Statement of C. Richard Dann, Union of American Physicians and Dentists

We are submitting this statement for the record for the June 15, 2006 Hearing on Social Security Disability Service Improvement on behalf of the Union of Physicians and Dentists (UAPD)/American Federation of State, County and Municipal Employees (AFSCME), AFL-CIO.  UAPD represents 140 Medical Consultants in California’s Disability Determination Services (DDS) and AFSCME represents 1.4 million public service and health care workers.

UAPD has been monitoring proposed changes to the Social Security Disability process since the Redesign was first proposed in April 1994.  We have offered written comments to the Social Security Administration (SSA) and our members have testified before this Subcommittee in the past with suggestions to improve the Disability process.

With final regulations in place, our members stand ready to implement the new system.  And, while we agree that many of the changes will improve the system, we have grave concerns about one requirement that is yet to be determined – specifically the qualifications for the position of Medical Expert in the Medical and Vocational Expert System (MVES).  The final regulations indicated that the Social Security Commissioner will publish the requirements for these positions at a later date.  Therefore, our comments will focus on the requirements that are under consideration by the Commissioner.

Last year the Institute of Medicine issued an interim report on the qualifications and organization of Medical Consultants in the New Disability Process.  The Institute report recommended that all Medical Consultants and Medical Examiners at the state and federal levels be Board certified. We strongly disagree and are concerned that the Commissioner will rely upon this flawed analysis to implement these recommendations in her final guidelines.  Board certification requirements will not enhance the speed or accuracy of adjudication, would greatly limit the number of potential candidates, creating a large backlog in the DDDs, and is simply not practical.

Commissioner Barnhart has expressed concerns that various medical specialties are not readily available to all DDS adjudicators.  However, there is a very limited need for such specialty consultation; well-versed generalists who understand the processes, treatments and prognosis for a wide range of diseases, as well as the federal statutes, are better qualified than specialists to make the vast majority of disability assessments at the state DDSs.

The standard medical model in the United States and most countries is that generalist providers initially evaluate patients so only the most ill or complicated cases are referred to specialists, effectively utilizing their unique skills. The factors to determine functional impairment are relatively simple and succinct: the ability to lift, carry, stand, walk, sit, reach, grasp, turn, push, pull, pinch, feel, bend, squat, climb, crawl, reach, see, hear, speak, and environmental tolerances do not require specialty assessment.  The basic findings for gait, station, range of motion, strength, dexterity, sensation, balance, vision and hearing are fairly simple medical concepts, and understanding of those factors is not enhanced significantly by specialty training. 

A specialist’s capabilities are not needed on every case involving that specialty.  For example, although hypertension involves the cardiovascular system, the vast majority of blood pressure prescribing is done by generalists, not cardiologists.  The vast majority of care for back pain is similarly done by generalist MDs, not orthopedists. Specialists are rarely better equipped to adjudicate most SSA Disability cases than generalists.

We strongly oppose replacing Medical Consultants with non-physician providers in DDS or MVES. While arbitrarily urging Board certification of all physicians and PhDs in the Program, the Commissioner has paradoxically indicated that they already are recruiting for nurse consultants for the Boston rollout of the new process.  Use of these other less credentialed medical sources offers no advantages; they have less medical training and knowledge than the physicians and PhDs employed currently as Medical Consultants, with the disadvantage of decreased legal defensibility in appeals.  

The DDS and Regional offices rely heavily Medical Consultants and it is estimated that currently five percent or less of the system’s PhD Medical Consultants are Board certified.  Requiring Board certification would leave a gaping hole in Psychiatric Medical Consultant capability, an area currently underserved in some states. Affordability and availability are the major obstacles to increasing the numbers of medical specialist experts in the SSA Disability program.  The Institute report further recommended a grandfather period of five years for current non-Board certified Medical Consultants.  After that period, those Medical Consultants without Board certification are presumed suddenly not to be qualified to make the same assessments that they have been making for five, ten or fifteen years.

Most current Medical Consultants are mid to late career professionals, and Board certification was not as prevalent 25 years ago.  Board certification requires multiple years of in-hospital residency training and passing Board examinations, and is just not feasible for a mid or late career DDS Medical Consultants.  If SSA makes Board certification mandatory, it should apply to new applicants only, and incumbent MCs should be grandfathered.  Any less accommodating policy will result in acute MC shortages and increased costs due to the higher salaries board certified doctors would demand.

And, finally, requiring Board certification is impractical because most National Medical Boards require Recertification after five or ten years.  Most recertification’s require ongoing practice in that specialty area since last certification, as well as passage of a written examination.  If SSA imposes this requirement, many medical consultants would not qualify for Board recertification because they would not have been in practice in their specialty.

As an alternative, we strongly endorse federal standardization of Medical Consultant training and would like to emphasize that this is not a new idea.  After over ten years of work by a group of DDS Training Coordinators, DDS Medical Consultants, Central Office Training staff, and Central Office Medical Consultants, a national SSA Disability Medical Consultant Training Curriculum was finally completed.  A UAPD medical consultant was one of the members of that SSA workgroup. 

We also would like to point out that the Board certification will not solve the problem of the high reversal rate by the Administrative Law Judges (ALJs).  The reasons for this discrepancy in the decision making process between the ALJs and the DDSs are actually pretty simple: the ALJ receives minimal medical training (typically two weeks in California, the nation’s largest DDS) and there is currently no SSA quality review of ALJ decisions as there is for DDS decisions.  The ALJ makes decisions based on “substantial evidence,” rather than the “preponderance of evidence” standard that the DDS applies. Our members who review cases for Continuing Disability Review (CDR) might find the following scenario: two DDS teams (initial and reconsideration) considered all evidence and arrived at a decision of  “no severe or minimal impairment;” an ALJ then heard the case and, based on poorly substantiated endorsement of disability from a treating source, assessed the claimant “disabled.”  This likely allowance error cannot be reversed at the next CDR due to the “Medical Improvement Review Standard.”  Under this standard, the primary assessment on a CDR is not current assessment of disability, but rather an assessment of whether “significant medical improvement” has occurred since the last assessment of disability.  If the two DDS teams judged that the claimant was capable of extensive work but the ALJ ruled that they were extremely limited with the same findings, subsequent CDRs will virtually never be able to show “significant medical improvement.” That seems quite contrary to the Commissioners goal of “fostering a return to work at all stages.”

The need for consistency between DDS and ALJ decisions is a very old problem.  Many attempts have been made to resolve it. In the 1990s Process Unification Training was undertaken to increase the rate of DDS allowances and decrease the number of ALJ reversals.  DDS allowances increased, but ALJ allowance rates have not fallen appreciably.  ALJ decisions should use the same standards as the DDS, should be subject to quality review, should have the same accountability, and a mechanism to reverse ALJ decisions unsupported by the evidence on CDRs.

We appreciate the opportunity to offer our perspective to this Subcommittee and we also urge the Subcommittee members to ensure that there are adequate resources for the current process and for implementation of the new process.   There already are large backloads of CDRs due to funding shortfalls, and without sufficient funding, neither the current process or the new process will provide high quality services to applicants and recipients.