Improving The Social Security Disability Decision Process

The Social Security Administration (SSA) provides Social Security Disability Insurance (SSDI) benefits to disabled persons of less than full retirement age and to their dependents. SSA also provides Supplemental Security Income (SSI) payments to disabled persons who are under age 65. For both programs, disability is defined as a "medically determinable physical or mental impairment" that prevents an individual from engaging in any substantial gainful activity and is expected to last at least 12 months or result in death. Assuming that an applicant meets the nonmedical requirements for eligibility (e.g., quarters of covered employment for SSDI; income and asset limits for SSI), the file is sent to the Disability Determination Services (DDS) agency operated by the state in which he or she lives for a determination of medical eligibility. SSA reimburses the states for the full costs of the DDSs. The DDSs apply a sequential decision process specified by SSA to make an initial decision whether a claim should be allowed or denied. If the claim is denied, the decision can be appealed through several levels of administrative and judicial review. On average, the DDSs allow 37 percent of the claims they adjudicate through the five-step process. A third of those denied decide to appeal, and three-quarters of the appeals result in allowances. Nearly 30 percent of the allowances made each year are made during the appeals process after an initial denial. In 2003, the Commissioner of Social Security announced her intent to develop a "new approach" to disability determination. In late 2004, SSA asked the Institute of Medicine (IOM) to help in two areas related to its initiatives to improve the disability decision process: 1) Improvements in the criteria for determining the severity of impairments, and 2) Improvements in the use of medical expertise in the disability decision process. This interim report provides preliminary recommendations addressing the three tasks that relate to medical expertise issues, with a special focus on the appropriate qualifications of medical and psychological experts involved in disability decision making. After further information gathering and analyses of the effectiveness of the disability decision process in identifying those who qualify for benefits and those who do not, the committee may refine its recommendations concerning medical and psychological expertise in the final report. The final report will address a number of issues with potential implications for the qualifications of the medical experts involved in the disability decision process.

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 Society Security disability program faces urgent challenges: more people receiving benefits than ever before, the prospect of even more claimants as baby boomers age, changing attitudes culminating in the Americans With Disabilities Act. Disability is now understood as a dynamic process, and Social Security must comprehend that process to plan adequately for the times ahead. The Dynamics of Disability provides expert analysis and recommendations in key areas: Understanding the current social, economic, and physical environmental factors in determining eligibility for disability benefits. Developing and implementing a monitoring system to measure and track trends in work disability. Improving the process for making decisions on disability claims. Building Social Security's capacity for conducting needed research. This book provides a wealth of detail on the workings of the Social Security disability program, recent and emerging disability trends, issues and previous experience in researching disability, and more. It will be of primary interest to federal policy makers, the Congress, and researchersâ€"and it will be useful to state disability officials, medical and rehabilitation professionals, and the disability community.

Each year, about 2.5 million people apply to the Social Security Admin. (SSA) for disability benefits. Disability determination services, which are state agencies that conduct disability determinations on behalf of SSA, award benefits to about 35 out of every 100 of these applicants. This report evaluates the SSA's decision-making process for disability determinations & assesses its efforts to improve the process. Reports on factors that contribute to differences between disability determination services & administrative law judges decisions & the SSA's actions to make decisions in initial & appealed cases more consistent. Tables.

The Social Security Administration (SSA) uses a screening tool called the Listing of Impairments to identify claimants who are so severely impaired that they cannot work at all and thus immediately qualify for benefits. In this report, the IOM makes several recommendations for improving SSA's capacity to determine disability benefits more quickly and efficiently using the Listings.