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Project Number: p05-06c

Medical, Functional and Occupational Factors in Disability Determination

Principal Investigators: Allen Heinemann, Elizabeth Durkin and Mary Grace Kovar

Project Type: Core Research

Project Year: 05

Thematic Category: Disability Determination Process

Project Summary:

The Need for Fundamental Change is both the title of the Social Security Advisory Board’s January 2001 report and an urgent reminder that the Social Security Administration’s (SSA) disability determination process faces major challenges. These problems include (1) growth in disability claims that threatens to overwhelm a policy and administrative infrastructure that is inadequate to meet public needs, (2) inadequate tools to make disability determination decisions, (3) a public perception that disability decisions are not made uniformly and consistently, and (4) unexplained variations in decision making that exposes the disability programs to charges of inequity. The Advisory Board is “convinced that the issues facing the disability programs cannot be resolved without making fundamental changes. In our view, these changes must be evaluated within the context of clear goals and objectives.”

One of the greatest challenges occurs when claimants have a severe impairment that does not meet or equal a medical listing. Claimants who allege a mental impairment pose some of the most challenging disability determination decisions. If a claimant does not meet or equal a list-ing, the decision process is based on vocational rather than strictly medical criteria. The DDS physician prepares an assessment of the claimant’s residual functional capacity (RFC) to com-pare to the requirements of past relevant work performed by the claimant. The RFC is used to determine whether the claimant can perform past relevant work. If claimants are capable of per-forming past work, their disability claim is denied. Those who are unable to do past work are evaluated in terms of ability to perform other work that exists in significant numbers in the na-tional economy. This step considers not only the claimants’ RFC, but also age, education, and prior work history. This step uses a grid of several factors to make structured decisions. If the claimants are judged to be able to do other work, their claim is denied.

The large number of DDS-reversed decisions by Administrative Law Judges (ALJs) illustrates the complexity of this decision process and consequent opportunities for disagreement. In fiscal year 2000, ALJs allowed 59% of DDS denials. While worsening medical condition, further de-velopment of medical information, and the opportunity to meet the claimant in person may ac-count for some of these reversals, it is disconcerting that the same information viewed by two different systems can result in radically different conclusions. It seems likely that Disability Quality Branch scrutiny of DDS decisions and Appeals Council scrutiny of ALJ decisions con-tributes to some of the differences. If so, the way information is considered and weighted may be quite different at the two levels of review. Needed is an analysis of why DDS and OHA deci-sions differ, the common or unique ways that decision makers in different offices use occupa-tional, medical and functional characteristics, a better understanding of the measurement proper-ties of SSA’s instruments, and consideration of contemporary instruments that could reduce de-nials that are over-turned on appeal.

The goal of this research project is to help SSA improve decision-making at step 4 and 5 by evaluating the functional and occupational factors that affect disability determinations for mental impairment claims. Little is known about the way in which job characteristics interact with medi-cal, demographic and functional characteristics so as to affect decisions at step 4 and 5. This study is designed to illuminate these issues.

Three questions guide the project:
1. How well can state DDS disability award decisions be predicted using demo-graphic, impairment, functional and occupational information?
2. How well can we predict claimant decisions to appeal DDS denials using claim file information?
3. To what extent can ALJ disability award decisions be predicted using demo-graphic, impairment, functional and occupational information?

Several supplemental questions will also be addressed:
4. Does the mental RFC instrument yield a reliable and valid measure, or do subsets of items form better measures?
5. How consistently are mental RFC judgments made by different raters for claim-ants with different mental impairments and at different stages in the disability de-cision process?
6. Are the characteristics that distinguish awards at step 3 the same from the claim-ant characteristics that distinguish awards at steps 4 and 5?
7. Are the characteristics that predict DDS decisions the same that predict ALJ deci-sions?
8. How well does the Adult Needs and Strengths Assessment (ANSA) instrument predict disability decisions?

The methods include (1) sampling SSDI applicants for a recent one year period within region IV stratified by listing, state, age, and decision (benefits awarded initially or after reconsideration, after hearing, or denial), (2) creating a coding scheme to characterize relevant aspects of medical, functional, and occupational factors from claimant files, (3) evaluating the extent to which rat-ings of mental residual functional capacity cohere to define reliable measures, (4) coding severity of mental impairment using a contemporary instrument, and (5) analyzing claimant data so as to answer the research questions. While the entire project will require a two-year work plan to ac-complish the project goals, a one-year phase is described for the fifth year of the Disability Re-search Institute budget period.