New report Examines Social Security's Process for Determining Disability in Adults

By Jane Farrell

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 a patient’s disease severity, disability, and ability to perform gainful activity.

The committee that conducted the study could not find an association, though, between health care utilization and disease severity in 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.

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 an 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, since statistics on hospitalizations have 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 Abraham Lincoln.