It hit me yesterday afternoon that critics of Social Security's disability determination process have little idea what is involved in the process. There seems to be an eagerness to jump to the conclusion that almost anyone who says they are disabled is found disabled. In the view of these critics, it's nothing but thinly disguised unemployment benefits. These critics are told this by experts at think tanks who produce impressive looking reports. This narrative fits in with the general worldview of a lot of people who work in white collar jobs, people who seldom interact in any meaningful way with those who hold down blue collar jobs, the kind of people who file most Social Security disability claims.
This hit me yesterday afternoon as I was reviewing the file that Social Security has on one of my clients. It runs to 1374 long, tedious pages, detailing this person's health problems over a time period of about seven years. It includes incredibly personal details of this client's life and a mind-numbing amount of detail about this client's medical history. Multiple health problems, multiple doctors, multiple hospitalizations, multiple emergency room reports and more medical tests than most people can imagine. There are duplicate copies of some records because Social Security doesn't have enough personnel to weed these out. Many of the records are hard to read because they were faxed or simply because Social Security stores the records in a low resolution digital format to save money on storage space and bandwidth. If you haven't tried to do it, you just can't imagine how complicated it is to try to follow such a complicated narrative over such a long period of time reading these sort of records. Some of the health problems sound serious at first but turn out to be minor. Others start out sounding minor but end up being major. A health problem may seem to have been resolved only to crop up later. Health problems interact with each other in complex ways, both medically and in how they relate to Social Security's rules. No, most files don't run to 1374 pages but a more typical length is still 500-600 pages and usually involves more than one impairment and possibly a red herring or two. How many of the experts at think tanks or the critics who listen to those supposed experts have ever tried to wade through files like this? I'll take an educated guess that the answer is exactly zero. How much can you know about the process if you haven't done this?
I may disagree with others who spend time reading these files but I respect them because I know they have a firm grounding in reality. The think tank "experts" and the critics who listen to them simply don't know what they're talking about. It's not easy to get on Social Security disability benefits. The process has plenty of flaws but every reasonable effort has been made to make it rigorous and maybe some of these efforts have been unreasonable. Social Security works hard at this. They're been trying to refine their processes for decades. You can't mull these problems over while drinking a cup of coffee and come up with some wonderful idea that no one has even though of. There aren't easy solutions.
19 comments:
OMG, Charles, we finally agree on something. Try wading through 10-15 of those files a week and do it right. The problem is, you can't. The Agency doesn't care. They want numbers moved. They give lip service to all of this by saying trite things like "Every case has a face". My problem is I want to do it right and do right by the claimant as I have been charged to. To do this, I must read the file and make notes and have proper questioning prepared for the claimant. I find it very, very hard to believe that anyone doing 50-60 cases a month is doing them properly. Management says I pay too much attenion to details. When a claimant's entire future is based upon my understanding and comprehension of their file and when $250,000.00-$400,000.00 of benefits is on the table, I don't feel that I can cut corners and make mistakes. You can't have quality and quantity. Everyone deserves a fair hearing. All tax payers deserve a thorough hearing to insure justice, fairness and protection of the trust fund when warranted. I, for one, will continue to fight for proper preparation and administration of our hearings, but I gotta tell ya, I feel awful lonely out here...
You can have it right, or you can have it quick, but you can't have it right quick.
please post this article on your blog, wonder if SSA is considering using this type of technology to quantify pain, if so, get ready for denials.
http://www.npr.org/blogs/health/2013/04/11/176734309/how-much-does-it-hurt-lets-scan-your-brain
Excellent post, 8:27 a.m., and Charles, you are quite right. Having dealt with some of those alleged experts while spending many years in headquarters, I am afraid that you have characterized them accurately. They sometimes mean well but don't have any real understanding of what happens in the process.
Spot on. I've been working at a state DDS for over 15 years, and the examiner job is amazingly complicated. We are bleeding examiners, and with both state and SSA hiring freezes (not to mention an increasingly anti-state-worker environment), our backlog is embarassingly large. There is pressure to move cases, and pressure for high quality. We do the best we can with the resources we have, but it is a crime for people to wait 5 months before an examiner can even look at a case. When claimants complain about delays, there's really nothing to say; I agree, I sympathize greatly.
And no, it is not easy to get on disability, it is a high bar that is set. One group of players complains that "everyone gets on disability." Another group complains that "we deny everyone until it gets to an ALJ." The truth, of course, is a very complicated middle.
There is no think-tank on the front lines, only the daily slogging through mountains of cases, trying to come up with an accurate decision, quickly. I think every Congress person should be forced to spend a week at a field office sitting with a CR taking claims, and a week at a DDS watching how an examiner balances a caseload. It would be an education they are sorely lacking.
Every case is individual, and personal history relevant to a case may have a single critical component to consider for a disabling condition or involve a long period of work, social, and physical impairment issues to consider. There are easy cases and hard cases and cases where someone has been denied disability benefits multiple times (those are the biggest files). The story in this example cannot be judged based on the limited information posted. Why is it important to review information 7 years old? Does this file include 1, 2 or more denials? It takes skill to quickly identify and handle the meaningful issues and it is very hard working with some clients. What about those who want to meet with their representative to talk over their life history for hours when the representative is limited for time so they can handle the next client? Large files can be the result of SSA striving to uncover all possible evidence to establish disability, even paying for this via consultative examinations, rather than make a quicker decision to deny because sufficient evidence does not exist. Should we blame SSA for being more detailed and careful?
The process to create, to manufacture, to evaluate anything be it a product, a service, or a poem is best understood by those directly involved in that process. Those paying for the results of that process can determine if they get value for the result. This is easily seen to the extent items are purchased and at what price. This is not as easy to measure for the services government provides. Critics of SSA's disability determination process do see inefficiency, unnecessary complications, questionable decisions, and expansion of a program to meet different needs. These issues must be reviewed. It is not unfair to question if we are getting what is paid for to decide if someone is disabled. If those involved handling claims or appeals find their job too demanding or if they do not like to have the process reviewed by outsiders who have a stake in the system, they may find job satisfaction elsewhere or work within the system to improve the process.
Having been on both sides of the claim file, first as an adjudicator and for the past 15 years as an attorney, I agree with Charles' impressions as well as most of the comments above.
My perception of things at the State agency level are a bit more jaded however. The #1 concern at DDS is production. Quality is a distant second. One only needs to look at the quality review process to see this. Of the cases that are sent for QR, only a small percentage are denials. The bulk of what is reviewed are proposed allowances. Why is this? One could argue that its because SSA is more concerned with $ than with justice. One could also argue, on the other side, that the appeal process provides the necessary safeguards to those who are wrongly denied at the State agency level. We all know that is BS however.
ALJs are being pushed in the same way now, quantity over quality. Template decisions with boilerplate meaningless language so the decisions can get out faster. I have repeatedly had ALJs state on the record in hearings that they haven't even reviewed the entire claim file before the hearing. Now we have video hearing mills, where critical witnesses are called on the phone to testify. It certainly paints a picture that SSA is primarily concerned with quantity these days.
As for the media commentators and those think-tank professorial types who seem to be trying to direct policy these days, they need to spend a couple weeks with our clients, not at the field office or DDS, to get a feel for what these folks are dealing with.
The bulk of what is reviewed are proposed allowances. Why is this?
See section 221(c)(3) of the Social Security Act
At Anonymous 12:32 PM
Yes, that section of the Act sets out that they must conduct reviews of proposed allowances, but it also states that they must conduct reviews of (ii) other determinations made by State agencies pursuant to this section to the extent necessary to assure a high level of accuracy in such other determinations. I do not believe that the level of review of denials assures a high level of accuracy. I routinely see cases where clear grids cases are missed by State agencies, where they have indicated that controlling weight was being given to a treating source only to develop their own "interpretation" of the source's opinion, and the list goes on and own.
Our State agency loves to boast about their high "decisional accuracy." I'd say that the high # of cases reversed at the hearing level stands to prove that their high decisional accuracy is bunk.
Well now you can't lay all the blame on the DDS' for the high ALJ reversal rate, there are many factors. The long waiting period to get to a hearing means the claimants have aged and can rise to a different voc profile, and their condition may have worsened during the wait. And, let's face it, ALJs just allow more cases for a number of reasons; Commish Astrue mentioned one in his recent cogressional hearing, saying many mechanically adopt treating source opinions without balancing with the objective evidence. If you've ever done CDRs, you'll know that a number of ALJ decisions are head scratchers.
What Commish Astrue didn't mention was that his obsession with numbers also leads to a higher allowance rate since Judges don't have the time or staff to properly develop and hear the cases so some err on the side of the claimant so they can sleep at night..
Chuck, I had the same thought recently. A person publishing an article on this issue who doesn't grasp the complexeties you mention would have as much chance of hitting the mark as a rocket ship designed by Curly, Larry and Moe would have of making it to the moon. Yet some journalists, think tank types and law professors who did not do their homework (or consult with those who know how it works) keep blindly firing away and embarassing themselves. It'll be a tragic victory for ignorance if their voices carry the day.
2:06- Agreed. Unfortunately we see the same thing at the DDS level. Staffing shortages can affect decisions, and that ain't right.
I'm a beneficiary. It's good to know well reasoned individuals are adjudicators at SSA.
I do have a question perhaps a insider would know.
Has the psc telephone representatives been retrained? I have noticed a professional improvement in their service from the last two i talked with.
This says so much about delay and 1000+ page records: "There are duplicate copies of some records because Social Security doesn't have enough personnel to weed these out." As of January 2011 the tool that I thought best addressed duplication & personnel was the bookmarking capability in e-view/efiled medical records. While working up cases at sr. legal assistant level one could bookmark significant medical events: surgery rprt, EKG, lab tests ini/subsequent/final, psych eval, etc. It seemed the more thorough one was at marking these events/tests/conditions within an exhibit using bookmarks, the more easily one could "sort" new from old and avoid duplication which unfortunately was still a problem at that time. Yes, providers often treat SSA employees as their own "secretaries". Providers who just submit all records again and again are saying "here, you do it". But that sorting at the GS6/7/8 level is most efficient for ALJ's and experts and most costly if done at the ALJ level.
6:14- re: PSC reps. Those are feds and as a state DDS employee I have little contact with them. I work more closely with the field office reps, and I'm not aware of any recent formal training in customer service. Like any group of people, a certain pecentage will be... less helpful than others. Lord knows I cringe when I hear what some examiners say to claimants.
To those defending DDS - I work as a rep in a prototype state, and beyond that, our ODAR has one of the quickest time frames from request to the hearing. So people don't age much and conditions don't have a lot of time to worsen. That's not an answer in my case as to why ALJs do, or should, overturn DDS.
It is astonishing to see the number of DDS decisions that come across my desk in which the decision has been shuffled out the door with a "non-severe" determination. HIV, insulin dependent diabetes, depression with recent psychiatric hospitalization are just 3 recent examples of DDS's obvious desire to just get rid of the claims.
I also work with clients who are the poorest of the poor, who have no insurance and rarely have a treating physician, relying on public clinics & hospitals. I wish I had ALJs who could defer to a treating physician!
And for commenter at 2:11 who speaks of journalists "firing away" and embarrassing themselves? They aren't worried in the slightest. Since they didn't care enough to research the issue before putting it into print, they can't be expected to care that much when their blithely expressed opinions are challenged. To the extent their writing is driving public policy, well, that's something we all need to be more vocal about.
10:12 AM, April 12, 2013
I can see you have a true heart for your work and care for the people you are helping. God bless you. Justin
I completely agree with the earlier posts, and the article, which discuss how difficult and time-consuming it is to read the case files, take notes, and conduct meaningful hearings in order to reach a decision in these cases. The files in my office tend to be rather large, and while files over 1000 pages are not the norm, they are certainly not uncommon. I work well over the 40 hours per week for which I am paid, and I can't do 500 cases per year. I suppose in some offices, where the cases are smaller, it would be easier to do 500 cases per year, and there are judges in my office who do 500 cases per year, but doing the numbers is their primary concern, doing it "right" is secondary.
Making these decisions, which greatly affect people's lives, is difficult, and I would not be able to sleep at night if I granted or denied people based on a gut decision, or anything less than fully considering the entire file because I felt I needed to meet SSA's arbitray goal. As the first poster stated, however, those of who feel and act this way are becoming rare in SSA. I am sure I make mistakes, and I am sure I have denied people based on my misinterpreting evidence and testimony, which grieves me, but I fully read every file and give each claimant the opportunity to tell me whatever they want.
Whether a judge is a high-payer or a low-payer should not be the issue -- that is much too simplistic, the issue should be do they read all the medical and non-medical evidence, give the claimant a full opportunity to discuss their problems, know the controlling regulations and rulings, conduct their hearings in a fair and impartial manner, and reasonably apply the law to the facts. If so, one might respectfully disagree with the decision, but still have respect for the process and the judge. On the other hand, if the judge has not taken the time to fully read and digest the evidence and testimony, whether they pay a lot or deny a lot, their decisions should be worthy of respect.
Unfortunately, in my view, SSA's primary concern is numbers, their second concern is speed, and a very distant third is quality. I have been with SSA OHA and ODAR a long time, and this has always been the case, but, in my view, under former Commissioner Astrue, the numbers thing got completely out of hand. He, management, and many judges who are overly concerned with their production are to blame. The focus should not be on high payers, low payers, or low producers, but on management's push for numbers and what judges do (or don't do) to reach those numbers.
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