Social Security Disability Programs: Clearer Guidance Could Help 
SSA Apply the Medical Improvement Standard More Consistently	 
(03-OCT-06, GAO-07-8).						 
                                                                 
The Social Security Act requires that the Social Security	 
Administration (SSA) find an improvement in a beneficiary's	 
medical condition in order to remove him or her from either the  
Disability Insurance (DI) or Supplemental Security Income (SSI)  
programs. GAO was asked to (1) examine the proportion of	 
beneficiaries who have improved medically and (2) determine if	 
factors associated with the standard pose challenges for SSA when
determining whether beneficiaries continue to be eligible for	 
benefits. To answer these questions, GAO surveyed all 55	 
Disability Determination Services (DDS) directors, interviewed	 
SSA officials, and reviewed pertinent SSA data. 		 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-07-8						        
    ACCNO:   A61764						        
  TITLE:     Social Security Disability Programs: Clearer Guidance    
Could Help SSA Apply the Medical Improvement Standard More	 
Consistently							 
     DATE:   10/03/2006 
  SUBJECT:   Disability benefits				 
	     Eligibility criteria				 
	     Federal social security programs			 
	     Health policy					 
	     Persons with disabilities				 
	     Policy evaluation					 
	     Program evaluation 				 
	     Social security beneficiaries			 
	     Social security benefits				 
	     Standards evaluation				 
	     Assessments					 
	     Disability Insurance Program			 
	     SSA Disability Determination Program		 
	     Supplemental Security Income Program		 

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GAO-07-8

     

     * Results In Brief
     * Background
          * History of the Medical Improvement Standard and the Current
     * Few Beneficiaries Are Removed from the Disability Programs B
          * Few Beneficiaries Are Removed from the Programs Due to Medic
          * Few Beneficiaries Who Receive Full Medical Continuing Disabi
     * Several Factors Challenge SSA's Ability to Assess Whether Be
          * Limitations in SSA Guidance for Applying the Medical Improve
          * A Majority of DDSs Incorrectly Apply SSA Guidelines Stating
          * Other Factors May Make Assessing Medical Improvement Difficu
     * Conclusions
     * Recommendation
     * Agency Comments and Our Evaluation
     * GAO Contact
     * Staff Acknowledgments
     * GAO's Mission
     * Obtaining Copies of GAO Reports and Testimony
          * Order by Mail or Phone
     * To Report Fraud, Waste, and Abuse in Federal Programs
     * Congressional Relations
     * Public Affairs

Report to the Chairman, Committee on Finance, U.S. Senate

United States Government Accountability Office

GAO

October 2006

SOCIAL SECURITY DISABILITY PROGRAMS

Clearer Guidance Could Help SSA Apply the Medical Improvement Standard
More Consistently

GAO-07-8

Contents

Letter 1

Results In Brief 3
Background 4
Few Beneficiaries Are Removed from the Disability Programs Because They
Are Found to Have Improved Medically 12
Several Factors Challenge SSA's Ability to Assess Whether Beneficiaries
Continue to Be Eligible for Benefits 15
Conclusions 22
Recommendation 23
Agency Comments and Our Evaluation 23
Appendix I Scope and Methodology 26
Appendix II The Continuing Disability Review Evaluation Process 30
Appendix III Comments from the Social Security Administration 33
Appendix IV GAO Contact and Staff Acknowledgments 39
Related GAO Products 40

Figures

Figure 1: Current Medical CDR Evaluation Process 10
Figure 2: Average Percentage of All Beneficiaries Who Were Removed from
the DI and SSI Programs by Category (Fiscal Years 1999 to 2005) 13
Figure 3: Number of Full Medical CDRs Conducted and Resulting Benefit
Discontinuations (Fiscal Years 1999 to 2005) 15

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Abbreviations

ALJ administrative law judge

DDS Disability Determination Services

DI Disability Insurance

CDR Continuing Disability Review

CPD comparison point decision

POMS Program Operations Manual System

RFC residual functional capacity

SGA substantial gainful activity

SSA Social Security Administration

SSI Supplemental Security Income

United States Government Accountability Office

Washington, DC 20548

October 3, 2006

The Honorable Charles E. Grassley Chairman Committee on Finance United
States Senate

Dear Mr. Chairman:

In fiscal year 2005, the Social Security Administration (SSA) paid about
$126 billion to approximately 12.8 million beneficiaries under the
Disability Insurance (DI) and Supplemental Security Income (SSI) programs.
These disability programs provide income support and in most cases, access
to medical care for people unable to work due to physical or mental
impairments, or both. In recent years, both programs have grown and are
poised to grow even faster as the baby boom generation enters its
disability-prone years. For example, SSA expects that by 2010 the number
of DI beneficiaries and their eligible family members will increase by
more than one-third over 2001 levels.

SSA is required to conduct periodic continuing disability reviews (CDR) to
ensure that only eligible people continue to receive benefits. These
reviews assess whether individuals are still eligible for benefits based
on their current medical condition and ability to work, among other
criteria.1 When SSA was conducting these reviews in the early 1980s, there
were concerns that some beneficiaries were being arbitrarily removed from
the programs. In response, Congress passed the Social Security Disability
Benefits Reform Act of 19842 (the act), which among other things
established a medical improvement standard (the standard). Under this
standard, unless certain exceptions apply, SSA must find improvement in a
beneficiary's medical condition and that the individual is able to work in
order to discontinue benefits.3 If SSA determines that the standard has
been met in the course of conducting a CDR, the beneficiary may continue
to receive benefits until the individual receives another CDR (which
potentially could result in a discontinuation of benefits), dies, or
transitions into Social Security retirement benefits.

1 In addition to medical CDRs, SSA also conducts "work CDRs" where it
assesses if an individual's earnings exceeded program limits. Our analysis
only looked at medical CDRs. It did not include work CDRs.

2 Pub. L. No. 98-460 (1984).

3 For this report, we refer to "medical improvement" and individuals who
have "improved medically" as a finding that meets the requirements of the
medical improvement standard (improvement in a beneficiary's medical
condition that is related to the ability to work).

Since the standard has been implemented, some observers have suggested
that certain factors associated with the standard may lead SSA to continue
benefits for some individuals who might otherwise be able to work. Given
this observation and the continued growth in the DI and SSI programs, the
Senate Committee on Finance asked us to (1) examine the proportion of
beneficiaries who are removed from the disability programs because they
have improved medically and (2) determine if factors associated with the
standard pose challenges when determining whether beneficiaries continue
to be eligible for benefits.

To address these questions, we reviewed the act, regulations, and SSA
guidance and processes for evaluating whether beneficiaries continue to be
eligible for benefits. We examined SSA data on CDR outcomes for a 7-year
period (fiscal years 1999 to 2005). We looked only at DI and SSI adult
beneficiaries.4 We verified the statistical data on CDR outcomes,
interviewed knowledgeable officials about the data, and determined that
the data were sufficiently reliable for the purposes of our review.
Furthermore, we conducted a national survey of all 55 Disability
Determination Services (DDS) directors and received 54 completed responses
to achieve a response rate of 98 percent. In addition, we interviewed
various SSA officials, disability experts, and disability advocacy groups
regarding the standard. We also conducted site visits in three states
(Massachusetts, Texas, and California). We selected these states based on
several criteria, including number of disability beneficiaries, proportion
of CDRs that result in a discontinuation of benefits, and geographic
dispersion, among other criteria. During these visits, we conducted
in-depth interviews with 80 selected SSA officials, including DDS
directors, CDR supervisors, disability examiners, 5 and medical
specialists. We also interviewed regional office disability officials,
regional Office of Disability Adjudication and Review officials,
administrative law judges, and regional Office of Quality Performance
officials and examiners. Moreover, we reviewed selected CDR cases to
obtain examples of how the standard may impact decisions to continue or
discontinue benefits. In addition, we consulted with outside groups
including the Social Security Advisory Board and disability advocacy
groups. We conducted our work from October 2005 through June 2006 in
accordance with generally accepted government auditing standards. Appendix
I discusses our scope and methodology in more detail. The survey and a
tabulation of the results can be viewed at
http://www.gao.gov/cgi-bin/getrpt?rptno=GAO-07-4sp .

4 For the purposes of our study, we only assessed DI and SSI adult
beneficiaries who received a full medical CDR. We did not include children
or the "age 18 re-determinations" in our analysis since there are
differences between the medical CDR sequential evaluation processes for
adults and children. Also, we only assessed the outcome of the full
medical CDRs.

5 During our site visits, we met with 11 CDR supervisors and disability
examiners who the DDS directors selected as the most knowledgeable in
their office about the CDR process and the medical improvement standard.

                                Results In Brief

On average, each year about 13,800 beneficiaries, or 1.4 percent of all
the people who left the disability programs between fiscal years 1999 and
2005, were removed because SSA found that they had improved medically.
More beneficiaries leave the programs because they die or convert to
regular retirement benefits. Moreover, while CDRs are the agency's most
comprehensive tool for determining whether a recipient continues to have a
disability, on average, about 2.8 percent of beneficiaries who undergo a
CDR leave the DI and SSI programs due to medical improvement. For example,
in fiscal year 2005, SSA conducted about 333,000 medical CDRs and
discontinued disability benefits for about 10,300 recipients for medical
improvement.

Our review suggests that several factors associated with the standard pose
challenges for SSA's ability to assess whether beneficiaries continue to
be eligible for benefits. First, limitations in SSA guidance may result in
inconsistent application of the standard. For example, we found that SSA
does not clearly define the degree of improvement needed to meet the
standard, and the directors we surveyed reported using different
thresholds to show medical improvement. From our survey, 17 DDS directors
reported that a large or very large increase in a recipient's ability to
perform basic work activities is required to show medical improvement,
while 24 reported that a moderate increase is required. In addition, while
the act does provide for certain exceptions to medical improvement that
could result in additional individuals having their benefits discontinued
following a CDR, most of the disability examiners whom we spoke with on
our site visits (7 of the 11 examiners) told us that they were uncertain
about when to apply the exceptions. Second, incorrect application of one
element of the standard by a majority of DDSs-CDRs should be conducted on
a neutral basis, without a presumption that an individual continues to
have a disability-may make it difficult to determine if beneficiaries have
improved medically. Finally, we found that other factors, such as
inadequate documentation of evidence and the judgmental nature of the
decision process concerning what constitutes medical improvement may make
it difficult for SSA to determine whether a beneficiary remains eligible
for benefits. These problems have implications for the consistency and
fairness of SSA's medical improvement decision-making process. However,
due to data limitations, we were unable to determine the extent to which
these problems actually affect decisions to continue or discontinue
benefits.

We are recommending that the Commissioner of Social Security clarify
policies for assessing medical improvement. Areas that could benefit from
improved clarity in guidance include what degree of improvement is needed
to meet the standard, when the use of exceptions is appropriate, as well
as clarification for DDSs about presumption of disability when conducting
CDRs.

SSA generally agreed with our recommendation but expressed reservations
about the need for further guidance on the proper use of the exceptions to
medical improvement. SSA believed that its implementation of the statutory
exceptions is appropriate and that its instructions are consistent with
the intent of the law. We revised the report to more clearly highlight
that the need for further guidance stems from our discussions with
disability examiners, most of whom expressed uncertainty regarding the
application of the exceptions.

                                   Background

The Social Security Administration (SSA) administers two programs under
the Social Security Act that provide benefits to people with disabilities:
(1) Disability Insurance (DI) and (2) Supplemental Security Income (SSI).6
Established in 1956, DI is an insurance program that provides benefits to
workers who become unable to work because of a long-term disability.
Workers who have paid into the Social Security Trust Fund are insured
under this program. At the end of calendar year 2005, the DI program
served about 8.3 million workers with disabilities, their spouses, and
dependent children and paid out about $85 billion in cash benefits
throughout the year. Once found entitled, individuals continue to receive
benefits until they either die, return to work and earn more than allowed
by program rules, are found to have improved medically and are able to
work, or reach regular retirement age7 (when disability benefits convert
to retirement benefits).

6 Some disability recipients receive both DI and SSI benefits because of
the low level of their income and resources.

SSI serves people with disabilities on the basis of need, regardless of
whether they have paid into the Social Security Trust Fund. Created in
1972, SSI is an income assistance program that provides cash benefits for
disabled, blind, or aged people who have low income and limited resources.
At the end of calendar year 2005, the SSI program served about 6.8 million
people and paid about $36 billion in federal cash benefits throughout the
year.8 These cash benefits are paid from general tax revenues. SSI
benefits generally can be discontinued for the same reasons as DI
benefits, although SSI benefits also may be discontinued if a person no
longer meets SSI income and resource requirements. Unlike the DI program,
SSI benefits can continue even after the person reaches full retirement
age.

The Social Security Act's definition of disability for adults is the same
under both programs. A person's physical or mental impairment must (1)
have lasted or be expected to last at least 1 year or to result in death
and (2) prevent or be expected to prevent him or her from being able to
engage in substantial gainful activity (SGA) for that period of time.
People are generally considered to be engaged in SGA if they earn above a
certain dollar level. For 2006, SSA considers countable earnings above
$860 a month to be SGA for an individual who is not blind and $1,450 a
month for an individual who is blind.

History of the Medical Improvement Standard and the Current Continuing
Disability Review Process

Prior to 1980, some studies indicated that many beneficiaries of the
disability programs no longer had a disability and could work. To ensure
that only eligible beneficiaries remained in the programs, Congress passed
a law requiring SSA to conduct continuing disability reviews (CDR)
beginning in January 1982. State Disability Determination Services (DDS)
examiners began conducting medical CDRs under the same criteria used to
evaluate initial disability claims. In 1981 and 1982, about 45 percent of
those individuals who received a CDR had their benefits discontinued.9
There was no statutory requirement for SSA to show that a beneficiary had
improved medically in order to remove him or her from the programs.
Disability advocacy groups and others became concerned that some
beneficiaries were being inappropriately removed from the disability
programs, and by 1984 SSA placed a moratorium on all CDRs.

7 Beginning at age 62, workers receiving DI benefits may elect to receive
retirement benefits in lieu of disability benefits.

8 Of these beneficiaries, about 5.7 million were blind or had a disability
and received about $31.8 billion in benefits. About 1.1 million
beneficiaries did not have a disability, but were aged and received about
$4.1 billion in benefits.

To address concerns that some beneficiaries were being inappropriately
removed from the programs, Congress enacted the Social Security Disability
Benefits Reform Act of 1984. The act included a provision requiring SSA to
find substantial evidence demonstrating medical improvement before ceasing
a recipient's benefits (the medical improvement standard). SSA resumed
CDRs in January 1986 using this standard, which is among the first steps
of the CDR evaluation process.10 The standard has the following two
elements that need to be met

           o  Is there improvement in a beneficiary's medical condition? The
           regulations implementing the act define improvement as any
           decrease in the medical severity of the beneficiary's
           impairment(s) since the last time SSA reviewed his or her
           disability, based on changes in symptoms, signs, or laboratory
           findings.

           o  Is this improvement related to the ability to work? Improvement
           related to the ability to work is evaluated two different ways,
           depending on whether the comparison point decision (CPD) was based
           on: (1) meeting or equaling a prior disability listing11 or (2) a
           residual functional capacity (RFC) assessment.12

                        o  Meeting or equaling the prior listing: In this
                        case, a disability examiner will determine if the
                        beneficiary's same impairment(s) still meets or
                        equals the prior listing. A disability examiner
                        compares the beneficiary's condition with the list of
                        impairments in effect at the time he or she was first
                        awarded disability benefits.13 If the impairment(s)
                        meets or equals the prior listing, then benefits are
                        continued. If not, then the examiner proceeds with
                        the CDR evaluation.

                        o  Residual functional capacity assessment: In this
                        case, a disability examiner compares the
                        beneficiary's previous functional capacity to the
                        current functional capacity for the same impairment.
                        If functional capacity for basic work activities has
                        improved, then the examiner finds that the medical
                        improvement is related to the ability to work and
                        proceeds with the CDR evaluation.

9 SSA officials noted that the discontinuation rate in the early 1980s may
not have been representative of the results of the CDR process before the
implementation of the medical improvement standard. SSA officials stated
that in response to reports that suggested that many individuals who did
not have a disability were receiving benefits, an aggressive effort was
initiated in 1981 to remove individuals from the DI program whose
impairments were not severe enough to entitle them to benefits. The agency
reported that this effort focused on beneficiaries who were deemed at the
time most likely to be determined not to have a disability and led to a
large, temporary increase in the number of DI program discontinuances in
the early to mid-1980s.

10 Before disability examiners assess if a beneficiary has improved
medically, they first assess if the beneficiary is working at the level of
SGA. If beneficiaries are working at or above the SGA level, then benefits
are discontinued. If not, then the CDR process proceeds to the second
step.

The act allows SSA to discontinue benefits even when the beneficiary has
not improved medically if one of the specific "exceptions" to medical
improvement applies14

           o  the person benefits from advances in medical or vocational
           therapy or technology,
           o  the person has undergone a vocational therapy program that
           could help him or her work,
           o  new or improved diagnostic techniques or evaluations reveal
           that the impairment is less disabling than originally thought, or
           o  the prior decision was in error.

11 SSA maintains a list of impairments that, by definition, are so severe
that they are disabling.

12 The assessment of a beneficiary's actual ability to work comes later in
the CDR process (steps 7 and 8). See appendix II for a more detailed
description of the CDR process.

13 At this step of the evaluation, a disability examiner considers only
the listings that were met (or equaled) the last time the beneficiary was
evaluated, not all of the listings that existed at the time of the last
review.

14 In addition to the Group I exceptions listed above, benefits may also
be discontinued if a DI beneficiary is engaging in substantial gainful
activity. The act also provides for other situations (called Group II
exceptions) where SSA can discontinue either DI or SSI benefits. Group II
exceptions are: (a) the prior determination or decision was fraudulently
obtained, (b) the beneficiary does not cooperate with SSA, (c) SSA is
unable to locate the beneficiary, and (d) the beneficiary fails to follow
prescribed treatment which would be expected to restore his or her ability
to do SGA. For Group II exceptions, SSA discontinues benefits immediately
without further development.

In order to be removed from the disability programs for one of the
exceptions, disability examiners must also show that the individual has
the ability to engage in SGA.

SSA does not conduct CDRs on all beneficiaries each year. At the time
beneficiaries enter the DI or SSI programs, DDSs determine when they will
be due for CDRs based on their likely potential for medical improvement.
Based on SSA regulations, DDSs classify beneficiaries into one of three
medical improvement categories

           o  medical improvement expected-CDR generally once every 6 to 18
           months;
           o  medical improvement possible-CDR once every 3 years; or
           o  medical improvement not expected-CDR once every 5 to 7 years.

SSA has also developed a method, called profiling, to determine the most
cost-effective method of conducting a CDR. SSA applies statistical
formulas that use data on beneficiary characteristics-such as age,
impairment type, length of time on disability programs, previous CDR
activity, and reported earnings-to predict the likelihood of medical
improvement and, therefore, of benefit discontinuation. SSA assigns a
"score" to beneficiaries indicating whether there is a high, medium, or
low likelihood of medical improvement. In general, beneficiaries with a
high score are referred for full medical CDRs. Beneficiaries with lower
scores are, at least initially, sent a questionnaire, known as a
"mailer."15 Full medical CDRs involve an in-depth examination of a
beneficiary's medical and possibly his or her vocational status. This may
include a review of the recipient's case file, physical and psychological
condition, and medical evidence by a disability examiner and physician.
Unlike full medical CDRs, CDR mailers consist of a short list of questions
asking beneficiaries to self-report information on their medical
condition, treatments, and work activities. Appendix II describes the
medical CDR evaluation process in detail.

15 If beneficiaries' responses to a mailer indicate possible improvement
in medical condition or vocational status, SSA may refer these individuals
for a full medical review. However, in most cases, SSA decides that a full
medical review is not warranted and that benefits should be continued.

SSA will find that disability has ended and discontinue benefits16 if it
determines that medical improvement related to the ability to work has
occurred or that one of the exceptions applies, and the person's
impairments are not severe or the person can do past work or other work.
If SSA determines that medical improvement has not occurred and that none
of the exceptions apply, then benefits are continued17 (see fig. 1).

16 Beneficiaries may elect to have benefits continued while they appeal
the decision that their disability has ended.

17 SSA also conducts work CDRs where it may remove a beneficiary from the
disability programs if their earnings exceed SGA.

Figure 1: Current Medical CDR Evaluation Process

aFor SSI beneficiaries, SGA is not considered and the CDR evaluation
process is started at Step 2. Instructions for SGA considerations differ
for beneficiaries covered by certain work incentive programs.

bIf a group II exception applies, discontinue benefits immediately without
a medical determination.

cConsider age and time on the disability programs.

If SSA finds that the individual no longer has a disability and
discontinues benefits following a CDR, the individual has the right to
appeal the CDR decision, first to another reviewer for a reconsideration,
second to an administrative law judge, then to the Appeals Council, and
finally to federal courts. At the hearing before the administrative law
judge (ALJ), the ALJ reviews the file, including any additional evidence
submitted after the DDS determination and may hear testimony from the
individual as well as medical and vocational experts.

SSA's Office of Quality Performance conducts quality reviews of disability
determination outcomes. To conduct these quality reviews, SSA selects a
random sample of cases each month from all final CDR decisions,
stratifying the selection of cases by state and outcome (cases where
benefits are continued and discontinued). Then, a quality examiner reviews
the case to ensure it adheres to SSA guidance, including a review of the
DDS decision, the documentation of that decision, and the evidence
contained in the case. During these reviews, physicians18 evaluate the
evidence to ensure that the decision adheres to the medical improvement
standard. In fiscal year 2005, SSA's Office of Quality Performance
reported nationwide accuracy rates for cases where CDR benefits were
continued and discontinued of 95 percent and 93 percent respectively. The
combined accuracy rate for all CDRs was about 95 percent.

18 A psychologist may evaluate the evidence if the individual has a
psychological impairment.

  Few Beneficiaries Are Removed from the Disability Programs Because They Are
                        Found to Have Improved Medically

We found that on average, about 1.4 percent of all individuals who left
the programs between fiscal years 1999 and 2005 were removed for medical
improvement. More beneficiaries leave the disability programs because they
either die or convert to social security retirement benefits. In addition,
while full medical CDRs are the agency's most comprehensive tool for
determining whether a beneficiary continues to have a disability, about
2.8 percent of those who receive these CDRs are found to no longer have a
disability under the medical improvement standard.

Few Beneficiaries Are Removed from the Programs Due to Medical Improvement

Between fiscal years 1999 and 2005, annually, an average of 13,80019
people-or about 1.4 percent of all individuals who left the disability
programs-were removed because SSA found that they had improved
medically.20 More people leave the programs when they die, convert to full
retirement benefits,21 or leave for other reasons. For example, between
fiscal years 1999 and 2005, each year an average of about 311,00022
recipients (about 32 percent of all recipients who were removed from the
disability programs) died, and about 209,000 (about 21 percent) converted
from DI benefits to retirement benefits. In addition, each year about
444,000 beneficiaries (about 45 percent) were removed from the disability
programs for other reasons. These include about 54,000 DI beneficiaries
who SSA determined had earnings in excess of SGA, about 11,000 DI
beneficiaries who either converted to old-age retirement benefits prior to
reaching the full retirement age23 or were found to be erroneously
eligible for benefits, and about 379,000 SSI beneficiaries who were
removed from the SSI program for all reasons other than death and medical
improvement (including earnings and resources above the limit allowed by
program guidelines) (see fig. 2).

19 For the purposes of our study, we only assessed DI and SSI adult
beneficiaries who received full medical CDRs. We did not include children
or the "age 18 re-determinations" in our analysis since there are
differences between the medical CDR sequential evaluation processes for
adults and children. Also, we only assessed the outcome of the full
medical CDRs. We did not assess the outcome of the CDR mailers or CDRs of
beneficiaries' earnings and work activity-referred to as work CDRs.

20 The 13,800 people who were removed from the disability programs for
medical improvement as a result of receiving a CDR represent about 0.1
percent of all adult DI and SSI disability beneficiaries. Of these 13,800
recipients, about 9,260 were DI recipients and about 4,580 were SSI
recipients.

21 SSA converts DI beneficiaries to retirement benefits when they attain
full retirement age.

22 The 311,000 recipients who died consisted of about 180,000 DI
recipients and about 131,000 SSI recipients.

23 Beginning at age 62, workers receiving DI benefits may elect to receive
retirement benefits in lieu of disability benefits. Although most
beneficiaries receiving DI benefits elect to receive their disability
benefits until full retirement age-at which time disability benefits
convert to benefits paid from the Old-Age and Survivors Insurance
program-some choose to switch earlier.

Figure 2: Average Percentage of All Beneficiaries Who Were Removed from
the DI and SSI Programs by Category (Fiscal Years 1999 to 2005)

Note: While the combined DI and SSI programs in figure 2 illustrate the
reasons why beneficiaries are removed from the DI and SSI programs, there
are some differences between these two programs. For the same time period,
for the DI program, about 2 percent of all recipients who were removed
from the DI program improved medically; about 45 percent converted from
disability benefits to retirement benefits; about 39 percent died; about
12 percent had earnings in excess of SGA; and about 2 percent left for
other reasons. For the SSI program, about 1 percent of all recipients who
were removed from the SSI program improved medically; about 25 percent
died; and about 74 percent left for other reasons.

During fiscal years 1999 to 2005, the proportion of all beneficiaries who
were removed from the programs in each of the above categories remained
fairly consistent. For example, during this period, the proportion of
individuals removed from the disability programs in a fiscal year for
medical improvement ranged from 1.0 percent to 1.7 percent; the proportion
of individuals who died ranged from 31.1 percent to 33.0 percent; and the
proportion of individuals who converted from disability benefits to
retirement benefits ranged from 19.7 percent to 22.7 percent.

Few Beneficiaries Who Receive Full Medical Continuing Disability Reviews Are
Removed from the Programs Each Year

SSA data show that few beneficiaries who receive medical CDRs are removed
from the disability programs. Full medical CDRs are the agency's primary
tool to determine whether a beneficiary has improved medically. Between
fiscal years 1999 and 2005, the number of full medical CDRs conducted
ranged from a high of 608,000 in 2001 to a low of 333,000 in 2005 (see
fig. 3). 24 Between fiscal years 1999 and 2005, an average of about 26,000
individuals each year (about 5.3 percent) were removed from the disability
programs as a result of receiving a medical CDR. Some of the officials we
interviewed stated that the medical improvement standard may artificially
limit the percentage of recipients who are found to have improved
medically. However, we were unable to identify any empirical data
regarding the impact of the standard on the percentage of recipients who
have their benefits discontinued, or what a "proper" discontinuation rate
should be.

While the number of CDRs conducted between fiscal years 1999 and 2005
fluctuated,25 the percentage of beneficiaries removed from the programs
remained fairly constant.26 For example, in fiscal years 1999, 2002, and
2004, the percentage of recipients who were removed from the disability
programs as a result of receiving a CDR was 5.4 percent, 5.6 percent, and
5 percent respectively. In addition to medical improvement, SSA also
removes beneficiaries for failing to cooperate during a CDR. For example,
a beneficiary may fail to appear for scheduled meetings with disability
examiners or physicians and thus may have their benefits discontinued. Of
the individuals removed from the programs as a result of receiving a CDR
between fiscal years 1999 and 2005, an average of about 13,800 individuals
(or 2.8 percent of all CDRs conducted between fiscal years 1999 and 2005)
were removed annually because SSA determined that they had improved
medically, while an average of about 10,300 individuals (or about 2.1
percent) were removed each year for failure to cooperate.

24 For fiscal years 2000 to 2004, in addition to the full medical CDRs,
SSA also conducted an average of about 834,000 CDR mailers annually,
ranging from a high of 960,000 mailers in 2000 to a low of 692,000 mailers
in 2003.

25 In the late 1990s Congress appropriated special funds for SSA to
alleviate backlogs of CDRs. These special funds began in fiscal year 1996
and expired at the end of fiscal year 2002. Because of this special
funding, the number of full medical CDRs conducted by SSA increased.

26 We did not determine why the discontinuation rate remained consistent
considering the change in the number of CDRs conducted.

Figure 3: Number of Full Medical CDRs Conducted and Resulting Benefit
Discontinuations (Fiscal Years 1999 to 2005)

Several Factors Challenge SSA's Ability to Assess Whether Beneficiaries Continue
                          to Be Eligible for Benefits

Our review suggests that several factors associated with the standard pose
challenges for SSA's ability to assess whether beneficiaries continue to
be eligible for benefits. First, limitations in SSA guidance may result in
inconsistent application of the standard. For example, we found that SSA
does not clearly define the degree of improvement needed to meet the
standard, and the DDS directors we surveyed reported using different
thresholds to show medical improvement. As a result of this apparent
limitation in SSA guidance, disability examiners may incorrectly decide to
continue or discontinue benefits. In addition, while the act provides for
certain exceptions that could result in additional individuals having
their benefits discontinued following a CDR, most of the disability
examiners we spoke with told us that they were uncertain about when to
apply the exceptions. Second, we found that most DDSs are incorrectly
conducting CDRs with the presumption that a beneficiary has a disability.
Finally, other factors, such as inadequate documentation of evidence and
the judgmental nature of the decision process for assessing medical
improvement may make it more difficult to determine whether a beneficiary
remains eligible for benefits. However, due to data limitations, we were
unable to determine the extent to which these challenges impact decisions
to continue or discontinue benefits during a CDR.

Limitations in SSA Guidance for Applying the Medical Improvement Standard May
Result in Inconsistent Disability Decisions

Our work shows that SSA does not clearly define the degree of improvement
needed for examiners to determine if a beneficiary has improved medically.
Many disability examiners and DDS officials told us that they were unsure
about the degree of improvement required to meet the standard, and some
said this confusion stems from unclear SSA guidance. In particular, SSA
guidance instructs examiners to disregard "minor" changes in a
beneficiary's condition.27 However, this guidance does not adequately
describe what constitutes a minor change. When we asked SSA officials to
clarify their understanding of what constitutes a minor change, they told
us that only changes that would not affect a beneficiary's ability to work
should be considered minor. However, this explanation of minor changes is
not included in the agency's guidance. As a result, some DDSs may be
inconsistently defining what constitutes a minor change. For example, five
DDS directors told us that they define minor changes to include those that
may actually improve functioning or allow the beneficiary to work. In
doing so, our review suggests that some DDSs may be inconsistently
applying the standard as to what constitutes medical improvement. However,
DDS directors differed on the extent to which the guidance to disregard
minor changes impacts CDRs.  Of the 52 DDS directors who answered a
question in our survey on "minor" changes, 21 reported that the practice
of disregarding minor changes is not an impediment to making a disability
determination, while 31 reported that it is an impediment.28

Similarly, we found that SSA guidance may not provide DDS examiners with
sufficient detail to determine whether improvements in beneficiaries'
medical conditions are related to their ability to work. At this step of
the CDR process, examiners look for changes in a beneficiary's ability to
perform basic work activities since the last review, such as lifting heavy
objects or standing or sitting for periods of time.29 The guidance
instructs examiners to ensure a "reasonable relationship" between the
amount of improvement and the increase in the ability to perform basic
work activities.30 However, the guidance does not require a specific
amount of increase in functioning. The DDS directors we surveyed reported
that they interpret this guidance differently. Specifically, 17 of 49
directors reported that a large or very large increase in a recipient's
ability to do basic work activities is required; 24 reported that a
moderate increase is required; and 8 reported that a minor or any increase
at all is required. Furthermore, two DDS directors in our survey
inaccurately noted that the standard requires that a beneficiary's
improvement be great enough so that it actually enables the individual to
work.31 One of these directors commented that because SSA guidance on this
aspect of the standard is open to broad interpretation, it is difficult to
document improvement to the extent the individual is able to work. As a
result, some DDSs may be inconsistently applying this aspect of the
standard that could potentially impact decisions to continue or
discontinue benefits. However, we were unable to determine how much of an
impact clarification of this guidance would have on CDR outcomes.

27 See SSA Program Operations Manual System (POMS) section DI 28010.015.

28 While we received 54 completed surveys, not every director responded to
every question. In presenting our results, we only included the directors
who answered a particular question with a value on our response scale. If
a director answered "no basis to judge," we did not count that response.

The disability advocates we spoke with differed in their views on the
clarity of SSA guidance on medical improvement. While some stated that it
is clear and adequate, others stated that the guidance on assessing
medical improvement in psychological impairments and determining if
improvement is related to the ability to work is confusing and unclear.
One advocate stated that current SSA policies contribute to some
recipients remaining in the disability programs despite their ability to
work.

We also found that while the act provides for exceptions to medical
improvement that could result in additional individuals having their
benefits discontinued as a result of receiving a CDR, most of the
disability examiners whom we spoke with on our site visits told us that
they were uncertain about when to apply the exceptions.32 SSA policies
allow for various exceptions, including when the prior decision was in
error or when persons benefit from education or training programs that
could help the individuals work. However, we found that while the
examiners and ALJs routinely assess whether a beneficiary has improved
medically, they do not routinely assess whether or not each of the
exceptions applies to the case. Moreover, many of the DDS officials and
examiners we interviewed told us that the guidelines for using the error
exception are written in a way that precludes its use, except in the most
extreme situations.33

29 At this step (step 4 of the CDR evaluation process), the assessment of
working at the level of SGA is not considered. SGA is evaluated in the
first step of the CDR evaluation process. See appendix II for a detailed
description of the CDR process.

30 See POMS section DI 28015.320.

31 The assessment of a beneficiary's actual ability to work comes later in
the CDR process (steps 7 and 8). See appendix II for a more detailed
description of the CDR process.

SSA officials explained that the exceptions were written to intentionally
limit their use in order to prevent examiners from circumventing the
standard, and that their infrequent use is appropriate. In addition, SSA
explained that when it issued the final rules governing the medical
improvement standard, it intended the exceptions to be true
"exceptions"-not to be routinely applied (including the error exception).
The agency also noted that a broader application of the error exception
could lead to a substitution of judgment by an adjudicator for the
original finding of disability in instances where a person's medical
condition had not substantially improved. Some disability advocates we
spoke with also noted that the narrow interpretation of the error
exception is appropriate because it prevents substitution of judgment and
arbitrary discontinuations.

A Majority of DDSs Incorrectly Apply SSA Guidelines Stating That CDRs Should Be
Conducted Neutrally, without a Presumption of Disability

According to our survey, a majority of DDSs incorrectly presume that a
beneficiary continues to have a disability when conducting CDRs, which may
make it more difficult for examiners to determine if a beneficiary has
improved medically. This is contrary to the act as well as SSA regulations
and policy, which require that CDR decisions be made on a "neutral basis."
SSA defines neutral basis as a review that neither presumes that a
beneficiary (1) is still disabled because he or she was previously found
disabled and (2) is no longer disabled because he or she was selected for
a CDR. Under a neutral review, it is assumed that beneficiaries had a
disability at the time of the prior decision, but it is not assumed they
still have a disability at the time of a CDR. However, in survey
responses, 31 DDS directors responded that in practice, CDRs are conducted
with the presumption that a beneficiary continues to have a disability.34
When asked to explain this response, directors cited various factors that
likely contribute to the presumption of disability during a CDR. Thirteen
directors commented that the individuals are already receiving disability
benefits, and as a result, the directors assume that the beneficiary
continues to have a disability. Some of these directors also noted that
they make this presumption because the beneficiary was found disabled when
initially awarded benefits, and examiners must show medical improvement to
remove them from the programs.

32 During our site visits, we met with 11 CDR supervisors and disability
examiners who the DDS directors selected as the most knowledgeable in
their office about the CDR process and the medical improvement standard.
Seven of these 11 individuals stated that they were uncertain about when
to apply the exceptions to medical improvement.

33 The error exception applies when an error was evident in the prior
decision.

Since a majority of DDSs are conducting CDRs with a presumption that
beneficiaries have a disability, those DDSs may be setting a higher bar
than required by the standard for these reviews. Moreover, by requiring
more evidence of medical improvement than is necessary under the standard,
it may be harder to assess whether a recipient no longer has a disability
and is able to work. Because 31 directors reported that examiners conduct
CDRs with the presumption that beneficiaries continue to have a
disability, a significant number of beneficiaries may be evaluated under
this higher standard, and some may have their benefits erroneously
continued. While these problems raise concerns about the consistency of
decisions when determining if medical improvement has occurred, the
ultimate impact of presuming that an individual has a disability on CDR
decisions is unknown because we were unable to empirically test how the
presumption of a disability impacts CDR decisions to continue or
discontinue benefits.

Other Factors May Make Assessing Medical Improvement Difficult

Inadequate documentation of evidence and the judgmental nature of the
process for assessing medical improvement are two additional factors that
make it challenging to assess medical improvement. The standard
establishes the prior decision as the starting point for conducting a CDR
and requires examiners to find evidence of medical improvement since this
last decision. Some DDS directors reported that it may be difficult to
assess medical improvement in cases where the prior disability decision
was based on incomplete or poorly documented evidence. For example, in one
of the CDR cases we reviewed, a beneficiary had his benefits continued
following the CDR because the rationale for the prior disability decision
was vague, according to the examiner who reviewed the case with us. This
beneficiary was originally awarded benefits on appeal based on recurrent
stomach problems and depression. When the case was selected for a CDR, the
case file included a general description of the beneficiary's medical
condition, but lacked sufficient evidence to determine if medical
improvement had occurred since the initial decision, according to the
examiner. As a result, medical improvement could not be shown and benefits
were continued. While many examiners and officials we interviewed agreed
that it is difficult to show medical improvement in cases that lack
adequate documentation, they differed in their opinions about how
frequently this occurs. Of the directors who answered our survey question
on insufficient documentation, 33 responded that they encounter cases with
insufficient documentation infrequently or very infrequently, and 17
responded that such cases occurred more often.35

34 Of the 48 DDS directors who responded to this question, 17 indicated
that CDR decisions are made on a neutral basis.

Survey respondents also differed in their opinions about the types of
cases that more typically lack adequate documentation, but 15 directors
commented that cases decided on appeal were the most likely to lack
adequate documentation. One possible explanation for this may be
streamlined processes at the appeals level. For example, one ALJ we
interviewed noted that, in an effort to process cases in a timely manner,
ALJs sometimes issue quick decisions in which most of the evidence is on
tapes that are not transcribed or placed in the beneficiary's case file.
In such instances, it is unlikely that the DDS examiner would have
complete information for conducting a CDR and determining if medical
improvement had taken place. Furthermore, several officials told us that
guidance instructs ALJs to include enough information in their decisions
so that the decisions will be legally sufficient. However, the guidance
does not specifically instruct ALJs to include all of the evidence that
will be needed to assess medical improvement at a future CDR. However, in
recent regulations to implement changes to its disability determination
process, SSA is taking steps that may help to address the problem of
incomplete documentation for future CDRs. Specifically, SSA is developing
requirements for training examiners to ensure they understand the
information needed to make accurate and adequately documented decisions,
has adopted guides for decision writing at the appeals level, and is in
the process of developing guides for use at the DDS level.

35 We asked directors to exclude cases missing the entire case file (i.e.
lost folders) in their responses to this survey question. We asked the
directors a separate question regarding how frequently or infrequently
they encounter cases where the entire case file is missing. Although SSA
has established a new electronic system to process initial claims, it has
yet to expand this new process to CDRs. As a result, CDRs are still being
conducted in a paper environment.

In addition to the challenges associated with problems of inadequate
documentation, many examiners also told us that the judgmental nature of
the decision process concerning what constitutes an improvement can make
it difficult to assess medical improvement. One examiner may determine
that a beneficiary has improved medically and discontinue benefits, while
another examiner may determine that medical improvement has not been shown
and will continue the individual's benefits. For example, in one of the
CDR cases that we reviewed, the examiner conducting the initial CDR
determined that medical improvement was shown and discontinued the
individual's benefits. The recipient was initially awarded disability
benefits for a back injury with limited range of motion in the recipient's
back. When the CDR was conducted, the examiner evaluated all of the
relevant evidence and concluded that the individual's range of motion had
improved. The examiner also noted that the individual's allegations of
pain did not correlate with the findings from both the physical exam and
the laboratory findings. As a result, the examiner concluded that medical
improvement had occurred. On appeal to reconsideration 6 months later, a
different DDS examiner conducted a review using the same medical evidence
as the original examiner, but determined that medical improvement had not
occurred, and continued benefits. The examiner conducting the appeal
concluded that the beneficiary continued to experience pain consistent
with the back condition, and thus medical improvement was not shown.
However, we had no basis for determining which decision was correct.

The amount of judgment involved in the decision-making process increases
when the process involves certain types of impairments that are difficult
to assess. More specifically, assessing medical improvement may be more
difficult in cases that involve certain types of psychological
impairments, such as depression, than cases with physical impairments,
such as amputations. In elaborating on their survey responses, 17
directors commented that assessing medical improvement is more difficult
in cases with psychological impairments because evidence of these
impairments is generally more subjective than evidence of many physical
impairments. In addition, six directors commented that evaluations of
psychological impairments tend to rely more heavily on assessment of
functionality. According to some of these officials, an assessment of
functionality is more subjective because it relies more on the
beneficiaries' account of their own conditions than on laboratory
findings. Furthermore, some officials reported that the severity of
psychological impairments can fluctuate over time, making it difficult to
assess whether improvement has taken place. Two directors commented that
determining whether there is medical improvement for some types of
psychological impairments can also be complicated because medical experts'
opinions can vary. One of these directors commented that the evidence to
support psychological impairments, such as evaluations for depression,
rely less on laboratory findings and more on clinical judgment. In
contrast, certain tests for physical impairments tend to be less open to
interpretation. For example, one director commented that X-rays of joint
deterioration can generally be interpreted consistently among
radiologists. The potential difficulty of assessing medical improvement in
beneficiaries whose disability is based on certain types of psychological
impairments is especially relevant, given that the proportion of all
individuals in the disability programs whose disability is based on a
psychological impairment has grown in recent years.

                                  Conclusions

SSA is responsible for assuring that individuals who truly have a
disability that prevents them from being able to work continue to receive
benefits. At the same time, SSA has a stewardship responsibility to
identify those beneficiaries who have improved medically and are no longer
eligible for benefits. The medical improvement standard is intended to
help SSA accomplish both of these responsibilities. However, several
factors associated with the standard pose challenges for ensuring that the
standard is implemented in a consistent and fair manner. Specifically,
potential limitations in SSA guidance regarding the degree of improvement
needed to meet the standard as well as a lack of clarity with respect to
the appropriate use of the exceptions to medical improvement may make it
difficult to assess if medical improvement has occurred. Clear guidance is
especially important in view of the judgmental nature of the disability
determination process. Additionally, while SSA guidelines regarding the
presumption of disability during CDRs tend to be generally clear,
incorrect application of these guidelines by several DDSs suggests that
the outcomes of CDRs could be affected and may result in benefit
continuation for some individuals who might otherwise been found to have
improved medically. Other factors, including inadequate documentation of
evidence, are more difficult to address in the short term. However, SSA is
taking actions intended to address some of these problems.

                                 Recommendation

To ensure that SSA is able to consistently assess whether DI and SSI
beneficiaries have improved medically, we recommend that the Commissioner
of Social Security clarify guidance for assessing medical improvement when
conducting CDRs. More specifically, SSA should clarify guidance concerning
(1) what degree of improvement is required to meet the standard and (2)
when the use of exceptions to medical improvement is appropriate. SSA
should also work with DDSs to ensure that CDRs are conducted on a neutral
basis, without a presumption that beneficiaries continue to have a
disability.

                       Agency Comments and Our Evaluation

We obtained written comments on a draft of this report from the
Commissioner of the Social Security Administration (SSA). The agency
generally agreed with our recommendation, but expressed reservations about
the need for further guidance on the use of exceptions. More specifically,
SSA believed that its implementation of the statutory exceptions to
medical improvement is appropriate and that its instructions are
consistent with the intent of the law. As such, SSA was concerned about
language in the draft report that characterized SSA's guidance as
discouraging and limiting the use of the exceptions. After considering
these comments, we revised the report to include additional information on
(1) examiners' confusion on the use of the exceptions when conducting CDRs
and (2) SSA's rationale for its current exception guidance. Having made
these changes, we continue to believe that additional guidance in this
area is warranted if only, as the report notes, because most of the
disability examiners whom we spoke with told us that they were uncertain
about when to apply the exceptions. Moreover, while answering a survey
question on the exceptions to medical improvement, 4 DDS directors
commented that more guidance regarding the use of the exceptions is
needed.

SSA generally agreed with the need for clarifying guidance concerning the
degree of improvement required to meet the medical improvement standard.
However, the agency believed that the report was unclear with regard to
whether this part of the recommendation applied only to guidance for
determining if there has been any medical improvement, or also to the
guidance for determining if any medical improvement is related to the
ability to work. As stated in the draft report, our discussion of medical
improvement encompasses both elements (improvement in a beneficiary's
medical condition and its relation to the ability to work). However, we
did further clarify this throughout the entire report to minimize any
confusion on this matter. Additionally, SSA indicated that clarification
of this guidance would probably have little noticeable impact on the
number of cases in which SSA finds that a disability has ended. As our
report notes, we cannot quantify the impact that clearer guidance would
have on the discontinuation of benefits. Even so, we continue to believe
that it is important for DDSs to consistently apply this aspect of the
medical improvement standard and that, towards that end, additional
guidance would be useful.

SSA agreed with the need for further training to ensure that CDRs be
conducted on a neutral basis. However, it believed that more adjudicator
training in this area would likely have little impact on discontinuing
benefits. We cannot predict the impact additional guidance and training
would have on continuing or discontinuing benefits. However, as the report
points out, there are large numbers of DDS directors who are incorrectly
applying the neutrality standard and, in our view, would benefit from
additional guidance in this area.

Beyond commenting on our recommendation, SSA suggested that we provide
additional context for some of the statistical information presented in
our discussion of the proportion of beneficiaries removed from the
disability programs each year. For example, SSA commented that the
disability discontinuation rates in the early 1980s may not have been
representative of the discontinuation rates prior to the implementation of
the medical improvement standard due to special targeted initiatives aimed
at removing individuals from the DI program who no longer had a
disability. We revised the report to take into account these suggestions.

The Commissioner's comments have been reproduced in appendix III. SSA also
provided additional technical comments, which have been incorporated in
the report as appropriate.

Unless you publicly announce its contents earlier, we plan no further
distribution until 30 days after the date of this report. At that time, we
will make copies available to other parties upon request. In addition, the
report will be available at no charge on GAO's Web site at
http//:www.gao.gov. This report does not contain all the results from the
survey. The survey and a more complete tabulation of the results can be
viewed at http://www.gao.gov/cgi-bin/getrpt?rptno=GAO-07-4sp .

If you or your staff have questions concerning this report, please contact
me at (202) 512-7215. Contact points for our Offices of Congressional
Relations and Public Affairs may be found on the last page of this report.
See appendix IV for a listing of major contributors to this report.

Robert E. Robertson,
Director, Education, Workforce, and Income Security Issues

Appendix I: Scope and Methodology

This appendix provides additional details about our analysis of the
medical improvement standard (the standard), including challenges the
standard poses for the Social Security Administration (SSA) when
conducting medical continuing disability reviews (CDR). To meet the
objectives of this review, we reviewed prior studies by GAO, SSA, SSA's
Inspector General, Congressional Research Service, and external
organizations related to the disability determination process and CDRs. We
also reviewed the Social Security Disability Benefits Reform Act of 1984,
regulations, and SSA policies and processes for assessing whether
beneficiaries continue to be eligible for benefits. In addition, we
analyzed SSA data on CDR outcomes over a 7-year period for fiscal years
1999 to 2005 as well as reports identifying the number of beneficiaries
who leave the disability programs and the reasons why they leave. For the
purposes of our study, we only assessed DI and SSI adult beneficiaries who
left the programs as a result of receiving a full medical CDR. We did not
include children or "age 18 re-determinations" in our analysis since there
are differences between the medical CDR sequential evaluation processes
for adults and children. We also did not assess the outcome of CDR mailers
or work CDRs. We verified the statistical data on CDR outcomes for
internal logic, consistency, and reasonableness. We determined that the
data were sufficiently reliable for the purposes of our review. We also
met with knowledgeable SSA officials to further document the reliability
of these data.

We interviewed 34 officials from SSA's central offices (including
officials from the Office of the Chief Actuary, the Office of Quality
Performance, the Office of General Counsel, the Office of Research and
Evaluation Statistics, the Office of Disability Programs, the Office of
Disability Adjudication and Review, and the Office of Program Development
and Research) to discuss the disability programs and the CDR process.

We conducted a national Web-based survey of all 55 Disability
Determination Services (DDS) directors in the 50 states, the District of
Columbia, Puerto Rico, the Virgin Islands, the Western Pacific Islands,
and the federal DDS. DDSs are the agencies responsible for conducting
periodic CDRs to determine if beneficiaries' medical conditions have
improved and if they are able to work. We received 54 completed surveys
for a response rate of 98 percent. The purpose of this survey was to
assess the extent to which the standard impacts outcomes of CDRs and
determine if the standard poses any special challenges for SSA when
determining whether beneficiaries continue to be eligible for benefits. We
asked the directors about particular elements of the standard and how
these elements, alone or in combination with other factors, impact CDR
outcomes. We also asked them how SSA guidance on implementing the standard
affects CDR outcomes. We determined that the survey data are sufficiently
reliable. Because this was not a sample survey, there are no sampling
errors. However, the practical difficulties of conducting any survey may
introduce errors, commonly referred to as nonsampling errors. For example,
difficulties in how a particular question is interpreted, in the sources
of information that are available to respondents, or in how the data are
entered into a database or were analyzed, can introduce unwanted
variability into the survey results. We took steps in the development of
the questionnaire, the data collection, and the data analysis to minimize
these nonsampling errors. For example, social science survey specialists
designed the questionnaire in collaboration with GAO staff with subject
matter expertise. Then, the draft questionnaire was pretested with a
number of state officials to ensure that the questions were relevant,
clearly stated, and easy to comprehend. The questionnaire was also
reviewed by an additional GAO survey specialist. When the data were
analyzed, a second, independent analyst checked all computer programs.
Since this was a Web-based survey, respondents entered their answers
directly into the electronic questionnaire. This eliminated the need to
have the data keyed into a database thus removing an additional source of
error. We conducted three pretests of this survey with DDS directors in
three different states. We modified the survey to take their comments into
account. We also provided SSA with a copy of the survey and incorporated
its technical comments into the final version. This report does not
contain all the results from the survey. The survey and a more complete
tabulation of the results can be viewed at
http://www.gao.gov/cgi-bin/getrpt?rptno=GAO-07-4sp .

To augment information from our state survey, we conducted independent
audit work in three states (California, Massachusetts, and Texas) to
examine how SSA policies and procedures are carried out in the field. We
selected locations for field visits based on the following criteria: (1)
geographic dispersion; (2) states with large numbers of CDRs conducted;
(3) states with CDR discontinuation rates above, below, and at the
national average; (4) states with varying DDS structures (i.e.,
centralized and decentralized); and (5) states with large numbers of
Disability Insurance (DI) beneficiaries and large DI expenditures. In each
state, we visited a DDS office, the SSA regional office, the regional
Office of Quality Performance, and the regional Office of Disability
Adjudication and Review (formerly known as the Office of Hearings and
Appeals). In total, we conducted in-depth interviews with 80 SSA and DDS
managers and line staff responsible for conducting medical CDRs, including
DDS directors, CDR supervisors and examiners, medical consultants, and
administrative law judges. 36

During our meetings with SSA and DDS officials, we documented management
and staff views on the challenges associated with applying the medical
improvement standard. In particular, we documented management and staff
views on (1) the impact of the standard on CDR outcomes, (2) the
effectiveness of SSA policies and procedures for applying the standard,
and (3) the degree to which factors external to the standard create
challenges when determining if a beneficiary has improved medically and is
able to work. To further assess how the standard is applied in practice,
we took a nonprobability sample of 12 CDR case files from the DDSs in
California and Texas. We asked CDR supervisors to provide several cases
that were (1) discontinued for medical improvement, (2) continued because
the beneficiary was clearly disabled, and (3) ambiguous cases where it was
difficult to apply the standard and determine if benefits should be
continued or discontinued. These case files serve to illustrate the
difficulties examiners face when determining if a beneficiary has improved
medically and is able to work.

In addition, we interviewed seven disability policy experts from national
disability research and advocacy organizations to obtain their input on
the impact of the standard on the disability programs and any challenges
it poses when assessing individuals' continued eligibility for benefits.
We spoke with individuals affiliated with the following organizations

           o  American Association of People with Disabilities,
           o  Center for Health Services Research and Policy at George
           Washington University,
           o  Center for the Study and Advancement of Disability Policy,
           o  Consortium for Citizens with Disabilities,
           o  Disability Law Center,
           o  Disability Policy Collaboration,
           o  National Organization of Social Security Claimants'
           Representatives, and
           o  National Organization on Disability.

36 During our site visits, we met with 11 CDR supervisors and disability
examiners who the DDS directors selected as the most knowledgeable in
their office about the CDR process and the medical improvement standard.

Finally, we spoke with representatives from the National Association of
Disability Examiners, the National Council of Disability Determination
Directors, and the Social Security Advisory Board. We spoke with these
disability experts about the effect of the standard on CDR outcomes and
any challenges it presents when conducting CDRs. We conducted our work
from October 2005 through June 2006 in accordance with generally accepted
government auditing standards.

Appendix II: The Continuing Disability Review Evaluation

In the first step of the CDR evaluation process for adult beneficiaries,
an SSA field office representative determines if the beneficiary is
working at the level of substantial gainful activity (SGA). A beneficiary
who is found to be not working or working but earning less than the SGA
level (minus allowable exclusions) has his or her case forwarded to the
state Disability Determination Services (DDS).37

The second step is to determine if the individual's current impairment(s)
is included on the current list of disabilities that SSA maintains. The
list describes impairments that, by definition, are so severe that they
are disabling. If the individual's current impairment(s) does meet or
equal a current listing, then the DDS continues the individual's benefits
and does not continue with the evaluation process. If the individual's
current impairment(s) does not meet or equal a current listing, then the
DDS proceeds to step three in the evaluation process.

The third step is to determine if improvement in the individual's medical
condition has occurred. This improvement is any decrease in the medical
severity of the impairment(s) that was present at the time of the most
recent favorable medical decision (i.e., the initial decision to award
disability benefits or the most recent CDR continuance-usually referred to
as the comparison point decision, or CPD). At this step, the DDS examiner
compares the current signs, symptoms, and laboratory findings associated
with the beneficiary's impairment(s) to those recorded from the last
review. If improvement has not occurred, the disability examiner skips to
the fifth step in the evaluation. If improvement has occurred, the
disability examiner proceeds to next step, the fourth step.

The fourth step is to determine if the improvement found in step three is
related to the ability to work. Improvement related to the ability to work
is evaluated two different ways, depending on whether the CPD was based
on: (1) meeting or equaling a prior listing or (2) a residual functional
capacity (RFC) assessment:

           o  Meeting or equaling the prior listing: In this case, the
           disability examiner will determine if the beneficiary's same
           impairment(s) still meets or equals the prior listing. Unlike step
           two, the examiner compares the beneficiary's condition with the
           list of impairments in effect at the time he or she was first
           awarded disability benefits. 38 If the impairment(s) no longer
           meets or equals the prior listing, then the examiner finds that
           the improvement is related to the ability to work and proceeds to
           step six of the evaluation process. If the impairment(s) meets or
           equals a prior listing, then benefits are continued.

           o  Residual functional capacity assessment: In this case, the
           disability examiner compares the beneficiary's previous functional
           capacity to the current functional capacity for the same
           impairment. If functional capacity for basic work activities has
           improved, then the examiner finds that the improvement is related
           to the ability to work and proceeds to step six of the evaluation
           process. If the current assessment does not show improvement, then
           the disability examiner proceeds to step five.

37 For SSI beneficiaries, do not consider SGA but skip to the second step
in the CDR evaluation.

The fifth step is to determine whether an exception to medical improvement
applies. The law provides for certain limited situations when the DDS may
discontinue a recipient's benefits even though medical improvement has not
occurred. The specific group I exceptions are (a) the individual is the
beneficiary of advances in medical or vocational therapy or technology
(related to the ability to work), (b) evidence shows that the individual
has undergone vocational therapy (related to the ability to work), (c)
evidence shows that, based on new or improved diagnostic or evaluative
techniques, the individual's impairment(s) is not as disabling as it was
considered at the time of the CPD, and (d) evidence shows that any prior
determination or decision was in error. If an exception applies, the
examiner continues through to step six of the evaluation process.39 If an
exception does not apply, benefits are continued.

The sixth step is to determine if the current impairments are severe. At
this step, the examiner considers all of the beneficiary's
impairments-those present at the previous decision as well as any new
impairments found in the current review. If the DDS determines that the
beneficiary's current impairment(s) is not severe, benefits are
discontinued without further development. If it is determined that the
impairment(s) is severe, then the examiner considers the impact of the
beneficiary's impairment(s) on his or her ability to function. This
consideration will result in a current residual functional capacity (RFC)
assessment that shows the beneficiary's ability to do basic work
activities and the evaluation continues to the seventh step.

38 At this step of the evaluation, a disability examiner considers only
the listings that were met (or equaled) the last time the beneficiary was
evaluated, not all of the listings that existed at the time of the last
review.

39 In addition to Group I exceptions, the law provides for additional
situations (called Group II exceptions) to show that that disability
discontinues. Group II exceptions are: (a) the individual's prior
determination or decision was fraudulently obtained, (b) the individual
does not cooperate with SSA, (c) SSA is unable to find the individual, and
(d) the individual fails to follow prescribed treatment that would be
expected to restore his or her ability to do SGA. In these situations, SSA
discontinues benefits immediately without further development. SSA does
not determine if medical improvement has occurred or if the individual is
able to do SGA.

The seventh step is to determine whether the beneficiary has the capacity
to do the work that he or she did before having a disability. If the
beneficiary has the ability to do past work, then benefits are
discontinued. If the beneficiary does not have the ability to do work he
or she has done in the past, the evaluation continues to the eighth step.

The eighth step is to determine if the beneficiary has the ability to do
other work. At this step, the disability examiner considers the complete
vocational profile (the beneficiary's age, education, and past relevant
work experience) together with the beneficiary's RFC to determine if he or
she has the ability to do other work. If the beneficiary has the ability
to do other work, disability benefits are discontinued. If he or she does
not have the ability to do other work, benefits are continued.

Appendix III: Comments from the Social Security Administration 

Appendix IV: GAO Contact and Staff Acknowledgments

GAO Contact

Robert E. Robertson, Director, (202) 512-7215.

Staff Acknowledgments

The following team members made key contributions to this report: Kelly
Agnese; Jeremy D. Cox; Susan E.M. Etzel; Stuart M. Kaufman; Luann M. Moy;
George H. Quinn, Jr.; Daniel A. Schwimer; Salvatore F. Sorbello; Wayne T.
Turowski; Vanessa R. Taylor; and Rachael C. Valliere.

Related GAO Products

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Its New Disability Determination Process, but Key Facets Are Still in
Development. GAO-06-779T . Washington, D.C.: June 15, 2006.

Social Security Disability Insurance: SSA Actions Could Enhance Assistance
to Claimants with Inflammatory Bowel Disease and Other Impairments.
GAO-05-495 . Washington, D.C.: May 31, 2005.

High Risk Series: An Update. GAO-05-207 . Washington, D.C.: January 2005.

SSA's Disability Programs: Improvements Could Increase the Usefulness of
Electronic Data for Program Oversight. GAO-05-100R . Washington, D.C.:
December 10, 2004.

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Prevent Overpayments. GAO-04-929 . Washington, D.C.: September 10, 2004.

Social Security Administration: More Effort Needed to Assess Consistency
of Disability Decisions. GAO-04-656 . Washington, D.C.: July 2, 2004.

Social Security Disability: Commissioner Proposes Strategy to Improve the
Claims Process, but Faces Implementation Challenges. GAO-04-552T .
Washington, D.C.: March 29, 2004.

SSA Disability Decision Making: Additional Steps Needed to Ensure Accuracy
and Fairness of Decisions at the Hearings Level. GAO-04-14 . Washington,
D.C.: November 12, 2003.

Social Security Disability: Reviews of Beneficiaries' Disability Status
Require Continued Attention to Achieve Timeliness and Cost-Effectiveness.
GAO-03-662 . Washington, D.C.: July 24, 2003.

Social Security Disability: Reviews of Beneficiaries' Disability Status
Require Continued Attention to Improve Service Delivery. GAO-03-1027T .
Washington, D.C.: July 24, 2003.

High Risk Series: An Update. GAO-03-119 . Washington, D.C.: January 2003.

Major Management Challenges and Program Risks: Social Security
Administration. GAO-03-117 . Washington, D.C.: January 2003.

SSA and VA Disability Programs: Re-Examination of Disability Criteria
Needed to Help Ensure Program Integrity. GAO-02-597 . Washington, D.C.:
August 9, 2002.

SSA Disability Programs: Fully Updating Disability Criteria Has
Implications for Program Design. GAO-02-919T . Washington, D.C.: July 11,
2002.

Social Security Disability: SSA Making Progress in Conducting Continuing
Disability Reviews. GAO/HEHS-98-198 . Washington, D.C.: September 18,
1998.

Supplemental Security Income: SSA Is Taking Steps to Review Recipients'
Disability Status. GAO/ HEHS-97-17 . Washington, D.C.: October 30, 1996.

Social Security Disability: SSA Quality Assurance Improvements Can Produce
More Accurate Payments. GAO/HEHS-94-107 . Washington, D.C.: June 3, 1994.

Social Security: Disability Rolls Keep Growing, While Explanations Remain
Elusive. GAO/ HEHS-94-34 . Washington, D.C.: February 11, 1994.

Social Security Disability: Implementing the Medical Improvement Review
Standard. GAO/HRD-88-108BR . Washington, D.C.: September 30, 1988.

Social Security Disability: Implementation of the Medical Improvement
Review Standard. GAO/ HRD-87-3BR . Washington, D.C.: December 16, 1986.

Review of the Eligibility of Persons Converted from State Disability Rolls
to the Supplemental Security Income Program. HRD-78-97. Washington, D.C.:
April 18, 1978.

(130525)

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www.gao.gov/cgi-bin/getrpt? GAO-07-8 .

To view the full product, click on the link above. To view results of
GAO's survey of DDS directors, click:
www.gao.gov/cgi-bin/getrpt?rptno=GAO-07-4sp. For more information, contact
Robert E. Robertson (202) 512-7215 or [email protected].

Highlights of GAO-07-8 , a report to the Chairman, Committee on Finance,
U.S. Senate

October 2006

SOCIAL SECURITY DISABILITY PROGRAMS

Clearer Guidance Could Help SSA Apply the Medical Improvement Standard
More Consistently

The Social Security Act requires that the Social Security Administration
(SSA) find an improvement in a beneficiary's medical condition in order to
remove him or her from either the Disability Insurance (DI) or
Supplemental Security Income (SSI) programs. GAO was asked to (1) examine
the proportion of beneficiaries who have improved medically and (2)
determine if factors associated with the standard pose challenges for SSA
when determining whether beneficiaries continue to be eligible for
benefits. To answer these questions, GAO surveyed all 55 Disability
Determination Services (DDS) directors, interviewed SSA officials, and
reviewed pertinent SSA data.

What GAO Recommends

GAO is making a recommendation to SSA to clarify guidance regarding the
degree of medical improvement required to meet the standard, the use of
exceptions, and the presumption of disability for assessing medical
improvement when conducting CDRs.

While generally agreeing with the value of additional guidance, SSA
expressed reservations about the need for further guidance on the
exceptions. GAO continues to see such a need since 7 of the 11 disability
examiners we spoke with were uncertain regarding when to apply the
exceptions.

Each year, about 13,800 beneficiaries, or 1.4 percent of all the people
who left the disability programs between fiscal years 1999 and 2005, did
so because SSA found that they had improved medically. More beneficiaries
leave because they convert to regular retirement benefits, die, or for
other reasons-including having earnings above program limits. In addition,
while continuing disability reviews (CDR) are SSA's most comprehensive
tool for determining whether a recipient continues to have a disability,
on average, 2.8 percent of beneficiaries were found to have improved
medically and to be able to work following a CDR during this 7-year
period.

Several factors associated with the medical improvement standard (the
standard) pose challenges for SSA when assessing whether beneficiaries
continue to be eligible for benefits. First, limitations in SSA guidance
may result in inconsistent application of the standard. For example, SSA
does not clearly define the degree of improvement needed to meet the
standard, and the DDS directors GAO surveyed reported that they use
different thresholds to assess if medical improvement has occurred.
Second, contrary to existing policy, disability examiners in a majority of
the DDSs are incorrectly conducting CDRs with the presumption that a
beneficiary has a disability rather than with a "neutral" perspective.
Other challenges associated with the standard include inadequate
documentation of evidence as well as the judgmental nature of medical
improvement determinations. All these factors have implications for the
consistency of CDR decisions. However, due to data limitations, GAO was
unable to determine the extent to which these problems affect decisions to
continue or discontinue benefits.

Average Percentage of All Beneficiaries Who Were Removed from the DI and
SSI Programs by Category (Fiscal Years 1999 to 2005)
*** End of document. ***