Social Security Disability:

SSA Must Hold Itself Accountable for Continued Improvement in Decision-making

HEHS-97-102: Published: Aug 12, 1997. Publicly Released: Aug 12, 1997.

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Pursuant to a congressional request, GAO reviewed the Social Security Administration's (SSA) decisionmaking process for disability determinations and efforts to improve the process, focusing on: (1) factors that contribute to differences between disability determination services' (DDS) and administrative law judges' (ALJ) decisions; and (2) SSA's actions to make decisions in initial and appealed cases more consistent.

GAO noted that: (1) ALJs made nearly 30 percent of all awards in 1996; (2) because two-thirds of all cases appealed to ALJs have resulted in awards, questions have arisen about the fairness, integrity, and cost of SSA disability programs; (3) differences in assessing applicants' functional capacity and procedural factors, as well as weaknesses in quality assurance, contribute to inconsistent decisions; (4) ALJs are far more likely than DDSs to find claimants unable to work on the basis of their functional capacity; (5) this outcome has occurred even when ALJ and DDS adjudicators review the same evidence for the same case; (6) most notably, DDS adjudicators tend to rely on medical evidence such as the results of laboratory test; ALJs tend to rely more on symptoms such as pain and fatigue; (7) DDS and ALJ decisionmaking practices and procedures also contribute to inconsistent results because they limit the usefulness of DDS evaluations as bases for ALJ decisions; (8) in addition, SSA procedures often lead to substantial differences between the evidentiary records examined by DDS and ALJs; (9) specifically, ALJs may examine new evidence submitted by a claimant and hear a claimant testify; (10) as a result, even with a well-explained DDS decision, ALJs could reach a different decision because the evidence in the case differs from that reviewed by the DDS; (11) SSA has not used its quality review systems to identify and reconcile differences in approach and procedures used by DDSs and ALJs; (12) the quality review systems for the initial level and appeals levels of the decisionmaking process merely reflect the differences between the levels; they do not help produce more consistent decisions; (13) although SSA has not managed the decisionmaking process well in the past, its current process unification initiatives, when fully implemented, could significantly help to produce more consistent decisions; (14) competing workload pressures at all adjudication levels could, however, jeopardize SSA's efforts; (15) as a result, SSA, in consultation with the Congress, will need to sort through its many priorities and be more accountable for meeting its deadlines and establishing explicit measures to assess its progress in reducing inconsistency; and (16) this may include, for example, setting a goal, under the Government Performance and Results Act, to foster consistency in results, set quantitative measures, and report on its progress in shifting the proportion of cases awarded from the ALJ to the DDS level.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: SSA issued regulations that established quality assurance procedures to help identify and resolve differences in how policies are understood and implemented at the different adjudication levels. SSA began reviewing claims using the new procedures and established a goal of reviewing 10,000 cases annually. SSA issued instructions requiring its hearing offices to return appealed cases that had new medical evidence introduced to the DDSs, where medical experts would evaluate and reexamine cases. According to SSA, it was not able to achieve its original estimate of the number of appealed cases returned to DDSs because hearing offices generally received new medical evidence too late to warrant returning the case. SSA decided to combine this initiative with other initiatives in its Hearings Process Improvement (HPI) plan issued in August 1999. The goals of the HPI plan are to reduce hearing office processing time, increase productivity, and enhance customer service.

    Recommendation: SSA is beginning to implement initiatives to reduce inconsistent decisions between DDSs and ALJs, realizing that the lengthy and complicated decisionmaking process and inconsistent decisions between adjudicative levels compromise the integrity of disability determinations. SSA should take immediate steps and be accountable for ensuring that they are implemented as quickly as feasible. For example, using available quality assurance systems, SSA should move quickly ahead to improve feedback to adjudicators at all levels. In addition, to better ensure that adjudicators review the same record, the agency should increase the number of cases it plans to return to DDSs when new evidence is submitted on appeal.

    Agency Affected: Social Security Administration

  2. Status: Closed - Not Implemented

    Comments: The primary action recommended is included in a more recent GAO report. In March 12, 1999, GAO recommended that SSA develop a comprehensive set of performance goals and measures to assess and monitor changes in the disability claims process (see HEHS-99-25). Since the prior recommendation to set performance goals and measures for SSA's process unification initiative is included in this more recent recommendation, separate tracking of the prior recommendation is no longer necessary.

    Recommendation: Given the magnitude and seriousness of the problem, the Commissioner of Social Security should, under the Results Act, articulate the process unification results that the agency hopes to achieve and establish a performance goal by which it could measure and report its progress in shifting the proportion of cases awarded from the ALJ to the DDS level.

    Agency Affected: Social Security Administration

 

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