SSA administers two programs under the Social Security Act that provide benefits to people with disabilities who are unable to work: Disability Insurance (DI) and Supplemental Security Income (SSI). According to SSA policy, to be eligible for either DI or SSI, an adult must be unable to engage in “substantial gainful activity”—typically work that results in earnings above a monthly threshold established each year by SSA—because of a medically determinable physical or mental impairment that is expected to last at least 12 months or result in death. Established in 1954, the DI program provides monthly benefits to workers (and their spouses and dependents) whose work history qualifies them for disability benefits and whose impairment is disabling. In 2007, SSA paid about $99 billion in DI benefits to about 8.1 million workers, spouses, and dependents. The average monthly benefit was $1,004 for disabled workers. SSI is a means- tested income assistance program created in 1972 that provides a financial safety net for people who are aged, blind, or disabled, and have low incomes and limited assets. Unlike the DI program, SSI has no prior work requirements. In 2007, SSA paid about $37 billion in SSI benefits. As of December 2007 about 7.4 million recipients received an average monthly benefit of $468. Some individuals with disabilities receive both DI and SSI benefits if they meet both DI’s work history requirements and SSI’s income and asset limits. The process to determine a claimant’s eligibility for SSA disability benefits is complex, involving several state and federal offices. The disability determination process, which is the same for DI and SSI claimants, involves an initial determination of disability and provides up to two levels of administrative review within SSA. A claimant first completes an application, or claim, for DI or SSI benefits, which includes information regarding illnesses, injuries, or conditions and a signature giving SSA permission to request medical records from medical care providers. Once the SSA field office staff verify that nonmedical eligibility requirements are met, the claim is sent to the state’s DDS office for determination of medical disability. If the claim is approved, a claimant will be notified and will receive benefits, including limited retroactive benefits for some DI claimants. Additionally, if the claim is approved, a claimant may become eligible for Medicaid or Medicare health coverage. If the claim is rejected, a claimant has 60 days to request that the DDS reconsider its decision. If the DDS reconsideration determination concurs with the initial denial of benefits, the claimant has 60 days to appeal and request a hearing before an SSA administrative law judge (ALJ). A claimant may appeal an unfavorable administrative law judge decision to SSA’s appeals council, which includes administrative appeals judges and appeals officers and, finally, to federal court. SSA and DDS officials (examiners and ALJs) determine disability using a five-step sequential process based on evidence such as medical findings and statements of functional capacity obtained during the initial determination process and updated as necessary at each appeal level. (See fig. 1.) Generally, SSA requires DDSs to develop a complete medical history for each claimant for at least a 12-month period prior to the application. SSA guidance directs DDSs to request records from all providers who have treated or evaluated the claimant during this time period, except those who treated only ailments clearly unrelated to the claimed impairment. DDSs generally pay providers for records and SSA pays the DDSs to cover these expenses. Each DDS determines its payment rates for medical and other services necessary to make determinations, subject to certain limits. DDSs request laboratory reports, X-rays, doctors’ notes, and other information used in assessing the claimant’s health and functional capability from many types of providers including: physicians or psychologists; hospitals; community health centers; schools (for child claimants); and Department of Veterans Affairs (VA), military, or prison health care facilities. In addition to medical evidence, DDSs review statements from the claimant or others about the claimant’s impairment and ability to perform daily activities. SSA directs DDSs to make “every reasonable effort” to help the claimant obtain medical reports, which SSA defines as one initial medical records request and, if needed, one follow-up request within 10 to 20 days, when providers have not responded, unless experience with a particular provider warrants more time. DDSs allow a minimum of 10 days after the follow-up request for the provider to reply. When records indicate the claimant has been to other medical providers, DDSs also contact those providers for records. Generally records are placed in the claimant’s case record. SSA regulations require that disability determinations place more, and in some cases controlling, weight on the opinions of a claimant’s treating providers. For example, a treating provider’s opinion about the nature and severity of the claimant’s impairment should generally be given controlling weight where their opinion is well supported by other substantial evidence in a claimant’s case record. In claims where the gathered medical and nonmedical evidence is insufficient to support a disability determination, DDSs may order consultative exams or tests. DDSs pay providers to perform these examinations and SSA pays them to cover these costs. SSA regulations require that payments to providers for consultative exams not exceed the highest rate paid by federal or other state agencies for the same or similar services. The regulation allows states to determine the rates of payment and, as a result, DDS rates of payment for consultative exams vary nationwide. SSA regulations specify the types of providers who may perform these exams or tests, and require DDSs to recruit, train, and oversee them. SSA regulations also state that the claimant’s own provider is generally the preferred source for consultative exams if qualified, equipped, and willing to perform the exams. (See fig. 2.) To support DDSs’ efforts to process claims quickly, SSA has established an expedited process for claims in which a determination of disability is likely. In September 2007, SSA implemented its Quick Disability Determination process nationwide after testing it in the Boston region. This process uses a computer model using certain key terms in the claim file to identify claims for which a decision of disability is likely and medical evidence establishing disability can be easily obtained. DDSs can use expedited processes for these claims; for example, DDS staff in a couple of states we visited explained how they request and receive medical records for Quick Disability Determination cases by fax. SSA reported, for fiscal year 2007, that the national average processing time for all initial claims was 83 days. By comparison, during the pilot, the Boston region decided Quick Disability Determination claims in an average of 11 days. SSA also has policies to expedite claims involving diseases such as certain types of cancer that are terminal or otherwise so severe that they clearly meet SSA’s definition of disability. SSA performs a quality assurance review of a sample of more than 30,000 DDS decisions each year. SSA assesses the accuracy of the DDSs’ determination and the sufficiency of the documentation for the DDSs’ compliance with requirements for medical records collection and consultative exams process. Decisional deficiencies occur when a different determination should have been made, and documentation deficiencies occur when additional documentation is necessary in order to make the correct determination. SSA also collects extensive data on spending for consultative exams and requires DDSs to routinely report substantial budget, program operations, and management data to SSA. In 2004, President Bush called for widespread adoption of interoperable electronic health records within 10 years and issued an executive order assigning the coordination of the effort to the Department of Health and Human Services. Under the department’s leadership, volunteer organizations designated to develop standards for the health care industry have prepared initial certification criteria for health information technology such as electronic patient records and records management systems. As businesses, providers decide when and whether to invest in these certified systems. Another executive order in 2006 directs certain federal agencies to “utilize, where available, health information technology systems and products that meet recognized interoperability standards.” HHS also has awarded several contracts related to health information technology to address issues such as standardization, networking, and privacy and security. SSA collection of medical evidence is affected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) which defines the circumstances in which an individual’s health information may be used or disclosed. In addition, HIPAA’s security provisions require entities that hold or transmit health information to maintain reasonable safeguards to protect the information against unauthorized use or disclosure and ensure its integrity and confidentiality. Determining eligibility for disability benefits is a complex, challenging task. DDS officials identified obtaining records from claimants’ medical providers as a major challenge to DDS examiners’ ability to quickly compile the necessary evidence for disability determinations. DDSs cited problems with the consistency of provider response to record requests, both in timeliness and completeness of records submitted. DDSs have responded to these challenges by conducting additional follow-up contacts with medical providers and claimants, and more than half of the 51 DDSs we surveyed reported adjusting their payment methods. Although SSA routinely reviews DDSs’ compliance with medical records collection requirements, SSA does not systematically identify and review the effectiveness of promising DDS medical evidence collection practices. DDS officials identified provider response to medical records requests as a challenge in our survey of 51 DDSs. One DDS director reported in our survey that more than 300 providers in the state were considered “nonproductive” so that the DDS must send claimants who are patients of those providers to consultative exams when evidence from other sources is insufficient. One DDS director noted that public health clinics and hospitals are overburdened providing patient care and that medical records programs get short shrift.