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New report examines social security's process for determining disability in adults

March 01, 2018

WASHINGTON -- A new report from the National Academies of Sciences, Engineering, and Medicine examines to what extent and in which ways health care utilization -- such as in-patient hospitalizations, emergency department use, and hospital readmission -- reflects disease severity, disability, and ability to perform gainful activity. The committee that conducted the study was unable to find an association between health care utilization and disease severity as it relates to the Social Security Administration's (SSA) determination of severe impairment -- an impairment or combination of impairments severe enough to prevent a person from performing any gainful activity regardless of age, education, or work experience.

Types of health care utilization vary with combinations of health conditions, and although there might be a connection between some types of utilization and impairment severity or disability, the committee could not make that specific connection on the basis of available data.

The SSA administers two programs that provide benefits based on disability. The Social Security Disability Insurance (SSDI) program provides disability benefits to people under the full retirement age who are no longer able to work because of a disabling medical condition or a terminal illness. The Supplemental Security Income (SSI) program is a means-tested income-assistance program for disabled, blind, and aged people who have limited income and resources regardless of their prior participation in the labor force.

The committee relied on hospitalization and other national data, given that annual data on hospitalizations has been collected in the U.S. since 1965, and it is easy to capture and more likely than data on other types of health care utilization to constitute a reliable measure of impairment severity associated with some diseases. However, care is given in many other settings, such as outpatient and urgent care centers, and this fragmented nature of the health care delivery system makes it difficult to account for all the types and locations of utilization for purposes of determining disease severity.

Many factors affect use of health care services, the report says, such as costs of care, availability of providers who accept the patient's insurance, and access to transportation options. Social determinants, such as race and ethnicity, language, income, and poverty, have a substantial effect on health care utilization and outcomes. In addition, different geographic regions experience varying degrees of availability of health care; urban regions have easier access than rural areas. People with disabilities face a number of barriers to accessing health care, including physical access -- lack of working elevators or ramps, automatic doors, hallways and doors wide enough to accommodate wheelchairs, and accessible parking -- and accommodation for barriers to communication, such as lack of staff willing to try to communicate with impaired patients during scheduling or other interactions.

Given appropriate data -- such as administrative records of past SSDI applications merged with data on health care utilization available at the time of determination and data on post-determination work outcomes -- there are models for quantifying the value of health care utilization for determining impairment severity, the report says. However, with the rapidly changing health care landscape, predictive models that are developed now might not have the same performance attributes later, and analyses will have to be repeated as changes occur.

The study was sponsored by the U.S. Social Security Administration. The National Academies of Sciences, Engineering, and Medicine are private, nonprofit institutions that provide independent, objective analysis and advice to the nation to solve complex problems and inform public policy decisions related to science, technology, and medicine. They operate under an 1863 congressional charter to the National Academy of Sciences, signed by President Lincoln. For more information, visit nationalacademies.org. A committee roster follows.
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Copies of Health-Care Utilization as a Proxy in Disability Determination are available from the National Academies Press on the Internet at http://www.nap.edu or by calling 202-334-3313 or 1-800-624-6242. Reporters may obtain a copy from the Office of News and Public Information (contacts listed above).

THE NATIONAL ACADEMIES OF SCIENCES, ENGINEERING, AND MEDICINE

Health and Medicine Division
Board on Health Care Services

Committee on Health Care Utilization and Adults with Disabilities

Dan G. Blazer, M.D., M.P.H., Ph.D.* (chair)
J.P. Gibbons Professor of Psychiatry (emeritus)
Duke University Medical Center
Durham, N.C.

Jeff Bazarian, M.D., M.P.H.
Professor
Departments of Emergency Medicine and Neurology
University of Rochester Medical Center
Rochester, N.Y.

Jennifer Bogner, Ph.D.
Professor
Department of Physical Medicine and Rehabilitation Wexner Medical Center
Ohio State University
Columbus

Annette L. Fitzpatrick, Ph.D.
Research Professor and Associate Dean for Academic Services
School of Public Health
University of Washington
Seattle

Tracie C. Harrison, Ph.D.
Professor and Director
Center for Excellence in Long Term Care
School of Nursing
University of Texas
Austin

Philip D. Harvey, Ph.D.
Leonard H. Miller Professor of Psychiatry
Miller School of Medicine
University of Miami
Miami

Miguel Hernan, Dr.P.H., M.D., M.P.H., Sc.M.
Kolokotrones Professor of Biostatistics and Epidemiology
Harvard T.H. Chan School of Public Health
Boston

Renee Y. Hsia, M.D.
Professor and Director of Health Policy Studies
Zuckerberg San Francisco General Hospital and Trauma Center
University of California
San Francisco

Nicole Maestas, Ph.D.
Associate Professor of Health Care Policy
Harvard Medical School
Boston

Judith McKenzie, M.D., M.P.H.
Professor and Division Chief
Division of Occupational Medicine
Perelman School of Medicine
University of Pennsylvania
Philadelphia

Kathleen J. Mullen, Ph.D.
Senior Economist and Director
Center for Disability Research
RAND Corp.
Santa Monica, Calif.

Linda Anh Nguyen, M.D.
Clinical Associate Professor of Medicine, and
Director of Gastrointestinal Motility and Neurogastroenterology
Stanford Medicine
Stanford, Calif.

Albert J. Osbahr III, M.D.
Medical Director
Occupational Health Services
Spartanburg Regional Healthcare System
Spartanburg, S.C.

Kevin A. Schulman, M.D.
Professor of Medicine
Duke University
Durham, N.C.

Seth Seabury, Ph.D.
Director
Keck-Schaeffer Initiative for Population Health
University of Southern California
Los Angeles

Donald H. Taylor Jr., Ph.D.
Professor
Sanford School of Public Policy
Duke University
Durham, N.C.

STAFF

Carolyn Fulco
Bernice Chu

*Member, National Academy of Medicine

National Academies of Sciences, Engineering, and Medicine

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