Articles from prior issues of The Advocate

July/August 2001

Cutting The Gordian Knot (Or What Will We Do With 1,000,000 More Adult Claims Per Year?)
by Bob Kanner, Buffalo NY DDS

We are told that due to the size and the aging of the baby boom generation, the Disability Program will eventually have to cope with 1,000,000 more adult claims per year than it does at present. How can the Program possibly hope to handle the coming flood of claims? One way would be to ask Congress for progressively larger amounts of money. And, while more resources will certainly be necessary, it is unrealistic to hope that the Program will obtain the resources needed for current adjudication plus 1,000,000 more adult claims per year. It would also appear that none of the plans, DCMs, pilots, or prototypes currently being discussed and/or tested will prove an effective solution to 1,000,000 more adult claims per year.

This all being the case, the questions is, what should be done with the Program to get it ready for 1,000,000 more adult claims per year? The answer is that we need to summon the courage to ask for legislative authority to change the way in which claims are adjudicated. Experience says that the greatest proportion of our resources and processing time on adult claims is spent trying to define Residual Functional Capacity (RFC) including the time it takes to come to a decision, money spent on consultative examinations, as well as brain power and time spent writing and adjudicating the Rulings such as those dealing with pain, credibility, and treating source opinion.

It would seem that the only way the system will be able to handle 1,000,000 more adult claims per year with the resources which will become available would be to liberalize the listings so that approximately the same amount of claimants would be allowed and do away with the consideration of RFC. A Listings only approach could be structured in one of several ways: 1) Create liberalized Listings which all claimants would have to meet or equal no matter their age, education, or work history. Under this proposal, all claimants with the same condition should receive the same decision. 2) Create liberalized Listings which are geared to a claimant’s age. Under this proposal, each Listing would be keyed to a certain age bracket. For instance, Listings could be created for ages 18-44, 45-49, 50-54, 55-59, and older than 59. Claimants in the same age bracket and with the same condition should receive the same decision. 3) Create liberalized Listings all of which would have multiple parts. For instance, suppose a new Ischemic Heart Disease Listing had 6 parts to it. Under this proposal, a younger claimant (for instance age 18-44) would have to meet or equal all 6 parts in order to be found disabled. A claimant aged 45-49 might have to meet or equal 5 out of 6 parts. A claimant aged 50-54 might have to meet or equal 4 out of 6 parts, and so on. Claimants of the same age and with the same condition should receive the same decision.

A Listings only approach would be less costly in terms of processing time, resources, personnel, and rules needed to adjudicate decisions.

There are several other comments which need to be made about this proposal: Current rulings such as those dealing with pain, credibility, treating source opinion will need to be maintained. A liberalized Listings only approach would probably result in less appeals since programs rules and the reason for denial of benefits would be easier for claimants, their representatives, and their doctors to understand The proposed approach might dovetail quite nicely with the Claimant Conference utilized in the current Prototype project. In fact, the liberalized Listings only approach outlined above and the Prototype project would probably be complimentary to each other in that they would both save time and resources. Also, this approach would also be easier to explain to claimants during Claimant Conferences. Current rules which permit favorable decisions for those with unfavorable profiles such as, but not limited to, older claimants with a long history of unskilled, arduous work or claimants who are age 55 or more who have a limited or less education, and a history of unskilled or no work, should be retained. In addition, the medical improvement standard should be retained.

In addition to the above, a way must be found to deal with the anticipated increase in appeals resulting from 1,000,000 more claims filed per year. Even if my proposal proves to be a more efficient way to handle claims, there will still be a very large increase in the number of appeals.

It is proposed that there be three types of appeals and that the claimant would make the choice as to which one to pursue: The first choice would be the current Prototype Process for a Claimant Conference—could be done very quickly but would be a less detailed The second choice would be a face to face hearing to be held by DDS personnel—would take somewhat longer and would be more detailed. The third choice would be to elect to have a face to face hearing with an ALJ.

The condition of filing for appeal would be that once the claimant makes a choice, they would be precluded from being able to pursue either of the other types of appeals. However, the claimant would have the ability to choose what type of appeal they desire.

A radical change in the way we adjudicate claims and permit appeals to be filed has been proposed. Some will say that we should not give Congress a reason to put its hands on the Program because the results would be uncertain. The answer is that Congress already has 100,000,000 reasons to put its hands on the Program. Some will say that these proposals are too radical may result in unintended harm to impaired claimants. While it is recognized that questions regarding these proposals will need to be considered, the answer is another question—What do YOU propose to do about 1,000,000 more adult claims per year? Don’t wait too long—the clock is ticking.

Responsible comments may be sent to the author at Rkat207@Worldnet.Att.Net.