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The Social Security Administration delegates to state agencies responsibility for making disability determinations. States in turn use medical experts, some staff some contracted. Either way, the Government Accountability Office found Social Security needs to shore up its oversight of state medical experts. For more, the Federal Drive with Tom Temin turned to the director of GAO’s Education, Workforce and Income Security Team Elizabeth Curda.
Tom Temin: And you have looked at disability payments, which from Social Security origination are actually dispersed by the states and state agencies, not directly by the federal government. And you found though that there could be, what, basically a little bit more oversight by the federal government on how the state agencies operate?
Elizabeth Curda: That’s right. We looked at the issue of the role that medical consultants play in the claims review process. And this process is conducted by state agencies on behalf of the SSA. And we looked at, in particular, the concern that some of these medical consultants who review the medical evidence in a disability claim are paid by the claim. And there’s a concern that consultants who are paid by the claim might prioritize quantity over the quality of those claims. And we did look at how SSA is overseeing these medical consultants.
Tom Temin: And the medical consultants when you say paid by the claim, that doesn’t mean they’re necessarily paid for successful application. That is, someone could be turned down, but they get paid regardless. Fair?
Elizabeth Curda: Correct. They are paid for each claim that they review and complete.
Tom Temin: And are these people state employees in general? Are they in turn contracted to a state agency? Or does that vary from state to state?
Elizabeth Curda: It does vary from state to state. And that was one of our findings is that, in fact, they are employed by states and that most states are using contracted medical consultants. Of the 52 state agencies we looked at, and the state agencies are called Disability Determination Service Agencies, 42 out of the 52 were using contracted medical consultants. And of those 42, 19 states were paying their consultants by the case.
Tom Temin: Right. So then is the bigger concern, the lack of oversight of the qualifications or the quality of what they’re doing? Or is the main concern the fact that they are simply incentivized to produce lots of claims?
Elizabeth Curda: Well, it’s a little bit of both, right? So when you have an employee, right, and you mean, you should be as concerned about employees who are salaried as whether and when you have the function being carried out by a contractor. And typically, when you have a contract to do the work, you specify things like quality and timeliness and basic performance considerations for the contractor. And what we found is by and large SSA delegates that oversight function and performance to the state agencies for their employees or their contractors. And each state did it a little differently. But with regard to overseeing the quality of the performance, most state agencies had some form of internal quality review process that they use that encompass their consultants. The areas where we saw a little less in terms of oversight was in the background checks of the contractor consultants, and also the training.
Tom Temin: Right. So, therefore, the states varied in the degree to which they used qualified individuals, essentially.
Elizabeth Curda: Well, we actually did a check of the background checks on a sample of the state agencies, and we did not find any specific cases of a medical consultant who had failed the background check, etc. However, we did find that since we only looked at a sample, we did find that quite a few of the state agencies did not routinely do this function of doing the background checks. And that SSA’s oversight of that was somewhat limited. So that’s an area where we made a recommendation to basically reinforce the policy that state agencies must do these background checks on their medical consultants when they initially hire them. And at least annually after that.
Tom Temin: We’re speaking with Elizabeth Curda, she’s director of GAO’s Education, Workforce and Income Security Team. And was there any evidence of variations in the amount of cases that were favorably disposed or turned down, that would be out of what you would expect in a statistical sample of a given area? And did that say anything about the qualifications or otherwise state anything about the process being used?
Elizabeth Curda: Yes, we did a statistical analysis. Basically, we had a sample of SSA quality data in which they reviewed the quality of state agencies’ reviews of the claims. And we had data on how each state pays their medical consultants. And so we looked for statistical differences between states that paid employees a salary on an hourly basis, and those who paid by the claim, and we did not find conclusive statistical significance that there was any difference between the quality of those two different kinds of consultants in terms of the quality of their reviews. And it was inconclusive, the data were somewhat limited – the sample size and so forth – because of a variety of reasons. If the data were a little better, I mean, it’s possible that we could find some differences, but we could not conclude that there were differences.
Tom Temin: So if that’s the case, then what’s the practical issue with having people paid by the case?
Elizabeth Curda: Well, I think the practical issue is just again, getting back to the quality issue. We found sort of two areas where SSA oversight was – there were gaps. And the two areas, as I mentioned, the first was the background checks. The other area was training. And not every state had in place procedures to ensure that the newly hired consultants were getting the initial training they needed to understand all the ins and outs of how to review medical evidence in a way that’s consistent with SSA’s medical criteria for disability, and they weren’t giving them refresher training. So those are sort of two very important things and SSA policy that states are supposed to be doing that some are not. And so that was our other recommendation was that SSA ensure that the states are providing that initial and refresher training to all of their medical consultants.
Tom Temin: Yes. So those are the two main recommendations. What did Social Security say to you about those?
Elizabeth Curda: Well, they agreed. And that was pretty much the extent of it. They have not yet updated us on sort of what they plan to do.
Tom Temin: Do they have the staff and the wherewithal to do that, because it sounds like a big task when you’ve got 50 state agencies and maybe more at the county level, that are looking into this?
Elizabeth Curda: Well, it’s an important oversight function. When it comes down to it, right, I mean, this is the mission of the agency is to process these claims for people a very, highly vulnerable population, and to do it correctly, and do it timely. So it’s very important that SSA use its resources to ensure that basic safeguards are in place, that they’re not hiring doctors who aren’t qualified, or have some kind of a black mark in their record, and that those consultants are trained and know how to follow the procedures that they produce quality outcomes. I mean, it’s not like there is no quality issues, right? Because they do audits, they do occasionally find quality problems. And it may not be just the medical consultants who are contracted, but just consultants in general.
Tom Temin: And the context here is that disability payments and quantities of people on disability is really rising faster than the population as a whole. And so you’ve got this burgeoning of disability claims going on in the country.
Elizabeth Curda: Correct. Yeah, at the moment, strangely enough claims are down. But I think that’s largely attributed to the pandemic and the fact that people who might have gone into a Social Security office to file a claim – those offices are closed right now. And so there’s sort of a backlog building up. I think what we’re going to see is as we come out of the pandemic – a really big influx of claims and backlogs developing. Right now, the initial claims is not as bad but the appeals are starting to get backlogged again, and appeals are when you are denied a claim, you can appeal it and that goes through a whole different process with a judge. And those are getting backlogged. So it’s always of concern, the workloads of the SSA and disability area. It’s one of our high risk issues.
Tom Temin: Right. And I guess that’s an interview for another day. What happens when this is all over and then the claims start to roll in. In the meantime, Elizabeth Curda is the director of the Education, Workforce, and Income Security Team at the Government Accountability Office. Thanks so much for joining me.