This is the accessible text file for GAO report number GAO-05-495
entitled 'Social Security Disability Insurance: SSA Actions Could
Enhance Assistance to Claimants with Inflammatory Bowel Disease and
Other Impairments' which was released on May 31, 2005.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Report to Congressional Committees:
United States Government Accountability Office:
GAO:
May 2005:
Social Security Disability Insurance:
SSA Actions Could Enhance Assistance to Claimants with Inflammatory
Bowel Disease and Other Impairments:
GAO-05-495:
GAO Highlights:
Highlights of GAO-04-495, a report to congressional committees:
Why GAO Did This Study:
Advocates for patients with inflammatory bowel disease (IBD) believe
that the Social Security Administration’s (SSA) process for determining
eligibility for Disability Insurance (DI) may treat some claimants
unfairly. As a result, claimants with IBD believe they are likely to be
denied benefits at the initial decision and reconsideration levels,
making it necessary for them to appeal to SSA’s hearings level to have
their claims allowed. This congressionally mandated study focuses on
(1) how SSA evaluates claims involving IBD to establish disability
under Title II of the Social Security Act and (2) what unique
challenges claimants with IBD encounter when applying for DI benefits,
and what actions, if any, SSA has taken to address these challenges.
What GAO Found:
SSA evaluates DI claims involving IBD just as it does all claims, using
a five-step sequential evaluation process to determine whether: (1) the
individual is working and earning an amount exceeding established
thresholds, (2) the impairment or combination of impairments
significantly limits a person’s physical or mental ability to perform
basic work activities, (3) the individual’s impairment meets or equals
a pre-established list of the medical criteria for impairments
considered severe enough to prevent an individual from earning wages
above the established threshold, (4) the claimant can return to
previous work based on what the individual can still do in a work
setting despite physical or mental limitations, or his or her “residual
functional capacity,” and (5) the claimant can do any work in the
economy. As claims move through the five-step process, their assessment
requires additional evidence and increasingly complex judgments on the
part of adjudicators. For example, at step three, claimants with IBD
who are diagnosed with Crohn’s disease would meet the medical criteria
if their weight fell below the minimum on SSA’s weight table. In
contrast, to determine the residual functional capacity of claimants
with IBD at steps four and five, SSA adjudicators must assess
claimants’ mental and physical capacity and make judgments regarding
allegations of pain and fatigue. Adjudicators at the initial,
reconsideration, and hearings levels use the same five-step process,
although differences exist between the levels that may affect
decisions. For example, claimants may be represented by an attorney or
nonattorney at the hearings level.
While claimants with IBD are somewhat less likely to be allowed DI
benefits than claimants with other impairments, their experiences
applying for disability benefits are not unique, and SSA has efforts
under way that may address some claimant concerns. When we analyzed DI
decisions in 2003 by decision-making levels, we found that claimants
with IBD, like many others, experienced lower allowance rates at the
initial and reconsideration levels compared to the hearings level,
although the difference between the levels was more pronounced for
claimants with IBD. Lower allowance rates at the initial levels and
higher allowance rates at the hearings level may reflect challenges
that claimants with IBD share with many other claimants in applying for
disability benefits. For example, both claimants with IBD and other
claimants are unlikely to be allowed at step five of the process at the
initial levels but not at the hearings level. SSA is pursuing efforts
that may address some claimant concerns. For example, the agency is
currently updating the medical criteria used for many impairments,
including IBD, and is proposing changes to its decision-making process
that may improve consistency between decision-making levels. SSA is
also trying to improve claimants’ understanding of the disability
claims evaluation process, but lacks assurance that the majority of
claimants who file in person or over the phone understand and provide
information critical to SSA’s assessment of their claims as part of
steps four and five of the process.
What GAO Recommends:
To help ensure that all claimants are informed of and provide SSA with
information needed to assess fairly how impairments limit claimants’
ability to work, GAO recommends that SSA emphasize the types and
importance of information claimants must submit for their claim. SSA
agreed with GAO’s recommendations, but thought that some perspectives
GAO provided on evaluating IBD claims were not relevant, and that GAO’s
characterization of one finding went too far. In response, GAO
clarified its treatment of these issues.
www.gao.gov/cgi-bin/getrpt?GAO-04-495.
To view the full product, including the scope and methodology, click on
the link above. For more information, contact Robert Robertson at (202)
512-7215 or robertsonr@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
SSA Evaluates IBD Claims Using the Same Evaluation Process as for All
Claims:
Claimants with IBD and Other Impairments Face Similar Challenges
Applying for DI, and SSA Efforts May Address Some Claimant Concerns:
Conclusions:
Recommendations:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methods:
Data Sources:
Scope:
Data Reliability:
Methods of Analysis:
Appendix II: Agency Comments:
GAO Comments:
Tables:
Table 1: Comparison of Overall Allowance Rates for IBD versus Other
Impairments:
Table 2: Allowance Rates for Claimants with IBD versus Other Claimants
by Decision-Making Level:
Table 3: Allowance Rates for Disability Decisions at Step Three by
Decision-Making Level:
Table 4: Comparison of Allowance Rates at Step Three for IBD versus
Other Impairments by Decision-Making Level:
Table 5: Allowance Rates for Disability Decisions at Step Five by
Decision-Making Level:
Table 6: Types of Comparisons Used in Report for IBD versus Other
Impairments:
Figure:
Figure 1: Five-Step Sequential Evaluation Process Used at Initial,
Reconsideration and Hearings Levels to Determine Disability:
Abbreviations:
ADL: activities of daily living:
ALJ: administrative law judge:
CCS: Case Control System:
DDS: Disability Determination Services:
DI: Disability Insurance:
IBD: inflammatory bowel disease:
NAS: National Academy of Sciences:
RFC: residual functional capacity:
SGA: substantial gainful activity:
SSA: Social Security Administration:
SSAB: Social Security Advisory Board:
SSI: Supplemental Security Income:
United States Government Accountability Office:
Washington, DC 20548:
May 31, 2005:
The Honorable Charles E. Grassley:
Chairman:
The Honorable Max Baucus:
Ranking Minority Member:
Committee on Finance:
United States Senate:
The Honorable Joe Barton:
Chairman:
The Honorable John D. Dingell:
Ranking Minority Member:
Committee on Energy and Commerce:
House of Representatives:
The Honorable William M. Thomas:
Chairman:
The Honorable Charles B. Rangel:
Ranking Minority Member:
Committee on Ways and Means:
House of Representatives:
In recent years, concerns have been raised that the process the Social
Security Administration (SSA) uses to determine which claimants are
eligible for Disability Insurance (DI) benefits may place some
individuals at a disadvantage for receiving the benefits to which they
are entitled. For example, advocates have recently stressed that the
process of qualifying for DI benefits may treat some claimants with
inflammatory bowel disease (IBD) unfairly. They believe that SSA field
staff are not familiar with the nature of their illness and that the
medical criteria used to establish disability for IBD patients do not
take into account the specifics of their illness, such as its episodic
and unpredictable nature. As a result, claimants with IBD believe that
they are likely to be denied benefits at the initial decision and
reconsideration levels, making it necessary for them to appeal to SSA's
hearings level to have their claims allowed. This appeal delays the
receipt of benefits and may require claimants to pay attorney fees.
These concerns have arisen in spite of efforts by SSA, which manages
the DI program and paid out $78.2 billion to 7.9 million beneficiaries
in 2004, to ensure that all claimants are assessed in a consistent
manner.
Partially in response to these concerns, the Congress passed the
Research Review Act of 2004 (Pub. L. No. 108-427), which mandated that
GAO study problems encountered by patients with IBD when applying for
DI benefits under Title II of the Social Security Act and identify
possible recommendations to improve the application process for these
patients.[Footnote 1]
This report will discuss (1) how SSA evaluates claims involving IBD to
establish disability under Title II of the Social Security Act and (2)
what unique challenges claimants with IBD encounter when applying for
DI benefits, and what actions, if any, SSA has taken to address these
challenges. To determine whether claimants with IBD were in fact
treated differently than claimants with other impairments, we analyzed
SSA data on all DI decisions made at three decision-making levels
(initial, reconsideration, and hearings) in 2003 and compared allowance
rates for claimants with IBD against those for claimants with other
impairments.[Footnote 2] We also reviewed a small, nonrepresentative
sample of cases to better understand how both the claimants and SSA
documented claims involving IBD. To identify problems IBD patients have
encountered, we interviewed representatives of IBD patient advocacy
groups such as the Crohn's and Colitis Foundation of America and the
Digestive Disease National Coalition. We discussed these issues with
officials at SSA and selected stakeholders with perspective on this
issue, such as the National Association of Disability Examiners, the
National Council of Disability Determination Directors, and the
National Organization of Social Security Claimants' Representatives. To
better understand the nature of the impairment and the experiences of
those in the IBD community who apply for DI, we reviewed literature on
IBD and SSA's application process and criteria as they pertain to
claimants with IBD. We performed reliability tests on selected data for
calendar year 2003 and found the data sufficiently reliable for use in
this report. We conducted our work between January 2005 and May 2005
according to generally accepted government accounting standards.
Results in Brief:
SSA evaluates claims involving IBD just as it does all claims, using a
five-step sequential evaluation process to determine if the claimant's
impairment or combination of impairments qualifies as a disability
under Title II of the Social Security Act. For all claims, adjudicators
establish first that the individual is not working and earning an
amount exceeding established thresholds (engaged in "substantial
gainful activity"), and second, whether the impairment(s) significantly
limits the individual's physical or mental ability to perform basic
work activities. Then, at step three of the process, the individual's
impairment(s) is compared to pre-established medical criteria in SSA's
Listing of Impairments. Listed impairments are considered severe enough
to prevent an individual from engaging in any gainful activity. For all
claims, if the severity and duration of the individual's impairment(s)-
-as documented by medical examinations, laboratory results, and other
required evidence--meet or are equivalent to (equal) the criteria for
an impairment on that list, the adjudicator would find the individual
to be "disabled" under SSA's rules and would allow the claim. For
example, a claimant with IBD who is diagnosed with Crohn's disease and
whose weight is below the minimum on SSA's weight table would be
"disabled" under SSA's rules. Claims that do not meet or equal the
medical criteria move to step four, where adjudicators determine if the
claimants can do previous work based on their "residual functional
capacity"; i.e., what they can still do in a work setting despite
physical or mental limitations, or their "residual functional
capacity." In assessing the residual functional capacity of a claimant
with IBD, for example, SSA might assess the claimant's ability to
stand, sit, and lift, as well as his or her mental capacity, pain, and
fatigue. If the claimant cannot return to previous work, SSA
adjudicators move to step five to determine if the claimant can do any
work in the national economy, based on his or her residual functional
capacity and the "vocational factors" of age, education, and work
experience--in addition to residual functional capacity. As claims move
through the five-step process, the assessments generally require
additional evidence and involve increasingly complex judgments on the
part of adjudicators. For example, adjudicators might need additional
information on daily activities and symptoms, such as fatigue, for
claimants with IBD whose impairment(s) does not meet or equal the
medical criteria of one of SSA's listed impairments. The adjudicators
will weigh this information along with medical evidence to assess how
claimants' impairments might limit their ability to function in a work
setting. Adjudicators at the initial, reconsideration, and hearings
levels use the same five-step process, although other differences exist
between the decision-making levels that may affect how adjudicators
decide on claims. For example, claimants may introduce new evidence and
allegations at each stage of the appeals process and are more likely to
be represented by an attorney or nonattorney during an appeal.
While claimants with IBD are somewhat less likely to be allowed than
claimants with other impairments, their experiences applying for
disability benefits are not unique relative to others, and SSA has
several efforts under way that may address some claimant concerns. When
we analyzed disability decisions made in 2003 for all decision-making
levels combined, we found that claimants with IBD had a somewhat lower
overall allowance rate than that of all other claimants (33 percent
versus 39 percent). When we made this same comparison for each decision-
making level separately, we found that, much like for other claimants,
the allowance rate for claimants with IBD was lower at the initial and
reconsideration levels compared to the hearings level, although the
difference in allowance rates between levels was greater for claimants
with IBD. Lower allowance rates at the initial and reconsideration
levels and higher allowance rates at the hearings level may reflect
challenges that claimants with IBD share with many other claimants in
applying for disability benefits. For example, both claimants with IBD
and many claimants with other impairments are less likely to be allowed
at step five of the process at the initial and reconsideration levels,
but more likely to be allowed on this basis at the hearings level. SSA
is pursuing efforts that may address some of the concerns of
individuals with IBD and other claimants. For example, the agency is
currently updating its Listing of Impairments, including the listings
for IBD, and is taking into account the views of the public in so
doing. The agency is also proposing changes to its decision-making
process that may improve consistency between the initial and
reconsideration levels and the hearings level. SSA has also taken steps
to improve all claimants' understanding of the disability claims
evaluation process. However, the agency's recently developed
"Disability Starter Kit" and other information available to the
majority of claimants who apply for benefits in person or over the
phone do not explain the types and importance of information needed to
assess claims at steps four and five of the process.
GAO is making several recommendations in this report to the
Commissioner of Social Security that will help ensure that claimants
with IBD and other claimants are made aware early in the process of the
types and importance of information claimants must provide with their
application. In commenting on the draft of this report, SSA agreed with
our recommendations but also expressed some concerns. For example, SSA
stated that our report discussed two issues the agency considered
irrelevant to our study of DI claimants with IBD--listings for
impairments other than IBD, and the decline in DI allowances based on
medical criteria. We modified the text to address some of the agency's
concerns, but we believe that a discussion of both of these issues is
relevant because it provides perspective on whether claimants with IBD
are treated differently than claimants with other impairments.
Background:
DI is the largest federal program providing cash assistance to people
with disabilities. Established in 1956, DI provides monthly payments to
workers with disabilities (and their dependents or survivors) under the
normal retirement age who have enough work experience to qualify for
disability benefits.[Footnote 3] The Social Security Act defines
disability as the inability to engage in any substantial gainful
activity by reason of any medically determinable physical or mental
impairment(s) (hereafter simply referred to as "impairment") which is
expected to result in death or which has lasted or can be expected to
last for a continuous period of not less than 12 months.[Footnote 4]
IBD encompasses two chronic autoimmune diseases of the intestinal
tract: ulcerative colitis and Crohn's disease. The two diseases are
often grouped together as IBD because of their similar symptoms, but
each disease has very different surgical options, and may be treated
with a spectrum of diverse medications. Common symptoms of IBD include,
but are not limited to: abdominal pain, weight loss, fever, rectal
bleeding, skin and eye irritations, fatigue, and diarrhea. IBD is
characterized by intervals of active disease, or "flares," and periods
of remission. Although it is estimated that as many as one million
Americans suffer from a form of IBD, most people with IBD are able to
work, and few apply for DI benefits. In 2003, less than 1 percent of DI
decisions (nearly 7,000) involved IBD patients.
To obtain DI benefits, a claimant must provide information through an
application and adult disability report[Footnote 5] filed on line, in
an interview by telephone, or in person at a Social Security office.
For claims taken by phone or in person, SSA field staff are responsible
for assisting the claimant in filling out the application form and the
adult disability report with complete information and for noting any
relevant information about the claimant observed during the interview.
If the claimant meets the nonmedical eligibility criteria, the field
staff forwards the claim to the appropriate Disability Determination
Services (DDS) office. DDS staff--generally a team comprising a
disability examiner and a medical consultant and, sometimes, a
vocational specialist--review the claimant's medical and other
evidence, obtaining additional evidence as needed to assess whether the
claimant's impairment satisfies program requirements, and make the
initial disability decision. If the claimant is not satisfied with this
decision, the claimant may request a reconsideration of the decision
within the same DDS.[Footnote 6] Another DDS team will review the
documentation in the case file, as well as any new evidence the
claimant may submit, and determine whether the claimant meets SSA's
definition of disability.
If the claimant is not satisfied with the reconsideration
determination, he or she may request a hearing before an administrative
law judge (ALJ). The ALJ conducts a new review of the claimant's file,
including any additional evidence the claimant submitted after the DDS
decision. At a hearing, the ALJ may hear testimony from the claimant,
medical experts on the claimant's medical condition, and vocational
experts regarding whether the claimant could perform work he or she has
done in the past or could perform other work currently available in the
national economy. The majority of claimants are represented at these
hearings by an attorney or other representative.[Footnote 7]
SSA has faced long-standing problems in administering this complex,
multilevel decision-making process. These problems center around a
process that can be confusing and unwieldy, with many applicants
appealing and waiting a long time for a final disability decision. In
addition, many within and outside of SSA have long believed that
differences between the adjudication levels might cause inconsistencies
in decision making, in turn resulting in too many claims being
initially denied and then allowed upon appeal and delaying the time it
may take for some deserving claimants to receive a final agency
decision. Concerned with the length of time it takes disability
claimants to receive a final agency decision, SSA has cited "improving
service in its disability programs" as one of its highest priorities
and established "making the right decision in its disability process as
early as possible" as one of its strategic objectives.
SSA Evaluates IBD Claims Using the Same Evaluation Process as for All
Claims:
SSA evaluates claims involving IBD just as it does all claims, using a
sequential evaluation process to determine if the claimant's impairment
qualifies as a disability under SSA's definition.[Footnote 8] This
process--which is used at all adjudication levels--consists of five
distinct steps, wherein the claimant's employment status, medical
condition, and functional limitations are considered. Figure 1 below
gives an overview of how a claim moves through the five-step evaluation
process.
Figure 1: Five-Step Sequential Evaluation Process Used at Initial,
Reconsideration and Hearings Levels to Determine Disability:
[See PDF for image]
[End of figure]
The first two steps of SSA's evaluation process allow SSA to screen out
cases where the claimant clearly does not meet SSA's definition of
disability. In step one, field staff determine whether the individual
is engaged in substantial gainful activity.[Footnote 9] If so, the
individual does not meet the definition of disability and the claim is
denied. If not, the claim moves to step two, and is forwarded to the
DDS office, where the adjudicator obtains medical and other evidence
and considers the severity of the impairment. If the impairment does
not significantly limit the person's physical or mental ability to
perform basic work activities, the impairment is considered not severe
and the claim is denied. For example, a diagnosis of IBD alone is not
sufficient; the condition must be severe, i.e., it must limit the
person's ability to perform basic work activities, for the claim to be
considered further. If the impairment is severe, the claim moves to
step three.
At step three, the impairment is evaluated to see if it meets or equals
in severity the medical criteria in SSA's Listing of Impairments (the
listings). The listings describe impairments considered severe enough
to prevent an individual from engaging in any gainful activity. If the
severity and duration of the claimant's impairment, as documented by
medical examinations, laboratory results, and other evidence meet the
criteria of a listing or is equivalent in severity to a listing, the
claim is allowed. For a claimant with IBD, there are different ways of
meeting or equaling the medical criteria. For example, a claimant
diagnosed with Crohn's disease whose weight is below the minimum weight
on SSA's established weight tables would be allowed.
For all claimants, if the impairment does not meet or equal the
criteria of a listing, the adjudicator must assess the claimant's
"residual functional capacity" (RFC) to determine what an applicant can
still do, despite physical and mental limitations, in a regular full-
time work setting. The claim then moves to step four, where the
adjudicator determines whether the claimant has the RFC to do any past
relevant work. Assessing physical RFC requires adjudicators to judge
individuals' ability to physically exert themselves in a variety of
activities (such as sitting, standing, walking, lifting, carrying,
pushing, and pulling) and to perform manipulative or postural functions
(such as reaching, handling, stooping, and crouching). Assessing mental
RFC requires adjudicators to judge, for example, the individual's
ability to understand, remember, and carry out instructions and to
respond appropriately to people and changes in work situations. Some
IBD claims include allegations of pain and fatigue, which may greatly
affect the claimant's RFC. Because these factors cannot be measured,
the adjudicator may need to assess the "credibility" of the claimant's
allegations by comparing such conditions or symptoms to other evidence
in the file. If the adjudicator determines that in spite of the
impairment, the claimant's RFC permits him or her to return to previous
work, the claim is denied.
On the other hand, if the adjudicator determines that the claimant's
RFC does not permit him or her to return to past relevant work, the
claim moves to step five, where the adjudicator determines whether the
claimant could do any other work in the national economy, based on the
claimant's RFC and the vocational factors of age, education, and work
experience. To do this, the adjudicator uses a complex system of rules
set out in SSA's regulations, including a grid of medical and
vocational factors that provides guidance for decision making. There
are three grid tables, which are based only on exertional limitations
(sedentary, light, and medium), and each table provides a variety of
combinations of age, education, and work experience. If, despite the
claimant's impairment and other factors, the grid indicates that there
are jobs the claimant could do, the claimant would be denied; likewise,
if the grid indicates that the claimant cannot do other work, the
claimant would be allowed. However, for the majority of disability
decisions, the grid is used only as guidance, because many claimants
have limitations that the grid does not capture. For example, severe
diarrhea necessitating frequent or extended trips to the bathroom may
greatly reduce the productivity of claimants with IBD without
necessarily causing any exertional limitations.
At any point after step one of the sequential evaluation, if the
medical evidence initially provided by the claimant or obtained by the
DDS is insufficient, the adjudicator may re-contact the claimant's own
doctors or request a "consultative examination" paid for by SSA. If
necessary--for example, for conditions or symptoms that are difficult
to document or measure--the adjudicator may ask the claimant to provide
more information by, for example, filling out a pain or fatigue
questionnaire, or an activities of daily living (ADL) form. To
corroborate a claimant's allegations of functional limitations, the
adjudicator may ask third parties, such as friends or relatives, about
the claimant's ability to perform various tasks in their daily lives.
For a claimant with IBD, for example, the adjudicator may need such
additional information to corroborate allegations of severe pain,
fatigue, or diarrhea.
Each step of the sequential evaluation process may require adjudicators
to obtain and consider more and different types of evidence and to make
increasingly complex judgments. For example, at the first step, only
the amount of earnings is needed. In contrast, at steps four and five,
adjudicators must evaluate medical evidence along with nonmedical
evidence, including the claimant's activities of daily living and past
work experience. In addition, the adjudicator may need to make
difficult assessments of subjective factors, such as the claimant's
physical or mental capacity with respect to a variety of settings and
situations, the weight to place on treating source opinions, and the
claimant's credibility with respect to allegations of pain, fatigue,
and other symptoms.
While the five-step evaluation process is the same at all levels, there
are differences between the decision-making levels that can affect how
adjudicators make decisions on cases. For example, a report by the
Social Security Advisory Board (SSAB) in 2001[Footnote 10] identified
some fundamental differences in the decision-making process between the
DDS and hearings levels that could potentially affect the overall
consistency of disability decision making between the two levels,
including the following:
* Most DDS decisions are made without a face-to-face contact with the
claimant, while the claimant typically appears at an ALJ hearing.
* Attorneys and other representatives are typically involved at the
hearings level, but not at the DDS levels.
* The law allows claimants to introduce new evidence and allegations--
of either new impairments or worsening of prior impairments over time-
-at each stage of the appeals process.
* Different quality assurance procedures are applied to the DDS-and
hearings-level decisions.
Claimants with IBD and Other Impairments Face Similar Challenges
Applying for DI, and SSA Efforts May Address Some Claimant Concerns:
While claimants with IBD have somewhat lower allowance rates than other
claimants, the experiences of these individuals are not unique relative
to claimants with other impairments. When we compared disability
decisions for claimants with IBD with those for other claimants, we
found that much like other claimants, claimants with IBD had lower
allowance rates at the DDS (initial and reconsideration) levels, but
higher allowance rates at the hearings level, although the differences
between levels are more pronounced for claimants with IBD. Allowance
rates that are lower at the DDS level and higher at the hearings level
may reflect challenges that claimants with IBD share with other
claimants. For example, IBD and other claimants face challenges meeting
or equaling SSA's medical criteria at step three of the process at all
adjudication levels. In addition, IBD and other claimants are less
likely to be allowed at step five of the process at the DDS levels
compared to the hearings level. Also like many other claimants,
claimants with IBD may not be sufficiently aware of the types and
importance of information they need to provide to support an allowance
at step five of the process at the DDS levels. SSA is pursuing efforts
that may address some of the difficulties encountered by IBD and other
claimants.
While the Experience of Claimants with IBD Is Not Unique, Their Overall
Allowance Rate Is Somewhat Lower Compared to Other Claimants:
Our analysis showed that, although the experience of claimants with IBD
is not unique, they tend to be allowed at lower rates compared to many
other claimants. For example, when we analyzed overall allowance
rates,[Footnote 11] we found that claimants with IBD were allowed 33
percent of the time, whereas all other claimants were allowed 39
percent of the time. Because impairments with low allowance rates and a
very large number of claims associated with them, such as hypertension
or epilepsy, could skew these results, we also calculated individual
overall allowance rates for IBD and 216 other impairments to determine
whether they were significantly higher than, lower than, or similar to
the overall allowance rate for claimants with IBD.[Footnote 12] As
shown in table 1, while we found that the majority of impairments had
statistically higher overall allowance rates, many other impairments
had similar or lower overall allowance rates.
Table 1: Comparison of Overall Allowance Rates for IBD versus Other
Impairments:
Other impairments compared to IBD: Significantly higher;
Number of impairments: 122;
Total decisions: 1,034,956.
Other impairments compared to IBD: Statistically similar;
Number of impairments: 29;
Total decisions: 61,941.
Other impairments compared to IBD: Significantly lower;
Number of impairments: 65;
Total decisions: 885,633.
Source: GAO analysis.
Notes: Analysis based on SSA DI disability decisions in 2003 at DDS and
hearings levels.
Impairments are classified as having higher, similar or lower allowance
rates than IBD, based on results from statistical models that estimate
the direction, size, and significance of the difference between each
impairment and IBD. Higher and lower impairments are those whose
difference from IBD is significant at the .05 level.
[End of table]
When we analyzed allowance rates by adjudication level (DDS versus
hearings levels), we found that, like many claimants with other
impairments, claimants with IBD experienced lower allowance rates at
the DDS and higher allowance rates at the hearings level.[Footnote 13]
At the same time, we found that the differences between claimants with
IBD and all other claimants were more pronounced when we analyzed the
DDS and hearings levels separately than when we combined them.
Specifically, at the DDS (initial and reconsideration) levels, the
allowance rate for claimants with IBD was 12 percentage points lower
than the average allowance rate for all other claimants (see table 2).
In contrast, at the hearings level, the allowance rate for claimants
with IBD was 10 percentage points higher than the average rate for all
other claimants included in this analysis. However, when we computed
the overall allowance rate, the two levels offset each other, resulting
in a difference of only 6 percentage points.
Table 2: Allowance Rates for Claimants with IBD versus Other Claimants
by Decision-Making Level:
Decision-making level: DDS (initial & reconsideration);
Allowance rate: Claimants with IBD: 22%;
Allowance rate: Other claimants: 34%;
Percentage point difference between allowance rates for claimants with
IBD and other claimants: -12*.
Decision-making level: Hearings;
Allowance rate: Claimants with IBD: 86%;
Allowance rate: Other claimants: 76%;
Percentage point difference between allowance rates for claimants with
IBD and other claimants: 10*.
Decision-making level: All levels;
Allowance rate: Claimants with IBD: 33%;
Allowance rate: Other claimants: 39%;
Percentage point difference between allowance rates for claimants with
IBD and other claimants: - 6*.
Source: GAO analysis.
Notes: Analysis based on SSA DI disability decisions in 2003 at DDS and
hearings levels.
Asterisks indicate differences between claimants with IBD and claimants
with other impairments that are significant at the .05 level. The error
associated with the estimated allowance rates for claimants with IBD is
+/-2 percent or less; the error associated with the estimated allowance
rates for all other claimants is +/-1percent or less.
[End of table]
There may be legitimate reasons for some of the differences in
allowance rates between adjudication levels and between claimants with
IBD and claimants with other impairments at the different levels, but
pinpointing these reasons through data analysis is difficult.
Relatively high allowance rates at the hearings level could be due to
new evidence reflecting new impairments or worsening of alleged
impairments or the fact that the evidence covers a longer period of
time, a potentially important factor for individuals with episodic
impairments like IBD. With respect to variance in allowance rates
between impairment groups, given the different types and
characteristics of impairments, it is reasonable that all impairments
should not necessarily have the same allowance rate, regardless of
adjudication level. Further, rather than analyzing claims filed in a
given year and following their outcomes through the various decision-
making levels, we analyzed data representing decisions at all levels
for 1 year. As a result, decisions at each level generally involved
different claimants with varying characteristics (such as age,
impairment severity, and work history) that influence decisions and
might account for some of the differences. To analyze whether
differences in IBD allowance rates by level are legitimate would
require a much more complex analysis, following a year of applicants
through the entire process and controlling for many factors that may
influence the decision-making process. Even with such an analysis, it
would be difficult to draw firm conclusions because some key data--such
as detailed information on changes in the claimant's medical condition
at the different decision-making levels--are not readily available for
analysis.
Claimants with IBD and Other DI Claimants Encounter Similar Challenges
in the Evaluation Process:
Lower allowance rates at the DDS and higher allowance rates at the
hearings level may reflect challenges that IBD and many other claimants
encounter in SSA's disability evaluation process. For example, many
claimants do not meet or equal SSA's medical criteria at step three of
the process, regardless of adjudication level. In addition, claims that
do not meet or equal the medical criteria at step three and are
evaluated at steps four and five are less likely to be allowed at step
five at the DDS than at the hearings level. Finally, claimants may not
be made sufficiently aware of the importance of documenting how the
impairment limits their ability to work, information that is critical
to steps four and five of the evaluation process. This lack of
documentation may place them at a disadvantage, particularly at the DDS
level.
Challenges Encountered at Step Three:
Both DI claimants with IBD and many other claimants face challenges
meeting or equaling SSA's medical criteria at step three of the
sequential evaluation process when their impairments are evaluated
according to SSA's medical criteria. Our analysis showed that the
allowance rate at step three was low (20 percent or less) for claimants
with IBD, as well as for claimants with other impairments, regardless
of adjudication level (see table 3).
Table 3: Allowance Rates for Disability Decisions at Step Three by
Decision-Making Level:
Decision-making level: DDS (initial & reconsideration);
Allowance rate at step three: IBD: 16%*;
Allowance rate at step three: Other impairments: 20%.
Decision-making level: Hearings;
Allowance rate at step three: IBD: 17%;
Allowance rate at step three: Other impairments: 17%.
Decision-making level: All levels;
Allowance rate at step three: IBD: 16%*;
Allowance rate at step three: Other impairments: 20%.
Source: GAO analysis.
Notes: Analysis based on SSA DI disability decisions in 2003 at DDS and
hearings levels.
Allowance rates at step three were derived by dividing allowances at
step three by all claims considered at step three. Asterisks indicate
differences between claimants with IBD and claimants with other
impairments that are significant at the .05 level. The error associated
with the estimated allowance rates for claimants with IBD is +/-2
percent or less; the error associated with the estimated allowance
rates for all other claimants is +/-1 percent or less.
[End of table]
To further analyze whether claimants with IBD experienced similar
challenges meeting or equaling SSA's medical criteria at step three
relative to other claimants, we calculated how many other types of
impairments had statistically higher, similar, or lower allowance rates
overall and by adjudication level. As shown in table 4, over 45 percent
of other impairments had similar or lower allowance rates at step
three, regardless of adjudication level.
Table 4: Comparison of Allowance Rates at Step Three for IBD versus
Other Impairments by Decision-Making Level:
Decision-making level: DDS (initial & reconsideration);
Allowance rates of other impairments compared to IBD: Significantly
higher;
Number of impairments: 115;
Total decisions: 710,132.
Decision-making level: DDS (initial & reconsideration);
Allowance rates of other impairments compared to IBD: Statistically
similar;
Number of impairments: 31;
Total decisions: 109,838.
Decision-making level: DDS (initial & reconsideration);
Allowance rates of other impairments compared to IBD: Significantly
lower;
Number of impairments: 70;
Total decisions: 918,970.
Decision-making level: Hearings;
Allowance rates of other impairments compared to IBD: Significantly
higher;
Number of impairments: 48;
Total decisions: 64,061.
Decision-making level: Hearings;
Allowance rates of other impairments compared to IBD: Statistically
similar;
Number of impairments: 124;
Total decisions: 36,204.
Decision-making level: Hearings;
Allowance rates of other impairments compared to IBD: Significantly
lower;
Number of impairments: 44;
Total decisions: 143,325.
Decision-making level: All levels;
Allowance rates of other impairments compared to IBD: Significantly
higher;
Number of impairments: 117;
Total decisions: 803,653.
Decision-making level: All levels;
Allowance rates of other impairments compared to IBD: Statistically
similar;
Number of impairments: 23;
Total decisions: 88,237.
Decision-making level: All levels;
Allowance rates of other impairments compared to IBD: Significantly
lower;
Number of impairments: 76;
Total decisions: 1,090,640.
Source: GAO analysis.
Notes: Analysis based on SSA DI disability decisions in 2003 at DDS and
hearings levels.
Allowance rates at step three were derived by dividing allowances at
step three by all cases considered at step three.
Impairments are classified as having higher, similar or lower allowance
rates than IBD, based on results from statistical models which estimate
the direction, size and significance of the difference between each
impairment and IBD. Higher and lower impairments are those whose
difference from IBD is significant at the .05 level.
[End of table]
Meeting or equaling SSA's medical criteria may be a problem for many DI
claimants, although the reasons may vary by impairment. Originally, the
medical criteria were developed as a way to quickly screen the large
majority of cases that could be allowed on reasonably objective medical
tests. However, over the years, SSA has experienced a general decline
in the percentage of DI claims awarded on the basis of meeting or
equaling the medical criteria at the DDS level, from 82 percent to 58
percent between 1983 and 2000. There are many factors that may have
contributed to the decline in allowance rates at step three, including
advances in medicine that can affect the applicability or usefulness of
listings, the general aging of the baby boomer generation, the mix of
impairments over the years, the addition of functional criteria to some
listings that make it more difficult for claimants to meet or equal the
listings, changes in or clarifications of SSA policies, and economic
swings that may affect the number or percentage of claimants with very
severe disabilities.
In addition, claimants with IBD and other claimants may encounter
problems meeting or equaling the medical criteria in part because SSA's
criteria may not be up to date and complete. According to doctors in
the IBD community, the IBD medical criteria in step three do not
consider some symptoms of IBD that may prevent a claimant from working,
such as severe diarrhea. For example, a claimant diagnosed with IBD may
experience a level and frequency of diarrhea that precludes working,
but that symptom is not part of the medical criteria for IBD. In
general, we previously reported that SSA's progress in updating its IBD
and other medical listings has been slow and may not be keeping pace
with medical advancements.[Footnote 14] However, we did not determine
and do not know whether updates to non-IBD listings would improve the
likelihood of DI claimants meeting or equaling SSA's medical criteria
at step three of the process.
Challenges Encountered at Steps Four and Five:
Claimants with IBD and others who are evaluated at steps four and five
of the sequential evaluation process may also encounter challenges
being allowed at the DDS versus the hearings level. As shown in table
5, our analysis found that step five allowance rates were higher at the
hearings level than at the DDS levels for both claimants with IBD and
claimants with other impairments, but the difference is even greater
for claimants with IBD.
Table 5: Allowance Rates for Disability Decisions at Step Five by
Decision-Making Level:
Decision-making level: DDS (initial & reconsideration);
Allowance rate at step five: Claimants with IBD: 13%*;
Allowance rate at step five: Other claimants: 25%.
Decision-making level: Hearings;
Allowance rate at step five: Claimants with IBD: 85%*;
Allowance rate at step five: Other claimants: 74%.
Decision-making level: All levels;
Allowance rate at step five: Claimants with IBD: 27%*;
Allowance rate at step five: Other claimants: 32%.
Source: GAO analysis.
Notes: Analysis based on SSA DI disability decisions in 2003 at DDS and
hearings levels.
Because only denial decisions are possible at step four, allowance
rates at step five were derived by dividing allowances at step five by
all claims considered at steps four and five. Asterisks indicate
differences between claimants with IBD and claimants with other
impairments that are significant at the .05 level. The error associated
with the estimated allowance rates for claimants with IBD is +/-2
percent or less; the error associated with the estimated allowance
rates for all other claimants is +/-1 percent or less.
[End of table]
The relatively high allowance rates at step five of the hearings level
may be due to a number of factors, including the presence of an
attorney or nonattorney representative at the hearings level or the
fact that the evidence covers a longer period of time, a potentially
important factor for individuals with episodic impairments like IBD. As
noted earlier, each step of the process requires increasingly complex
judgments by adjudicators, and being represented by an attorney or
nonattorney who is familiar with SSA's complex rules and decision-
making process may help claimants better present their cases. A GAO
report in 2003[Footnote 15] 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. The report also noted three
possible reasons for the increased likelihood of being awarded benefits
for those represented by an attorney: attorneys provide assistance with
the development of evidence over and above SSA's efforts to develop
evidence; attorneys prepare claimants, to improve their effectiveness
and credibility as witnesses; and attorneys may screen cases to select
claimants with strong cases. In 2004, for 68.4 percent of all hearings-
level decisions, the claimant was represented by either an attorney or
a nonattorney. In contrast, claimants generally do not acquire
attorneys or other representation to assist them with filing their
claims at the DDS levels, although they are allowed to do so.
In the past, SSA and GAO have reported that potential inconsistencies
between the interpretation and application of standards at the DDS
levels versus the hearings level might explain higher allowance rates
at step five at the hearings level.[Footnote 16] For example, GAO
reported on SSA studies that found that ALJs were more likely than DDS
adjudicators to find that claimants are credible with respect to
allegations of pain, fatigue, and other symptoms not identifiable in
laboratory tests or confirmable by medical observations.[Footnote 17]
In addition, past SSA studies have found that the different roles that
medical staff play at the two levels can affect allowance rates at step
five. Specifically, SSA studies have found that DDS medical staff (who
generally perform assessments of claimants' RFC themselves) tend to
find that claimants had higher capacities to function in the workplace
than ALJs (who may consult with medical experts, but have sole
authority to make the RFC finding), even when these different
adjudicators were given the same cases to review.
To help address these inconsistencies, SSA began process unification
efforts in 1994 to ensure that both levels more consistently
interpreted and applied SSA's policy guidance. These efforts included
creating additional policy guidance by publishing rulings and
regulations to clarify such policy areas as credibility, pain, and the
weight given to the opinion of the treating physician. However, GAO
reported in 2004[Footnote 18] that SSA has not adequately assessed the
impact of its process unification efforts and has yet to perform
assessments that provide a clear understanding of the extent or causes
of possible inconsistencies in decisions between adjudicative levels.
Difficulties Understanding the Application Process:
Challenges associated with claimants understanding the application
process and providing critical information to support their claim,
particularly at steps four and five, are common among claimants,
regardless of their impairment. Having complete information to support
a step five allowance is particularly significant because, according to
the Social Security Advisory Board,[Footnote 19] the percentage of
claims allowed at step five has more than doubled, from 18 percent of
all awards in 1983 to nearly 42 percent in 2000. However,
representatives of stakeholder groups we spoke with believe that many
claimants, including those with IBD, may be unaware of the importance
of including detailed information on how their impairment limits their
ability to work. In fact, some doctors and officials in the IBD
advocacy community whom we interviewed believed that if a claimant's
impairment did not meet or equal the medical listings, the claim would
be denied. They were unaware of steps four and five in the sequential
claim evaluation process, where nonmedical factors are considered.
Unless sufficiently prompted by SSA, claimants might not provide enough
information when they file their claim about how their impairment
limits their ability to work, which could reduce the likelihood of an
allowance at step five at the DDS level. In our review of 20 disability
claim folders for claims decided in 2003, we found that the prior
version of the adult disability report did not clearly state the
importance of providing detailed and complete information about how the
impairment limited the ability to work. In responding to the question
on the paper disability report then used, some claimants provided only
minimal information, sometimes just a few words. For example, one
claimant responded to the question about how his impairment limited the
ability to work by saying "pain, limited movement." In another case
that was denied at the initial DDS level, the claimant provided minimal
information concerning how the impairment limited work activities.
In contrast, the new interactive adult disability report on the
agency's Web site contains instructions, explanations, and examples
that assist claimants in filling out the report. For example, in asking
about how the impairment limits the claimant's ability to work, the
report notes: "This is one of the most important pages in the report."
It goes on to explain that, "You can help your case by giving us a
detailed description of all of your conditions, and any symptoms that
limit your ability to work. Please do not assume that your condition is
self-explanatory." The report also provides examples of how to document
the conditions and symptoms that may limit the ability to work,
including the type of information and level of detail needed, such as
"I have trouble concentrating and have become more and more forgetful.
My friend at work reminds me about important work assignments. Once I
forgot to take the daily receipts to the bank. Sometimes I can't
remember how to add or subtract." However, to view the on-line
instructions, explanations and examples given in the interactive adult
disability report, a claimant must provide a name and legitimate Social
Security number, fill out the report, and reach the section asking how
the impairment limits the ability to work. Further, these more detailed
instructions and examples are directly available only to those
claimants who apply on line, which accounts for only about two percent
of claimants, according to an SSA official. Since the majority of
applicants apply in person or over the phone, most claimants never see
this information.
For the majority of claimants who apply in person or over the phone,
SSA field staff have the option of reviewing and reading to claimants
examples that illustrate the types and importance of information
requested. However, the Social Security Advisory Board and others
believe that field staff lack the time to sufficiently explain program
rules and procedures so that applicants can understand what items of
information they need to document their case. SSA does not track, and
we did not determine, the extent to which SSA field staff read this
information to claimants applying in person or over the phone.
Brochures and other information are available on line and routinely
provided by SSA to claimants when they arrange an appointment to file a
disability claim. SSA provides this information in order to help ensure
that claimants can gather the information needed and have it available
when they meet with the claims representative to complete the
application. However, this information does not explain the type of
information and level of detail needed if the impairment does not meet
or equal the medical criteria at step three and the claim must be
decided at steps four and five. As a result, claimants may not be
sufficiently informed to give SSA enough information at the time of
application to support the allegation that their impairment makes them
unable to work.
Another opportunity exists for the DDS to collect information from
claimants that is relevant to steps 4 and 5 in the evaluation of the
initial claim. Specifically, DDS procedures call for the adjudicator to
request additional information from the claimant, if (1) it is
warranted based on the disability alleged by the claimant and (2) the
information is not already in the adult disability report completed by
the claimant or by field staff for the claimant. Requested information
might include responses to a pain or fatigue questionnaire or an
activities of daily living form. Again, SSA does not track, and we did
not determine, the extent to which this is done.
SSA's Efforts May Address Some Challenges Faced by Claimants with IBD
and Others:
SSA is pursuing efforts that may address some but not all the
difficulties encountered by claimants with IBD and other claimants. The
agency is currently updating the medical criteria used at step three
for all impairments, including IBD and is taking into account the views
of the public in so doing. However, SSA officials told us that agency
rules prohibit the discussion of specific changes prior to their
publication. The process of updating criteria is lengthy, and the
updates to the medical criteria for IBD may not be completed until late
in 2005.
SSA also has broader efforts under way that may affect future changes
to medical criteria. For example, SSA has begun holding public meetings
to discuss changes in medical criteria for certain impairments, such as
mental conditions and immune disorders, including HIV/AIDS. According
to SSA officials, this approach allows SSA to obtain valuable input
from outside the agency, prior to the drafting of proposed changes to
medical criteria. In addition, SSA has contracted with the Institute of
Medicine, part of the National Academy of Sciences (NAS), to conduct a
broad review of its medical criteria. This review will study such
things as developing the process for determining when the criteria need
to be updated, establishing feedback mechanisms to continuously assess
and evaluate the criteria, and examining the advisability of
integrating functional assessment into the criteria.
In addition to changes that affect IBD and other medical criteria, SSA
has several proposed changes currently under consideration that may
improve the consistency of decisions between the DDS and hearings
levels. Specifically, in 2004, GAO reported[Footnote 20] that most SSA
stakeholders believe the following proposals--announced by the
Commissioner in 2003--may increase the extent to which DDS and hearings-
level adjudicators arrive at similar decisions on similar cases:
* requiring DDS adjudicators to more fully develop and document their
decisions;
* changing the quality control process for hearings-level decisions in
a way that makes it more consistent with that of the DDS level;
* providing both the DDS and the hearings levels with equal access to
more centralized medical expertise; and:
* requiring ALJs to address agency reports that recommend either
denying the claim or outlining the evidence needed to fully support the
claim.
SSA is also trying to improve all claimants' understanding of the
disability claims evaluation process, through the interactive adult
disability report and other information available on SSA's Web site.
SSA's Web site contains information on various aspects of the DI
program, including the evaluation process, and SSA periodically reviews
and updates information provided on its Web site. However, except for
the interactive adult disability report, SSA's Web site does not
provide claimants with detailed instructions, explanations, and
examples to assist them with completing the adult disability report.
Moreover, SSA recently developed a Disability Starter Kit, available on
the Web site and also given to all disability claimants who apply in
person or by phone, which provides answers to frequently asked
questions and materials to help them prepare for the disability
interview. However, the Disability Starter Kit does not include the
instructions, explanations, and examples available on the interactive
adult disability report, for describing how an impairment limits the
ability to work and the importance of providing this information.
Conclusions:
Claimants with IBD believe that SSA tends to initially deny their
claims, only to allow them at the hearings level, and our analysis of
2003 DI decisions confirms that most IBD claims are denied at the
initial level, and a high rate of claims are allowed upon appeal.
However, we also found that the experience of claimants with IBD is
much like that of claimants with many other impairments. This situation
may be due in part to a general shift away from allowing cases at the
DDS level based on meeting or equaling the medical criteria in the
listings. This in turn results in more and more cases being assessed at
step five of the process--a step that involves complex judgments
concerning the RFC of the claimant and assessments of factors like pain
and the credibility of the claimant. Past studies have found that
relative to counterparts at the hearings level, DDS adjudicators have
been less inclined to find that claimants are credible or cannot
perform past or other work in the national economy, and therefore less
likely to allow claimants on these bases at step five of the sequential
process. Inconsistencies in how adjudicators at different levels make
decisions may help explain the relatively low allowance rates at the
DDS levels and high allowance rates at the hearings level for IBD and
other claimants whose impairments do not fit neatly into SSA's medical
criteria and generally require adjudicators to perform more complex and
subjective assessments. SSA has some efforts under way that may address
some of these issues, but it is too early to gauge success. For
example, SSA is updating its medical criteria for IBD and other
impairments, but SSA is unable to discuss any changes prior to
publication. SSA also contracted with the NAS to conduct a broad review
of its medical criteria. However, this effort is in its initial stages,
and the NAS report is not expected until March of 2006. SSA has also
proposed several changes to its decision-making process that may
address inconsistencies in how adjudicators at different levels view
cases. However, as we previously recommended, SSA needs to collect
better information to help it determine whether problems with
inconsistency have been resolved.
We also found that SSA's application and claims evaluation process may
not be well understood by many claimants, and thus some claimants may
not provide SSA with all the information necessary for their initial
decisions. SSA's on-line adult disability report provides useful
instructions, explanations, and examples to the small percentage of
claimants who actually fill out the report on line. However, that
information cannot easily be viewed on SSA's Web site and is not
available in the other materials provided to applicants. Further, for
the majority of claimants who file in person or on the phone, SSA lacks
assurance that SSA field staff explain to claimants the types and
importance of information needed to support a claim assessed at steps
four and five of the process. As a result, claimants may not be
providing sufficient information on how their impairments prevent them
from working, and SSA may be missing the opportunity to gather key
information for meeting one of its key strategic objectives, that is,
to make the right decision in the disability process as early as
possible.
Recommendations:
To help ensure that claimants with IBD and other claimants are informed
of and ultimately provide SSA with information critical to a complete
assessment of their impairment at the earliest possible point in the
decision-making process, SSA should implement the following three
recommendations:
* Update its Web site to include more accessible information that
clarifies the type and importance of information that claimants must
submit for steps four and five of the sequential evaluation process.
SSA should also consider making the information currently in its
interactive adult disability report--including instructions,
explanations and examples--more readily available to all claimants on
its Web site.
* Update the Disability Starter Kit--which is provided to all claimants
who apply by phone or in person--to include an explanation of the types
and importance of information that claimants must submit for steps four
and five of the sequential evaluation process. SSA should consider
adding instructions, explanations, and examples that are currently
available in the on-line form, to the extent that it is cost-effective
to do so.
* Explore options for ensuring that field office and DDS staff
appropriately explain and collect the types of information needed to
assess how claimants' impairments impact their ability to work.
Agency Comments and Our Evaluation:
We provided a draft of this report to SSA for comment. SSA agreed with
our recommendations. Specifically, SSA agreed with our first
recommendation and will take the steps necessary to ensure that, at a
minimum, the information currently available in the interactive adult
disability report is available to all claimants on the Web site. In its
response to our second recommendation, SSA said that it would consider
the inclusion of information and/or instructions along with other
suggestions to the Disability Starter Kit that would address the
importance of obtaining information from the disability applicant about
steps four and five of the sequential evaluation process, taking into
account factors such as expense and space. SSA agreed with our third
recommendation and will continue to emphasize and train DDS and Social
Security employees on the importance of appropriately explaining all
aspects of the disability process to claimants and ensuring that the
appropriate information is provided to and received from the claimants.
Although SSA agreed with our recommendations, the agency expressed
concern with two statements in our report. SSA stated that our report
discussed issues the agency considers irrelevant to our study of DI
claimants with IBD--the addition of functional criteria to the listings
for impairments other than IBD and the decline in DI allowances based
on medical criteria. To respond to agency concerns, we de-emphasized
our discussion of functional criteria in the listings by simply
identifying it as one of many reasons for the decline in allowance
rates at step three. We also clarified in our "Conclusions" section
that we were discussing a decline in allowances at step three, rather
than a decline in allowances based on medical criteria. However, we
believe that the addition of functional criteria to the listings is
relevant to our study, as is the decline in allowance rates at step
three, because they provide perspective on whether claimants with IBD
are treated differently than claimants with other impairments. SSA also
expressed concern with how we characterized part of our analysis in the
"Conclusions" section, and we modified the text in the "Conclusions" to
be more specific about what our analysis found.
SSA provided additional general comments, which we have included (along
with our responses to them) in appendix II and addressed in the body of
our report where appropriate. SSA also provided technical comments that
we have incorporated in the report as appropriate.
We are sending copies of this report to the appropriate congressional
committees, the Social Security Administration, and other interested
parties. We will also make copies available to others on request. In
addition, the report will be available at no charge on GAO's Web site
at http://www.gao.gov.
If you or your staff have any questions concerning this report, please
contact me or Michele Grgich, Assistant Director, at (202) 512-7215.
You may also reach us by e-mail at robertsonr@gao.gov or
grgichm@gao.gov. Other major contributors to this assignment were Jill
D. Yost, Ann T. Walker, Corinna Nicolaou, Daniel Schwimer, Doug Sloane,
and Shana Wallace.
Signed by:
Robert E. Robertson:
Director, Education, Workforce, and Income Security Issues:
[End of section]
Appendix I: Scope and Methods:
To determine whether claimants with IBD were treated differently than
claimants with other impairments, we analyzed SSA data from 2003 on all
Disability Insurance (DI) decisions made at three decision-making
levels (initial, reconsideration, and hearings), and compared allowance
rates for claimants with IBD to those for claimants with other
impairments. This appendix describes (1) the sources of the data we
used, (2) the scope of our analysis, (3) steps we took to ensure data
reliability, and (4) our methods for analyzing the data.
Data Sources:
We collected information from two sources on all DI decisions made in
2003 at the three decision-making levels:
* SSA's 831 file (also referred to as the National Disability
Determinations Services System), which contains an electronic record of
all initial and reconsideration decisions made at the DDS and:
* SSA's Case Control System (CCS), which contains an electronic record
of all decisions made at the hearings level.
Scope:
The Research Review Act mandated GAO to study problems encountered by
patients with IBD when applying for DI benefits under Title II of the
Social Security Act. Therefore, we limited our data analyses to
decisions that involved Title II (Disability Insurance or DI)
claims.[Footnote 21] We restricted our analyses to DI decisions that
resulted in an allowance or a denial at one of the five steps[Footnote
22] in the sequential process and excluded cases denied for such
reasons as lack of cooperation or failure to follow prescribed
treatment, because such denials are not associated with one of the five
steps.
Data Reliability:
We determined that the 831 and CCS files were sufficiently reliable
based on reliability assessments of specific variables and records
pertinent to our analyses that we had performed for a previous
report.[Footnote 23] For that report, we reviewed reports by GAO, the
SSA Office of Inspector General, and SSA contractors on data quality.
We also interviewed staff responsible for managing and using the data
to assess the controls and processes in the disability system and
performed electronic testing of some variables. In addition, for this
report, we performed the following:
* We reviewed records in the 831 and CCS files representing DI
decisions made in 2003 to identify missing data for the three variables
used in this study: impairment, decision, and step of the sequential
evaluation process (i.e., regulation basis code). We did not find any
instances of missing data for these three variables.
* We reviewed impairment codes used for 2003 decisions and found
records that did not indicate a specific diagnosis (e.g., 6490,
"impairment unknown; insufficient medical evidence"). Because there
were a large number of records with such impairment codes, we retained
them in our analyses which compared claimants with IBD with all other
claimants. After we determined the differences in allowance rates based
on the total number of decisions regardless of impairment, we conducted
a second analysis of allowance rates that considered the allowance rate
for each impairment code. In the second analysis, we used impairment
codes for which there were 100 or more decisions in 2003, including
those impairment codes that did not indicate a specific diagnosis.
* We compared decision outcomes with the regulation basis code
indicating at which step the decision was made, and found cases with
obvious conflicts between the decision and the step. Specifically we
found records that were denied at step three (one case) or allowed at
step four (1,021 cases). The five-step evaluation process does not
permit denials at step three or allowances at step four, so we excluded
these records from our analysis. Given the large number of claims
(approximately 2 million), the error produced by the exclusion of these
cases is very small.
Methods of Analysis:
In order to determine whether claimants with IBD were in fact treated
differently than claimants with other impairments, we compared decision
outcomes in two ways: (1) claimants with IBD versus all other
claimants, and (2) IBD impairments versus 216 other individual
impairments.
Claimants with IBD versus All Other Claimants:
To determine the extent to which claimants with IBD were allowed at a
different rate than other claimants, regardless of impairment type, we
compared the allowance rate of claimants with IBD to that of all other
claimants. The allowance rate for IBD was calculated by combining
decisions for the two IBD impairments--Crohn's disease and ulcerative
colitis. We then compared the percentage of claims allowed for those
impairments with the percentage allowed for all other claimants
combined. We estimated the sampling error associated with these
percentages, given the size of the samples on which they were based,
and tested the significance of the difference between them using a
simple chi-square statistic. The error associated with the estimated
allowance rate for claimants with IBD is +/-2 percent or less. The
error associated with allowance rates for all other claimants is +/-1
percent or less. We tested the significance of the differences between
claimants with IBD and other claimants using the .05 level of
significance.
As indicated in table 6 below, a total of nine comparisons were made
using these calculations. As noted in the table, the denominator for
step three comparisons included only cases considered at step three
(i.e., cases that were not denied at steps one and two), whereas the
denominator for step five included cases considered at steps four and
five. The reason for the difference is that assessments performed at
steps four and five are highly inter-related; for example, the RFC
assessment performed at step four would be used to support a denial at
either step four or five, or an allowance at step five. As such, it
seemed appropriate to consider allowances at step five relative to all
decisions made at steps four and five.
Table 6: Types of Comparisons Used in Report for IBD versus Other
Impairments:
DDS (initial and reconsideration) level;
Allowance rate for all steps of the sequential evaluation process: DDS
allowances divided by all DDS decisions;
Allowance rate at step three: DDS allowances at step three divided by
all cases considered at the DDS level at step three;
Allowance rate at step five: DDS allowances at step five divided by all
cases considered at the DDS level at steps four and five.
Hearings level;
Allowance rate for all steps of the sequential evaluation process:
Hearings allowances divided by all hearings decisions;
Allowance rate at step three: Hearings allowances at step three divided
by all cases considered at the hearings level at step three;
Allowance rate at step five: Hearings allowances at step five divided
by all cases considered at the hearings level at steps four and five.
Overall (all decision-making levels);
Allowance rate for all steps of the sequential evaluation process: 2003
allowances divided by all 2003 decisions;
Allowance rate at step three: 2003 allowances at step three divided by
all 2003 decisions considered at step three;
Allowance rate at step five: 2003 allowances at step five divided by
all 2003 decisions considered at steps four and five.
Source: GAO.
[End of table]
IBD Impairment versus 216 Other Individual Impairments:
We performed separate analyses to determine whether claimants with IBD
had an allowance rate that was different from the allowance rates for
claimants with other impairments, or whether the allowance rate for
claimants with IBD was higher than for some other impairments, but
lower for others. We performed this extra step because we did not know
whether certain impairments might have a large number of records
associated with them, and therefore might have greatly influenced the
allowance rates for claimants with impairments other than IBD. This
additional analysis reveals where claimants with IBD fall in the range
of allowance rates by impairment, regardless of the number of claims
associated with each impairment.
The allowance rate for claimants with IBD was calculated as we did in
the first analysis described above. We used this allowance rate as the
reference category and employed categorical logistic regression models,
with 216 dummy variables for the other categories of impairments, to
test the direction and significance of the difference in allowance
rates between each of the other impairments and IBD. These models used
Wald statistics and .05 level of significance to test differences, and
were able to classify other impairments as having significantly higher,
statistically similar, or significantly lower allowance rates than IBD.
A total of four comparisons were made by impairment: overall allowance
rate (all sequential evaluation steps and decision-making levels
combined), and step three at the DDS, hearings, and combined levels. We
reported the overall comparison as an extra test of the results of our
first analysis. We reported comparisons of impairments at step three
because this step involves an assessment by SSA adjudicators of medical
criteria by impairment. Although we also compared impairments at step
five, we did not report the comparison because we found the results to
be consistent with our analysis of claimants with IBD versus other
claimants.
[End of section]
Appendix II: Agency Comments:
SOCIAL SECURITY:
The Commissioner:
May 11, 2005:
Mr. Robert E. Robertson:
Director, Education, Workforce and Income Security Issues:
U.S. Government Accountability Office:
Room 5-T-57:
441 G Street, NW:
Washington, D.C. 20548:
Dear Mr. Robertson:
Thank you for the opportunity to review and comment on the draft report
"SOCIAL SECURITY DISABILITY INSURANCE: SSA Actions Could Enhance
Assistance to Claimants with Inflammatory Bowel Disease and Other
Impairments" (GAO-05-495). Our comments on the report are enclosed.
If you have any questions, please have your staff contact Candace
Skurnik, Director, Audit Management and Liaison Staff at (410) 965-
4636.
Sincerely,
Signed by:
Jo Anne B. Barnhart:
Enclosures (2):
COMMENTS ON THE GOVERNMENT ACCOUNTABILITY OFFICE (GAO) DRAFT REPORT
"SOCIAL SECURITY DISABILITY INSURANCE: SSA ACTIONS COULD ENHANCE
ASSISTANCE TO CLAIMANTS WITH INFLAMMATORY BOWEL DISEASE AND OTHER
IMPAIRMENTS" (GAO-05-495):
We appreciate the opportunity to comment on the GAO draft report
concerning the Social Security Administration's (SSA) actions in
adjudicating claims for Disability Insurance (DI) benefits filed by
individuals with inflammatory bowel disease (IBD). We agree with the
recommendations and commend GAO for doing the work and writing the
report in so short a time.
However, we do have two relatively major concerns with statements in
the draft. First, we believe the report should not address general
listings issues. On pages 16 and 23 of the draft report, the report
addresses why the proportion of allowances based on the Listing of
Impairments (the listings) has been falling over the past 20 years
while the proportion of allowances at step 5 has been increasing. We
strongly advise that you consider removing these discussions because
they are not relevant to the study in this report. Further, as the
report notes, we currently have a contract with the Institute of
Medicine, National Academy of Sciences, to address this specific issue.
The bulk of the text that addresses this issue repeats the theory that
the listings have changed from their "original intent" and that there
has been a "general shift away from allowing cases based on medical
criteria;" that is, there has been a shift toward using more functional
criteria in the listings. Even if these assertions were accurate, they
would not be relevant to the study on IBD because the criteria in the
listings for IBD--listings 5.06 and 5.07--are in fact solely medical;
that is, they consist entirely of clinical and laboratory findings.
Moreover, there has been no shift in the "intent" of the listings
related to IBD because listings 5.06 and 5.07 have not changed since
they were published in 1979. For these reasons, even if it were the
case that other listings had shifted to a more functional basis and
away from a solely medically based analysis, it would not be true of
the listings we use to evaluate 11313. Further, the third sentence of
the conclusion paragraph on page 23 of the draft ("This situation may
be due in part to a general shift away from allowing cases based on
medical criteria.") would be clearly erroneous with regard to the IBD
listings.
Other statements in the draft about the general listings issue are also
incorrect. For example, one individual believed that the original
intent of the listings was to match the statutory standard of
"inability to work" and that the current intent is "inability to
function," a standard that the individual believed was "much more
stringent." However, that is not the case. Since 1980, §404.1525(a) of
our regulations has provided that the listings describe impairments
that are severe enough to prevent a person from doing "any gainful
activity," not just "any substantial gainful activity." This is by
definition a more stringent standard than the statutory definition of
inability to work. (For a further discussion of this policy and why it
was not new even in 1980, see the preamble to the publication of the
1980 regulations, 45 FR 55566, at 55575-55576 (1980).) In any case, the
discussion of function in the listings appears to shift the report away
from the Congressional mandate to evaluate issues that claimants with
IBD face.
Therefore, we recommend that you delete this discussion entirely.
However, if you still believe that it is necessary to include it, we
recommend that you do so in a footnote so that readers do not
erroneously conclude that the discussion of function in the listings
affects people suffering from IBD.
Second, the analysis in the draft report does not confirm the belief of
claimants with IBD that they must go to the administrative law judge
(ALJ) hearing level in order to win their cases. Thus, we question the
last part of the first sentence of the "Conclusions" section on page 23
of the draft report: "IBD claimants believe that SSA tends to initially
deny their claims, only to allow them at the hearings level, and our
analysis of 2003 DI decisions confirms this." (Emphasis added.) The
first part of the sentence implies that claimants believe they must go
to the ALJ hearing level in order to be found disabled. This is
confirmed by the report on page I that: "As a result, claimants with
IBD believe that they are likely to be denied benefits at the initial
decision and reconsideration levels, making it necessary for them to
appeal to SSA's hearings level to have their claims allowed."
We do not question the report's findings that people with IBD are
allowed at a lower rate at the initial level and a higher rate at the
ALJ hearing level. We also take this information quite seriously, and
we appreciate that the report notes that we are considering public
input as we revise the IBD listings for final publication in the
relatively near future. However, the body of the report does not appear
to support the conclusion that claimants must go to the ALJ hearing
level in order to be found disabled. Further, we believe the data you
used do not support this conclusion. The data in the report tell only
about the relative proportions of people who were allowed in 2003, not
the numbers of people who were allowed, so they do not appear to
address this issue at all. However, the underlying data for the
percentages you report--i.e., the data showing the numbers of people
who were allowed at each level--show that, of the people with IBD who
qualified in 2003, the majority were allowed by Disability
Determination Services (DDS), and that, by far, most of those
individuals were allowed at the initial level. In other words, most
people with IBD who were allowed "won" their cases on their first try
without having to appeal.
Therefore, we believe it is not accurate for the report to say your
analysis "confirm[ed]" the claimants' belief, and we recommend that GAO
revise it to more accurately state what the data showed. Also, we note
that the conclusion section does not refer to the analysis on page 14
of the draft report, which spells out many of the legitimate reasons
why there may be differences in allowances rates between adjudication
levels.
We have the following comments on the GAO recommendations.
Recommendation 1: SSA should update its Web site to include more
accessible information that clarifies the type and importance of
information that claimants must submit for steps four and five of the
sequential evaluation process. SSA should also consider making
information currently in its interactive adult disability report - -
including instructions, explanations and examples --more readily
available to all claimants on its Web site.
Response:
We agree on the importance of providing claimants with complete and
accurate information about all aspects of the disability process. We
currently provide links (More Information about Disability and the
Application Process and How the Disability Application Process Works),
which provide an explanation of the sequential evaluation process in
detail and other application processing information under SSA's Online
Claims and Services web page via the Adult Disability and Work History
Report. This section of the web site can be further expanded to include
similar information currently available in the interactive disability
reports. SSA will take the steps necessary to ensure that, at a
minimum, the information currently available in the interactive adult
disability report is available to all claimants on the web site.
Recommendation 2: SSA should update the Disability Starter Kit --which
is provided to all claimants who apply by phone or in person --to
include an explanation of the types and importance of information that
claimants must submit for steps four and five of the sequential
evaluation process. SSA should consider adding instructions,
explanations and examples that are currently available in the on-fine
form, to the extent that it is cost-effective to do so.
Response:
We will consider the inclusion of information and/or instructions along
with other suggestions to the starter kit that would address the
importance of obtaining information from the disability applicant about
steps four and five of the sequential evaluation process, taking into
account factors such as expense and space.
Recommendation 3: SSA should explore options for ensuring that field
office and DDS staff appropriately explain and collect the types of
information needed to assess how claimants' impairments impact their
ability to work.
Response:
We appreciate the comments and will continue to emphasize and train DDS
and Social Security employees on the importance of appropriately
explaining all aspects of the disability process to claimants and
ensuring that the appropriate information is provided to and received
from the claimants. Each Regional Office web site currently provides
access to a "Disability Interview Guide" for the FO claims
representative (CR). CRs are accustomed to using this resource kit for
the front-end interview process. The DDS generally submits functional
reports to applicants which address limitations in activities of daily
living and symptom questionnaires to further address limitations. We
recognize the need for (and are now conducting) additional FO training
regarding the disability interview process to further assist the DDSs
in their determination process.
GAO Comments:
1. In response to SSA's comments, we de-emphasized our discussion of
functional criteria in the listings by simply identifying it as one of
many reasons for the decline in allowance rates at step three. Although
we agree that functional elements have not been added to the medical
criteria for the IBD listings, we believe that the addition of
functional criteria to some listings is relevant to our study because
they provide perspective on whether claimants with IBD are treated
differently than claimants with other impairments. We also clarified
our text in the "Conclusions" section to discuss the decline in
allowances based on meeting or equaling the medical criteria in the
listings (i.e., step three allowances), instead of allowances based on
medical criteria. In any case, we commend SSA for contracting with the
Institute of Medicine of the National Academy of Sciences to study
issues related to the listings.
2. We agree that a shift away from medical criteria toward more
functional criteria is only one of many possible explanations for the
downward trend of allowances at step three for DI claimants, and may
not specifically apply to claimants with IBD. As discussed in comment
1, we modified our text in the body of the report and in the
"Conclusions" section to place less emphasis on this particular
explanation.
3. We revised the text in the "Conclusions" section to state more
specifically what our analysis of 2003 decisions found.
4. We agree that, of those allowed, a larger number of allowances are
made at the initial level for claimants with IBD as well as for other
claimants, and we added a footnote to the body of the report confirming
this. However, SSA's point that most allowances occur at the initial
level does not detract from the importance of our discussion of
relative rates. The low rate of allowances at the DDS level means that
a large majority of claimants were initially denied, many of whom
likely did not appeal their initial decision. Our analysis does not
allow us to say whether the high allowance rate at the hearings level
is a function of the merit of the appealed cases or, if more of those
denied claims had been appealed to the hearings level (where more than
half of claims are allowed), a larger number of claims might have been
allowed at the hearings level, and therefore claims allowed by the DDS
would be a smaller percentage of the total number of allowed claims.
Thus, reporting only the total number of claims allowed at the
different decision-making levels may not accurately represent the
situation.
5. See comment 3. We did not revise the "Conclusions" section further
because we believe the report sufficiently identifies a number of
legitimate reasons that may explain some of the differences in
allowance rates between adjudication levels.
FOOTNOTES
[1] The Research Review Act of 2004 also mandated that GAO report on
the Medicare and Medicaid coverage standards for certain therapies used
by patients with IBD.
[2] See appendix I for a detailed description of the methods we used to
analyze 2003 data.
[3] SSA also manages Title XVI of the Social Security Act, which
created the Supplemental Security Income (SSI) program in 1972. SSI is
a means-tested, income assistance program that provides monthly
payments to adults or children who are blind or who have other
disabilities and whose income and assets fall below a certain level.
[4] The SSI program uses the same definition of disability as the DI
program.
[5] For all disability claims, claimants must fill out the disability
application form and the adult disability report.
[6] In September 2003, SSA's Commissioner proposed eliminating
reconsideration and the Appeals Council as part of a large set of
revisions to the disability decision-making process.
[7] Under the current process, if the claimant is not satisfied with
the ALJ's decision, he or she may request a review of the decision by
SSA's Appeals Council, which is the final administrative appeal within
SSA. If the Appeals Council denies the request for review or the
claimant is not otherwise satisfied with the Appeals Council's
decision, the claimant may appeal to a federal district court. The
claimant can continue legal appeals to the U.S. Circuit Court of
Appeals, and ultimately to the Supreme Court of the United States.
[8] The sequential claims evaluation process applies equally to DI and
SSI claims.
[9] The 2005 substantial gainful activity (SGA) level for claimants who
are not blind is $830; SGA for blind claimants is $1,380.
[10] Social Security Advisory Board, Charting the Future of Social
Security's Disability Programs: The Need for Fundamental Change
(Washington, D.C.: January 2001).
[11] To calculate overall allowance rates, we divided the number of
allowances at all levels (initial, reconsideration, and hearings) by
the number of decisions at all levels.
[12] The number of impairments we included in this analysis (218,
including the two IBD impairments, ulcerative colitis, and Crohn's
disease) was determined by identifying all primary impairments listed
in the 2003 decisions, minus those involving fewer than 100 decisions
in 2003.
[13] Although the allowance rate at the DDS is lower than the rate at
the hearings level, this does not mean that fewer people were allowed
at the DDS than at the hearings level. In fact, of the 2,257 claimants
with IBD who were allowed at either level in 2003, 55 percent (or
1,241) were allowed at the DDS level. Similarly, of those claimants
with other impairments who were allowed at either level, 76 percent
(584,613) were allowed at the DDS level.
[14] GAO, SSA and VA Disability Programs: Re-Examination of Disability
Criteria Needed to Help Ensure Program Integrity, GAO-02-597
(Washington, D.C.: Aug. 9, 2002).
[15] GAO, SSA Disability Decision Making: Additional Steps Needed to
Ensure Accuracy and Fairness of Decisions at the Hearings Level, GAO-04-
14 (Washington, D.C.: Nov. 12, 2003).
[16] Secretary of Health and Human Services, Implementation of Section
304 (g) Public Law 96-265, Social Security Disability Amendments of
1980, the Bellmon Report (Washington, D.C.: January1982).
[17] GAO, Social Security Disability: SSA Must Hold Itself Accountable
for Continued Improvement in Decision-making, GAO/HEHS-97-102
(Washington, D.C.: Aug. 12, 1997).
[18] GAO, Social Security Administration: More Effort Needed to Assess
Consistency of Disability Decisions, GAO-04-656 (Washington, D.C.: July
2, 2004).
[19] Social Security Advisory Board, Disability Decision Making:
Selected Aspects of Disability Decision Making (Washington, D.C.:
January 2001).
[20] GAO-04-656.
[21] Some of these DI decisions involved a concurrent claim, that is,
the claimant filed for DI and SSI concurrently and a decision of
disability is the same for both programs.
[22] Although most step one denials were made at an SSA field office
and were not included in our analysis, a small number of claims (1,563,
or less than 0.1 percent) were denied at step one at the DDS and
hearings levels.
[23] GAO, SSA's Disability Programs: Improvements Could Increase the
Usefulness of Electronic Data for Program Oversight, GAO-05-100R
(Washington, D.C.: Dec. 10, 2004).
GAO's Mission:
The Government Accountability Office, the investigative arm of
Congress, exists to support Congress in meeting its constitutional
responsibilities and to help improve the performance and accountability
of the federal government for the American people. GAO examines the use
of public funds; evaluates federal programs and policies; and provides
analyses, recommendations, and other assistance to help Congress make
informed oversight, policy, and funding decisions. GAO's commitment to
good government is reflected in its core values of accountability,
integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through the Internet. GAO's Web site ( www.gao.gov ) contains
abstracts and full-text files of current reports and testimony and an
expanding archive of older products. The Web site features a search
engine to help you locate documents using key words and phrases. You
can print these documents in their entirety, including charts and other
graphics.
Each day, GAO issues a list of newly released reports, testimony, and
correspondence. GAO posts this list, known as "Today's Reports," on its
Web site daily. The list contains links to the full-text document
files. To have GAO e-mail this list to you every afternoon, go to
www.gao.gov and select "Subscribe to e-mail alerts" under the "Order
GAO Products" heading.
Order by Mail or Phone:
The first copy of each printed report is free. Additional copies are $2
each. A check or money order should be made out to the Superintendent
of Documents. GAO also accepts VISA and Mastercard. Orders for 100 or
more copies mailed to a single address are discounted 25 percent.
Orders should be sent to:
U.S. Government Accountability Office
441 G Street NW, Room LM
Washington, D.C. 20548:
To order by Phone:
Voice: (202) 512-6000:
TDD: (202) 512-2537:
Fax: (202) 512-6061:
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: www.gao.gov/fraudnet/fraudnet.htm
E-mail: fraudnet@gao.gov
Automated answering system: (800) 424-5454 or (202) 512-7470:
Public Affairs:
Jeff Nelligan, managing director,
NelliganJ@gao.gov
(202) 512-4800
U.S. Government Accountability Office,
441 G Street NW, Room 7149
Washington, D.C. 20548: