Why Does SSA Need to Hire 90 Nurse Case Managers For Disability Service Improvement?

The Government Accountability Office Report on the Disability Service Improvement (DSI) plan, delivered at last week's House Social Security Subcommittee hearing, contains the news that as part of DSI Social Security plans to hire 90 nurse case managers by the end of 2006. By contrast, Social Security plans to hire 103 Reviewing Officers by the end of 2006. The GAO report says the following about the nurse case managers:

In addition, SSA is creating a Medical and Vocational Expert System, staffed by a unit of nurse case managers who will oversee a national network of medical, psychological, and vocational experts, which are together responsible for assisting adjudicators in identifying and obtaining needed expertise.

Why does Social Security need almost as many nurse case managers as Reviewing Officers? The "national network" does not exist at this time as anything other than a hazy concept, at least insofar as the public has been informed. In Region I there may not be as many as 90 people total employed by state disability determination units as physicans and vocational experts. Why are 90 people needed to manage them?

Why would this "national network" need anyone with the title of "nurse case manager" anyway? Here is a definition of "case management" from the Commission for Case Management Certification (CCMC): which certifies nurses as case managers:

Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcome

The CCMC goes on to state:

Case management is an area of specialty practice within one's health and human services profession. Its underlying premise is that everyone benefits when clients reach their optimum level of wellness, self-management, and functional capability: the clients being served; their support systems; the health care delivery systems; and the various payer sources.

This does not sound like a job in which an individual merely makes sure that physicians and vocational experts are available for consultation with decisionmakers. It sounds a lot like someone who would work directly with a claimant to try to get him or her back to work. That is how nurse case managers have been used by insurance companies dealing with workers compensation and long term disability (LTD) cases. Nurse case managers in workers compensation and LTD cases often end up in an adversarial relationship with the people whose cases they are managing.

At a time when Social Security's resources are stretched to the point that the Commissioner of Social Security is threatening to furlough employees, the nurse case manager position must be an incredibly high priority to justify hiring 90 new employees. That justification is not immediately obvious. The temptation is to suspect that some controversial role for the nurse case managers is in the works.

SSAB Report

The Social Security Advisory Board (SSAB) has pulled together an interesting report of the status of Social Security's disability programs. It is primarily a statistical report with many interesting charts and graphic displays.

Social Security Employee Furloughs On The Way?

The Cleveland Plain Dealer reports that Jo Anne Barnhart, Commissioner of Social Security threatened to send Social Security employees home for a week without pay if the agency receives additional budget cuts. She described the situation as "very serious." Barnhart predicted that budget cuts already approved would cause serious problems and stated that she would like to hire 100 additional Administrative Law Judges, but would be unable to hire any in the next year without additional funds.

A Letter To The Editor

From the St. Petersberg Times:

Try calling the Social Security office in Port Richey and see how frustrated you get.

"Here's a thought. ...''

That's the lead-in to a recorded message that tells you about a Web site you can visit for general information about Social Security or to obtain forms to fill out. No claim or appeal assistance is available from this site.

When you call this number, this message plays four times with on-hold silence between and then it clicks and cuts off your call. No matter which selection you chose, the same thing happens.

Apparently, the next available person to help you is never available because after trying for 14 working days straight, eight to 10 times each day, there has been no way to get anyone to answer the phone. This is the response my friend has received while trying to obtain information regarding a Social Security disability claim appeal. The appeal was mailed return-receipt requested on May 10. There is a time limit of 60 days for filing an appeal of this nature, so time is of the essence.

Not being able to get an answer from the Port Richey office, my friend contacted the 800 phone number for Social Security to see if they could be of assistance. Their response was that nothing had been entered into the main computer files regarding this appeal and that her only recourse was to contact the Port Richey office.

My friend has subsequently learned from the Social Security office that claims are processed in the order in which they are received and that there is only one person assigned to process these claims. This person happens to be on vacation at this time, so not only are these claims being put into a pile, according to when they were received, but that pile is going unprocessed because of a vacation.

It is understood that processing these claims takes time; however, it is not understood why it should take such a long time to get them put back into the system for processing. It has already been one month since the appeal was sent.

Lives are being put on hold. Is this how the government responds to helping a disabled citizen who has no other source of income or any other source of assistance? These citizens certainly did not put the government on hold and then cut them off repeatedly when paying into Social Security for so many years and their contributions did not stop while they were on vacation.

Here's a thought: How is it that such a huge and powerful government can assign only one person to control thousands of claims and do it in a timely fashion?

Here's another thought: Someone with the authority to intercede on behalf of these poor individuals with the Social Security Administration should step up and do so on behalf of these citizens.

Gary Morrow, Hudson

Mr. Morrow does not know it, but this could and, indeed, would have happened almost anywhere in the country.

More From Social Security Subcommittee Hearing

Here are some excerpts from the written statements for witnesses as the House Social Security Subcommittee. Note in particular the information from GAO about the new position of nurse case manager. This may be of enormous importance and comes out of nowhere. Note also the obvious anger from the union that represents many SSA employees. SSA management may have some legitimate grievances with the union, but this rancor cannot be a good thing for SSA.

Robert Robertson, Director, Education, Workforce, and Income Security Issues, U.S. Government Accountability Office:

... we found that the public and stakeholders expressed two overriding concerns regarding the replacement of the Appeals Council with the Decision Review board—that the workload of the federal courts will rise if the council is eliminated and that this change will present additional hardship for claimants. ...

While stakeholders have expressed concern that SSA will not be able to hire and sufficiently train staff in time for the new process, we found that the agency has taken a number of steps in this area. With respect to hiring for new positions, the agency has already developed position descriptions and posted hiring announcements for nurse case managers, who will work in the new Medical and Vocational Expert Unit, as well as for federal reviewing officials. To date, SSA officials have begun assessing more than 100 eligible applicants for the reviewing official slots, and expect to hire 70 by late June and another 43 in early 2007. SSA officials also said they posted announcements to hire nurse case managers, and that they expect to hire as many as 90 before the end of the rollout’s first year in the Boston region.

SSA officials also said that the agency has posted announcements to hire support staff for both the reviewing officials and nurse case managers, but the exact number SSA is seeking to hire has not been decided. Several stakeholders we spoke with were particularly concerned that SSA will need to hire or otherwise provide adequate support staff for reviewing officials to ensure their effectiveness. Specifically, several of the ALJs we interviewed told us that at the hearings level, judges and their staff currently spend significant time developing case files. They noted that if the reviewing official position is designed to focus on case development, then attorneys in this role will need support staff to help them with this time-consuming work.

With respect to training, the agency has been creating a variety of training materials for new and current staff, with plans to deliver training at different times, in different ways. SSA officials reported working on development of a uniform training package for all staff with some flexible components for more specialized needs. Specifically, about 80 percent of the package is common content for all employees, and 20 percent will be adaptable to train disability examiners, medical experts, ALJs, and others involved in the adjudication process. SSA officials said they developed the package with the federal reviewing officials in mind, but also with an eye toward a centralized training content that could apply to current and new staff down the line. SSA plans to provide the full training package, which constitutes about 8 weeks of course work and 13 modules, to reviewing officials in late June, once all attorneys for that position are hired. Among the sessions included are the basics of the disability determination process, eDib and its use, medical listings and their application, and decision writing. ...

SSA will continue to provide accuracy rates for DDS decisions, but these accuracy rates will be generated by a centralized quality assurance review, replacing the agency’s older system of regionally based quality review boards and thereby eliminating the potential differences among regional reviews that were a cause for inconsistent decisions among DDSs. ...

Witold Skwierczynski, President, National Council of SSA Field Operations Locals, American Federation of Government Employees, AFL-CIO:

Although SSA’s workloads have increased by 12.6 percent over the last 5 years, and 2.7 percent in FY 05, Congress appropriated $300 million less for SSA than proposed in the President’s FY06 budget request. The result was a 2368 reduction in budgeted work years. While SSA’s proposed budget requests have compared favorably compared to many other agencies, AFGE is concerned that the recent budget cuts may result in dangerous levels of inadequate service to the public and stewardship of the programs under SSA’s jurisdiction. ...

In February 2006, SSA informed AFGE that the budget cuts would be absorbed in staffing resources. Since then, Commissioner Barnhart imposed a hiring reduction wherein the Agency will replace only 1 of 8 employees engaged in direct public service work in field offices who leave SSA. These are the employees who interview disability and disability appeals applicants. ...

AFGE is very concerned that such staffing cuts will drastically affect SSA’s ability to provide adequate public service to the disabled community. AFGE also raises a number of questions regarding the decisions to reduce direct service staffing. Why are such cuts necessary if SSA has the resources to implement Disability Services Improvement (DSI) which is a system that has never been tested and will cost billions of dollars to implement? If there are insufficient Claims Representatives and Technical Experts to take and process initial claims, all the DSI improvements in the world won’t improve the system. The entire system requires sufficient staffing resources on the front end to enable the public to file applications for disability benefits that fully address the nature of their condition, their medical sources and how their disability impacts their ability to work and to perform routine tasks. There is currently insufficient staff to do this job. Commissioner Barnhart’s staff replacement plan will further reduce the staff that processes disability claims. Flooding the appellate system with dollars while slicing the staff that takes applications makes no sense and is not an effective way of improving the system. ...

The record should be clarified with regards to Commissioner Barnhart’s statement that she met with the organizations that represent SSA employees. She did. She held one meeting with all 6 SSA AFGE presidents for the purpose of introducing her plan. That was 3 years ago. Ms. Barnhart was not receptive to our constructive criticisms. ...

Ms. Barnhart does not have the support or the buy-in of SSA workers. In fact, SSA employees overwhelmingly oppose this disability plan.

James Hill, President, Chapter 224, National Treasury Employees Union:

As of the end of April 2006 there were 727,629 cases pending at ODAR hearing offices. The optimal level of cases for efficient ODAR HO operations is 350,000 cases. While DSI will significantly improve the adjudication process, it will have little impact on the current backlog. In fact, if the backlog problem is not addressed it will strangle the Commissioner’s DSI initiative. Unless the backlog at ODAR hearing offices is eliminated, DSI will be no more effective in providing timely service they we are now. Fortunately, history provides the vehicle for the resolution of the backlog problem – the Senior Attorney Program begun in 1995. The solution is to use current staff to perform the adjudication needed to deal with this problem.
...

As discouraging as the increase of cases pending may be, it does not fully reflect the harmful effect of the backlog on the public. Average processing time at the hearing office level was approximately 270 days at the beginning of FY 2000; now it is nearly 480 days. In some locales, claimants have to wait nearly two years for a hearing. This is an unconscionably long wait for a disability decision, and it is causing untold harm to some of the most vulnerable members of society. None will dispute that the public deserves far better service than SSA is presently providing.

The backlog has risen despite system and process improvements and record ALJ productivity levels. Current initiatives have not materially affected the backlog because they fail to deal with the underlying causes of the backlog. The root causes of the hearing office backlog are the number of receipts, too few adjudicators for the size of the caseload, and an inefficient adjudicatory process.

Commissioner Barnhart at House Social Security Subcommittee

Social Security Commissioner Jo Anne Barnhart is testifying today before the House Social Security Subcommittee on her Disability Service Improvement plan. There is little new in her prepared remarks. The following is a new, however:

I also established a new Office of Quality Performance to manage the Agency’s newly developed and still evolving integrated quality system which I believe will improve our disability determination process, as well as other program areas such as the Social Security retirement program and the SSI age-based program. The new Office of Quality Performance will manage a new quality system that includes both in-line and end-of-line quality review throughout the new DSI process. The Office of Quality Performance will be able quickly to identify problem areas, implement corrective actions, and identify related training as we implement the new DSI process.

The problem is that she gives no explanation of how the Office of Quality Performance is different from its predecessor, the Disability Quality Branch. Barnhart has already changed the name of Social Security's Office of Hearings and Appeals to the Office of Disability Appeals and Reviews without making any meaningful change in its operations. Without more information, it is tempting to label this change as being just as meaningless.

She goes on in her prepared remarks to say:

So far, we have developed major new computer systems to support the DSI initiative. We have performed all of the personnel and hiring work necessary to make sure that we have the new employees in their new positions, properly trained, in time to perform their new DSI duties when implementation begins. We are working to ensure that effective training is prepared and presented to every employee who will be involved with the new disability determination process. Although we do not have the same kind of personnel or hiring issues at the hearing level as we do for other levels, we do have systems needs unique to the hearing level, and we are currently working to ensure that the necessary computer systems are in place by the time the first DSI claim reaches the hearing level.

The report that the major computer systems for DSI have been developed is reassuring, but the fact that this statement is coupled with a statement that "all of the personnel and hiring work" for the Reviewing Officer (RO) position has been performed is unsettling. It is clear that all of the hiring work for the RO position has not been done since the RO jobs have only recently been advertised. It is unlikely that anyone has been hired as an RO or RO supervisor so far. Clerical positions to support the ROs have not even been announced yet. She only states that Social Security is "working" on preparing training, which suggests that Social Security has much further to go in this area.

SSA Releases "Congressional Statistics"

Social Security has released what it calls "Congressional Statistics" that show the number of Social Security benefit recipients per state and county and their average benefit.

Monthly Statistics Released

Social Security has released its monthly statistical package for Title II and Title XVI of the Social Security Act.