1. SSA-NIH-BU Collaboration to Improve the Disability Determination Process Presentation for the SSA Occupational Information Development Advisory Panel: 12/08/10 Beth Rasch, PT, PhD

2. 2 Point of clarification This exploratory work, being conducted by NIH and BU, examines ways in which claimants and their health care providers can quickly and easily provide information about claimants’ function. SSA has not yet adopted or endorsed this approach.

3. 3 Background August, 2007 SSA sought help from NIH Identify new diagnostics tests that might expedite allowances Paradigm: Diagnosis or impairment ≈ disability SSA / RMD Inter-Agency Agreement NIH signed 3-year agreement with SSA Initiated on 2/1/08 New 5-year agreement with SSA Initiated on 2/1/10

4. 4 Broad objectives 1)Data analysis 2)Computer Adaptive Tests (CAT) To improve SSA disability determination process through: Unprecedented access to SSA data Focus on function

5. 5 Medical model: disability as a personal trait Conceptualizing disability: Two opposing perspectives Social model: disability as a socially created problem

6. 6 Prominent models of disability Nagi model Verbrugge and Jette’s “Disablement Process” IOM model Social model WHO International Classification of Functioning, Disability, and Health (ICF)

7. 7 Health Condition ActivitiesParticipation Environmental Factors Personal Factors Body Functions Body Structures ICF: World Health Organization, 2001 Conceptualization

8. 8 Contemporary concepts of disability Interactive Not solely an individual attribute—diagnosis alone cannot predict disability Multidimensional Complex theoretical models map the interaction of conceptual elements that constitute the definition of disability Continuum Not an “all or nothing” concept Dynamic Disability influenced by the environment Disability can change over time

9. 9 Measuring such a concept poses a methodological challenge To operationalize this concept, individual attributes and environmental features must be measured Operational definition depends on purpose of data collection process Measuring disability

10. 10 SSA purpose Identify individuals who are unable to engage in substantial gainful employment due to medically determinable physical or mental impairment/s which can be expected to result in death or which have lasted or are expected to last > 12 months SEC. 223. [42 U.S.C. 423](d)(1) Physical or mental impairment/s must be of such severity that the individual is not only unable to do previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial gainful work which exists in the national economy… SEC. 223. [42 U.S.C. 423](d)(2)(A)

11. 11 Framing the problem There is a gap between contemporary notions of disability and how SSA operationalizes its statutory definition of disability SSA’s operationalization is focused on physical and mental impairments (medical model) Contemporary disability models depict disability as the gap between an individual’s functional ability and environmental demands Diagnosis and impairment may be poor predictors of work disability Jette & Badley: Conceptual issues in the measurement of work disability. Wunderlich et al, Eds. The Dynamics of Disability. National Academy Press, Washington, DC, 2002

12. 12 Measurement Health Condition Participation Environmental factors Personal factors Source: ICF, WHO, 2001 Body structure & function

13. 13 SSA’s data gaps Viewed through the ICF, current SSA assessment processes could improve content coverage of “activity” domains relevant to work. Limited information captured on: Learning and applying knowledge General tasks and demands such as multi-tasking or organizing time, space and materials for a task Communication Interpersonal interactions and relationships

14. 14 Domain selection Priorities for SSA-IAA Interpersonal interactions and relationships Mobility Learning and applying knowledge Communication Self care General tasks and demands

15. 15 Recommendations: Whole person approach Capture all conditions during the application process to characterize the sum total of their impact on functioning as it relates to work Depression Knee arthritis Heart disease

16. 16 FY 2005 initial applications (2.6 million) Recommendations: Focus on function Reconsiderations (0.6 million) ALJ disposition (0.5 million) Of appeals, 62% allowed by ALJ Functional Information Assess function: Comprehensively Uniformly Early

17. 17 Usefulness for SSA Dramatically improve breadth, completeness, uniformity, and precision of medical evidence Collect data when its most useful for decision making Even small improvements in the process may lead to: less processing time and costs improved accuracy and uniformity of decisions reduced backlogs

18. 18 Questions This exploratory work, being conducted by NIH and BU, examines ways in which claimants and their health care providers can quickly and easily provide information about claimants’ function. SSA has not yet adopted or endorsed this approach.