SSA-NIH-BU Collaboration to Improve the Disability Determination Process

1. SSA-NIH-BU Collaboration to Improve the Disability Determination Process Presentation for the SSA Occupational Information Development Advisory Panel: 12/08/10 Beth Rasch, PT, PhD

2. Point of clarification This exploratory work, being conducted by NIH and BU, examines ways in which claimants and their health care providers can quickly and easily provide information about claimants’ function. SSA has not yet adopted or endorsed this approach.

3. Background August, 2007 • SSA sought help from NIH • Identify new diagnostics tests that might expedite allowances • Paradigm: Diagnosis or impairment ≈ disability SSA / RMD Inter-Agency Agreement • NIH signed 3-year agreement with SSA • Initiated on 2/1/08 • New 5-year agreement with SSA • Initiated on 2/1/10

4. Broad objectives Data analysis Computer Adaptive Tests (CAT) To improve SSA disability determination process through: Focus on function Unprecedented access to SSA data

5. Conceptualizing disability: Two opposing perspectives Medical model: disability as a personal trait Social model: disability as a socially created problem

6. Prominent models of disability • Nagi model • Verbrugge and Jette’s “Disablement Process” • IOM model • Social model • WHO International Classification of Functioning, Disability, and Health (ICF)

7. Conceptualization Health Condition Body Functions Body Structures Activities Participation Environmental Factors Personal Factors ICF: World Health Organization, 2001

8. Contemporary concepts of disability • Interactive • Not solely an individual attribute—diagnosis alone cannot predict disability • Multidimensional • Complex theoretical models map the interaction of conceptual elements that constitute the definition of disability • Continuum • Not an “all or nothing” concept • Dynamic • Disability influenced by the environment • Disability can change over time

9. Measuring disability • Measuring such a concept poses a methodological challenge • To operationalize this concept, individual attributes and environmental features must be measured • Operational definition depends on purpose of data collection process

10. SSA purpose • Identify individuals who are unable to engage in substantial gainful employment due to medically determinable physical or mental impairment/s which can be expected to result in death or which have lasted or are expected to last > 12 months SEC. 223. [42 U.S.C. 423](d)(1) • Physical or mental impairment/s must be of such severity that the individual is not only unable to do previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy… SEC. 223. [42 U.S.C. 423](d)(2)(A)

11. Framing the problem • There is a gap between contemporary notions of disability and how SSA operationalizes its statutory definition of disability • SSA’s operationalization is focused on physical and mental impairments (medical model) • Contemporary disability models depict disability as the gap between an individual’s functional ability and environmental demands • Diagnosis and impairment may be poor predictors of work disability Jette & Badley: Conceptual issues in the measurement of work disability. Wunderlich et al, Eds. The Dynamics of Disability. National Academy Press, Washington, DC, 2002

12. Measurement Health Condition ACTIVITY Body structure & function Participation Environmental factors Personal factors Source: ICF, WHO, 2001

13. Viewed through the ICF, currentSSA assessment processes could improve content coverage of “activity” domains relevant to work. Limited information captured on: Learning and applying knowledge General tasks and demands such as multi-tasking or organizing time, space and materials for a task Communication Interpersonal interactions and relationships SSA’s data gaps

14. Domain selection Priorities for SSA-IAA • Interpersonal interactions and relationships • Mobility • Learning and applying knowledge • Communication • Self care • General tasks and demands

15. Capture all conditions during the application process to characterize the sum total of their impact on functioning as it relates to work Recommendations:Whole person approach Depression Knee arthritis Heart disease

16. Recommendations:Focus on function FY 2005 initial applications (2.6 million) Reconsiderations (0.6 million) Assess function: • Comprehensively • Uniformly • Early Functional Information ALJ disposition (0.5 million) Of appeals, 62% allowed by ALJ

17. Dramatically improve breadth, completeness, uniformity, and precision of medical evidence Collect data when its most useful for decision making Even small improvements in the process may lead to: less processing time and costs improved accuracy and uniformity of decisions reduced backlogs Usefulness for SSA

18. Questions This exploratory work, being conducted by NIH and BU, examines ways in which claimants and their health care providers can quickly and easily provide information about claimants’ function. SSA has not yet adopted or endorsed this approach.