Social Security Administration: Agency Is Positioning Itself to Implement Its New Disability Determination Process, but Key Facets Are Still in Development
Published: 2006-06-15T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: In March 2006, the Social Security Administration (SSA) published a rule that fundamentally alters the way claims for disability benefits are processed and considered. The rule establishes the Disability Service Improvement process (DSI)--intended to improve the accuracy, timeliness, consistency, and fairness of determinations. DSI's changes include an opportunity for an expedited decision during the initial determination process and the elimination of the Appeals Council, which had given claimants the right to appeal administrative law judge (ALJ) decisions before pursuing federal court review. DSI replaces the council with a Decision Review Board, which will selectively review ALJ decisions. However, dissatisfied claimants whose cases are not selected for board review must now appeal directly to the federal courts. Based on its ongoing work, GAO was asked to testify on (1) public and stakeholder concerns about the elimination of the Appeals Council and its replacement by the Decision Review Board and SSA's response to these concerns, as well as (2) the steps that SSA has taken to help facilitate a smooth implementation of the DSI process.
section_title: What GAO Found
paragraphs: Concerns regarding the replacement of the Appeals Council with the Decision Review Board--raised by the public and stakeholder groups, such as claimant representatives--generally fall into two areas: (1) potential for increasing the workload of the federal courts and (2) anticipated hardship for claimants in terms of the loss of an administrative appeal level and difficulties associated with pursuing their claim in federal court. SSA's response to concerns regarding the federal court workload is that all changes associated with the new DSI process--taken together--should reduce the need for appeal to the federal courts; at the same time, SSA plans to implement this final step gradually and with additional safeguards to minimize impact on the courts. In response to concerns about the loss of appeal rights, SSA contends that DSI introduces enhanced levels of federal review earlier in the process and that claimants should experience a decline in the amount of time it takes to receive a final agency decision. SSA has prepared in significant ways for the initial rollout of DSI in its Boston region, but the agency's timetable is ambitious and much work remains. The agency has moved forward in key areas that underpin the new system--human capital development, technical infrastructure, and quality assurance--taking actions consistent with past GAO recommendations for improving the disability determination process. For example, SSA has taken steps to ensure that key technical supports, particularly its electronic disability case processing system, are in place--even though it has allowed itself little time to address and resolve any glitches that may arise prior to implementation. SSA has also taken several steps to lay a foundation for quality assurance by centralizing its quality assurance reviews, establishing a Decision Review Board for reviewing decisions, and developing writing tools that should foster consistency and thorough documentation at all phases of the determination process. Further, we found that SSA's decision to implement DSI first in one small region prior to its introduction nationally is a good change management strategy that reflects our earlier recommendations. Additionally SSA has taken a proactive, collaborative approach to both the design and the implementation of the new determination process. Nevertheless, key facets of SSA's plan to monitor and evaluate the Boston rollout remain to be developed. For example, performance measures for assessing the execution of the rollout are still unclear to us, and mechanisms for delivering feedback to staff on the clarity and soundness of their decision writing have not yet been fully developed.

section_title: Letter
paragraphs: Thank you for inviting me today to discuss stakeholder concerns about  various aspects of the Social Security Administration’s (SSA) new  Disability Service Improvement process (DSI) and the steps that SSA has  taken to address these concerns. SSA is preparing to implement its new  process first in its Boston region for at least 1 year beginning in August  2006.
In July 2005, SSA issued a notice of proposed rule making to obtain public  comment on DSI proposals that would fundamentally redesign the way  claims for disability benefits are processed and considered, with the  purpose of improving the accuracy, consistency and fairness of its  disability decisions, and making correct decisions earlier in the process.  After reviewing comments submitted in response to its notice, SSA issued  its final rule in March 2006, codifying many of its proposed changes. One  of the many changes envisioned under DSI is the elimination of the  Appeals Council, which had afforded claimants the ability to appeal  unfavorable decisions made by administrative law judges (ALJ) to SSA  before filing suit with a federal court. Once DSI is fully implemented,  decisions made by the ALJs become the final agency decision, unless they  are selected for review by a new Decision Review Board. The cases  selected for review will be those identified through use of a statistical  model as claims that are complex or prone to erroneous decisions. As you  know, many have expressed concern over the elimination of the Appeals  Council as a forum that claimants could avail themselves of before  resorting to a federal court.
The information I am providing today is based on work that we conducted  between February 22, 2006, and June 2, 2006, as part of ongoing work in  this area, in accordance with generally accepted government auditing  standards. I will be discussing (1) concerns raised about the replacement  of the Appeals Council with the Decision Review Board and how SSA has  responded to them, and (2) steps SSA has taken to help facilitate a smooth  implementation of the DSI process.
To conduct our work, we reviewed a large sample (252 in total) of the  comment letters that were submitted by the public in response to SSA’s  notice of proposed rule making and that focused on the replacement of the  Appeals Council with the Decision Review Board. In addition, we  interviewed 10 stakeholder groups—such as claimant representatives,  employee groups, and disability advocacy organizations that SSA has  previously consulted with—to learn more about their perspectives on the  elimination of the Appeals Council as well as on the near-term rollout of  the DSI process in the Boston region. In addition, we conducted extensive  interviews with SSA officials and reviewed available agency documents to  determine their position on and collect data relevant to eliminating the  Appeals Council, as well as their efforts and plans related to DSI  implementation.  Further, we reviewed our past reports on improving  SSA’s disability process in a number of areas, including human capital; its  electronic records system—known as eDib; quality assurance; and  implementing change and managing for success. For a more detailed  description of our methodology, please see appendix I.
In summary, we found that the public and stakeholders expressed two  overriding concerns regarding the replacement of the Appeals Council  with the Decision Review board—that the workload of the federal courts  will rise if the council is eliminated and that this change will present  additional hardship for claimants. In our review of the comment letters  submitted to SSA that specifically addressed the elimination of the  Appeals Council, we found that about half expressed concern that  petitions to federal courts would rise, given the council’s termination, and  that claimants would lose an additional level of administrative review.  About 40 percent of comments highlighted recent improvements in the  Appeals Council’s processes and noted that eliminating the council would  not improve adjudication. Stakeholder groups we spoke with basically  underscored these same two points—that eliminating the Appeals Council  would result in an increase in disability claims cases that are appealed in  federal district courts and that some claimants may drop meritorious  claims rather than pursue a seemingly complicated and intimidating  federal court appeal. Acknowledging these concerns, SSA contends that  DSI will improve decision making earlier in the process, decrease the time  it takes the agency to reach a final decision, and reduce the need for  appeal. SSA also maintains that because DSI affords claimants the right to  appeal their initially denied claims to reviewing officials who are now  centrally managed, claimants will not experience an overall loss in  administrative review at the federal level. At the same time, both  stakeholders and SSA believe it will be important for the agency to closely  monitor DSI in order to evaluate its impact on claimants and the courts.
SSA has made substantial preparation for DSI on all fronts related to  successful implementation—human capital, technical infrastructure, and  quality assurance. However, the timetable is ambitious and much work  remains. While stakeholders have expressed concern that SSA will not be  able to hire and sufficiently train staff in time for the new process to get  under way, we found that the agency has, to date, posted hiring  announcements for new positions and developed training packages for  onboard staff. SSA is also taking steps, as we had previously  recommended, to ensure that key technical supports, particularly the  electronic disability system known as eDib, are in place for Boston staff to  adjudicate claims under the new process. At the same time, the agency has  allowed itself very little time to identify and resolve any potential glitches  that may arise before the Boston rollout in August. Regarding quality  assurance, SSA has taken several steps to lay a foundation for a more  cohesive program, as we had recommended in our earlier reports. For  example, features of the new DSI process—including centralizing quality  assurance reviews of initial state disability determination service (DDS)  decisions, establishing a Decision Review Board for hearing decisions, and  developing several tools to aid decision writing—may address problems  with decisional consistency that we have identified in the past by allowing  for a cohesive analysis of decisions. In addition, SSA officials plan to  monitor and evaluate the execution of the Boston rollout, although some  performance measures for this initiative, such as for assessing a new  medical expert system that is part of DSI, are still unclear to us, and  mechanisms for delivering feedback to staff on the clarity and soundness  of their decision writing have not yet been fully developed. Finally, SSA is  undertaking other, broad steps that we consider consistent with effective  change management strategies that we have previously recommended. For  example, the decision to implement the new system first on a small  scale—that is, in one small region—before introducing it elsewhere should  allow for careful integration of the new systems and staff and for working  out problems before they become serious impediments to success.  Additionally, SSA has employed a proactive, collaborative approach with  the stakeholder community in both designing and implementing the new  disability determination process.
subsections: section_title: Background
paragraphs: SSA operates the Disability Insurance (DI) and Supplemental Security  Income (SSI) programs—the two largest federal programs providing cash  benefits to people with disabilities. The law defines disability for both  programs as the inability to engage in any substantial gainful activity by  reason of a severe physical or mental impairment that is medically  determinable and is expected to last at least 12 months or result in death.  In fiscal year 2005, the agency made payments of approximately   $126 billion to about 12.8 million beneficiaries and their families. We have  conducted a number of reviews of SSA’s disability programs over the past  decade, and the agency’s management difficulties were a significant  reason why we added modernizing federal disability programs to our high- risk list in 2003. In particular, SSA’s challenges include the lengthy time  the agency takes to process disability applications and concerns regarding  inconsistencies in disability decisions across adjudication levels and  locations that raise questions about the fairness, integrity, and cost of  these programs.
The process SSA uses to determine that a claimant meets eligibility  criteria—the disability determination process—is complex, involving more  than one office and often more than one decision maker. Under the  current structure—that is, DSI notwithstanding—the process begins at an  SSA field office, where an SSA representative determines whether a  claimant meets the programs’ nonmedical eligibility criteria.  Claims  meeting these criteria are forwarded to a DDS to determine if a claimant  meets the medical eligibility criteria. At the DDS, the disability examiner  and the medical or psychological consultants work as a team to analyze a  claimant’s documentation, gather additional evidence as appropriate, and  approve or deny the claim. A denied claimant may ask the DDS to review  the claim again—a step in the process known as reconsideration. If the  denied claim is upheld, a claimant may pursue an appeal with an ALJ, who  will review the case.  At this step, the ALJ usually conducts a hearing in  which the claimant and others may testify and present new evidence. In  making the disability decision, the ALJ considers information from the  hearing and from the DDS, including the findings of the DDS’s medical  consultant. If the claimant is not satisfied with the ALJ decision, the  claimant may request a review by SSA’s Appeals Council, which is the final  administrative appeal within SSA. If denied again, the claimant may file  suit in federal court.
In March 2006, SSA published a final rule to establish DSI, which is  intended to improve the accuracy, consistency, and fairness of decision  making and to make correct decisions as early in the process as possible.  While DDSs will continue to make the initial determination, claims with a  high potential for a fully favorable decision will be referred to a new Quick  Disability Determination (QDD) process. If the claimant is dissatisfied  with the DDS’s initial determination or QDD, the claimant may now  request a review by a federal reviewing official—a new position to be  staffed by centrally managed attorneys.  The federal reviewing official  replaces the reconsideration step at the DDS level, and creates a new level  of federal review earlier in the process. The claimant’s right to request a  hearing before an ALJ remains unchanged. However, the Appeals Council  is eliminated under the new process, and as a result the ALJ’s decision  becomes the final agency decision except in cases where the claim is  referred to the new Decision Review Board. Claims with a high likelihood  of error, or involving new areas of policy, rules, or procedures, are  candidates for board review. If the board issues a new decision, it  becomes the final agency decision. As before, claimants dissatisfied with  the final agency decision may seek judicial review in federal court. DSI  also includes the introduction of new decision-writing tools that will be  used at each adjudication level, and are intended to streamline decision  making and facilitate training and feedback to staff. In addition, SSA is  creating a Medical and Vocational Expert System, staffed by a unit of  nurse case managers who will oversee a national network of medical,  psychological, and vocational experts, which are together responsible for  assisting adjudicators in identifying and obtaining needed expertise. In its  final rule, SSA indicated that DSI will further be supported by  improvements, such as a new electronic disability system and an  integrated, more comprehensive quality system.  As noted, the changes introduced by DSI were codified in SSA’s final rule  on the subject. Table 1 highlights these new features and associated  elements.
Implementation of DSI will begin on August 1, 2006, in the Boston region,  which includes the states of Connecticut, Massachusetts, Maine, New  Hampshire, Rhode Island, and Vermont. Therefore, only those claims filed  with SSA in the Boston region on or after August 1 will be subject to the  new process. All claims currently in process in the Boston region, and  claims filed elsewhere, will continue to be handled under current  procedural regulations until SSA takes further action. In addition, for  cases filed in the Boston region during the first year of DSI  implementation, all ALJ decisions—both allowances and disallowances— will be reviewed by a new Decision Review Board with authority to affirm,  modify, reverse, or remand decisions to the ALJ. Since DSI will only affect  new claims initiated in the Boston region, claimants whose cases were  already in process before August—as well as those filing outside the  Boston region—will still have access to the Appeals Council.
section_title: Concerns Include Fear of Increased Court and Claimant Hardship, while SSA Believes Its New Process Will Reduce the Need for Appeal
paragraphs: In their written comments to SSA and discussions with us, public and  stakeholder groups, such as claimant representatives and disability  advocacy groups, expressed two broad areas of concern regarding the  replacement of the Appeals Council with the Decision Review Board:   (1) potential for increasing the workload of the federal courts and   (2) anticipated hardship for claimants in terms of loss of an administrative  appeal level and difficulties associated with pursuing their claims in  federal court. SSA’s response to concerns regarding the federal court  workload is that all changes associated with new DSI process—taken  together—should reduce the need for appeal to the federal courts. At the  same time, SSA plans to implement this final step gradually and with  additional safeguards to minimize the impact on the courts. In response to  concerns about the loss of appeal rights, SSA contends that under the new  DSI process, claimants will have a new level of federal review earlier in the  process, and should experience a decline in the amount of time it takes to  receive a final agency decision without being overly burdened by the  Decision Review Board under the new process.
subsections: section_title: Public and Stakeholders Anticipate a Larger Caseload for Courts, while SSA Maintains That Better Decisions Earlier in the Process Will Reduce the Need for Appeal
paragraphs: Concerns expressed in comment letters to SSA and in our interviews  revolved largely around the possibility that the replacement of the Appeals  Council with the Decision Review Board would result in rising appeals to  the federal courts. Specifically, more than half of the 252 comment letters  we reviewed indicated that the Appeals Council provides an important  screening function for the federal courts, and that its replacement with the  Decision Review Board could result in rising caseloads at the federal court  level. Stakeholder groups with whom we spoke reiterated this concern.  With the imminent rollout in the Boston region, several stakeholders  suggested that SSA closely monitor the effectiveness of the board and the  impact of this change on the federal courts.
Data from SSA suggest that the Appeals Council is both screening out a  number of cases that might otherwise have been pursued in the federal  courts and identifying many claims that require additional agency analysis.  Between 2001 and 2005, the number of disability cases appealed to SSA’s  Appeals Council rose 13 percent.  At the same time, the number of  disability cases filed with the federal courts (both DI and SSI) declined 9  percent. Figure 1 illustrates the volume of receipts at both the federal  court and the Appeals Council levels during this period.
Further, the Appeals Council consistently remanded about 25 percent of  the claims it reviewed between 2001 and 2005 for further adjudication by  the administrative law judge—see figure 2—providing more evidence that  the Appeals Council is identifying a significant number of claims that  require additional agency review and modification.
SSA believes that the implementation of DSI as an entire process will help  it make the correct disability determination at the earliest adjudication  stage possible and thereby reduce the need for appeal. According to SSA,  several elements of the DSI process will contribute to improved decision  making. These include the federal reviewing official position, which  presents an enhanced opportunity for the agency to thoroughly review  case records—with the assistance of medical and vocational experts—- early in the process, as well as new online policy guidance and new tools  to aid decision writing, which will be used at each adjudication level to  facilitate consistency and help the agency identify and correct errors more  quickly. Last, SSA believes that the number of requests for voluntary  remands that SSA makes to the federal courts is an indicator that the  Appeals Council is not fully addressing errors in the case or otherwise  reviewing the case effectively so as to prevent the federal courts from  reviewing appeals that should have been handled administratively.  SSA  believes the Decision Review Board will more effectively screen cases  from federal court review by focusing on error-prone claims identified  through a predictive model.
SSA acknowledges that the agency cannot predict the likely impact on the  federal courts’ workload and cannot prevent denied claimants from filing  suit with the federal courts. To reduce the likelihood of too many appeals  reaching the federal court level, SSA stated in its final rule that it is  pursuing a gradual rollout by implementing the DSI process in one small  region—the Boston region—and plans to have the board initially review all  of the ALJ decisions in that region. According to SSA officials, the board’s  review of all ALJ decisions will allow them to test the efficacy of the new  predictive model, to help ensure that the model is identifying the most- error prone cases that might otherwise find their way to federal court.  Further, SSA officials told us that they are working with the federal court  system to develop a way to gauge changes in the court’s caseload. Finally,  SSA’s internal counsel told us that the agency has begun a systematic data  collection process to better understand the circumstances surrounding  remands from the federal court. To date, SSA attorneys have analyzed the  reasons for federal court remands in more than 1,600 cases, but they are  still working on a quality control mechanism to ensure that their  information has been entered properly and are therefore unwilling to  report on the results of their analysis at this time.
section_title: Public and Stakeholders Anticipate Increased Hardship for Claimants, but SSA Believes the New Federal Reviewing Official Position Will Improve Decision Making Earlier
paragraphs: In their comments on the proposed rule and in subsequent conversations  with us, stakeholders expressed concern that eliminating the Appeals  Council would cause claimants hardship both by eliminating the  opportunity to appeal an ALJ decision to the Appeals Council and by  increasing the cost and difficulty associated with pursuing cases in federal  court.
In particular, 48 percent of the 252 comment letters we reviewed  expressed concern that the replacement of the Appeals Council with the  Decision Review Board would represent a loss in claimant appeal rights  within SSA. These letters, as well as subsequent discussions with  stakeholders, emphasized the concern that claimants will not have a say in  which cases are reviewed by the board. Further, stakeholders were  concerned that in the Boston region, claimants whose cases were allowed  at the ALJ level could be overturned by the board, presenting additional  hardship for claimants as they await a decision.
In addition, claimant representatives and disability advocacy organizations  are concerned that appealing at the federal court rather than Appeals  Council level would be costlier and more intimidating for claimants. For  example, there is a filing fee associated with the federal courts, and  stakeholders commenting on SSA’s final rule said that the filing procedure  is more complicated than that required for an appeal before the Appeals  Council. In addition, claimants seeking representation must find  attorneys who, among other requirements, have membership in the district  court bar in which the case is to be filed. As a result of these hardships,  claimant representatives and disability advocacy organizations, in  particular, were concerned that claimants would drop meritorious claims  rather than pursue a seemingly complicated and intimidating federal court  appeal.
About 40 percent of the comment letters asserted that the amount of time  the Appeals Council spent adjudicating cases—also referred to as its  processing time—has improved recently, and letter writers did not believe  that terminating the Appeals Council would improve the adjudicative  process. Although SSA has contended that the Appeals Council has  historically taken too much time without providing claimants relief,  stakeholders’ claims that the Appeals Council processing time has  decreased significantly in recent years was confirmed by SSA data—see  figure 3. In light of these concerns, many stakeholder groups we spoke  with suggested that SSA should roll out the Decision Review Board  carefully and closely evaluate outcomes from claimants’ perspectives.
In their final rule and in conversations with us, SSA officials stated that the  new process still affords claimants comparable appeal rights along with  the promise of a faster agency decision. Specifically, SSA stated that DSI  includes two federal levels of thorough case development and  administrative review—one by the new federal reviewing official and  another by an ALJ at the hearings level. SSA contends that the new federal  reviewing official position is a marked departure from the reconsideration  step, in that the position will be managed centrally and staffed by  attorneys specifically charged with enhancing the development of a case  and working with a new cadre of medical and vocational experts to make  decisions. SSA believes that this new position, along with other changes in  the new process, will result in many more cases being correctly  adjudicated earlier in the process, resulting in fewer decisions appealed  and reviewed by ALJs at the hearings level.
SSA also argues—recent improvements in processing time  notwithstanding—that the elimination of the Appeals Council step will  reduce the length of time it takes the agency to reach a final decision on  behalf of the claimant. Further, SSA maintains that the replacement of the  Appeals Council with the board will not be prejudicial to or complicated  for the claimant. SSA indicated that claimants will have an opportunity to  submit written statements to the Decision Review Board, thus providing  another chance to assert their circumstances. SSA maintains that aside  from the written statement, further action is not required on the part of the  claimant until the board issues its decision.
SSA has told us that it plans to monitor stakeholder concerns in several  ways. For example, SSA plans to track the length of time it takes to reach  final decisions as well as the allowance rate. SSA also plans to review  written statements submitted by claimants to help assess the validity of  the board’s predictive model.
section_title: SSA Has Taken Constructive Steps to Implement the New DSI Process, but Its Schedule Is Ambitious and Many Details Are Not Yet Finalized
paragraphs: SSA has prepared in significant ways for DSI, but the agency’s timetable is  ambitious and substantive work remains. SSA has moved forward in key  areas that should underpin the new system—human capital development,  technical infrastructure, and quality assurance. However, some essential  measures remain under development, particularly for quality assurance.  Nevertheless, on balance, the agency has begun to employ a number of  change management strategies we recommended earlier for successful  transitioning.
subsections: section_title: SSA Has Moved to Hire and Train Staff, but It Faces Short Timetables
paragraphs: While stakeholders have expressed concern that SSA will not be able to  hire and sufficiently train staff in time for the new process, we found that  the agency has taken a number of steps in this area. With respect to hiring  for new positions, the agency has already developed position descriptions  and posted hiring announcements for nurse case managers, who will work  in the new Medical and Vocational Expert Unit, as well as for federal  reviewing officials. To date, SSA officials have begun assessing more than  100 eligible applicants for the reviewing official slots, and expect to hire 70  by late June and another 43 in early 2007.  SSA officials also said they  posted announcements to hire nurse case managers, and that they expect  to hire as many as 90 before the end of the rollout’s first year in the Boston  region.
SSA officials also said that the agency has posted announcements to hire  support staff for both the reviewing officials and nurse case managers, but  the exact number SSA is seeking to hire has not been decided. Several  stakeholders we spoke with were particularly concerned that SSA will  need to hire or otherwise provide adequate support staff for reviewing  officials to ensure their effectiveness. Specifically, several of the ALJs we  interviewed told us that at the hearings level, judges and their staff  currently spend significant time developing case files. They noted that if  the reviewing official position is designed to focus on case development,  then attorneys in this role will need support staff to help them with this  time-consuming work.
With respect to training, the agency has been creating a variety of training  materials for new and current staff, with plans to deliver training at  different times, in different ways. SSA officials reported working on  development of a uniform training package for all staff with some flexible  components for more specialized needs. Specifically, about 80 percent of  the package is common content for all employees, and 20 percent will be  adaptable to train disability examiners, medical experts, ALJs, and others  involved in the adjudication process. SSA officials said they developed the  package with the federal reviewing officials in mind, but also with an eye  toward a centralized training content that could apply to current and new  staff down the line. SSA plans to provide the full training package, which  constitutes about 8 weeks of course work and 13 modules, to reviewing  officials in late June, once all attorneys for that position are hired. Among  the sessions included are the basics of the disability determination  process, eDib and its use, medical listings and their application, and  decision writing.
Given that the rule was finalized in March and rollout is set for August,  agency timetables for hiring, training, and deploying more than 100 new  staff—as well as for training existing examiners—in the six states in the  Boston region are extremely short. SSA officials have acknowledged the  tight time frame, but hope to deliver training by using more than one  medium—in person, online, or by video. SSA still expects to accomplish  all hiring and training for the Boston region staff in time for an August 1  launch of the new process.
section_title: SSA Has Readied eDib for the Boston Region, but Time for Resolving Last- Minute Glitches before Rollout Will Be Limited
paragraphs: SSA has also taken steps, as we had previously recommended, to ensure  that key technical supports, particularly an electronic disability case  recording and tracking system known as eDib, are in place in time for  Boston staff to adjudicate claims under DSI electronically. The agency has  made a variety of efforts to familiarize employees with the system and  facilitate their ability to use it as early as possible. First, SSA positioned  the Boston region for a fast transition to eDib by reducing the region’s  paper case backlog. According to a Boston region ALJ, pending case  records are being converted now to familiarize judges and decision writers  with the eDib system so they will be comfortable with it when new cases  reach that level after August 1. Then SSA worked with Boston region staff  to certify that the region’s DDS offices were ready for full eDib  implementation.
According to claimant representatives, SSA has also worked to facilitate  their transition to eDib, and according to SSA officials, the agency has  developed a system called Electronic Records Express to facilitate  medical providers’ submission of records to SSA. A stakeholder group of  claimant representatives told us that SSA has offered them training and  that they have met regularly with agency staff to smooth out eDib issues,  such as difficulties associated with the use of electronic folders— electronic storage devices that replace paper folders as the official record  of evidence in a claimant’s case file. This stakeholders group also reported  that its members have voluntarily coordinated with SSA to test new  techniques that might further facilitate eDib implementation.
SSA has also been developing electronic templates to streamline decision  writing. ALJs have already received some training on theirs, which is  known as the Findings Integrated Template. According to SSA officials,  this template is now used, voluntarily, by ALJs nationwide, after months of  extensive testing and refinement. For DDS-level decisions, SSA is  designing a template—called the Electronic Case Analysis Tool (E-CAT)— which it expects to be partially operational by July and fully implemented  by November. DDS examiners in the Boston region will receive training on  the tool in July and will also receive training prior to then on the elements  of sound decision making. A similar tool is in development for the  reviewing officials.
While SSA officials expressed confidence in having technical supports  sufficiently in place in time for implementation of DSI in August,  unanticipated problems associated with new technology may challenge  their ability to do so. In addition to eDib and E-CAT, SSA is implementing  other new software systems to support the rollout (such as the predictive  models and electronic medical records transmission)—any one of which  may involve unexpected problems. For example, in 2005 we reported that  a number of DDSs were experiencing operational slowdowns and system  glitches associated with the new eDib system. It remains to be seen  whether the Boston region experiences similar problems with eDib, or  problems with other new systems, and whether SSA will be able to resolve  technical issues that may arise before implementation begins in August.
section_title: SSA Is Improving Its Quality Assurance System as Part of DSI Rollout, although Key Elements Have Yet to Be Revealed
paragraphs: SSA is taking steps to improve its quality assurance system that have  potential for improving the accuracy and consistency of decisions among  and between levels of review, in a manner that is consistent with our past  recommendations. As early as 1999, GAO recommended that in order to  improve the likelihood of making improvements to its disability claims  process, SSA should focus resources on initiatives such as process  unification and quality assurance, and ensure that quality assurance  processes are in place that both monitor and promote the quality of  disability decisions. Consistent with these recommendations, many of  SSA’s current efforts involve adding steps and tools to the decision-making  process that promote quality and consistency of decisions and provide for  additional monitoring and feedback. While these developments are  promising, many important details of SSA’s quality assurance system have  yet to be finalized or revealed to us.
SSA has recently elevated responsibility for its quality assurance system to  a new deputy-level position and office—the Office of Quality Performance.  This office is responsible for quality assurance across all levels of  adjudication. Listed below are new aspects of the quality assurance system  that this office oversees and that hold promise for promoting quality and  consistency of decisions.
SSA will continue to provide accuracy rates for DDS decisions, but  these accuracy rates will be generated by a centralized quality  assurance review, replacing the agency’s older system of regionally  based quality review boards and thereby eliminating the potential  differences among regional reviews that were a cause for inconsistent  decisions among DDSs.
As part of the DSI rollout, SSA plans to incorporate new electronic  tools for decision writing to be used by disability examiners, federal  reviewing officials, and ALJs. The tools are intended to promote quality  in two ways. First, the tools will require decision makers to document  the rationale behind decisions in a consistent manner while specifically  addressing areas that have contributed to errors in the past, such as  failing to list a medical expert’s credentials or inaccurately  characterizing medical evidence. Second, the tools will help provide a  feedback loop, by which adjudicators and decision writers can learn  why and under what circumstances their decisions were remanded or  reversed. SSA officials told us that once the tools are in full use, the  Office of Quality Performance will collect and analyze their content to  identify errors or areas lacking clarity. They also plan to provide  monthly reports to regional managers in order to help them better  guide staff on how to improve the soundness of their decisions and the  quality of their writing.
The establishment of the Decision Review Board, with responsibility  for reviewing ALJ decisions, is intended to promote quality and  consistency of decisions in two ways. First, once DSI is rolled out  nationwide, the board will be tasked to review error-prone ALJ  decisions with the intent of further ensuring the correctness of these  decisions before they are finalized. Second, during the initial rollout  phase, SSA plans to have the board review all ALJ decisions to verify  that the predictive model used to select error-prone cases is doing so as  intended. Importantly, both the tools and the board’s assessment are  consistent with our prior recommendations that SSA engage in more  sophisticated analysis to identify inconsistencies across its levels of  adjudication and improve decision making once the causes of  inconsistency among them have been identified.
In addition to these actions, SSA told us it plans to measure outcomes  related to how DSI is affecting claimants, such as allowance rates and  processing times at each adjudication stage, and the proportion of cases  remanded from the federal courts and the rationales for these remands.  Further, officials told us they will work with the federal courts to track  changes in their workload. SSA officials also told us they are working to  monitor changes in costs associated with the new DSI process, in terms of  both the administrative costs of the process, as well as its overall effect on  benefit payments.  Officials also said that SSA will track the length of time  it takes the agency to reach a final decision from the claimant’s  perspective, which we have recommended in the past. Although SSA  officials told us that ALJ accuracy rates will be generated from the board’s  review of all ALJ decisions, they said they were not yet certain how they  will measure these rates once DSI is rolled out nationwide and the board is  no longer reviewing all ALJ decisions.
While these developments are promising, aspects of these changes and of  SSA’s plans to monitor the DSI implementation have either not been  finalized or not been revealed to us. For example, SSA has not yet revealed  the types of reports it will be able to provide decision makers based on the  decision-writing tools. In addition, while SSA plans to measure the  effectiveness of the new process, its timeline for doing so and the  performance measures it plans to use have not been finalized. According  to SSA officials, potential measures include how well the predictive  models have targeted cases for quick decisions at the initial DDS level or  error-prone cases for the board, and whether feedback loops are providing  information that actually improves the way adjudicators and decision  writers perform their work.
section_title: SSA Has Employed Other Change Management Practices to Implement DSI
paragraphs: SSA’s efforts and plans show commitment to implementing DSI gradually,  using tested concepts, involving top-level management, and  communicating frequently with key stakeholders—practices that adhere  closely to our prior recommendations on effective change management  practices.
With regard to gradual implementation, we had previously suggested that  SSA test promising concepts in a few sites to allow for careful integration  of the new processes in a cost-effective manner before changes are  implemented on a larger scale. SSA’s decision to implement DSI in one  small region is consistent with this recommendation. SSA officials told us  they selected Boston because it represents the smallest share of cases  reviewed at the hearings level and because it is geographically close to  SSA’s headquarters to facilitate close monitoring. While SSA officials  acknowledged that unanticipated problems and issues are likely to arise  with implementation, they assert that they will be able to identify major  issues in the first 60 to 90 days. SSA officials believe this will give them  plenty of time to make changes before rollout begins in a second region.  SSA has also indicated that it plans to roll DSI out next in another  relatively small region.
Also consistent with our past recommendations, SSA officials noted that  some new elements of DSI have been tested prior to integration. For  example, the ALJ tool for decision writing has been tested extensively  during development, and they anticipate having fewer challenges when  similar tools are used more widely. In addition, SSA has said that it has  rigorously tested its model related to the Quick Disability Determination  System and that it will continue to check the selection of cases and  monitor the length of time it takes for quick decisions to be rendered.
SSA’s efforts and plans are also consistent with effective change  management practices in that they ensure the commitment and  involvement of top management. Specifically, SSA’s Commissioner first  proposed DSI-related changes in September 2003, and the agency began  restructuring itself soon after the rule was finalized. In addition, SSA  created a deputy-level post for its new Office of Quality Performance and  appointed a new Deputy Commissioner in its newly created Office of  Disability Adjudication and Review, which oversees the hearing and  appeals processes.
We have also encouraged top managers to work actively to promote and  facilitate change, and SSA appears to be adhering to these principles as  well. For example, SSA officials told us that the Deputy Commissioners  from SSA’s offices of Personnel and Human Capital have collaborated with  their counterparts in policy units to develop position descriptions and  competencies for nurse case managers and federal reviewing officials.  According to SSA officials, these leaders are also collaborating to develop  interview questions for eligible candidates. Further, SSA officials told us  their new human capital plan will be released sometime in July and that it  will emphasize the goals of DSI, as well as the personnel changes that will  accompany it.
Finally, SSA’s communication efforts with stakeholders align with change  management principles in several respects. For example, SSA has  employed a proactive, collaborative approach to engaging the stakeholder  community both during DSI’s design and in its planning for  implementation in order to explain why change is necessary, workable,  and beneficial. Even before the notice of proposed rule making on DSI was  published, SSA began to meet with stakeholder groups to develop the  proposal that would eventually shape the new structure. Then, once the  proposed rule was issued, SSA officials told us they formed a team to read  and analyze the hundreds of comment letters that stakeholders submitted.  In addition, they conducted a number of meetings with external  stakeholders to help the agency identify common areas of concern and  develop an approach to resolving the issues stakeholders raised before  rollout began.  According to SSA officials responsible for these meetings,  the Commissioner attended more than 100 meetings to hear stakeholder  concerns directly.  Further, SSA recently scheduled a meeting for early  July with claimant representatives to discuss that group’s particular  concerns about how the new process will affect their work and their  disability clients. SSA officials told us that senior-level staff will lead the  meeting and that about 100 claimant representatives from the Boston  region will attend.
In addition, SSA officials have also worked to ensure that there are open  lines of communication with its internal stakeholders, thereby ensuring  that disability examiners and staff in the Boston region are knowledgeable  about DSI-related changes. For example, SSA solicited comments and  questions from the Boston region’s staff about the specifics of the rollout  and held a day-long meeting in the region, led by Deputy Commissioners,  to respond to these concerns.
section_title: Concluding Observations
paragraphs: For some time, SSA has been striving to address long-standing problems in  its disability claims process. From our perspective, it appears that SSA is  implementing the new claims process by drawing upon many lessons  learned from past redesign efforts and acting on, or at least aligning its  actions with, our past recommendations. For example, significant aspects  of the DSI rollout are consistent with our recommendations to focus  resources on what is critical to improving the disability claims process,  such as quality assurance and computer support. SSA’s incremental  approach to implementing DSI—taking a year to monitor the process and  testing new decision-writing tools, for example—is also consistent with  our recommendation to explore options before committing significant  resources to their adoption. Thus, the agency is positioning itself to make  necessary modifications before implementing the new process in  subsequent locations. Finally, and fundamental to all of this, SSA’s top  leadership has shown a commitment to informing affected stakeholders  and listening to their advice and concerns with respect to the development  and implementation of this process.
While SSA’s steps and plans look promising, we want to stress the  importance of diligence and follow-through in two key areas. The first is  quality assurance, which entails both effective monitoring and evaluation.  A solid monitoring plan is key to helping SSA quickly identify and correct  problems that surface in the Boston rollout, because any failure to correct  problems could put the entire process at risk. An evaluation plan is critical  for ensuring that processes are working as intended and that SSA is  achieving its overarching goals of making accurate, consistent decisions as  early in the process as possible. The second key area is communication. It  is important for SSA’s top leadership to support open lines of  communication throughout implementation if the agency is to facilitate a  successful transition. Failure to, for example, provide useful feedback to  staff—many of whom will be new to the agency or at least to the new  tools—could significantly jeopardize opportunities for improvement. Just  as important, SSA’s top management needs to ensure that the concerns  and questions of stakeholders affected by the new process are heard, and  that concerned parties are kept apprised of how SSA intends to respond.
The eventual elimination of the Appeals Council and its replacement with  the Decision Review Board with a very different purpose has been a great  cause of concern for a number of stakeholders. SSA appropriately has  plans to assess its impact by tracking decisions resulting from each stage  of the new process, as well as the effect of the process on the federal  courts’ caseloads and claimants at large. To its credit, SSA plans to reduce  any immediate impact on the courts by requiring that the board initially  review all ALJ decisions in the Boston region. However, given that the  agency plans to rely heavily on new positions, such as the federal  reviewing official, and on new technology, SSA will need to ensure that  staff are well trained, and that each adjudicator has the support staff  needed to work effectively. Focusing on one small region will, it is hoped,  allow the agency to ensure that training, technology, and other resources  are well developed to achieve expected goals before DSI is expanded to  other parts of the country.
Mr. Chairman, this concludes my prepared remarks. I would be happy to  answer any questions that you or other members of the subcommittee may  have.
section_title: GAO Contact
paragraphs: For future contacts regarding this testimony, please contact me at (202)  512-7215 or RobertsonR@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of this testimony.
section_title: Staff Acknowledgments
paragraphs: The following individuals have made major contributions to this  statement— Susan Bernstein, Candace Carpenter, Joy Gambino, Michele  Grgich, Luann Moy, Daniel Schwimer, and Albert Sim.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: To learn more about the public’s and stakeholders’ views with regard to  the Appeals Council and the Decision Review Board, we reviewed and  analyzed a large sample of comment letters they submitted to the Social  Security Administration (SSA) in response to its July 2005 notice of  proposed rule making on the Disability Service Improvement process  (DSI) that were related to these topics. We also interviewed a number of  key stakeholder groups to solicit their opinions once the rule had been  finalized.
subsections: section_title: Reviewing and Analyzing Comment Letters
paragraphs: To review and analyze the comment letters, we first downloaded all   1,143 comments that SSA had received and posted to its public Web site.  In order to focus our review on only those letters that related to the  Appeals Council and the Decision Review Board, we then applied a word  search to restrict our analysis to the responses that used the terms  “Decision Review Board,” “DRB,” and “Council.” Applying these search  terms reduced the number of comment letters for review to 683. We  discarded 43 of these 683 letters over the course of our review because  they were duplicates of letters by the same authors or did not contain  relevant comments. As a result, our final analysis was based on the  remaining 640 letters.
To classify the nature of the comments contained in these 640 letters, we  coded the opinions as related to one of more of the following concerns:    The Appeals Council is improving, and its termination will not  improve the disability determinations process.
There is a risk that the Decision Review Board may not select the  most appropriate cases for review.
There is a risk that Decision Review Board could unfairly evaluate  or influence administrative law judge decisions.  In the absence of an Appeals Council, the claimant no longer has  the right to initiate subsequent case review.
There is no opportunity for the claimant or his or her representative  to argue before the Decision Review Board.
A claimant’s benefit might be protracted or delayed during Decision  Review Board assessment.
Petitions to the federal court are likely to increase.    Appeals to the federal court are costly or intimidating, and  claimants may not have the wherewithal to pursue the claim at this  level.
Of the 640 letters in our review, we initially identified 388 as form letters,  or letters containing identical comments, even though they had different  authors. To simplify our review, we coded these form letters separately  from the other letters. For the 252 letters that we did not initially identify  as form letters, one analyst reviewed and coded each letter, while a second  analyst verified that he or she had coded the statements appropriately. If  the first and second analysts did not come to an agreement, a third analyst  reviewed the comment and made the final decision for how the content  should be classified. Table 2 below indicates the percentage of the 252  letters citing one or more of the above concerns.
For the 388 form letters, we coded one letter according to the process  described above. Because the text of the form letters was identical for  each, we then applied the same codes to each of the other form letters. All  388 form letters expressed each of the concerns above.
section_title: Identifying and Interviewing Stakeholders
paragraphs: To identify key stakeholders, we first referenced the list of organizations  that SSA included in its notice of proposed rule making as having met with  the agency during its development of the final rule. We then narrowed this  list by obtaining suggestions from SSA officials about organizations that  are the most active and cover a broad spectrum of disability issues. In  total, we spoke with representatives from 10 groups:    Administrative Office of the U.S. Courts’ Judicial Conference  Committee on Federal-State Jurisdiction,    Association of Administrative Law Judges (AALJ),    Consortium for Citizens with Disabilities’ Social Security Task  Force (CCD),    National Association of Councils on Developmental Disabilities    National Association of Disability Examiners (NADE),    National Association of Disability Representatives (NADR),    National Council of Disability Determination Directors (NCDDD),    National Council of Social Security Management Associations    National Organization of Social Security Claimants’ Representatives  (NOSCCR), and    Social Security Advisory Board.
section_title: Related GAO Products
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