National Disability Coalition (Winter 2015)

Determining medical improvement

In my work for the Vermont Disability Determination Services (DDS) and for National Council of Disability Determination Directors (NCDDD), I have heard various ideas related to the question of medical improvement and continuing disability review (CDR) processing. I will describe some of these ideas below for the purposes of this discussion. Please note that neither NCDDD nor the Vermont DDS has taken an official position on any of these ideas.


1. SSA should initiate CDRs timely in relation to the medical diary dates set for review whenever a case is allowed. When SSA’s administrative budget is tight, the initiating and processing of CDRs falls behind. Sufficient funding for these reviews as well as the regular disability workloads is necessary. Policy for the setting of diary dates could be updated to provide for better identification and prioritization of disorders that are likely to improve.


2. I have heard a few people advocate for making benefits time-limited, after which beneficiaries must reapply and submit a new claim if they believe they are still disabled. There is an obvious downside to this idea for people who have extremely severe conditions for whom even temporary loss of benefits and the reapplication process would be a hardship and a potential health hazard. Benefits might stop at critical times in the course of their illness and treatment. Administratively, this idea would increase the initial claims workload greatly (and unnecessarily for a significant number of cases), whereas with proper management, the CDR process can be targeted to people whose disorders are most likely to improve at the time when that improvement is most likely to have occurred.


3. Requiring people on disability benefits to provide periodic reporting of their condition could supplement the diary date projections that are made when the case is allowed or continued. SSA has used mailers (questionnaires mailed to beneficiaries) to screen their need for a full medical CDR. What does analysis of the data show SSA about the efficacy and cost/benefit of CDR reviews? With the work being done on objective measurement of functioning, could more sophisticated questionnaires be developed for more accurate identification of potential medical improvement?


4. Anecdotally it appears that CDRs are often initiated many years past the diary dates, especially for children. For certain conditions, there are some very effective therapies and special education programs, such that children with severe disorders do make significant improvement. When these cases do not have timely CDRs during their childhood, benefits continue longer than appropriate, and those children and their families are unprepared for the loss of those benefits when the legally required Age 18 redetermination is done and the children are found not to meet the adult standard. With more timely CDRs targeted for childhood conditions that are most likely to improve, there can be better transition preparation for the child and the family.


5. Return to work incentives, increasing participation in vocational rehabilitation, ADA supports for people with disabilities who are working, and finding structural ways to decrease the “benefit cliff” (where the loss of an array of related benefits when a person on disability goes to work makes them worse off working than on benefits) may be helpful.


6. The Medical Improvement Review Standard (MIRS) policy was developed to address the problem that arose in the early 1980s when regular CDRs were first mandated by law and resulted many people being taken off the rolls. Without the MIRS consideration, their benefits were removed without consideration that there had been no change in their condition, they had been on the rolls for many years, and many really could not adjust to work. The resulting outcry led to a moratorium on CDRs in the mid-1980s until MIRS policy was developed.


The MIRS policy was written carefully with appropriate exceptions for various factors, including prior decisions being in error. However, to find error, CDR adjudicators could not merely substitute their judgment for the judgment of the previous decision-maker. The error must be a clear and objective misinterpretation of the evidence or in misapplication of policy.


Some may think that the solution is to do away with the MIRS policy, notwithstanding the needed protection it provided, which the experience of the early 1980s clearly demonstrated. Other possibilities that might mitigate the problems with MIRS include careful review, updating and clarification of the policy and the exceptions. Analysis of the inconsistencies in initial adjudication across all components with all cases, and improving policies so that they can be more uniformly applied by all in all cases, would lead not only to more consistent initial determinations, but also to better decisions for the CDRs that follow.


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Idea No. 68