SSA administers two of the largest disability programs: the Disability Insurance (DI) program, enacted in 1956, and the Supplemental Security Income (SSI) program, enacted in 1972. In order to be eligible for DI or SSI benefits based on a disability, an individual must meet the definition of disability for these programs—that is, they must have a medically determinable physical or mental impairment that (1) prevents the individual from engaging in any substantial gainful activity, and (2) has lasted or is expected to last at least one year or result in death. To determine eligibility, SSA uses a five-step sequential process that is intended, in part, to expedite disability decisions when possible and limit administrative costs by conducting less intensive assessments at earlier steps (see fig. 1). At steps 1 and 2 of the process, SSA determines whether an applicant is working and meets income thresholds as well as the medical severity of impairments. If so, the applicant moves to step 3 of the process. At this step, SSA examiners assess the applicant’s medical impairment(s) against the Listings of Impairments, also known as the medical listings, which are organized into 14 major body systems for adults and reflect medical conditions that have been determined by the agency to be severe enough to qualify an applicant for benefits. If the individual’s impairment meets or is equal in severity to one or more of those in the listings, the individual is determined to have a disability. If not, SSA performs an assessment of the individual’s physical and mental residual functional capacity. Based on this assessment, SSA determines whether the individual is able to perform past relevant work (step 4) or any work that is performed in the national economy (step 5). To inform determinations at steps 4 and 5, SSA uses a Department of Labor database—known as the Dictionary of Occupational Titles (DOT)—for an inventory of occupations performed in the national economy. Since 2003, SSA’s and other federal disability programs have remained on our high-risk list, in part, because their programs emphasize medical conditions in assessing work capacity without adequate consideration of work opportunities afforded by advances in medicine, technology, and job demands. Since the 1990s, we, along with SSA’s Office of Inspector General and the Social Security Advisory Board, have expressed concerns that the medical listings being used no longer provide sufficient criteria to evaluate disability applicants’ inability to work and that SSA was simply extending the listings instead of periodically updating them. In 2008, we reported that SSA had established a new process for revising the listings—referred to by SSA as the “business process”—to better incorporate feedback into its continuous updates. This process, which has been in effect since 2003, includes incorporating feedback from multiple parties, including medical experts and claims examiners, to update their medical criteria. SSA should also gather external feedback through comments associated with regulatory actions, such as the publication of advanced notices of proposed rulemaking (advanced notices) and notices of proposed rulemaking (notices) in the Federal Register. In addition, one year after a revision is made, SSA should conduct a study reviewing the changes. According to SSA documentation, this internal case study, now referred to as the postimplementation study, should involve surveying the field regarding the results of the regulation and areas to improve, as well as reviewing the data to determine whether expectations from the revision have been proven. With respect to information on jobs in the national economy that supports SSA’s occupational criteria, we and others have reported that the DOT, which SSA still relies on to assess eligibility at steps 4 and 5 of the process, is outdated. The DOT has not been updated since 1991, and Labor has since replaced the DOT with a new database called the Occupational Information Network (O*NET).determined that O*NET is not sufficiently detailed for evaluating DI and SSI disability claims and therefore has begun developing its own OIS in order to better reflect the physical and mental demands of work in the national economy. Since our last review in 2008, SSA has made several changes that hold promise for improving medical listings updates. First, the agency is using a two-tiered system for ongoing revisions to the listings. Under this system, SSA first completes a comprehensive listings update for a body system that reviews all the diseases and disorders listed within that system and makes revisions it determines are needed. For subsequent updates of listings for a body system that underwent a comprehensive revision, SSA will pursue a more targeted approach—that is, SSA will conduct ongoing reviews with the expectation of making targeted revisions for a small number of medical diseases or disorders that need to be updated. Agency officials told us that targeted updates should be completed more quickly than comprehensive updates, allowing them to focus on the most critical changes needed. However, officials also noted that these ongoing reviews could result in major or even no changes, as appropriate. As of early March 2012, SSA had begun the ongoing review process to consider opportunities for targeted revisions for 8 out of 14 adult body systems that were recently comprehensively revised. Also as of early March 2012, the agency had not yet completed comprehensive revisions for the six remaining systems, which the agency expects to do before they conduct subsequent reviews under the targeted approach. Another change, according to agency officials, is that in 2010 the SSA Commissioner set a 5-year cycle time for updating listings for each body system. Previously, SSA set expiration dates for periodically updating listings according to each body system, ranging from 3 to 8 years, but frequently extended them. SSA officials believe that conducting targeted reviews will generally allow the agency to conclude any necessary revisions prior to the 5-year expiration period. Additionally, they expect that using the “business process,” which requires early public notification of changes and obtaining necessary data and feedback from internal and external parties, should help keep continuous reviews on track. See figure 2 for the status and expiration dates of listings for the 14 adult body systems, undergoing review for either comprehensive or possible targeted revisions, as of early March 2012. SSA has made another change by more extensively engaging the medical community to identify ways to improve the medical listings. For example, SSA contracted with the Institute of Medicine to study its medical criteria for determining disability and to make recommendations for improving the timeliness and accuracy of its disability decisions, resulting in a 2007 report with recommendations and a symposium of experts in 2010. SSA has addressed some of the institute’s recommendations, such as making better use of its administrative data to update criteria and creating a standing committee through the institute to provide recommendations for listings revisions. SSA continues to face delays in completing both comprehensive and other ongoing updates. For example, as of early March 2012, SSA officials told us they still needed to complete comprehensive revisions for listings of six body systems that have been ongoing for the last 19 to 33 years, after numerous extensions beyond the original expiration periods (see table 1). Two of the remaining six body system listings—mental and neurological disorders, which are among those SSA uses most frequently in its eligibility determination process—have not been comprehensively revised for 27 years.to expire in 2012. Of these four, SSA is developing a notice of proposed rulemaking for three of them and has issued a notice on the fourth. However, it is unclear whether SSA will complete the revisions before they are set to expire. In 2008, SSA began a multiyear project to develop a new source of occupational information that will replace the outdated information currently being used to determine if claimants are able to do their past work or any other work in the national economy. Since the 1960s, SSA has been using the DOT, which contains a list of job titles found in the national economy and was last updated in 1991. The DOT provides SSA with descriptions of the physical demands of work—such as climbing, balancing, and environmental requirements—for each of the more than 12,000 occupations listed. According to SSA, these descriptions have been essential to its evaluations of how much a claimant can do despite his or her impairment and whether this level of functioning enables the claimant to do his or her past work or any other work. After its last limited update, Labor decided to replace the DOT with O*NET, which has far fewer job titles compared with the DOT, but has served Labor’s purposes more efficiently. According to an SSA report, after investigating potential alternatives, SSA decided that O*NET and other existing databases with occupational information were not sufficiently detailed and able to withstand legal challenges for use in its decision-making process. SSA further decided to develop its own occupational information system, which would contain detailed information as in the DOT, but would also include additional information, such as the mental demands of work. In addition, the OIS should (1) meet SSA’s legal, program, and data requirements; (2) be flexible enough to incorporate changes in SSA’s policies and processes; and (3) be able to be updated to reflect the evolving workplace environment. In 2008, SSA began taking several steps to guide the development of its OIS. SSA created an internal office and working group, as well as an Occupational Information Development Advisory Panel, comprised of external experts in areas related to the development of occupational information systems. The advisory panel holds quarterly public meetings and has several subcommittees that review material and make recommendations to SSA on developing various components of the OIS. For example, in a 2009 report, the advisory panel supported the need for SSA to develop a new source of occupational information, rather than adapt O*NET, and recommended the type of data SSA should collect, as well as suggested ways to classify occupations. To further inform its efforts, SSA has sought input from agencies or organizations that either collect occupational information or also use the DOT.