Executive Summary

In 2010, more than 3.3 million individuals are expected to apply to the Social Security Administration (SSA) for disability benefits. SSA uses a five-step evaluation process to determine disability. This sequential decision process is both time and resource intensive, because determining whether applicants (referred to as claimants in this report) qualify for benefits is a complex process.

To streamline the process, SSA uses a screening tool called the Listing of Impairments (known as the Listings) to identify claimants who are the most severely impaired, that is, disabled to such a degree that they do not need to go through the full sequential decision process. These individuals, if evidence in their medical records indicates that they cannot work or that their illness is likely to be terminal within a relatively short period of time, are found to be disabled immediately. Claimants whose medical conditions do not meet SSA’s criteria at the Listings step are not necessarily denied; rather, they are further evaluated based on their functional capacity, work history, education, and age. There are different, non-work-based criteria for children under age 18 in the Supplemental Security Income program. However, as for adults, the Listings for children are meant to identify the most severely impaired claimants so that SSA does not have to go through the entire disability evaluation process. The Listings also apply to beneficiaries (i.e., people who are already receiving disability benefits) who must undergo a periodic review of their continuing disability. The purpose of the Listings is to provide a more rapid decision for individuals, whether claimants or beneficiaries, who clearly would qualify based on the severity of their medi-



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Executive Summary In 2010, more than 3.3 million individuals are expected to apply to the Social Security Administration (SSA) for disability benefits. SSA uses a five-step evaluation process to determine disability. This sequential decision process is both time and resource intensive, because determining whether applicants (referred to as claimants in this report) qualify for benefits is a complex process. To streamline the process, SSA uses a screening tool called the Listing of Impairments (known as the Listings) to identify claimants who are the most severely impaired, that is, disabled to such a degree that they do not need to go through the full sequential decision process. These individuals, if evidence in their medical records indicates that they cannot work or that their illness is likely to be terminal within a relatively short period of time, are found to be disabled immediately. Claimants whose medical conditions do not meet SSA’s criteria at the Listings step are not necessarily denied; rather, they are further evaluated based on their functional capacity, work history, education, and age. There are different, non-work-based criteria for children under age 18 in the Supplemental Security Income program. How- ever, as for adults, the Listings for children are meant to identify the most severely impaired claimants so that SSA does not have to go through the entire disability evaluation process. The Listings also apply to beneficiaries (i.e., people who are already receiving disability benefits) who must undergo a periodic review of their continuing disability. The purpose of the Listings is to provide a more rapid decision for individuals, whether claimants or beneficiaries, who clearly would qualify based on the severity of their medi- 

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 CaRdIoVaSCUlaR dISabIlIty cal condition, at the same time saving SSA the substantial administrative costs of an in-depth vocational evaluation. SSA currently organizes the Listings under 15 body systems, including the cardiovascular system. Because of the key role the Listings play in the disability determination process, they should reflect advances in medical treatment and diagnostic methods, be cognizant of the changing nature of employment in the United States, and be administratively practical to apply. SSA asked the Institute of Medicine (IOM) to convene an expert committee to recommend improvements in the cardiovascular system listings. Last re- vised in 2006, the cardiovascular system comprises eight adult and five child categories of impairments. In response to its charge, the IOM committee concluded that the functional performance of individuals with cardiovas- cular conditions, or with multiple conditions across body systems, deserves greater emphasis in determining disability under the listings. In considering changes that SSA could make to the listings, the committee concluded that relying solely on objective anatomical measures of impairment to assess an individual’s disability status without considering function would be insuf- ficient, as such measures generally correlate only weakly with degree of dis- ability. Incorporating measures of functional assessment allows for a more effective evaluation of the work capacity of the whole person. The committee’s approach to developing listing-level criteria was first to determine if a test result (e.g., reduced left ventricular ejection fraction) or set of test results is sufficient to ensure that virtually all individuals with such results are unable to work. Second, if anatomical measures are insuf- ficient to evaluate work disability, as is the case for most cardiovascular conditions, the committee recommended that evidence-based functional assessments, if not already required in the listing, should also be applied to meet a listing. Exercise tests on a treadmill or bicycle provide an objective measure of a person’s maximal aerobic capacity and are commonly used to pro- vide diagnostic and prognostic information. The information can also be compared with the aerobic demands of various jobs, usually expressed as metabolic equivalents (METs). SSA currently uses inability to achieve five METs as a listing-level criterion for ischemic heart disease, heart failure, and congenital heart disease in adults, and will pay to have such tests per- formed if they are necessary for adjudication and considered safe for the claimant. The committee determined that the current state of medical evidence shows that exercise tests are generally safe for patients with cardiovascular conditions such as ischemic heart disease, heart failure, and congenital heart disease, and found that SSA’s criteria for determining whether it is safe to order an exercise test are too strict. The committee urges SSA to update the safety criteria to allow broader use of exercise testing in the disability

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 ExECUtIVE SUmmaRy evaluation process. In cases in which exercise testing is not useful or safe for the claimant, the committee recommends that SSA use alternative pro- cedures such as the 6-minute walk or heel rise tests. SSA should also use validated instruments to assess a claimant’s capacity to perform everyday activities, such as activities of daily living (ADLs) and instrumental ADLs, where exercise is not possible or contraindicated (e.g., in cases of severe peripheral vascular disease, valve disease, or arrhythmias). This report provides 24 recommendations, most of which offer detailed advice for revising the current listings. The committee also recommends establishing new listings in the cardiovascular system for pulmonary hy- pertension with vascular causes and for severe symptomatic aortic stenosis, and adding more criteria for heart failure caused by cardiomyopathy or right heart failure. Suggested criteria for these new listings are provided. The report also addresses some common comorbidities associated with cardiovascular diseases. Unfortunately, there is no validated method for quantifying the combined effects of comorbidities, such as major depression and cardiovascular impairments. However, the report provides information on the impact of comorbidities on individuals with cardiovascular diseases and urges SSA to provide such information to its adjudicators and maintain its currency. During the course of its work, the committee encountered several critical knowledge gaps (for example, the relationship of anatomical sever- ity measures and functional limitation and the effect of comorbidities), and recommends that SSA pursue research opportunities, both within the organization and externally, to improve the quality of the Listings and to better inform future revisions of the cardiovascular and other body systems. In the final chapter, the committee suggests several ways to approach this research.

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