Allen W. Heinemann, PhD, ABPP

Professor, Physical Medicine and Rehabilitation

Feinberg School of Medicine, Northwestern University

Director, Center for Rehabilitation Outcomes Research

Rehabilitation Institute of Chicago

Disability Determination Process: The Need for Fundamental Change

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The Need for Fundamental Change

Social Security Advisory Board: January 2001

Major concerns described in report1. Growth in disability claims threaten to overwhelm the system

2. Inadequate tools exist to make disability determination decisions.

3. Public perceptions of inequity

4. Unexplained variations in decision making exposes the disability programs to accusations that decisions are not made uniformly and consistently

Four years later, that need still exists

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5-Step Sequential Disability Determination Process

STEP ONE:Evaluation ofWork Activity

SGANon-SGA

DeniedSeverity ofImpairmentIs Irrelevant

Forwarded toState DDS toReview M ER

PerformingSGA?

Yes.BenefitsDenied

No.Go ToStep 2.

STEP TWO:Evaluation of

Severity ofImpairment

Severe.Go ToStep 3

Not Severe; orno medicallydeterminableimpairment.

BenefitsDenied

STEP THREE:Impairment

Compared ToSSA Listings

Does NotM eet or Equal

SSA ListingGo To Step 4

M eets orEqualsan SSAListing

BenefitsAw arded

STEP FOUR:Evaluation of

Resid. FunctionalCapacity

Unable ToDo PastW ork.Go ToStep 5.

Capable ofPerform ingPast W ork

BenefitsDenied

STEP FIVE:Assessment of

Ability to DoOther Work

Capable ofPerformingOther Work

BenefitsDenied

Unable ToDo AnyW ork.

BenefitsAw arded.

4

Appeals Process…

Initial DDS Determination

Decisions by ALJs

59%41%

BenefitsAwarded

BenefitsDenied

62%

38%Appeal for Re-Consideration

Initia l DDS DecisionReversed (16%)

Initia l DDS DecisionUpheld (84% )

Hearing w /Adm in. Law

Judge

DDS DecisionReversed (59% )

DDS Decision Upheld orCase Dismissed (41%)

AppealsCouncil

Benefits Allow ed (2% )

Rem and (22% )

Benefits Denied orCase Dism issed (76% )

Federa lCourt

Benefits Allow ed (6% )

Rem and (48% )

Benefits Denied orCase Dism issed (45% )

Source: Social Security Advisory Board, January 2001.

5

Appeals Burden

Average appeal: 525 days due to backlogged cases

628 days to move through the process

Total appeals time: 1,153 days – roughly 3 years and 2 months

Additional time required to navigate through the initial decision

Source: Honorable Jo Anne B. Barnhart, Commissioner of Social Security. Testimony before the House Ways and Means Committee, 9/25/03

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Costs of Appeals

Many claimants give up and drop out of the system

For those who don’t give up, most ultimately receive benefits

59% of all appeals are reversed by OHA

Additional claims are paid as claims continue their way through the remaining stages of the appeals process

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OHA Appeals Outcome

Administrative Law Judge Decisions

59%

41%ALJs ReverseDDS Decision

DDS DecisionUpheld

Large numbers of decisions reversed by ALJs illustrate the complexity in the decision process and opportunities for disagreement

Worsening medical conditions and the opportunity to meet claimants in person may account for some of these reversals

However, minor variations do not explain why the same information being viewed by two different systems often results in radically different conclusions

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Disability Research Institute Project

Rehabilitation Institute of Chicago / Northwestern University researchers are evaluating the functional and occupational factors that affect claim decisions

Goal: Inform SSA regarding factors that affect different decisions reached by DDS and OHA, particularly at Steps 4 and 5

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Project Design and Sample

Cross-sectional national sample of disability applications from 2002

Claims under listings for – Affective disorders (12.04)– Anxiety-related disorders (12.06)– Personality disorders (12.08)

Stratified by state, age, and benefits decision

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SSA Forms for Data Extraction

831 Disability Determination & Transmittal 3367 Disability Report, Field Office 3368 Disability Report 3369 Vocational Report 101 Determination of Award 561 Request for Reconsideration 3341 Reconsideration Disability Report 501 Request for Hearing by ALJ 1696 Appointment of Representative 4734 Physical Residual Functional Capacity Assessment 4734-F4-SUP Mental Residual Functional Capacity Assessment 2506 Psychiatric Review Technique Form

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Unprecedented Opportunity

Use of primary “folder data” is the first of its kind

Previously, no other researchers have had direct access to information necessary to conduct an evaluation of the disability determination process

All researchers must undergo background/security screenings

All IRS information (i.e., wages and other earnings) must be removed before data can be accessed.

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Data Analysis

Classification and Regression Tree Analysis (CART)

Use existing data to predict state DDS disability award decisions and ALJ decisions

Identify what factors influence a claimants decisions to appeal

Determine if the mental RFC instrument yields a reliable and valid measure, or if subsets of items form better measures

Identify what characteristics distinguish awards at step 3 from awards at steps 4 and 5

Determine how well the Adult Needs and Strengths Assessment (ANSA) instrument predicts disability decisions

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Implications & Next Steps

Based on findings, a larger sample may be needed to explain variability by region and other issues that may be revealed.

It has been suggested that some claimants might be less willing return to work because it took so long to receive benefits.

We hope this study will help create a more fair, equitable, and streamlined system that also promotes return to work.