Articles from prior issues of The Advocate

July/August, 2000

Pacific Regional Conference Highlights

Washington DDS Director Don Larson and Regional Commissioner Carmen Keller Address Regional Conference by Nancy Morris

Don Larson, Director of the Washington DDS welcomed all delegates to the conference. During his presentation, he mentioned that about fifty percent of the Disability Analysts in Washington have less than three years of adjudicative experience. That has led them to adopt a program of in-line reviews similar to Washington DC DDS. This in-line review has four stops where the file is reviewed. When the claim comes through the door at the DDS, it goes through initial development and the first in-line review when initial development is completed. The second review is after 30 days. The next review comes when the Residual Functional Capacity (RFC) or Mental Residual Functional Capacity (MRFC) is completed or when the file goes to the Medical Consultant (MC) for review. The final review is at the end of the line. Washington has 115 Disability Analysts and nine of them are dedicated to in-line reviews.

The management team does another type of review. This team consists of Unit supervisors, the Quality Assurance (QA) supervisor, MCs and the trainer. This team staffs the case to make sure all are on the “same page”.

Washington, along with other Pacific Region States, have noticed a definite increase in case intake. At least fifty percent of the incoming claims are because of other state programs. For example, in order to receive General Assistance, the applicant is required to apply for Social Security Disability benefits. Many other programs have the same requirement. Carmen Keller was the next speaker to welcome the delegates to the conference. She made a big hit by starting off with the presentation of a Commissioner’s citation to Idaho and noted that they have won this honor ten of the last 12 years. She spoke of the future and how SSA is attempting to plan for it. They have set up a group, headed by Sue Davis, who once headed the SDM program, to develop a vision of what the program will look like in 2010. A paper is expected by sometime in August. She said the vision will be incorporated in the SSA strategic plan.

Among many statistics Carmen shared was that reviewing CDRs has saved SSA $5.6 billion. In 1994, only 10,000 CDRs were reviewed compared to 1.7 million that were reviewed in 1999.

She expanded on Don Larson’s observation that over half of the DDS analysts in Washington have less than three year’s tenure by pointing out that nationally, in 1995, DDS staffing was at 13, 000. In 1999 the staff count had risen to 14,600. This is because there was a 32.6 percent growth in the number of title II/XVI claims flowing through the DDS.

This trend is likely to continue with the aging population. She said that SSA faces many challenges, among them the increase in minority communities and with it communication issues. Reduction in work force at the same time the work load is increasing is another big issue SSA will have to face.

SSA plans to meet the challenges by automating much of what we do and creating interfaces between the DDS, the field offices, and OHA. In the Seattle region, the Regional Office staff are actually participating in taking claims and filling out the 3368. She commented on the tests that states are doing as well, mentioning the Oregon geographic distribution pilot specifically. She was very complimentary of the Pacific Region of NADE for setting aside money specifically for a leadership session within the conference and reminded us that we are all leaders and that we need to be creative. She quoted Albert Einstein’s famous: “Imagination is more important than knowledge” and told us how important she thinks teamwork is and will be. For us she sees relationships as a big issue and recommends that we pay attention to details in our jobs and in our program.

Phil Landis on Prototype by Ken Forbes

Phil Landis spoke in place of Ken Nibali, who had a speaking commitment to a small group of 500 attorneys.

He reported on the progress SSA is seeing in Process Unification. Peer reviews are showing an increase in the quality of the decisions coming out of OHA. Also, the allowance rate at the DDS is coming up while the number of cases OHA is reversing is going down.

So, what’s going on with Prototype? Early experience is showing very positive experience at all levels of staff in each site. He said the examiners are telling SSA that this is the right way to do cases and that both examiners and MCs really like the changes in authority. The process requires a major cultural shift and has had a significant impact on productivity in the states involved.

Since they decided to maintain the old process for pipeline cases, Phil indicated they do not have good data on savings from the elimination of reconsideration claims. He said they have revised their timetable for implementation because the learning curve is much longer than they anticipated.

Keys to success? 1) focused local training; 2) having a great Field Office product; 3) direct and immediate claimant contact; 4) early phasing in of work changes (analyst completion of the Residual Functional Capacity form for example); and 5) finding an alternative for the pipeline process.

Landis said that SSA visited all the prototype states and found that the baseline environment in those states affects progress. It was clear from those visits that the tone set by management is critical to the success of the change. They also found the claimant conference to be a big issue. The wording of the notice confused many claimants and SSA is working to simplify it. The conference should be our opportunity to educate the claimants about the needs of the program and to relate any additional information to the requirements of the program.

What’s next? SSA will clarify the goals of the claimant conference and improve the process for the conference. He said there needs to be better training on analysis and writing, and they need to survey the non-prototype states to get some baseline information. Finally, they need to develop the roll-out strategy.

One comment Landis made that I found particularly interesting was that, when examiners do a good job of explaining how evidence relates to disability, claimants appeal behavior is affected. This implies that claimants will appeal less if examiners provide good explanations. Hmmm.

User’s Guide to Psychological Testing by Peter LeBray, Ph.D.

Dr. Ellen Lehr, psychologist with Regional DQB and experienced DDS consultant and adjudicator, presented a 90 minute overview of psychological testing to the general session on May 4, 2000. This included practical issues in ordering testing exams, use of test data, working with consultative examiners and summary of test recommendations per various mental listings. Psychological evaluations and tests can be especially useful in: (1) documenting presence and severity of mental disorders; (2) delineation of intact functioning/skills to show adequacy of performance in daily and vocational areas; (3) providing clinical opinion regarding credibility and functional severity of alleged impairments. Factors to consider in ordering such exams include: whether a new impairment is alleged, whether there has been a worsening of alleged conditions, whether there are discrepancies or treatment effects, or more specific issues on a case by case basis (e.g., malingering, need for diagnosis; resolve inconsistencies).

In working with CE providers, Dr. Lehr advises: limit the exam to specific areas of interest or concern; communicate the focus and issues to address in the exam; provide background and available reports for review; if in doubt, discuss with DDS psychological consultant; discuss with CE provider alternatives and needs if a particular test or measure is inappropriate. For example, the Bayley scales may not apply to children above 42 months, but there are other tests with similar yield.

Excellent review of listing areas along with a useful handout was provided including: Mental Impairments: Mental Retardation, Borderline Intellect, Learning Disorders, neurocognitive disorders (TBI, dementias).

Dr. Lehr said that testing is valid if done after claimant is age 16 and there is no reason to expect significant changes in function. For younger children, IQs of less than 40 are good for only two years if administered between birth and the age of six and for four years if administered between the ages of seven and 16. An IQ over 40 is good for one year between birth and the age of six and for just two years between the ages of seven and sixteen. A current IQ exam is needed if: prior findings are not deemed valid, there is a wide variation in scores not easily explained, or claimant’s cognitive condition has deteriorated. For mental retardation with onset prior to age 22, valid IQs and significant adaptive deficits must be documented. Adaptive functioning described by credible third parties or by adaptive scale instruments is essential in determining severity of mental/cognitive disorders.

The following disorders can be effectively assessed via detailed mental status exam, interview and background information including effectiveness of treatment: Depression, Bipolar Disorder, Anxiety, PTSD, Personality Disorder, Somatic and Psychotic Disorders. Instruments such as MMPI-2 or Millon scales may be helpful for differential diagnosis and severity assessments.

ADHD is a condition often not observable in the one-to-one “special” exam setting, and should be assessed via credible third parties (parents, teachers) and severity scales. Formal tests of attention-concentration are helpful, but not definitive.

Memory Disorders: A mental status exam including concentration and recall can be useful along with more formal tests such as Wechsler Memory Scale-III. Third party input, when very familiar with claimant’s daily functioning, can be important. If memory problems are due to affective disorder (eg, depression), then evaluation of severity of depression and the effects of treatment are most relevant and useful.

Substance Abuse: Current information on substance use per claimant and from reliable third parties along with daily functioning (DAA questionnaire, ADLs) are necessary, especially when “using”. Personality and emotional factors (substance-induced mood disorders) and possible cognitive deficits should be addressed via formal tests.

Dr. Lehr provided an overview of common tests and instruments useful in aiding the disability determination process. Some examples include: WAIS-III (ages 16-89); WISC-III (ages 6-16); Bayley Scales of Infant Development II (birth to 43 months); WASI (Wechsler Abbreviated Scale of Intelligence for screening only). There are culture fair/free tests which can be discussed with specific IQ CE providers.

Conditions such as “organicity” (alleged neurocognitive deficits) warrant a Neuropsychological Screening exam (eg, WAIS-III; WMS-III; Trailmaking Tests; Aphasia Screening Test; others). Memory testing using the WMS –III or Memory Assessment Scales can be useful. Personality testing can use Minnesota Multiphasic Personality Inventory-2 (MMPI-2) with 566 items, taking 1-2 hours and a 7th grade reading level. The Millon Clinical Multiaxial Inventory (MCMI) takes 30-45 minutes, 150-175 items with reading at 8th grade level. The Rorschach (so called ink-blots) and other tests can be used depending on expertise of the examiner.

Other tests and instruments which may be ordered as necessary include validity testing (motivation, effort, malingering), adaptive function scales (eg, Vineland), achievement tests (eg, Wechsler Individual Achievement Test, ages 5-19) or more detailed mental status exams.

Dr. Lehr discussed the importance of test data providing an objective basis for determining and assessing various mental conditions and gave us an overview of examples of tests. Analysts were encouraged to provide CE providers with as much information and specific questions as possible and to confer often with DDS psychological consultants as well in obtaining appropriate exams and interpretation of findings.¨ Integrative Medicine: The Joining of Traditional and Alternative Treatment Modalities in a Community Health Center Setting by Tanya Webber

Thomas Trompeter, Executive Director of Community Health Centers (CHC) of King County, presented this session at the Pacific Regional Training Conference.

Naturopathic medicine and acupuncture are becoming increasingly accepted as treatment modalities throughout the Northwest. Both Washington and Oregon have educational institutions which specialize in naturopathic medicine and acupuncture, otherwise known as alternative medicine.

CHC offers treatment, prevention and health education to the residents of King County. The mission of the agency is to affirm the dignity of all individuals regardless of their socioeconomic status. Naturopaths, acupuncturists and traditional medical doctors staff the CHC. Low-income consumers pay on a sliding scale, based upon income. Eighty percent of patients at CHC are white, five percent are black, less than five percent are Asian/Latino and a small percentage are refugees and immigrants. Alternative medical treatment has proven effective with: hypertension, diabetes, musculoskeletal conditions, gynecological problems, fibromyalgia, migraine headaches, back pain, allergies and some psychiatric disorders such as depression and ADHD.

In order to best serve the patients at CHC, guidelines were established to effectively treat life threatening medical conditions. For instance, a diabetic whose blood sugar is greater than 270 would be treated by a traditionally oriented physician on staff. If less than 270, a naturopathic physician would provide treatment. Patients are referred to the hospital for certain acute conditions. While in the hospital, the patient is followed by a CHC traditionally oriented physician who coordinates patient care with a CHC naturopathic physician. Patients are also referred to chiropractors, massage therapists and psychiatrists.

When a patient’s funds are limited, remedies are prescribed to maximize benefit at minimal cost. The patient’s choice is respected as long as it is clinically sound.

Integrative medicine at CHC draws the best from both traditional and alternative medicine with the intent of providing ultimate health care for the patient at an affordable cost.¨

The Orthopedic Exam: It's MoreThan ROM by Cristal Milburger

Many cases adjudicated at the DDS offices involve orthopedic allegations. Thomas Fleming, M.D. gave a presentation on orthopedic examinations at the Pacific Regional Conference in Seattle, Washington. He demonstrated what a complete orthopedic examination should include and also explained the terminology used in the reports. Dr. Fleming discussed normal range of motion values as well as strength and sensation testing. The information given was very helpful for those who attended.

The other aspect of the presentation dealt with how to determine if a claimant’s allegations are consistent with objective findings. There are specific tests that are performed during an exam which test for possible malingering and/or over reaction. This information was helpful in showing better ways to address credibility when looking at these types of impairments.

Specifically, Dr. Fleming mentioned the Drop Arm test for malingering and the Waddell’s tests for overreaction. The Waddell’s tests are a group of exam maneuvers to help differentiate organic, orthopedic, or neurologic factors in low back pain from non-organic factors.

The physician will use the history and exam to see what structural abnormality or process is best supported by the data. For any organ system, a physician must determine if the findings make sense from what we know about anatomy and physiology. When the Waddell’s tests are administered, they can indicate that non-organic, non-physiologic factors may be involved in the patient’s presentation.

Regional Director’s Corner by Ken Forbes

What a quarter we have had! The Pacific Region held its annual training conference in Seattle and attracted a lot of people from various chapters. The bulk of our attendees came from the Renton and Olympia chapters with a few making the trek over from Spokane. Idaho was well represented with five, and California managed three from LA and four from Sacramento.

Alaska had two attendees and Oregon rounded out our attendance with nine. Besides the membership, we did have a number of attendees from the Region X offices of SSA and several people who were not yet members but who really wanted to know more about the training opportunity and about NADE.

We also completed our first ever Leadership Development session at the end of the Regional Conference. Over a dozen people attended and the follow-up surveys have been very positive about the experience that everyone had. We combined lecture with games and interactive sessions and showed off our high-tech skills by supporting the whole presentation with Power Point.

The attendees unanimously requested that we put on another session at the bi-regional conference next year in Boise. For those who haven’t heard, the Pacific and Great Plains Regions are putting on next year’s conference and it will be held in Boise either in late April or early May. Information can be obtained from Harry Herbert at the Idaho DDS. Our thanks go out to the Idaho chapter and one of the newer members who really supports and encourages these activities, Barbara Bauer (Director of the Idaho DDS).

At a national level, NADE continues to be involved in activities that support the membership and carry out our mission of improving the disability program while promoting the professional development of our members.

We are currently struggling with the direction that SSA seems to be taking relative to the certification of disability examiners. SSA had asked us for input and we told them that we had a certification process that seemed as effective as it could be made considering the restrictions we all work under. We even followed up with a survey of DDS Directors specifically looking for whether a certification will make a difference in the ability of our members to be hired or to be paid more. The results for hiring were very disappointing. Many of the Directors indicated that they just did not have any control over whether they hired certified analysts. They said everyone has to pass the state process for skill assessment and there were no exceptions based on certification. Even with that information, SSA has gone forward with a solicitation to have someone bid to develop a certification process.

NADE has gone on record with Commissioner Apfel asking him to consider the financial implications of the Prototype roll-out because we are very concerned with whether the DDS community can actually get the job done with the funds available. This year is a prime example. Even under the normal process, with only a few pilots besides the big prototype going on, SSA is not able to fund the DDSs to clear all the claims that are expected to be received.

In reviewing the data put out about the prototype, and talking to the people who are actually doing the work, it appears that there is a reduction of at least one-fourth in the number of claims that can be cleared by the “normal analyst”. So, it costs more to move the same number of cases because you have to have more people working on them.

Two things seem obvious:

1) It will cost more to move the same number of claims and

2) If we just move the number of claims we are budgeted for, we will have backlogs building all over the country.

Am I just dense or is something wrong with this picture? The prototype is supposed to be designed to provide better customer service. And, the people who have learned how to do it and are devoting the time to it say they believe they can produce a better product. They just can’t produce as many. Unfortunately, we seem to have lost sight of the fact that customer service is a balance between the speed with which someone receives the product and the amount of effort you can put into producing the product. It is the old principle of increasing costs: to eliminate defects in any manufactured product costs money. Beyond a certain point, it will cost more than you can afford to eliminate the defects.

If we want to process all the claims submitted and we want to maintain a low enough case-load that analysts can devote the time and effort required to produce the product envisioned in prototype then we have to have a lot more analysts and that means a lot more money. Considering that Congress is in the process of reducing the amount of money that SSA has, it isn’t likely that the DDSs will get more money to staff appropriately for the prototype roll-out.

At this point, we haven’t even seen the effects this new process will have on the Office of Hearings and Appeals workload. Some people still hope that eliminating the reconsideration step will save lots of bucks to pay for the implementation of prototype in the DDSs, but almost everyone else now agrees that will not happen. But what about the increased workload that will go to OHA? Certainly an increase in allowance rate at the DDS will keep some people from requesting hearings. But, what about all the people who currently request reconsideration, get their denial affirmed, but don’t go on to request a hearing? Since they have demonstrated their desire to enter the appeal process, some portion of them will request a hearing. The workload at OHA will go up. This involves lots of administrative dollars because processing cases at OHA is significantly more expensive than processing the same case at the DDS. Has anyone calculated how much of the limited SSA budget will have to be diverted from the DDS to OHA to cover these costs?

Like everyone else I’ve talked to in NADE, I support the prototype concepts and believe a better quality decision can be produced by using this process. I am however very concerned about the costs involved and what it will mean to our members and the DDSs.

While I was not here at the time, many of my colleagues tell me of the time in the past when analysts regularly did many of the “prototype” processes such as the personal interview and the detailed rationale. When I ask why we stopped they almost always say the same thing, workload increases and it cost too much.

Back to more local issues. The Pacific Region will be proposing that NADE adopt a resolution at the national conference in Puerto Rico. We would like NADE to go on record in support of a change in the listings that would allow the use of some tools in addition to the Goldman for determining visual field loss. While there are some Goldmans around, there are very few people qualified to administer the test and interpret the results.