Can Pain Be Measured?

     From the New England Journal of Medicine:

Persistent pain is measured by means of self-report, the sole reliance on which hampers diagnosis and treatment. Functional magnetic resonance imaging (fMRI) holds promise for identifying objective measures of pain, but brain measures that are sensitive and specific to physical pain have not yet been identified. ...

In study 1, the neurologic signature showed sensitivity and specificity of 94% or more (95% confidence interval [CI], 89 to 98) in discriminating painful heat from nonpainful warmth, pain anticipation, and pain recall. In study 2, the signature discriminated between painful heat and nonpainful warmth with 93% sensitivity and specificity (95% CI, 84 to 100). In study 3, it discriminated between physical pain and social pain with 85% sensitivity (95% CI, 76 to 94) and 73% specificity (95% CI, 61 to 84) and with 95% sensitivity and specificity in a forced-choice test of which of two conditions was more painful. In study 4, the strength of the signature response was substantially reduced when remifentanil was administered.

     Before anyone gets excited at the thought that Social Security can finally measure pain, a few caveats are in order:

• There were only 114 participants in the study. 
• The test subjects were described as healthy with a median age of just under 25 years. The study's authors caution that the results might be different in non-healthy individuals.
• The pain that was "measured" was administered by the researchers -- "thermal stimuli" to the left forearm of varying degrees of severity.
• The study's authors indicate that if the validity of the study could be shown to extent to "clinical populations", the test might be used to confirm pain in patients who cannot communicate. Also, the study could be used as a basis for other studies. The study's authors are not even suggesting that the fMRI could have forensic uses.
• The study's authors caution that the study's results would have to be validated across persons, scanning protocols and research sites.
• The study's authors caution that the results might be different depending upon the site in the body where the pain is generated, the clinical cause of the pain and the type of the pain. For instance, would visceral pain register differently than the cutaneous pain that the researchers generated in their study? How would neuropathic pain compare with the pain from arthritis?
• fMRIs are expensive. They are an uncommon test with limited uses at the moment. Probably, there would be no clinical reason to use the fMRI to evaluate pain in a person who can communicate, meaning that if used for disability determination purposes, Social Security would probably have to foot that expensive bill.

Yeah, I Kinda Thought So

     From Taegan Goddard's Political Wire:

[National Republican Campaign Committee] Chairman Greg Walden (R-OR) touched a nerve when he savaged the entitlement changes in President Obama's budget as a "shocking attack on seniors," Roll Call reports.

But "it's the lack of fallout" that may be more revealing.

The debate Walden's remarks "has set off inside the GOP shows many Republicans harbor deep-seated fears about publicly supporting the entitlement cuts they supposedly back and have demanded Obama and other Democrats embrace since taking control of the House in 2011."

NOSSCR Issues Press Release To Combat Attacks On Social Security Disability Programs

     The National Organization of Social Security Claimants Representatives has put out a press release on the "dramatic, sensationalized media reports about the Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) programs, based on anecdotes, half-truths and misrepresentation of facts."

Chained CPI Proposal Creates Republican Disgreement

     From the Chicago Tribune:

President Obama's proposal to trim Social Security's cost-of-living adjustments has sparked not only Democratic outrage, but Republican confusion.

In the days since Obama put the idea in his 2014 budget, Republicans' reactions have included support, opposition and refusal to commit. The proposal was once a mainstay of the GOP's deficit-reduction overtures to the White House.

House Speaker John A. Boehner said Thursday that the idea, the so-called chained Consumer Price Index, “is the least we must do to begin to solve the problems in Social Security.”

But the chairman of the House Republican Congressional Committee, who is trying to preserve the party's majority in the House in the next election, called it a “shocking attack on seniors.”

“You're trying to balance this budget on the backs of seniors and I just think it's not the right way to go,” Rep. Greg Walden of Oregon told CNN.  

That potentially off-message comment provoked swift rebuke from the powerful Club for Growth, the conservative advocacy group that supports the measure as a starting point for reining in spending on government entitlement programs. ...

Rep. Paul D. Ryan of Wisconsin, the former Republican vice presidential nominee and the top party guru on budget issues, said the president was to be “commended” for taking on Democrats with the hot-button proposal in the budget. But Ryan panned it as a “modest” attempt at deficit reduction and declined to immediately lend his support.

One Republican Seems To Like Chained CPI

     From a House Ways and Means Committee press release (emphasis in original):

U.S. Congressman Sam Johnson (R-TX), Chairman of the House Committee on Ways and Means Subcommittee on Social Security, today announced the first in a series of hearings on the President’s and other bipartisan entitlement reform proposals.  This hearing will focus on using the Chained Consumer Price Index to determine the Social Security cost-of-living adjustment.   This proposal was included in the President’s Fiscal Year 2014 Budget, the report by the National Commission on Fiscal Responsibility and Reform, and the report of the Bipartisan Policy Center’s Debt Reduction Task Force.  The hearing will take place on Thursday, April 18, 2013, in B-318 Rayburn House Office Building, beginning at 9:30 a.m. ...

The President likes to say that if we agree on a policy, then we should act and not let our differences hold us up, and I agree.  This hearing will include a full discussion of a policy with bipartisan support – more accurately measuring inflation in order to strengthen the Social Security program.”

     However, the chairman of the National Republican Campaign Committee said recently that chained CPI is an attempt "to balance this budget on the backs of seniors and I just think it's not the right way to go."

CNN Money On Increase In Disability Claims

    There's a piece in CNN Money on the increase in the number of disability claims. It's not as unbalanced an article as most but the author still lists the recession first as a causes for the increase. The idea that economics explains anything and everything has gotten so strong in the minds of so many people that it's hard to get them to look at the compelling evidence that demographics is the overwhelming explanation for what is happening here.

Thoughts On Reviewing A 1374 Page File

     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.

A First Look At The President's Budget For SSA

     The President's recommended budget for fiscal year (FY) 2014, which begins on October 1, 2013, provides for a 7% increase in administrative funding for the agency over FY 2012 and "Establishes a dependable source of funding for Continuing Disability Reviews and Supplemental Security Income Redeterminations." I don't yet know what is meant by a "dependable source." Chained CPI is in the budget, of course.

     Update: I'd like to give you detailed budget information but I can't just yet. Social Security has tried to post this information on its budget website but the links aren't working. Perhaps it's a work in progress.
   Further Update: I can now see the detailed numbers on Social Security's website but only by switching from Foxfire to Internet Explorer. Some weirdness that I don't understand. At the bottom is an extracted page showing the most important numbers. You can click twice on the page to view it full size. Here are some other items I found, quoted in the order I came upon them:

• The language provides for the use of up to $1,000,000 derived from fees charged to non-attorneys who apply for certification to represent claimants.
• Beginning in FY 2014, the budget proposes to remove discretionary funding above the base amount of $273 million from the Limitation on Administrative Expenses (LAE) Account and instead, provide a mandatory appropriation for program integrity activities in a newly established Program Integrity Administrative Expenses (PIAE) account. These mandatory funds will be in addition to amounts provided to the Social Security Administration (SSA) in the LAE account and will be available for two years. In 2015 and beyond, the proposal would replace both base and cap funding for program integrity and the cap on discretionary appropriations would be lowered by a commensurate amount.
• Full funding of the FY 2014 President’s Budget will allow us to resume mailing Social Security Statements to all eligible workers 25 years old or older.
• Key Performance Targets: Initial Disability Claims Completed (thousands) FY 2012 3,207, FY 2013 2,970, FY 2014 2,851; Reconsiderations Completed (thousands) FY 2012 809, FY 2013 803, FY 2014 725; SSA Hearings Completed (thousands) FY 2012 820, FY 2013 836, FY 2014 807; Average Speed of Answer (ASA) [on Social Security's 800 number] (seconds) FY 2012 294, FY 2013 455, FY 2014 482
• The Budget proposes to amend the Social Security Act to limit access to the "Death Master File" to prevent this information from being used to file fraudulent claims for benefits or tax refunds. This proposal provides that death information that we maintain may be used by agencies, subject to such safeguards as the Commissioner of Social Security determines are necessary or appropriate for the purpose of public health or safety, law enforcement, tax administration, health oversight, debt collection, payment certification, disbursement of payments, and for the prevention, identification or recoupment of improper payments.
• The FY 2014 President’s Budget proposes a technical correction relating to when Social Security benefits stop due to divorce. A parent and stepchild may receive benefits on the record of a worker, but, if the marriage terminates in less than 10 years, they are no longer eligible for benefits. Currently when a stepchild’s parent is divorced and no longer eligible for benefits from a former spouse, benefits for the parent terminate in the month before the month in which the divorce becomes final. However, benefits for the stepchild terminate one month later, in the month the divorce becomes final. This proposal would provide equal treatment for the stepchild and his or her parent; both benefits would end in the month before the month in which the divorce becomes final.
• The FY 2014 President’s Budget takes other critical steps to finds savings in government programs by making smart reforms that root out duplicative or wasteful spending, such as reducing an individual's Disability Insurance (DI) benefit in any month in which that person also receives a state or Federal unemployment benefit. This proposal would eliminate dual benefit payments covering the same period a beneficiary is out of the workforce, while still providing a base level of income support. Enacting this offset would save $1 billion over 10 years.