Social Security Disability Insurance: SSA Actions Could Enhance
Assistance to Claimants with Inflammatory Bowel Disease and Other
Impairments (31-MAY-05, GAO-05-495).
Advocates for patients with inflammatory bowel disease (IBD)
believe that the Social Security Administration's (SSA) process
for determining eligibility for Disability Insurance (DI) may
treat some claimants unfairly. As a result, claimants with IBD
believe they are likely to be denied benefits at the initial
decision and reconsideration levels, making it necessary for them
to appeal to SSA's hearings level to have their claims allowed.
This congressionally mandated study focuses on (1) how SSA
evaluates claims involving IBD to establish disability under
Title II of the Social Security Act and (2) what unique
challenges claimants with IBD encounter when applying for DI
benefits, and what actions, if any, SSA has taken to address
these challenges.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-05-495
ACCNO: A25379
TITLE: Social Security Disability Insurance: SSA Actions Could
Enhance Assistance to Claimants with Inflammatory Bowel Disease
and Other Impairments
DATE: 05/31/2005
SUBJECT: Aid for the disabled
Claims
Claims adjudicators
Claims processing
Claims settlement
Comparative analysis
Decision making
Disability benefits
Disability insurance
Diseases
Eligibility determinations
Evaluation criteria
Persons with disabilities
Program management
Social Security Disability Insurance
Program
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GAO-05-495
United States Government Accountability Office
GAO
Report to Congressional Committees
May 2005
SOCIAL SECURITY DISABILITY INSURANCE
SSA Actions Could Enhance Assistance to Claimants with Inflammatory Bowel
Disease and Other Impairments
GAO-05-495
[IMG]
May 2005
SOCIAL SECURITY DISABILITY INSURANCE
SSA Actions Could Enhance Assistance to Claimants with Inflammatory Bowel
Disease and Other Impairments
What GAO Found
SSA evaluates DI claims involving IBD just as it does all claims, using a
fivestep sequential evaluation process to determine whether: (1) the
individual is working and earning an amount exceeding established
thresholds, (2) the impairment or combination of impairments significantly
limits a person's physical or mental ability to perform basic work
activities, (3) the individual's impairment meets or equals a
pre-established list of the medical criteria for impairments considered
severe enough to prevent an individual from earning wages above the
established threshold, (4) the claimant can return to previous work based
on what the individual can still do in a work setting despite physical or
mental limitations, or his or her "residual functional capacity," and (5)
the claimant can do any work in the economy. As claims move through the
five-step process, their assessment requires additional evidence and
increasingly complex judgments on the part of adjudicators. For example,
at step three, claimants with IBD who are diagnosed with Crohn's disease
would meet the medical criteria if their weight fell below the minimum on
SSA's weight table. In contrast, to determine the residual functional
capacity of claimants with IBD at steps four and five, SSA adjudicators
must assess claimants' mental and physical capacity and make judgments
regarding allegations of pain and fatigue. Adjudicators at the initial,
reconsideration, and hearings levels use the same five-step process,
although differences exist between the levels that may affect decisions.
For example, claimants may be represented by an attorney or nonattorney at
the hearings level.
While claimants with IBD are somewhat less likely to be allowed DI
benefits than claimants with other impairments, their experiences applying
for disability benefits are not unique, and SSA has efforts under way that
may address some claimant concerns. When we analyzed DI decisions in 2003
by decision-making levels, we found that claimants with IBD, like many
others, experienced lower allowance rates at the initial and
reconsideration levels compared to the hearings level, although the
difference between the levels was more pronounced for claimants with IBD.
Lower allowance rates at the initial levels and higher allowance rates at
the hearings level may reflect challenges that claimants with IBD share
with many other claimants in applying for disability benefits. For
example, both claimants with IBD and other claimants are unlikely to be
allowed at step five of the process at the initial levels but not at the
hearings level. SSA is pursuing efforts that may address some claimant
concerns. For example, the agency is currently updating the medical
criteria used for many impairments, including IBD, and is proposing
changes to its decision-making process that may improve consistency
between decision-making levels. SSA is also trying to improve claimants'
understanding of the disability claims evaluation process, but lacks
assurance that the majority of claimants who file in person or over the
phone understand and provide information critical to SSA's assessment of
their claims as part of steps four and five of the process.
United States Government Accountability Office
Contents
Letter
Results in Brief
Background
SSA Evaluates IBD Claims Using the Same Evaluation Process as
for All Claims
Claimants with IBD and Other Impairments Face Similar Challenges Applying
for DI, and SSA Efforts May Address Some Claimant Concerns
Conclusions
Recommendations
Agency Comments and Our Evaluation
1
2 5
7
12 23 24 25
Appendix I Scope and Methods 27
Data Sources 27
Scope 27
Data Reliability 27
Methods of Analysis 28
Appendix II Agency Comments 32
GAO Comments 37
Tables
Table 1: Comparison of Overall Allowance Rates for IBD versus Other
Impairments 13 Table 2: Allowance Rates for Claimants with IBD versus
Other Claimants by Decision-Making Level 14 Table 3: Allowance Rates for
Disability Decisions at Step Three by Decision-Making Level 15 Table 4:
Comparison of Allowance Rates at Step Three for IBD versus Other
Impairments by Decision-Making Level 16 Table 5: Allowance Rates for
Disability Decisions at Step Five by Decision-Making Level 17 Table 6:
Types of Comparisons Used in Report for IBD versus Other Impairments 30
Figure
Figure 1: Five-Step Sequential Evaluation Process Used at Initial,
Reconsideration and Hearings Levels to Determine Disability
Abbreviations
ADL activities of daily living
ALJ administrative law judge
CCS Case Control System
DDS Disability Determination Services
DI Disability Insurance
IBD inflammatory bowel disease
NAS National Academy of Sciences
RFC residual functional capacity
SGA substantial gainful activity
SSA Social Security Administration
SSAB Social Security Advisory Board
SSI Supplemental Security Income
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
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separately.
United States Government Accountability Office Washington, DC 20548
May 31, 2005
The Honorable Charles E. Grassley
Chairman
The Honorable Max Baucus
Ranking Minority Member
Committee on Finance
United States Senate
The Honorable Joe Barton
Chairman
The Honorable John D. Dingell
Ranking Minority Member
Committee on Energy and Commerce
House of Representatives
The Honorable William M. Thomas
Chairman
The Honorable Charles B. Rangel
Ranking Minority Member
Committee on Ways and Means
House of Representatives
In recent years, concerns have been raised that the process the Social
Security Administration (SSA) uses to determine which claimants are
eligible for Disability Insurance (DI) benefits may place some individuals
at a disadvantage for receiving the benefits to which they are entitled.
For
example, advocates have recently stressed that the process of qualifying
for DI benefits may treat some claimants with inflammatory bowel disease
(IBD) unfairly. They believe that SSA field staff are not familiar with
the
nature of their illness and that the medical criteria used to establish
disability for IBD patients do not take into account the specifics of
their
illness, such as its episodic and unpredictable nature. As a result,
claimants with IBD believe that they are likely to be denied benefits at
the
initial decision and reconsideration levels, making it necessary for them
to
appeal to SSA's hearings level to have their claims allowed. This appeal
delays the receipt of benefits and may require claimants to pay attorney
fees. These concerns have arisen in spite of efforts by SSA, which manages
the DI program and paid out $78.2 billion to 7.9 million beneficiaries in
2004, to ensure that all claimants are assessed in a consistent manner.
Partially in response to these concerns, the Congress passed the Research
Review Act of 2004 (Pub. L. No. 108-427), which mandated that GAO study
problems encountered by patients with IBD when applying for DI benefits
under Title II of the Social Security Act and identify possible
recommendations to improve the application process for these patients.1
This report will discuss (1) how SSA evaluates claims involving IBD to
establish disability under Title II of the Social Security Act and (2)
what unique challenges claimants with IBD encounter when applying for DI
benefits, and what actions, if any, SSA has taken to address these
challenges. To determine whether claimants with IBD were in fact treated
differently than claimants with other impairments, we analyzed SSA data on
all DI decisions made at three decision-making levels (initial,
reconsideration, and hearings) in 2003 and compared allowance rates for
claimants with IBD against those for claimants with other impairments.2 We
also reviewed a small, nonrepresentative sample of cases to better
understand how both the claimants and SSA documented claims involving IBD.
To identify problems IBD patients have encountered, we interviewed
representatives of IBD patient advocacy groups such as the Crohn's and
Colitis Foundation of America and the Digestive Disease National
Coalition. We discussed these issues with officials at SSA and selected
stakeholders with perspective on this issue, such as the National
Association of Disability Examiners, the National Council of Disability
Determination Directors, and the National Organization of Social Security
Claimants' Representatives. To better understand the nature of the
impairment and the experiences of those in the IBD community who apply for
DI, we reviewed literature on IBD and SSA's application process and
criteria as they pertain to claimants with IBD. We performed reliability
tests on selected data for calendar year 2003 and found the data
sufficiently reliable for use in this report. We conducted our work
between January 2005 and May 2005 according to generally accepted
government accounting standards.
SSA evaluates claims involving IBD just as it does all claims, using a
fivestep sequential evaluation process to determine if the claimant's
impairment or combination of impairments qualifies as a disability under
1The Research Review Act of 2004 also mandated that GAO report on the
Medicare and Medicaid coverage standards for certain therapies used by
patients with IBD.
2See appendix I for a detailed description of the methods we used to
analyze 2003 data.
Results in Brief
Title II of the Social Security Act. For all claims, adjudicators
establish first that the individual is not working and earning an amount
exceeding established thresholds (engaged in "substantial gainful
activity"), and second, whether the impairment(s) significantly limits the
individual's physical or mental ability to perform basic work activities.
Then, at step three of the process, the individual's impairment(s) is
compared to preestablished medical criteria in SSA's Listing of
Impairments. Listed impairments are considered severe enough to prevent an
individual from engaging in any gainful activity. For all claims, if the
severity and duration of the individual's impairment(s)-as documented by
medical examinations, laboratory results, and other required evidence-meet
or are equivalent to (equal) the criteria for an impairment on that list,
the adjudicator would find the individual to be "disabled" under SSA's
rules and would allow the claim. For example, a claimant with IBD who is
diagnosed with Crohn's disease and whose weight is below the minimum on
SSA's weight table would be "disabled" under SSA's rules. Claims that do
not meet or equal the medical criteria move to step four, where
adjudicators determine if the claimants can do previous work based on
their "residual functional capacity"; i.e., what they can still do in a
work setting despite physical or mental limitations, or their "residual
functional capacity." In assessing the residual functional capacity of a
claimant with IBD, for example, SSA might assess the claimant's ability to
stand, sit, and lift, as well as his or her mental capacity, pain, and
fatigue. If the claimant cannot return to previous work, SSA adjudicators
move to step five to determine if the claimant can do any work in the
national economy, based on his or her residual functional capacity and the
"vocational factors" of age, education, and work experience-in addition to
residual functional capacity. As claims move through the five-step
process, the assessments generally require additional evidence and involve
increasingly complex judgments on the part of adjudicators. For example,
adjudicators might need additional information on daily activities and
symptoms, such as fatigue, for claimants with IBD whose impairment(s) does
not meet or equal the medical criteria of one of SSA's listed impairments.
The adjudicators will weigh this information along with medical evidence
to assess how claimants' impairments might limit their ability to function
in a work setting. Adjudicators at the initial, reconsideration, and
hearings levels use the same five-step process, although other differences
exist between the decision-making levels that may affect how adjudicators
decide on claims. For example, claimants may introduce new evidence and
allegations at each stage of the appeals process and are more likely to be
represented by an attorney or nonattorney during an appeal.
While claimants with IBD are somewhat less likely to be allowed than
claimants with other impairments, their experiences applying for
disability benefits are not unique relative to others, and SSA has several
efforts under way that may address some claimant concerns. When we
analyzed disability decisions made in 2003 for all decision-making levels
combined, we found that claimants with IBD had a somewhat lower overall
allowance rate than that of all other claimants (33 percent versus 39
percent). When we made this same comparison for each decisionmaking level
separately, we found that, much like for other claimants, the allowance
rate for claimants with IBD was lower at the initial and reconsideration
levels compared to the hearings level, although the difference in
allowance rates between levels was greater for claimants with IBD. Lower
allowance rates at the initial and reconsideration levels and higher
allowance rates at the hearings level may reflect challenges that
claimants with IBD share with many other claimants in applying for
disability benefits. For example, both claimants with IBD and many
claimants with other impairments are less likely to be allowed at step
five of the process at the initial and reconsideration levels, but more
likely to be allowed on this basis at the hearings level. SSA is pursuing
efforts that may address some of the concerns of individuals with IBD and
other claimants. For example, the agency is currently updating its Listing
of Impairments, including the listings for IBD, and is taking into account
the views of the public in so doing. The agency is also proposing changes
to its decision-making process that may improve consistency between the
initial and reconsideration levels and the hearings level. SSA has also
taken steps to improve all claimants' understanding of the disability
claims evaluation process. However, the agency's recently developed
"Disability Starter Kit" and other information available to the majority
of claimants who apply for benefits in person or over the phone do not
explain the types and importance of information needed to assess claims at
steps four and five of the process.
GAO is making several recommendations in this report to the Commissioner
of Social Security that will help ensure that claimants with IBD and other
claimants are made aware early in the process of the types and importance
of information claimants must provide with their application. In
commenting on the draft of this report, SSA agreed with our
recommendations but also expressed some concerns. For example, SSA stated
that our report discussed two issues the agency considered irrelevant to
our study of DI claimants with IBD-listings for impairments other than
IBD, and the decline in DI allowances based on medical criteria. We
modified the text to address some of the agency's concerns, but we believe
that a discussion of both of these issues is relevant because
Background
it provides perspective on whether claimants with IBD are treated
differently than claimants with other impairments.
DI is the largest federal program providing cash assistance to people with
disabilities. Established in 1956, DI provides monthly payments to workers
with disabilities (and their dependents or survivors) under the normal
retirement age who have enough work experience to qualify for disability
benefits.3 The Social Security Act defines disability as the inability to
engage in any substantial gainful activity by reason of any medically
determinable physical or mental impairment(s) (hereafter simply referred
to as "impairment") which is 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.4
IBD encompasses two chronic autoimmune diseases of the intestinal tract:
ulcerative colitis and Crohn's disease. The two diseases are often grouped
together as IBD because of their similar symptoms, but each disease has
very different surgical options, and may be treated with a spectrum of
diverse medications. Common symptoms of IBD include, but are not limited
to: abdominal pain, weight loss, fever, rectal bleeding, skin and eye
irritations, fatigue, and diarrhea. IBD is characterized by intervals of
active disease, or "flares," and periods of remission. Although it is
estimated that as many as one million Americans suffer from a form of IBD,
most people with IBD are able to work, and few apply for DI benefits. In
2003, less than 1 percent of DI decisions (nearly 7,000) involved IBD
patients.
To obtain DI benefits, a claimant must provide information through an
application and adult disability report5 filed on line, in an interview by
telephone, or in person at a Social Security office. For claims taken by
phone or in person, SSA field staff are responsible for assisting the
claimant in filling out the application form and the adult disability
report
3SSA also manages Title XVI of the Social Security Act, which created the
Supplemental Security Income (SSI) program in 1972. SSI is a means-tested,
income assistance program that provides monthly payments to adults or
children who are blind or who have other disabilities and whose income and
assets fall below a certain level.
4The SSI program uses the same definition of disability as the DI program.
5For all disability claims, claimants must fill out the disability
application form and the adult disability report.
with complete information and for noting any relevant information about
the claimant observed during the interview.
If the claimant meets the nonmedical eligibility criteria, the field staff
forwards the claim to the appropriate Disability Determination Services
(DDS) office. DDS staff-generally a team comprising a disability examiner
and a medical consultant and, sometimes, a vocational specialist-review
the claimant's medical and other evidence, obtaining additional evidence
as needed to assess whether the claimant's impairment satisfies program
requirements, and make the initial disability decision. If the claimant is
not satisfied with this decision, the claimant may request a
reconsideration of the decision within the same DDS.6 Another DDS team
will review the documentation in the case file, as well as any new
evidence the claimant may submit, and determine whether the claimant meets
SSA's definition of disability.
If the claimant is not satisfied with the reconsideration determination,
he or she may request a hearing before an administrative law judge (ALJ).
The ALJ conducts a new review of the claimant's file, including any
additional evidence the claimant submitted after the DDS decision. At a
hearing, the ALJ may hear testimony from the claimant, medical experts on
the claimant's medical condition, and vocational experts regarding whether
the claimant could perform work he or she has done in the past or could
perform other work currently available in the national economy. The
majority of claimants are represented at these hearings by an attorney or
other representative.7
SSA has faced long-standing problems in administering this complex,
multilevel decision-making process. These problems center around a process
that can be confusing and unwieldy, with many applicants appealing and
waiting a long time for a final disability decision. In addition, many
within and outside of SSA have long believed that differences between the
adjudication levels might cause inconsistencies in
6In September 2003, SSA's Commissioner proposed eliminating
reconsideration and the Appeals Council as part of a large set of
revisions to the disability decision-making process.
7Under the current process, if the claimant is not satisfied with the
ALJ's decision, he or she may request a review of the decision by SSA's
Appeals Council, which is the final administrative appeal within SSA. If
the Appeals Council denies the request for review or the claimant is not
otherwise satisfied with the Appeals Council's decision, the claimant may
appeal to a federal district court. The claimant can continue legal
appeals to the U.S. Circuit Court of Appeals, and ultimately to the
Supreme Court of the United States.
decision making, in turn resulting in too many claims being initially
denied and then allowed upon appeal and delaying the time it may take for
some deserving claimants to receive a final agency decision. Concerned
with the length of time it takes disability claimants to receive a final
agency decision, SSA has cited "improving service in its disability
programs" as one of its highest priorities and established "making the
right decision in its disability process as early as possible" as one of
its strategic objectives.
SSA evaluates claims involving IBD just as it does all claims, using a
sequential evaluation process to determine if the claimant's impairment
qualifies as a disability under SSA's definition.8 This process-which is
used at all adjudication levels-consists of five distinct steps, wherein
the claimant's employment status, medical condition, and functional
limitations are considered. Figure 1 below gives an overview of how a
claim moves through the five-step evaluation process.
SSA Evaluates IBD Claims Using the Same Evaluation Process as for All Claims
8The sequential claims evaluation process applies equally to DI and SSI
claims.
Figure 1: Five-Step Sequential Evaluation Process Used at Initial,
Reconsideration and Hearings Levels to Determine Disability
Source: GAO.
The first two steps of SSA's evaluation process allow SSA to screen out
cases where the claimant clearly does not meet SSA's definition of
disability. In step one, field staff determine whether the individual is
engaged in substantial gainful activity.9 If so, the individual does not
meet the definition of disability and the claim is denied. If not, the
claim moves to step two, and is forwarded to the DDS office, where the
adjudicator obtains medical and other evidence and considers the severity
of the impairment. If the impairment does not significantly limit the
person's physical or mental ability to perform basic work activities, the
impairment is considered not severe and the claim is denied. For example,
a diagnosis of IBD alone is not sufficient; the condition must be severe,
i.e., it must limit the person's ability to perform basic work activities,
for the claim to be considered further. If the impairment is severe, the
claim moves to step three.
At step three, the impairment is evaluated to see if it meets or equals in
severity the medical criteria in SSA's Listing of Impairments (the
listings). The listings describe impairments considered severe enough to
prevent an individual from engaging in any gainful activity. If the
severity and duration of the claimant's impairment, as documented by
medical examinations, laboratory results, and other evidence meet the
criteria of a listing or is equivalent in severity to a listing, the claim
is allowed. For a claimant with IBD, there are different ways of meeting
or equaling the medical criteria. For example, a claimant diagnosed with
Crohn's disease whose weight is below the minimum weight on SSA's
established weight tables would be allowed.
For all claimants, if the impairment does not meet or equal the criteria
of a listing, the adjudicator must assess the claimant's "residual
functional capacity" (RFC) to determine what an applicant can still do,
despite physical and mental limitations, in a regular full-time work
setting. The claim then moves to step four, where the adjudicator
determines whether the claimant has the RFC to do any past relevant work.
Assessing physical RFC requires adjudicators to judge individuals' ability
to physically exert themselves in a variety of activities (such as
sitting, standing, walking, lifting, carrying, pushing, and pulling) and
to perform manipulative or postural functions (such as reaching, handling,
stooping, and crouching). Assessing mental RFC requires adjudicators to
judge, for example, the individual's ability to understand, remember, and
carry out instructions and to respond appropriately to people and changes
in work situations.
9The 2005 substantial gainful activity (SGA) level for claimants who are
not blind is $830; SGA for blind claimants is $1,380.
Some IBD claims include allegations of pain and fatigue, which may greatly
affect the claimant's RFC. Because these factors cannot be measured, the
adjudicator may need to assess the "credibility" of the claimant's
allegations by comparing such conditions or symptoms to other evidence in
the file. If the adjudicator determines that in spite of the impairment,
the claimant's RFC permits him or her to return to previous work, the
claim is denied.
On the other hand, if the adjudicator determines that the claimant's RFC
does not permit him or her to return to past relevant work, the claim
moves to step five, where the adjudicator determines whether the claimant
could do any other work in the national economy, based on the claimant's
RFC and the vocational factors of age, education, and work experience. To
do this, the adjudicator uses a complex system of rules set out in SSA's
regulations, including a grid of medical and vocational factors that
provides guidance for decision making. There are three grid tables, which
are based only on exertional limitations (sedentary, light, and medium),
and each table provides a variety of combinations of age, education, and
work experience. If, despite the claimant's impairment and other factors,
the grid indicates that there are jobs the claimant could do, the claimant
would be denied; likewise, if the grid indicates that the claimant cannot
do other work, the claimant would be allowed. However, for the majority of
disability decisions, the grid is used only as guidance, because many
claimants have limitations that the grid does not capture. For example,
severe diarrhea necessitating frequent or extended trips to the bathroom
may greatly reduce the productivity of claimants with IBD without
necessarily causing any exertional limitations.
At any point after step one of the sequential evaluation, if the medical
evidence initially provided by the claimant or obtained by the DDS is
insufficient, the adjudicator may re-contact the claimant's own doctors or
request a "consultative examination" paid for by SSA. If necessary-for
example, for conditions or symptoms that are difficult to document or
measure-the adjudicator may ask the claimant to provide more information
by, for example, filling out a pain or fatigue questionnaire, or an
activities of daily living (ADL) form. To corroborate a claimant's
allegations of functional limitations, the adjudicator may ask third
parties, such as friends or relatives, about the claimant's ability to
perform various tasks in their daily lives. For a claimant with IBD, for
example, the adjudicator may need such additional information to
corroborate allegations of severe pain, fatigue, or diarrhea.
Each step of the sequential evaluation process may require adjudicators to
obtain and consider more and different types of evidence and to make
increasingly complex judgments. For example, at the first step, only the
amount of earnings is needed. In contrast, at steps four and five,
adjudicators must evaluate medical evidence along with nonmedical
evidence, including the claimant's activities of daily living and past
work experience. In addition, the adjudicator may need to make difficult
assessments of subjective factors, such as the claimant's physical or
mental capacity with respect to a variety of settings and situations, the
weight to place on treating source opinions, and the claimant's
credibility with respect to allegations of pain, fatigue, and other
symptoms.
While the five-step evaluation process is the same at all levels, there
are
differences between the decision-making levels that can affect how
adjudicators make decisions on cases. For example, a report by the Social
Security Advisory Board (SSAB) in 200110 identified some fundamental
differences in the decision-making process between the DDS and hearings
levels that could potentially affect the overall consistency of disability
decision making between the two levels, including the following:
o Most DDS decisions are made without a face-to-face contact with the
claimant, while the claimant typically appears at an ALJ hearing.
o Attorneys and other representatives are typically involved at the
hearings level, but not at the DDS levels.
o The law allows claimants to introduce new evidence and allegations-of
either new impairments or worsening of prior impairments over time-at each
stage of the appeals process.
o Different quality assurance procedures are applied to the DDS- and
hearings-level decisions.
10Social Security Advisory Board, Charting the Future of Social Security's
Disability Programs: The Need for Fundamental Change (Washington, D.C.:
January 2001).
Claimants with IBD and Other Impairments Face Similar Challenges Applying for
DI, and SSA Efforts May Address Some Claimant Concerns
While claimants with IBD have somewhat lower allowance rates than other
claimants, the experiences of these individuals are not unique relative to
claimants with other impairments. When we compared disability decisions
for claimants with IBD with those for other claimants, we found that much
like other claimants, claimants with IBD had lower allowance rates at the
DDS (initial and reconsideration) levels, but higher allowance rates at
the hearings level, although the differences between levels are more
pronounced for claimants with IBD. Allowance rates that are lower at the
DDS level and higher at the hearings level may reflect challenges that
claimants with IBD share with other claimants. For example, IBD and other
claimants face challenges meeting or equaling SSA's medical criteria at
step three of the process at all adjudication levels. In addition, IBD and
other claimants are less likely to be allowed at step five of the process
at the DDS levels compared to the hearings level. Also like many other
claimants, claimants with IBD may not be sufficiently aware of the types
and importance of information they need to provide to support an allowance
at step five of the process at the DDS levels. SSA is pursuing efforts
that may address some of the difficulties encountered by IBD and other
claimants.
While the Experience of Claimants with IBD Is Not Unique, Their Overall
Allowance Rate Is Somewhat Lower Compared to Other Claimants
Our analysis showed that, although the experience of claimants with IBD is
not unique, they tend to be allowed at lower rates compared to many other
claimants. For example, when we analyzed overall allowance rates,11 we
found that claimants with IBD were allowed 33 percent of the time, whereas
all other claimants were allowed 39 percent of the time. Because
impairments with low allowance rates and a very large number of claims
associated with them, such as hypertension or epilepsy, could skew these
results, we also calculated individual overall allowance rates for IBD and
216 other impairments to determine whether they were significantly higher
than, lower than, or similar to the overall allowance rate for claimants
with IBD.12 As shown in table 1, while we found that the majority of
impairments had statistically higher overall allowance rates, many other
impairments had similar or lower overall allowance rates.
11To calculate overall allowance rates, we divided the number of
allowances at all levels (initial, reconsideration, and hearings) by the
number of decisions at all levels.
12The number of impairments we included in this analysis (218, including
the two IBD impairments, ulcerative colitis, and Crohn's disease) was
determined by identifying all primary impairments listed in the 2003
decisions, minus those involving fewer than 100 decisions in 2003.
Table 1: Comparison of Overall Allowance Rates for IBD versus Other Impairments
Other impairments compared Number of Total
to IBD impairments decisions
Significantly higher 122 1,034,956
Statistically similar 29 61,941
Significantly lower 65 885,633
Source: GAO analysis.
Notes: Analysis based on SSA DI disability decisions in 2003 at DDS and
hearings levels.
Impairments are classified as having higher, similar or lower allowance
rates than IBD, based on results from statistical models that estimate the
direction, size, and significance of the difference between each
impairment and IBD. Higher and lower impairments are those whose
difference from IBD is significant at the .05 level.
When we analyzed allowance rates by adjudication level (DDS versus
hearings levels), we found that, like many claimants with other
impairments, claimants with IBD experienced lower allowance rates at the
DDS and higher allowance rates at the hearings level.13 At the same time,
we found that the differences between claimants with IBD and all other
claimants were more pronounced when we analyzed the DDS and hearings
levels separately than when we combined them. Specifically, at the DDS
(initial and reconsideration) levels, the allowance rate for claimants
with IBD was 12 percentage points lower than the average allowance rate
for all other claimants (see table 2). In contrast, at the hearings level,
the allowance rate for claimants with IBD was 10 percentage points higher
than the average rate for all other claimants included in this analysis.
However, when we computed the overall allowance rate, the two levels
offset each other, resulting in a difference of only 6 percentage points.
13Although the allowance rate at the DDS is lower than the rate at the
hearings level, this does not mean that fewer people were allowed at the
DDS than at the hearings level. In fact, of the 2,257 claimants with IBD
who were allowed at either level in 2003, 55 percent (or 1,241) were
allowed at the DDS level. Similarly, of those claimants with other
impairments who were allowed at either level, 76 percent (584,613) were
allowed at the DDS level.
Table 2: Allowance Rates for Claimants with IBD versus Other Claimants by
Decision-Making Level
Allowance rate
Percentage point difference between Decision-making Claimants Other
allowance rates for claimants with level with IBD claimants IBD and other
claimants
DDS (initial &
reconsideration) 22% 34% -12*
Hearings 86% 76% 10*
All levels 33% 39% -6*
Source: GAO analysis.
Notes: Analysis based on SSA DI disability decisions in 2003 at DDS and
hearings levels.
Asterisks indicate differences between claimants with IBD and claimants
with other impairments that are significant at the .05 level. The error
associated with the estimated allowance rates for claimants with IBD is
+/- 2 percent or less; the error associated with the estimated allowance
rates for all other claimants is +/- 1 percent or less.
There may be legitimate reasons for some of the differences in allowance
rates between adjudication levels and between claimants with IBD and
claimants with other impairments at the different levels, but pinpointing
these reasons through data analysis is difficult. Relatively high
allowance rates at the hearings level could be due to new evidence
reflecting new impairments or worsening of alleged impairments or the fact
that the evidence covers a longer period of time, a potentially important
factor for individuals with episodic impairments like IBD. With respect to
variance in allowance rates between impairment groups, given the different
types and characteristics of impairments, it is reasonable that all
impairments should not necessarily have the same allowance rate,
regardless of adjudication level. Further, rather than analyzing claims
filed in a given year and following their outcomes through the various
decision-making levels, we analyzed data representing decisions at all
levels for 1 year. As a result, decisions at each level generally involved
different claimants with varying characteristics (such as age, impairment
severity, and work history) that influence decisions and might account for
some of the differences. To analyze whether differences in IBD allowance
rates by level are legitimate would require a much more complex analysis,
following a year of applicants through the entire process and controlling
for many factors that may influence the decision-making process. Even with
such an analysis, it would be difficult to draw firm conclusions because
some key data-such as detailed information on changes in the claimant's
medical condition at the different decision-making levels-are not readily
available for analysis.
Claimants with IBD and Other DI Claimants Encounter Similar Challenges in
the Evaluation Process
Challenges Encountered at Step Three
Lower allowance rates at the DDS and higher allowance rates at the
hearings level may reflect challenges that IBD and many other claimants
encounter in SSA's disability evaluation process. For example, many
claimants do not meet or equal SSA's medical criteria at step three of the
process, regardless of adjudication level. In addition, claims that do not
meet or equal the medical criteria at step three and are evaluated at
steps four and five are less likely to be allowed at step five at the DDS
than at the hearings level. Finally, claimants may not be made
sufficiently aware of the importance of documenting how the impairment
limits their ability to work, information that is critical to steps four
and five of the evaluation process. This lack of documentation may place
them at a disadvantage, particularly at the DDS level.
Both DI claimants with IBD and many other claimants face challenges
meeting or equaling SSA's medical criteria at step three of the sequential
evaluation process when their impairments are evaluated according to SSA's
medical criteria. Our analysis showed that the allowance rate at step
three was low (20 percent or less) for claimants with IBD, as well as for
claimants with other impairments, regardless of adjudication level (see
table 3).
Table 3: Allowance Rates for Disability Decisions at Step Three by
Decision-Making Level
Allowance rate at step three
Decision-making level IBD Other impairments
DDS (initial & reconsideration) 16%* 20%
Hearings 17% 17%
All levels 16%* 20%
Source: GAO analysis.
Notes: Analysis based on SSA DI disability decisions in 2003 at DDS and
hearings levels.
Allowance rates at step three were derived by dividing allowances at step
three by all claims considered at step three. Asterisks indicate
differences between claimants with IBD and claimants with other
impairments that are significant at the .05 level. The error associated
with the estimated allowance rates for claimants with IBD is +/- 2 percent
or less; the error associated with the estimated allowance rates for all
other claimants is +/-1 percent or less.
To further analyze whether claimants with IBD experienced similar
challenges meeting or equaling SSA's medical criteria at step three
relative to other claimants, we calculated how many other types of
impairments had statistically higher, similar, or lower allowance rates
overall and by adjudication level. As shown in table 4, over 45 percent of
other
impairments had similar or lower allowance rates at step three, regardless
of adjudication level.
Table 4: Comparison of Allowance Rates at Step Three for IBD versus Other
Impairments by Decision-Making Level
Allowance rates of
Decision-making other impairments Number of Total
level compared to IBD impairments decisions
DDS (initial &
reconsideration) Significantly higher 115 710,132
Statistically similar 31 109,838
Significantly lower 70 918,970
Hearings Significantly higher 48 64,061
Statistically similar 124 36,204
Significantly lower 44 143,325
All levels Significantly higher 117 803,653
Statistically similar 23 88,237
Significantly lower 76 1,090,640
Source: GAO analysis.
Notes: Analysis based on SSA DI disability decisions in 2003 at DDS and
hearings levels.
Allowance rates at step three were derived by dividing allowances at step
three by all cases considered at step three.
Impairments are classified as having higher, similar or lower allowance
rates than IBD, based on results from statistical models which estimate
the direction, size and significance of the difference between each
impairment and IBD. Higher and lower impairments are those whose
difference from IBD is significant at the .05 level.
Meeting or equaling SSA's medical criteria may be a problem for many DI
claimants, although the reasons may vary by impairment. Originally, the
medical criteria were developed as a way to quickly screen the large
majority of cases that could be allowed on reasonably objective medical
tests. However, over the years, SSA has experienced a general decline in
the percentage of DI claims awarded on the basis of meeting or equaling
the medical criteria at the DDS level, from 82 percent to 58 percent
between 1983 and 2000. There are many factors that may have contributed to
the decline in allowance rates at step three, including advances in
medicine that can affect the applicability or usefulness of listings, the
general aging of the baby boomer generation, the mix of impairments over
the years, the addition of functional criteria to some listings that make
it more difficult for claimants to meet or equal the listings, changes in
or clarifications of SSA policies, and economic swings that may affect the
number or percentage of claimants with very severe disabilities.
In addition, claimants with IBD and other claimants may encounter problems
meeting or equaling the medical criteria in part because SSA's criteria
may not be up to date and complete. According to doctors in the IBD
community, the IBD medical criteria in step three do not consider some
symptoms of IBD that may prevent a claimant from working, such as severe
diarrhea. For example, a claimant diagnosed with IBD may experience a
level and frequency of diarrhea that precludes working, but that symptom
is not part of the medical criteria for IBD. In general, we previously
reported that SSA's progress in updating its IBD and other medical
listings has been slow and may not be keeping pace with medical
advancements.14 However, we did not determine and do not know whether
updates to non-IBD listings would improve the likelihood of DI claimants
meeting or equaling SSA's medical criteria at step three of the process.
Claimants with IBD and others who are evaluated at steps four and five of
the sequential evaluation process may also encounter challenges being
allowed at the DDS versus the hearings level. As shown in table 5, our
analysis found that step five allowance rates were higher at the hearings
level than at the DDS levels for both claimants with IBD and claimants
with other impairments, but the difference is even greater for claimants
with IBD.
Challenges Encountered at Steps Four and Five
Table 5: Allowance Rates for Disability Decisions at Step Five by
Decision-Making Level
Allowance rate at step five Decision-making level Claimants with IBD Other
claimants
DDS (initial & reconsideration) 13%* 25%
Hearings 85%* 74%
All levels 27%* 32%
Source: GAO analysis.
Notes: Analysis based on SSA DI disability decisions in 2003 at DDS and
hearings levels.
Because only denial decisions are possible at step four, allowance rates
at step five were derived by dividing allowances at step five by all
claims considered at steps four and five. Asterisks indicate differences
between claimants with IBD and claimants with other impairments that are
significant at the .05 level. The error associated with the estimated
allowance rates for claimants with IBD is +/- 2 percent or less; the error
associated with the estimated allowance rates for all other claimants is
+/-1 percent or less.
14GAO, SSA and VA Disability Programs: Re-Examination of Disability
Criteria Needed to Help Ensure Program Integrity, GAO-02-597 (Washington,
D.C.: Aug. 9, 2002).
The relatively high allowance rates at step five of the hearings level may
be due to a number of factors, including the presence of an attorney or
nonattorney representative at the hearings level or the fact that the
evidence covers a longer period of time, a potentially important factor
for individuals with episodic impairments like IBD. As noted earlier, each
step of the process requires increasingly complex judgments by
adjudicators, and being represented by an attorney or nonattorney who is
familiar with SSA's complex rules and decision-making process may help
claimants better present their cases. A GAO report in 200315 found that
claimants who were represented by an attorney (or a person who is not an
attorney, such as a legal aide, relative, or friend) were more likely to
be allowed than claimants who had no representative. The report also noted
three possible reasons for the increased likelihood of being awarded
benefits for those represented by an attorney: attorneys provide
assistance with the development of evidence over and above SSA's efforts
to develop evidence; attorneys prepare claimants, to improve their
effectiveness and credibility as witnesses; and attorneys may screen cases
to select claimants with strong cases. In 2004, for 68.4 percent of all
hearings-level decisions, the claimant was represented by either an
attorney or a nonattorney. In contrast, claimants generally do not acquire
attorneys or other representation to assist them with filing their claims
at the DDS levels, although they are allowed to do so.
In the past, SSA and GAO have reported that potential inconsistencies
between the interpretation and application of standards at the DDS levels
versus the hearings level might explain higher allowance rates at step
five at the hearings level.16 For example, GAO reported on SSA studies
that found that ALJs were more likely than DDS adjudicators to find that
claimants are credible with respect to allegations of pain, fatigue, and
other symptoms not identifiable in laboratory tests or confirmable by
medical observations.17 In addition, past SSA studies have found that the
different roles that medical staff play at the two levels can affect
15GAO, SSA Disability Decision Making: Additional Steps Needed to Ensure
Accuracy and Fairness of Decisions at the Hearings Level, GAO-04-14
(Washington, D.C.: Nov. 12, 2003).
16Secretary of Health and Human Services, Implementation of Section 304
(g) Public Law 96-265, Social Security Disability Amendments of 1980, the
Bellmon Report
(Washington, D.C.: January1982).
17GAO, Social Security Disability: SSA Must Hold Itself Accountable for
Continued Improvement in Decision-making, GAO/HEHS-97-102 (Washington,
D.C.: Aug. 12, 1997).
allowance rates at step five. Specifically, SSA studies have found that
DDS medical staff (who generally perform assessments of claimants' RFC
themselves) tend to find that claimants had higher capacities to function
in the workplace than ALJs (who may consult with medical experts, but have
sole authority to make the RFC finding), even when these different
adjudicators were given the same cases to review.
To help address these inconsistencies, SSA began process unification
efforts in 1994 to ensure that both levels more consistently interpreted
and applied SSA's policy guidance. These efforts included creating
additional policy guidance by publishing rulings and regulations to
clarify such policy areas as credibility, pain, and the weight given to
the opinion of the treating physician. However, GAO reported in 200418
that SSA has not adequately assessed the impact of its process unification
efforts and has yet to perform assessments that provide a clear
understanding of the extent or causes of possible inconsistencies in
decisions between adjudicative levels.
Challenges associated with claimants understanding the application process
and providing critical information to support their claim, particularly at
steps four and five, are common among claimants, regardless of their
impairment. Having complete information to support a step five allowance
is particularly significant because, according to the Social Security
Advisory Board,19 the percentage of claims allowed at step five has more
than doubled, from 18 percent of all awards in 1983 to nearly 42 percent
in 2000. However, representatives of stakeholder groups we spoke with
believe that many claimants, including those with IBD, may be unaware of
the importance of including detailed information on how their impairment
limits their ability to work. In fact, some doctors and officials in the
IBD advocacy community whom we interviewed believed that if a claimant's
impairment did not meet or equal the medical listings, the claim would be
denied. They were unaware of steps four and five in the sequential claim
evaluation process, where nonmedical factors are considered.
Difficulties Understanding the Application Process
18GAO, Social Security Administration: More Effort Needed to Assess
Consistency of Disability Decisions, GAO-04-656 (Washington, D.C.: July 2,
2004).
19Social Security Advisory Board, Disability Decision Making: Selected
Aspects of Disability Decision Making (Washington, D.C.: January 2001).
Unless sufficiently prompted by SSA, claimants might not provide enough
information when they file their claim about how their impairment limits
their ability to work, which could reduce the likelihood of an allowance
at step five at the DDS level. In our review of 20 disability claim
folders for claims decided in 2003, we found that the prior version of the
adult disability report did not clearly state the importance of providing
detailed and complete information about how the impairment limited the
ability to work. In responding to the question on the paper disability
report then used, some claimants provided only minimal information,
sometimes just a few words. For example, one claimant responded to the
question about how his impairment limited the ability to work by saying
"pain, limited movement." In another case that was denied at the initial
DDS level, the claimant provided minimal information concerning how the
impairment limited work activities.
In contrast, the new interactive adult disability report on the agency's
Web site contains instructions, explanations, and examples that assist
claimants in filling out the report. For example, in asking about how the
impairment limits the claimant's ability to work, the report notes: "This
is one of the most important pages in the report." It goes on to explain
that, "You can help your case by giving us a detailed description of all
of your conditions, and any symptoms that limit your ability to work.
Please do not assume that your condition is self-explanatory." The report
also provides examples of how to document the conditions and symptoms that
may limit the ability to work, including the type of information and level
of detail needed, such as "I have trouble concentrating and have become
more and more forgetful. My friend at work reminds me about important work
assignments. Once I forgot to take the daily receipts to the bank.
Sometimes I can't remember how to add or subtract." However, to view the
on-line instructions, explanations and examples given in the interactive
adult disability report, a claimant must provide a name and legitimate
Social Security number, fill out the report, and reach the section asking
how the impairment limits the ability to work. Further, these more
detailed instructions and examples are directly available only to those
claimants who apply on line, which accounts for only about two percent of
claimants, according to an SSA official. Since the majority of applicants
apply in person or over the phone, most claimants never see this
information.
For the majority of claimants who apply in person or over the phone, SSA
field staff have the option of reviewing and reading to claimants examples
that illustrate the types and importance of information requested.
However, the Social Security Advisory Board and others believe that field
staff lack the time to sufficiently explain program rules and procedures
so that applicants can understand what items of information they need to
document their case. SSA does not track, and we did not determine, the
extent to which SSA field staff read this information to claimants
applying in person or over the phone.
Brochures and other information are available on line and routinely
provided by SSA to claimants when they arrange an appointment to file a
disability claim. SSA provides this information in order to help ensure
that claimants can gather the information needed and have it available
when they meet with the claims representative to complete the application.
However, this information does not explain the type of information and
level of detail needed if the impairment does not meet or equal the
medical criteria at step three and the claim must be decided at steps four
and five. As a result, claimants may not be sufficiently informed to give
SSA enough information at the time of application to support the
allegation that their impairment makes them unable to work.
Another opportunity exists for the DDS to collect information from
claimants that is relevant to steps 4 and 5 in the evaluation of the
initial claim. Specifically, DDS procedures call for the adjudicator to
request additional information from the claimant, if (1) it is warranted
based on the disability alleged by the claimant and (2) the information is
not already in the adult disability report completed by the claimant or by
field staff for the claimant. Requested information might include
responses to a pain or fatigue questionnaire or an activities of daily
living form. Again, SSA does not track, and we did not determine, the
extent to which this is done.
SSA's Efforts May Address Some Challenges Faced by Claimants with IBD and
Others
SSA is pursuing efforts that may address some but not all the difficulties
encountered by claimants with IBD and other claimants. The agency is
currently updating the medical criteria used at step three for all
impairments, including IBD and is taking into account the views of the
public in so doing. However, SSA officials told us that agency rules
prohibit the discussion of specific changes prior to their publication.
The process of updating criteria is lengthy, and the updates to the
medical criteria for IBD may not be completed until late in 2005.
SSA also has broader efforts under way that may affect future changes to
medical criteria. For example, SSA has begun holding public meetings to
discuss changes in medical criteria for certain impairments, such as
mental conditions and immune disorders, including HIV/AIDS. According to
SSA officials, this approach allows SSA to obtain valuable input from
outside the agency, prior to the drafting of proposed changes to medical
criteria. In addition, SSA has contracted with the Institute of Medicine,
part of the National Academy of Sciences (NAS), to conduct a broad review
of its medical criteria. This review will study such things as developing
the process for determining when the criteria need to be updated,
establishing feedback mechanisms to continuously assess and evaluate the
criteria, and examining the advisability of integrating functional
assessment into the criteria.
In addition to changes that affect IBD and other medical criteria, SSA has
several proposed changes currently under consideration that may improve
the consistency of decisions between the DDS and hearings levels.
Specifically, in 2004, GAO reported20 that most SSA stakeholders believe
the following proposals-announced by the Commissioner in 2003-may increase
the extent to which DDS and hearings-level adjudicators arrive at similar
decisions on similar cases
o requiring DDS adjudicators to more fully develop and document their
decisions;
o changing the quality control process for hearings-level decisions in a
way that makes it more consistent with that of the DDS level;
o providing both the DDS and the hearings levels with equal access to
more centralized medical expertise; and
o requiring ALJs to address agency reports that recommend either denying
the claim or outlining the evidence needed to fully support the claim.
SSA is also trying to improve all claimants' understanding of the
disability claims evaluation process, through the interactive adult
disability report and other information available on SSA's Web site. SSA's
Web site contains information on various aspects of the DI program,
including the evaluation process, and SSA periodically reviews and updates
information provided on its Web site. However, except for the interactive
adult disability report, SSA's Web site does not provide claimants with
detailed instructions, explanations, and examples to assist them with
completing the adult disability report.
20GAO-04-656.
Conclusions
Moreover, SSA recently developed a Disability Starter Kit, available on
the Web site and also given to all disability claimants who apply in
person or by phone, which provides answers to frequently asked questions
and materials to help them prepare for the disability interview. However,
the Disability Starter Kit does not include the instructions,
explanations, and examples available on the interactive adult disability
report, for describing how an impairment limits the ability to work and
the importance of providing this information.
Claimants with IBD believe that SSA tends to initially deny their claims,
only to allow them at the hearings level, and our analysis of 2003 DI
decisions confirms that most IBD claims are denied at the initial level,
and a high rate of claims are allowed upon appeal. However, we also found
that the experience of claimants with IBD is much like that of claimants
with many other impairments. This situation may be due in part to a
general shift away from allowing cases at the DDS level based on meeting
or equaling the medical criteria in the listings. This in turn results in
more and more cases being assessed at step five of the process-a step that
involves complex judgments concerning the RFC of the claimant and
assessments of factors like pain and the credibility of the claimant. Past
studies have found that relative to counterparts at the hearings level,
DDS adjudicators have been less inclined to find that claimants are
credible or cannot perform past or other work in the national economy, and
therefore less likely to allow claimants on these bases at step five of
the sequential process. Inconsistencies in how adjudicators at different
levels make decisions may help explain the relatively low allowance rates
at the DDS levels and high allowance rates at the hearings level for IBD
and other claimants whose impairments do not fit neatly into SSA's medical
criteria and generally require adjudicators to perform more complex and
subjective assessments. SSA has some efforts under way that may address
some of these issues, but it is too early to gauge success. For example,
SSA is updating its medical criteria for IBD and other impairments, but
SSA is unable to discuss any changes prior to publication. SSA also
contracted with the NAS to conduct a broad review of its medical criteria.
However, this effort is in its initial stages, and the NAS report is not
expected until March of 2006. SSA has also proposed several changes to its
decision-making process that may address inconsistencies in how
adjudicators at different levels view cases. However, as we previously
recommended, SSA needs to collect better information to help it determine
whether problems with inconsistency have been resolved.
Recommendations
We also found that SSA's application and claims evaluation process may not
be well understood by many claimants, and thus some claimants may not
provide SSA with all the information necessary for their initial
decisions. SSA's on-line adult disability report provides useful
instructions, explanations, and examples to the small percentage of
claimants who actually fill out the report on line. However, that
information cannot easily be viewed on SSA's Web site and is not available
in the other materials provided to applicants. Further, for the majority
of claimants who file in person or on the phone, SSA lacks assurance that
SSA field staff explain to claimants the types and importance of
information needed to support a claim assessed at steps four and five of
the process. As a result, claimants may not be providing sufficient
information on how their impairments prevent them from working, and SSA
may be missing the opportunity to gather key information for meeting one
of its key strategic objectives, that is, to make the right decision in
the disability process as early as possible.
To help ensure that claimants with IBD and other claimants are informed of
and ultimately provide SSA with information critical to a complete
assessment of their impairment at the earliest possible point in the
decision-making process, SSA should implement the following three
recommendations:
o Update its Web site to include more accessible information that
clarifies the type and importance of information that claimants must
submit for steps four and five of the sequential evaluation process. SSA
should also consider making the information currently in its interactive
adult disability report-including instructions, explanations and
examples-more readily available to all claimants on its Web site.
o Update the Disability Starter Kit-which is provided to all claimants
who apply by phone or in person-to include an explanation of the types and
importance of information that claimants must submit for steps four and
five of the sequential evaluation process. SSA should consider adding
instructions, explanations, and examples that are currently available in
the on-line form, to the extent that it is cost-effective to do so.
o Explore options for ensuring that field office and DDS staff
appropriately explain and collect the types of information needed to
assess how claimants' impairments impact their ability to work.
Agency Comments
and Our Evaluation
We provided a draft of this report to SSA for comment. SSA agreed with our
recommendations. Specifically, SSA agreed with our first recommendation
and will take the steps necessary to ensure that, at a minimum, the
information currently available in the interactive adult disability report
is available to all claimants on the Web site. In its response to our
second recommendation, SSA said that it would consider the inclusion of
information and/or instructions along with other suggestions to the
Disability Starter Kit that would address the importance of obtaining
information from the disability applicant about steps four and five of the
sequential evaluation process, taking into account factors such as expense
and space. SSA agreed with our third recommendation and will continue to
emphasize and train DDS and Social Security employees on the importance of
appropriately explaining all aspects of the disability process to
claimants and ensuring that the appropriate information is provided to and
received from the claimants.
Although SSA agreed with our recommendations, the agency expressed concern
with two statements in our report. SSA stated that our report discussed
issues the agency considers irrelevant to our study of DI claimants with
IBD-the addition of functional criteria to the listings for impairments
other than IBD and the decline in DI allowances based on medical criteria.
To respond to agency concerns, we de-emphasized our discussion of
functional criteria in the listings by simply identifying it as one of
many reasons for the decline in allowance rates at step three. We also
clarified in our "Conclusions" section that we were discussing a decline
in allowances at step three, rather than a decline in allowances based on
medical criteria. However, we believe that the addition of functional
criteria to the listings is relevant to our study, as is the decline in
allowance rates at step three, because they provide perspective on whether
claimants with IBD are treated differently than claimants with other
impairments. SSA also expressed concern with how we characterized part of
our analysis in the "Conclusions" section, and we modified the text in the
"Conclusions" to be more specific about what our analysis found.
SSA provided additional general comments, which we have included (along
with our responses to them) in appendix II and addressed in the body of
our report where appropriate. SSA also provided technical comments that we
have incorporated in the report as appropriate.
We are sending copies of this report to the appropriate congressional
committees, the Social Security Administration, and other interested
parties. We will also make copies available to others on request. In
addition, the report will be available at no charge on GAO's Web site at
http://www.gao.gov.
If you or your staff have any questions concerning this report, please
contact me or Michele Grgich, Assistant Director, at (202) 512-7215. You
may also reach us by e-mail at [email protected] or [email protected].
Other major contributors to this assignment were Jill D. Yost,
Ann T. Walker, Corinna Nicolaou, Daniel Schwimer, Doug Sloane, and
Shana Wallace.
Robert E. Robertson Director, Education, Workforce, and Income Security
Issues
Appendix I: Scope and Methods
To determine whether claimants with IBD were treated differently than
claimants with other impairments, we analyzed SSA data from 2003 on all
Disability Insurance (DI) decisions made at three decision-making levels
(initial, reconsideration, and hearings), and compared allowance rates for
claimants with IBD to those for claimants with other impairments. This
appendix describes (1) the sources of the data we used, (2) the scope of
our analysis, (3) steps we took to ensure data reliability, and (4) our
methods for analyzing the data.
Data Sources
o
o
Scope
Data Reliability
We collected information from two sources on all DI decisions made in 2003
at the three decision-making levels
SSA's 831 file (also referred to as the National Disability Determinations
Services System), which contains an electronic record of all initial and
reconsideration decisions made at the DDS and
SSA's Case Control System (CCS), which contains an electronic record of
all decisions made at the hearings level.
The Research Review Act mandated GAO to study problems encountered by
patients with IBD when applying for DI benefits under Title II of the
Social Security Act. Therefore, we limited our data analyses to decisions
that involved Title II (Disability Insurance or DI) claims.1 We restricted
our analyses to DI decisions that resulted in an allowance or a denial at
one of the five steps2 in the sequential process and excluded cases denied
for such reasons as lack of cooperation or failure to follow prescribed
treatment, because such denials are not associated with one of the five
steps.
We determined that the 831 and CCS files were sufficiently reliable based
on reliability assessments of specific variables and records pertinent to
our analyses that we had performed for a previous report.3 For that
report,
1Some of these DI decisions involved a concurrent claim, that is, the
claimant filed for DI and SSI concurrently and a decision of disability is
the same for both programs.
2Although most step one denials were made at an SSA field office and were
not included in our analysis, a small number of claims (1,563, or less
than 0.1 percent) were denied at step one at the DDS and hearings levels.
3GAO, SSA's Disability Programs: Improvements Could Increase the
Usefulness of Electronic Data for Program Oversight, GAO-05-100R
(Washington, D.C.: Dec. 10, 2004).
Appendix I: Scope and Methods
we reviewed reports by GAO, the SSA Office of Inspector General, and SSA
contractors on data quality. We also interviewed staff responsible for
managing and using the data to assess the controls and processes in the
disability system and performed electronic testing of some variables. In
addition, for this report, we performed the following:
o We reviewed records in the 831 and CCS files representing DI decisions
made in 2003 to identify missing data for the three variables used in this
study: impairment, decision, and step of the sequential evaluation process
(i.e., regulation basis code). We did not find any instances of missing
data for these three variables.
o We reviewed impairment codes used for 2003 decisions and found records
that did not indicate a specific diagnosis (e.g., 6490, "impairment
unknown; insufficient medical evidence"). Because there were a large
number of records with such impairment codes, we retained them in our
analyses which compared claimants with IBD with all other claimants. After
we determined the differences in allowance rates based on the total number
of decisions regardless of impairment, we conducted a second analysis of
allowance rates that considered the allowance rate for each impairment
code. In the second analysis, we used impairment codes for which there
were 100 or more decisions in 2003, including those impairment codes that
did not indicate a specific diagnosis.
o We compared decision outcomes with the regulation basis code
indicating at which step the decision was made, and found cases with
obvious conflicts between the decision and the step. Specifically we found
records that were denied at step three (one case) or allowed at step four
(1,021 cases). The five-step evaluation process does not permit denials at
step three or allowances at step four, so we excluded these records from
our analysis. Given the large number of claims (approximately 2 million),
the error produced by the exclusion of these cases is very small.
Methods of Analysis In order to determine whether claimants with IBD were
in fact treated differently than claimants with other impairments, we
compared decision outcomes in two ways: (1) claimants with IBD versus all
other claimants, and (2) IBD impairments versus 216 other individual
impairments.
Claimants with IBD versus To determine the extent to which claimants with
IBD were allowed at a
All Other Claimants different rate than other claimants, regardless of
impairment type, we compared the allowance rate of claimants with IBD to
that of all other claimants. The allowance rate for IBD was calculated by
combining
Appendix I: Scope and Methods
decisions for the two IBD impairments-Crohn's disease and ulcerative
colitis. We then compared the percentage of claims allowed for those
impairments with the percentage allowed for all other claimants combined.
We estimated the sampling error associated with these percentages, given
the size of the samples on which they were based, and tested the
significance of the difference between them using a simple chisquare
statistic. The error associated with the estimated allowance rate for
claimants with IBD is +/- 2 percent or less. The error associated with
allowance rates for all other claimants is +/- 1 percent or less. We
tested the significance of the differences between claimants with IBD and
other claimants using the .05 level of significance.
As indicated in table 6 below, a total of nine comparisons were made using
these calculations. As noted in the table, the denominator for step three
comparisons included only cases considered at step three (i.e., cases that
were not denied at steps one and two), whereas the denominator for step
five included cases considered at steps four and five. The reason for the
difference is that assessments performed at steps four and five are highly
inter-related; for example, the RFC assessment performed at step four
would be used to support a denial at either step four or five, or an
allowance at step five. As such, it seemed appropriate to consider
allowances at step five relative to all decisions made at steps four and
five.
Appendix I: Scope and Methods
Table 6: Types of Comparisons Used in Report for IBD versus Other Impairments
Allowance rate for all steps of the sequential evaluation process
decisions
Allowance rate at step three
DDS allowances at step three divided by all cases considered at the DDS
level at step three
Allowance rate at step five
DDS allowances at step five divided by all cases considered at the DDS
level at steps four and five DDS (initial and DDS allowances
reconsideration) level divided by all DDS
Hearings level Hearings allowances divided by all hearings decisions
Hearings allowances at step three divided by all cases considered at the
hearings level at step three Hearings allowances at step five divided by
all cases considered at the hearings level at steps four and five
Overall (all decision2003 allowances 2003 allowances at
2003 allowances at step five divided by all 2003 decisions considered at
steps four and five
making levels)
divided by all 2003 decisions
step three divided by all 2003 decisions considered at step three
Source: GAO.
IBD Impairment versus 216 Other Individual Impairments
We performed separate analyses to determine whether claimants with IBD had
an allowance rate that was different from the allowance rates for
claimants with other impairments, or whether the allowance rate for
claimants with IBD was higher than for some other impairments, but lower
for others. We performed this extra step because we did not know whether
certain impairments might have a large number of records associated with
them, and therefore might have greatly influenced the allowance rates for
claimants with impairments other than IBD. This additional analysis
reveals where claimants with IBD fall in the range of allowance rates by
impairment, regardless of the number of claims associated with each
impairment.
The allowance rate for claimants with IBD was calculated as we did in the
first analysis described above. We used this allowance rate as the
reference category and employed categorical logistic regression models,
with 216 dummy variables for the other categories of impairments, to test
the direction and significance of the difference in allowance rates
between each of the other impairments and IBD. These models used Wald
statistics and .05 level of significance to test differences, and were
able to classify
Appendix I: Scope and Methods
other impairments as having significantly higher, statistically similar,
or significantly lower allowance rates than IBD.
A total of four comparisons were made by impairment: overall allowance
rate (all sequential evaluation steps and decision-making levels
combined), and step three at the DDS, hearings, and combined levels. We
reported the overall comparison as an extra test of the results of our
first analysis. We reported comparisons of impairments at step three
because this step involves an assessment by SSA adjudicators of medical
criteria by impairment. Although we also compared impairments at step
five, we did not report the comparison because we found the results to be
consistent with our analysis of claimants with IBD versus other claimants.
Appendix II: Agency Comments
Appendix II: Agency Comments
See comment 1.
See comments 1 and 2.
See comments 1 and 2.
Appendix II: Agency Comments
See comments 1 and 2.
See comment 3.
See comment 4.
See comment 5.
Appendix II: Agency Comments Appendix II: Agency Comments
Appendix II: Agency Comments
GAO Comments
1. In response to SSA's comments, we de-emphasized our discussion of
functional criteria in the listings by simply identifying it as one of
many reasons for the decline in allowance rates at step three. Although we
agree that functional elements have not been added to the medical criteria
for the IBD listings, we believe that the addition of functional criteria
to some listings is relevant to our study because they provide perspective
on whether claimants with IBD are treated differently than claimants with
other impairments. We also clarified our text in the "Conclusions" section
to discuss the decline in allowances based on meeting or equaling the
medical criteria in the listings (i.e., step three allowances), instead of
allowances based on medical criteria. In any case, we commend SSA for
contracting with the Institute of Medicine of the National Academy of
Sciences to study issues related to the listings.
2. We agree that a shift away from medical criteria toward more
functional criteria is only one of many possible explanations for the
downward trend of allowances at step three for DI claimants, and may not
specifically apply to claimants with IBD. As discussed in comment 1, we
modified our text in the body of the report and in the "Conclusions"
section to place less emphasis on this particular explanation.
3. We revised the text in the "Conclusions" section to state more
specifically what our analysis of 2003 decisions found.
4. We agree that, of those allowed, a larger number of allowances are
made at the initial level for claimants with IBD as well as for other
claimants, and we added a footnote to the body of the report confirming
this. However, SSA's point that most allowances occur at the initial level
does not detract from the importance of our discussion of relative rates.
The low rate of allowances at the DDS level means that a large majority of
claimants were initially denied, many of whom likely did not appeal their
initial decision. Our analysis does not allow us to say whether the high
allowance rate at the hearings level is a function of the merit of the
appealed cases or, if more of those denied claims had been appealed to the
hearings level (where more than half of claims are allowed), a larger
number of claims might have been allowed at the hearings level, and
therefore claims allowed by the DDS would be a smaller percentage of the
total number of allowed claims. Thus, reporting only the total number of
claims allowed at the different decision-making levels may not accurately
represent the situation.
5. See comment 3. We did not revise the "Conclusions" section further
because we believe the report sufficiently identifies a number of
Page 37 GAO-05-495 SSA Disability Decision Making
Appendix II: Agency Comments
legitimate reasons that may explain some of the differences in allowance
rates between adjudication levels.
(130442) Page 38 GAO-05-495 SSA Disability Decision Making
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