Report Summary
Social Security Administration
Office of the Inspector General

SOCIAL SECURITY ADMINISTRATION

THE SOCIAL SECURITY ADMINISTRATION’S
LISTING OF IMPAIRMENTS

March 2009

A-01-08-18023

AUDIT REPORT

Mission

By conducting independent and objective audits, evaluations and investigations, we inspire public confidence in the integrity and security of SSA’s programs and operations and protect them against fraud, waste and abuse. We provide timely, useful and reliable information and advice to Administration officials, Congress and the public.

Authority

The Inspector General Act created independent audit and investigative units, called the Office of Inspector General (OIG). The mission of the OIG, as spelled out in the Act, is to:

 Conduct and supervise independent and objective audits and investigations relating to agency programs and operations.
 Promote economy, effectiveness, and efficiency within the agency.
 Prevent and detect fraud, waste, and abuse in agency programs and operations.
 Review and make recommendations regarding existing and proposed legislation and regulations relating to agency programs and operations.
 Keep the agency head and the Congress fully and currently informed of problems in agency programs and operations.

To ensure objectivity, the IG Act empowers the IG with:

 Independence to determine what reviews to perform.
 Access to all information necessary for the reviews.
 Authority to publish findings and recommendations based on the reviews.

Vision

We strive for continual improvement in SSA’s programs, operations and management by proactively seeking new ways to prevent and deter fraud, waste and abuse. We commit to integrity and excellence by supporting an environment that provides a valuable public service while encouraging employee development and retention and fostering diversity and innovation.

MEMORANDUM

Date: March 27, 2009 Refer To:

To: The Commissioner

From: Inspector General

Subject: The Social Security Administration’s Listing of Impairments (A-01-08-18023)

OBJECTIVE

Our objective was to assess the Social Security Administration’s (SSA) efforts to update the Listing of Impairments (the listings) used to determine whether a person is disabled.

BACKGROUND

SSA first included the listings in its regulations in 1968 to help expedite the processing of disability claims under the Disability Insurance program. The listings have also been used for the Supplemental Security Income program since it began in 1974. The listings for each body system describe impairments that are considered severe enough to prevent an adult from doing any gainful activity or to cause marked and severe functional limitations in a child younger than 18 years old. Most of the listed impairments are permanent or expected to result in death; however, some include a specific statement of duration. For all others, the evidence must show the impairment has lasted or can be expected to last for a continuous period of at least 12 months. (See Appendix B for information about SSA’s process for evaluating a disability.)

The listings are organized by major body systems—14 for adults (Part A) and 15 for children (Part B), but adult criteria can be applied to children if the disease processes have a similar effect on adults and children (see Table 1). Altogether, SSA has over 100 listed impairments.

Table 1: SSA’s Listing of Impairments by Body System
Adults Children
100.00 Growth Impairment
1.00 Musculoskeletal System 101.00 Musculoskeletal System
2.00 Special Senses and Speech 102.00 Special Senses and Speech
3.00 Respiratory System 103.00 Respiratory System
4.00 Cardiovascular System 104.00 Cardiovascular System
5.00 Digestive System 105.00 Digestive System
6.00 Genitourinary Impairments 106.00 Genitourinary Impairments
7.00 Hematological Disorders 107.00 Hematological Disorders
8.00 Skin Disorders 108.00 Skin Disorders
9.00 Endocrine System 109.00 Endocrine System
10.00 Impairments that Affect Multiple Body Systems 110.00 Impairments that Affect Multiple Body Systems
11.00 Neurological 111.00 Neurological
12.00 Mental Disorders 112.00 Mental Disorders
13.00 Malignant Neoplastic Diseases 113.00 Malignant Neoplastic Diseases
14.00 Immune System Disorders 114.00 Immune System Disorders

The listings help ensure disability determinations have a sound medical basis, claimants receive equal treatment based on specific criteria, and disabled individuals can be readily identified and awarded benefits if appropriate. All disability claimants who are not performing substantial gainful activity (SGA) and have severe impairments are screened against the listings to quickly identify individuals who clearly meet the definition of disability. If the claim is not allowed based solely on the medical evidence, the Agency makes a disability determination based on the claimant’s abilities, age, education and vocational history. Quick identification of obvious cases allows SSA to avoid time-consuming and resource-intensive inquiries into all of the facts of many cases.
The proportion of initial claims allowed based on the listings have declined through the years. In the early years of the program, about 93 percent of initial allowances were based on listings. This declined to 82 percent in 1983 and 49 percent in 2004, and the rate has remained at that level since. As shown in Chart 1, 58 percent of the 1,021,001 initial and reconsideration allowances in Fiscal Year (FY) 2008 met or equaled a listing.

Chart 2 shows that the Mental Disorders body system had the highest percentage of allowances. SSA has not comprehensively revised this body system in 23 years but plans to do so by December 2009.

UPDATES TO THE LISTINGS

From 1968 to the mid-1980s, SSA revised the listings for various reasons by adding and/or deleting information/criteria as necessary. The last major update of the listings was made in 1985, when expiration dates ranging from 3 to 8 years were inserted for listing sections. SSA stated that expiration dates were necessary to ensure the Agency periodically reviews (and, if necessary, updates) the listings to consider medical advances in the treatment and evaluation of disabilities and program experience.

By the late 1990s, the Office of the Inspector General (OIG), Government Accountability Office (GAO), and Social Security Advisory Board were expressing concern that SSA was not updating the listings regularly but was simply extending the expiration dates for a number of years before they expired. For example, in 1997, SSA asked the OIG for comments on a regulation package to extend the expiration dates for eight listings. The OIG expressed its concern that blanket extension of listings that have not been reviewed frustrates the purpose of setting expiration dates.

In August 2000, we found that SSA had not updated some listings in over 10 years and that the Mental Disorders body system—which accounted for the highest percentage of new disability awards—had not had a comprehensive revision since 1985.
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In 2002, GAO reported that the listings had not been fully updated to reflect medical and technological advances.

Recent scientific advances in medicine and assistive technology and changes in the nature of work and the types of jobs in our national economy have generally enhanced the potential for people with disabilities to perform work-related activities. Advances in medicine have afforded the scientific community a deeper understanding of and ability to treat disease and injury. Medical advances in treatment (such as organ transplantations), therapy, and rehabilitation have reduced the severity of some medical conditions and have allowed individuals to live with greater independence and function in settings such as the workplace.

Since 2000, the OIG and GAO have issued several other reports and made recommendations related to the listings. In general, these reports highlighted the fact that the listings were not up to date, although SSA was working to update them. (See Appendix C for details of these reports.)

METHODOLOGY

To perform this review, we researched issues related to the listings in the Social Security Act; SSA’s regulations, policies and procedures; the Federal Register; and prior reports issued by the OIG and the GAO. We also interviewed SSA officials to obtain information to determine the status of updates to the listings. (See Appendix D for additional information on our Scope and Methodology.)

RESULTS OF REVIEW

SSA has made progress in updating its listings, but some listings have not been updated in many years and do not reflect recent medical and technological advances. Therefore, the listings may not be as effective a screening tool as they were in the past.

SSA’S NEW PROCESS FOR UPDATING THE LISTINGS

In 2003, SSA implemented a new process for revising the listings. This new process was designed to ensure there are continuous updates and monitoring of the listings about every 3 to 4 years. Under this new process, the Agency conducts a case study within 1 year of the newly published listing and determines whether an action is necessary—such as training, formal instructions, or a new regulation. If no action is needed, SSA will continue to monitor the listing, conduct another case study 4 years before the expiration date of the listing and begin the process of updating the listing. (See Appendix E for a flowchart of the entire Listing Revision Business Process.)

Under this new model, SSA has incorporated a feedback loop to allow for increased input. After a regulation is published, SSA solicits questions from Agency components and performs internal and external studies 1 year after the listing is published. An Advance Notice of Proposed Rulemaking (ANPRM) is published in the Federal Register. The Agency solicits comments regarding the ANPRM through outreach efforts to medical experts, advocacy groups, patients, and adjudicators and receives input from SSA Regional staff and Medical Specialists. SSA performs case studies and gathers comments on the proposed listing, and the Office of Management and Budget reviews the ANPRM. SSA then publishes a Notice of Proposed Rulemaking (NPRM) and again seeks input and conducts reviews and case studies before publishing the final regulation.

CONTRACTS WITH THE INSTITUTE OF MEDICINE

In 2004, SSA awarded a contract to the Institute of Medicine (IOM), seeking advice on improving the listings. The IOM recommended that SSA increase the value and utility of the listings by examining and monitoring their performance, evaluating and improving their effectiveness in expediting awards in obvious cases, and making timely changes in response to these evaluations.

In October 2008, SSA contracted with the IOM to establish a Standing Committee of medical experts to advise the Agency in keeping the listings up to date. In FY 2009, SSA plans to form the Standing Committee—consisting of approximately 15 members who will serve a 3-year term and survey literature, look for ideas to improve the listings, hold meetings, and organize workgroups and public sessions. Once the Standing Committee is organized, SSA will form Consensus Study Committees specific for each body system and consisting of members from the Standing Committee and additional experts. The Agency expects to have two to four Consensus Study Committees working at a time.

STATUS OF UPDATES TO THE LISTINGS

In its 2008-2013 Strategic Plan, SSA set a goal to improve the speed and quality of the disability process. One objective of this goal was to regularly update the disability policies and procedures, which include the listings. SSA has developed a schedule to ensure it updates all the listings at least once every 5 years.

As of March 2009, of the 15 body systems (detailed in Table 2),

• 1 had not been updated within 5 years, and the Agency had not published a time frame for issuing a revision (Growth Impairment);

• 6 had not been updated within 5 years, but SSA expected to update them in the next 12 months; and

• 8 had been updated within 5 years.

Table 2: Status of the Listings by Body System
Listing Effective Date of Last Revision Years Since Last Revision Status as of March 2009
Growth Impairment March 16, 1977 31 NPRM expected December 2009
Neurological January 6, 1986 23 NPRM expected January 2010
Hematological Disorders January 6, 1986 23 NPRM expected September 2009
Endocrine System January 6, 1986 23 NPRM expected November 2009
Mental Disorders August 28, 1985 (adults)
December 12, 1990 (children) 23

18 NPRM expected in September 2009
Respiratory System October 7, 1993 15 NPRM expected November 2009
Musculoskeletal System February 19, 2002 6 NPRM expected September 2009
Malignant Neoplastic Diseases December 15, 2004 4 Final expected in August 2009
Skin Disorders July 9, 2004 4 ANPRM expected in June 2009
Genitourinary Impairments September 6, 2005 3 Set to expire September 2013
Impairments that Affect Multiple Body Systems October 31, 2005 3 Set to expire November 2013
Cardiovascular System April 13, 2006 2 NPRM expected October 2009
Special Senses and Speech February 20, 2007 (vision) 2 Final expected in September 2009 (hearing)
Digestive System December 18, 2007 1 NPRM expected October 2009
Immune System Disorders June 16, 2008 1 NPRM expected October 2009 (HIV only)

As of March 2009, several body systems had not been comprehensively revised in over 15 years, including the Growth Impairment body system—not updated in 31 years, and four body systems (Neurological, Hematological Disorders, Endocrine System, and Mental Disorders for adults) that have not been updated in 23 years.

In January 2008, SSA officials informed GAO the Agency expected to finish updating all listings by mid-2010. In January 2009, SSA reported it was still on track to meet this goal.

CONCLUSION AND RECOMMENDATIONS

Overall, SSA has made progress in updating the listings and has plans to keep them current. In addition, the Agency has developed a new process for updating the listings. According to SSA, advocate groups are positive about this new process. One advocacy group testified before the House Committee on Ways and Means and applauded SSA’s new process for reviewing the current listings. They believe that the public input SSA solicits will help to significantly improve the quality of the final provisions.

To ensure the listings are current, we recommend SSA:

1. Update all listings over 5 years old.

2. Continue to monitor the listings to ensure they reflect medical and technological advances.

AGENCY COMMENTS

SSA agreed with the recommendations (see Appendix F).

/s/
Patrick P. O’Carroll, Jr.

Appendices
APPENDIX A – Acronyms
APPENDIX B – The Social Security Administration’s Process for Evaluating Disability
APPENDIX C – Prior Reports Related to Listings
APPENDIX D – Scope and Methodology
APPENDIX E – Listings Revision Business Process
APPENDIX F – Agency Comments
APPENDIX G – OIG Contacts and Staff Acknowledgments

Appendix A
Acronyms

ANPRM Advance Notice of Proposed Rulemaking
C.F.R. Code of Federal Regulations
DDS Disability Determination Services
FY Fiscal Year
GAO Government Accountability Office
IOM Institute of Medicine
NPRM Notice of Proposed Rulemaking
ODAR Office of Disability Adjudication and Review
OIG Office of the Inspector General
POMS Program Operations Manual System
RFC Residual Functional Capacity
RO Regional Office
SGA Substantial Gainful Activity
SSA Social Security Administration

Appendix B
The Social Security Administration’s Process for Evaluating Disability

The Social Security Administration (SSA) has a five-step sequential process for evaluating disability for adults, which generally follows the definition of disability in the Social Security Act and the regulations (Chart B 1). An individual is considered to be disabled under SSA’s regulations if he or she is unable to engage in substantial gainful activity (SGA) by reason of a medically determinable physical or mental impairment that can be expected to result in death or has lasted or can be expected to last for a continuous period of not less than 12 months.

At step one in the process, SSA generally considers whether the claimant is still working. If the claimant is not performing SGA, the claim is sent for a medical determination of disability. When the claim is initially developed, the adjudicator concurrently requests all the evidence needed for consideration at steps two through five of the sequential evaluation process. The adjudication process stops whenever the SSA obtains evidence sufficient to allow the claim or if the claim is a denial after step five.

At step two, SSA determines whether the claimant’s condition is severe. If a claimant has a medically determinable severe impairment, the Agency applies step three and looks to the listings. If the severity of the impairment meets or medically equals a specific listing, the individual is determined to be disabled.

If the individual’s impairment does not meet or medically equal a listing, the Agency looks to steps 4 and 5. At step 4, the Agency determines whether the claimant can perform past relevant work, considering his or her residual functional capacity (RFC) and the physical and mental demands of the work he or she did. If the claimant can perform past relevant work, then the claim is denied. If the claimant cannot perform past relevant work, then at step 5, the Agency determines whether the claimant can perform any other work, considering his or her RFC, age, education, and past work experience. If the claimant cannot perform any other work, then SSA finds him or her disabled.

As shown in Chart B-2, SSA has a similar sequential process with three steps for evaluating disability for children. Steps one and two are the same as for adults. At step three for children, SSA determines whether the impairment(s) meets or medically equals a listing or functionally equals the listings.

Appendix C
Prior Reports Related to the Listings

The Office of the Inspector General (OIG) and Government Accountability Office (GAO) have issued several reports related to the listings.

In August 2000, we issued our report, Status of the Social Security Administration’s Updates to the Medical Listings (A-01-99-21009). In this report, we stated that the Social Security Administration (SSA) had not updated some listings in over 10 years. We also found that the Mental Disorders body system, which accounted for the highest percentage of new disability awards, had not had a comprehensive revision since 1985. We recommended that SSA establish a performance measure for its initiative to update the listings, with a specific timetable for each of the planned phases. While SSA agreed to keep a focus on updating the listings, the Agency did not believe that it should be accomplished through the establishment of a performance measure.

In August 2002, GAO issued a report titled, SSA and VA Disability Programs, Re Examination of Disability Criteria Needed to Help Ensure Program Integrity (GAO 02 597). GAO found the length of time SSA took to revise the medical criteria could undermine the purpose of an update, the updates had not fully captured the benefits afforded by advances in treatment, and SSA had not incorporated labor market changes. GAO recommended that SSA use its annual performance plan to delineate strategies for, and progress in, periodically updating the listings and that SSA study and report to Congress the effect that a comprehensive consideration of medical treatment and assistive technologies would have on SSA disability programs’ eligibility criteria and benefit package.

In January 2007, GAO issued a report titled, High Risk Series, An Update (GAO 07 310). GAO found that SSA’s disability program was based on definitions and concepts that originated over 50 years ago, despite scientific advances that reduced the severity of some medical conditions and allowed individuals to live with greater independence and function in work settings. Although SSA had made some progress toward improving its disability program, significant challenges remained.

In December 2007, GAO issued a report titled, Social Security Disability, Better Planning, Management, and Evaluation Could Help Address Backlogs (GAO-08-40). This report discussed the hearings backlog reduction plan, which focused on updating SSA’s medical eligibility criteria, expediting cases for which eligibility was more clear-cut, improving the electronic processing system, and focusing heavily on clearing the backlog at the hearings level through a number of targeted actions. The Commissioner informed GAO that as part of the effort to expedite cases, the listings would be updated so that disability categories were better defined.

In May 2008, GAO issued a report titled, Federal Disability Programs, More Strategic Coordination Could Help Overcome Challenges to Needed Transformation (GAO 08 635). GAO found that SSA had implemented a new process for updating its eligibility criteria, using an outreach-based model to update the listings and incorporate feedback from multiple parties, including medical experts and disability examiners. GAO also found that SSA had made changes to one-half of its 14 body systems to reflect medical advances. SSA officials informed GAO that the Agency expected to finish updating the remaining seven body systems by mid-2010.

Appendix D
Scope and Methodology

To accomplish our objective, we:

 Researched the Social Security Act and the Social Security Administration’s (SSA) regulations, policies, and procedures related to the listings.

 Researched the Federal Register to identify updates to the listings.

 Researched prior reports issued by the Office of the Inspector General and Government Accountability Office related to the listings.

 Interviewed SSA officials to obtain information on the status of the listings.

We performed our review from October 2008 through February 2009 in Boston, Massachusetts. The entity reviewed was the Office of Disability Programs under the Deputy Commissioner for Retirement and Disability Policy. We conducted this performance audit in accordance with generally accepted government auditing standards. Those standards require that we plan and perform the audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our findings and conclusions based on our audit objectives. We believe the evidence obtained provides a reasonable basis for our findings and conclusions based on our audit objectives.

Appendix E
Listings Revision Business Process
The Social Security Administration implemented a new process for updating the listings. See the flowchart below for details (and Appendix A for acronyms).

Appendix F
Agency Comments

MEMORANDUM

Date: March 25, 2009 Refer Refer To: S1J-3

To: Patrick P. O’Carroll, Jr.
Inspector General

From: James A. Winn /s/
Chief of Staff

Subject: Office of the Inspector General (OIG) Draft Report, “The Social Security Administration’s Listing of Impairments” (A-01-08-18023)

Thank you for the opportunity to review and comment on the draft report. We appreciate OIG’s efforts in conducting this review. Our response to the report findings and recommendations is attached.

Please let me know if we can be of further assistance. You may direct staff inquiries to
Ms. Candace Skurnik, Director, Audit Management and Liaison Staff, at (410) 965-4636.

Attachment:
SSA Response

COMMENTS ON THE OFFICE OF THE INSPECTOR GENERAL (OIG) DRAFT REPORT, “THE SOCIAL SECURITY ADMINISTRATION’S LISTING OF IMPAIRMENTS” (A-01-08-18023)

In general, we agree with the report and recommendations and provide responses to the specific recommendations below. We are committed to updating the Listing of Impairments (the listings) at timely intervals. Our new process includes continuous updates and monitoring every 3 to 4 years. These efforts are underway with a goal of updating all of the listings by mid-2010.

Recommendation 1

Update all listings over 5 years old.

Comment

We agree. We have made unprecedented progress in updating the listings over the last
5 years. Not only did we update eight body system listings, we also introduced a Quick Disability Determination process and a Compassionate Allowance initiative to identify and process very quickly claims that have an extremely high potential for an allowance. We also published an Advance Notice of Proposed Rulemaking and hosted outreach conferences for body system listings that still require updating. Comprehensive updates to these listings are well under way.

Of equal importance is the new business process we developed to make sure that our listings stay up to date. This business process seeks input from internal and external stakeholders and is being praised by the disability advocacy community.

Recommendation 2

Continue to monitor the listings to ensure they reflect medical and technological advances.

Comment

We agree. See our response to recommendation #1.

Appendix G
OIG Contacts and Staff Acknowledgments
OIG Contacts

Judith Oliveira, Director, Boston Audit Division

David Mazzola, Audit Manager

Phillip Hanvy, Acting Audit Manager

Acknowledgments

In addition to those named above:

Katie Greenwood, Auditor

For additional copies of this report, please visit our web site at www.socialsecurity.gov/oig or contact the Office of the Inspector General’s Public Affairs Staff Assistant at (410) 965-4518. Refer to Common Identification Number A 01 08 18023.

DISTRIBUTION SCHEDULE

Commissioner of Social Security
Office of Management and Budget, Income Maintenance Branch
Chairman and Ranking Member, Committee on Ways and Means
Chief of Staff, Committee on Ways and Means
Chairman and Ranking Minority Member, Subcommittee on Social Security
Majority and Minority Staff Director, Subcommittee on Social Security
Chairman and Ranking Minority Member, Committee on the Budget, House of Representatives
Chairman and Ranking Minority Member, Committee on Oversight and Government Reform
Chairman and Ranking Minority Member, Committee on Appropriations, House of Representatives
Chairman and Ranking Minority, Subcommittee on Labor, Health and Human Services, Education and Related Agencies, Committee on Appropriations,
House of Representatives
Chairman and Ranking Minority Member, Committee on Appropriations, U.S. Senate
Chairman and Ranking Minority Member, Subcommittee on Labor, Health and Human Services, Education and Related Agencies, Committee on Appropriations, U.S. Senate
Chairman and Ranking Minority Member, Committee on Finance
Chairman and Ranking Minority Member, Subcommittee on Social Security Pensions and Family Policy
Chairman and Ranking Minority Member, Senate Special Committee on Aging
Social Security Advisory Board

Overview of the Office of the Inspector General
The Office of the Inspector General (OIG) is comprised of an Office of Audit (OA), Office of Investigations (OI), Office of the Counsel to the Inspector General (OCIG), Office of External Relations (OER), and Office of Technology and Resource Management (OTRM). To ensure compliance with policies and procedures, internal controls, and professional standards, the OIG also has a comprehensive Professional Responsibility and Quality Assurance program.
Office of Audit
OA conducts financial and performance audits of the Social Security Administration’s (SSA) programs and operations and makes recommendations to ensure program objectives are achieved effectively and efficiently. Financial audits assess whether SSA’s financial statements fairly present SSA’s financial position, results of operations, and cash flow. Performance audits review the economy, efficiency, and effectiveness of SSA’s programs and operations. OA also conducts short-term management reviews and program evaluations on issues of concern to SSA, Congress, and the general public.
Office of Investigations
OI conducts investigations related to fraud, waste, abuse, and mismanagement in SSA programs and operations. This includes wrongdoing by applicants, beneficiaries, contractors, third parties, or SSA employees performing their official duties. This office serves as liaison to the Department of Justice on all matters relating to the investigation of SSA programs and personnel. OI also conducts joint investigations with other Federal, State, and local law enforcement agencies.
Office of the Counsel to the Inspector General
OCIG provides independent legal advice and counsel to the IG on various matters, including statutes, regulations, legislation, and policy directives. OCIG also advises the IG on investigative procedures and techniques, as well as on legal implications and conclusions to be drawn from audit and investigative material. Also, OCCIG administers the Civil Monetary Penalty program.
Office of External Relations
OER manages OIG’s external and public affairs programs, and serves as the principal advisor on news releases and in providing information to the various news reporting services. OER develops OIG’s media and public information policies, directs OIG’s external and public affairs programs, and serves as the primary contact for those seeking information about OIG. OER prepares OIG publications, speeches, and presentations to internal and external organizations, and responds to Congressional correspondence.
Office of Technology and Resource Management
OTRM supports OIG by providing information management and systems security. OTRM also coordinates OIG’s budget, procurement, telecommunications, facilities, and human resources. In addition, OTRM is the focal point for OIG’s strategic planning function, and the development and monitoring of performance measures. In addition, OTRM receives and assigns for action allegations of criminal and administrative violations of Social Security laws, identifies fugitives receiving benefit payments from SSA, and provides technological assistance to investigations.