Social Security Disability Programs
Clearer Guidance Could Help SSA Apply the Medical Improvement Standard More Consistently Gao ID: GAO-07-8 October 3, 2006The Social Security Act requires that the Social Security Administration (SSA) find an improvement in a beneficiary's medical condition in order to remove him or her from either the Disability Insurance (DI) or Supplemental Security Income (SSI) programs. GAO was asked to (1) examine the proportion of beneficiaries who have improved medically and (2) determine if factors associated with the standard pose challenges for SSA when determining whether beneficiaries continue to be eligible for benefits. To answer these questions, GAO surveyed all 55 Disability Determination Services (DDS) directors, interviewed SSA officials, and reviewed pertinent SSA data.
Each year, about 13,800 beneficiaries, or 1.4 percent of all the people who left the disability programs between fiscal years 1999 and 2005, did so because SSA found that they had improved medically. More beneficiaries leave because they convert to regular retirement benefits, die, or for other reasons--including having earnings above program limits. In addition, while continuing disability reviews (CDR) are SSA's most comprehensive tool for determining whether a recipient continues to have a disability, on average, 2.8 percent of beneficiaries were found to have improved medically and to be able to work following a CDR during this 7-year period. Several factors associated with the medical improvement standard (the standard) pose challenges for SSA when assessing whether beneficiaries continue to be eligible for benefits. First, limitations in SSA guidance may result in inconsistent application of the standard. For example, SSA does not clearly define the degree of improvement needed to meet the standard, and the DDS directors GAO surveyed reported that they use different thresholds to assess if medical improvement has occurred. Second, contrary to existing policy, disability examiners in a majority of the DDSs are incorrectly conducting CDRs with the presumption that a beneficiary has a disability rather than with a "neutral" perspective. Other challenges associated with the standard include inadequate documentation of evidence as well as the judgmental nature of medical improvement determinations. All these factors have implications for the consistency of CDR decisions. However, due to data limitations, GAO was unable to determine the extent to which these problems affect decisions to continue or discontinue benefits.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-07-8, Social Security Disability Programs: Clearer Guidance Could Help SSA Apply the Medical Improvement Standard More Consistently
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Report to the Chairman, Committee on Finance, U.S. Senate:
United States Government Accountability Office:
GAO:
October 2006:
Social Security Disability Programs:
Clearer Guidance Could Help SSA Apply the Medical Improvement Standard
More Consistently:
Social Security Disability Programs:
GAO-07-8:
GAO Highlights:
Highlights of GAO-07-8, a report to the Chairman, Committee on Finance,
U.S. Senate
Why GAO Did This Study:
The Social Security Act requires that the Social Security
Administration (SSA) find an improvement in a beneficiary‘s medical
condition in order to remove him or her from either the Disability
Insurance (DI) or Supplemental Security Income (SSI) programs. GAO was
asked to (1) examine the proportion of beneficiaries who have improved
medically and (2) determine if factors associated with the standard
pose challenges for SSA when determining whether beneficiaries continue
to be eligible for benefits. To answer these questions, GAO surveyed
all 55 Disability Determination Services (DDS) directors, interviewed
SSA officials, and reviewed pertinent SSA data.
What GAO Found:
Each year, about 13,800 beneficiaries, or 1.4 percent of all the people
who left the disability programs between fiscal years 1999 and 2005,
did so because SSA found that they had improved medically. More
beneficiaries leave because they convert to regular retirement
benefits, die, or for other reasons”including having earnings above
program limits. In addition, while continuing disability reviews (CDR)
are SSA‘s most comprehensive tool for determining whether a recipient
continues to have a disability, on average, 2.8 percent of
beneficiaries were found to have improved medically and to be able to
work following a CDR during this 7-year period.
Several factors associated with the medical improvement standard (the
standard) pose challenges for SSA when assessing whether beneficiaries
continue to be eligible for benefits. First, limitations in SSA
guidance may result in inconsistent application of the standard. For
example, SSA does not clearly define the degree of improvement needed
to meet the standard, and the DDS directors GAO surveyed reported that
they use different thresholds to assess if medical improvement has
occurred. Second, contrary to existing policy, disability examiners in
a majority of the DDSs are incorrectly conducting CDRs with the
presumption that a beneficiary has a disability rather than with a
’neutral“ perspective. Other challenges associated with the standard
include inadequate documentation of evidence as well as the judgmental
nature of medical improvement determinations. All these factors have
implications for the consistency of CDR decisions. However, due to data
limitations, GAO was unable to determine the extent to which these
problems affect decisions to continue or discontinue benefits.
Figure: Average Percentage of All Beneficiaries Who Were Removed from
the DI and SSI Programs by Category (Fiscal Years 1999 to 2005):
[See PDF for Image]
Source: GAO analysis of SSA data.
[End of Figure]
What GAO Recommends:
GAO is making a recommendation to SSA to clarify guidance regarding the
degree of medical improvement required to meet the standard, the use of
exceptions, and the presumption of disability for assessing medical
improvement when conducting CDRs.
While generally agreeing with the value of additional guidance, SSA
expressed reservations about the need for further guidance on the
exceptions. GAO continues to see such a need since 7 of the 11
disability examiners we spoke with were uncertain regarding when to
apply the exceptions.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-8].
To view the full product, click on the link above. To view results of
GAO‘s survey of DDS directors, click: [Hyperlink,
http://www.gao.gov/cgibin/getrpt?rptno=GAO-07-4sp]. For more
information, contact Robert E. Robertson (202) 512-7215 or
robertsonr@gao.gov.
[End of Section]
Contents:
Letter:
Results In Brief:
Background:
Few Beneficiaries Are Removed from the Disability Programs Because They
Are Found to Have Improved Medically:
Several Factors Challenge SSA's Ability to Assess Whether Beneficiaries
Continue to Be Eligible for Benefits:
Conclusions:
Recommendation:
Agency Comments and Our Evaluation:
Appendix I: Scope and Methodology:
Appendix II: he Continuing Disability Review Evaluation Process:
Appendix III: Comments from the Social Security Administration:
Appendix IV: GAO Contact and Staff Acknowledgments:
Related GAO Products:
Figures:
Figure 1: Current Medical CDR Evaluation Process:
Figure 2: Average Percentage of All Beneficiaries Who Were Removed from
the DI and SSI Programs by Category (Fiscal Years 1999 to 2005):
Figure 3: Number of Full Medical CDRs Conducted and Resulting Benefit
Discontinuations (Fiscal Years 1999 to 2005):
Abbreviations:
ALJ: administrative law judge:
DDS: Disability Determination Services:
DI: Disability Insurance:
CDR: Continuing Disability Review:
CPD: comparison point decision:
POMS: Program Operations Manual System:
RFC: residual functional capacity:
SGA: substantial gainful activity:
SSA: Social Security Administration:
SSI: Supplemental Security Income:
United States Government Accountability Office:
Washington, DC 20548:
October 3, 2006:
The Honorable Charles E. Grassley:
Chairman:
Committee on Finance:
United States Senate:
Dear Mr. Chairman:
In fiscal year 2005, the Social Security Administration (SSA) paid
about $126 billion to approximately 12.8 million beneficiaries under
the Disability Insurance (DI) and Supplemental Security Income (SSI)
programs. These disability programs provide income support and in most
cases, access to medical care for people unable to work due to physical
or mental impairments, or both. In recent years, both programs have
grown and are poised to grow even faster as the baby boom generation
enters its disability-prone years. For example, SSA expects that by
2010 the number of DI beneficiaries and their eligible family members
will increase by more than one-third over 2001 levels.
SSA is required to conduct periodic continuing disability reviews (CDR)
to ensure that only eligible people continue to receive benefits. These
reviews assess whether individuals are still eligible for benefits
based on their current medical condition and ability to work, among
other criteria.[Footnote 1] When SSA was conducting these reviews in
the early 1980s, there were concerns that some beneficiaries were being
arbitrarily removed from the programs. In response, Congress passed the
Social Security Disability Benefits Reform Act of 1984[Footnote 2] (the
act), which among other things established a medical improvement
standard (the standard). Under this standard, unless certain exceptions
apply, SSA must find improvement in a beneficiary's medical condition
and that the individual is able to work in order to discontinue
benefits.[Footnote 3] If SSA determines that the standard has been met
in the course of conducting a CDR, the beneficiary may continue to
receive benefits until the individual receives another CDR (which
potentially could result in a discontinuation of benefits), dies, or
transitions into Social Security retirement benefits.
Since the standard has been implemented, some observers have suggested
that certain factors associated with the standard may lead SSA to
continue benefits for some individuals who might otherwise be able to
work. Given this observation and the continued growth in the DI and SSI
programs, the Senate Committee on Finance asked us to (1) examine the
proportion of beneficiaries who are removed from the disability
programs because they have improved medically and (2) determine if
factors associated with the standard pose challenges when determining
whether beneficiaries continue to be eligible for benefits.
To address these questions, we reviewed the act, regulations, and SSA
guidance and processes for evaluating whether beneficiaries continue to
be eligible for benefits. We examined SSA data on CDR outcomes for a 7-
year period (fiscal years 1999 to 2005). We looked only at DI and SSI
adult beneficiaries.[Footnote 4] We verified the statistical data on
CDR outcomes, interviewed knowledgeable officials about the data, and
determined that the data were sufficiently reliable for the purposes of
our review. Furthermore, we conducted a national survey of all 55
Disability Determination Services (DDS) directors and received 54
completed responses to achieve a response rate of 98 percent. In
addition, we interviewed various SSA officials, disability experts, and
disability advocacy groups regarding the standard. We also conducted
site visits in three states (Massachusetts, Texas, and California). We
selected these states based on several criteria, including number of
disability beneficiaries, proportion of CDRs that result in a
discontinuation of benefits, and geographic dispersion, among other
criteria. During these visits, we conducted in-depth interviews with 80
selected SSA officials, including DDS directors, CDR supervisors,
disability examiners,[Footnote 5] and medical specialists. We also
interviewed regional office disability officials, regional Office of
Disability Adjudication and Review officials, administrative law
judges, and regional Office of Quality Performance officials and
examiners. Moreover, we reviewed selected CDR cases to obtain examples
of how the standard may impact decisions to continue or discontinue
benefits. In addition, we consulted with outside groups including the
Social Security Advisory Board and disability advocacy groups. We
conducted our work from October 2005 through June 2006 in accordance
with generally accepted government auditing standards. Appendix I
discusses our scope and methodology in more detail. The survey and a
tabulation of the results can be viewed at [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?rptno=GAO-07-4sp].
Results In Brief:
On average, each year about 13,800 beneficiaries, or 1.4 percent of all
the people who left the disability programs between fiscal years 1999
and 2005, were removed because SSA found that they had improved
medically. More beneficiaries leave the programs because they die or
convert to regular retirement benefits. Moreover, while CDRs are the
agency's most comprehensive tool for determining whether a recipient
continues to have a disability, on average, about 2.8 percent of
beneficiaries who undergo a CDR leave the DI and SSI programs due to
medical improvement. For example, in fiscal year 2005, SSA conducted
about 333,000 medical CDRs and discontinued disability benefits for
about 10,300 recipients for medical improvement.
Our review suggests that several factors associated with the standard
pose challenges for SSA's ability to assess whether beneficiaries
continue to be eligible for benefits. First, limitations in SSA
guidance may result in inconsistent application of the standard. For
example, we found that SSA does not clearly define the degree of
improvement needed to meet the standard, and the directors we surveyed
reported using different thresholds to show medical improvement. From
our survey, 17 DDS directors reported that a large or very large
increase in a recipient's ability to perform basic work activities is
required to show medical improvement, while 24 reported that a moderate
increase is required. In addition, while the act does provide for
certain exceptions to medical improvement that could result in
additional individuals having their benefits discontinued following a
CDR, most of the disability examiners whom we spoke with on our site
visits (7 of the 11 examiners) told us that they were uncertain about
when to apply the exceptions. Second, incorrect application of one
element of the standard by a majority of DDSs--CDRs should be conducted
on a neutral basis, without a presumption that an individual continues
to have a disability--may make it difficult to determine if
beneficiaries have improved medically. Finally, we found that other
factors, such as inadequate documentation of evidence and the
judgmental nature of the decision process concerning what constitutes
medical improvement may make it difficult for SSA to determine whether
a beneficiary remains eligible for benefits. These problems have
implications for the consistency and fairness of SSA's medical
improvement decision-making process. However, due to data limitations,
we were unable to determine the extent to which these problems actually
affect decisions to continue or discontinue benefits.
We are recommending that the Commissioner of Social Security clarify
policies for assessing medical improvement. Areas that could benefit
from improved clarity in guidance include what degree of improvement is
needed to meet the standard, when the use of exceptions is appropriate,
as well as clarification for DDSs about presumption of disability when
conducting CDRs.
SSA generally agreed with our recommendation but expressed reservations
about the need for further guidance on the proper use of the exceptions
to medical improvement. SSA believed that its implementation of the
statutory exceptions is appropriate and that its instructions are
consistent with the intent of the law. We revised the report to more
clearly highlight that the need for further guidance stems from our
discussions with disability examiners, most of whom expressed
uncertainty regarding the application of the exceptions.
Background:
The Social Security Administration (SSA) administers two programs under
the Social Security Act that provide benefits to people with
disabilities: (1) Disability Insurance (DI) and (2) Supplemental
Security Income (SSI).[Footnote 6] Established in 1956, DI is an
insurance program that provides benefits to workers who become unable
to work because of a long-term disability. Workers who have paid into
the Social Security Trust Fund are insured under this program. At the
end of calendar year 2005, the DI program served about 8.3 million
workers with disabilities, their spouses, and dependent children and
paid out about $85 billion in cash benefits throughout the year. Once
found entitled, individuals continue to receive benefits until they
either die, return to work and earn more than allowed by program rules,
are found to have improved medically and are able to work, or reach
regular retirement age[Footnote 7] (when disability benefits convert to
retirement benefits).
SSI serves people with disabilities on the basis of need, regardless of
whether they have paid into the Social Security Trust Fund. Created in
1972, SSI is an income assistance program that provides cash benefits
for disabled, blind, or aged people who have low income and limited
resources. At the end of calendar year 2005, the SSI program served
about 6.8 million people and paid about $36 billion in federal cash
benefits throughout the year.[Footnote 8] These cash benefits are paid
from general tax revenues. SSI benefits generally can be discontinued
for the same reasons as DI benefits, although SSI benefits also may be
discontinued if a person no longer meets SSI income and resource
requirements. Unlike the DI program, SSI benefits can continue even
after the person reaches full retirement age.
The Social Security Act's definition of disability for adults is the
same under both programs. A person's physical or mental impairment must
(1) have lasted or be expected to last at least 1 year or to result in
death and (2) prevent or be expected to prevent him or her from being
able to engage in substantial gainful activity (SGA) for that period of
time. People are generally considered to be engaged in SGA if they earn
above a certain dollar level. For 2006, SSA considers countable
earnings above $860 a month to be SGA for an individual who is not
blind and $1,450 a month for an individual who is blind.
History of the Medical Improvement Standard and the Current Continuing
Disability Review Process:
Prior to 1980, some studies indicated that many beneficiaries of the
disability programs no longer had a disability and could work. To
ensure that only eligible beneficiaries remained in the programs,
Congress passed a law requiring SSA to conduct continuing disability
reviews (CDR) beginning in January 1982. State Disability Determination
Services (DDS) examiners began conducting medical CDRs under the same
criteria used to evaluate initial disability claims. In 1981 and 1982,
about 45 percent of those individuals who received a CDR had their
benefits discontinued.[Footnote 9] There was no statutory requirement
for SSA to show that a beneficiary had improved medically in order to
remove him or her from the programs. Disability advocacy groups and
others became concerned that some beneficiaries were being
inappropriately removed from the disability programs, and by 1984 SSA
placed a moratorium on all CDRs.
To address concerns that some beneficiaries were being inappropriately
removed from the programs, Congress enacted the Social Security
Disability Benefits Reform Act of 1984. The act included a provision
requiring SSA to find substantial evidence demonstrating medical
improvement before ceasing a recipient's benefits (the medical
improvement standard). SSA resumed CDRs in January 1986 using this
standard, which is among the first steps of the CDR evaluation
process.[Footnote 10] The standard has the following two elements that
need to be met:
* Is there improvement in a beneficiary's medical condition? The
regulations implementing the act define improvement as any decrease in
the medical severity of the beneficiary's impairment(s) since the last
time SSA reviewed his or her disability, based on changes in symptoms,
signs, or laboratory findings.
* Is this improvement related to the ability to work? Improvement
related to the ability to work is evaluated two different ways,
depending on whether the comparison point decision (CPD) was based on:
(1) meeting or equaling a prior disability listing[Footnote 11] or (2)
a residual functional capacity (RFC) assessment.[Footnote 12]
* Meeting or equaling the prior listing: In this case, a disability
examiner will determine if the beneficiary's same impairment(s) still
meets or equals the prior listing. A disability examiner compares the
beneficiary's condition with the list of impairments in effect at the
time he or she was first awarded disability benefits.[Footnote 13] If
the impairment(s) meets or equals the prior listing, then benefits are
continued. If not, then the examiner proceeds with the CDR evaluation.
* Residual functional capacity assessment: In this case, a disability
examiner compares the beneficiary's previous functional capacity to the
current functional capacity for the same impairment. If functional
capacity for basic work activities has improved, then the examiner
finds that the medical improvement is related to the ability to work
and proceeds with the CDR evaluation.
The act allows SSA to discontinue benefits even when the beneficiary
has not improved medically if one of the specific "exceptions" to
medical improvement applies[Footnote 14]
* the person benefits from advances in medical or vocational therapy or
technology,
* the person has undergone a vocational therapy program that could help
him or her work,
* new or improved diagnostic techniques or evaluations reveal that the
impairment is less disabling than originally thought, or:
* the prior decision was in error.
In order to be removed from the disability programs for one of the
exceptions, disability examiners must also show that the individual has
the ability to engage in SGA.
SSA does not conduct CDRs on all beneficiaries each year. At the time
beneficiaries enter the DI or SSI programs, DDSs determine when they
will be due for CDRs based on their likely potential for medical
improvement. Based on SSA regulations, DDSs classify beneficiaries into
one of three medical improvement categories:
* medical improvement expected--CDR generally once every 6 to 18
months;
* medical improvement possible--CDR once every 3 years; or:
* medical improvement not expected--CDR once every 5 to 7 years.
SSA has also developed a method, called profiling, to determine the
most cost-effective method of conducting a CDR. SSA applies statistical
formulas that use data on beneficiary characteristics--such as age,
impairment type, length of time on disability programs, previous CDR
activity, and reported earnings--to predict the likelihood of medical
improvement and, therefore, of benefit discontinuation. SSA assigns a
"score" to beneficiaries indicating whether there is a high, medium, or
low likelihood of medical improvement. In general, beneficiaries with a
high score are referred for full medical CDRs. Beneficiaries with lower
scores are, at least initially, sent a questionnaire, known as a
"mailer."[Footnote 15] Full medical CDRs involve an in-depth
examination of a beneficiary's medical and possibly his or her
vocational status. This may include a review of the recipient's case
file, physical and psychological condition, and medical evidence by a
disability examiner and physician. Unlike full medical CDRs, CDR
mailers consist of a short list of questions asking beneficiaries to
self-report information on their medical condition, treatments, and
work activities. Appendix II describes the medical CDR evaluation
process in detail.
SSA will find that disability has ended and discontinue
benefits[Footnote 16] if it determines that medical improvement related
to the ability to work has occurred or that one of the exceptions
applies, and the person's impairments are not severe or the person can
do past work or other work. If SSA determines that medical improvement
has not occurred and that none of the exceptions apply, then benefits
are continued[Footnote 17] (see fig. 1).
Figure 1: Current Medical CDR Evaluation Process:
[See PDF for image]
Source: GAO and SSA.
[A] For SSI beneficiaries, SGA is not considered and the CDR evaluation
process is started at Step 2. Instructions for SGA considerations
differ for beneficiaries covered by certain work incentive programs.
[B] If a group II exception applies, discontinue benefits immediately
without a medical determination.
[C] Consider age and time on the disability programs.
[End of figure]
If SSA finds that the individual no longer has a disability and
discontinues benefits following a CDR, the individual has the right to
appeal the CDR decision, first to another reviewer for a
reconsideration, second to an administrative law judge, then to the
Appeals Council, and finally to federal courts. At the hearing before
the administrative law judge (ALJ), the ALJ reviews the file, including
any additional evidence submitted after the DDS determination and may
hear testimony from the individual as well as medical and vocational
experts.
SSA's Office of Quality Performance conducts quality reviews of
disability determination outcomes. To conduct these quality reviews,
SSA selects a random sample of cases each month from all final CDR
decisions, stratifying the selection of cases by state and outcome
(cases where benefits are continued and discontinued). Then, a quality
examiner reviews the case to ensure it adheres to SSA guidance,
including a review of the DDS decision, the documentation of that
decision, and the evidence contained in the case. During these reviews,
physicians[Footnote 18] evaluate the evidence to ensure that the
decision adheres to the medical improvement standard. In fiscal year
2005, SSA's Office of Quality Performance reported nationwide accuracy
rates for cases where CDR benefits were continued and discontinued of
95 percent and 93 percent respectively. The combined accuracy rate for
all CDRs was about 95 percent.
Few Beneficiaries Are Removed from the Disability Programs Because They
Are Found to Have Improved Medically:
We found that on average, about 1.4 percent of all individuals who left
the programs between fiscal years 1999 and 2005 were removed for
medical improvement. More beneficiaries leave the disability programs
because they either die or convert to social security retirement
benefits. In addition, while full medical CDRs are the agency's most
comprehensive tool for determining whether a beneficiary continues to
have a disability, about 2.8 percent of those who receive these CDRs
are found to no longer have a disability under the medical improvement
standard.
Few Beneficiaries Are Removed from the Programs Due to Medical
Improvement:
Between fiscal years 1999 and 2005, annually, an average of
13,800[Footnote 19] people--or about 1.4 percent of all individuals who
left the disability programs--were removed because SSA found that they
had improved medically.[Footnote 20] More people leave the programs
when they die, convert to full retirement benefits,[Footnote 21] or
leave for other reasons. For example, between fiscal years 1999 and
2005, each year an average of about 311,000[Footnote 22] recipients
(about 32 percent of all recipients who were removed from the
disability programs) died, and about 209,000 (about 21 percent)
converted from DI benefits to retirement benefits. In addition, each
year about 444,000 beneficiaries (about 45 percent) were removed from
the disability programs for other reasons. These include about 54,000
DI beneficiaries who SSA determined had earnings in excess of SGA,
about 11,000 DI beneficiaries who either converted to old-age
retirement benefits prior to reaching the full retirement age[Footnote
23] or were found to be erroneously eligible for benefits, and about
379,000 SSI beneficiaries who were removed from the SSI program for all
reasons other than death and medical improvement (including earnings
and resources above the limit allowed by program guidelines) (see fig.
2).
Figure 2: Average Percentage of All Beneficiaries Who Were Removed from
the DI and SSI Programs by Category (Fiscal Years 1999 to 2005):
[See PDF for image]
Source: GAO analysis of SSA data.
Note: While the combined DI and SSI programs in figure 2 illustrate the
reasons why beneficiaries are removed from the DI and SSI programs,
there are some differences between these two programs. For the same
time period, for the DI program, about 2 percent of all recipients who
were removed from the DI program improved medically; about 45 percent
converted from disability benefits to retirement benefits; about 39
percent died; about 12 percent had earnings in excess of SGA; and about
2 percent left for other reasons. For the SSI program, about 1 percent
of all recipients who were removed from the SSI program improved
medically; about 25 percent died; and about 74 percent left for other
reasons.
[End of figure]
During fiscal years 1999 to 2005, the proportion of all beneficiaries
who were removed from the programs in each of the above categories
remained fairly consistent. For example, during this period, the
proportion of individuals removed from the disability programs in a
fiscal year for medical improvement ranged from 1.0 percent to 1.7
percent; the proportion of individuals who died ranged from 31.1
percent to 33.0 percent; and the proportion of individuals who
converted from disability benefits to retirement benefits ranged from
19.7 percent to 22.7 percent.
Few Beneficiaries Who Receive Full Medical Continuing Disability
Reviews Are Removed from the Programs Each Year:
SSA data show that few beneficiaries who receive medical CDRs are
removed from the disability programs. Full medical CDRs are the
agency's primary tool to determine whether a beneficiary has improved
medically. Between fiscal years 1999 and 2005, the number of full
medical CDRs conducted ranged from a high of 608,000 in 2001 to a low
of 333,000 in 2005 (see fig. 3).[Footnote 24] Between fiscal years 1999
and 2005, an average of about 26,000 individuals each year (about 5.3
percent) were removed from the disability programs as a result of
receiving a medical CDR. Some of the officials we interviewed stated
that the medical improvement standard may artificially limit the
percentage of recipients who are found to have improved medically.
However, we were unable to identify any empirical data regarding the
impact of the standard on the percentage of recipients who have their
benefits discontinued, or what a "proper" discontinuation rate should
be.
While the number of CDRs conducted between fiscal years 1999 and 2005
fluctuated,[Footnote 25] the percentage of beneficiaries removed from
the programs remained fairly constant.[Footnote 26] For example, in
fiscal years 1999, 2002, and 2004, the percentage of recipients who
were removed from the disability programs as a result of receiving a
CDR was 5.4 percent, 5.6 percent, and 5 percent respectively. In
addition to medical improvement, SSA also removes beneficiaries for
failing to cooperate during a CDR. For example, a beneficiary may fail
to appear for scheduled meetings with disability examiners or
physicians and thus may have their benefits discontinued. Of the
individuals removed from the programs as a result of receiving a CDR
between fiscal years 1999 and 2005, an average of about 13,800
individuals (or 2.8 percent of all CDRs conducted between fiscal years
1999 and 2005) were removed annually because SSA determined that they
had improved medically, while an average of about 10,300 individuals
(or about 2.1 percent) were removed each year for failure to cooperate.
Figure 3: Number of Full Medical CDRs Conducted and Resulting Benefit
Discontinuations (Fiscal Years 1999 to 2005):
[See PDF for image]
Source: GAO analysis of SSA data.
[End of figure]
Several Factors Challenge SSA's Ability to Assess Whether Beneficiaries
Continue to Be Eligible for Benefits:
Our review suggests that several factors associated with the standard
pose challenges for SSA's ability to assess whether beneficiaries
continue to be eligible for benefits. First, limitations in SSA
guidance may result in inconsistent application of the standard. For
example, we found that SSA does not clearly define the degree of
improvement needed to meet the standard, and the DDS directors we
surveyed reported using different thresholds to show medical
improvement. As a result of this apparent limitation in SSA guidance,
disability examiners may incorrectly decide to continue or discontinue
benefits. In addition, while the act provides for certain exceptions
that could result in additional individuals having their benefits
discontinued following a CDR, most of the disability examiners we spoke
with told us that they were uncertain about when to apply the
exceptions. Second, we found that most DDSs are incorrectly conducting
CDRs with the presumption that a beneficiary has a disability. Finally,
other factors, such as inadequate documentation of evidence and the
judgmental nature of the decision process for assessing medical
improvement may make it more difficult to determine whether a
beneficiary remains eligible for benefits. However, due to data
limitations, we were unable to determine the extent to which these
challenges impact decisions to continue or discontinue benefits during
a CDR.
Limitations in SSA Guidance for Applying the Medical Improvement
Standard May Result in Inconsistent Disability Decisions:
Our work shows that SSA does not clearly define the degree of
improvement needed for examiners to determine if a beneficiary has
improved medically. Many disability examiners and DDS officials told us
that they were unsure about the degree of improvement required to meet
the standard, and some said this confusion stems from unclear SSA
guidance. In particular, SSA guidance instructs examiners to disregard
"minor" changes in a beneficiary's condition.[Footnote 27] However,
this guidance does not adequately describe what constitutes a minor
change. When we asked SSA officials to clarify their understanding of
what constitutes a minor change, they told us that only changes that
would not affect a beneficiary's ability to work should be considered
minor. However, this explanation of minor changes is not included in
the agency's guidance. As a result, some DDSs may be inconsistently
defining what constitutes a minor change. For example, five DDS
directors told us that they define minor changes to include those that
may actually improve functioning or allow the beneficiary to work. In
doing so, our review suggests that some DDSs may be inconsistently
applying the standard as to what constitutes medical improvement.
However, DDS directors differed on the extent to which the guidance to
disregard minor changes impacts CDRs. Of the 52 DDS directors who
answered a question in our survey on "minor" changes, 21 reported that
the practice of disregarding minor changes is not an impediment to
making a disability determination, while 31 reported that it is an
impediment.[Footnote 28]
Similarly, we found that SSA guidance may not provide DDS examiners
with sufficient detail to determine whether improvements in
beneficiaries' medical conditions are related to their ability to work.
At this step of the CDR process, examiners look for changes in a
beneficiary's ability to perform basic work activities since the last
review, such as lifting heavy objects or standing or sitting for
periods of time.[Footnote 29] The guidance instructs examiners to
ensure a "reasonable relationship" between the amount of improvement
and the increase in the ability to perform basic work
activities.[Footnote 30] However, the guidance does not require a
specific amount of increase in functioning. The DDS directors we
surveyed reported that they interpret this guidance differently.
Specifically, 17 of 49 directors reported that a large or very large
increase in a recipient's ability to do basic work activities is
required; 24 reported that a moderate increase is required; and 8
reported that a minor or any increase at all is required. Furthermore,
two DDS directors in our survey inaccurately noted that the standard
requires that a beneficiary's improvement be great enough so that it
actually enables the individual to work.[Footnote 31] One of these
directors commented that because SSA guidance on this aspect of the
standard is open to broad interpretation, it is difficult to document
improvement to the extent the individual is able to work. As a result,
some DDSs may be inconsistently applying this aspect of the standard
that could potentially impact decisions to continue or discontinue
benefits. However, we were unable to determine how much of an impact
clarification of this guidance would have on CDR outcomes.
The disability advocates we spoke with differed in their views on the
clarity of SSA guidance on medical improvement. While some stated that
it is clear and adequate, others stated that the guidance on assessing
medical improvement in psychological impairments and determining if
improvement is related to the ability to work is confusing and unclear.
One advocate stated that current SSA policies contribute to some
recipients remaining in the disability programs despite their ability
to work.
We also found that while the act provides for exceptions to medical
improvement that could result in additional individuals having their
benefits discontinued as a result of receiving a CDR, most of the
disability examiners whom we spoke with on our site visits told us that
they were uncertain about when to apply the exceptions.[Footnote 32]
SSA policies allow for various exceptions, including when the prior
decision was in error or when persons benefit from education or
training programs that could help the individuals work. However, we
found that while the examiners and ALJs routinely assess whether a
beneficiary has improved medically, they do not routinely assess
whether or not each of the exceptions applies to the case. Moreover,
many of the DDS officials and examiners we interviewed told us that the
guidelines for using the error exception are written in a way that
precludes its use, except in the most extreme situations.[Footnote 33]
SSA officials explained that the exceptions were written to
intentionally limit their use in order to prevent examiners from
circumventing the standard, and that their infrequent use is
appropriate. In addition, SSA explained that when it issued the final
rules governing the medical improvement standard, it intended the
exceptions to be true "exceptions"--not to be routinely applied
(including the error exception). The agency also noted that a broader
application of the error exception could lead to a substitution of
judgment by an adjudicator for the original finding of disability in
instances where a person's medical condition had not substantially
improved. Some disability advocates we spoke with also noted that the
narrow interpretation of the error exception is appropriate because it
prevents substitution of judgment and arbitrary discontinuations.
A Majority of DDSs Incorrectly Apply SSA Guidelines Stating That CDRs
Should Be Conducted Neutrally, without a Presumption of Disability:
According to our survey, a majority of DDSs incorrectly presume that a
beneficiary continues to have a disability when conducting CDRs, which
may make it more difficult for examiners to determine if a beneficiary
has improved medically. This is contrary to the act as well as SSA
regulations and policy, which require that CDR decisions be made on a
"neutral basis." SSA defines neutral basis as a review that neither
presumes that a beneficiary (1) is still disabled because he or she was
previously found disabled and (2) is no longer disabled because he or
she was selected for a CDR. Under a neutral review, it is assumed that
beneficiaries had a disability at the time of the prior decision, but
it is not assumed they still have a disability at the time of a CDR.
However, in survey responses, 31 DDS directors responded that in
practice, CDRs are conducted with the presumption that a beneficiary
continues to have a disability.[Footnote 34] When asked to explain this
response, directors cited various factors that likely contribute to the
presumption of disability during a CDR. Thirteen directors commented
that the individuals are already receiving disability benefits, and as
a result, the directors assume that the beneficiary continues to have a
disability. Some of these directors also noted that they make this
presumption because the beneficiary was found disabled when initially
awarded benefits, and examiners must show medical improvement to remove
them from the programs.
Since a majority of DDSs are conducting CDRs with a presumption that
beneficiaries have a disability, those DDSs may be setting a higher bar
than required by the standard for these reviews. Moreover, by requiring
more evidence of medical improvement than is necessary under the
standard, it may be harder to assess whether a recipient no longer has
a disability and is able to work. Because 31 directors reported that
examiners conduct CDRs with the presumption that beneficiaries continue
to have a disability, a significant number of beneficiaries may be
evaluated under this higher standard, and some may have their benefits
erroneously continued. While these problems raise concerns about the
consistency of decisions when determining if medical improvement has
occurred, the ultimate impact of presuming that an individual has a
disability on CDR decisions is unknown because we were unable to
empirically test how the presumption of a disability impacts CDR
decisions to continue or discontinue benefits.
Other Factors May Make Assessing Medical Improvement Difficult:
Inadequate documentation of evidence and the judgmental nature of the
process for assessing medical improvement are two additional factors
that make it challenging to assess medical improvement. The standard
establishes the prior decision as the starting point for conducting a
CDR and requires examiners to find evidence of medical improvement
since this last decision. Some DDS directors reported that it may be
difficult to assess medical improvement in cases where the prior
disability decision was based on incomplete or poorly documented
evidence. For example, in one of the CDR cases we reviewed, a
beneficiary had his benefits continued following the CDR because the
rationale for the prior disability decision was vague, according to the
examiner who reviewed the case with us. This beneficiary was originally
awarded benefits on appeal based on recurrent stomach problems and
depression. When the case was selected for a CDR, the case file
included a general description of the beneficiary's medical condition,
but lacked sufficient evidence to determine if medical improvement had
occurred since the initial decision, according to the examiner. As a
result, medical improvement could not be shown and benefits were
continued. While many examiners and officials we interviewed agreed
that it is difficult to show medical improvement in cases that lack
adequate documentation, they differed in their opinions about how
frequently this occurs. Of the directors who answered our survey
question on insufficient documentation, 33 responded that they
encounter cases with insufficient documentation infrequently or very
infrequently, and 17 responded that such cases occurred more
often.[Footnote 35]
Survey respondents also differed in their opinions about the types of
cases that more typically lack adequate documentation, but 15 directors
commented that cases decided on appeal were the most likely to lack
adequate documentation. One possible explanation for this may be
streamlined processes at the appeals level. For example, one ALJ we
interviewed noted that, in an effort to process cases in a timely
manner, ALJs sometimes issue quick decisions in which most of the
evidence is on tapes that are not transcribed or placed in the
beneficiary's case file. In such instances, it is unlikely that the DDS
examiner would have complete information for conducting a CDR and
determining if medical improvement had taken place. Furthermore,
several officials told us that guidance instructs ALJs to include
enough information in their decisions so that the decisions will be
legally sufficient. However, the guidance does not specifically
instruct ALJs to include all of the evidence that will be needed to
assess medical improvement at a future CDR. However, in recent
regulations to implement changes to its disability determination
process, SSA is taking steps that may help to address the problem of
incomplete documentation for future CDRs. Specifically, SSA is
developing requirements for training examiners to ensure they
understand the information needed to make accurate and adequately
documented decisions, has adopted guides for decision writing at the
appeals level, and is in the process of developing guides for use at
the DDS level.
In addition to the challenges associated with problems of inadequate
documentation, many examiners also told us that the judgmental nature
of the decision process concerning what constitutes an improvement can
make it difficult to assess medical improvement. One examiner may
determine that a beneficiary has improved medically and discontinue
benefits, while another examiner may determine that medical improvement
has not been shown and will continue the individual's benefits. For
example, in one of the CDR cases that we reviewed, the examiner
conducting the initial CDR determined that medical improvement was
shown and discontinued the individual's benefits. The recipient was
initially awarded disability benefits for a back injury with limited
range of motion in the recipient's back. When the CDR was conducted,
the examiner evaluated all of the relevant evidence and concluded that
the individual's range of motion had improved. The examiner also noted
that the individual's allegations of pain did not correlate with the
findings from both the physical exam and the laboratory findings. As a
result, the examiner concluded that medical improvement had occurred.
On appeal to reconsideration 6 months later, a different DDS examiner
conducted a review using the same medical evidence as the original
examiner, but determined that medical improvement had not occurred, and
continued benefits. The examiner conducting the appeal concluded that
the beneficiary continued to experience pain consistent with the back
condition, and thus medical improvement was not shown. However, we had
no basis for determining which decision was correct.
The amount of judgment involved in the decision-making process
increases when the process involves certain types of impairments that
are difficult to assess. More specifically, assessing medical
improvement may be more difficult in cases that involve certain types
of psychological impairments, such as depression, than cases with
physical impairments, such as amputations. In elaborating on their
survey responses, 17 directors commented that assessing medical
improvement is more difficult in cases with psychological impairments
because evidence of these impairments is generally more subjective than
evidence of many physical impairments. In addition, six directors
commented that evaluations of psychological impairments tend to rely
more heavily on assessment of functionality. According to some of these
officials, an assessment of functionality is more subjective because it
relies more on the beneficiaries' account of their own conditions than
on laboratory findings. Furthermore, some officials reported that the
severity of psychological impairments can fluctuate over time, making
it difficult to assess whether improvement has taken place. Two
directors commented that determining whether there is medical
improvement for some types of psychological impairments can also be
complicated because medical experts' opinions can vary. One of these
directors commented that the evidence to support psychological
impairments, such as evaluations for depression, rely less on
laboratory findings and more on clinical judgment. In contrast, certain
tests for physical impairments tend to be less open to interpretation.
For example, one director commented that X-rays of joint deterioration
can generally be interpreted consistently among radiologists. The
potential difficulty of assessing medical improvement in beneficiaries
whose disability is based on certain types of psychological impairments
is especially relevant, given that the proportion of all individuals in
the disability programs whose disability is based on a psychological
impairment has grown in recent years.
Conclusions:
SSA is responsible for assuring that individuals who truly have a
disability that prevents them from being able to work continue to
receive benefits. At the same time, SSA has a stewardship
responsibility to identify those beneficiaries who have improved
medically and are no longer eligible for benefits. The medical
improvement standard is intended to help SSA accomplish both of these
responsibilities. However, several factors associated with the standard
pose challenges for ensuring that the standard is implemented in a
consistent and fair manner. Specifically, potential limitations in SSA
guidance regarding the degree of improvement needed to meet the
standard as well as a lack of clarity with respect to the appropriate
use of the exceptions to medical improvement may make it difficult to
assess if medical improvement has occurred. Clear guidance is
especially important in view of the judgmental nature of the disability
determination process. Additionally, while SSA guidelines regarding the
presumption of disability during CDRs tend to be generally clear,
incorrect application of these guidelines by several DDSs suggests that
the outcomes of CDRs could be affected and may result in benefit
continuation for some individuals who might otherwise been found to
have improved medically. Other factors, including inadequate
documentation of evidence, are more difficult to address in the short
term. However, SSA is taking actions intended to address some of these
problems.
Recommendation:
To ensure that SSA is able to consistently assess whether DI and SSI
beneficiaries have improved medically, we recommend that the
Commissioner of Social Security clarify guidance for assessing medical
improvement when conducting CDRs. More specifically, SSA should clarify
guidance concerning (1) what degree of improvement is required to meet
the standard and (2) when the use of exceptions to medical improvement
is appropriate. SSA should also work with DDSs to ensure that CDRs are
conducted on a neutral basis, without a presumption that beneficiaries
continue to have a disability.
Agency Comments and Our Evaluation:
We obtained written comments on a draft of this report from the
Commissioner of the Social Security Administration (SSA). The agency
generally agreed with our recommendation, but expressed reservations
about the need for further guidance on the use of exceptions. More
specifically, SSA believed that its implementation of the statutory
exceptions to medical improvement is appropriate and that its
instructions are consistent with the intent of the law. As such, SSA
was concerned about language in the draft report that characterized
SSA's guidance as discouraging and limiting the use of the exceptions.
After considering these comments, we revised the report to include
additional information on (1) examiners' confusion on the use of the
exceptions when conducting CDRs and (2) SSA's rationale for its current
exception guidance. Having made these changes, we continue to believe
that additional guidance in this area is warranted if only, as the
report notes, because most of the disability examiners whom we spoke
with told us that they were uncertain about when to apply the
exceptions. Moreover, while answering a survey question on the
exceptions to medical improvement, 4 DDS directors commented that more
guidance regarding the use of the exceptions is needed.
SSA generally agreed with the need for clarifying guidance concerning
the degree of improvement required to meet the medical improvement
standard. However, the agency believed that the report was unclear with
regard to whether this part of the recommendation applied only to
guidance for determining if there has been any medical improvement, or
also to the guidance for determining if any medical improvement is
related to the ability to work. As stated in the draft report, our
discussion of medical improvement encompasses both elements
(improvement in a beneficiary's medical condition and its relation to
the ability to work). However, we did further clarify this throughout
the entire report to minimize any confusion on this matter.
Additionally, SSA indicated that clarification of this guidance would
probably have little noticeable impact on the number of cases in which
SSA finds that a disability has ended. As our report notes, we cannot
quantify the impact that clearer guidance would have on the
discontinuation of benefits. Even so, we continue to believe that it is
important for DDSs to consistently apply this aspect of the medical
improvement standard and that, towards that end, additional guidance
would be useful.
SSA agreed with the need for further training to ensure that CDRs be
conducted on a neutral basis. However, it believed that more
adjudicator training in this area would likely have little impact on
discontinuing benefits. We cannot predict the impact additional
guidance and training would have on continuing or discontinuing
benefits. However, as the report points out, there are large numbers of
DDS directors who are incorrectly applying the neutrality standard and,
in our view, would benefit from additional guidance in this area.
Beyond commenting on our recommendation, SSA suggested that we provide
additional context for some of the statistical information presented in
our discussion of the proportion of beneficiaries removed from the
disability programs each year. For example, SSA commented that the
disability discontinuation rates in the early 1980s may not have been
representative of the discontinuation rates prior to the implementation
of the medical improvement standard due to special targeted initiatives
aimed at removing individuals from the DI program who no longer had a
disability. We revised the report to take into account these
suggestions.
The Commissioner's comments have been reproduced in appendix III. SSA
also provided additional technical comments, which have been
incorporated in the report as appropriate.
Unless you publicly announce its contents earlier, we plan no further
distribution until 30 days after the date of this report. At that time,
we will make copies available to other parties upon request. In
addition, the report will be available at no charge on GAO's Web site
at [Hyperlink, http://www.gao.gov]. This report does not contain all
the results from the survey. The survey and a more complete tabulation
of the results can be viewed at [Hyperlink, http://www.gao.gov/cgi-
bin/getrpt?rptno=GAO-07-4sp].
If you or your staff have questions concerning this report, please
contact me at (202) 512-7215. Contact points for our Offices of
Congressional Relations and Public Affairs may be found on the last
page of this report. See appendix IV for a listing of major
contributors to this report.
Signed by:
Robert E. Robertson, Director, Education, Workforce, and Income
Security Issues:
[End of section]
Appendix I: Scope and Methodology:
This appendix provides additional details about our analysis of the
medical improvement standard (the standard), including challenges the
standard poses for the Social Security Administration (SSA) when
conducting medical continuing disability reviews (CDR). To meet the
objectives of this review, we reviewed prior studies by GAO, SSA, SSA's
Inspector General, Congressional Research Service, and external
organizations related to the disability determination process and CDRs.
We also reviewed the Social Security Disability Benefits Reform Act of
1984, regulations, and SSA policies and processes for assessing whether
beneficiaries continue to be eligible for benefits. In addition, we
analyzed SSA data on CDR outcomes over a 7-year period for fiscal years
1999 to 2005 as well as reports identifying the number of beneficiaries
who leave the disability programs and the reasons why they leave. For
the purposes of our study, we only assessed DI and SSI adult
beneficiaries who left the programs as a result of receiving a full
medical CDR. We did not include children or "age 18 re-determinations"
in our analysis since there are differences between the medical CDR
sequential evaluation processes for adults and children. We also did
not assess the outcome of CDR mailers or work CDRs. We verified the
statistical data on CDR outcomes for internal logic, consistency, and
reasonableness. We determined that the data were sufficiently reliable
for the purposes of our review. We also met with knowledgeable SSA
officials to further document the reliability of these data.
We interviewed 34 officials from SSA's central offices (including
officials from the Office of the Chief Actuary, the Office of Quality
Performance, the Office of General Counsel, the Office of Research and
Evaluation Statistics, the Office of Disability Programs, the Office of
Disability Adjudication and Review, and the Office of Program
Development and Research) to discuss the disability programs and the
CDR process.
We conducted a national Web-based survey of all 55 Disability
Determination Services (DDS) directors in the 50 states, the District
of Columbia, Puerto Rico, the Virgin Islands, the Western Pacific
Islands, and the federal DDS. DDSs are the agencies responsible for
conducting periodic CDRs to determine if beneficiaries' medical
conditions have improved and if they are able to work. We received 54
completed surveys for a response rate of 98 percent. The purpose of
this survey was to assess the extent to which the standard impacts
outcomes of CDRs and determine if the standard poses any special
challenges for SSA when determining whether beneficiaries continue to
be eligible for benefits. We asked the directors about particular
elements of the standard and how these elements, alone or in
combination with other factors, impact CDR outcomes. We also asked them
how SSA guidance on implementing the standard affects CDR outcomes. We
determined that the survey data are sufficiently reliable. Because this
was not a sample survey, there are no sampling errors. However, the
practical difficulties of conducting any survey may introduce errors,
commonly referred to as nonsampling errors. For example, difficulties
in how a particular question is interpreted, in the sources of
information that are available to respondents, or in how the data are
entered into a database or were analyzed, can introduce unwanted
variability into the survey results. We took steps in the development
of the questionnaire, the data collection, and the data analysis to
minimize these nonsampling errors. For example, social science survey
specialists designed the questionnaire in collaboration with GAO staff
with subject matter expertise. Then, the draft questionnaire was
pretested with a number of state officials to ensure that the questions
were relevant, clearly stated, and easy to comprehend. The
questionnaire was also reviewed by an additional GAO survey specialist.
When the data were analyzed, a second, independent analyst checked all
computer programs. Since this was a Web-based survey, respondents
entered their answers directly into the electronic questionnaire. This
eliminated the need to have the data keyed into a database thus
removing an additional source of error. We conducted three pretests of
this survey with DDS directors in three different states. We modified
the survey to take their comments into account. We also provided SSA
with a copy of the survey and incorporated its technical comments into
the final version. This report does not contain all the results from
the survey. The survey and a more complete tabulation of the results
can be viewed at [Hyperlink, http://www.gao.gov/cgi-
bin/getrpt?rptno=GAO-07-4sp].
To augment information from our state survey, we conducted independent
audit work in three states (California, Massachusetts, and Texas) to
examine how SSA policies and procedures are carried out in the field.
We selected locations for field visits based on the following criteria:
(1) geographic dispersion; (2) states with large numbers of CDRs
conducted; (3) states with CDR discontinuation rates above, below, and
at the national average; (4) states with varying DDS structures (i.e.,
centralized and decentralized); and (5) states with large numbers of
Disability Insurance (DI) beneficiaries and large DI expenditures. In
each state, we visited a DDS office, the SSA regional office, the
regional Office of Quality Performance, and the regional Office of
Disability Adjudication and Review (formerly known as the Office of
Hearings and Appeals). In total, we conducted in-depth interviews with
80 SSA and DDS managers and line staff responsible for conducting
medical CDRs, including DDS directors, CDR supervisors and examiners,
medical consultants, and administrative law judges.[Footnote 36]
During our meetings with SSA and DDS officials, we documented
management and staff views on the challenges associated with applying
the medical improvement standard. In particular, we documented
management and staff views on (1) the impact of the standard on CDR
outcomes, (2) the effectiveness of SSA policies and procedures for
applying the standard, and (3) the degree to which factors external to
the standard create challenges when determining if a beneficiary has
improved medically and is able to work. To further assess how the
standard is applied in practice, we took a nonprobability sample of 12
CDR case files from the DDSs in California and Texas. We asked CDR
supervisors to provide several cases that were (1) discontinued for
medical improvement, (2) continued because the beneficiary was clearly
disabled, and (3) ambiguous cases where it was difficult to apply the
standard and determine if benefits should be continued or discontinued.
These case files serve to illustrate the difficulties examiners face
when determining if a beneficiary has improved medically and is able to
work.
In addition, we interviewed seven disability policy experts from
national disability research and advocacy organizations to obtain their
input on the impact of the standard on the disability programs and any
challenges it poses when assessing individuals' continued eligibility
for benefits. We spoke with individuals affiliated with the following
organizations:
* American Association of People with Disabilities,
* Center for Health Services Research and Policy at George Washington
University,
* Center for the Study and Advancement of Disability Policy,
* Consortium for Citizens with Disabilities,
* Disability Law Center,
* Disability Policy Collaboration,
* National Organization of Social Security Claimants' Representatives,
and:
* National Organization on Disability.
Finally, we spoke with representatives from the National Association of
Disability Examiners, the National Council of Disability Determination
Directors, and the Social Security Advisory Board. We spoke with these
disability experts about the effect of the standard on CDR outcomes and
any challenges it presents when conducting CDRs. We conducted our work
from October 2005 through June 2006 in accordance with generally
accepted government auditing standards.
[End of section]
Appendix II: The Continuing Disability Review Evaluation Process:
In the first step of the CDR evaluation process for adult
beneficiaries, an SSA field office representative determines if the
beneficiary is working at the level of substantial gainful activity
(SGA). A beneficiary who is found to be not working or working but
earning less than the SGA level (minus allowable exclusions) has his or
her case forwarded to the state Disability Determination Services
(DDS).[Footnote 37]
The second step is to determine if the individual's current
impairment(s) is included on the current list of disabilities that SSA
maintains. The list describes impairments that, by definition, are so
severe that they are disabling. If the individual's current
impairment(s) does meet or equal a current listing, then the DDS
continues the individual's benefits and does not continue with the
evaluation process. If the individual's current impairment(s) does not
meet or equal a current listing, then the DDS proceeds to step three in
the evaluation process.
The third step is to determine if improvement in the individual's
medical condition has occurred. This improvement is any decrease in the
medical severity of the impairment(s) that was present at the time of
the most recent favorable medical decision (i.e., the initial decision
to award disability benefits or the most recent CDR continuance--
usually referred to as the comparison point decision, or CPD). At this
step, the DDS examiner compares the current signs, symptoms, and
laboratory findings associated with the beneficiary's impairment(s) to
those recorded from the last review. If improvement has not occurred,
the disability examiner skips to the fifth step in the evaluation. If
improvement has occurred, the disability examiner proceeds to next
step, the fourth step.
The fourth step is to determine if the improvement found in step three
is related to the ability to work. Improvement related to the ability
to work is evaluated two different ways, depending on whether the CPD
was based on: (1) meeting or equaling a prior listing or (2) a residual
functional capacity (RFC) assessment:
* Meeting or equaling the prior listing: In this case, the disability
examiner will determine if the beneficiary's same impairment(s) still
meets or equals the prior listing. Unlike step two, the examiner
compares the beneficiary's condition with the list of impairments in
effect at the time he or she was first awarded disability
benefits.[Footnote 38] If the impairment(s) no longer meets or equals
the prior listing, then the examiner finds that the improvement is
related to the ability to work and proceeds to step six of the
evaluation process. If the impairment(s) meets or equals a prior
listing, then benefits are continued.
* Residual functional capacity assessment: In this case, the disability
examiner compares the beneficiary's previous functional capacity to the
current functional capacity for the same impairment. If functional
capacity for basic work activities has improved, then the examiner
finds that the improvement is related to the ability to work and
proceeds to step six of the evaluation process. If the current
assessment does not show improvement, then the disability examiner
proceeds to step five.
The fifth step is to determine whether an exception to medical
improvement applies. The law provides for certain limited situations
when the DDS may discontinue a recipient's benefits even though medical
improvement has not occurred. The specific group I exceptions are (a)
the individual is the beneficiary of advances in medical or vocational
therapy or technology (related to the ability to work), (b) evidence
shows that the individual has undergone vocational therapy (related to
the ability to work), (c) evidence shows that, based on new or improved
diagnostic or evaluative techniques, the individual's impairment(s) is
not as disabling as it was considered at the time of the CPD, and (d)
evidence shows that any prior determination or decision was in error.
If an exception applies, the examiner continues through to step six of
the evaluation process.[Footnote 39] If an exception does not apply,
benefits are continued.
The sixth step is to determine if the current impairments are severe.
At this step, the examiner considers all of the beneficiary's
impairments--those present at the previous decision as well as any new
impairments found in the current review. If the DDS determines that the
beneficiary's current impairment(s) is not severe, benefits are
discontinued without further development. If it is determined that the
impairment(s) is severe, then the examiner considers the impact of the
beneficiary's impairment(s) on his or her ability to function. This
consideration will result in a current residual functional capacity
(RFC) assessment that shows the beneficiary's ability to do basic work
activities and the evaluation continues to the seventh step.
The seventh step is to determine whether the beneficiary has the
capacity to do the work that he or she did before having a disability.
If the beneficiary has the ability to do past work, then benefits are
discontinued. If the beneficiary does not have the ability to do work
he or she has done in the past, the evaluation continues to the eighth
step.
The eighth step is to determine if the beneficiary has the ability to
do other work. At this step, the disability examiner considers the
complete vocational profile (the beneficiary's age, education, and past
relevant work experience) together with the beneficiary's RFC to
determine if he or she has the ability to do other work. If the
beneficiary has the ability to do other work, disability benefits are
discontinued. If he or she does not have the ability to do other work,
benefits are continued.
[End of section]
Appendix III: Comments from the Social Security Administration:
USA Social Security:
The Commissioner:
September 8, 2006:
Mr. Robert E. Robertson:
Director, Education, Workforce and Income Security Issues:
U.S. Government Accountability Office:
Room 5-T-57:
441 G Street, NW:
Washington, D.C. 20548:
Dear Mr. Robertson:
Thank you for the opportunity to review and comment on the draft report
"Social Security Disability Programs - Clearer Guidance Could Help SSA
Apply the Medical Improvement Standard More Consistently" (GAO-07-8).
Our comments on the report are enclosed.
If you have any questions, please have your staff contact Candace
Skurnik, Director, Audit Management and Liaison Staff at (410) 965-
4636.
Sincerely,
Signed by:
Jo Anne B. Barnhart:
Enclosure:
Social Security Administration Baltimore MD 21235-0001:
Comments On The Government Accountability Office (GAO) Draft Report,
"Disability Programs: Clearer Guidance Could Help SSA Apply The Medical
Improvement Review Standard More Consistently" (GAO-07-08):
Thank you for sharing the draft report with us for comment.
We agree with GAO that our medical improvement review standard (MIRS)
regulatory framework, and present-day application of such framework,
protects beneficiaries' rights. We also agree with GAO that we should
provide refresher training on MIRS to ensure consistent adjudication in
all MIRS cases.
We appreciate that the draft report does not make specific
recommendations about what GAO believes to be the appropriate degree of
medical improvement necessary to meet the standard or how we should
provide clarification of the rules for deciding medical improvement. As
we indicate in several of our more detailed comments below, there is an
inherent degree of judgment in these determinations, as well as
virtually limitless variations in case facts, such that it may not be
possible to quantify a more specific standard that would be meaningful
and helpful. We also note that GAO gathered survey opinions that might
suggest lowering the threshold for showing medical improvement; we
believe that requiring evidence of only de minimis or minor medical
improvement would arguably circumvent and be contrary to the intent and
spirit of the MIRS statutory provision.
Our more detailed comments follow.
GAO was asked (1) to examine the proportion of beneficiaries who are
removed from the disability programs because they have medically
improved and (2) to determine if factors associated with the standard
pose challenges when determining whether beneficiaries continue to be
eligible for benefits. With regard to the second request, GAO concluded
that:
* Limitations in SSA guidance for assessing medical improvement may
result in inconsistent application of the standard.
* SSA guidance regarding the exceptions to the medical improvement
review standard (MIRS) tends to limit their use and may result in
benefits continuing for some individuals who may be able to work.
* There is an incorrect application of one element of the standard,
specifically that continuing disability reviews (CDRs) should be
conducted on a neutral basis and without a presumption that an
individual continues to be disabled.
* Decisions whether disability ends are limited by inadequate
documentation of evidence and the judgmental nature of the decision
process concerning what constitutes medical improvement.
We address each of these issues in turn, after first commenting on some
of the statistical data included in the draft report.
1. The proportion of beneficiaries who are removed from the disability
programs because they have medically improved and other data in the
draft report:
The draft report (on page 5) provides data for the 1981-82 period, when
about 45 percent of CDRs resulted in termination, which can be
contrasted with the data provided for the 1999-2005 period (on pages 1
and 2), when only 2.8 percent of beneficiaries who received a CDR were
terminated. Presumably, this comparison is intended to illustrate the
dramatic effect of the change to the MIRS in 1985 as a result of the
1984 legislation enacted by Congress. However, the 1981-82 period is
not representative of the results of the CDR process before the MIRS
standard was introduced. In response to the 1980 Social Security
amendments and reports that suggested there were many non-disabled
persons receiving disability benefits, an aggressive effort was
initiated in 1981 to remove beneficiaries from the DI program whose
impairments were not severe enough to entitle them to benefits. This
effort focused on beneficiaries who were deemed at the time most likely
to be determined not disabled and led to a temporary large increase in
the number of DI program terminations in the early to mid-1980's. We
suggest that GAO use a period prior to 1981 for a more appropriate
comparison of the effects of the two approaches to evaluating
continuing disability.
Also, the pie chart on page 12 of the draft report shows that 19
percent of terminations are due to conversion to retirement benefits
and 45 percent are due to "other" reasons. However, about 44 percent of
DI terminations are due to retirement conversion and less than 5
percent are for "other" reasons, while there is no retirement
conversion in the SSI program and the most prominent reason for SSI
terminations is excess income, which accounts for about 60 percent of
all terminations. We believe that using one pie chart for both programs
may be misleading and mask program differences. Therefore, we suggest
that the report include a separate pie chart for each program.
2. Limitations in SSA guidance for assessing medical improvement may
result in inconsistent application of the standard:
The draft report actually seems to make two related recommendations in
this regard, although only one of them is presented consistently. The
draft report correctly notes that under the Act we may find that an
adult's disability has ended only if the evidence establishes both that
there has been medical improvement and that any medical improvement is
"related to the ability to work." Under our regulations, these are
separate inquiries, but the draft report does not consistently state
whether GAO is recommending that we clarify both policies or just the
policy for determining if there has been medical improvement. However,
we were impressed by the extent and variety of opinions GAO was able to
gather from our Disability Determination Services, Administrative Law
Judges, and others within the agency who use and interpret our
instructions and it is clear to us that we should do some training to
clarify how adjudicators should address these issues.
Nevertheless, the implication in the draft that any such clarification
will have a noticeable, if not significant, impact on the number of
cases in which we find that disability has ended is probably not well
founded. For example, even if f we were to "clarify" that a relatively
small change in a sign, symptom, or laboratory finding would be
sufficient to show that there was medical improvement it would be very
unlikely that such a small change would be shown to be "related to the
ability to work" at the next step of the MIRS sequential evaluation
process or result in a finding that the individual has again become
able to work. Therefore, unless they are using very high thresholds for
determining whether there is medical improvement, the fact that some
DDSs report that they use relatively higher thresholds than
others[Footnote 40] is unlikely to make a significant difference in the
number of their determinations that disability has ended.[Footnote 41]
3. SSA guidance regarding the exceptions to the medical improvement
review standard tends to limit their use and may result in benefits
continuing for some individuals who may be able to work:
The purpose of GAO's recommendation that we provide training on the
appropriate use of the exceptions was not clear to us. The body of the
draft report suggests that SSA guidance "appears to discourage and
limit the use of the exceptions," especially the exception that allows
a subsequent adjudicator to determine that a prior adjudicator's
finding of disability (or continuing disability) was in error.[Footnote
42] The draft reports anecdotal information from adjudicators who may
have expressed concerns that they were unable to change prior favorable
decisions in as many cases as they might have liked.
The draft does not provide a GAO opinion about this finding, nor does
it indicate that GAO found any evidence that the exceptions are being
misapplied or not used in situations in which they should be used.
Therefore, it was not clear what GAO is suggesting we should train
about, and we suggest that the report explain why GAO believes we
should provide such training; for example, whether GAO believes that we
should broaden our interpretation of the error exception and allow
adjudicators to make findings of decisional error more often or
encourage them to consider whether prior decisions were in error more
often than they do now.
We believe that our implementation of the statutory exceptions to
medical improvement is appropriate and that our instructions are
consistent with the intent of the law. We recommend that, in presenting
this issue in the final report, GAO discuss not only the anecdotal and
opinion information they gathered but the legislative history of the
exception provisions and SSA's statements about those provisions in the
preamble to the publication of the original MIRS regulations in
1985.[Footnote 43] In the preamble to the final rules, we explained in
essence that we did intend the exceptions to be true "exceptions"--that
is, not to be applied routinely--including our reasons for limiting the
"error" exception in the manner that GAO found and our adjudicators
reported. A broader application of the error exception could lead to a
substitution of judgment by an adjudicator for the original finding of
disability when the person's "medical condition has not changed
substantially." This quote from the 1984 legislative history indicates
disapproval of termination for individuals whose medical condition had
not changed substantially since the time they were awarded benefits.
4. There is an incorrect application of one element of the standard,
specifically that continuing disability reviews (CDRs) should be
conducted on a neutral basis and without a presumption that an
individual continues to be disabled:
Based on GAO's findings regarding adjudicator knowledge and application
of this provision of the statute and our regulations, we agree that
training is needed and will provide it. However, we would also like to
comment that the implication in the draft report that better, more
consistent adjudicator understanding of this provision would result in
more cessations is unlikely. We believe that the major reasons for the
provision in the statute were to address the climate of the times: the
perception that the Agency had gone too far in the early 1980's in
terminating beneficiaries, perhaps based on a presumption of non-
disability, and court decisions of the time that held that there was a
continuing presumption of disability on the other. The conference
report for the legislation (98-1039, September 19, 1984) explained:
The conference agreement attempts to strike a balance between the
concern that a medical improvement standard could be interpreted to
grant claimants a presumption of eligibility, which might make it
extremely difficult to remove ineligible individuals from the benefit
rolls, and the concern that the absence of an explicit standard of
review or some alternative standard could be interpreted to imply a
presumption of ineligibility or to allow arbitrary termination
decisions, which might lead to many individuals being improperly
removed from the rolls.
These issues are best addressed by ensuring that the MIRS sequential
evaluation process is correctly followed. However, we agree with the
draft that determinations of continuing disability, like determinations
of initial entitlement, are often inherently subjective so we agree
that it is appropriate that we take steps to ensure that adjudicators
approach these cases neutrally, as required by the statue and our
regulations.
5. Decisions that disability ends are limited by inadequate
documentation of evidence and the judgmental nature of the decision
process concerning what constitutes medical improvement:
We appreciate the recognition in the draft report that we are taking
steps to improve the quality of our case development and decisions. The
report also correctly recognizes that the determinations in many of
these cases are inherently subjective. It appears that there is no
additional recommendation in the report regarding these issues.
[End of section]
Appendix IV: GAO Contact and Staff Acknowledgments:
GAO Contact:
Robert E. Robertson, Director, (202) 512-7215.
Staff Acknowledgments:
The following team members made key contributions to this report: Kelly
Agnese; Jeremy D. Cox; Susan E.M. Etzel; Stuart M. Kaufman; Luann M.
Moy; George H. Quinn, Jr; Daniel A. Schwimer; Salvatore F. Sorbello;
Wayne T. Turowski; Vanessa R. Taylor; and Rachael C. Valliere.
[End of section]
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FOOTNOTES
[1] In addition to medical CDRs, SSA also conducts "work CDRs" where it
assesses if an individual's earnings exceeded program limits. Our
analysis only looked at medical CDRs. It did not include work CDRs.
[2] Pub. L. No. 98-460 (1984).
[3] For this report, we refer to "medical improvement" and individuals
who have "improved medically" as a finding that meets the requirements
of the medical improvement standard (improvement in a beneficiary's
medical condition that is related to the ability to work).
[4] For the purposes of our study, we only assessed DI and SSI adult
beneficiaries who received a full medical CDR. We did not include
children or the "age 18 re-determinations" in our analysis since there
are differences between the medical CDR sequential evaluation processes
for adults and children. Also, we only assessed the outcome of the full
medical CDRs.
[5] During our site visits, we met with 11 CDR supervisors and
disability examiners who the DDS directors selected as the most
knowledgeable in their office about the CDR process and the medical
improvement standard.
[6] Some disability recipients receive both DI and SSI benefits because
of the low level of their income and resources.
[7] Beginning at age 62, workers receiving DI benefits may elect to
receive retirement benefits in lieu of disability benefits.
[8] Of these beneficiaries, about 5.7 million were blind or had a
disability and received about $31.8 billion in benefits. About 1.1
million beneficiaries did not have a disability, but were aged and
received about $4.1 billion in benefits.
[9] SSA officials noted that the discontinuation rate in the early
1980s may not have been representative of the results of the CDR
process before the implementation of the medical improvement standard.
SSA officials stated that in response to reports that suggested that
many individuals who did not have a disability were receiving benefits,
an aggressive effort was initiated in 1981 to remove individuals from
the DI program whose impairments were not severe enough to entitle them
to benefits. The agency reported that this effort focused on
beneficiaries who were deemed at the time most likely to be determined
not to have a disability and led to a large, temporary increase in the
number of DI program discontinuances in the early to mid-1980s.
[10] Before disability examiners assess if a beneficiary has improved
medically, they first assess if the beneficiary is working at the level
of SGA. If beneficiaries are working at or above the SGA level, then
benefits are discontinued. If not, then the CDR process proceeds to the
second step.
[11] SSA maintains a list of impairments that, by definition, are so
severe that they are disabling.
[12] The assessment of a beneficiary's actual ability to work comes
later in the CDR process (steps 7 and 8). See appendix II for a more
detailed description of the CDR process.
[13] At this step of the evaluation, a disability examiner considers
only the listings that were met (or equaled) the last time the
beneficiary was evaluated, not all of the listings that existed at the
time of the last review.
[14] In addition to the Group I exceptions listed above, benefits may
also be discontinued if a DI beneficiary is engaging in substantial
gainful activity. The act also provides for other situations (called
Group II exceptions) where SSA can discontinue either DI or SSI
benefits. Group II exceptions are: (a) the prior determination or
decision was fraudulently obtained, (b) the beneficiary does not
cooperate with SSA, (c) SSA is unable to locate the beneficiary, and
(d) the beneficiary fails to follow prescribed treatment which would be
expected to restore his or her ability to do SGA. For Group II
exceptions, SSA discontinues benefits immediately without further
development.
[15] If beneficiaries' responses to a mailer indicate possible
improvement in medical condition or vocational status, SSA may refer
these individuals for a full medical review. However, in most cases,
SSA decides that a full medical review is not warranted and that
benefits should be continued.
[16] Beneficiaries may elect to have benefits continued while they
appeal the decision that their disability has ended.
[17] SSA also conducts work CDRs where it may remove a beneficiary from
the disability programs if their earnings exceed SGA.
[18] A psychologist may evaluate the evidence if the individual has a
psychological impairment.
[19] For the purposes of our study, we only assessed DI and SSI adult
beneficiaries who received full medical CDRs. We did not include
children or the "age 18 re-determinations" in our analysis since there
are differences between the medical CDR sequential evaluation processes
for adults and children. Also, we only assessed the outcome of the full
medical CDRs. We did not assess the outcome of the CDR mailers or CDRs
of beneficiaries' earnings and work activity--referred to as work CDRs.
[20] The 13,800 people who were removed from the disability programs
for medical improvement as a result of receiving a CDR represent about
0.1 percent of all adult DI and SSI disability beneficiaries. Of these
13,800 recipients, about 9,260 were DI recipients and about 4,580 were
SSI recipients.
[21] SSA converts DI beneficiaries to retirement benefits when they
attain full retirement age.
[22] The 311,000 recipients who died consisted of about 180,000 DI
recipients and about 131,000 SSI recipients.
[23] Beginning at age 62, workers receiving DI benefits may elect to
receive retirement benefits in lieu of disability benefits. Although
most beneficiaries receiving DI benefits elect to receive their
disability benefits until full retirement age--at which time disability
benefits convert to benefits paid from the Old-Age and Survivors
Insurance program--some choose to switch earlier.
[24] For fiscal years 2000 to 2004, in addition to the full medical
CDRs, SSA also conducted an average of about 834,000 CDR mailers
annually, ranging from a high of 960,000 mailers in 2000 to a low of
692,000 mailers in 2003.
[25] In the late 1990s Congress appropriated special funds for SSA to
alleviate backlogs of CDRs. These special funds began in fiscal year
1996 and expired at the end of fiscal year 2002. Because of this
special funding, the number of full medical CDRs conducted by SSA
increased.
[26] We did not determine why the discontinuation rate remained
consistent considering the change in the number of CDRs conducted.
[27] See SSA Program Operations Manual System (POMS) section DI
28010.015.
[28] While we received 54 completed surveys, not every director
responded to every question. In presenting our results, we only
included the directors who answered a particular question with a value
on our response scale. If a director answered "no basis to judge," we
did not count that response.
[29] At this step (step 4 of the CDR evaluation process), the
assessment of working at the level of SGA is not considered. SGA is
evaluated in the first step of the CDR evaluation process. See appendix
II for a detailed description of the CDR process.
[30] See POMS section DI 28015.320.
[31] The assessment of a beneficiary's actual ability to work comes
later in the CDR process (steps 7 and 8). See appendix II for a more
detailed description of the CDR process.
[32] During our site visits, we met with 11 CDR supervisors and
disability examiners who the DDS directors selected as the most
knowledgeable in their office about the CDR process and the medical
improvement standard. Seven of these 11 individuals stated that they
were uncertain about when to apply the exceptions to medical
improvement.
[33] The error exception applies when an error was evident in the prior
decision.
[34] Of the 48 DDS directors who responded to this question, 17
indicated that CDR decisions are made on a neutral basis.
[35] We asked directors to exclude cases missing the entire case file
(i.e. lost folders) in their responses to this survey question. We
asked the directors a separate question regarding how frequently or
infrequently they encounter cases where the entire case file is
missing. Although SSA has established a new electronic system to
process initial claims, it has yet to expand this new process to CDRs.
As a result, CDRs are still being conducted in a paper environment.
[36] During our site visits, we met with 11 CDR supervisors and
disability examiners who the DDS directors selected as the most
knowledgeable in their office about the CDR process and the medical
improvement standard.
[37] For SSI beneficiaries, do not consider SGA but skip to the second
step in the CDR evaluation.
[38] At this step of the evaluation, a disability examiner considers
only the listings that were met (or equaled) the last time the
beneficiary was evaluated, not all of the listings that existed at the
time of the last review.
[39] In addition to Group I exceptions, the law provides for additional
situations (called Group II exceptions) to show that that disability
discontinues. Group II exceptions are: (a) the individual's prior
determination or decision was fraudulently obtained, (b) the individual
does not cooperate with SSA, (c) SSA is unable to find the individual,
and (d) the individual fails to follow prescribed treatment that would
be expected to restore his or her ability to do SGA. In these
situations, SSA discontinues benefits immediately without further
development. SSA does not determine if medical improvement has occurred
or if the individual is able to do SGA.
[40] We noted on page 16 of the draft the statement that,
"Specifically, 17 of 49 [DDS] directors reported that a large or very
large increase in a recipient's ability to do basic work activities is
required; 24 reported that a moderate increase is required; and 8
reported that a minor or any increase at all is required." However,
since at least one of the terms ("moderate") used in the question was
itself vague, it is not clear what standard the DDS administrators had
in mind when they answered the question, nor do we believe that it
would be especially helpful to add such terms to our instructions; for
example, we do not believe it would be significantly better to require
that there must be a "moderate" improvement in a sign, symptom, or
laboratory finding to show medical improvement instead of more than
"minor." It would be difficult, if not impossible, to quantify "the
degree of improvement required to meet the standard" (draft, page 22)
in every case. Also, please see the technical comments that follow
these comments. It appears that the survey question may have improperly
conflated the policy of "medical improvement" with consideration of the
ability to do work-related activities.
[41] In this regard, we note on page 15 of the draft the statement, "Of
the 52 DDS directors who answered a question in our survey on `minor'
changes, 21 reported that the practice of disregarding minor changes is
not an impediment to making a disability determination, while 31
reported that it is an impediment." The draft draws no inferences from
this statement, but we must point out that our policy not to consider
"minor" changes appears to be consistent with the Act's requirement
that there be "substantial evidence" demonstrating not only that there
has been "any medical improvement" but that the improvement must be
related to the ability to work. While a requirement for more than a
minor change in the individual's medical condition might be an
"impediment" to a subsequent reviewer's ability to cease entitlement,
we believe that such a requirement is consistent with legislative
history of the 1984 amendments indicating disapproval of termination
for individuals "whose medical condition has not changed substantially
since they were allowed."
[42] Draft pp. 16-17. For the recommendation, see pp. 21-22.
[43] See 50 FR 50118, 50120 and 50123.
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