Physicians; Steve Geiringer, Wayne State University and American Academy of Physical Medicine and Rehabilitation; Elizabeth Genovese, American College of Occupational and Environmental Medicine; Sandra Hall, American Association of Occupational Health Nurses; Joanne Ebert, Association of Rehabilitation Nurses; Michael Borek, Medical Director, Delaware DDS; Joseph Aaron, Chief Medical Officer, New Jersey DDS; William Humphreys, former medical consultant, Virginia DDS; Barry Eigen, Office of Disability and Income Security Programs; Monte Hetland, Pediatric Medical Officer, Office of Medical Policy, SSA; George Jesien and Rhoda Schulzinger, Association of University Centers on Disabilities; Howard Goldman, University of Maryland School of Medicine; and Thomas Yates, Health and Disability Advocates, Chicago. At its fourth and fifth meetings in August and October 2005, the committee heard from Christine Hartel, National Research Council (NRC); Susan Van Hemel, NRC; Kristin Johnson, Charles Sweet, and Katherine Edwards, Disability Evaluation Services, University of Massachusetts Medical School; Jo Anne Barnhart, Commissioner of Social

OCR for page R1
Improving the Social Security Disability Decision Process: Interim Report Security; Patricia Owens, Consultation in Health and Disability Programs, Brooklyn, NY; and Ethan Balk, AHRQ Evidence-based Practice Center, Tufts-New England Medical Center. I would like to thank the officials of the Social Security Administration who not only requested the study, made presentations and answered questions at committee meetings, and met with committee staff, but also contributed information, documents, and statistics and made available the directors and medical directors of state Disability Determination Services agencies and administrative law judges in the Office of Hearings and Appeals who met with the committee (listed above). These officials are Jo Anne B. Barnhart, Commissioner of Social Security, who met with the committee on October 6, 2005, to describe her plans for improving the disability decision process and answer questions from committee members; Martin H.Gerry, Deputy Commissioner for Disability and Income Security Programs; Glenn Sklar, Associate Commissioner for Disability Programs; Pamela Mazerski, Associate Commissioner for Program Development and Research; and Nancy Schoenberg, Office of Disability Programs, the project officer for this study who greatly facilitated responses to the committee’s requests for information. The staff would like to thank the following for providing information or other assistance: Bob L.Appleton, Office of Disability Programs, SSA; Barbara Barzansky, American Medical Association; Kathleen M.Bernett, American Board of Independent Medical Examiners; Howard Bradley, Office of Research, Evaluation and Statistics, Social Security Administration (SSA); Shari Bratt, National Association of Disability Examiners (NADE); Dean M.Burgess, American Association of Occupational Health Nurses; Shanklin Cannon, Northwestern Mutual; Lenore Carlson, Office of Disability Determinations, SSA; Winthrop S.Cashdollar, America’s Health Insurance Plans; Joanne Castello, Office of Disability Programs, SSA; Thomas Charest, Jefferson Pilot Financial; Mary Chatel, Office of the Commissioner, SSA; Carol G.Cook, U.S. Office of Personnel Management; Deborah A.Cotter, American Psychological Association; Ann R.Cox, American Association of Occupational Health Nurses; Beverly Crawford, Government Accountability Office (GAO); Susan David, Office of Disability Programs, SSA; Laurence Desi, Office of Medical Policy, SSA; Anne Deutsch, Northwestern University; Terry Dodson, Office of Disability Programs, SSA; Shelia Drake, GAO; Dan Dougherty, Prudential Disability Management Services; Barry Eigen, Office of Disability Programs, SSA; Barry Eisenberg, Academy of Occupational and Environmental Medicine; Judith Feder, Georgetown University; Angela Foehl, American Psychiatric Association; Claire Green, Office of Hearings and Appeals (OHA), SSA; David Hatfield, OHA, SSA; Michael Heitz, OHA, SSA; Monte Hetland, Office of Medical Policy, SSA; Jay Himmelstein, University of Massachusetts Medical School; Deena Howell, Florida Retirement System; Sunmee Jo, OHA, SSA; Carol Jones, Office of Disability Programs, SSA; Patricia Jonas, Assistant Deputy Commissioner for Disability and Income Security Programs, SSA; Jim Julian, Office of Medical Policy, SSA; Karen Kadell, Minnesota State Retirement System; Cille Kennedy, Department of Health and Human Services; Theresa Klubertanz, NADE; Joseph LaDou, University of California Medical School-San Francisco; Susanne Lapierre, Liberty Mutual; Joni Lavery, National Academy of Social Insurance (NASI); Barry S.Levy, Tufts University; Cathy Lively, Office of Medical Policy, SSA; Jeffrey S.Lubbers, Washington College of Law, American University;

OCR for page R1
Improving the Social Security Disability Decision Process: Interim Report Margaret Malone, Office of the Commissioner, SSA; Martha Marshall, NADE; Kathleen H.McGinley, National Association of Protection and Advocacy Systems; Paul Martin, Aetna Insurance Company; Jill F.Mocarski, Northwestern Mutual; Mark Nadel, Georgetown University; William E.Narrow, American Psychiatric Institute for Research and Education; Dorothy Nettles, Office of Disability Determinations; Paul Newacheck, University of California-San Francisco; Barbara Otto, Health & Disability Advocates, Chicago; Georgann Ozanich, Minnesota State Retirement System; Diane M.Pedulla, American Psychological Association; Carol Dawn Petersen, GAO; Clark Pickett, Office of Research, Evaluation and Statistics, SSA; Marquita Rand, Office of Medical Policy, SSA; Virginia Reno, NASI; Robert Rich, University of Illinois at Urbana-Champaign; Robert E.Robertson, GAO; John M.Rogers, The Hartford Life Insurance Companies; Gloria Barone Rosanio, CIGNA Disability Management Solutions; Jane Ross, National Research Council (NRC); Vince Sabatino, Office of Program Development and Research, SSA; Sandra Z.Salan, Office of Medical Policy, SSA; Stephen Schmidt, Office of Workers’ Compensation Programs, U.S. Department of Labor; Frank Schuster, Office of Medical Policy, SSA; Art Spencer, Office of Disability Programs, SSA; Steven Sperka, Northwestern Mutual Life; Kaye Sullivan-McDevitt, UnumProvident Portland Disability Benefits Center; Lauren Swanson, CIGNA Disability Management Solutions; Patricia Thomas, MetLife Disability; Tiana Tozer, The Standard; Michael Weinrich, National Center for Medical Rehabilitation Research, National Institutes of Health; Mimi Wirtanen, NADE; Gooloo Wunderlich, NRC; Sandra Yost, American Academy of Disability Evaluating Physicians; and Barry Zevin, Tom Waddell Health Center, San Francisco Department of Public Health. Finally, I would like to thank the staff members who have worked hard to help the committee organize its meetings and produce this interim report on a compressed time schedule. They are Michael McGeary, Study Director; Rick Erdtmann, Director, Medical Follow-up Agency; Morgan Ford, Program Officer (since October 2005); Susan McCutchen, Research Associate; Reine Homawoo, Senior Program Assistant; and David K.Barnes, Consultant. John D.Stobo, M.D. Chair

OCR for page R1
Improving the Social Security Disability Decision Process: Interim Report Contents     Summary of Recommendations   1     Introduction   15      Overview of Social Security Disability Programs,   15      IOM Study Charge,   17      IOM Committee,   17      Interim Committee Report,   18      SSA’s Proposed Disability Decision Process Changes,   18      Trends in the Disability Decision Process   20      Program Growth,   20      Variability in Disability Decisions,   20      Appeals and Allowances on Appeal,   21      Decision Timeliness,   22      Implications of Trends for the Interim Report,   23      Constraints on the Disability Decision Process   24      Organization of Medical Expertise   26      Medical Expertise and the Disability Adjudication Process,   26      Specialization of Medical Consultants and Experts,   28      Qualifications of Medical Consultants,   35      Training of Medical Consultants,   38      Better Use of Medical Expertise,   39      Other Sources of Medical Expertise,   41      Involvement of Treating Physicians and Other Treating Sources,   42      Qualifications of OHA Medical Experts,   44      Training and Certification of Consultative Examiners   46      Training and Certification Requirements for Consultative Examiners,   47      Adequate Reimbursement of CE Providers,   51      Focused Requests for CEs Based on What is Needed in Each Case,   53

OCR for page R1
Improving the Social Security Disability Decision Process: Interim Report      Presumptive Disability Categories   54      Revising the Presumptive Disability Categories with Explicit Criteria,   58      Increasing Consistency in Use of Presumptive Disability,   61      Learning from Terminal Illness (TERI) Procedures,   62      Afterword   63     References   65 Appendix.   List of Committee Tasks   69     Appendix Tables   71

OCR for page R1
Improving the Social Security Disability Decision Process: Interim Report Figures and Tables FIGURES 1   Processing time for disability claims in days, CY 2004,   22 2   Percentage of allowed claims by decision level, CY 2004,   23 3   Medical consultants by specialty, June 2004,   29 4   Comparison of MC specialty mix with initial case mix,   29 5   Medical experts by specialty, June 2005,   30 6   Number of different medical expert specialties, by region, June 2005,   31 TABLES 1   Field Office Presumptive Disability Decisions, by Presumptive Disability Category, CY 2004,   56 2   DDS Presumptive Disability Decisions, by Impairment Code, CY 2004,   57 3   Approximate Costs of Presumptive Disability Cases Ultimately Disallowed, CY 2004 Data,   59 4   Approximate Costs of Adopting Different Allowance Rates to Determine Presumptive Disability Cases, CY 2004 Data,   60 5   Field Office Use of Presumptive Disability Categories for High-Allowance-Rate Impairments, CY 2004,   61

OCR for page R1
Improving the Social Security Disability Decision Process: Interim Report APPENDIX TABLES 1   DDS Medical Consultants by Specialty, June 2004,   71 2   Number of DDS Medical Consultants by Specialty and State, June 2004,   72 3   Case Mix Compared with Mix of Medical Consultant Specialties,   75 4   Number of Medical Experts by Specialty, June 2005,   76 5   Number of Medical Experts by Specialty and Federal Region, June 2005,   77 6   Impairment Codes of DDS Presumptive Disability Decisions with a Reversal Rate of Less Than 5 percent, CY 2004,   78 7   SSA Impairment Codes by Allowance Rate, from Highest to Lowest, CY 2004,   80

OCR for page R1
Improving the Social Security Disability Decision Process: Interim Report Abbreviations and Acronyms AAMRO American Association of Medical Review Officers ABMS American Board of Medical Specialties ABPP American Board of Professional Psychologists ACUS Administrative Conference of the United States AHC academic health center ALJ administrative law judge ALS amyotrophic lateral sclerosis AMA American Medical Association AME aviation medical examiners AUCD Association of University Centers on Disabilities CE consultative examination CFR Code of Federal Regulations CME continuing medical education COPD chronic obstructive pulmonary disease CPP/OAS Canada Pension Plan/Old Age Security CPT Current Procedural Terminology, AMA CY calendar year DDS Disability Determination Services DE disability examiner DHHS U.S. Department of Health and Human Services DOL U.S. Department of Labor DOT U.S. Department of Transportation Ed. Edition eDib electronic disability process ESRD end stage renal disease

OCR for page R1
Improving the Social Security Disability Decision Process: Interim Report FAA Federal Aviation Administration FEU Federal Expert Unit FY fiscal year GAO Government Accountability Office HIV human immunodeficiency virus IME independent medical examination IOM Institute of Medicine MC medical consultant M.D. doctor of medicine ME medical expert MRO medical review officers NIH National Institutes of Health NIOSH National Institute for Occupational Safety and Health NPRM Notice of Proposed Rulemaking OHA Office of Hearings and Appeals, SSA OWCP Office of Workers’ Compensation Programs, DOL PD presumptive disability PER pre-effectuation review Ph.D. doctor of philosophy POMS DI Program Operations Manual System—Disability Insurance, SSA Psy.D. doctor of psychology QA quality assurance QME Qualified Medical Examiner RVU relative value unit SDM single decision maker SSA Social Security Administration SSAB Social Security Advisory Board SSDI Social Security Disability Insurance SSI Supplemental Security Income TERI terminal illness U.S. United States VA Department of Veterans Affairs