Monday, November 21, 2011

Social Security Changes Disability Analysis Processes -- Not For the Better

From the Wall Street Journal today.
Earlier this year, senior managers at the Social Security Administration in Baltimore, frustrated by a growing backlog of applications for federal disability benefits, called meetings with 140 of the agency's doctors.
The message was blunt: The number of people seeking benefits had soared. Doctors had to work faster to move cases. Instead of earning $90 an hour, as they had previously, they would receive about $80 per case—a pay cut for many cases which can take 60 to 90 minutes to review—unless the doctors worked faster. Most notably, it no longer mattered if doctors strayed far from their areas of expertise when taking a case.
"The implication there was that you really didn't have to be that careful and study the whole thing," said Rodrigo Toro, a neurologist who analyzed cases for the Social Security Administration for more than 10 years. Some doctors, including Dr. Toro, quit following the changes. Others were fired. In all, 45 of the 140 left within months, the agency said.
The upheaval, described by current and former doctors and agency officials, is the latest strain on a cash-strapped program struggling to deal with a giant influx of applications.
In targeting the doctors, the Social Security Administration says it is seeking to overhaul a part of the disability-review process that can be both expensive and slow.
A System under Strain
See how the percentage of residents ages 18 to 64 receiving disability benefits has changed in each state since 2001.
But many doctors and former agency officials say the changes threaten the quality of decisions. Several doctors said medical opinions were now prone to inaccuracy since many specialists don't have the backgrounds to make decisions outside their areas of expertise. The new policy could make doctors more likely to award benefits to those who don't qualify and deny benefits to those who are entitled, these doctors said.
After the procedures were implemented in Baltimore, an eye doctor was assigned back-pain cases, several doctors said. A dermatologist reviewed the files of someone who had a stroke. A gastroenterologist reviewed the case of someone with partial deafness, the doctors said.
All of the medical consultants working in the program went to medical school or had other extensive training, preparing them for the wide range of cases that might cross their desks, according to interviews with more than 10 of the program's current and former doctors.
But many of the doctors haven't practiced outside their specialty in decades, if at all, making the complexities of disability cases even harder to analyze, several doctors said.
Doctors who specialize in nerve disorders "would be hard pressed to evaluate diabetes and heart disease and … leukemia," said James McPhillips, a doctor who left the program in April once he realized the changes that were coming.
"People who shouldn't be getting [disability] are getting it, and people who should be getting it aren't getting it," said Neil Novin, former chief of surgery at Baltimore's Harbor Hospital, who worked for Social Security part time for about 10 years. In August, Dr. Novin said, he was pressured by a supervisor to change his medical opinion and award benefits to someone he didn't believe had disabilities that would prevent the person from working.
"I will not sign my name, MD, on this," Dr. Novin recalled telling the official. He said he was cited for being "offensive and intimidating" and fired. Dr. Novin can't recall details of the case, he said, but it was outside his area of specialization.
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Melissa Golden for The Wall Street Journal
Neil Novin, recently fired by the Social Security Administration, says the agency is rushing disability decisions.
Two other doctors also said they were pressured to award benefits in cases where they were reluctant. Supervisors told them that certain ailments should be considered "severe," even if the doctors disagreed.
Social Security Administration spokesman Mark Hinkle would not comment specifically on Dr. Novin or other doctor's cases. But he said the changes in Baltimore were likely to speed up the process for analyzing benefit requests, and are "providing the agency with a more accurate and cost-effective business process."
Mr. Hinkle added: "The decisions are timelier—and all would agree that is a good thing—but this does not mean we are sacrificing quality for 'speed.' It's a balance."
When it introduced the new policies, agency officials began reviewing more of the medical consultants' work and found that some didn't fully understand SSA policy or properly explain their medical opinions. Mr. Hinkle said the agency stepped up training and other guidance, but "some did not improve and some resented our efforts."
Mr. Hinkle said the new system would put doctors in a better position to consider whether multiple health issues on a single case met the criteria for a disability. He added that specialists were available to review any case if a doctor requests it.
The new policies in Baltimore had already been adopted in other states several years ago and officials were happy with the results, supporters of the changes said.
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But some doctors have complained to the Social Security inspector general that they have been pressured to change their medical opinions to conform to targets or goals set by SSA officials, and they feared they would be fired if they resisted, according to investigations conducted by the inspector general.
In February 2010, the inspector general, as part of a probe investigating complaints by a doctor, discovered a doctor in the Alabama disability determination office who approved between 80 and 100 decisions a day. Another Alabama doctor signed off on 30 cases an hour after performing only a "cursory review of each case." The investigation said several doctors complained of pressure from superiors to approve a higher number of applications to meet statistical goals.
The Social Security Administration, in a response to the investigation, said it planned to make certain changes, but defended the Alabama office, saying it "excels" in "performance standards on timeliness and accuracy rates."
The federal disability system is designed to help people who can no longer work. For many, it represents the social safety net of last resort. Successful applicants receive a monthly stipend and access to federal health-care programs, often for life.
Through a combination of high unemployment, an aging population and an uneven process for awarding benefits, the disability system is under strain and could run out of reserves within six to seven years, say budget experts. That would make it the first major federal entitlement program to go bust in recent history. Applications and appeals, meanwhile, are accumulating in a giant backlog, in part because of the deep and lasting economic slump.
It's a toxic combination. The agency is under political pressure to reduce the backlog. But its efforts to do so—such as revamping medical procedures—are, in some ways, compounding the system's woes, said several doctors.
The Social Security Disability Insurance program paid $124 billion in benefits in 2010, up from $55 billion in 2001. The backlog of pending appeals in September was 771,318, up from 705,367 in 2010 and 392,397 in 2001.
The disability application process has many layers, including hundreds of state-based field offices that accept applications and administrative law judges who weigh appeals.
In addition, the Social Security Administration spends millions of dollars each year on more than 2,000 medical consultants who scour the medical records of Americans who believe they have a disability so severe they can't work. Most doctors work for the state agencies that administer the program and are sometimes the only people with medical expertise to review claims. Others, like those in Baltimore, contract directly with the Social Security Administration.
Many medical consultants are retired or semi-retired doctors seeking additional income and working under contract, meaning they can be fired with little cause.
The Baltimore office is considered the flagship, according to several doctors and John Delpaine, who oversaw medical consultants there before retiring in December. In its procedures and structure, Mr. Delpaine said, the office sets the standards for offices throughout the U.S.
As an application backlog grew over the past decade, Social Security Administration officials worried that doctors were a cause. In some offices, different doctors would review separate medical issues of an individual applicant. A patient with a knee injury and cancer, for example, would be reviewed by an orthopedist and an oncologist. With 3.2 million people trying to enter the program this year, such duplication became problematic.
Earlier this year, SSA bosses began pressing doctors to move cases more rapidly, designing a "holistic" process requiring one doctor to review each case, according to a document outlining the overhaul and reviewed by The Wall Street Journal.
Those uncomfortable in a particular specialty could brush up by taking short refresher courses. Doctors in Baltimore who didn't have a background in blood disease, for example, could take a one-hour seminar.
The approach in Baltimore has drawn critics. William Bunn, 47 years old, a truck driver from Peoria, Ill., found his disability claim rejected, in part, on the recommendation of a retired pediatrician.
Mr. Bunn was diagnosed with small-fiber neuropathy in 2009, a type of nerve disorder that primarily affects older people. Mr. Bunn, who began suffering from pain and numbness in his legs, said he couldn't drive a truck with his condition and quit his job. His application was supported by two private doctors. But it was rejected after two reviews by the Illinois Bureau of Disability Determination Services, one of which was performed by the pediatrician.
His appeal took more than two years. During that time, the family of four had their two cars repossessed and had to rely on food stamps for groceries.
William Wombacher, Mr. Bunn's Peoria attorney, objected to the pediatrician's review when the case was heard by an administrative law judge. The judge, in a rare move, awarded benefits on the spot.
Mr. Bunn said the extended wait brought him "a lot of heartache and misery."
The SSA's Mr. Hinkle wouldn't comment on the case. But, he said, "Just because one doctor works on a case and makes the decision on that case does not mean that a specialist wasn't consulted."
The Social Security Administration has tried previously, with limited success, to improve its medical screening. In 2005, it proposed creating a Federal Expert Unit, which would spearhead a national network of specialists to better align expertise to cases.
"We want to ensure that each case is seen by the right medical eyes," then-SSA commissioner Jo Anne Barnhart told Congress in 2006. In her testimony, she noted that, at the time, 20% of disability applicants had musculoskeletal problems, but just 2.5% of medical consultants were orthopedists.
The expert unit was never created. SSA officials said they didn't realize how costly it would be to set up a network of specialists and needed more time to study the idea.
In the past few years, a number of senior SSA officials began pressing the Baltimore office to abandon its reliance on medical "specialists," said Mr. Delpaine, who oversaw the doctors there.
But he said he "kept them at bay." His 39-year tenure within the Social Security system impressed on him that specialists played a vital role. When he stepped down in December, the changes were almost immediate.
"They think that a doctor is a doctor is a doctor," he said. "I don't think they have an understanding or an appreciation of what a specialist's input can add."
Phil Gambino, an assistant deputy commissioner at the SSA, said the generalist approach has been used in other states for more than a decade. "Mr. Delpaine's assertion is wrong," he said, "and calls into question his credibility on the issue."
Mark Isaacs, former chief of psychological services at Spring Grove Hospital in Catonsville, Md., who is known as an elder statesman of the program, said "the whole atmosphere became charged with tension" after the changes earlier this year.
Mr. Isaacs, a 25-year veteran of the agency, watched as his colleagues, one by one, stopped coming to work. After Dr. Toro, the neurologist, quit his post in April, several others followed.
"Some were asked to go," Mr. Isaacs said. "Others went because they had a big argument over their medical opinion not being accepted. Others left because who the hell needs all that tension and anxiety?"
Arguments with managers escalated over the summer, with some doctors getting into heated public confrontations with Social Security officials for either ignoring their medical opinion or pressuring them to change it, several doctors said.
In late September, Mr. Isaacs received a critique from one manager questioning the quality of one of his reviews. He wouldn't give details of the case, but said the critique was "unreasonable." He resigned.
Mr. Hinkle of the SSA wouldn't comment on the allegations by doctors. He said the 45 people who left the agency this year departed for a number of reasons, including the new pay structure, health or family issues, or performance problems.

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