Better Training Needed for the Social Security Disability Program
Based on an email I received about this letter from a former member of the Social Security Administration's Training Cadre, I need to clarify the following issues:
- Comments in this letter are based on my experience with DDS offices in Georgia and Florida only, and do not pertain to any other states.
- Comments regarding the Single Decision Maker (SDM) prototype pertain only to the state of Florida.
- Comments regarding administrative law judges (ALJs) pertain only to my experience with ALJs in Georgia.
- The main idea of this letter is that all levels of the decision making process need better training in regards to the medical aspects of disability claims.
- I do regret that I did not include the concept that better training is needed for medical consultants.
- It was not my intention to infer that all claims should be reviewed by a medical consultant. In fact, better training would decrease the need for medical consultants.
- I apologize if anyone is offended by this letter, but it is based on MY experiences, and was written to point out problems and offer advice for improvement.
- The letter not only offers criticism, but outlines steps to improve the training process. The advice for improving the training process is found in the complete letter, which is available for download by clicking on the link at the bottom of the excerpt.
On September 27, 2005, the Congressional Committee on Ways and Means held a "Joint Hearing on Commissioner of Social Security's Proposed Improvements to the Disability Determination Process." On September 23, 2005, I submitted a letters for the record. What follows is an excerpt from that letter.
To: Joint Hearing on Commissioner of Social Security’s Proposed Improvements to the Disability Determination ProcessSeptember 23, 2005
Dear Members of the Joint Hearing,
I am a licensed physician, board certified in Internal Medicine, and was a medical consultant for Florida’s Department of Disability Determination Services ( DDS ) for seven years. I also worked for Georgia’s department of Disability Adjudication Services for fifteen months.
I’m disturbed by the fact that Social Security’s proposed rule for the “Administrative Review Process for Adjudicating Initial Disability Claims” does not outline an enhanced training program for its decision makers. Ask any successful major corporation, and they’ll tell you that having an effective training program for its workers is as important as having money to perform its daily functions. I argue that Social Security’s failings at prior attempts to redesign the adjudicative process are, in part, based on the lack of an effective training program; and that this ongoing oversight will play a role in the possible failure of this current attempt.
The Commissioner’s new plan proposes that State agencies will better document and explain the basis for determinations so as to result in more accurate initial determinations. The Commissioner told the “National Association of Disability Examiners” that state DDS examiners would be responsible for development and review of the medical and vocational input, writing the RFC, and preparing the denial following a legal decisional logic thought process. The examiner will be required to fully document and explain the basis for their determination.
This reflects what the Commissioner has said about administrative law judges expressing concern about the quality of adjudicated records they receive. Clearly, many claimants’ cases are not fully developed and documented by disability examiners. This is due to multiple reasons. I have discussed this situation with examiners in Florida and Georgia after I found that a significant number of cases that had not been properly developed were routinely routed to medical consultants. The main reasons stated for not doing so were that caseloads were excessive and unmanageable, job expectations were unrealistic, and training was woefully inadequate.
Case management by disability examiners, from the medical perspective, is sometimes inadequate, partly due to their lack of understanding of the clinical and functional aspects of claims. Inconsistency in training, and the lack of sufficient ongoing medical training once examiners reach their assigned units, produces a core group of examiners who do not understand the clinical aspects of cases. This results in examiners who can’t develop medical issues with any significant degree of consistency or efficiency. This is part of the reason why some examiners admittedly don’t attempt to read or develop the medical evidence in some complex cases. They route those cases to a medical consultant to unravel the issues, and subsequently complete the proper form, or return the case with recommendations for further development. This problem is only magnified in the significant number of DDS offices that have a high turnover of examiners, as those offices are relying on a large group of novices with little training and experience. It is well-known that examiners can’t perform their jobs efficiently until they have had one to two years of training.
Examiners are expected to act as medical detectives and determiners of functional ability relating to physical and mental impairments. They are expected to have this capability despite a training curriculum which is essentially a crash course of very limited medical terminology and pathophysiology. The training they receive is very basic with an emphasis on anatomy and medical terms. This training emphasizes terms rather than clinical concepts, and is given in a relatively short time frame without sufficient ongoing medical education. This limits their ability to think critically in applying that knowledge to complex medical issues found in many cases.
Some States have been designated “prototype” States, in which examiners are allowed to adjudicate claims without input from medical consultants. In one review, it was found that approximately 70% of examiners sought input from medical consultants anyway. That is a strong indication that those examiners, who supposedly had been trained to adjudicate claims without medical consultant input, did not feel qualified to do so. In fact, I spoke to examiners in Florida who were not happy with the fact that they had been instructed by supervisors to do “Single Decision Maker (SDM)” claims in an effort to reduce case loads and decrease cost. Common statements made by them included, “I am not a doctor” and “I don’t have the training to do this.”
The concept behind SDM is that examiners in these prototype States would decide which cases were easiest to adjudicate, and make SDM decisions on those without input from medical consultants. As with most good intentions undermined by poor planning, this experiment morphed into a short-cut for examiners to expedite clearance of cases without proper oversight by medical experts. When many DDSs in these prototype States formed units to do “Quick Decision” cases even before the Commissioner touted this concept, that left examiners on regular units with the more difficult cases to adjudicate. With SDM being praised by the SSA leaders as a way to save millions of dollars by not having to pay medical consultants for their input, these States felt obliged to press examiners to perform SDM claims even though many no longer had access to the easiest cases. The result is that many difficult claims that should have had expert medical input before being adjudicated were decided by examiners without proper insight or training.
In relation to the purely medical aspects of disability claims, this practice is comparable to letting a medical assistant in a doctor’s office complete the Residual Functional Capacity (RFC) form or Psychiatric Review Technique Form (PRTF). The irony is that while medical assistants and examiners have similar non-clinical medical training, medical assistants, unlike most disability examiners, have clinical medical experience. Theoretically, this clinical experience would let medical assistants do a better job of completing those residual function forms. This fact is clearly a disservice to disability applicants, as well as improperly trained disability examiners.
The majority of examiners I spoke with in Georgia and Florida made it clear to me that they do not feel they have been properly trained to complete an RFC or PRTF, much less write a detailed rationale for their decision. They admitted they do not have a clear grasp on how the physiologic issues relating to medical impairments impact functional abilities. This type of application of knowledge requires critical thinking. Critical thinking involves solving problems, formulating inferences, calculating likelihoods, and making decisions when the thinker is using skills that are effective for a particular context and type of thinking task. In the role of the examiner, it requires judging ambiguity and judging whether statements made by authorities are acceptable in the context of complex medical issues. It also requires examiners to have the ability to respond to material by distinguishing between facts and personal opinions, judgments and inferences, and the objective and subjective.
Compound this issue with the fact that some States don’t require examiners to have more than a high school education, and you are looking at a set-up for failure. This issue of State job requirements for disability examiners, which plays a role in the inconsistency of decision making between different States, is only one example of the many problems associated with the current federal-state relationship in the Social Security disability program. See the GAO’s January 2004 publication, “Strategic Workforce Planning Needed to Address Human Capital Challenges Facing the Disability Determination Services” for more information on this topic.
The current DDS training program, which I was a part of, in no way adequately prepares disability examiners for their job duties. Issues of inadequate training have been voiced by numerous organizations providing oversight for the SSA. The Social Security Advisory Board’s (SSAB) August 1998 report “How SSA’s Disability Programs Can Be Improved,” stated “The most important step SSA can take to improve consistency and fairness in the disability determination process is to develop and implement an on-going joint training program for all of the 15,000 disability adjudicators, including employees of State disability determination agencies (DDSs), Administrative Law Judges (ALJs) and others in the Office of Hearing and Appeals (OHA), and the quality assessment staff who judge the accuracy of decisions made by others in the decision making process.” It went on to say “We urge the Commissioner to make a strong ongoing training program a centerpiece of the agency’s effort to improve the accuracy, consistency, and fairness of the disability determination process, and to see that the necessary resources are provided to carry it out.”
There is a recurring theme among professional organizations that provide oversight to the SSA showing a persistent and uncorrected problem of inadequate training in the Social Security disability program. Every proficient business model contains an effective training program to address the training needs of its workforce. Could inadequate training be at the heart of why SSA’s previous attempts at redesign failed to obtain most of its objectives? I don’t think it’s a stretch to say that inadequate training significantly contributed to those failures. Based on SSA’s failures at prior attempts of redesign in which none of those initiatives successfully integrated a consistent and enhanced training program, it would be wise to consider the recommendations made by both the GAO and the SSAB; and attempt to formulate a better training program.
The SSA should establish an enhanced training program for examiners that emphasizes the clinical application of medical knowledge relating to medical impairments and their physiologic impact on a claimant’s function. This training should be ongoing for old and new examiners, and should be provided for all levels of the decision-making process who must reason through a disability decision, including administrative law judges (ALJ).
If adjudicators at all levels aren’t effectively taught the mental and physical issues relating to an impairment’s impact on function, how can they be expected to accurately reason through a decision? I was amazed at the lack of emphasis the SSA and DDSs placed on this type of training, which has directly contributed to the inconsistency in disability decisions across the program. Some DDS leaders voiced concern that such ongoing examiner training given in more frequent increments would be disruptive as it would take examiners away from case development. That type of reasoning clearly reflects an emphasis on case development of quantity over quality.
Not only have examiners been given inadequate training, but ALJs have been given even less medical training. I do not understand how ALJs are supposed to reason through a decision relating to medical issues based on a legal education. I acknowledge that a claim is supposed to be fully developed from a medical perspective by the time it reaches them, but by that time, months, if not years, have passed; and there may be a whole new slew of allegations or alleged worsening of prior allegations.
My experience with some ALJs was that they basically just started from scratch developing medical allegations by ordering multiple specialized exams. Some also ordered multiple diagnostic tests when they weren’t even sure how to interpret the results. These practices are not cost effective. Some relied on medical experts for advice, but others did not. Calling in medical experts can be time consuming and adds to case processing times. This is partly due to finding a convenient time for a medical expert to be present, and providing time for a claimant’s attorney to cross- examine the medical expert.
In some cases, ALJs just relied on what the treating physician opined as a level of residual function, regardless of whether the objective evidence supported the opinion. That is an example of selective interpretation of Process Unification rulings. But ALJs are just trying to do the best job they can given the limitations and flaws inherent in the program.
I found that due to a high turnover of staff in DDSs, some examiners were prematurely promoted to supervisor positions. By default, this resulted in a small number of supervisors who lacked adequate medical knowledge to be able to sufficiently guide examiners in their unit on medical development of certain claims. Thus, this enhanced training program should encompass all levels of the decision making process, including unit supervisors.
The SSA cannot afford to ignore the repeated warnings and suggestions made by individual stakeholders and professional organizations about making a strong ongoing training program the centerpiece to improve the disability determination process. The SSA should start focusing on one of the core issues of why its attempts at redesign keep failing; and that core issue is training.
Sincerely,
Keith R. Holden, M.D.
To download a copy of the entire letter, which details the proposed enhanced training program, click on the link below.
Better Training Needed for the Social Security Disability Program