Inflammatory Bowel Disease and Allowance Rates
Inflammatory bowel disease (IBD)
Inflammatory bowel disease (IBD) is thought to be an autoimmune disorder, which includes ulcerative colitis (UC) and Chron’s disease (CD). IBD causes chronic inflammation of the gastrointestinal tract resulting in such symptoms as abdominal pain, diarrhea, weight loss, fever, fatigue, nausea, vomiting, and joint pain. Blood in stools may cause anemia (low red blood cell count). IBD may also cause iritis (inflammation of the eye), arthritis; and skin problems, including fissures and fistulas near the rectum.
IBD applicants unfairly denied benefits
Advocates for patients with inflammatory bowel disease (IBD) have voiced concerns that the Social Security Administration’s (SSA) disability evaluation process for Disability Insurance (DI) claims may treat some applicants unfairly. They believe applicants with IBD are likely to be denied benefits at the Disability Determination Services ( DDS ) initial and reconsideration levels, making it necessary for them to appeal to the administrative law judge (ALJ) hearings level to be allowed. This may result in delays for benefits and may require applicants to pay attorneys fees.
These advocates feel DDS staff are not familiar enough with the nature of IBD, and that the medical criteria (the listings) used to establish disability for applicants with IBD do not take into account specific issues of IBD, such as its episodic and unpredictable nature.
2003 Disability Insurance (DI) decision study
Partially in response to those concerns, Congress mandated a General Accountability Office (GAO) study of 2003 Disability Insurance (DI) decisions to address problems patients with IBD experience when applying for benefits. This study did not review claims for Supplemental Security Income (SSI) benefits, but some of the findings are likely apply to those applicants also.
In May of 2005, the GAO, an independent and nonpartisan investigative arm of Congress, released its findings in a report titled, “SSA Actions Could Enhance Assistance to Claimants with Inflammatory Bowel Disease and Other Impairments.” Based on their findings, the GAO recommended that SSA should emphasize the types and importance of information applicants should submit with their claim.
This recommendation was based on finding that applicants don’t understand the application process, and often don’t provide enough detailed and complete information about how their condition limits their ability to work. The GAO found that in responding to questions on the paper disability report, some claimants gave only minimal information, sometimes just a few words. For example, one applicant responded to the question about how his impairment limited the ability to work by saying “pain, limited movement.”
Detailed information critical to disability decisions
This finding supports what I have asserted all along in many articles I’ve written for this web site – that providing detailed and complete information in disability application forms can be critical to the disability decision. Also, the GAO feels that SSA does not provide detailed instructions and examples of how to give this type of information except in its new interactive adult “Disability Report” on SSA’s web site. But only about two percent of applicants apply online.
The GAO noted that the Social Security Advisory Board and others believe that SSA field office (FO) staff lack the time to sufficiently explain program rules and procedures so applicants can understand what information is needed to document their case.
At the end of this article, I will tell you where to find a great resource that shows adults filing initial Social Security disability claims how to answer questions on application forms with complete and detailed information.
Step three of the sequential evaluation process
It is important that readers of this article understand the five-step sequential evaluation process SSA uses to decide if an applicant’s impairment (medical condition) qualifies for disability under Social Security's rules. If you are not familiar with this five-step process, please read the “Sequential Evaluation” section on this web site. I will briefly review steps three through five in this article.
At step three of the sequential evaluation process, SSA compares the applicant’s impairment to the established medical criteria in SSA’s “Listing of Impairments.” These listings outline certain medical findings considered bad enough to prevent a person from doing any significant work activity.
The GAO report noted that doctors who treat IBD feel that SSA’s medical criteria for evaluating IBD at step three do not consider some symptoms of IBD that may prevent an applicant from working, such as severe diarrhea. The GAO had previously reported that SSA’s progress in updating its medical listings has been slow and may not be keeping pace with medical advancements. The listings for inflammatory bowel disease (IBD) are as follows:
Listings for inflammatory bowel disease
5.06 Chronic Ulcerative or Granulomatous Colitis (demonstrated by endoscopy barium enema, biopsy, or operative findings) . With:
A. Recurrent Bloody Stools documented on repeated examinations and anemia manifested by hematocrit of 30 percent or less on repeated examinations; or
B. Persistent or recurrent systemic manifestations, such as arthritis, iritis, fever, or liver dysfunction, not attributable to other causes; or
C. Intermittent obstruction due to intractable abscess, fistula formation, or stenosis; or
D. Recurrence of findings of A, B, or C, above after total colectomy: or
E. Weight loss as described under 5.08.
5.07 Regional Enteritis (Demonstrated by operative findings, barium studies, biopsy, or endoscopy). With:
A. Persistent or recurrent intestinal obstruction evidenced by abdominal pain, distention, nausea, and vomiting and accompanied by stenotic areas of small bowel with proximal intestinal dilation; or
B. Persistent or recurrent systemic manifestations such as arthritis, iritis, fever, or liver dysfunction, not attributable to other causes; or
C. Intermittent obstruction due to intractable abscess or fistula formation; or
D. Weight loss as described under 5.08.
At step three, if the applicant’s medical records show that their IBD condition matches, or closely matches findings in the above listings, the applicant would be found disabled under SSA’s rules. If not, the applicant’s claim goes to step four of the sequential evaluation.
Step four of the sequential evaluation process
At step four, SSA decides if the applicant can do previous work based on their “residual functional capacity (RFC),” the most work activity an applicant can do on a sustained basis in an 8-hour work-day. At step four, SSA must consider the applicant’s ability to do such things as lift, carry, sit, stand, and walk. They must also consider such issues as mental capacity, pain and fatigue. Based on the RFC, if the applicant can do previous work, the claim is denied. If the applicant cannot do previous work based on the RFC, the claim moves to step five of the sequential evaluation process.
Step five of the sequential evaluation process
At step five of the sequential evaluation process, SSA looks at an applicant’s current level of function (RFC), and combines that information with vocational factors of age, education, and work experience to decide if the applicant can do any other work in the national economy. If so, the claim is denied. If the applicant cannot do other work based on those factors, the claim is allowed for benefits.
As claims move through the five-step process, the evaluation becomes increasingly complex, and usually requires more detailed information about the applicant’s ability to do daily activities. In addition, the evaluation usually requires more information about symptoms, such as pain and fatigue.
For IBD applicants, SSA should also consider the frequency of diarrhea and whether the applicant requires extended trips to the bathroom. Though this type of information is necessary in some cases, SSA’s current decision grid for evaluating medical conditions does not easily factor in these types of limitations because they don’t involve exertional (strength) activities.
Consideration of subjective (self-reported) symptoms by applicants is difficult for decision-makers because there is no way to objectively measure symptoms someone else experiences. The SSA decision-maker must then assess the “credibility” of the reported symptoms by comparing those symptoms to what is reported in the medical records. This is not an easy task because medical records are commonly not detailed enough to make this comparison.
If the medical evidence obtained by SSA is insufficient to make an accurate assessment of the applicant’s condition, they may request additional information by having applicants and treating doctors fill out forms to corroborate an applicant’s reported symptoms and functional abilities. It is important that applicants understand why this detailed information is needed and how to provide that information up-front when completing disability application forms.
SSA may also order a consultative exam and/or tests to further evaluate the condition. See the "Consultative Exam" section on this web site for more information.
DDS allowance rates lower than hearings allowance rates
The GAO found that applicants with IBD have somewhat lower overall allowance rates (33 percent) than applicants with other conditions (39 percent). When the GAO compared allowance rates at the DDS level versus the hearings level, they found that the allowance rates for applicants with IBD at the DDS (initial and reconsideration) level was 12 percentage points lower than the average allowance rates for all other applicants. But, at the hearings level, allowance rates for applicants with IBD were 10 percentage points higher than the average rate for all other applicants included in the study.
The GAO study also found that step five allowance rates were higher at the hearings level (85 percent) than at the DDS levels (13 percent) for applicants with IBD. It also found this same scenario for step five allowance rates for other applicants – 74 percent at the hearings level versus 25 percent at the DDS levels.
Higher allowance rates at the hearings level could be due to new evidence that was submitted or due to worsening of the applicant’s condition by the time they reached the hearings level. The GAO did acknowledge that it was difficult to draw firm conclusions for these differences in allowance rates because some key data was not available to them, such as age, impairment severity, and work history.
The GAO also reported that higher step five allowance rates at the hearings level could be associated with the presence of an attorney or nonattorney representative at the hearings level.
Representation results in higher allowance rates at hearings level
A November 2003 GAO (04-14) report found that claimants who were represented by an attorney or a person who is not an attorney (such as a legal aide, relative, or friend) were more likely to be allowed than claimants who had no representative.
That study showed that the odds of being allowed benefits for African-American claimants with attorneys are 5.16 times higher than the odds of being allowed benefits for African-American claimants without attorneys. In contrast, the odds of being allowed benefits for white claimants with attorneys are 2.93 times higher than the odds of being allowed benefits for white claimants without attorneys.
ALJs more likely to find subjective complaints credible
SSA studies have found that ALJs were more likely than DDS decision-makers to find that applicants are credible with respect to subjective allegations of pain, fatigue, and other symptoms.
SSA studies have also shown that DDS medical staff (who usually assess an applicant’s RFC themselves) tend to find that applicants had a greater capacity to perform work than ALJs (who may consult with medical experts, but have sole authority to make the RFC finding), even when these different decision-makers were given the same cases to review.
Failure of process unification
To improve consistency between the DDS and the hearings level, SSA began a “process unification” initiative in 1994. Like many other SSA initiatives (some called “prototypes”) begun in an attempt to improve the disability decision-making process, process unification failed to fulfill its goal.
It failed mainly because SSA never fully implemented the initiative, and because SSA decided that further efforts to unify policy guidance used by both levels would be a massive undertaking and not worth the cost. In other words, SSA decided it was too difficult and too expensive, despite the “cost” to applicants. As in other GAO reports critical of SSA’s disability program, the failed process unification initiative rears its ugly head.
Updating the listings
SSA is pursuing efforts to address some but not all of the difficulties encountered by applicants, including those with IBD. SSA is currently updating its “Listing of Impairments” used at step three of the sequential evaluation process. While the GAO says that updates to the medical criteria for IBD may not be completed until late 2005, I would say that the updated listings for IBD won’t be available any earlier than the spring of 2006. This is based on a timeline of tentative dates set by SSA for publishing updated listings, which shows SSA is running behind schedule. To download a copy of this timeline, click on the following link:
Efforts to improve applicants’ understanding
SSA is also attempting to improve applicants’ understanding of the disability decision process through its interactive adult disability report and other information found on its web site. Though, the GAO notes that except for the interactive adult disability report, SSA’s web site does not provide claimants with detailed instructions, explanations, and examples to help them with completing the adult disability report. Even SSA’s “Disability Starter Kit,” available on it web site does not include these important instructions.
Summary
In summary, the GAO found that most IBD claims are denied at the initial level, and a high rate of claims are allowed on appeal. They also found that this experience by applicants with IBD is much like that of applicants with other impairments. Inconsistencies in how decision-makers at different levels decide claims and the complexity of evaluating applicants'subjective complaints may help explain the relatively low allowance rates at the DDS levels versus the high allowance rates at the hearings level.
SSA’s disability decision process is not well understood by many applicants, and some applicants don’t provide SSA with all of the information necessary for their initial decision. This necessary information includes a detailed description of how their impairment (condition) prevents them from working.
To download the GAO report discussed in this article, click on the following link:
Inflammatory Bowel Disease GAO Report
Keith R. Holden, M.D.