SSA’s Disability Determination of Mental Impairments: A Review Toward an Agenda for Research

March 1999

(Updated October 2001)

Cille Kennedy, Ph.D.1

The Social Security Administration (SSA) operates two disability benefit programs; Social Security Disability Insurance (SSDI) for disabled workers and Supplemental Security Income (SSI) for disabled impoverished adults and children. Both of these programs come under periodic scrutiny. Of present concern is the process by which claims for disability benefits are adjudicated. In an effort to provide policymakers with a scientific base for future deliberations and indicated directions, the Institute of Medicine (IOM) and the Committee on National Statistics (CNSTAT) have been asked to examine the reliability, validity, adequacy, and appropriateness of SSA’s current and proposed research activities as they related to the proposed redesign of the disability determination (Wunderlich and Kalsbeek, 1997).

The focus of this paper, commissioned by the Committee to Review the Social Security Administrations’ Disability Decision Process Research (the committee), is on the determination of disability status of initial claims, based on mental disorders, for SSDI and SSI disability benefits. The scope of this paper covers the initial determination and emphasizes the medical aspects of the process. It is limited to the adjudication of adult claims. The paper draws heavily on the evaluation—contracted by the

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Cille Kennedy is a Policy Analyst at the Office of Disability, Aging and Long-Term Care Policy, Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services in Washington, D.C.



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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs SSA’s Disability Determination of Mental Impairments: A Review Toward an Agenda for Research March 1999 (Updated October 2001) Cille Kennedy, Ph.D.1 The Social Security Administration (SSA) operates two disability benefit programs; Social Security Disability Insurance (SSDI) for disabled workers and Supplemental Security Income (SSI) for disabled impoverished adults and children. Both of these programs come under periodic scrutiny. Of present concern is the process by which claims for disability benefits are adjudicated. In an effort to provide policymakers with a scientific base for future deliberations and indicated directions, the Institute of Medicine (IOM) and the Committee on National Statistics (CNSTAT) have been asked to examine the reliability, validity, adequacy, and appropriateness of SSA’s current and proposed research activities as they related to the proposed redesign of the disability determination (Wunderlich and Kalsbeek, 1997). The focus of this paper, commissioned by the Committee to Review the Social Security Administrations’ Disability Decision Process Research (the committee), is on the determination of disability status of initial claims, based on mental disorders, for SSDI and SSI disability benefits. The scope of this paper covers the initial determination and emphasizes the medical aspects of the process. It is limited to the adjudication of adult claims. The paper draws heavily on the evaluation—contracted by the 1   Cille Kennedy is a Policy Analyst at the Office of Disability, Aging and Long-Term Care Policy, Office of the Assistant Secretary for Planning and Evaluation, Department of Health and Human Services in Washington, D.C.

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs SSA and conducted by the American Psychiatric Association (APA)—of SSA’s standards and guidelines used in the determination of claims based on mental disorders. Building upon this base, the paper reviews the conceptual model and taxonomy of the World Health Organization’s (WHO) International Classification of Functioning, Disability and Health (ICF) (WHO, 2001) and related WHO disability assessment instruments, and their potential utility in the redesign of the determination process, and toward a cohesive agenda for research. The paper is intended to stimulate an agenda for research to inform future modifications of the disability determination whether or not a formal redesign is undertaken. BACKGROUND Statutory Definition of Disability The foundation of the SSA’s two disability programs is the statutory definition of disability in the Social Security Act. The same definition applies to both the SSDI and the SSI programs and is the standard that the SSA puts into operation for the determination of claims for disability benefits. The definition can be changed only by an act of Congress. According to the Social Security Act, the definition of disability is “Inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment which can be expected to result in death or which has lasted or can be expected to last for a continuous period on not less than 12 months” (Section 223(d)(1)(A)). The term “substantial gainful activity” means work that is remunerated at a rate specified by regulations. As of January 1, 2001, the rate is $740 per month. In other words, an individual may not be earning more than $740 per month in order to be eligible for disability benefits. The statute further states that the physical or mental impairments must be so severe that the claimant cannot do any work in the national economy that exists in substantial numbers. It does not matter whether or not jobs are available in the local region or whether or not the person would actually be hired if a job existed. If a type of job exists in substantial numbers somewhere in the country that the claimant could do, then she or he is not given disability benefits. Conversely, consideration is given to the person’s age, educational level, and past work experience. A person nearing retirement age is treated differently by SSA than a younger, working age individual. The older person is more likely to be considered favorably for disability benefits. A person with a grade school education is not expected to be able to work at an available occupation that requires advanced educational expertise, and a person with a work history of manual labor is not expected to

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs obtain an available position as a business executive. The bottom line for SSA disability is that the person cannot do the simplest, least demanding, existing work whether it is available or not. The reason that an individual is unable to work must be due to a physical or mental impairment that is medically detectable. The statute goes on to define physical and mental impairments as resulting from “anatomical, physiological, or psychological abnormalities which are demonstrable by medically acceptable clinical and laboratory techniques” (Section 223(d)(3)). The effect of any one impairment or any combination of impairments is to be evaluated for severity in determining disability for work. If one impairment is so severe that the person cannot work, then the person is considered disabled. If a combination of impairments precludes work, then the person would be considered disabled even if no single impairment would be considered severe by itself (Section 223(d)(2)(C)). Sequential Evaluation The process by which SSA adjudicates initial claims for both SSDI and SSI disability benefits is called sequential evaluation. There are five steps in the initial process. Responsibility for completing these steps is divided between federal SSA workers in local SSA district offices (DOs) and state employees working in state Disability Determination Services (DDSs). The SSA contracts with state agencies, such as departments of social services or rehabilitation, to act as DDSs. The first step in the sequential evaluation takes place at the local DO. The person claiming disability (or a representative) appears and applies for benefits. Here, the DO staff determines whether or not the individual is currently working according to the criteria established by the regulated amount considered to be “substantial” (currently $740 per month). If the person is earning at or above this level, the claim is denied at this step. If the claim is not denied, then it is necessary to decide whether the claim should be processed for SSDI or SSI benefits, or both. Although the process is the same, the administrative criteria and cash award amounts differ. SSDI is an entitlement program for workers. There are specific work history requirements for SSDI. Workers pay into the Social Security system and therefore have the right to receive cash benefits if disabled. The SSI program is for people whose income and resources are below a certain monthly level and who are blind, aged, or disabled. Children are eligible for SSI. It is possible to receive both SSDI and SSI benefits simultaneously. Once the decision is made about which disability program the person is eligible for, the SSA DO staff requests that the applicant supply the necessary medical evidence and work history to support the claim of disability. The SSA DO staff then forwards the claim to the state DDS.

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs The second step begins when the application is received in the state DDS. Here a team collects and evaluates the medical evidence and work history. There must be sufficient medical evidence to substantiate a determination of the claimant’s disability status. The team consists of a Disability Analyst and a Reviewing Medical Consultant. For claims based on mental impairments, the Reviewing Medical Consultant is usually a psychiatrist or clinical psychologist. The Listings of Mental Impairments (the Listings) are the standard for the evaluation of the medical evidence for demonstrable signs, symptoms, and restrictions in daily life (described below). They are the translation of the medical component of SSA’s definition of disability. The review of claims based on mental impairment is put into operation against the standards of the Listings using the Psychiatric Review Technique Form (PRTF) (described below.) The PRTF guides the decision-making process, conforming to SSA regulations (SSA Regulations, 404.1520 and 404.1520a) as to how decisions are to be made. The Reviewing Medical Consultant determines whether an impairment exists, and—if so—whether the impairment is considered severe. An impairment for SSA is analogous to a diagnosis of one of nine alcohol, drug, or mental disorders. Severity is concluded on the basis of whether the claimant’s condition results in slight or marked restriction of activities. If the impairment is found to be slight or ‘not severe,’ the claim is denied on the basis of this medical consideration alone. If the impairment is considered severe, the claim continues in the sequential evaluation process. The third step involves severe cases only. The assessment at this step inquires whether the impairments are so severe as to preclude work on the basis of medical evidence alone. In this step, the Reviewing Medical Consultant decides whether or not the claimant’s impairment(s) “meet or equal” standards set by the Listings of Mental Impairments.2 If a case meets or equals the Listings as indicated on the PRTF, then the claimant is allowed benefits by this medical evaluation. If this severe case does not either meet or equal the Listings, it continues in the sequential evaluation. Steps 2 and 3 are the only steps that permit a disability decision based on medical assessment alone. In step 2 the Reviewing Medical Consultant may determine that a claim is “not severe” and the claim is denied. The Listings of Mental Impairment are constructed in such a way that an 2   A claim “meets” the Listings if the condition is of such severity that it precisely matches the findings. If the impairment does not match but is clinically equivalent to and exceeds the severity of one of the Listings (as is required in “meeting” a Listing), it is considered to “equal” the Listing that it most closely resembles.

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs individual who ‘meets or equals’ them in step 3 of sequential evaluation cannot reasonably be expected to work and the claimant is awarded SSA disability benefits. The fourth step applies to those severe claims that have not been found so severe as to be allowed disability benefits on the basis of medical evidence alone. For these claims, the nonmedical factors of age, education, and work history are taken into account. Another difference in this step is that the Reviewing Medical Consultant provides additional input into the decision by completing the Mental Residual Functional Capacity Assessment (MRFCA) (see description below); it is the Disability Analyst who combines the narrative summary of the MRFCA with the age, educational level, and work history of the claimant to determine whether or not the claimant is capable of working at the level of her or his past employment. This decision is made in light of jobs available in the national economy. If the Disability Analyst finds that the claimant can do previous work, the claim is denied. If the finding is that the claimant cannot do previous work, the claim continues one final step in the initial review. The fifth step applies the same claim material to the question of whether the claimant can do any job in the national economy. If the Disability Analyst determines that the claimant can do work—irrespective of whether it is locally available or whether the person would actually be hired—then the claim is denied. If the person cannot do any work in the national economy, then the claimant is awarded disability benefits. The next section describes the standards and guidelines upon which these medical judgments are based. Listings of Mental Impairments The Listings of Impairments (SSA, 2001) are published by the SSA and updated periodically. Chapter 12 of the Listings is devoted to mental disorders, otherwise known as the Listings of Mental Impairments. Major revisions to the Listings of Mental Impairments, currently being applied to claims for disability benefits, were published in 19853 and have since undergone relatively minor modifications. The 1985 revision was intended to bring the Listings in line with then-current psychiatric practice to reflect the APA’s third edition of its Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (APA, 1980). The process of this revision was unique in SSA’s history. It was the first time that the SSA had sought outside expertise to revise its Listings. The APA, the American Psychological 3   The most recent edition of the Listings of Impairments was published in 2001. No substantive changes were made to the Listings of Mental Impairment that have impact on this report.

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs Association, and other mental health experts participated with the SSA in the process. There are currently nine Listings of Mental Impairment designed to reflect the major psychiatric diagnostic categories likely to cause disability for work.4 There are three sets of criteria within the Listings of Mental Impairments: A, B, and, for a subset of categories, C. The purpose of the A criteria for mental disorders is to medically substantiate the presence of a mental disorder. The categories for adults follow: Organic Mental Disorders; Schizophrenic, Paranoid and Other Psychotic Disorders; Affective Disorders; Mental Retardation; Anxiety-Related Disorders; Somatoform Disorders; Personality Disorders; Substance Addiction Disorders; and Autistic Disorder and Other Pervasive Developmental Disorders. The categories contain either two or three sets of criteria.5 The A criteria are essentially diagnostic-like symptoms. They are not exact replicas of the DSM-III but are analogous to them. Each of the categories, except mental retardation and substance addiction, lists clinical findings. With the noted two exceptions, the threshold for the A criteria is that at least one of the clinical findings must be present. For example, to fulfill the A criteria for the category of Schizophrenia, Paranoid and Other Psychotic Disorders, there must be medically documented evidence of persistence, either continuous or intermittent, of at least one of the following: delusions or hallucinations; catatonic or other grossly disorganized behavior; or incoherence, loosening of associations, illogical thinking, or poverty of content of speech associated with one of the following: blunt affect, flat affect, or inappropriate affect; or emotional withdrawal and/or isolation. 4   The 1985 revision contained eight Listings of Mental Impairment. 5   The Listing for Mental Retardation contains four sets of criteria. The Listing for Substance Addiction Disorders contains nine. They are outside the scope of this review.

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs The categories of Mental Retardation and Substance Addiction Disorders each differ and are not discussed as part of this review. They require special expertise and attention to detail beyond the scope of this paper. The B criteria are applied to the category for which the A criteria are fulfilled. The purpose of the B criteria for mental disorders is to describe the functional restrictions that are incompatible with work and are associated with the mental impairments of the A criteria. The B criteria follow: marked restriction of activities of daily living; marked difficulties in maintaining social functioning; marked difficulties in maintaining concentration, persistence, or pace; and repeated episodes of decompensation, each of extended duration. As an example, the SSA describes activities of daily living to include cleaning, shopping, cooking, taking public transportation, caring for one’s grooming and hygiene, among others. These activities are referred to as activities of daily living and instrumental activities of daily living in the professional literature. The C criteria apply to all categories except Mental Retardation, Personality Disorder, Substance Addiction, and Autistic Disorder.6 The C criteria are additional considerations for cases that do not reach the threshold of the B criteria. For example, the C criteria for Schizophrenia, Paranoid, and Other Psychotic Disorders are intended to compensate for such instances when claimants are living in supportive residential settings or are otherwise adapted to a special environment that could not be sustained if the person went to work. These C criteria also consider individuals who have a history of serious episodes of disorder or disability and are currently functioning at a relatively high level through the benefits of medication but whose delicate functional status would be jeopardized by the additional stress of work. In other words, the relatively high degree of functioning is attributed to the compensatory medications or supports. Work would jeopardize this accomplishment and would vitiate the level of functioning attained. The C criteria for Anxiety-Related Disorders are designed to accommodate individuals with agoraphobia who are totally unable to function outside their homes but can function successfully within the home. The following description of the forms show how decisions are made that put the sequential evaluation into effect for the medical component of the disability determination. 6   Although the Listings for both Mental Retardation and Substance Addiction Disorders do have C criteria, they are of an entirely different conceptual nature.

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs Forms Used by the Reviewing Medical Consultant The Reviewing Medical Consultant uses two forms in the sequential evaluation. The forms are used to document the existence of the medical condition and its impact on the domains of functioning related to the ability to work. The Psychiatric Review Technique Form puts the Listings of Mental Impairment into operation. The Mental Residual Functional Capacity Assessment is used to assess remaining functioning for claimants who are considered severe, but not sufficiently severe to be awarded benefits on the sole basis of the medical evidence using the PRTF. The MRFCA is intended to document what the person can do in spite of severe impairment. Unlike the B criteria of the Listings that ask the degree of limitation, the MRFCA intends to look at residual functioning—what the person can still do. Psychiatric Review Technique Form This is designed to facilitate a review of the medical evidence and guide a medical decision as to the disability status of the claimant. The cover sheet, Section I, contains the summary of the medical review in two parts: the medical disposition and the category on which the medical disposition is based. The second page, Section II, provides space for the Reviewing Medical Consultant’s notes. Following this is Section III, which lists the different categories of mental impairments along with their A criteria. At the top of each category are two checkboxes in which to indicate whether or not evidence of a cluster or syndrome exists that fits the particular diagnostic-like category. Beneath those two checkboxes, each of the category’s A criteria is preceded by three checkboxes in which to indicate whether the specific item is present or absent, or whether insufficient evidence is provided in the medical information. The Reviewing Medical Consultant selects the one diagnostic-like category under which the claim will be reviewed and fills out the boxes for those items. If the A criteria are fulfilled, the Reviewing Medical Consultant then proceeds to the section that contains the four B criteria. The page dedicated to the B criteria has two sections. The first is a chart that has the four B criteria, the areas of functional limitation listed on the left, and to the right, four or five checkboxes with which to rate the degree of limitation. Although degree of limitation is generally conceptualized as a continuum, for programmatic practicality, five intervals are identified. For example, restrictions in activities of daily living (the B1 criterion) can range from none, to slight, moderate, marked, and extreme. These degrees of limitation are used to make two decisions: whether the claimant is (1) slightly limited (a step 2 denial) or (2) so severely limited that a benefit can be awarded (step 3). A slight impairment exists if all four B criteria are checked in the two left-hand columns (none, slight,

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs never, or seldom). All other claims are considered severe. For a claim to be so severe as to meet or equal the Listings of Mental Impairments, two of the B criteria must be checked in the two columns to the right (marked, extreme, frequent, constant, repeated, or continual). As noted above, somatoform and personality disorders require that three of the B criteria must be so designated. The C criteria are assessed as to their presence or absence. This detailed description of the forms is not presented without reason. The judgments made by using the checkboxes result in two medically based disability determinations: denials for nonsevere claims and allowances for claims that are medically considered so severe as to preclude work. A “marked” limitation is considered a clinical decision. SSA describes “marked” as between a moderate and an extreme limitation. How sound are these decisions? Mental Residual Functional Capacity Assessment This is used only for claims that are severe but have not been allowed disability benefits in the previous step of sequential evaluation, either meeting or equaling the listings. The MRFCA provides additional medical review for the Disability Analyst to combine with the nonmedical factors of age, education, and work history. The MRFCA is a checklist of 20 items subaggregated into four categories: (1) understanding and memory; (2) sustained concentration and persistence; (3) social interaction; and (4) adaptation. The form calls for a rating of limitation in the context of the individual’s capacity to sustain the listed activity over a normal workday and workweek, on an ongoing basis. These items are rated on a three-point scale from “not significantly limited” to “markedly limited.” Two other checkboxes permit ratings of “no evidence of limitation” and “not ratable on available evidence.” “Not ratable” is to be used if the Reviewing Medical Consultant feels that there may be a limitation but cannot support a finding on the existing evidence. “No evidence” is for cases where none would be expected. Of note is that item 11 essentially encapsulates the entire disability determination in one question: “The ability to complete a normal workday and workweek without interruptions from psychologically based symptoms and to perform at a consistent pace without an unreasonable number and length of rest periods.” This is the essential question for the whole disability determination. Using the 20 ratings as a foundation, the Reviewing Medical Consultant drafts a narrative in a section titled “Summary Conclusions.” This narrative is the documentation that is used by the Disability Analyst. The ratings are not considered by the Disability Analyst.

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs Medical Evidence The initial disability determination is a case record review, a paper review. It is the responsibility of the individual who is claiming to be disabled to provide the SSA with medical evidence to support the claim. Medical evidence consists of clinical signs, symptoms, and/or laboratory or psychological test findings. Clinical signs are medically demonstrable phenomena that reflect specific abnormalities of behavior, affect, thought, memory, orientation or contact with reality. A psychiatrist or psychologist generally assesses clinical signs. Symptoms are complaints presented by the individual. The findings may indicate an intermittent or persistent impairment depending on the nature of the disorder. Medical evidence also includes information from other informed sources, such as family members and rehabilitation therapists, who have relevant knowledge of the claimant’s functional capacity and limitations. This information is germane to the assessment of the B criteria on the PRTF and for the MRFCA review. There are no SSA-mandated forms for the provision of medical evidence. The collection of medical evidence is initiated by the local SSA district office and continued by the state-level DDS reviewing team to the point at which a disability determination of either an allowance or denial can be substantiated. If the sources of medical evidence identified by the claimant do not provide sufficient evidence necessary to make a disability determination, a consultative examination can be provided. The SSA or DDS pays to have the claimant interviewed and a report sent to the DDS. The Consultative Examiner is generally someone not known to the claimant. The Listings of Mental Impairment, and the forms used by Reviewing Medical Consultants—the PRTF and MRFCA—constitute the medical aspect of disability determination. For claims that do not result in a medical determination (i.e., a denial at step 2 using the PRTF because the disability is not severe or an allowance at step 3 because the disability is so severe that it precludes work on a medical review alone), the Disability Analyst continues the review with additional nonmedical factors. It is the medical aspect of the review of claims for disability benefits based on mental disorders that received a scientific evaluation. AMERICAN PSYCHIATRIC ASSOCIATION EVALUATION STUDY In 1984, prior to the publication of the 1985 Listings of Mental Impairments, the SSA, under the direction of the then-Assistant Commissioner for Disability Patricia Owens, contracted with the APA to design an evaluation of the soon-to-be-released standards and guidelines for the evaluation of mental impairments. The evaluation would include the Listings,

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs the operational definitions for their implementation, and the forms (PRTF and MRFCA) that would be used in practice. The designed evaluation was accepted, and in 1985 the SSA awarded a contract to the APA to conduct the two-year evaluation.7 The following description is a summary of the study. Scope of the Study The study was designed to ascertain the accuracy with which the medical standards and guidelines used by SSA’s medical consultants operationalized the statutory definition of disability due to mental impairment and their consistency with contemporary psychiatric knowledge and practice. Within this broad objective, the study sought to identify and characterize cases that were difficult to evaluate with the medical standards and guidelines and to pinpoint the specific source of difficulty, and suggest solutions (Pincus et al., 1991). Methodology The study consisted of three components. The first investigated the compatibility of the SSA’s revised medical standards and guidelines with the statutory definition of disability. This component provided the bulk of the study’s empirical data. Component I employed 72 psychiatrists who were a demographically and professionally heterogeneous sample of APA’s membership recruited from five geographically diverse cities. “Professional heterogeneity” meant the orientation or “school” of psychiatry represented, such as expertise in psychopharmacology or psychoanalysis, or experience with inpatient or outpatient, acute or chronic clients. Each psychiatrist was assigned to one of two study conditions. One—the sequential evaluation condition—received training and applied the SSA disability determination process and forms (e.g., PRTF and MRFCA) used by SSA’s Reviewing Medical Consultants in actual case-work. SSA staff participated in the training. The second study condition—the statutory definition condition—reviewed claims on the basis of psychiatrists’ knowledge of the characteristics and limitations associated with the disorders experienced by the claimants. Training for this study condition consisted of in-depth discussions of the statutory definition of disability, claimants’ impairments, functional limitations, and whether or not the claimants would be considered disabled according to the law. None of SSA’s forms were used by this study condition. 7   The Listings of Mental Impairments have been modified slightly since the APA conducted the evaluation. However, the essential study findings are still relevant.

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs Listings as rated on the PRTF. This too is a relatively easy group to identify. It was not considered problematic in the APA study. One proposed revision to SSA’s process would use an Index of Disabling Impairments to make this decision. The committee’ second interim report (Wunderlich and Rice, 1998, p. 19) noted that the Index is supposed to be simple enough so that laypersons will be able to understand what is required and to demonstrate a disabling impairment. The Index is being or about to be developed. Yet, there is already a scientifically based finding that the B criteria of mental impairments review work well. Would it not be worth investigating whether those same criteria would work as well for claims based on physical conditions? Next, disability determination sorts the dichotomous decision of ability or inability to work for the remaining claims in the middle. Without knowing the scientific justification of collapsing steps 4 and 5 of the present sequential evaluation, it seems a reasonable step on face value. The difficult claims to adjudicate are those close to the line in the middle. This is the group in which false positives and false negatives are most likely to occur. False positives are those who can truly work but are erroneously allowed disability benefits. These individuals will not appeal. Are they likely to stay on the rolls? False negatives are likely to appeal. This is the step in sequential evaluation that the APA study identified as problematic. It is also the step at which SSA has considered using an individualized functional assessment. For claims based on mental disorders, this new assessment would replace the MRFCA. In the existing sequential evaluation, steps 2 (slight) and 3 (so severe) appear to be quite separate. In fact, they are two decisions made at the same point, using the same information. After claims have had their medical condition identified by the A criteria, the medical evidence is rated using the B criteria. The ratings sort those with slight limitations from those who are very severely limited and those in the middle. This one part of the process actually makes three decisions: denials for slight limitations; allowances for very severe limitations; and those in the middle who need more thought. If the decisions are correct, it is a very effective and efficient step—the rating of the B criteria. What makes sense is to have the DO staff conduct step 1 (is the person involved in substantial gainful activity?) and document the health condition or combination of health conditions that are causing the purported disability for work, and record the onset of the health condition and the onset of the period of disability, thus identifying the period of review. The SSA’s form for adults, SSA-3368-BK, contains the applicant’s report of these dates and is collected by the DO. Medical evidence can substantiate the health condition and its onset. This would eliminate a time-consuming review with A criteria.

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs Once medical evidence has been added to the case folder, it might make sense to turn to a brief functional assessment such as the WHO DAS II 12-item screening questions to eliminate the slightly and very severely limited claims as is currently done for claims based on mental disorders. This would settle the claims at both extremes of the distribution. Research here could investigate the applicability of the three B criteria to claims based on physical health conditions and foster a more robust set of B criteria and scale points For the remaining claims, SSA could build on the APA study and look for the factors that predict difficult-to-adjudicate claims: coexisting mental and physical conditions; onset of less than 12 months; and female claimants. SSA can identify other characteristics from among the claims whose decisions are reversed upon appeal. Additionally, scores or patterns of ratings on the WHO DAS II 12-item screening questions might distinguish routine from difficult-to-determine claims. These will be the claims likely to be closest to the border of able or not able to work. The APA suggested that these difficult claims might be best served by a review by a panel of Reviewing Medical Consultants. Information SSA Already Has The answers to the following questions reside either in the various datasets of SSA or in reports submitted to it by such informed sources as the National Academy of Social Insurance. These data can identify the strengths and weaknesses in the existing process. SSA can identify the distribution of disability among its claimants. It should do this for three groups: all claims; claims based on physical conditions; and claims based on mental conditions. SSA may suggest reasons why this should be done for both disability programs and SSDI and SSI separately for the three groups of claimants. The reason for conducting separate analyses for physical and mental conditions is to understand the generalizability of the APA findings to claims based on physical disorder. SSA may also consider separate analyses of other problematic categories of physical disorders. SSA can identify the magnitude of importance for slight and very severe disability decisions. How many of these decisions are made? What proportion of claims do they represent? How many denials based on slight limitation are appealed and reversed? How many very severely limited people leave the rolls and return to work? How long does a claim take to assess when it is denied at step 2? How long does a claim take to adjudicate that is allowed at step 3?

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs What are the characteristics of claims that take a long time to adjudicate? What are the characteristics of claims that are denied at steps 4 and 5 that are appealed and have the disability decision reversed? Can SSA identify the types of medical evidence that are most difficult and/or take the most time to obtain? The above information can begin to establish priorities for additional research. The information tells us what is working well and what is problematic. If it is working, why change?19 Nonetheless, with improvements in the submission of medical evidence, the number and percent of claims that can receive a disability determination at steps 2 and 3 are likely to be increased, thus reducing the number that continue in the determination process. Information based on ICF items might be requested as part of a standard submission of medical evidence. The next issue is to sort the claims remaining after the slightly limited and very severely limited have been handled. For these claims, additional functional assessment—but no consideration of age, education, and work history—is planned in the proposed process. This is where new functional assessment forms or instruments are required. Research would have to explore these alternatives and the medical evidence needed for the assessment. The above statements are consistent with Recommendation 4-1 made by the IOM committee in its second interim report (Wunderlich and Rice, 1998, p. 21).20 Problems Already Identified by Research The lack of sufficient medical evidence and the low quality of the medical evidence that is provided were identified as serious issues by participating psychiatrists in the APA study. This was their impression even though the claims had been through an SSA review for the quality of the evidence. In other words, they may have been better or more complete than average claims adjudicated in the DDSs. In addition to the APA’s 19   This may be the information to which the committee alluded in its second interim report (Wunderlich and Rice, 1998, p. 13) in discussing the nature and extent of the problem with the disability decision process. The above information may provide sufficient information to act as a needs assessment. 20   The committee recommended that early in its redesign effort, the SSA should specify how it will define, measure, and assess the criteria it will use to evaluate the current disability determination process, as well as any alternative processes being developed.

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs recommendation that a standard form for medical evidence be designed and used nationally, other medical evidence collection procedures might be reviewed. For example, although SSA is seeking to streamline its process, something may be gained by collecting medical evidence in two stages: the first stage for slight and very severe decisions based on a modification to the first three B criteria, the second for more in-depth assessment of the remaining claims, notably those that are expected to be inherently difficult, near the border of able or unable to work. What is needed? Which items in ICF can guide the development of medical evidence forms(s)? Have some states developed standard medical evidence forms, and if so, how are they working? The APA study also identified problems in reviewing claims based on mental disorder when a physical condition was present. This issue might be addressed by a de novo consideration of the confluence of review of claims based on mental and physical disorders—the basic requirements of work for the two groups do not differ. Can a useful set of work-related factors be identified across disorder groups? For example, the items in ICF include general tasks and demands that are the basis for work-related activities (ICF d210 through d299); communications (ICF d310 through d349); interpersonal interactions and relationships (ICF d710 through d7109, d740 through d7409); and tasks needed to find, get, and keep a job (ICF d845 through d8459). A review of the ICF along with SSA’s regulations and relevant Program Operations Manual System might reveal additional items. Any rating of these items would be consciously made in view of the claimant’s health condition and other criteria outlined in the SSA definition of disability. How might the first three B criteria for claims based on mental disorders and their rating be approved and made applicable to people claiming disability based on physical disorders? Again, the ICF offers a rich resource both for the items and for rating the items. The fourth B criterion might be revisited along with the C criteria to create a method to acknowledge that certain individuals appear not to be disabled for work but are only compensated in their existing environment or accommodated to their current level of stress. A change to a work environment would destroy their fragile state. Of note is that there are no analogous B criteria for the Listings for physical conditions. In general, functional restrictions in the Listings for physical conditions are limitations in the function of a body part, such as motion of a joint. Only in the Residual Physical Functional Capacity Assessment (analogous to the MRFCA) are there any physical functioning ratings that apply to all of the physical categories. Not all of them are limitations in activities such as lifting and carrying; some are limitations of specific body parts or systems, such as visual acuity. Many of the physical

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs limitations are redundant with functions of body parts of the Listings of physical impairments (e.g., reaching in all directions [Residual Physical Functional Capacity Assessment] and range of motion in joints [physical Listings]). STRATEGY FOR DEVELOPING AN SSA DISABILITY RESEARCH PROGRAM Prior to developing a program of research, identifying issues for research, and specifying research mechanisms and methodologies, a strategy for establishing priorities needs to be created. At present, compelling research questions are vying for attention. The IOM committee may wish to consider establishing a working group to draft an outline of work that addresses the following three issues preliminary to creating priorities for research: Using SSA information, identify weak points in the existing adjudication process (e.g., slight limitation denials) and identify strong points that can be built on or generalized across claims based on physical and mental disorders: Develop a plan for “fixing” the sequential process. For example, if the first two steps work well, keep them. Then go to the third step to look at problem areas (keeping in mind that for claims based on mental disorders, steps 2 and 3 are not readily distinguishable as steps only for the decision that is made). Acknowledging that there will always be inherently difficult claims, develop a way of preselecting them and creating a process for handling them (e.g., panel of reviewers). Explore the differences between the adjudication materials for claims based on mental disorders and those used on physical disorders to see if the strengths identified by the APA study might not apply to the adjudication of physically disordered claimants, and attend to the weaknesses as well: If the A criteria are to be eliminated as has been suggested at times, identify some method of documenting the association of the health condition with the disabled state. Explore the factors that need to be included in the medical evidence and how the medical evidence will interface with SSA assessment forms.

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs Review the ICF, ICF Checklist, WHO DAS II, and WHO DAS II screening questions to identify which components can: be used to create a standard form for the submission of medical evidence; can be used as a screen of slight and very severe claims; and can provide the basis for a fuller, more detailed version of the functional limitation criteria for both physical and mental conditions, and conduct a thorough investigation of the scale points and ratings as they calibrate to disability decisions (not severe, so severe, and disabled for work) for both physical and mental conditions. The product of this working group has the potential to lead to a cogent research agenda that allows the inclusion of additional important research topics. It will also make evident the type of research that needs to be conducted, such as clinical trials or instrument development research, and the methods and mechanisms by which this research should be conducted. It also might suggest partners in this important national and federal endeavor. RECOMMENDATIONS There are four overarching areas in which recommendations can be grouped: (1) disability determination; (2) identifying priorities; (3) conceptual, taxonomic, and assessment resources; and (4) research agenda. All of the following recommendations are empirically based and made with the proviso that each be accompanied by research in an iterative process to provide a scientific base to identify and substantiate improvements. These recommendations are based on the disability determination of claims based on mental disorders and on research of the process, standards, and guidelines used in the adjudication of claims based on mental disorder. Disability Determination Existing research on disability claims-based mental disorders finds that no major change to sequential evaluation or to the standards and guidelines used in this process (notably the Listings of Mental Impairments and the PRTF) is warranted—only refinements. Because basic work requirements are independent of health conditions, the adjudication of functional capacity for work should be the same for claims for disability benefits irrespective of the type of health condition (i.e., physical or mental disorder). The current process of sequential evaluation should be maintained with the following modifications:

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs There should be four steps to sequential evaluation: the current steps 4 and 5 should be combined. The first judgment in the medical review should be identification of the date of onset and period of review. As long as the health condition causing the disability for work (i.e., the A criteria of the Listings of Mental Impairment) can be identified, substantiated, and linked with functional limitations, the focus of these criteria can be shifted to a more thorough and substantive evaluation of functional capacity for work. Based on an evaluation of functional capacity for work, sequential evaluation should screen out claims that are not severe and those that are so severe. These two disability decisions (i.e., denials for not severe and allowances for so severe) are currently steps 2 and 3 in the sequential evaluation. These two medical judgments of disability status are focused on the two extremes of the distribution of disability claims. For the remaining claims, SSA should apply clinical and demographic factors that identify difficult-to-adjudicate claims and select these claims for review using a panel process that combines additional functional assessment and nonmedical factors as the last step in sequential evaluation. For claims not identified as difficult to adjudicate, the final step in sequential evaluation should be applied, which combines additional functional assessment and nonmedical factors. Identifying Priorities SSA should analyze its existing data to identify and prioritize areas for revision and refinement. SSA should compare the magnitude of its caseload and the decisions made at each step in sequential evaluation for all claims for disability benefits in the SSDI and SSI programs, all claims for disability benefits based on physical conditions in the SSDI and SSI programs, and all claims for disability benefits based on mental conditions in the SSDI and SSI programs. SSA should identify and prioritize the weak points and strengths in the existing sequential evaluation for claims based on physical conditions and for those based on mental conditions by examining the magnitude of decisions made at each step in the process and by the proportion of denied claims that are successfully appealed. Steps 2, 4, and 5 can be evaluated in this fashion.

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs SSA can identify claimants awarded disability benefits at step 3 who leave the rolls and return to work. Using existing data, SSA can identify the characteristics of claims that are difficult to adjudicate. Based on the APA study findings, SSA can explore clinical and demographic factors that predict difficulty in reaching a disability determination. SSA can identify inherently difficult claims by specifying the characteristics of those that take a long time to reach a disability determination. SSA can examine the types of claims that are likely to be reversed on appeal to identify inherently difficult claims. Conceptual, Taxonomic, and Assessment Resources The WHO’s ICF, an international classification of disablement and functioning, provides a culturally sensitive, research-based, rigorous yet flexible conceptual foundation for revisions to SSA’s disability determination for claims based on mental and physical conditions. One of its specified applications is for Social Security disability benefit programs. The ICF conceptual model is consistent with the definition of disability in the Social Security Act and with the process that puts disability determination into operation. Domains and items in ICF are readily utilized in modifications to existing SSA disability determination forms in sequential evaluation. They would enrich SSA’s conceptual development and assessment of functional capacity to work. The ICF has related disablement assessment and research instruments that can be modified for use as standard forms for medical evidence and in sequential evaluation: The ICF Checklist can be used as the basis for the development of a universal form for submission of medical evidence. It should be reviewed for possible inclusion of additional items related to work activities. The WHO DAS II contains six domains, five of which relate to work as currently conceptualized in the Listings/PRTF B criteria applied to claims based on mental conditions. This instrument could be supplemented with additional physically exertional items and used as the residual functional capacity assessment

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs for both mental and physical conditions in the last step of sequential evaluation. Additional research should be conducted on the WHO DAS II as adapted above, and on its scoring and scale point definitions, to provide a scientific judgment about work capacity. (At present, the part of the MRFCA form that is used in the determination is a narrative summary. The 20-item ratings are considered a worksheet.) The WHO DAS II 12-item screening questions is composed of two items from each of the six domains. The scaling of these items can be tested against the current B criteria thresholds for identification of the two extremes not-severe and so-severe claims. They can then be used for claims based on physical and mental conditions to make disability determinations at steps 2 and 3 of sequential evaluation. Research Agenda A working group of researchers from SSA, the National Institute of Mental Health, other federal agencies, and knowledgeable researchers from the private sector should be organized to develop a research agenda to review the ICF, ICF Checklist, WHO DAS II, and WHO DAS II 12-item screening questions for needed modifications for applicability in SSA sequential evaluation; refine assessment instruments for the evaluation of disability for work based on physical and mental conditions for use in sequential evaluation; calibrate scaling of assessment to disability for work based on physical and mental conditions; create a standard medical evidence form; review SSA databases to analyze existing data and identify priorities for research; and review IOM recommendations for research. All refinements to the existing system should be based on research findings. The development of revisions should be an iterative process with research findings providing an empirical base. Appropriate research methodologies should be identified for the diverse research issues.

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs In summary, the evaluation of claims for disability benefits is a complex and difficult task. This task is also a small component of the many extrinsic factors that have bearing on the shape of the disability program, such as long- and short-range economic factors, the changing characteristics of the general population and labor force, and the general priority and ideology held regarding people with disabilities. This paper has limited its focus to the medical review of claims for disability benefits based on mental conditions and has been informed by the APA’s evaluation of SSA’s standards and guidelines used in disability determination. With the recent revision of WHO’s ICF and the development of related disability assessment and research instruments, a new and valuable resource has become available for use in modifications of the tools used in sequential evaluation. Building on the research database provided by the APA study, the development of the ICF as a conceptual model, and on a classification system of disablement and functioning and its related instruments, it is possible to suggest recommendations for a research-based agenda to refine sequential evaluation and the standards and guidelines that implement disability determination for claims based on both mental and physical conditions. This is made possible because basic work requirements are consistent across disorder types. Each of the recommendations that have been made is intended to be a component of an explicit research plan developed by an interagency working group. Finally, it is important to note that all recommendations are made within the context of the SSA’s definition of disability. There are no indications that any change to the statutory definition should be considered. REFERENCES Americans with Disabilities Act. 1990. Public Law 101–336. American Psychiatric Association. 1980. Diagnostic and Statistical Manual of Mental Disorders (3rd Ed.) Washington, DC: American Psychiatric Press. Pincus HA, Kennedy C, Simmens SJ, Goldman HH, Sirovatka P, Sharfstein S. 1991. Determining disability due to mental impairment: APA’s evaluation of Social Security Administration guidelines. American Journal of Psychiatry 148(8):1037–1043. Pope AM, Tarlov AR. 1991. Disability in America: Toward a National Agenda for Prevention. Washington, DC: National Academy Press. Social Security Act. as in effect January 2001. Social Security Administration. 2001. Disability Evaluation under Social Security. Listing of Impairments Adult [Online]. Available: http://www.ssa.gov/disability/professionals/bluebook/AdultListings.htm [accessed September 24, 2001]. Social Security Administration Regulations. 20 CFR Ch.III 404.1520 [Online]. Available: http://www.ssa.gov/OP_Home/cfr20/404/404-0000.htm [accessed September 24, 2001]. Social Security Administration Regulations. 20 CFR Ch.III 404.1520a [Online]. Available: http://www.ssa.gov/OP_Home/cfr20/404/404-0000.htm [accessed September 24, 2001].

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The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs World Health Organization (WHO). ICF Checklist [Online]. Available: http://www3.who.int/icf/icftemplate.cfm [accessed September 24, 2001]. WHO. 1980. International Classification of Impairments, Disabilities, and Handicaps: A Manual of Classification Relating to the Consequences of Disease. World Health Organization, Geneva. WHO. 1993. International Statistical Classification of Diseases and Related Health Problems: Tenth Revision. World Health Organization, Geneva. WHO. 2001. International Classification of Functioning, Disability and Health. World Health Organization, Geneva. WHO [Online]. Available: http://www.who.int/icidh/whodas/index.html [accessed September 24, 2001]. Wunderlich GS, Kalsbeek WD, eds. 1997. Disability Evaluation Study Design: First Interim Report. Washington, DC: National Academy Press. Wunderlich GS, Rice DP, eds. 1998. The Social Security Administration’s Disability Decision Process: A Framework for Research. Second Interim Report. Washington, DC: National Academy Press.