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



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 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

OCR for page R1
Improving the Social Security Disability Decision Process 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. 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 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 2007 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. Suggested citation: IOM (Institute of Medicine). 2007. Improving the Social Security disability decision process. Washington, DC: The National Academies Press.

OCR for page R1
Improving the Social Security Disability Decision Process “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 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 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

OCR for page R1
Improving the Social Security Disability Decision Process 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

OCR for page R1
Improving the Social Security Disability Decision Process 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

OCR for page R1
Improving the Social Security Disability Decision Process 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.

OCR for page R1
Improving the Social Security Disability Decision Process 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

OCR for page R1
Improving the Social Security Disability Decision Process 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

OCR for page R1
Improving the Social Security Disability Decision Process 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

OCR for page R1
Improving the Social Security Disability Decision Process This page intentionally left blank.

OCR for page R1
Improving the Social Security Disability Decision Process Contents     ABBREVIATIONS AND ACRONYMS   xvii     SUMMARY   1 1   INTRODUCTION   13      SSA’s Request to IOM,   15      References,   16 2   EVOLVING CONCEPTS OF DISABILITY   18      Conceptual Models of Disability,   19      Summary,   25      Conceptual Basis of the Listings,   26      References,   28 3   INDIVIDUALS WITH DISABILITIES   30      Information from Surveys on Individuals with Disabilities,   30      Social Security Disability Applicants,   38      References,   45 4   SSA’S DISABILITY PROGRAMS   47      Initial Disability Claims Process,   49      The Administrative Review (Appeal) Process,   50      The Disability Decision-Making Process,   51      Disability Decisions Outcomes and the Sequential Evaluation Process,   55

OCR for page R1
Improving the Social Security Disability Decision Process                 Problems with the Disability Decision Process,   57      Disability Service Improvement Plan,   62      References,   64 5   THE LISTING OF IMPAIRMENTS—OVERVIEW   66      Origins and Development of the Listings,   68      Evolution of the Listings,   73      References,   77 6   THE LISTING OF IMPAIRMENTS—ISSUES   78      The Listings as a Screening Tool,   79      Functioning in the Listings,   82      Listings Revision Process,   85      References,   87 7   FINDINGS AND RECOMMENDATIONS   89      Value and Utility of the Current Listings,   89      Conceptual Models for Organizing the Listings,   98      Revising the Listings to Be More Consistent and Up to Date,   100      Adaptability of the Listings,   105      Evaluating Multiple Impairments,   106      Integrating Functional Assessment in the Listings,   108      Research to Support the Listings,   110      References,   111     APPENDIXES     A   Biographical Sketches of Committee Members   113 B   Committee Charge   122 C   Interim Report, December 2005   125 D   Appendix Tables   239

OCR for page R1
Improving the Social Security Disability Decision Process 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

OCR for page R1
Improving the Social Security Disability Decision Process 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

OCR for page R1
Improving the Social Security Disability Decision Process 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

OCR for page R1
Improving the Social Security Disability Decision Process 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

OCR for page R1
Improving the Social Security Disability Decision Process 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

OCR for page R1
Improving the Social Security Disability Decision Process This page intentionally left blank.