THE NADE VIEW

INSTITUTE OF MEDICINE’S INTERIM REPORT

IMPROVING THE SOCIAL SECURITY DISABILITY DECISION PROCESS

After carefully reviewing the Institute of Medicine’s (IOM) Interim Report on Improving the Social Security Disability Decision Process, the National Association of Disability Examiners (NADE) offers the following comments on the committee’s early recommendations in this report.

NADE is a professional association whose purpose is to promote the art and science of disability evaluation.  The majority of our members are employed by state Disability Determination Service (DDS) agencies and thus are on the “front-line” of the disability evaluation process.  However, our membership also includes SSA personnel, attorneys, physicians and claimant advocates.  It is the diversity of our membership, combined with our extensive program knowledge and “hands on” experience, which enables NADE to offer a perspective on disability issues which is both unique and pragmatic.

NADE members, whether in state DDSs, in SSA, or in the private sector, are deeply concerned about the integrity and efficiency of both the Social Security and Supplemental Security Income (SSI) disability programs.  Any change in the use of medical expertise in the disability decision process must promote viability and stability in the program as well as maintain the integrity of the disability trust fund by providing good customer service.  At the same time, the trust fund must be protected against abuse.  Quality claimant service and lowered administrative costs should play key roles in any changes to the use of medical expertise in the disability decision process.  Any changes made must be practical and affordable.  NADE is not convinced that all the recommendations of the IOM’s interim report will achieve that end.  We are, in fact, concerned that some of the recommendations will increase both administrative and programmatic costs.

Constraints on the Disability Decision Process:

NADE concurs with the IOM regarding the constraints on the disability decision process.  Disability decision makers in the DDSs are definitely subject to strong pressures from SSA to decide cases quickly and to reduce administrative costs (including medical costs) per case.  In addition, increased workloads, constant changing of complex rules, limitations in funding, reduced staffing and an electronic case processing environment impinge on the ability of the DDS to accurately, thoroughly and timely process all of its work.

The IOM correctly points out that the “contrasting set of incentives for DDSs and administrative law judges…has the effect of pushing decision outcomes in different directions at different levels of adjudication”.  The recently passed legislation requiring pre-effectuation reviews of DDS SSI allowance decisions will compound this problem.

Both the Social Security and SSI disability programs provide a vital safety net for an extremely vulnerable population.  The accountability to SSA rules, regulations and procedures, should be reasonably and consistently applied at each level of the process.

NADE strongly endorses the need for consistency and accuracy of decisions at all levels of the adjudicative process and supports increasing decisional accuracy and consistency in the program and accountability for the quality of disability decisions made by all adjudicators at every step in the process.  However, as long as judicial review of disability appeals continue to occur in multiple district courts across the country, a bifurcated disability process will continue to exist as different DDSs and ALJs operate under different court rulings and regulations depending upon what part of the country the claimant lives in.  For this reason, NADE has long advocated establishment of a Social Security Court.

NADE also concurs with the IOM that “fundamental change is needed in the SSA quality review process to place equal emphasis on allowances and denials”.  To that effect, in 2004, NADE prepared a position paper addressing proposed quality initiatives.  A copy of that position paper is available on NADE’s web site at: www.nade.org or upon request from the NADE President, Shari Bratt.

NADE strongly supports increasing accuracy and consistency in the program and insuring that the right determination is made as early as possible in the process.   Nationally uniform decisions with consistent application of policy at all adjudicative levels require a consistent and inclusive quality assurance (QA) review process.  A well-defined and implemented QA process provides an effective deterrent to mismanagement, fraud and abuse in the Social Security disability program.  There is a need for in-line and end-of-line quality review at all levels of adjudication.  A centralized quality review process of all components involved in disability adjudication would eliminate regional differences in the application of Social Security Administration policies from state to state and component to component.  We believe that an improved quality assurance process will promote national consistency, and in turn, will build credibility into the process.

However, as long as quality reviews of disability decisions are based on different evidentiary standards, it will be difficult, if not impossible, to achieve consistency in decision-making across all components.  Although SSA’s proposed NPRM stipulates that all components are to use a preponderance of evidence standard to adjudicate claims and arrive at a disability decision, only the DDSs and RO disability decisions will be reviewed using that standard.  The ALJ decisions will be reviewed using the substantial evidence standard.  Unless this is changed, consistency of decisions between the various components will be difficult to achieve.

Task 9 – Organization of medical expertise

Throughout the nearly 50 year history of the Social Security Administration’s disability programs, the medical consultants in the state Disability Determination Service (DDS) agencies have played a crucial role in the development and adjudication of claims. An adjudicative team, generally composed of a Disability Examiner and a DDS Medical Consultant, makes the initial disability determination in accordance with an ever-changing complex set of federal rules and regulations.  This team also evaluates reconsideration and continuing disability review cases using other complex and ever-changing rules and regulations.

The DDS Medical Consultant interacts with Disability Examiners on a daily basis in difficult claims and offers advice on complex case development or decision-making issues.   He/she maintains liaison with the local medical community and has knowledge of local care patterns and the availability of diagnostic studies and state regulations to facilitate the adjudication process within the complex Social Security system.  There are many critical consultative examination issues that require combined medical knowledge and program experience to ensure that risks to applicants are minimized in any diagnostic tests needed for adjudication.  In fact, many local state laws require a medical doctor licensed within that state to authorize these tests before the applicant can participate.

NADE strongly supports on-site medical expertise. Examiner/medical consultant communication is essential for efficient development and decision-making. DDS examiners now have face-to-face interaction with Medical Consultants.  In addition to resulting in extremely efficient case development and decision-making, this process adds value in that it provides important medical training of less experienced examiners and ongoing mentoring of all examiners as medical practice evolves.

The ability of an examiner to have face-to-face, ongoing access to an in-agency doctor with whom the examiner is familiar and who is familiar with the details of practice in the area, leads to better accuracy, processing time, productivity, costs and customer service.

Specialization of Medical Consultants – Recommendation #1-1:

NADE concurs with the need for SSA to ensure that state DDS and ALJs have ready access to the full range of physician specialties and other health professionals needed to evaluate cases. Currently, the majority of DDSs lack easy access to the full range of medical specialists. While the vast majority of SSA and SSI disability claims do not require review by a medical specialist, NADE does agree that adjudicators at all levels need access to such specialists.  While NADE supports this concept being used to supplement the expertise of the medical consultant at the DDS, we feel that most cases at the initial level of adjudication can continue to be reviewed and evaluated by current state agency medical consultants.

Using direct patient care and current medical staffing models, it is important to note that the most effective utilization of medical specialists is to have well trained generalists (internists, general practitioners, family practitioners, etc.) screen patients first, treat the ones they can, and refer to specialists the ones who do not respond to treatment or whose medical conditions are so complex or severe as to require specialty care.

Adjudication of cases that have more than a single impairment require assessment of how all impairments, alone or in combination affect an individual’s ability to function.  The use of specialists alone would result in numerous hand-offs, adding significantly to costs and processing time.  This would also decrease the quality of decisions if there were no method in place to pull all of the specialty conditions together into an overall, global assessment of their impact on functioning.

NADE is concerned that the insertion of a new federal bureaucracy – the Medical Vocational Expert System, which  – has the potential of significantly increasing the amount of time it takes to arrive at a disability decision.  Having specialists review impairments individually is a time consuming, costly proposal.  Specialty consultants with limited scope and experience cannot fully assess the combined effects of multiple impairments on the claimant’s functioning.  DDS medical consultants are not only medical specialists—physicians, psychologists, and speech/language pathologists—they are also SSA program specialists.

There is a wealth of specialty Medical Consultant expertise employed in or under contract with DDS offices throughout the country.  In addition, there is also a substantial number of specialty Medical Consultants employed in or under contract with SSA’s Regional Offices who do medical reviews for the Disability Quality Branch (DQB) offices; there are Medical Consultants in the Federal DDS who perform case reviews and in SSA’s Central Office who address policy issues and second-level rebuttals when the need arises.   These medical specialists have experience with the Social Security and SSI disability programs and, with the accessibility provided by the electronic disability folder, could form a cadre of federal medical experts to consult with DDS Medical Consultants, Disability Examiners and Administrative Law Judges (ALJs). Fostering a collegial, educational and cooperative relationship between all SSA components would be vastly superior to what currently seems like an adversarial and counterproductive relationship.

Utilizing the existing expertise of current medical DDS, Regional Office, and Central Office specialists already trained in SSA disability rules and regulations is a low cost and immediate way to provide consultation across all components of the disability program, DDSs, DQBs, OHAs and the Appeals Council.

Qualifications of Medical Consultants – Recommendation 1-2:

NADE does not concur with the recommendation that SSA mandate that all physicians and psychologists be board certified.  NADE does not feel this is a very cost effective or reasonable requirement.  It is difficult for the DDS to recruit and retain good medical consultants, and requiring mandatory board certification will not only make it even more difficult to do so. but will also pose significant costs to the program and inappropriately eliminate many currently well trained, experienced and qualified DDS medical and psychological consultants from serving in that capacity.

The majority of disability claims do not have one single discrete impairment but multiple conditions that can impact on functioning.  Adjudication requires the evaluation and assessment of how all of these conditions, alone or in combination, impact on an individual’s functioning.  The use of board certified specialists alone could result in too many handoffs, adding significantly to processing time, as well as decrease quality of decisions, if there were no method in place to pull all of the specialty conditions together into an overall global assessment of their impact on functioning.

Neither SSA nor IOM has presented any evidence which shows, or even suggests, that board certification would improve disability case adjudication by Medical Consultants. Prior to implementing this requirement, NADE believes that SSA should be required to review the accuracy and quality of disability decisions currently done by DDS Board Certified MCs vs. DDS non-Board Certified MCs. If there is no qualitative difference, then there is no basis for making this change and lots of cost reasons for not doing so.

Board certification may ensure a higher level of knowledge in treating a certain range of impairments but would offer no particular value in assessing the residual capacity of these individuals.  A good generalist, knowledgeable in all aspects of disability adjudication, provides a much more cost effective and reasonable approach following direct patient care practices.  Further, since many of our claims involve multiple body systems, having a series of specialists look at a case will exponentially increase the cost of the program and the case will probably still need to have the integration of all the opinions by a good generalist.

Most disability applicants have multiple impairments involving more than one body system and require a comprehensive view of the combined limitations and resultant impact on function.  Board certified specialty consultants with limited scope and experience cannot fully assess the combined effects of multiple impairments on an applicant’s functioning.  The SSA programmatically trained DDS Medical Consultant has the education, clinical experience and decision-making skills, along with expertise in evaluating medical records and disease conditions and making prognosis predictions regarding a claimant’s function and future condition, to more accurately assess the case as a whole.

Evaluating Social Security disability cases requires a unique knowledge of:

-SSA’s complex rules and regulations and regional variants of those regulations

-the ability to read and understand the claimant’s records

-medical expertise in many fields

-knowledge of local medical sources and individual state health care systems

-familiarity with DDS examiner staff, quality specialists and supervisors, and

-the ability to derive relevant information and to apply the law.

Board certification training does not provide this background or specific knowledge and therefore, is not necessary for this process. 

The Social Security Administration’s disability programs are unique among disability programs. The decision regarding an applicant’s eligibility to receive Social Security or SSI disability benefits is not solely a medical decision, nor is it solely a legal decision.  It is an administrative decision. An impairment is disabling only if it prevents an adult from working or a child from functioning in normal age-appropriate activities. While other disability programs may accept a treating source or a consultant’s opinion that an individual is disabled, this is not true in the SSDI or SSI disability programs. Based on all information in the file the DDS Medical Consultant must independently determine if a medical impairment is present, assess the severity of that impairment (or impairments) and, if the applicant is an adult, assess his or her remaining ability to perform work related activities (standing, walking, reaching, bending, talking, listening, following directions, relating to supervisors and co-workers, etc.).

Because the Social Security and SSI disability programs themselves are unique, the individuals who evaluate these claims, including the DDS Medical Consultant, whether he or she is a physician, a psychologist or a speech/language pathologist, must also possess a unique combination of knowledge and skills and must be specially trained to assess functional capacity based on exam, laboratory and diagnostic test findings. The program knowledge required to adjudicate Social Security and Supplemental Security Income disability claims is not acquired in medical school or as part of an individual’s professional training.  Rather, it is learned through formal SSA training, case reviews and on-going interaction with other members of the adjudicative team.

There is a very real difference between clinical and regulatory medicine and it takes at least a year to become proficient in Social Security disability rules and regulations.

The DDS Medical Consultant must be able to translate the medical concept of clinical severity into the legal concepts of the Social Security program. He or she must evaluate the impact of the impairment and treatment on the applicant’s ability to function and place that assessment within the framework of SSA rules and regulations.  The DDS Medical Consultant must recognize the disabling aspects of the alleged disorders and their treatments, the typical clinical course and prognosis, and the resultant impact upon function both psychiatrically and physically.  In addition, he or she must be able to recognize the impact of multiple impairments, and be aware of related additional impairments that the applicant may not have alleged that could factor in the individual’s residual functional capacity for work activities.

Regional SSA court cases and acquiescence rulings impact individual DDSs differently.  The DDS Medical Consultant is aware of the impact of those decisions on local case development and adjudication.   Based on knowledge of the SSA disability program’s evidentiary requirements, local medical practices, and court decisions and acquiescence rulings affecting that specific DDS, the DDS Medical Consultant helps to assess whether additional development is needed to accurately adjudicate the case, and determine whether the additional development would change the decision of disability or simply satisfy the clinical desire to make a diagnosis.  The DDS Medical Consultant is pivotal in cost containment of DDS expenditures for consultative examinations (CE’s) by reviewing the medical evidence in file and contacting treating sources when appropriate.

Only through experience with the Social Security disability program is the DDS Medical Consultant able to ascertain what evidence is needed or, conversely, what evidence is not needed, to make a correct decision while preventing costs and processing time from becoming prohibitive.   It normally takes a year to become proficient in this process.

Because medical consultants determine the functional capacities of individual claimants only, the clinical course, prognosis and functional abilities of other persons with the same diagnosis (as described in textbooks or learned from clinical experience) is of little importance to the disability determination process, even though it may be of academic interest. The individual claimant’s ability to sustain work activities is the proper focus of the adjudication process, not the textbook case.  DDS and SSA medical consultants do not recommend treatment or become involved in the care management of claimants.  In fact, a substantial part of training in Social Security disability adjudication focuses on redirecting medical and psychological consultants from their traditional clinical modes of thinking about patients to thinking in terms of substantial evidence, laws, regulations, Social Security disability procedures and issues such as equal protection under the law.

For physicians, board certification normally consists of three to five years (9,000 to 15,000 hours) of residency training and the passing of examinations. Residency training focuses intensely on patient management and particularly on diagnostic techniques, pharmacologic management, special non-surgical procedures (such as tracheal intubation, cardiopulmonary resuscitation, etc.), indications for surgery, specialized surgical procedures (cataract extraction, gastric bypass, etc.) and post-surgical management. Board certification tests candidates in these areas. Most physicians who become board certified do so without any knowledge of Social Security disability laws, regulations, procedures or the evaluation of residual functional capacity.  Many may not even be aware of the existence of the Social Security disability program.  The evaluation of impairment according to AMA guidelines, which some learn, has almost no relevance to the disability determination process.

For psychologists, board certification normally consists of two or more years (4,000 or more hours) of supervised training and the passing of examinations. Training focuses intensely on patient management and particularly on diagnostic techniques, psychological testing, psychotherapy and, to some extent, pharmacologic management.  The requirements vary considerably, according to the specific Board.  Board certification tests the competency of candidates in these areas. Only about 5% of psychologists become board certified. Most individuals who become board certified do so without any knowledge of Social Security disability laws, regulations, procedures or the evaluation of residual functional capacity. Many may not even be aware of the existence of the Social Security disability program.

Current training programs for the board certification of physicians and psychologists include no significant training in or testing of Social Security disability case evaluation.

Because the skills which board certified physicians and psychologists obtain beyond medical school and graduate school in psychology are directed at patient management, board certification provides little or no additional benefit in the adjudication of disability cases.

A board certification requirement would increase the cost of disability adjudication at a time when efforts to control costs are stressed. Since only about 5% of psychologists are board certified, it would eliminate most current State disability determination service psychologists and greatly reduce the pool of psychologists who can be recruited for disability work. It would also significantly reduce the pool of available medical consultants.  There is no substantial evidence that any board is superior to any other in clinical practice, much less in disability adjudication. Any requirement favoring one board over another should be based on substantial evidence that the favored board is superior to the others for the intended purpose and currently no such evidence exists.

Because board certification was much less common for physicians entering practice during or before the 1960’s, a board certification requirement would have a much greater impact upon older consultants than upon younger consultants. For older physicians board certification would require closing their practices, leaving their current residences, moving to new locations, engaging in from 3 to 5 years (about 9,000 to 15,000 hours) of strenuous residency training, and passing board certification tests. For psychologists, board certification would have comparable requirements (see above).

The interest in board certification appears to be based on an assumption that board certified medical and psychological specialists are somehow more able to evaluate disability, particularly in “complex cases.” To make this possible, the individuals would have to have some special training and specific tools to use. There is currently no such training nor evidence that such tools exist.

Of disability claims, the difficult ones are those in which the claimant is neither extremely disabled nor fully-functional (or nearly so). The extreme cases are the easiest to adjudicate and are currently adjudicated quickly and with a high degree of accuracy.

They commonly meet the requirements of listings or have no significant work-related impairment. The difficult cases are usually those of persons with common, physical and mental impairments which are neither extremely mild nor extremely severe.

Because of the lack of any demonstrated correlation between allegations, examination findings, laboratory tests, radiological studies and other tests, and because of the lack of any scientific way to combine any of these findings to determine a claimant’s ability to sustain work activities eight hours a day and five days a week, board certified specialists would have no advantage over the generalist in the adjudication of disability claims.

The majority of disability claims include multiple allegations. Sometimes there are dozens of allegations. If the Social Security Administration required that claims be reviewed by board certified specialists in all the related areas, most cases would have to be reviewed by multiple specialists. In addition, the specialists would have to hold conferences before adjudicating cases. The cost of such a process would far exceed the cost of case adjudication today, with no documentation or guarantee that the outcome will be improved.

NADE recommends that board certification not be a requirement for DDS medical and psychological consultants.  NADE recommends that if board certification is adopted as a mandatory requirement, then all current DDS medical and psychological consultants be excluded from this requirement and be grandfathered in.   In addition, if it is felt critical that Board certification is necessary, NADE recommends that SSA pursue developing and establishing independent board certification in Social Security disability adjudication.

Training of Medical Consultants – Recommendation 1-3:

NADE agrees that SSA should develop and implement a mandatory national training program for all MCs, both within and outside the DDS, as well as for all adjudicators, including administrative law judges.  As stated previously, adjudication of Social Security disability claims requires a specialized knowledge not readily available elsewhere. For that reason, there should be an established training program to ensure consistency and uniformity of the training presented.  The fact that specialized knowledge is required for Social Security disability adjudication supports NADE’s stand that board certification is not a requirement for medical and psychological consultants.

NADE places a high value on initial and on-going continuing education training to maintain and enhance disability expertise in the Social Security disability program.

Just as physicians, psychologists and speech/language pathologists must participate in ongoing medical education in order to keep their clinical skills and knowledge current, it is through ongoing SSA case reviews and SSA-sponsored training that DDS Medical Consultants maintain their program knowledge and skills.  While SSA’s Program Operations Manual and other regulations provide some structure for addressing various allegations, the accuracy of the decision is a function of the knowledge of the requirements of the SSA and SSI disability program.  Assisting Disability Examiners in sorting out and weighing of evidence of varying quality and credibility provided by treating physician opinions or evaluations by nurses and other medical sources requires a SSA programmatically trained physician.

NADE holds annual regional and national training conferences for its members, offering the most up-to-date information in medical treatment and advances in medicine and SSA program changes.  These conferences serve to enhance our members’ knowledge base, develop their professional expertise and further the enhancement of the disability profession.

NADE is committed to furthering the art and science of disability evaluation and the professionalism of its members.  To that end, NADE is proud of its certification program which has been in existence since 1971.  NADE’s certification program recognizes Social Security disability experience, continuing education and training efforts of its members involved in the disability program.

Specific criteria for NADE certification are required in three different categories: as a disability professional, disability support professional or disability medical consultant.

Minimum standards must be met to be eligible for consideration for NADE certification.  Education, training and experience in the disability program are considered.  NADE certified medical consultants are required to obtain 25 hours of continuing education credits every three years in order to continue their certification status.  NADE’s unique training opportunities supplement training provided by SSA, cover medical and policy issues related to disability determinations and provide a forum for which to exchange ideas and best practices among the various states.

Better Use of Medical Expertise – Recommendation 1-4:

NADE does not agree with this recommendation.  NADE does not support the addition of a nurse consultant or other health care professionals to the process. This adds an unnecessary step to the process between the disability examiner and the medical consultant which does not currently exist.  NADE believes that the addition of this hand-off in the process adds no value and increases the potential for errors in communication.

Extensive training in the adjudicative process would be required in order for the nurse to effectively communicate with medical consultants and examiners. There is nothing in the training that these professionals have to go through that would make them superior to an experienced DE to serve in an adjudicative triage or advisor function. These professions are taught how to treat medical issues, not how to relate them to disability. There is a critical difference between the clinical perspective that a nurse would be expected to have and the disability assessment perspective required by the program.  The ability of the disability examiner to access face-to-face medical consultations and develop rapport and familiarity between team members should not be altered or breached.

SSA does not even recognize these professions as acceptable medical sources.  One of the reasons is the lack of a national standard set of requirements for these professions.   This should be a reason for not using them in the role discussed here as well.  A standard, uniform training program for all adjudicators will be a much more effective, efficient and cost effective process than adding other more costly health professionals to the process.

Other Sources of Medical Expertise – Recommendation 1-5:

NADE supports the recommendation that SSA develop “formal working relationships with specialized clinical research centers”.   However, these centers should not be used to assist in the adjudicating of individual cases but rather to assist with reviewing the listings, evaluating the disability process, and researching and exploring the definition of disability itself. These centers could also advise SSA in how to improve the training given to disability examiners, medical consultants, administrative law judges and all other levels of adjudicators.

Involvement of Treating Physicians and Other Treating Sources – Recommendation 1-6: NADE supports this recommendation.  However, though this sounds like a good idea in theory, in practice, it will disastrous to try to implement without adequate funding. To date, there is little evidence to show that such funding would be forthcoming.  Whenever funding is limited (which in practical application is every fiscal year), the emphasis on DDS has been to cut and curtail medical costs.  In fact, in the interests of cost containment and time savings, SSA is working with several national copy services to standardize the submission of electronic records to SSA.  Implementation of a standard VA/DDS summary extract of medical records has already occurred in a number of DDSs.  In addition, individual states may have limits on what they are allowed to pay for retrieval of vendor records.

Qualifications of OHA Medical Experts – Recommendation 1-7:

See NADE’s comments under recommendations #1-2 and 1-3.  NADE supports national uniform training for all medical consultants.  NADE also supports adequate compensation for services performed.  However, again, unless such funding is forthcoming, this is not a practical option.

Task 10 – Training and certification of consultative examiners:

Training and Certification Requirements for Consultative Examiners – Recommendation 2-1:

NADE supports this recommendation but it will be disastrous to try to implement it without adequately funding it. Implementation without adequate funding will make a currently bad situation even worse.  Also, see NADE comments under recommendation 1-6.

Adequate Reimbursement for CE Providers – Recommendation 2-2:

NADE supports this recommendation.  However, if the price per CE goes up sharply without an increase in funds to pay for CEs, it will simply make them much harder to get.  In addition, individual states may have limits on how much can be paid for CEs.

Requests for CEs Focused on What is Needed in Each Case – Recommendation 2-3:

NADE supports this recommendation.  Clearly, it should improve our product. However, it will also take more time for examiners who have already had way too much added to their job. There must be some recognition that added duties per individual claim simply means that fewer claims can be processed.  The practical reality is that though workloads are increasing and there are proposals to more thoroughly document individual case records, the funding is not being provided to handle these tasks.

Task 8 – Presumptive disability categories:

Revising the Presumptive Disability Categories with Explicit Criteria – Recommendation 3-1:

NADE agrees with this recommendation but would also add that input from the people who actually process the claims should be sought.

Increasing Consistency in Presumptive Disability Decision Making – Recommendation 3-2:

NADE does not believe that mandates should be developed in this area.  However, NADE does believe that SSA should set parameters they want DDSs to achieve. SSA should establish targets with rewards for the states that achieve them.

Learning from Terminal Illness (TERI) Procedures – Recommendation 3-3:

NADE supports the concept of quick decisions for those individuals who are obviously disabled.  NADE believes that DDSs are best equipped in terms of adjudicative expertise, medical community outreach, and systems support to fast track claims and gather evidence to make a decision timely, accurately, and cost effectively.  DDS disability examiners are well versed in the evaluation of disability onset issues, unsuccessful work attempts and work despite a severe impairment provisions to quickly and efficiently determine the correct onset for quick decision conditions.

NADE certainly supports looking at TERI procedures in an effort to improve them, but not necessarily for use in quick decision cases.  We would point out that some Field Offices already struggle with the concept of recognizing presumptive disabilities and TERI cases.  The experienced disability examiner is the most effective weapon SSA has at its disposal to combat fraud as proposed in previous reports and testimony from the Social Security Advisory Board and SSA’s Office of Inspector General.

It is imperative that any changes in this area accurately identify the appropriate cases for TERI processing.  Selection criteria should include issues other than diagnosis, including involvement in current treatment, current insured status and a specifically identifiable impairment proven most likely to result in death.  SSA field office performance will also be critical for success of identifying TERI cases.  NADE suggests that more extensive in-line quality assurance and end-of-line quality control be applied if any such changes to TERI criteria are implemented.

NADE thanks IOM for the opportunity to provide comments on the interim report and we look forward to working with the IOM as the committee works on Tasks 1-7.

Shari Bratt

NADE President

Approved by the NADE Board, March 2006