The Dynamics of Disability Measuring and Monitoring Disability for Social Security Programs (2002) / Chapter Skim
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SSA's Disability Determination of Mental Impairments: A Review Toward an Agenda for Research
SSA's Disability Determination of Mental Impairments: A Review Toward an Agenda for Research
Pages 241-280
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From page 241... ...
, is on the determination of disability status of irutial claims, based on mental disorders, for SSDI and SSI disability benefits. The scope of this paper covers the initial determination and emphasizes the medical aspects of the process.
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From page 242... ...
The paper is intended to stimulate an agenda for research to inform future modifications of the disability determination whether or not a formal redesign is undertaken. BACKGROUND Statutory Definition of Disability The foundation of the SSA's two disability programs is the statutory definition of disability in the Social Security Act.
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From page 243... ...
~. Sequential Evaluation The process by which SSA adjudicates initial claims for both SSDI and SSI disability benefits is called sequential evaluation.
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From page 244... ...
For claims based on mental impairments, the Reviewing Medical Consultant is usually a psychiatrist or clinical psychologist. The Listings of Mental Impairments (the Listings)
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From page 245... ...
Major revisions to the Listings of Mental Impairments, currently being applied to claims for disability benefits, were published in 19853 and have since undergone relatively minor modifications. The 1985 revision was intended to bring the Listings in line win then-current psychiatric practice to reflect Me APA's third edidon of its Diagnostic and Statistical Manual of Mental Disorders (DSM-m)
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From page 246... ...
The categories for adults follow: Organic Mental Disorders; Schizophrenic, Paranoid and Other Psychotic Disorders; Affective Disorders; Mental Retardation; Anxiety-Related Disorders; Somatoform Disorders; Personality Disorders; Substance Addiction Disorders; and Autistic Disorder and Other Pervasive Developmental Disorders. The categories contain either two or three sets of criteria.5 The A criteria are essentially diagnostic-like symptoms.
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From page 247... ...
The C criteria for Anxiety-Related Disorders are designed to accommodate individuals with agoraphobia who are totally unable to function outside Weir homes but can function successfully within the home. The following description of the forms show how decisions are made that put the sequential evaluation into effect for the medical component of the disability determination.
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From page 248... ...
The Psychiatric Review Technique Form puts the Listings of Mental Impairment into operation. The Mental Residual Functional Capacity Assessment is used to assess remaining functioning for claimants who are considered severe, but not sufficiently severe to be awarded benefits on the sole basis of the medical evidence using the PRTF.
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From page 249... ...
Mental Residual Functional Capacity Assessment This is used only for claims that are severe but have not been allowed disability benefits in the previous step of sequential evaluation, either meeting or equaling the listings. The MRFCA provides additional medical review for the Disability Analyst to combine with the nonmedical factors of age, education, and work history.
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From page 250... ...
The Listings of Mental Impairment, and the forms used by Reviewing Medical Consultants the PRTF and MRFCA—constitute the medical aspect of disability determination. For claims that do not result in a medical determination (i.e., a denial at step 2 using the PRTF because the disability is not severe or an allowance at step 3 because the disability is so severe that it precludes work on a medical review alone)
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From page 251... ...
Each psychiatrist was assigned to one of two study conditions. One the sequential evaluation condition received training and applied the SSA disability determination process and forms (e.g., I'1 |
From page 252... ...
First, the statutory definition condition needed to document a decision as to disability status. Second, the sequential evaluation condition needed to record a ~lisability finding at the fourth and fifth steps in sequential evaluation.8 The CDSR is a 10-point scale from -5 (unable to work)
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From page 253... ...
Analysis of the Listings/PRTF The next series of analyses examined the agreement between study conditions for each of the seven categories of mental impairment of the Listings as reviewed using the PRTF. Three of the Listings categoriesOrganic Mental Disorders; Schizophrenia, Paranoid and Other Psychotic Disorders; and Anxiety Disorders—were found to work well.
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From page 254... ...
showed some reliability and validity but was weak overall.l° The C criteria for schizophrenia, paranoid, and other psychotic disorders were found to have low reliability but were valid. There were insufficient data to analyze the C criteria for Anxiety-Related Disorders.
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From page 255... ...
The "clinical" factors that were included in the analysis were the presence of a notable physical disorder; the time of onset of impairment; work history; and notable alcohol or drug abuse. The demographic variables were age and gender.
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From page 256... ...
All recommendations were made on the premise that the basic construct of the SSA's medical standards and guidelines for the evaluation of claims based on mental impairment should be retained. Recommendations from the APA study, described below, reflect those that are consonant with the focus of the IOM committee and are detailed to indicate areas for a research agenda.
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From page 257... ...
Because the premise upon which all APA recommendations were made was that the basic construct of SSA's medical standards and guidelines should be maintained for claims based on mental impairment, any changes, modifications, or refinements would have to be based on input Hat is conceptually compatible and scientifically robust. The WHO's ICF is such a resource.
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From page 258... ...
The ICF classification covers a person's functioning and disabilities associated with health conditions at the body, person, and society levels. Functioning in the ICF refers to all body functions, activities, and participation as an umbrella term.
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From page 259... ...
In France, the ICIDH-1980 definition of "handicap" became the basis for the national law upon which its disability benefits are based. Some research instruments based on ICIDH-1980 were developed, and a nascent body of disability research exists.
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From page 260... ...
The third unique feature was a series of formal field trials that were designed to collect empirical evidence for additional revision. Included in He field trials were such queries as the cross-cultural applicability of the concepts and model underlying ICF and the meaningfulness and sensitivity of the ICF domains and items in different cultures throughout the world.
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From page 261... ...
Body functions are the physiological functions of body systems including psychological functions. Body structures are anatomical parts of the body such as organs, limbs, and their components.
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From page 262... ...
It can be applied to legal definitions or program criteria and used to put them into operation. The SSA's statutory definition of disability, some sequential evaluation components, and even the basic premise of SSA's disability benefits can readily be mapped onto this interactive conceptual model.
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From page 263... ...
Disability benefits are essentially the replacement of earned income (stemming from SSDI) that facilitates participation in various domains of social life.
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From page 264... ...
Coding for both performance and capacity qualifiers is identical to body functions and to the first qualifier of body structures: it identifies the degree of difficulty. 1h the structure of ICF qualifiers, there is room for consideration of additional qualifiers.
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From page 265... ...
In the development of its first revision efforts, the International MH/ ABCD Task Force reviewed SSA's disability determination and the PRTF to ensure the inclusion of appropriate domains and items pertaining to disability for work. Particular attention was paid to the inclusion of the first three B criteria.
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From page 266... ...
Use of the ICF Checldist is based on the qualifiers found in the ICF rather than a dichotomous rating inferred by the name. The ICF Checklist offers SSA a basis for a standard form for provision of medical evidence for claims based on all physical or mental conditions.
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From page 267... ...
It is calibrated for use to assess disabilities associated with mental as well as physical conditions. The WHO DAS II is conceptually based on the ICE and queries six domains: 1.
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From page 268... ...
19~. The APA study suggests that the medical component of sequential evaluation for claims based on mental impairment works sufficiently well that only refinements to SSA forms, identification of a period of review, and improvement of the medical evidence (e.g., development of a standard form for basic medical evidence)
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From page 269... ...
The first step of claims for both SSDI and SSI benefits based on either mental or physical disorders in sequential evaluation decides whether the claimant is already working. These people are not processed beyond the DO and do not appear above.
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From page 270... ...
Would it not be worth investigating whether those same criteria would work as well for claims based on physical conditions? Next, disability determination sorts the dichotomous decision of ability or inability to work for the remaining claims in the middle.
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From page 271... ...
Research here could investigate the applicability of the three B criteria to claims based on physical health conditions and foster a more robust set of B criteria and scale points For the remaining claims, SSA could build on the APA study and look for the factors that predict difficult-to-adjudicate claims: coexisting mental and physical conditions; onset of less than 12 months; and female claimants. SSA can identify other characteristics from among the claims whose decisions are reversed upon appeal.
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From page 272... ...
The above information may provide sufficient information to act as a needs assessment. 20The committee recommended that early in its redesign effort, the SSA should specify how it will define, measure, and assess the criteria it will use to evaluate the current disability determination process, as well as any alternative processes being developed.
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From page 273... ...
How might the first three B criteria for claims based on mental disorders and their rating be approved and made applicable to people claiming disability based on physical disorders? Again, the ICF offers a rich resource both for the items and for rating the items.
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From page 274... ...
2. Explore the differences between the adjudication materials for claims based on mental disorders and those used on physical disorders to see if the strengths identified by the APA study might not apply to the adjudication of physically disordered claimants, and attend to the weaknesses as well: If the A criteria are to be eliminated as has been suggested at times, identify some method of documenting the association of the health condition with the disabled state.
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From page 275... ...
Existing research on disability claims-based mental disorders finds that no major change to sequential evaluation or to the standards and guidelines used in this process (notably the Listings of Mental Impairments and the PRTF) is warranted—only refinements.
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From page 276... ...
. · SSA should compare the magnitude of its caseload and the decisions made at each step in sequential evaluation for all claims for disability benefits in the SSDI and SSI programs, all claims for disability benefits based on physical conditions in the SSDI and SSI programs, and all claims for disability benefits based on mental conditions in the SSDI and SSI programs.
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From page 277... ...
· Domains and items in ICF are readily utilized in modifications to existing SSA disability determination forms in sequential evaluation. They would enrich SSA's conceptual development and assessment of functional capacity to work.
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From page 278... ...
The scaling of these items can be tested against the current B criteria thresholds for identification of the two extremes not-severe and so-severe claims. They can then be used for claims based on physical and mental conditions to make disability determinations at steps 2 and 3 of sequential evaluation.
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From page 279... ...
This paper has limited its focus to the medical review of claims for disability benefits based on mental conditions and has been informed by the APA's evaluation of SSA's standards and guidelines used in disability determination. With the recent revision of WHO's ICE and the development of related disability assessment and research instruments, a new and valuable resource has become available for use in modifications of the tools used in sequential evaluation.
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From page 280... ...
1998. The Social Security Administration's Disability Decision Process: A Framework for Research.
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