- Email: [email protected]
Incentive to Remain Ill? How Disability Benefits Affect Health Status
Incentive to Remain Ill? How Disability Benefits Affect Health Status Kim Brew, DNP, FNP-BC, and Robyn Panther Gleason, PhD, FNP-BC ABSTRACT
Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) were created to provide a temporary safety net for people who become disabled to protect them from impoverishment. Currently, many people receive SSDI or SSI until they reach retirement age. This literature review explored the impact these programs have on people reaching their optimal level of health. Results show the number of people voluntarily returning to work is 0.2%, demonstrating that most people receiving disability benefits stay with the programs instead of returning to the workplace. Keywords: access to health care, barriers to employment, disability, SSDI, SSI, vocational rehabilitation Ó 2014 Elsevier, Inc. All rights reserved.
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ocial Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) were created to provide a temporary safety net for people who become disabled to protect them from impoverishment. However, many people who receive SSDI or SSI under those circumstances remain in the programs until they reach retirement age. Mr J, a 67-year-old man with chronic pain from 2 lumbar fusions, is an example. Mr J was 50 years old at the time of his injury. He had sustained 2 ruptured lumbar discs and a vertebral fracture from an accident and had planned to return to work after his initial surgery. However, a second surgery was necessary because of postoperative complications. His employer could not keep his job open indefinitely, so Mr J lost his job and his medical insurance benefits and applied for SSDI. The eligibility process for SSDI lasted 5 years. Mr J was 55 when he became eligible and began receiving SSDI benefits, including Medicare. His chronic pain prevented him from returning to his previous job and limited his ability to perform other full-time jobs. Parttime work would not have included medical benefits and would have paid less than his monthly disability check. His fear of losing the SSDI benefits outweighed the desire to feel productive by working and affected www.npjournal.org
his willingness to explore treatment that might have enabled him to return to work. He stated that he felt trapped and worthless. Mr J’s story illustrates a common scenario seen in primary care practice. Patient reports such as his prompted an extensive literature review to explore the effects of becoming part of the disability benefit process on health status and treatment adherence. METHODS
A literature review was conducted using MD Consult, CINAHL, Cochrane Library, PubMed, and US government Web sites, using key search words of disability, SSDI, SSI, vocational rehabilitation, barriers to employment, and access to healthcare. Articles discussing eligibility for SSI and SSDI, recipient demographics, diagnoses, and impact on attitudes of recipients and providers were included. Articles written by selfserving or biased entities, such as law firms promoting assistance in gaining eligibility, were not included. The literature search retrieved 45 journal articles, white papers, books, briefs, and federal government documents. Of those, 27 journal articles were not used because of repetitive publication or a toonarrow focus on small demographic segments of the total disability population. The Journal for Nurse Practitioners - JNP
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DESCRIPTION OF SSDI AND SSI PROGRAMS
Currently, SSDI and SSI are the largest federal programs related to disability.1 The SSDI program provides monthly payments for workers to replace earnings lost by a work-limiting disability. In addition to receiving a monthly payment, SSDI beneficiaries are eligible to receive Medicare health benefits after a 24-month waiting period.2 The SSI income program was designed to provide financial assistance to blind and disabled adults and children with limited income and resources. SSI benefits are also payable to nondisabled adults over 65 years old with limited income and resources. SSI beneficiaries may also be immediately eligible for Medicaid benefits, depending on the state.2 Recipient Demographics
In 2011, 6.6 million low-income adults received SSI and 8.6 million people received SSDI (Table 1).3 Many of the people in this group are seriously ill; approximately 1/5 men and 1/7 women die within the first 5 years of receiving benefits.3 The median income of a family with at least 1 disabled member was approximately $39,000 per year. The median family income with no disabled family members was approximately $54,515. The average employment rate of working age people with disabilities was 38.5%, compared with 83.7% among people with no disabilities.4 People with disabilities have less potential upward job mobility than those without disabilities. They are 28% less likely to achieve management-level positions or college degrees than nondisabled people.4 Livermore (2009)5 discussed the work characteristics of SSI and SSDI beneficiaries 18-64 years old based on a nationally representative survey. Only 9% of the people surveyed reported being employed or attempting to be employed. The SSI recipients
showed a greater interest in finding a job, compared to the SSDI recipients. Livermore found that in the younger population of SSI recipients, benefits decrease in relation to the amount they earn, whereas the SSDI recipients may lose all of their benefits immediately if they are perceived as able to work. Only 22% of the people reported making more than $8 per hour or greater than $810 per month during working years. A prospective cohort study by Proctor et al6 examined the characteristics of SSI and SSDI recipients related to their completion of a functional restoration program to return people to work. The participants had similar disabilities preventing them from working and represented the general population of disability recipients with musculoskeletal issues. Those who did not complete the program tended to be less educated, less likely to be white, and more likely to be Hispanic, with an overall higher rate of comorbid health conditions compared to the completer group. Common Medical Diagnoses
Approximately 12.4 million people between ages 18-64 receive SSI and SSDI benefits (Table 2). Drug addiction and alcoholism (DAA) is not included in the list of disabilities. Although the Social Security Administration (SSA) acknowledges that DAA is classified as a disorder, the agency does not recognize it as a disability. If DAA is determined to be a contributing factor to the claimant’s disability, the claimant is ineligible to receive disability benefits;7 this regulation has been in effect since 1996.8 Controversy continues regarding whether or not DAA should be considered a disability. A study by Table 2. Common Diagnoses of Disability Population Ages 18-64
Table 1. Characteristics of Disability Populations 2011
SSI
SSDI
Mental Impairment
41%a
Musculoskeletal conditions
29%b
< 65, 71.2% > 65, 28.8%
> 65, 70%
Cardiovascular, neurological, sensory conditions
9%
Age of disability population
More women
More men
Income
Poverty or near poverty level
Poverty or near poverty level
Injuries, cancers, infectious diseases, diabetes, respiratory diseases and other conditions
21%
Gender
a
12% of mental impairments are developmental or intellectual impairments. More older than 50.
b
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Shaner et al9 supported the perception of misuse of disability payments, documenting increased use of cocaine among cocaine-dependent disabled veterans with schizophrenia upon receipt of monthly checks. In contrast, a 2006 study by Rosen et al10 found homeless mentally ill people with newly awarded benefits did not have any different drug use changes than those without benefits. The participants in these studies had mental illnesses along with DAA, which could have a confounding effect on the results. More studies are needed to evaluate DAA as a stand-alone diagnosis when considering use/misuse of disability benefits. SSI also includes benefits for disabled children. Table 3 lists the most common pediatric diagnoses.
provider list. If there is a discrepancy between the applicant’s description of disability and the medical provider’s documentation, the SSA may request a consultative examination with another medical provider unrelated to the applicant. The subjective information obtained by the consultation will be reviewed by the SSA; however, the applicant’s treating physician documentation will always be given priority.2 The SSA must prove in step 5 that the applicant can participate in substantial gainful activity available in the marketplace. About 35% of the claims are approved at this point.2 If the claim is denied, the applicant can request an appeal. Table 5 outlines the appeal process.
Criteria for Benefits Qualification
Continuation of Disability Designation
The SSA equates disability with work disability. This definition may not predict the ability to work and does not necessarily link a person’s occupational demands with his or her functional abilities.2 The SSA definition and the process involved in qualifying someone to receive benefits create ambiguities and leave much room for subjective opinions about a person’s true state of function. There are 5 steps in the process for determining qualifications to receive benefits (Table 4). A 2008 General Accounting Office (GAO) survey of DDS directors11 found that DDS frequently requested the applicant’s medical provider to perform the consultative exams and most refused to do them. Interestingly, physical and occupational therapists, the providers best trained to assess physical functional ability, are not included on the acceptable medical
Beneficiaries of SSDI and SSI can continue receiving benefits as long as they meet the disability criteria mentioned previously. There are situations in which the SSA allows a person receiving disability benefits to work without losing them. The SSA considers an attempt at working for less than 90 days an unsuccessful work attempt, which will not jeopardize disability benefits.12 Another situation is a trial work period consisting of 9 months within a 36-month rolling period in which a person receiving benefits may work and exceed a predetermined monetary benefit amount. If he or she continues to work and earnings meet or exceed the predetermined amount in the 10th month, benefits will stop.12 If the SSA obtains information that the person is working and the person has not reported those work efforts, he or she may be fined, accused of fraud, and may have to repay the SSA any disability earnings deemed not justified.12
Table 3. Common Diagnoses of Disabled Children Amputations Blindness
LONG-TERM EFFECTS OF DISABILITY
Deafness
A study by Hawleya, Diaza, and Reidb13 discussed the psychological and sociological aspects of workers with work-limiting disabilities as they moved through the disability system. The authors found that, according to the GAO, fewer than 1 in 500 SSDI beneficiaries returned to work and a third of those individuals stopped working and returned to receiving SSDI benefits.
Immobility Cerebral vascular accident Cerebral palsy Muscular dystrophy Mental deficiencies (including Down syndrome) Data from Medical Home Portal.19
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Table 4. Five-Step Qualification Process Steps
SSI
SSDI
1. Income
Meets low income requirements
Past income contribution to SSA fund
2. Expected length of Disability
At least 12 months; medical records are requested; may request assessment of functional abilities
At least 12 months; medical records are requested; may request assessment of functional abilities
3. Compare impairments to SSA’s list
If comparison is inadequate, a residual functional capacity (RFC) assessment is completed
If comparison is inadequate, a residual functional capacity assessment is completed
4. Comparison of past work with RFC results
Incapable of similar work
Incapable of similar work
5. SSA determination
If denied, appeal process begins
If denied, appeal process begins
Indirect costs incurred as a result of having a disability can also have profound negative effects. Epidemiological research supports this finding, demonstrating that prolonged absence from a person’s job or inability to carry out normal roles is detrimental to the person’s physical and mental health and overall well-being.13 Other factors that may affect the well-being of individuals on SSI or SSDI are the type of disability and the age at which it occurred. Chronic conditions such as diabetes, cardiovascular disease, or multiple sclerosis will affect a person’s ability to work as he or she gets older. Employers may not be as aggressive in assisting a person back into the workplace because of age or concern over incurring higher health care expenses in premiums and time lost to illness. This leaves the person dependent on SSDI funds, usually receiving a lower rate of income than gainful employment. Younger people receiving SSI tend to be in a low socioeconomic group, with minimal education, and may have difficulty finding a job when in good health. When they become ill or disabled they may perceive finding a job or being desirable as an employee to be even more difficult, lowering their feelings of self-worth.14 Table 5. Four-Level Appeal Process 1. Reviewed by new group of evaluators 2. Administrative law judge review—75% are overturned 3. SSA Appeals Council 4. File a civil suit—can take 5 years
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Three major aspects of the lives of disabled people change when they are faced with a prolonged absence from work: they lose social relationships with coworkers, the self-respect or self-worth derived from supporting themselves and their families is affected, and they lose their work role identity. Unfortunately, many people take on a new identity as a “disabled or chronically ill” person. Their lives begin to revolve around their disability or illness and their quality of life deteriorates.15 Accessing health care for people in the application process for SSI or SSDI can be difficult. Empirical studies have shown that availability of health insurance or lack of health care access during a critical time can lead to job loss and a life of dependency on government programs.16 During the application process, people are either limited in how much they can work or they must not work at all to become eligible for SSI or SSDI. They may only want or need the benefits to assist them through a health crisis. However, because of eligibility rules, the person often loses any employer-sponsored insurance and must use continuation of employer health benefit provisions, which can be very expensive, or go without any health care coverage.17 People applying for SSI may be eligible to receive Medicaid, but finding providers who accept Medicaid may be difficult or the waiting time for appointments very long (particularly for specialty providers).4 In this author’s experience providing primary care to the Medicaid population in Jacksonville, Florida, Medicaid patients can wait as long as 6 months for a mental health and pain Volume 10, Issue 2, February 2014
management appointment and 3 to 6 months for other specialists. Persons younger than 65 applying for SSDI can begin receiving Medicare benefits only 24 months after they become eligible for SSDI. Since the eligibility process can take from several months to several years, the latter being more common, this group of people will have no health care benefit coverage until they are approved, limiting their access to care when they need it the most.16 PRIMARY CARE PROVIDER ROLES
There is little in the literature reflecting the role of health care providers in assisting beneficiary reentry into the workforce. A review by Rainville et al17 examined the performance of primary care physicians (PCPs) as advisors or mediators of temporary and permanent disability and found that recommendations between PCPs were extremely inconsistent for patients with similar complaints. The patients in the literature review had chronic musculoskeletal complaints. Several factors were identified in determining how the providers carried out their roles. The PCPs’ attitudes and beliefs about pain were often reflected in their return-to-work recommendations. PCPs were also found to acquiesce to the patient’s requests about the length of time needed to recover from an injury from concerns about harming the physicianpatient relationship, relying more on patient input for disability assessment rather than objective tests. This finding could be related to physician education or access to appropriate tests to assist in discerning functional disability, rather than perceived disability. The patient’s fear of re-injury or causing increased pain by returning to work also influenced physician determination of disability. Other identified factors influencing physician decisions included lack of knowledge about the patient’s job duties, lack of communication with the employer, lack of alternative duties offered by an employer, and fear of becoming involved in litigious situations.18 DISCUSSION
The entire disability program focuses on disability or illness and how it affects patients’ ability to work. There is little incentive and opportunity, once the process is started, for the person to do anything www.npjournal.org
except remain out of work. During the eligibility process documented medical evidence must support the applicant’s claimed disability. Often the task of determining eligibility falls on primary care providers, who have limited education on assessing disabilities and may rely on the patient’s subjective information to make a determination. Family and adult primary care nurse practitioner (NP) education does not specifically focus on disability assessments. However, there is extensive emphasis on prevention, health promotion, and awareness of the psychosocial impacts illness or injury can have on patients, as well as assessment of functional abilities. NPs are trained to consider all aspects of a person’s life when dealing with an illness and injury and, therefore, might better communicate the impacts that prolonged absences from work will have on their patients, while providing them with resources to assist with their re-entry into the workforce. Recipients of SSDI and SSI who can return to work should be encouraged to do so by their health care providers through a cooperative patient-provider effort to develop a plan of care to optimize the patient’s functional potential. Patients’ self-worth and earning potential will be enhanced by returning to the workforce. The proper utilization of disability benefits will help ensure that funds will be available to people whose disabilities are too great to return to work. SUGGESTIONS FOR IMPROVEMENT
The focus of SSA assistance for people with disabilities should be on their functional, mental, and educational capabilities. Eligibility assessments should be given by providers trained to assess the claimed disability’s effect on functional ability to work. Evidence-based guidelines should be used for all assessments and treatment of the claimed disabilities. SSDI applicants should be allowed to do a minimal amount of work while going through the eligibility process so that they can maintain their health care benefits and some income. This could be achieved by using the same rules as those applied to SSI applicants/beneficiaries, basing benefit income on the level of employment income. SSDI applicants who lose their health care benefits or cannot afford insurance should be allowed to receive Medicaid The Journal for Nurse Practitioners - JNP
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during the application process in order to access needed medical care. The length of the application process should be streamlined. As 75% of the denials for disability benefits are overturned at the second level of the appeal process, either inappropriate claims are being approved or there are major flaws in the first 4 steps, leading to inappropriate denials. For beneficiaries, financial incentives for returning to work should outweigh the amount of monthly disability benefits. Availability of health care coverage will improve once the Patient Protection and Affordable Care Act becomes fully operational in 2014, but its effect on those awaiting disability determination remains to be seen. References 1. Social Security Administration. SSI Annual Statistical Report. 2009. http:// www.ssa.gov/policy/docs/statcomps/ssi_asr/2009/index.html. Accessed October 3, 2013. 2. Brandt DE, Houtenville AJ, Huynh MT, Chan L, Rasch EK. Connecting contemporary paradigms to the Social Security Administration’s disability evaluation process. J Disability Policy Stud. 2011;22(2):116-128. 3. National Academy of Social Insurance. What is Social Security Disability Insurance?. 2011. http://www.nasi.org/learn/socialsecurity/disabilityinsurance. Accessed October 3, 2013. 4. Klayman D, Mochel M, Hale M, Belson S. Health and wellness research study: access to health care. 2009. http://www.dol.gov/odep/research/ AccessHealthCareResearchLiteratureReview.pdf. Accessed October 3, 2013. 5. Livermore GA. Work-Oriented Social Security Disability Beneficiaries: Characteristics and Employment-Related Activities. Washington, DC: Mathematica Policy Research, Inc.; 2009. 6. Proctor T, Mayer T, Theodore B, Gatchel R. Failure to complete a functional restoration program for chronic musculoskeletal disorders: a prospective 1-year outcome study. Arch Phys Med Rehabil. 2005;86(8):1509-1515. 7. Social Security Administration. Research, statistics, & policy analysis: fast facts & figures about Social Security. http://www.ssa.gov/policy/docs/ chartbooks/fast_facts. Accessed October 3, 2013. 8. SSI and SSDI: Will it be more open to addicts or less? Alcoholism & Drug Abuse Weekly. 2010 February 8. 9. Shaner A, Eckman TA, Roberts LJ, et al. Disability income, cocaine use, and repeated hospitalization among schizophrenic cocaine abusersea government-sponsored revolving door? N Engl J Med. 1995;333(12):777-783.
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10. Rosen MI, McMahon TJ, Lin H, Rosenheck RA. Effect of Social Security payments on substance abuse in a homeless mentally ill cohort. Health Serv Res. 2006;41(1):173-191. 11. United States Government Accountability Office. Collection of medical evidence could be improved with evaluations to identify promising collection practices. GAO-09-149. http://www.gao.gov/assets/290/284422.pdf. Published December 2008. Accessed October 23, 2013. 12. Social Security Disability Resource Center. Can I work without it affecting my social security disability or SSI? http://www.ssdrc.com/prem38.html. Accessed October 23, 2013. 13. Hawleya C, Diaza S, Reidb C. Healthcare employees’ progression through disability benefits. Work. 2009;34:53-66. 14. American College of Occupational and Environmental Medicine. Preventing needless work disability by helping people stay employed. http://www. acoem.org/PreventingNeedlessWorkDisability.aspx. Accessed October 3, 2013. 15. American College of Occupational and Environmental Medicine. The personal physician’s role in helping patients with medical conditions stay at work or return to work. http://www.acoem.org/PhysiciansRole_ReturntoWork.aspx. Accessed October 3, 2013. 16. Livermore G, Stapleton D, Claypool H. Health Insurance and Health Care Access Before and After SSDI Entry. 2009. http://www.commonwealthfund. org/Publications/Fund-Reports/2009/May/Health-Insurance-and-Health-CareAccess-Before-and-After.aspx. Accessed October 3, 2013. 17. US Department of Labor. Frequently asked questions: COBRA continuation health coverage. http://www.dol.gov/ebsa/faqs/faq-consumer-cobra.html. Accessed October 3, 2013. 18. Rainville J, Pransky G, Indahl A, Mayer E. The physician as disability advisor for patients with musculoskeletal complaints. Spine. 2005;30(22): 2579-2584. 19. Medical Home Portal. Diagnoses for which SSI eligibility is presumptive. 2011. http://www.medicalhomeportal.org/issue/diagnoses-for-whichssieligibility-is-presumptive. Accessed October 3, 2013.
Kim Brew, DNP, ARNP, FNP-BC, is an advanced registered nurse practitioner at MCCI Normandy in Jacksonville, FL, and can be reached at kbrew@ufl.edu. Robyn Panther Gleason, PhD, MPH, ARNP, FNP-BC, is a clinical assistant professor at the University of Florida College of Nursing in Gainesville. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/13/$ see front matter © 2014 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2013.07.003
Volume 10, Issue 2, February 2014
Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) were created to provide a temporary safety net for people who become disabled to protect them from impoverishment. Currently, many people receive SSDI or SSI until they reach retirement age. This literature review explored the impact these programs have on people reaching their optimal level of health. Results show the number of people voluntarily returning to work is 0.2%, demonstrating that most people receiving disability benefits stay with the programs instead of returning to the workplace. Keywords: access to health care, barriers to employment, disability, SSDI, SSI, vocational rehabilitation Ó 2014 Elsevier, Inc. All rights reserved.
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ocial Security Disability Insurance (SSDI) and Supplemental Security Income (SSI) were created to provide a temporary safety net for people who become disabled to protect them from impoverishment. However, many people who receive SSDI or SSI under those circumstances remain in the programs until they reach retirement age. Mr J, a 67-year-old man with chronic pain from 2 lumbar fusions, is an example. Mr J was 50 years old at the time of his injury. He had sustained 2 ruptured lumbar discs and a vertebral fracture from an accident and had planned to return to work after his initial surgery. However, a second surgery was necessary because of postoperative complications. His employer could not keep his job open indefinitely, so Mr J lost his job and his medical insurance benefits and applied for SSDI. The eligibility process for SSDI lasted 5 years. Mr J was 55 when he became eligible and began receiving SSDI benefits, including Medicare. His chronic pain prevented him from returning to his previous job and limited his ability to perform other full-time jobs. Parttime work would not have included medical benefits and would have paid less than his monthly disability check. His fear of losing the SSDI benefits outweighed the desire to feel productive by working and affected www.npjournal.org
his willingness to explore treatment that might have enabled him to return to work. He stated that he felt trapped and worthless. Mr J’s story illustrates a common scenario seen in primary care practice. Patient reports such as his prompted an extensive literature review to explore the effects of becoming part of the disability benefit process on health status and treatment adherence. METHODS
A literature review was conducted using MD Consult, CINAHL, Cochrane Library, PubMed, and US government Web sites, using key search words of disability, SSDI, SSI, vocational rehabilitation, barriers to employment, and access to healthcare. Articles discussing eligibility for SSI and SSDI, recipient demographics, diagnoses, and impact on attitudes of recipients and providers were included. Articles written by selfserving or biased entities, such as law firms promoting assistance in gaining eligibility, were not included. The literature search retrieved 45 journal articles, white papers, books, briefs, and federal government documents. Of those, 27 journal articles were not used because of repetitive publication or a toonarrow focus on small demographic segments of the total disability population. The Journal for Nurse Practitioners - JNP
107
DESCRIPTION OF SSDI AND SSI PROGRAMS
Currently, SSDI and SSI are the largest federal programs related to disability.1 The SSDI program provides monthly payments for workers to replace earnings lost by a work-limiting disability. In addition to receiving a monthly payment, SSDI beneficiaries are eligible to receive Medicare health benefits after a 24-month waiting period.2 The SSI income program was designed to provide financial assistance to blind and disabled adults and children with limited income and resources. SSI benefits are also payable to nondisabled adults over 65 years old with limited income and resources. SSI beneficiaries may also be immediately eligible for Medicaid benefits, depending on the state.2 Recipient Demographics
In 2011, 6.6 million low-income adults received SSI and 8.6 million people received SSDI (Table 1).3 Many of the people in this group are seriously ill; approximately 1/5 men and 1/7 women die within the first 5 years of receiving benefits.3 The median income of a family with at least 1 disabled member was approximately $39,000 per year. The median family income with no disabled family members was approximately $54,515. The average employment rate of working age people with disabilities was 38.5%, compared with 83.7% among people with no disabilities.4 People with disabilities have less potential upward job mobility than those without disabilities. They are 28% less likely to achieve management-level positions or college degrees than nondisabled people.4 Livermore (2009)5 discussed the work characteristics of SSI and SSDI beneficiaries 18-64 years old based on a nationally representative survey. Only 9% of the people surveyed reported being employed or attempting to be employed. The SSI recipients
showed a greater interest in finding a job, compared to the SSDI recipients. Livermore found that in the younger population of SSI recipients, benefits decrease in relation to the amount they earn, whereas the SSDI recipients may lose all of their benefits immediately if they are perceived as able to work. Only 22% of the people reported making more than $8 per hour or greater than $810 per month during working years. A prospective cohort study by Proctor et al6 examined the characteristics of SSI and SSDI recipients related to their completion of a functional restoration program to return people to work. The participants had similar disabilities preventing them from working and represented the general population of disability recipients with musculoskeletal issues. Those who did not complete the program tended to be less educated, less likely to be white, and more likely to be Hispanic, with an overall higher rate of comorbid health conditions compared to the completer group. Common Medical Diagnoses
Approximately 12.4 million people between ages 18-64 receive SSI and SSDI benefits (Table 2). Drug addiction and alcoholism (DAA) is not included in the list of disabilities. Although the Social Security Administration (SSA) acknowledges that DAA is classified as a disorder, the agency does not recognize it as a disability. If DAA is determined to be a contributing factor to the claimant’s disability, the claimant is ineligible to receive disability benefits;7 this regulation has been in effect since 1996.8 Controversy continues regarding whether or not DAA should be considered a disability. A study by Table 2. Common Diagnoses of Disability Population Ages 18-64
Table 1. Characteristics of Disability Populations 2011
SSI
SSDI
Mental Impairment
41%a
Musculoskeletal conditions
29%b
< 65, 71.2% > 65, 28.8%
> 65, 70%
Cardiovascular, neurological, sensory conditions
9%
Age of disability population
More women
More men
Income
Poverty or near poverty level
Poverty or near poverty level
Injuries, cancers, infectious diseases, diabetes, respiratory diseases and other conditions
21%
Gender
a
12% of mental impairments are developmental or intellectual impairments. More older than 50.
b
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Shaner et al9 supported the perception of misuse of disability payments, documenting increased use of cocaine among cocaine-dependent disabled veterans with schizophrenia upon receipt of monthly checks. In contrast, a 2006 study by Rosen et al10 found homeless mentally ill people with newly awarded benefits did not have any different drug use changes than those without benefits. The participants in these studies had mental illnesses along with DAA, which could have a confounding effect on the results. More studies are needed to evaluate DAA as a stand-alone diagnosis when considering use/misuse of disability benefits. SSI also includes benefits for disabled children. Table 3 lists the most common pediatric diagnoses.
provider list. If there is a discrepancy between the applicant’s description of disability and the medical provider’s documentation, the SSA may request a consultative examination with another medical provider unrelated to the applicant. The subjective information obtained by the consultation will be reviewed by the SSA; however, the applicant’s treating physician documentation will always be given priority.2 The SSA must prove in step 5 that the applicant can participate in substantial gainful activity available in the marketplace. About 35% of the claims are approved at this point.2 If the claim is denied, the applicant can request an appeal. Table 5 outlines the appeal process.
Criteria for Benefits Qualification
Continuation of Disability Designation
The SSA equates disability with work disability. This definition may not predict the ability to work and does not necessarily link a person’s occupational demands with his or her functional abilities.2 The SSA definition and the process involved in qualifying someone to receive benefits create ambiguities and leave much room for subjective opinions about a person’s true state of function. There are 5 steps in the process for determining qualifications to receive benefits (Table 4). A 2008 General Accounting Office (GAO) survey of DDS directors11 found that DDS frequently requested the applicant’s medical provider to perform the consultative exams and most refused to do them. Interestingly, physical and occupational therapists, the providers best trained to assess physical functional ability, are not included on the acceptable medical
Beneficiaries of SSDI and SSI can continue receiving benefits as long as they meet the disability criteria mentioned previously. There are situations in which the SSA allows a person receiving disability benefits to work without losing them. The SSA considers an attempt at working for less than 90 days an unsuccessful work attempt, which will not jeopardize disability benefits.12 Another situation is a trial work period consisting of 9 months within a 36-month rolling period in which a person receiving benefits may work and exceed a predetermined monetary benefit amount. If he or she continues to work and earnings meet or exceed the predetermined amount in the 10th month, benefits will stop.12 If the SSA obtains information that the person is working and the person has not reported those work efforts, he or she may be fined, accused of fraud, and may have to repay the SSA any disability earnings deemed not justified.12
Table 3. Common Diagnoses of Disabled Children Amputations Blindness
LONG-TERM EFFECTS OF DISABILITY
Deafness
A study by Hawleya, Diaza, and Reidb13 discussed the psychological and sociological aspects of workers with work-limiting disabilities as they moved through the disability system. The authors found that, according to the GAO, fewer than 1 in 500 SSDI beneficiaries returned to work and a third of those individuals stopped working and returned to receiving SSDI benefits.
Immobility Cerebral vascular accident Cerebral palsy Muscular dystrophy Mental deficiencies (including Down syndrome) Data from Medical Home Portal.19
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Table 4. Five-Step Qualification Process Steps
SSI
SSDI
1. Income
Meets low income requirements
Past income contribution to SSA fund
2. Expected length of Disability
At least 12 months; medical records are requested; may request assessment of functional abilities
At least 12 months; medical records are requested; may request assessment of functional abilities
3. Compare impairments to SSA’s list
If comparison is inadequate, a residual functional capacity (RFC) assessment is completed
If comparison is inadequate, a residual functional capacity assessment is completed
4. Comparison of past work with RFC results
Incapable of similar work
Incapable of similar work
5. SSA determination
If denied, appeal process begins
If denied, appeal process begins
Indirect costs incurred as a result of having a disability can also have profound negative effects. Epidemiological research supports this finding, demonstrating that prolonged absence from a person’s job or inability to carry out normal roles is detrimental to the person’s physical and mental health and overall well-being.13 Other factors that may affect the well-being of individuals on SSI or SSDI are the type of disability and the age at which it occurred. Chronic conditions such as diabetes, cardiovascular disease, or multiple sclerosis will affect a person’s ability to work as he or she gets older. Employers may not be as aggressive in assisting a person back into the workplace because of age or concern over incurring higher health care expenses in premiums and time lost to illness. This leaves the person dependent on SSDI funds, usually receiving a lower rate of income than gainful employment. Younger people receiving SSI tend to be in a low socioeconomic group, with minimal education, and may have difficulty finding a job when in good health. When they become ill or disabled they may perceive finding a job or being desirable as an employee to be even more difficult, lowering their feelings of self-worth.14 Table 5. Four-Level Appeal Process 1. Reviewed by new group of evaluators 2. Administrative law judge review—75% are overturned 3. SSA Appeals Council 4. File a civil suit—can take 5 years
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Three major aspects of the lives of disabled people change when they are faced with a prolonged absence from work: they lose social relationships with coworkers, the self-respect or self-worth derived from supporting themselves and their families is affected, and they lose their work role identity. Unfortunately, many people take on a new identity as a “disabled or chronically ill” person. Their lives begin to revolve around their disability or illness and their quality of life deteriorates.15 Accessing health care for people in the application process for SSI or SSDI can be difficult. Empirical studies have shown that availability of health insurance or lack of health care access during a critical time can lead to job loss and a life of dependency on government programs.16 During the application process, people are either limited in how much they can work or they must not work at all to become eligible for SSI or SSDI. They may only want or need the benefits to assist them through a health crisis. However, because of eligibility rules, the person often loses any employer-sponsored insurance and must use continuation of employer health benefit provisions, which can be very expensive, or go without any health care coverage.17 People applying for SSI may be eligible to receive Medicaid, but finding providers who accept Medicaid may be difficult or the waiting time for appointments very long (particularly for specialty providers).4 In this author’s experience providing primary care to the Medicaid population in Jacksonville, Florida, Medicaid patients can wait as long as 6 months for a mental health and pain Volume 10, Issue 2, February 2014
management appointment and 3 to 6 months for other specialists. Persons younger than 65 applying for SSDI can begin receiving Medicare benefits only 24 months after they become eligible for SSDI. Since the eligibility process can take from several months to several years, the latter being more common, this group of people will have no health care benefit coverage until they are approved, limiting their access to care when they need it the most.16 PRIMARY CARE PROVIDER ROLES
There is little in the literature reflecting the role of health care providers in assisting beneficiary reentry into the workforce. A review by Rainville et al17 examined the performance of primary care physicians (PCPs) as advisors or mediators of temporary and permanent disability and found that recommendations between PCPs were extremely inconsistent for patients with similar complaints. The patients in the literature review had chronic musculoskeletal complaints. Several factors were identified in determining how the providers carried out their roles. The PCPs’ attitudes and beliefs about pain were often reflected in their return-to-work recommendations. PCPs were also found to acquiesce to the patient’s requests about the length of time needed to recover from an injury from concerns about harming the physicianpatient relationship, relying more on patient input for disability assessment rather than objective tests. This finding could be related to physician education or access to appropriate tests to assist in discerning functional disability, rather than perceived disability. The patient’s fear of re-injury or causing increased pain by returning to work also influenced physician determination of disability. Other identified factors influencing physician decisions included lack of knowledge about the patient’s job duties, lack of communication with the employer, lack of alternative duties offered by an employer, and fear of becoming involved in litigious situations.18 DISCUSSION
The entire disability program focuses on disability or illness and how it affects patients’ ability to work. There is little incentive and opportunity, once the process is started, for the person to do anything www.npjournal.org
except remain out of work. During the eligibility process documented medical evidence must support the applicant’s claimed disability. Often the task of determining eligibility falls on primary care providers, who have limited education on assessing disabilities and may rely on the patient’s subjective information to make a determination. Family and adult primary care nurse practitioner (NP) education does not specifically focus on disability assessments. However, there is extensive emphasis on prevention, health promotion, and awareness of the psychosocial impacts illness or injury can have on patients, as well as assessment of functional abilities. NPs are trained to consider all aspects of a person’s life when dealing with an illness and injury and, therefore, might better communicate the impacts that prolonged absences from work will have on their patients, while providing them with resources to assist with their re-entry into the workforce. Recipients of SSDI and SSI who can return to work should be encouraged to do so by their health care providers through a cooperative patient-provider effort to develop a plan of care to optimize the patient’s functional potential. Patients’ self-worth and earning potential will be enhanced by returning to the workforce. The proper utilization of disability benefits will help ensure that funds will be available to people whose disabilities are too great to return to work. SUGGESTIONS FOR IMPROVEMENT
The focus of SSA assistance for people with disabilities should be on their functional, mental, and educational capabilities. Eligibility assessments should be given by providers trained to assess the claimed disability’s effect on functional ability to work. Evidence-based guidelines should be used for all assessments and treatment of the claimed disabilities. SSDI applicants should be allowed to do a minimal amount of work while going through the eligibility process so that they can maintain their health care benefits and some income. This could be achieved by using the same rules as those applied to SSI applicants/beneficiaries, basing benefit income on the level of employment income. SSDI applicants who lose their health care benefits or cannot afford insurance should be allowed to receive Medicaid The Journal for Nurse Practitioners - JNP
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during the application process in order to access needed medical care. The length of the application process should be streamlined. As 75% of the denials for disability benefits are overturned at the second level of the appeal process, either inappropriate claims are being approved or there are major flaws in the first 4 steps, leading to inappropriate denials. For beneficiaries, financial incentives for returning to work should outweigh the amount of monthly disability benefits. Availability of health care coverage will improve once the Patient Protection and Affordable Care Act becomes fully operational in 2014, but its effect on those awaiting disability determination remains to be seen. References 1. Social Security Administration. SSI Annual Statistical Report. 2009. http:// www.ssa.gov/policy/docs/statcomps/ssi_asr/2009/index.html. Accessed October 3, 2013. 2. Brandt DE, Houtenville AJ, Huynh MT, Chan L, Rasch EK. Connecting contemporary paradigms to the Social Security Administration’s disability evaluation process. J Disability Policy Stud. 2011;22(2):116-128. 3. National Academy of Social Insurance. What is Social Security Disability Insurance?. 2011. http://www.nasi.org/learn/socialsecurity/disabilityinsurance. Accessed October 3, 2013. 4. Klayman D, Mochel M, Hale M, Belson S. Health and wellness research study: access to health care. 2009. http://www.dol.gov/odep/research/ AccessHealthCareResearchLiteratureReview.pdf. Accessed October 3, 2013. 5. Livermore GA. Work-Oriented Social Security Disability Beneficiaries: Characteristics and Employment-Related Activities. Washington, DC: Mathematica Policy Research, Inc.; 2009. 6. Proctor T, Mayer T, Theodore B, Gatchel R. Failure to complete a functional restoration program for chronic musculoskeletal disorders: a prospective 1-year outcome study. Arch Phys Med Rehabil. 2005;86(8):1509-1515. 7. Social Security Administration. Research, statistics, & policy analysis: fast facts & figures about Social Security. http://www.ssa.gov/policy/docs/ chartbooks/fast_facts. Accessed October 3, 2013. 8. SSI and SSDI: Will it be more open to addicts or less? Alcoholism & Drug Abuse Weekly. 2010 February 8. 9. Shaner A, Eckman TA, Roberts LJ, et al. Disability income, cocaine use, and repeated hospitalization among schizophrenic cocaine abusersea government-sponsored revolving door? N Engl J Med. 1995;333(12):777-783.
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10. Rosen MI, McMahon TJ, Lin H, Rosenheck RA. Effect of Social Security payments on substance abuse in a homeless mentally ill cohort. Health Serv Res. 2006;41(1):173-191. 11. United States Government Accountability Office. Collection of medical evidence could be improved with evaluations to identify promising collection practices. GAO-09-149. http://www.gao.gov/assets/290/284422.pdf. Published December 2008. Accessed October 23, 2013. 12. Social Security Disability Resource Center. Can I work without it affecting my social security disability or SSI? http://www.ssdrc.com/prem38.html. Accessed October 23, 2013. 13. Hawleya C, Diaza S, Reidb C. Healthcare employees’ progression through disability benefits. Work. 2009;34:53-66. 14. American College of Occupational and Environmental Medicine. Preventing needless work disability by helping people stay employed. http://www. acoem.org/PreventingNeedlessWorkDisability.aspx. Accessed October 3, 2013. 15. American College of Occupational and Environmental Medicine. The personal physician’s role in helping patients with medical conditions stay at work or return to work. http://www.acoem.org/PhysiciansRole_ReturntoWork.aspx. Accessed October 3, 2013. 16. Livermore G, Stapleton D, Claypool H. Health Insurance and Health Care Access Before and After SSDI Entry. 2009. http://www.commonwealthfund. org/Publications/Fund-Reports/2009/May/Health-Insurance-and-Health-CareAccess-Before-and-After.aspx. Accessed October 3, 2013. 17. US Department of Labor. Frequently asked questions: COBRA continuation health coverage. http://www.dol.gov/ebsa/faqs/faq-consumer-cobra.html. Accessed October 3, 2013. 18. Rainville J, Pransky G, Indahl A, Mayer E. The physician as disability advisor for patients with musculoskeletal complaints. Spine. 2005;30(22): 2579-2584. 19. Medical Home Portal. Diagnoses for which SSI eligibility is presumptive. 2011. http://www.medicalhomeportal.org/issue/diagnoses-for-whichssieligibility-is-presumptive. Accessed October 3, 2013.
Kim Brew, DNP, ARNP, FNP-BC, is an advanced registered nurse practitioner at MCCI Normandy in Jacksonville, FL, and can be reached at kbrew@ufl.edu. Robyn Panther Gleason, PhD, MPH, ARNP, FNP-BC, is a clinical assistant professor at the University of Florida College of Nursing in Gainesville. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/13/$ see front matter © 2014 Elsevier, Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2013.07.003
Volume 10, Issue 2, February 2014