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Audit Report - A-13-97-21009


Office of Audit

Missing Data Hinders Vocational Rehabilitation Referrals - A-13-97-21009 - 2/5/97

TABLE OF CONTENTS

EXECUTIVE SUMMARY

INTRODUCTION

FINDINGS

Referral Decision Codes Were Missing for Over One-Fifth of all Applicants Reviewed

Over Two-Thirds of all Applicants’ Records Were Incomplete in at Least One of the Demographic Categories Reviewed

The Missing Codes Prevent SSA From Evaluating and Improving Its VR Referral System

RECOMMENDATIONS

APPENDICES

List of Contributors

EXECUTIVE SUMMARY

PURPOSE

To obtain and summarize baseline demographic information about disabled adults who are considered candidates for vocational rehabilitation (VR).

BACKGROUND

The Social Security Administration (SSA) administers two disability programs, Social Security Disability Insurance (DI) and Supplemental Security Income (SSI), which pay benefits to qualified disabled individuals. The Department of Education`s VR program provides comprehensive vocational rehabilitation services designed to help those with the most severe physical and mental disabilities return to the work force.

The Social Security Act permits payment of SSA funds to States for VR services to make services more readily available to SSA beneficiaries and to achieve savings for the SSA trust funds. Regulations permit the Commissioner of Social Security to enter into agreements or contracts with alternative service providers in cases where a State agency declines to participate in providing VR services.

We extracted data from SSA’s Disability Determination File (SSA-831) for this review. We selected all adult, nonblind disability and SSI applicants who filed initial claims and who were issued a medical decision (approved or denied) in Calendar Year (CY) 1992.

We originally intended to gather baseline data about disabled adults who were considered candidates for VR. With such data, we had hoped to evaluate referral practices. However, we were unable to carry out our study. We discovered that needed codes were missing from the records.

FINDINGS

Referral Decision Codes Were Missing for Over One-Fifth of All Applicants Reviewed

Almost 22 percent (550,740) of the 2.5 million applicants did not have a referral decision code. No referral decision was annotated in the SSA-831 record.

Over Two-thirds of All Applicant`s Records Were Incomplete In At Least One Of The Demographic Categories Reviewed

At least two-thirds of the records involved in the sample were incomplete in at least one of the demographic categories reviewed. About 67 percent (1,683,770) of all applicants and 48 percent (90,070) of all referrals had an "unknown" past customary occupation code. Additionally, over 24 percent (620,550) of known applicants and 18 percent (35,410) of known referrals had an "unknown" educational level code.

The Missing Codes Prevent SSA From Evaluating and Improving Its VR Referral System

Successfully enrolling all appropriate disability beneficiaries in VR programs depends in large part upon the completeness and accuracy of basic demographic data required to accurately identify potential candidates. The absence of such data:

  • Inhibits identification and referral of all possible candidates for VR. Prevents SSA from identifying claimants which the State chooses not to accept, so that potential referral to private rehabilitation organizations can be accomplished.
  • Precludes collection of accurate baseline and longitudinal data needed to accurately assess which applicants are being referred, as recommended in the Disability Advisory Council`s 1988 Report to the Congress.
  • Hinders the ability to automate the screening process to efficiently select appropriate candidates for VR services, as previously recommended in the Department of Health and Human Services` Office of Inspector General (HHS/OIG) report released in April 1990 entitled, "Social Security Payments for Vocational Rehabilitation" (OEI-07-89-00950), and encouraged in the 1994 report released by the Joint Vocational Rehabilitation Task Force.

RECOMMENDATIONS

SSA SHOULD ENSURE, THROUGH MANDATORY CODING, THAT:

  • Complete and accurate demographic information is entered into the Disability Determination File.
  • The Disability Determination File reflects which candidates are referred and accepted for State VR services.

Agency Comments

SSA agrees that complete and accurate demographic data needs to be recorded for VR management information purposes. However, there is disagreement concerning our recommendations for collecting VR information to assure the identification and referral of all possible candidates for VR. The Office of the Inspector General’s (OIG) response to SSA’s concerns is in the agency comments and OIG’s response on page 6.

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INTRODUCTION

PURPOSE

To obtain and summarize baseline demographic information about disabled adults who are considered candidates for VR.

BACKGROUND

Social Security Administration

SSA administers two disability programs, Social Security DI and SSI, which pay benefits to qualified disabled individuals. The DI program, authorized by title II of the Social Security Act, provides benefits to insured disability workers and their families in amounts determined by the wage earner`s work history. The SSI program, authorized by title XVI of the Social Security Act, provides payments to financially needy, aged, blind, and disabled persons, including individuals that do not have the required insured status to receive Social Security DI payments. In 1993, the DI program and SSI program paid out $34.6 billion and $17.3 billion, respectively to approximately 5.3 million and 4.2 million disabled beneficiaries and their families.

In its March 1988 report to the Congress, the Disability Advisory Council reported that in any given year, "fewer than 15 percent of beneficiaries are referred for VR services and only a small portion of these individuals received services." The SSA`s published statistics also showed that less than one-half of one percent of disabled individuals approved for DI or SSI are removed from the disability roles due to their return to work.

Claims representatives in SSA’s field offices (FO) take initial disability claims information from applicants. If the applicant meets the nonmedical criteria, then medical documentation is forwarded to State disability determination services (DDS) offices for further processing. The SSA FO completing the disability claim for the applicant, prepares a paper Form SSA-831 containing identifying data such as name, Social Security number, type(s) of claim, sex, etc., then keys this data into the SSA-831 system.

Disability Determination Services

DDSs are State organizations funded by SSA. They are responsible for adjudicating disability claims based on Federal statutes and SSA rules and regulations governing the DI program. They also determine whether medical and work history information shows that the applicant has the potential for rehabilitation and should be referred to the Vocational Rehabilitation Agency (VRA). This determination is performed by applying screening criteria developed jointly by SSA, DDSs and Vocational Rehabilitation Agencies (VRA). If an examiner decides to refer the applicant for VR services, copies of the application and any relevant medical or vocational evidence are forwarded to the VRA. Upon completion of the medical determination, the DDS inputs decisional data such as past occupation and education, impairment, allowance or denial, as well as the decision to refer or not refer the applicant for VR.

State VR Agencies

The Rehabilitation Act of 1973, as amended, authorizes the Department of Education`s VR program to provide comprehensive VR services. This program is designed to help those with physical and mental disabilities return to the work force. This is primarily done through Federal funding to State VRAs that directly provide services. These services can include counseling, work evaluation, work adjustment training, job skills training, job-seeking skills training and medical rehabilitation management.

The Federal/State VR program is operated and administered through a combination of about 80 State general and blind-only VRAs and various other State and private facilities. The VRAs provide individualized VR services to accepted beneficiaries according to a written rehabilitation plan that is developed jointly by a VRA counselor and the individual.

Counselors at VRAs evaluate whether there is a reasonable expectation that the individual may benefit from VR services in terms of employability. This judgment is based on the individual`s impairment and the availability of services and resources.

SSA Reimbursement

SSA reimburses the States for the cost of rehabilitation in those cases where the services are found to have resulted in the beneficiary`s performance of substantial work for a continuous period of at least 9 months. Payment can also be made for services provided to a beneficiary who, without good cause, refuses to continue to accept VR services or fails to cooperate, if the beneficiary`s benefits have been suspended. Under the current program, States must submit individual claims for reimbursement, showing the cost of VRA`s services provided each beneficiary and the period during which services were provided.

The Social Security Act and implementing regulations permit the Commissioner of Social Security to enter into agreements or contracts with alternative service providers in cases where a State agency declines to participate in providing VR services.

Past Relevant Studies

In March 1988, the Report of the Disability Advisory Council recommended that the Congress direct SSA to collect data concerning the characteristics and outcomes of beneficiaries who are and are not served by State VRAs. Further, the report stated that "Implementation of this recommendation will assist SSA in validating its current VR referral criteria and in determining which beneficiaries are the best candidates for VR services. It will also provide data on the relative cost-to-benefit ratios of SSA`s VR programs. . . ."

In April 1990, the HHS/OIG released a report entitled, "Social Security Payments for Vocational Rehabilitation" (OEI-07-89-00950). The report recommended that "SSA should strengthen the linkage between the SSA VR payment program and actions to . . . rehabilitate SSA clients." Further, it recommended that SSA require States to establish a formal automated mechanism to screen and enroll those SSA clients who show the greatest potential for successful rehabilitation.

On May 13, 1994, the Joint Vocational Rehabilitation Referral Task Force issued its final report which identified obstacles to achieving greater numbers of referral acceptances by the VRAs under the existing process. The report found that DDS referrals are not monitored and that no regular follow-up exists. In discussing methods to make the best use of DDS/VRA resources, the task force described an automated screening system developed by the New York VRA. This system is designed to consider the screening logic typically followed by a VR counselor. The task force ". . . encouraged the use of automation for screening referrals."

METHODOLOGY

SSA collects and maintains data on disability applicants in a computerized data base called the Disability Determination File (SSA-831). SSA’s FOs and DDSs input information into this data base including the applicant’s name, Social Security number, type of claim, sex, race, age, alleged impairment, occupation, education, referral determination, and decision on the claim. From this data base we selected all adult, nonblind DI and SSI applicants who filed initial claims and who were issued a medical decision in CY 1992. We included applicants whose claims were approved, as well as those whose claims were denied. This resulted in a data base of 2.5 million applicants.

We originally intended to gather baseline data about disabled adults who were considered candidates for VR. With such data, we had hoped to evaluate referral practices. However, we were unable to carry out our study. We discovered that needed codes were missing from the records.

Our review was conducted between December 1994 and December 1995 in Baltimore, Maryland. We conducted this inspection in accordance with the Quality Standards for Inspections issued by the President`s Council on Integrity and Efficiency.

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FINDINGS

REFERRAL DECISION CODES WERE MISSING FOR OVER ONE-FIFTH OF ALL APPLICANTS REVIEWED

Almost 22 percent (550,740) of the 2.5 million applicants did not have a referral decision code annotated in the SSA-831 file. The table below illustrates the extent of the missing data.

APPLICANTS

REFERRED

NOT REFERRED

BLANK REFERRAL CODE

2,502,150

187,600

1,763,810

550,740

OVER TWO-THIRDS OF ALL APPLICANTS’ RECORDS WERE INCOMPLETE IN AT LEAST ONE OF THE DEMOGRAPHIC CATEGORIES REVIEWED

At least two-thirds of the claims involved in our sample were incomplete in at least one of the demographic categories reviewed. For example, about 67 percent (1,683,770) of all applicants and 48 percent (90,070) of all referrals had a missing past customary occupation code. Additionally, over 24 percent (620,550) of known applicants and 18 percent (35,410) of known referrals had a missing educational level code. The following tables identify the numbers and types of missing codes for these applicants.

ALL APPLICANTS

MISSING DEMOGRAPHIC CATEGORIES

# of Claims
Missing Code

% of
Claims Filed

Occupation

1,683,767

67.03

Education

620,557

24.70


REFERRED APPLICANTS

MISSING DEMOGRAPHIC CATEGORIES

# of Referred Claims Missing Code

% of Referred Applicants

Occupation

90,071

48.01

Education

35,413

18.88

Two demographic categories always coded were race code and the alleged impairment (body system) code. An interface between the Disability Determination File and the Numident File ensures that the race code is always captured. The alleged impairment (body system) code was always completed, since it is mandatory that this field be coded before the claim can be adjudicated.

MISSING CODES PREVENT SSA FROM EVALUATING AND IMPROVING ITS VR REFERRAL SYSTEM

Successfully enrolling all appropriate disability beneficiaries in VR programs depends in a large part upon the completeness and accuracy of basic demographic data required to accurately identify potential candidates. The absence of such data:

  • Inhibits identification and referral of all possible candidates for VR. Prevents SSA from identifying claimants which the State chooses not to accept, so that potential referral to private rehabilitation organizations can be accomplished.
  • Precludes collection of accurate baseline and longitudinal data needed to accurately assess which applicants are being referred, as recommended in the Disability Advisory Council`s 1988 Report to the Congress.
  • Hinders the ability to automate the screening process to efficiently select appropriate candidates for VR services, as previously recommended in the HHS/OIG report released in April 1990 entitled, "Social Security Payments for Vocational Rehabilitation" (OEI-07-89-00950), and encouraged in the 1994 report released by the Joint Vocational Rehabilitation Task Force.

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RECOMMENDATIONS

SSA SHOULD ENSURE, THROUGH MANDATORY CODING, THAT:

  • Complete and accurate demographic information is entered into the Disability Determination File.
  • The Disability Determination File reflects which candidates are referred and accepted for State VR services.

Agency Comments and OIG Response

SSA`s comments are contained in their entirety in Appendix A. SSA agrees that complete and accurate demographic data needs to be recorded for VR management information purposes. There is disagreement, however, that coding the Form SSA-831 is the only way to collect these data, or that the absence of such coding indicates that State DDSs do not have all the information necessary for making a VR referral decision. The comments indicate that several other data sources are used to collect VR management information.

There appears to be some confusion concerning our recommendations. It is not our assumption that SSA is unable to collect management information necessary for DDSs to identify and refer all possible candidates for VR referrals. Rather, our position is that the collection of VR information in a piecemeal fashion, as described in the SSA comments, is an inefficient process. Our recommendations are intended to enhance the identification and referral of all possible candidates for VR. Moreover, our recommendations are intended to facilitate the development of an automated screening process to capture and control baseline information about candidates for VR services.

We believe that an automated system that captures and controls baseline information about individuals referred for VR services is essential. Disability applications will likely continue to exceed 2 million per year, and continued reliance on a manual process is inefficient. The fact that the demographic information exists in a combination of data systems or paper files which require manual access is an impediment to an efficient VR selection and referral process.

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APPENDIX B

LIST OF CONTRIBUTORS

This evaluation report was prepared by the Office of Audit under the direction of Scott Patterson, Director, Evaluation and Technical Services. Project staff included Alan Stubbs, Senior Evaluator. The following individuals from the Department of Health and Human Services/Office of Inspector General, were responsible for production of the draft report of this project:

Kansas City Region Headquarters

James H. Wolf, Regional Inspector General Linda Moscoe
Linda Paddock, Project Leader
Tim Dold
Perry Seaton
Dennis Tharp

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