Long-term public disability programs in the United States and several other countries have incorporated fast-track (FT) procedures that share a common goal of accelerating applicants through various stages of the disability determination process—generally for those with severe disabilities, blindness, or terminal illness. This article identifies a variety of FT procedures either implemented or under consideration in public long-term disability programs operated in the United States and other countries; compares FT procedures in those disability programs with respect to specific program features, differences with respect to the administrative components involved in those procedures, and the level of technology used; examines more generally why countries may consider implementing FT procedures; and describes how FT procedures may be employed to improve overall processing of claims and contribute to disability case management.
David Rajnes is a research analyst with the Division of Program Studies, Office of Research, Evaluation, and Statistics, Office of Retirement and Disability Policy, Social Security Administration.
Acknowledgments: The author gratefully acknowledges the invaluable assistance from many individuals at SSA while preparing this article: L. Scott Muller (Office of Research, Evaluation, and Statistics); Nancy Schoenberg (Office of Compassionate Allowances and Disability Outreach); Dalmer Hoskins (Division of Program Studies); and Susan Grad (Office of Research, Evaluation, and Statistics). In addition, the author is indebted to John Kearney (formerly with SSA) for proposing the topic of this study. Finally, this article benefited greatly from the feedback provided by agency staff in the several countries discussed here.
The findings and conclusions presented in the Bulletin are those of the authors and do not necessarily represent the views of the Social Security Administration.
|CPP||Canada Pension Plan|
|CPP-D||Canada Pension Plan Disability|
|DDS||Disability Determination Service|
|DLA||Disability Living Allowance|
|DSP||Disability Support Pension|
|DWP||Department for Work and Pensions|
|ESA||Employment and Support Allowance|
|HCP||health care professional|
|JCA||job capacity assessment|
|NII||National Insurance Institute|
|QDD||Quick Disability Determination|
|SSA||US Social Security Administration|
|SSI||Supplemental Security Income|
This article explores the domestic and international experience with "fast-track" (FT)1 procedures in the determination process of public disability programs. FT procedures target applicants with severe disabilities who are likely to receive favorable determinations. Disability programs in the United States and several other countries have adopted a variety of FT procedures. Those procedures reduce delays, which negatively affect individuals and their families, and may help governments with disability caseload management.
In the United States, the Social Security Administration (SSA) expanded its list of FT procedures in recent years with the introduction of the Quick Disability Determination (QDD) and Compassionate Allowance (CAL) initiatives. Known collectively as "fast-track disability processes" by SSA, those initiatives provide additional tools for the agency to manage the growth of disability applications from the American baby boomer population.2 Complementing the more traditional "expediting" procedures operated by SSA, QDD and CAL take advantage of sophistiacated software, which enables fast-tracking operations within an electronic disability process.
Other countries have introduced a variety of FT procedures. Like the United States (US), the four other countries in this sample are in the process of experimenting with or fine tuning recent disability reform efforts in the area of fast tracking disability determinations. While country-specific goals and medical conditions of interest tend to be similar, the variety of disability program designs, associated claims processes, and administrative arrangements give rise to subtle and some not-so-subtle differences.
The article is divided into five sections, the first of which introduces the five countries examined in the study and chronicles the methodology used in the selection process for the non-US sample. The next section documents how country-specific FT procedures operate in the context of the application and decision-making processes. This is followed by a comparison of the operational aspects of fast tracking disability claims across the country sample as laid out in the previous section. In the last sections, some tentative conclusions are offered based on a data review and the country descriptions, which are followed by several brief observations.
Country Selection and Methodological Approach
This research produces a qualitative assessment of FT strategies using the United States as its starting point. In the process, several countries are identified as operating public disability programs with FT features employed at various stages of the determination process. To the author's knowledge, there is no cross-national study on this topic in the disability literature. The subject matter discussion relies on the availability of material provided by staff in national disability agencies who have agreed to participate in this study. As a result, the country presentations that follow constitute the best information on these countries available at this stage.
Work began in 2008 to identify countries other than the United States with long-term public disability programs operating FT procedures. A survey questionnaire was drafted (see the Appendix) to circulate among staff in selected countries with a track record of participation in previous major cross-country disability studies conducted by the Organisation for Economic Co-operation and Development (OECD 2003), or included in an SSA-funded survey conducted in the late 1990s (Westat 1998).3 Eventually the author settled on disability agencies in 23 OECD member countries as potential respondents to receive an e-mailed survey questionnaire.4
The search process netted six positive responses to the survey: four robust responses (from Australia, Canada, Israel, and the United Kingdom) and two responses (Norway and Germany) indicating the presence of FT procedures, but lacking enough detail to include those national disability programs in this study.5 The five-country sample examined in this article represents those countries offering the best opportunity to date to examine how various countries use FT processes, which is conducive for broad comparison. It cannot be overemphasized that information collected in this study relied heavily on the expert knowledge of staff at several national disability agencies. Those country-based contacts provided much of the descriptions incorporated into this analysis and verified the data collected, thus making the study possible. Once included in the sample, staff at participating national agencies provided a steady stream of data, references, and dialogue—for more than a year—which helped to enlighten the author about how FT procedures operate in each case.
Several factors could have influenced the overall response to the survey. Not surprising (given the English-language questionnaire), all participating national agencies are based in English-speaking countries. Besides language, another potential factor that may have limited the number of positive responses was the wording of the questionnaire, which emphasized the two most recent FT procedures used at SSA—both highlighting the use of sophisticated software. One cannot be certain, but mentioning other more traditional examples of FT methods used at SSA could have resulted in a higher number of positive responses, thus eliminating a potential negative bias associated with the highly technical emphasis in the wording of the survey questionnaire.
Countries with Fast-Track Processes
This section provides the details of FT processes in each country surveyed. Procedures in the United States are presented first and provide a reference point for comparing FT processes in other national systems. In what follows, each national summary contains an outline of the administrative responsibilities of the major parties involved in the decision process, an explanation of relevant FT procedures, a description of the evaluation procedures faced by claimants, and some country highlights of FT procedures.
Cross-country comparisons of FT processes are framed with respect to the following three questions:
- What is the decision process and who are the key parties responsible for making decisions (including FT decisions) on disability claims?
- How are FT procedures (including technology) integrated into each nation's disability claims process?
- What is the claims processing sequence for disability applications?
Table 1 introduces the five-country sample and provides an overview of some design features in each national disability program, including how disability is defined, program eligibility requirements, benefit amounts and indexation, program financing, and dependent coverage, as well as the treatment of work following the granting of a disability pension. Some significant programmatic differences can be observed, such as Israel's residency-only eligibility criterion or Australia's means-tested social programs financed by general revenue.
|Characteristic||United States||Australia||Canada||Israel||United Kingdom|
|Definition of disability to qualify for benefits||Inability to engage in substantial gainful activity (SGA) because of medically determined impairment lasting or expected to last 12 months or longer or result in death.||Diagnosis of permanent blindness or at least 20% level of physical, mental, or psychiatric impairment causing inability to work for next 2 years; or person not able to undertake educational/vocational training, allowing work within next 2 years.||Impairment must be severe and prolonged and must prevent one from working any job regularly. Legislation defines severe disability as one preventing worker from doing former job, or any job, regularly. Disability is prolonged when it is likely to be lengthy, of indefinite duration, or likely to result in death.||Must pass medical and functional tests. That applies to workers whose earning capacity is lost or reduced as a result of impairment and to nonworking spouses whose functionality in the household is lost or reduced.||Individuals must have limited capacity for work, meaning current health conditions or disability restricts their ability to work.|
|Eligibility criteria||Insured status based on length and recency of employment.||Insured status based on length of residency and recency of employment.||Insured status based on length and recency of employment.||Insured status based on residency.||Insured status based on length and recency of employment.|
|Work or other||Length and recency of work test.||Prevented from working 15 or more (formerly 30) hours weekly, or retraining for work within the next 2 years; relevant income/assets tests (unless blind) also apply.||Length and recency of work test.||Residency only.||Entitled once 13-week Statutory Sick Pay is exhausted. Most people receiving Employment and Support Allowance (ESA) expected to undertake work-related activity (interviews/action plan), with the aim of eventually returning to work.|
|Age||Up to age 66.||Aged 16 to 65 (men) and aged 16 to 64 (women); converging to age 67 for men and women by July 2023.||Aged 18 to 65.||Aged 18 to 66.7 (men) and aged 18 to 61.7 (women); moving to age 70 for men and age 66.7 for women by 2027.||Aged 16 to 65 (men) and aged 16 to 60 (women); moving to age 65 for women by 2025 and to age 68 for men and women by 2046.|
|Financing source(s)||Total contributions of 1.8% of earnings equally shared by worker/employer. Maximum monthly earnings for contribution/benefit purposes in 2010 was US$8,900.||All federal assistance programs are funded through general revenue.||Total contributions paid on earnings of 1.8% equally shared by worker/employer. Maximum annual earnings for contribution/benefit purposes in 2009 was C$46,300 (US$40,870).||Employer (employee) contributed 0.30% (0.11%) of employee earnings below 60% of national average wage (7,663 new shekels monthly or US$2,372 in 2008) plus 0.42% (1.86%) of earnings above that amount. Maximum annual earnings for contribution/benefit purposes are 5 times national average wage, as of January 1 each year.||Shared responsibility: Employers required to pay benefits for up to 13 weeks; government pays if employee is ineligible for employer-paid benefits, and it pays after employee is absent over 13 weeks. Government also pays noncontributory benefits (for example, Disability Living Allowance (DLA)).|
|Benefit amounts||Pension based on insured worker's average covered earnings since 1950 (or year attaining age 22) and indexed for past wage inflation, up to onset of disability, excluding up to 5 years of lowest earnings.||Pension is identical to the amount for the old-age pension.||Benefit based on 75% of old-age pension plus a basic monthly pension up to a maximum.||Pension linked to basic amount used to calculate public pensions. If insured person is assessed as 75% or more disabled, full pension equals 25% of basic amount plus 7% of that amount. No earnings test. Pensions proportionately reduced for less severe impairments.||ESA paid at three rates, which increase with duration of the benefit—short term (lower rate), short term (higher rate), and long-term benefit. DLA has care and mobility component, which determines the duration/level of payment.|
|Cost of living adjustment||Yes.||Yes.||Yes.||Yes.||Yes.|
|Treatment of work while disabled||Program has incentives to work. Successful return to SGA (currently earning in excess of $1,010 monthly or more than $1,690 monthly for statutory blindness) results in benefit suspension after trial work period and termination after extended period of eligibility.||Up to 15 hours of work weekly and retraining are allowed.||Beneficiaries may do volunteer work, attend school, and retrain without losing benefits. In 2009, they could also earn up to C$4,600 (US$4,061) before taxes.||Pension gradually decreases as person's income from work increases: higher income from work yields higher total income (work/pension combined).||Includes voluntary work (no time limit); being in supervised treatment, or work-related public/voluntary job search (under 16 hours weekly at minimum wage); unlimited work under £20 weekly (US$31); or work up to 26 weeks as long as it is done in less than 16 hours weekly and for less than minimum wage.|
|Dependent coverage||Yes—spouse and dependent children eligible based on worker's coverage.||No.||Yes—child supplement based on worker's eligibility.||Yes—spouse and child (up to 2) supplement.||Yes—eligible based on worker's coverage.|
|SOURCES: Compiled by the author using Social Security Programs Throughout the World (various volumes and years). United Kingdom financing information taken from IBIS eVisor (2009).|
Another view of the five-country sample, captured in Table 2, highlights selected demographic and FT aspects of each country's national disability programs. Those data indicate that self-reported disability rates as a percentage of the working-age population range from around 12 percent in Canada, nearly 15 percent in Australia, approximately 18 percent in both Israel and the United Kingdom, to nearly 19 percent in the United States. Also relevant to this analysis are the annual disability program expenditure levels calculated for each country as a percentage of gross domestic product (GDP) and the share of FT claims in those disability programs. Expenditure levels on long-term disability programs range from a low of 0.2 percent of GDP in Canada to the much higher levels found in Israel (1.3 percent) and the United Kingdom (2.1 percent), to more moderate percentages recorded for the United States (0.9)6 and Australia (1.0). In general (with one exception—Israel),7 countries with FT processes reflect similar percentages of FT applicants among their respective claimant populations (roughly 4 to 6 percent) despite differences in overall expenditure levels in their disability programs or other distinguishing features. Meanwhile, a fairly wide range exists across the sample with respect to the general disability beneficiary population as a share of the working–age population (approximately 1 to 6 percent).
|Country||Working-age (15–64) population (millions)||Self-reported disability rates a (as a percentage of working-age population)||Disability beneficiaries||Annual disability claims||Annual disability program cash benefits (as a percentage of GDP)|
|Program||Actual count||As a percentage of working-age population||Total new disability claims||FT claims||FT claims as a percentage of new total|
|United States||212.3||18.6||DI b||7.8 million||3.6||2.8 million||128,000 c||4.5||0.9|
|United Kingdom||40.1||18.3||IB (now ESA)||2.6 million||6.5||681,000||40,860||6.0||2.1|
|SOURCES: Compiled by SSA staff. Population figures come from the World Population Prospects: The 2010 Revision Population Database, United Nations (2011) and country sources. Pension program costs for the United States are based on the Annual Statistical Supplement to the Social Security Bulletin, 2010 (SSA 2011a). US percentages of self-reported disability of 18.6 percent, reported by the Decennial Census of 2000, counts individuals with some type of long-lasting condition. The Decennial Census included impairments involving vision or hearing, certain physical limitations, and difficulty performing certain activities because of a physical, mental, or emotional condition (Waldrop and Stern 2003). Australia's percentages for self-reported disability come from the 2009 Survey of Disability, Ageing and Carers, where disability is defined as any limitation, restriction, or impairment that restricts everyday activities and has lasted or is expected to last for at least 6 months (Australian Bureau of Statistics 2010). Canada's percentages of self-reported disability are taken from the Participation and Activity Limitation Survey, 2006, which defines disability as difficulty hearing, seeing, communicating, walking, climbing stairs, bending, learning or doing any similar activities, in addition to indicating a physical or mental condition or health problem that impairs an individual's ordinary level of functioning (Statistics Canada 2009). Israel's percentages of self-reported disability are taken from People with Disability in the Community (Israel Ministry of Health 2009). Pension disability program costs for the United States are based on the Annual Statistical Supplement to the Social Security Bulletin, 2007 (SSA 2008); United Kingdom program costs are based on fiscal year (FY) 2007 data taken from OECD (2011). Israel's disability prevalence statistics for 2010 come from NII. Similar statistics for the United Kingdom come from the Department for Work and Pensions, Disability and Carer's Division, which estimates the number of people with a long-standing illness, disability, or infirmity who have significant difficulty with day-to-day activities.|
|NOTES: All new disability claims were made in FY 2010, except for Canada in which new claims were made in FY 2008.|
|CPP-D = Canada Pension Plan Disability; DI = Disability Insurance; DSP = Disability Support Pension; ESA = Employment and Support Allowance; FT = fast track; GDP = gross domestic product; IB = Incapacity Benefit; N/A = data not available; NII = National Insurance Institute; SSA = US Social Security Administration.|
|a. Self-reporting of disability differs by ages across countries: In Canada and the United Kingdom, self-reported individuals include those aged 16–64; in Israel, that population includes persons aged 20–64; in Australia, the self-reported disability population includes those aged 15–64; and in the United States, self-reported individuals include those aged 16–64, for US Census purposes.|
|b. In this table, disability figures for the United States reflect only the DI program. In December of 2009, there were 7.8 million disabled-worker beneficiaries on the DI rolls. In addition, the program paid benefits to 1.9 million nondisabled dependents of disabled workers, 236,000 disabled widow(er)s, and 921,000 disabled adult children. Widow(er)s and most disabled adult children are not paid from the DI Trust Fund, so technically, they are not included under DI expenditures. Medicare and administrative costs are not included in DI figures. Administrative costs brought the total for DI Trust Fund expenditures for 2009 up to approximately US$121.5 billion.|
|d. In Canada, there were also 88,555 children receiving benefits in addition to the CPP-D beneficiaries listed here.|
|e. In Israel, there were an estimated 721,067 persons with a "nonsevere" disability (Israel Ministry of Health 2009).|
Fast-Track Experience with Public Disability Programs in the United States
In the United States, SSA manages two programs that provide benefits based on disability or blindness, the Social Security Disability Insurance (DI) program and the Supplemental Security Income (SSI) program.8 The DI program provides benefits to disabled or blind persons who are insured workers—those who have made the required contributions9 to the Social Security Trust Fund.10 By contrast, the SSI program makes cash-assistance payments to aged, blind, and disabled persons (including children) who have limited income and resources. For SSI, there is no requirement for a work history. The government funds SSI from general tax revenue.11 Both disability programs use FT procedures.
Disability is defined in the United States as the inability to engage in any "substantial gainful activity" (SGA) because of a medically determinable physical or mental impairment(s) that is expected to result in death or that has lasted, or is expected to last, for a continuous period of not less than 12 months. SSA assesses disability under both DI and SSI through a five-step sequential evaluation process used to determine whether an adult is disabled (SSA 2009a; Honeycutt and Brucker 2006; GAO 2008).12 The process for determining disability comprises a work test, an impairment severity test, a medical listing test,13 a test for ability to perform previous work, and a test for ability to perform any type of work.14
Disability Assessment Process
Social Security disability claims are processed initially through a network of local SSA field offices and state agencies (called Disability Determination Services, or DDSs). Social Security field office representatives obtain applications for disability benefits in person, by telephone, by mail, or online. The application and related forms ask for a description of the claimant's impairment(s), treatment sources, and other information that relates to an alleged disability. The field office is responsible for verifying nonmedical eligibility requirements, which may include age, employment, marital status, or Social Security coverage information; it then sends the case to a DDS for evaluation of disability.
The DDSs, funded by the federal government, are state agencies responsible for compiling medical evidence and rendering the initial determination on whether a claimant is disabled (including blindness)15 under the law. Usually the DDS tries to obtain evidence from the claimant's own medical sources first. If that evidence is unavailable or insufficient to make a determination, the DDS will arrange for a consultative examination to obtain the additional information needed.
After completing its development of the evidence, DDS staff makes the initial disability determination. Then the DDS returns the case to the field office for appropriate action. If the DDS finds that the claimant is disabled, SSA computes the benefit amount and begins paying benefits. If the claimant is dissatisfied with an unfavorable determination, the order of appeals is as follows: reconsideration by the DDS, a hearing in front of a federal administrative law judge (ALJ) in SSA's Office of Disability Adjudication and Review, a request that the Appeals Council review the ALJ's decision, and an appeal to the federal court system.
An important characteristic that has set the claims process in the United States apart from other countries in the sample is SSA's replacement of the traditional paper-based claims folder with an electronic folder to store case-related data and images. Implementation of that technology began in 2004, and by early 2006, all DDSs had begun processing more than half of new disability claims in a completely electronic format (Green and others 2006).16 The automated electronic disability collect system (EDCS) records information about the claimant's alleged disabling condition(s) and transfers data to the electronic folder. SSA creates that folder (containing all essential documentation), which can be accessed by all case-processing agency components (field offices, DDSs, and so forth) through an associated electronic folder interface. That interface enables the downloading of electronic folder data as cases move from one office to another throughout the determination process. At the initial application stage, the combination of the electronic folder and EDCS has enabled the use of electronic indicators to flag cases and is a predictive model for identifying claims that are likely to receive approval. Since 2008, new claims are handled solely by the electronic folder.17
SSA employs six FT18 procedures that accelerate the claims process in the disability programs it administers (see Table 3). In general, one procedure only applies to claims under the SSI program, while the remaining processes either fall under DI or apply to both DI and SSI. However, there is some overlap in the identification process and application. The more recent initiatives are described in the following subsections. The newest procedures, QDD and CAL, are referred to as "fast track" by SSA, while the others are generally referred to as "expedited procedures."
|Country||Program/initiative and fast-track (FT) process||Date implemented||Description and features of interest|
|United States||Both Disability Insurance (DI) and Supplemental Security Income (SSI)
|Australia||Disability Support Pension (DSP)
||Five categories of manifest grants:
|Canada||Canada Pension Plan (CPP)
Canada Pension Plan Disability (CPP-D)
|SOURCE: Compiled by the author.|
Quick Disability Determination (QDD). SSA began using the QDD process in August 2006 on a pilot basis,19 issued final regulations effective September 2007, and extended the QDD process nationwide by February 2008. QDD uses a predictive model to analyze specific elements of data within electronic files. Cases selected for QDD processing (this step takes about a second) are forwarded to a DDS within 24 hours of receipt and are very likely to receive favorable determinations using medical information that is readily available.
Compassionate Allowance (CAL). As another recent FT initiative, the CAL process was launched initially in the fall of 2008 and currently targets 27 cancers and 86 other specific medical conditions.20 All CAL-identified conditions are selected for CAL processing based solely on the claimant's allegations. Unlike QDD, CAL does not score the disability claim. Instead, CAL uses sophisticated software to quickly identify diseases and other medical conditions that invariably qualify under the Listing of Impairments based on minimal, but sufficient, objective medical information. Trained professionals must determine whether the evidence confirms the diagnosis. If so, the claim can be approved in a matter of days, compared with the several months it may take on average for a claim to be approved at the initial determination level. SSA developed the list of CAL conditions from information received at public outreach hearings, public comment from an advance notice of proposed rule making, comments received from SSA and DDS communities, and from counsel by medical and scientific experts.21
Terminal Illness (TERI) cases. When a case is deemed TERI, it merits special handling, with carefully prescribed protocols for appointment setting, labeling and flagging (as TERI cases), tracking, and continuous monitoring of timing to ensure fast processing. When a new claim is filed, the TERI designation can be input into the electronic folder. Other types of cases (CAL, QDD, and so forth) may be designated for processing as TERI if they meet the TERI criteria. TERI cases, which can be assigned at any time and at any level of adjudication, may be identified by the teleservice center (telephone call center), field office, or DDS—where management is responsible for tracking and controlling TERI cases through the initial and reconsideration levels of review at the DDS, 10 days following the receipt of the claim and every 10 days thereafter.
Suitable applicants with an "untreatable impairment(s)"—which cannot be reversed and is expected to end in death—must present a credible claim themselves or from a friend, family member, personal doctor, or other medical source, although TERI cases can also be identified by the field office or DDS during standard processing. Qualifying claims may be based on a diagnosis, such as amyotrophic lateral sclerosis (ALS, or Lou Gehrig's disease) or a statement that the claimant is receiving in-patient hospice care. Additional qualifying conditions include a bone marrow transplant, any stage IV malignancy, and small cell or throat cell lung cancer, among others.
Military Service Casualty Cases (MSCC). SSA expedites the processing of disability claims by military service members seriously injured while on active duty on or after October 1, 2001, with assistance from the Veterans Administration (VA) and the Department of Defense (DoD).22 To give priority to those cases, SSA has encouraged the identification of these "wounded warrior" claims in two ways (GAO 2009). First, since 2005, claimants can self-identify under the MSCC program when filing for disability. SSA has added questions on its application form to help recognize military service members and veterans and their dates of service. Second, DoD agreed (in a 2008 memorandum) to send weekly electronic updates to SSA with information about service members' status as "wounded, injured, or became ill" connected with military operations in Afghanistan and Iraq.
To qualify for disability benefits under MSCC, military personnel must be unable to do substantial work because of their medical condition(s)—either physical or mental—and the medical condition(s) must have lasted or be expected to last at least 1 year, or is expected to result in death. Service members frequently undergo a qualifying medical exam or medical test to assist in the case evaluation. Field office and DDS staff are instructed to expedite processing those claims and to follow TERI procedures through all stages of case development and adjudication. Once the field office refers the application to a DDS for review, it follows up within 7 days to ensure receipt by the DDS system. DDS staff is required to consider wounded warrior cases as early as possible and explore all potential physical and mental impairments. In addition, SSA staff at the hearing level is required to schedule wounded warrior cases in the first available open hearing slots; such cases receive an electronic indicator so that an adjudicator knows to expedite case processing.
Presumptive Disability (PD)/Presumptive Blindness (PB) cases. PD/PB status dates back to the introduction of SSI in 1974. First-time disability claimants may receive payments in advance of the formal medical determination by the DDS if there is a "high degree of probability" that the DDS will find the claimant disabled after obtaining all the necessary evidence. There are a limited number of conditions one must have to be eligible for receipt of payments, and the field office is authorized to make PD or PB determinations. The DDS can make such determinations in any case with a high probability of allowance.
PD/PB disability cases must meet all nonmedical factors of eligibility. Benefits begin the month after a claimant files an application, if PD/PB requirements are met. These are presumptive payments, which present a notable difference from other FT categories. Claimants may receive up to 6 months of payments based on PD or PB prior to the formal DDS determination. If the DDS finds that the claimant is not disabled, the claimant is not required to return the presumptive payments.
Qualifying impairments from which an SSA field office worker can identify include the amputation of two limbs; amputation of a leg at the hip; allegations of total blindness, total deafness, or a cerebral vascular accident (stroke) more than 3 months prior to application with the claimant having marked difficulty walking or using a hand or arm. Additional such impairments include alleged muscular dystrophy; muscular atrophy; or cerebral palsy with the claimant having marked difficulty walking, speaking, or coordinating his or her hands or arms; and terminal illness with a physician's confirmation of the expectation of death within 6 months. As previously noted, DDSs are not confined to the list of special categories that SSA field office workers use, but can make determinations of presumptive disability in any case involving any impairment in which the adjudicators have sufficient evidence to determine that there is a high probability of allowance.
Expedited Reinstatement (EXR) cases. EXR, which became effective January 1, 2001, is a safety net for persons who successfully return to work and later lose their entitlement to DI or SSI because of their work activity. EXR is not an expedited initial application, but a postentitlement process. An application does not need to be completed at the time the individual is terminated for SGA, but he or she can subsequently no longer work because of the same or related medical condition(s). As a result, the standards are not the same as those for the initial decision. Moreover, the process is not impairment-specific, but applies to individuals who allege the same impairment(s) as that stated in their original application.
If a person's entitlement ended because he or she had resumed work and received earnings, but stopped working within 5 years of when those benefits ended because of the same medical condition(s), it is possible for SSA to restart benefits without the individual filing a new application. If a person qualifies for EXR, SSA may pay up to 6 months of temporary (provisional) cash payments while the DDS conducts a medical review. In addition, the person is also eligible for medical insurance (Medicaid or Medicare) during the 6-month provisional benefit period. Provisional payments are made beginning with the month that the claimant files the EXR request.
Application Sequence and Administration of Disability Claims
To apply for disability benefits in the United States, applicants can complete an online application in many cases, mail or bring in a completed disability report, or file a report at their local Social Security office. Once a claimant's application is complete, field office staff electronically transfers the claim to a central office for disability determination. At that point, sophisticated software electronically evaluates the claim, determining whether the case qualifies for processing as a QDD and/or CAL case.23
For QDD, a predictive model rapidly searches data from the disability report and evaluates variables including alleged impairments, medication, age, education, and work history. The model sums the weighted variables and generates a likelihood score for the case becoming a QDD. More specifically, a QDD case is identified electronically by the model as having a high degree of probability that the claimant is disabled; evidence of the claimant's allegations is expected to be readily available and the case can be processed quickly by the DDS. If the model identifies a claim as QDD (sufficiently high score), the claim is electronically marked "QDD" and routed to the state DDS.24 Following receipt at the DDS, a QDD case is assigned to a disability examiner, also known as a disability claims adjudicator, who reviews the allegations and whatever medical evidence is submitted at the time of filing. If warranted, the disability examiner tries to obtain additional evidence as needed. Then the DDS, in coordination with a medical consultant, prepares a determination and returns the updated electronic folder to the Social Security field office.25
Similar to the process for QDD cases, potential CAL cases are identified at initial application using sophisticated software. CAL cases also receive expedited handling at the DDS level. However, in contrast to QDD cases, CAL cases are not selected on the basis of a likelihood (probability) score. Instead, medical conditions preidentified as CAL are loaded into global reference tables by impairment name, common synonyms, and abbreviations. When the CAL-selection software identifies the name of a CAL condition on an application, the case is electronically marked "CAL" and routed to the DDS for expedited handling.26
To expedite the processing of CAL claims, SSA has provided disability adjudicators with impairment summaries for CAL conditions. The impairment summaries contain information about each listed condition, indicate the type of medical evidence needed to confirm a diagnosis, and suggest the Listing of Impairment criteria under which the claim may be evaluated.
Fast-Track Highlights in the United States
In sum, SSA uses six FT procedures that accelerate the claims process in the disability programs it administers, including sophisticated software to enable the following newest initiatives, QDD and CAL:
- For QDD, SSA's operational instructions state that the disability determination should be made quickly after the claim is received in the DDS and provide a recommended time frame of 20 days or less in the DDS.
- Nearly 4 percent of all disability applications went through QDD/CAL processing in fiscal year (FY) 2009, and this share grew to 4.5 percent by the end of FY 2010; the goal for FY 2011 was 5 percent.
Experience of Other Countries Operating Fast-Track Procedures
Other countries have FT procedures in their disability programs. Table 3 lists the FT procedures described in the United States and the other four countries examined in this article. Of significance is the variety of procedures found in nearly every country under study.
While the US complement not only contains six FT processes that address a variety of impairments, the availability of an electronic claims process has permitted the introduction of predictive modeling and automated case selection software. That innovation has the potential to lower processing times and improve impairment identification in submitted claims. As noted earlier, the QDD process selects cases based on a likelihood (probability) score, whereas the CAL process primarily relies on the software to identify the terms of a preidentified medical condition. The latter CAL-style approach is used in the other countries listed in Table 3, although with less emphasis on technology. However, the situation in some of these other countries may change given announced reforms involving steps to upgrade the operational systems of their respective disability programs.
Fast-track strategies detailed for two countries in Table 3 are particularly noteworthy. In Canada, FT processes target individuals in the process of submitting an application for a claim, as well as those who have returned to the labor force after suffering a relapse, which is similar to expedited reinstatement cases administered by SSA. Another country with an interesting FT feature is the United Kingdom, which not only has an FT process for its long-term disability program, but also operates a supplementary program providing additional benefits for care and mobility needs, with FT features. More generally, all countries in this study target claimants with a terminal illness, and nearly all (except Israel) have recently changed their FT procedures and listed disabling conditions.
Table 4 allows a comparison of the general decision procedure for disability claims (column 1) and claims with FT processing (columns 2–5), including the country-specific decision process, FT procedures, FT technology, specific time lines; and the motivation for implementing FT procedures.
Multiple stages characterize the decision process in all countries, with the responsibility for decision making typically conferred on a disability examiner who may share this obligation with a medical specialist. The descriptions covering technology and time frames vary the most. The innovations in software and electronic claims processing of the United States may be followed by Israel and Australia in the future, with limited changes observed in the other countries sampled. In general, the time horizons indicate dramatically lower processing times that the various disability programs establish and achieve using FT claims procedures.
|Country||Decision procedure||Fast-track processing||Fast-track technology||Time frames||Objectives|
|United States||Application is filed; claim is forwarded to state Disability Determination Service (DDS), which collects medical/other evidence and makes decision for Social Security Administration (SSA). DDS may require one of more independent medical examinations. The disability examiner (DE) and a medical professional review evidence and make determination based on five-step evaluation process. Person may be found disabled based on list of impairments or assessment of functional limitations and vocational issues. New regulations (effective 2010) allow qualified DEs to issue some favorable Quick Disability Determination (QDD) and Compassionate Allowance (CAL) decisions alone. DEs may consult state medical professionals in those cases, but are not required to do so.||Six fast-track (FT) initiatives to accelerate the claims process. Of those, only one (presumptive disability/presumptive blindness) operates solely under Supplemental Security Income (SSI), while the others fall under Disability Insurance (DI) and SSI. Newer initiatives (QDD and CAL) rely on sophisticated software. QDD relies on probabilistic modeling to identify claims, while CAL uses that software to identify cases based on medical terms.||Electronic folder (EF) is replacing paper claims folder. System collects data on claimant's disabling condition(s) and transfers it to EF, accessible to all case-processing agency components. Sophisticated software analyzes data within EF to identify cases with high potential of claimant being disabled and where SSA can quickly obtain evidence of person's allegations.||No established time frames for rendering decision. For FT processes, persons with most severe disabilities will generally be approved for benefits in less than the 3–4 months it typically takes for initial decision. For QDD, guidelines call for 20–30 days; for CAL, time frame is not mandated.||Processes enable fast tracking applicants with most severe disabilities. FT systems increase efficiency/productivity of process and may help free up resources so SSA can better cope with recent large increases in DI applications. For SSI recipients, expedited approvals also ensure immediate medical coverage for many individuals.|
|Australia||Disability Support Pension (DSP) applicants, except those manifestly disabled, must undergo job capacity assessment (JCA) to evaluate work capacity/barriers to find work. Assessor collects medical files, employment history, and so forth. JCA provides Centrelink with information on applicant's recommended impairment rating/work capacity. Decision to grant/reject DSP made by Centrelink based on all available evidence.||Claimants for DSP are generally required to undergo independent assessment, JCA, for level of impairment/work capacity. People in select categories can be granted DSP without need for JCA, including those permanently blind; terminally ill; having intellectual disability; requiring nursing home–level care; or having category 4 HIV/AIDS. New FT impairment lists (2010) use SSA's CAL as starting point.||Currently, paper medical reports from practitioners are stored in DSP claimant's paper file. Since 2010, those reports and other paper-based medical data can be electronically scanned and stored on claimant's computer record. Initially, this will only be done for new claimants. Centrelink decision makers/assessors can access electronically stored medical information.||Timeline standard for processing new DSP claims is for 70% completion within 49 days. Centrelink (agency that determines claims and makes payments for Department of Families, Housing, Community Services and Indigenous Affairs) consistently meets target. No separate statistics kept on FT manifest grants, but most of those grants would be completed within 49 days.||Manifest grants of DSP only made in specific cases and in limited number of specific circumstances. Before 2002, the manifest grant rules were significantly looser with more discretion, but were found to be applied inconsistently by decision makers.|
|Canada||Canada Pension Plan (CPP) reviews application, medical report, and other documents before sending for medical adjudication. Adjudicators responsible for making decisions for CPP disability benefits. CPP assesses severity of disability, and if claimant does not meet severe criterion (unable to regularly pursue substantial gainful occupation), then CPP does not consider question of whether disability is prolonged. Once confirmed that claimant made required contributions and is granted a CPP disability benefit, then prior contributions are used to calculate monthly benefit.||In the case of terminal illness, key performance indicator is 48 hours from receipt of three information pieces: application, applicant's questionnaire, and medical report.||Claims processing consists of paper-based folder, with documents manually scanned into system initially on a flow basis. At initial adjudication/reconsideration levels, all charting conducted by Service Canada is saved electronically as are letters (generated from automated letter-writing program) to client/third parties. At reassessment levels, automated claimant/physician questionnaires, using special software, are available to assist evaluation of claimant responses to produce recommendation with supporting rationale specific to case.||Canada Pension Plan Disability (CPP-D) able to adjudicate 75% of initial files in 120 days. Process begins once necessary information received: application, applicant's questionnaire, and medical report. For terminal illness, standard time frame is 48 hours from receipt of that data. By law, benefits start 4 months after date Service Canada determines the person is disabled. Thus, there is a 3-month waiting period.||Standardized procedures for adjudicating applications for the terminally ill adopted in 2002 to ensure compassionate, sensitive, and timely service for applicants by requiring applications be adjudicated within 48 hours of receipt. That process was streamlined in 2010. Automatic reinstatement of benefits was implemented in 2005 to provide financial safety net and encourage beneficiaries to try to return to regular employment. FT reapplication (1995) allows additional measure of support.|
|Israel||Two-stage process of determining entitlement: 1) National Insurance Institute (NII) physician determines medical disability percentage, and 2) claims officer determines degree of incapacity to earn/function after consultation with authorized physician and rehabilitation clerk. At times, the opinion of rehabilitation clerk regarding incapacity degree may be influenced by variables such as labor market situation and claimant's area of residence.||According to a 1990s government decree, determinations must be reached for persons with severe disabilities within 3 weeks of day claim submitted. When authorized physician makes decision and transfers claim to second stage, he or she must indicate if claimant has severe disability. If claimant has 100% disability from single impairment, there is no need at first stage to diagnose other impairments. Persons with severe (at least 80%) disability are given priority in summons before medical committees.||Public programs use electronic databases during application process, disability assessment, and benefit payment, which include data on disability criteria and results of medical/functional assessments. NII has central computer located in headquarters with online accessibility from local branches. Patients have electronic medical records (EMRs) via sick funds (similar to HMOs in United States). NII working to gain access to records for claims processing and planning a computerized system (Tevel) with focus on diagnosis (International Classification of Diseases, 9th edition-based) and document management (including EMR data obtained from sick funds).||By law, entitlement to/and payment of benefit begins only after 90 days have elapsed since incapacity began (determining date). Every claim is transferred to a doctor. If person severely disabled (generally 70% or more), claim processed within 21 days. Average time frame for processing claims is 70 days.||Disability pension is provided to resident applicants. Motivated by humanitarian reasons, the government's decree in the 1990s mandated a decision within 3 weeks following submission of a claim for persons assessed severely disabled.|
|United Kingdom||When claiming Employment and Support Allowance (ESA), claimants enter 13-week assessment. During that phase, claimants take part in work capability assessment (WCA) to determine ESA eligibility/capability for work. Special rules permit exceptions to WCA (terminal illness and so forth). While awaiting assessment, claimants receive basic assessment rate. Once assessed, they are placed in one of two categories: "support group" or "work-related activity group." Amount of ESA benefit depends on category assignment.||ESA provisions allow claimants with terminal illness and sufficient deeming conditions to be fast tracked before reaching medical questionnaire or in-person assessment stage, which determine eligibility. If applicant wishes to claim under special rules, case passes to health care professional (HCP) for assessment. Similar provisions apply for claiming Disability Living Allowance (DLA) under special rules, where HCP has 48-hour target to provide medical advice upon receiving case. If condition(s) is discovered at later stage, claimant can then be fast tracked.||Computerization of certain features exists in general claims process. Diagnostic system developed to permit claims administrators to check range of symptoms and progression of disease based on average prognosis, by evaluating reports provided by claimants and their physicians. No automatic processing guides FT strategies. Under special rules for terminally ill, applicants check box on claim form to indicate claiming under this provision.||While eligibility for ESA is determined, claimants receive basic rate of benefit for 13 weeks. Claimants who state they are terminally ill or suffer from deeming conditions have cases reviewed by HCP within 24 hours of referral. If satisfied, HCP recommends claimant be paid highest level of ESA, without providing further data or undergoing in-person assessment. For typical DLA claims, the target for clearing applications is within an average of 35 days; special rules FT cases are processed in 6.1 (target of 8) days.||The focus is to improve mainstream employment programs for the sick and disabled. An important goal is to help persons move from receiving benefits back into the workforce. For the terminally ill and others, FT processes help accelerate claimants through the determination process to provide benefits more quickly.|
|SOURCE: Compiled by the author using online country websites, Westat (1998), and Honeycutt and Mitra (2005).|
Fast-Track Experience in Australia's Public Disability Programs
Australia is one of a small number of developed countries with social security programs based on social assistance rather than a social insurance approach. All major support systems, including those related to disability, are funded through general revenue and are based on income and assets tests (Clayton and Honeycutt 2005). Eligibility determination, payments and services provided by public disability programs, as well as unemployment and other pensions, are the responsibility of the government service provision agency, Centrelink.27 The Department of Families, Housing, Community Services and Indigenous Affairs (FaHCSIA) sets policy for disability programs.28
The primary mode for providing income support in Australia for persons with disabilities is the Disability Support Pension (DSP). To qualify for DSP, an applicant must meet age, residency, disability, and employment criteria. Applicants must be aged 16–64 (or 16–65, depending on sex) and satisfy minimal residency criteria.29
An applicant can satisfy the disability requirements for the DSP in two ways. The first requirement involves a diagnosis of permanent blindness. Persons who are permanently blind automatically meet the medical eligibility criteria for the DSP and are exempt from the income and assets test that applies to all other DSP recipients. The second requirement is a permanent physical, intellectual, or psychiatric impairment assessed at 20 points or more using the Impairment Tables, which assess an applicant's functional limitations related to work in terms of effects on "body systems" rather than a specific diagnosis. The Impairment Tables have a maximum range of 40 to 50 points.30 To be eligible, the person must also be unable to perform any work of at least 15 hours a week at or above the relevant minimum wage, or be unable to train for such work for at least the next 2 years, as evidenced by a job capacity assessment (JCA). To confirm the impairment rating under the Impairment Tables, the physical, psychological, or psychiatric impairment must be permanent—that is, fully diagnosed, treated, and stabilized, and unlikely to show any significant functional improvement within 2 years, with or without reasonable treatment.
A reform of Australia's disability programs was introduced as part of the 2009–2010 budget, including a new assessment process, more stringent eligibility rules, a new advisory unit to give DSP assessors independent advice, and a comprehensive revision of the Impairment Tables used to measure how a person's impairment(s) affects their ability to work. The tighter eligibility rules and new Impairment Tables are scheduled to be implemented in 2012.
Disability Assessment Process
All DSP applicants, except for those considered "manifestly disabled" (with impairments described in the following section), must undergo a job capacity assessment, which has a dual role of assessing the individual's work capacity and barriers to find work and of referring the person to appropriate assistance when needed. For this purpose, the assessor collects medical files, employment history, and other relevant information about the person. Since July 1, 2010, assessors have electronic access to the applicant's medical information via computer.
"Job capacity assessors" are allied health professionals, such as psychologists, social workers, rehabilitation counselors, occupational therapists, and physiotherapists. (JCA providers have been contracted by the Australian Department of Education, Employment and Workplace Relations.31) Assessors have to undertake training courses and follow service guidelines to ensure that assessments are delivered consistently across the country. Assessors and claimants are able to discuss claimants' educational attainment, work history, skills, qualifications, and interests, as well as the effects of their medical condition(s) including treatment history and the stability and prognosis of any episodic condition(s). Assessors are also able to discuss with claimants other factors that could affect the claimant's ability to work, such as language difficulties or mobility problems. This assessment provides expert advice about the impairment rating and the impact of the medical condition(s) on the person's capacity to work.
The JCA provides Centrelink staff with information on the applicant's recommended impairment rating under the Impairment Tables and his or her work capacity. The assessor completes the JCA report electronically and that report is transmitted to Centrelink and stored on the DSP claimant's computer record. The decision to grant or reject the DSP is then made by Centrelink personnel based on all available evidence, including the information provided by the claimant and by the JCA.
Claimants in select impairment categories can be granted a DSP without the need to undergo an independent JCA of their level of impairment and work capacity. Those manifest grants are made to claimants with one of the following conditions:
- Permanent (legal) blindness—based on the information provided in an ophthalmologist/optometrist report
- Terminal illness—current medical condition(s) is chronic and debilitating with a prognosis that the life expectancy is 24 months or less
- Intellectual disability—supporting documentation clearly indicates an impairment rating of 20 points or more under the Impairment Tables
- Condition requiring nursing home–level care
- Category 4 HIV/AIDS
Supplementing those manifest grant categories are two fast-tracking lists of conditions, which were introduced in July 2010, using SSA's CAL conditions as a starting point. Claimants with a condition on list 1 are fast-tracked to a DSP on the basis of diagnosis alone. If the claimant has a condition on list 2, then more information on the prognosis/severity needs to be obtained from the doctor/specialist before deciding whether to fast track the claim or refer the claimant for a JCA. If the DSP claimant's medical report lists such a condition, then the newly created Health Professional Advice Unit (HPAU) provides immediate advice about a condition, treatment regime, and likely prognosis. The HPAU doctor may be able to confirm the expected prognosis, that is, whether terminal or catastrophic, or may contact the treating physician to clarify and thereby expedite the claim without further assessment. At the same time, treating physicians are eligible to receive payment after providing information on the claimant—enabling DSP assessors to make a more informed decision—at the request of the HPAU.
Application Sequence and Administration of Disability Claims
Applicants are encouraged to register their intention to claim the DSP to ensure they will be paid from the earliest possible date. That step can be accomplished online, by telephone, or in person at a Centrelink customer service center. Once an applicant has registered his or her intent to file a claim, a Centrelink customer service officer will send the applicant a paper claim pack; those claim forms can also be downloaded online. The three forms that must be completed include one for the claim, one for income and assets, and the medical report. Completed forms may be sent to the nearest customer service center or submitted in person by the claimant or another person on the claimant's behalf.
It is up to the DSP claimant to make an appointment and arrange for his or her treating medical practitioner to complete the medical report. The treating medical practitioner usually gives the completed report to the DSP claimant to submit to Centrelink, or the doctor may mail it directly to Centrelink. The paper-based medical report provides information on the diagnosis, clinical features, treatment details, and the impact of the medical condition(s) on the claimant's ability to function.
Historically, the paper-based medical reports from medical practitioners were stored in the DSP claimant's paper-based file. Since July 2010, those paper reports and other paper-based medical information are being electronically scanned and stored on the claimant's computer record. Initially, this is the process for new claimants, but it is expected that all existing medical information will eventually be scanned and stored electronically for access by Centrelink decision makers and job capacity assessors.
In addition, under the updated DSP fast-tracking procedure, the condition(s) listed in the DSP claimant's medical report are checked against the list of conditions to see if it is on one of the two lists; if so, eligibility is established for the manifest grant without the need for a JCA. For example, if a Centrelink customer service officer attempts to set up a JCA appointment for a DSP claimant who has a medical condition code that corresponds to a condition on list 1 or list 2, a warning flag will appear advising the staff to consider whether fast tracking would be appropriate before booking the JCA appointment. Therefore, those lists assist Centrelink customer service staff in recognizing conditions that may deserve a DSP manifest grant under the existing guidelines so that the advisor could then consider fast tracking the claim. The new lists are particularly useful for some of the lesser-known disorders, providing clearer information than was previously available.
Fast-Track Highlights in Australia
The following list shows Australia's experience with fast tracking disability claims:
- A disability reform implemented in 2010 aims to lead to fewer claims overall, but generates faster FT processing for manifest grants, including the addition of two CAL-style listings. The reform also created a new Health Professional Advice Unit to give DSP assessors independent advice and to comprehensively revise the tables used to measure how a person's impairment affects their ability to work.
- Since July 2010, Centrelink has had access to electronic medical files for new claims.
- Over 6 percent of DSP grants in the 2008–2009 period were manifest grants, with slightly more than half approved because of a terminal illness.
- While no separate statistics are kept on processing times of FT manifest grants, disability program staff in Australia indicates that approximately 70 percent of new disability claims are processed within 49 days, and that FT claims fall well within this time frame.
- Manifest grants by category for the 2008–2009 period, as a percentage of all successful approved grants, include permanent blindness (0.37 percent), terminal illness (3.30 percent), intellectual/learning disability (2.12 percent), nursing home–level care (0.54 percent), and HIV/AIDS (negligible).
Fast-Track Experience in Canada's Federal Disability Programs
The Canada Pension Plan Disability (CPP-D) program provides monthly benefits to Canada Pension Plan (CPP) program contributors who cannot work at any job because of a "severe" and "prolonged" physical and/or mental disability. Severe means that applicants are incapable of regularly pursuing any gainful occupation because the disability prevents them from doing any type of work on a regular basis. Prolonged means that (1) the disability is of long and indefinite duration, or (2) the disability is likely to result in death.
Service Canada offers a "single-window access" to a range of government programs and services for Canadian citizens, including the CPP-D program, through its more than 600 points of service located across the country, call centers, and the Internet.32
Disability Assessment Process
The CPP-D program involves a two-part test for eligibility—the earnings test and the medical requirement. To be eligible for a CPP disability benefit, an applicant (referred to as a "client") must have made enough CPP contributions in at least 4 of the last 6 years, or have contributed for at least 25 years, including 3 of the last 6 years prior to becoming disabled.33 In the process, the provisions that follow may be used to help the client: late applicant provision, child-rearing, drop-out provision, credit splitting provision, and international agreements. The "minimum qualifying period" (MQP) is the minimum number of contribution years needed to be eligible for a disability benefit. Service Canada staff must calculate a claimant's MQP before it can assess medical eligibility.
Next, a CPP-D medical report is reviewed, including documentation of clinical observations, diagnosis, and long-term prognosis of an applicant's medical condition(s). Medical adjudicators, who are trained health care professionals (generally nurses) knowledgeable in CPP disability legislation and policies, are responsible for making a decision on a CPP-D application. They decide first whether the client's medical condition(s) meets the severe and prolonged criteria as discussed below.34 For more complex cases, adjudicators may consult with a CPP physician. Eligibility is not based on a specific medical diagnosis, but considers other factors as well, including the nature and severity of the medical condition(s); the impact of the medical condition(s) and treatment on the claimant's capacity to work at any job; personal characteristics (for example, age, education, and work history); and the applicant's work performance and productivity.
In addition to the detailed information provided by the applicant, CPP (like SSA in the United States) may consult with employers, schools, and other third parties who may be able to provide additional information on the applicant's functional capacity. The information provided by the applicant's treating physician is also important to the adjudicators making the decision. If required, the adjudicators may also seek information from non-CPP specialists or independent medical examiners. This ensures that CPP has enough information to be reasonably satisfied that the applicant meets the eligibility requirements.
CPP assesses the severity of the disability first, and if the client does meet the severe criterion (client is unable to regularly pursue any substantial gainful occupation), then CPP considers the question of whether the disability is prolonged. If the medical adjudicator determines that the client meets the criteria of severe and prolonged and grants the CPP disability benefit, then the benefit officer calculates the monthly benefit based on the client's previous contributions.
A national policy, with standardized procedures for the adjudication of disability applications for clients with a terminal illness, was adopted in June 2002. It was enacted to ensure "compassionate, sensitive, and timely" service for applicants by requiring that their disability application be adjudicated within 48 hours of receipt in the disability unit. This process was updated in March 2010 to streamline the application process at all levels for applicants whose medical condition(s) is considered terminal.35
The process begins once the application is received in the mail processing center and the program service delivery clerk manually scans for one of the following key terms, which could indicate a terminal illness, upon receipt of an application: "stage III or IV cancer," "end stage," "failure," "malignant," "metastatic/mets," "palliative," "terminal," "carcinoma," "sarcoma," and "blastoma." The clerk tags terminal illness files based on the diagnosis section of the medical report—a "red urgent" tag is stapled to the folder to note the 48-hour contact frame, and the "urgent box" is checked in the automated file tracking system. The clerk requests any previous file(s), verifies the date of birth and social insurance number, and then ascertains whether there are current earnings. If required, the clerk forwards the file to the benefits officer for an earnings investigation. Throughout that process, incomplete files will trigger a telephone call to applicants to alert them about any missing information. If everything is in order, the file is forwarded for medical adjudication. If the claim is denied based on nonmedical information, a call is placed to the client explaining the decision and his or her right to request reconsideration, and a denial letter is sent out, including an information sheet regarding additional resources available in the community.
If the claim is not denied based on nonmedical information, the medical adjudicator assesses the file to determine if the client meets the impairment criteria of being severe and prolonged. The adjudicator processes the file immediately when the information clearly indicates the status is terminal, obtaining medical confirmation of the status by telephone or fax. If the adjudicator does not find that the client has a terminal illness, he or she deactivates the terminal-status indicators and returns the file to the queue for normal processing. Upon receipt, additional documents are added to the file throughout this step. For terminal cases, the client will be notified of the decision within 48 hours from the clerk's first receipt of the file in the mail processing center.
The CPP-D program operates other FT initiatives that enhance the decision process described earlier, including policies for the automatic reinstatement of returning applicants to their previous CPP-D benefits and assistance to potential applicants in their document preparation prior to submitting a formal application.
Fast-track reapplication and automatic reinstatement. Since January 31, 2005, former disability beneficiaries who have returned to regular employment (and whose benefits have ceased as a result) are entitled to automatic reinstatement of benefits if they cannot continue working because of a recurrence of their disabling condition(s). This is a postentitlement policy similar to the Expedited Reinstatement (EXR) policy operated by SSA in the United States. For CPP-D beneficiaries, this policy provides a financial safety net to encourage a return to regular employment. It is particularly beneficial for persons with episodic disabilities, as there is no limit on the number of times a claimant can use this provision. To use the automatic reinstatement provision, the claimant must have informed the CPP-D about his or her return to work and benefits must have ceased. The claimant is sent an automatic reinstatement information kit to use in the event that his or her disability recurs and prevents the continuation of work. A request for automatic reinstatement is not a readjudication; there is a process of completing a simple form in addition to providing a statement from a physician verifying that the person has the same or recurring medical condition(s). The automatic reinstatement entitlement is available for 2 years following the month the CPP-D benefits stopped. In addition, the request for reinstatement must be made within 1 year following the month in which the recurrence of the disability caused the individual to stop working.
Another earlier policy, fast-track reapplication, was introduced in 1995 to encourage CPP-D beneficiaries to attempt a return to work. The provision allows contributors to reapply at any time within a 5-year period after the termination of CPP-D benefits. That allows an additional measure of support for applicants who may not meet the time lines or medical eligibility requirement for the automatic reinstatement of benefits, provided that valid earnings and contributions are made each year following the cessation of the previous disability benefit. As with the automatic reinstatement provision, there is no limit to the number of times the process may be used. Claimants who reapply within 5 years will receive priority processing status, and approved individuals will receive a benefit payment the month following the date of application.
Terminal Illness Application (TIA) pilot. CPP-D has been testing an abridged format and process for terminally ill applicants. Anecdotal information has indicated that it takes approximately 4 months on average for claimants to complete the regular CPP-D application form (33 pages).36 The TIA is a streamlined 8-page form. Service Canada has partnered with service providers—social workers; extramural nurses; cancer care "navigators" (nursing professionals who help patients and families understand cancer diagnosis, treatment, and other factors); and physicians in hospitals and clinics—who work directly with terminally ill clients. Those service providers assist the client with the shortened form, coordinate the completion of the medical report, and fax the application directly to the mail processing center to begin the formal claims process. Once all of the pieces of the application are received for processing, a decision is finalized within 1 to 2 days. Pretest of the TIA, which began with 6 hospitals in the fall of 2007, has now been expanded to more than 32 agencies/hospitals. According to Service Canada, an estimated 1.8 percent of CPP-D clients may benefit from a TIA. Service Canada has received positive feedback from service providers indicating that the form and process are much easier to complete.37 The next steps in the policy evaluation process will include further analysis of the TIA pilot data and a review of any lessons learned from the exercise.
Application Sequence and Administration of Disability Claims
Individuals wishing to apply for a CPP-D benefit may contact Service Canada to obtain the CPP-D benefit application kit. Applicants can also get an online version of the application kit to print out. The kit includes several forms: an Application for Disability Benefits (to be completed by the applicant), a Questionnaire for Disability Benefits (to be completed by the applicant), and a Medical Report (to be completed by the applicant's physician). Additional reports from specialists are encouraged and can be submitted with the application on behalf of the client.
There is an "early client contact" policy active throughout the application and claims process. The policy is designed to obtain additional information from the client and ensure that he or she understands the basis for the decision. Once the client has filed an application, he or she receives a call from a Service Canada representative to gather and/or provide information about the application form, time lines, and what steps to anticipate in the adjudicative process. Once a decision to grant or deny has been issued, the client is contacted again by Service Canada and provided with information about the decision and related matters, such as the appeals process and other resources that are available.
Fast-Track Highlights in Canada
The range of FT strategies includes a 48-hour processing policy for the terminally ill (introduced in 2002 and updated in 2010), FT reapplication and automatic reinstatement policies, and the Terminal Illness Application pilot—all assisted by an early client contact policy. The following items describe the results of FT strategies undertaken in Canada.
- CPP-D has been able to adjudicate 75 percent of initial general disability claims within 120 days, but the standard is 48 hours for fast tracking terminal illness cases.
- A terminal illness application pilot, introduced in 2007, provides a shortened and simplified application form and assists potential claimants before their applications are submitted. This initiative has been expanded.
- Fast-track reapplication (introduced in 1995) and automatic reinstatement (updated in 2005) help former beneficiaries who returned to work, but who have had to reapply for CPP-D benefits after benefit termination because of a reoccurrence of the disabling condition(s).
Fast-Track Experience in Israel's Public Disability Programs
Disability insurance in Israel provides a minimum subsistence income for persons with disabilities.38 The disability pension is paid to residents of Israel between the ages of 18 and the retirement age who meet all the qualifying conditions. There are two main groups of entitled persons, according to the entitlement test: (1) disabled persons whose earning capacity has been lost or reduced as a result of their impairment (earners), and (2) disabled nonworking spouses (or common-law wives) whose capacity to function as "housewives" has been lost or reduced.
More specifically, the definition of a disabled earner is an individual who—as a result of a physical, mental, or emotional impairment stemming from an illness, accident, or birth defect—satisfies the criteria for one of the following categories:
- Being unable to self-support from work/occupation, or the capacity to self-support by working has been reduced as a result of the impairment(s) by 50 percent or more
- Having no actual income from work/occupation
- Being a working disabled person with income from work/occupation no higher than 60 percent of the average monthly wage, or no more than 4,984 new shekels (NS) or US$1,448 (as of July 2011); entitled to a disability pension for a long period;39 and designated as severely disabled40
- Being a working disabled person with income from work/occupation no higher than 45 percent of the average monthly wage, or no more than NS3,738 or US$1,086 (as of July 2011) and who does not have a severe disability or was not entitled to a disability pension for a long period
For disability purposes, a housewife is a married woman (including common-law marriage) who has not worked outside the household for a period determined by law and who—because of a physical, mental, or emotional impairment stemming from an illness, accident, or birth defect—does not have the capacity to function and carry out regular household chores, or her capacity for doing such work has been reduced by at least 50 percent.
The National Insurance Law was amended on August 1, 2009. The amendment encourages disability pension recipients to join the workforce, and it recognizes the rights of disability beneficiaries who do not work. Key provisions of the amendment include the following:
- If a degree of permanent incapacity has been established, beneficiaries will not be reexamined upon joining the workforce. The overall amount received from work and from the pension will always be higher than the amount of the pension alone.
- A 3-year safety net was created for beneficiaries; if they stop working or if their earnings from work decrease, they will be allowed to return to receiving the disability pension as before, without an additional examination.
- A new incentive pension was created to replace the disability pension and will be paid automatically to beneficiaries who are also working. The pension will then be gradually reduced as the income from work increases, so the overall amount received from both working and from the pension will always be higher than the disability pension alone.
Disability Assessment Process
There are two stages in the process of determining entitlement to a disability pension (Israel's National Insurance Institute (NII), Research and Planning Administration, unpublished memo). In the first stage, a physician appointed by NII determines the medical disability percentage. Entitlement to the pension is then examined for earners where a medical disability percentage of at least 60 percent has been determined (or 40 percent, if at least 25 percent is determined from a single impairment) and for housewives for whom a medical disability percentage of at least 50 percent is determined. If the calculated degree of disability is less than the respective thresholds at this stage, then the claim is rejected, and the second stage of examining earning capacity and household functioning is not carried out.
If the requisite medical disability percentage is determined in the first stage, a second stage involves the claims officer determining the degree of incapacity to earn/function after consultation with an authorized physician and a rehabilitation clerk. The determination of the degree of incapacity is based mainly on the earner's personal characteristics, such as an ability to return to the previous job (on a full-time or part-time basis); work at a different job; or to learn a new profession (taking into account the claimant's education level, physical capacity, and health condition(s)). Under certain circumstances, the opinion of the claims officer regarding the incapacity degree may be influenced by other variables, such as the labor market situation in the disabled person's area of residence. Regarding housewives, the examination of capacity loss is based on functioning in the home.
According to NII, a new disability system is being designed, known as the Tevel, which will incorporate electronic technology to minimize the intervention of a claims officer (David Rajnes (author) and NII staff, personal communication). The new computerized system is expected to take 10 years to complete. The first phase includes activities associated with preparing the claim for the medical board evaluation. Essentially, NII is creating a paperless chart, similar to SSA's electronic folder. All incoming paper work will be scanned and have extensive key words attached. All claims will then be linked to the 9th version of the International Statistical Classification of Diseases and Related Health Problems (ICD9), which is used by NII. This new system is expected to include the following features:
- Supporting the filing of disability claims via the Internet
- Receiving medical records directly from sickness insurance funds (similar to private health maintenance organizations (HMOs) in the United States)
- Developing a listing of all medical documents with associated key words to enable search and retrieval functions
- Allowing claimants to be notified if they may be entitled to additional benefits
- Supporting simultaneous work by staff on a claim
- Incorporating a computer-driven "logic engine" to enable numerous warnings and alerts
- Producing a task-driven system that translates the workload into tasks for staff to handle
- Generating reports and quality assurance, including numerous metrics and data to allow ongoing evaluation and improvement of the system
In the 1990s, the government decreed that decisions must be reached on claims for persons having severe disabilities within 3 weeks of the day that their claims are submitted. The NII introduced this Green Route to comply with the government mandate, which was enacted for humanitarian reasons, to quickly process claimants (for example, those who are terminally ill) projected to have shorter life spans than normal. When an authorized physician makes the decision and transfers the claim to the second stage, he or she must indicate if the claimant has one of the following cases of severe disability: cancer; amyotrophic lateral sclerosis (ALS, or Lou Gehrig's disease); blindness; is incapable of working at all for at least 1 year from the day of the submission of the claim; or the medical disability determination is at least 80 percent.
NII physicians may request special documents in order to make their decision.41 If it is clear that the claimant has 100 percent disability from a single impairment, there is no need at the first stage to diagnose other impairments. Persons with severe disabilities are given priority by summons before "medical committees." In certain cases, such persons do not have to be physically present at the committee sessions, which is the stage that usually lengthens the determination process. If, despite all efforts, the decision on a claim of a person with a severe disability is not yet made after 3 weeks have elapsed since the submission of the claim and entitlement is probable, then an advance payment is made to the claimant.42
Application Sequence and Administration of Disability Claims
Persons who believe they are entitled to a monthly disability pension may contact the NII branch nearest their place of residence and submit a claim for a pension. By law, NII must consider the claim for a disability pension within 90 days (except for persons with severe disabilities as indicated earlier) following the day on which the applicant lost earning capacity (or capacity to perform housekeeping tasks for nonworking spousal applicants) or when the claimant's earning capacity was reduced by 50 percent or more.
The claim should be submitted by the applicant, although another person may represent the claimant and submit the claim on the applicant's behalf, if he or she is unable to submit the claim in person because of a physical or mental condition. Medical documents, certification of employment and salary, and any other document proving the applicant's entitlement to a disability pension, should be attached to the claim.
The next step in the determination process is for the claimant to appear before a medical committee, composed of one NII doctor who specializes in a particular medical field and a secretary whose job is to ensure that the applicant's rights are protected and to record the committee report. Claimants reporting a number of conditions or medical impairments may need to be examined by several NII specialists and if, following the examination, it is determined that an additional examination is required by another specialist, one or more additional committees may be assembled. The opinions of those NII specialists are then submitted to the "certified physician."
Once the medical examination is concluded, the doctor reads the medical findings to the secretary and makes a decision in accordance with the medical documents on file, the claimant's application, and the completed examination. The doctor determines the degree of disability according to the "List of Impairments" in the examinations book (which contains a defined percentage of disability for every medical impairment according to NII regulations), sets the date for the start of the medical disability percentage, and determines whether the medical disability is temporary or permanent. If the committee believes that the claimant must undergo additional medical examinations or provide additional medical documents, it will not establish a percentage of medical disability, but will instead wait for the additional material. In such cases, a letter is sent to the claimant explaining what the committee requires. Upon receipt of the requested material, the committee determines the percentage of the claimant's medical disability.
Entitlement to a pension begins 90 days after the date of commencement of incapacity to earn/perform housekeeping tasks (the "determining date") for nonworking spousal applicants. The earliest possible date of commencement of incapacity is 15 months before a claim is submitted. Benefit levels are based on the disability percentage rating level assessed by this process.
Fast-Track Highlights in Israel
The following list summarizes strategies Israel has taken to address fast tracking disability claims:
- A 1990s government decree mandated that a decision must be reached on claims for persons with severe disabilities within 3 weeks of the day that claims are submitted. This is known as the Green Route.
- Tevel is the new computerized disability processing system expected to take 10 years to complete. The first phase includes activities associated with preparing the claim for the medical board evaluation. All incoming paper work will be scanned and have extensive key words attached and then linked to the International Statistical Classification of Diseases and Related Health Problems (ICD9).
Fast-Track Experience in the United Kingdom's Public Disability Programs
The disability benefit system in the United Kingdom is quite complex, including programs for temporary disability benefits, working tax credits, and return-to-work incentives (Mitra, Corden, and Thornton 2005; IBIS eVisor 2009).43 Statutory Sick Pay (SSP) is an employer-funded and administered temporary benefit, where employees who are unable to continue working because of illness or nonrelated work injuries can receive up to 13 weeks of cash benefits. An employee who has exhausted SSP and does not return to work may apply to the public contributory permanent disability program under the Department for Work and Pensions (DWP), which oversees the administration of the Employment and Support Allowance (ESA). ESA—which replaced the Incapacity Benefit and the income support paid to new claimants in October 2008—is designed to help persons who are sick or disabled return to work. In addition, the disability system in the United Kingdom has noncontributory means-tested benefits, as well as benefits that are not means tested, to help meet the extra costs of living with a disability—a Disability Living Allowance (DLA) for persons younger than age 65 and an Attendance Allowance for those aged 65 or older.44
Disability Assessment Process
To claim ESA, individuals must be between age 16 and the normal retirement age (currently 60 for women, 65 for men), have exhausted their entitlement to SSP, and not be eligible for social assistance or unemployment benefits. After making a claim for ESA, individuals typically take part in a work capability assessment, which takes place at around 13 weeks, to evaluate their eligibility for ESA and capability for work. While awaiting the assessment outcome, claimants receive a basic benefit. Once a determination is made, individuals are assigned to one of two categories: a "support group"—the group in ESA that does not require the claimant to take part in any back-to-work activity—or a "work-related activity group." The work capacity assessment may also include a medical assessment before a decision can be reached on the applicant's capability for work. An approved doctor, referred to as a health care professional (HCP),45 assesses how the illness or disability affects the applicant's capacity for work or work-related activity and provides advice to a decision maker employed by Jobcentre Plus (part of DWP), which is responsible for administering benefit claims.
The medical input required by decision makers includes medical examinations, reports, and advice.46 Examining HCPs base their assessment on information provided by the claimant, any information available to them from the claimant's doctor, and their own observations. After conducting the exam, the HCP completes a report for the decision maker. Somewhat differently, decisions about DLA entitlement are made by Disability and Carers Service decision makers, working from a network of nine "disability benefits centres" around the country. To qualify for DLA, individuals must indicate their applicable needs for 3 months before they make a claim and must show that they expect to need such help for 6 months after the claim. Decision makers examine, follow up, and weigh evidence submitted as part of the DLA claim before issuing a decision.
Two possible sets of assessments are relevant for fast tracking disability benefits in the United Kingdom: one for the ESA and another for the extra costs of disability provided by the DLA. ESA allows claimants with a terminal illness or with other severe conditions to be fast tracked to the support group. Claimants in this group may be fast tracked before they reach the medical questionnaire or face-to-face assessment stages, which form part of the work capability assessment that helps determine ESA eligibility.
When the claimant first applies for the ESA, he or she is asked—by a call center operator over the phone or in one of the questions on the online form—whether the claim should be made under special rules. Special rules apply to anyone who has a terminal illness and is not expected to live past 6 months or who suffers from specific "deeming conditions" (for example, kidney dialysis, double amputees, and severely deaf/blind) regarded sufficient in themselves. If the claimant says that he or she wishes to apply under special rules, then the case will immediately be forwarded to an HCP. If the HCP is satisfied that the claimant is terminally ill, he or she will advise that the claimant be placed in the support group and paid the highest level of ESA immediately.
HCPs can provide advice more quickly if the claimant submits a DS1500 form with his or her claim (David Rajnes (author) and DWP officials, personal communication). By obtaining the DS1500 from a personal physician, the claimant shows that he or she is terminally ill and is not expected to live beyond 6 months. If an HCP receives one of those forms with the claim, then he or she may take this as sufficient evidence of a terminal illness. This form is used for both ESA and DLA claims. Under special rules, the DLA (and the Attendance Allowance) benefit will usually be awarded for a period of 3 years. When 3 years have passed, the beneficiary is asked to renew the claim.
Similar provisions apply to those claiming DLA benefits because of terminal illness. If the HCP receives a special rules case and if there is no DS1500 form included, he or she will check to see if a claim has also been submitted for DLA. If there has been a successful claim to DLA in the past 6 months, either with or without the DS1500, this information may provide sufficient evidence of the claimant's terminal illness and a medical review is not repeated. The HCP advises DWP about that status. If a claimant has provided a DS1500 for a DLA claim, another similar form is not required for the ESA claim.
If there is no DS1500 and there has been no previous DLA claim, the HCP will contact the relevant doctor or other medical professional dealing with the claimant's case to ask for further evidence. HCPs have a 48-hour target for providing advice to DWP on special rules cases. If a terminal illness is discovered at a later stage of the claims process—either by the claimant informing the department or the HCP recognizing the illness from the medical evidence submitted—the claimant will be fast tracked to the support group from that point on.
Application Sequence and Administration of Disability Claims
Individuals can claim ESA in several ways. Telephones and text phones (used by those who find it hard to speak or hear clearly) are available for those requiring assistance. An adviser at the contact center can help applicants complete the application. Alternatively, applicants may complete the claim form themselves by downloading it from the Internet, printing it out, filling it in manually or online, and sending it to Jobcentre Plus.
After the initial claim for ESA is filed, applicants have to complete a questionnaire indicating how the illness or disability affects their ability to perform everyday tasks. The applicant's own doctor may be asked to provide a medical report. An approved HCP will consider the questionnaire and any medical reports, along with any other information the applicant may have provided. If the HCP needs more information to make a decision on the benefit claim, he or she will recommend a face-to-face medical assessment, which usually takes place in 1 of 12 medical centres near the applicant's residence. If the applicant is unfit to travel, the approved HCP may visit him or her at home.
Fast-Track Highlights in the United Kingdom
The following list summarizes the experience of the United Kingdom with fast tracking disability claims:
- Claimants who state they are terminally ill or suffer from deeming conditions have their case reviewed under special rules by an HCP within 48 hours of referral.
- Approximately 5 percent of disability claims receive FT processing.
- Two possible sets of assessments are possible for fast tracking disability benefits: (1) a contributory permanent disability provision, ESA, designed to help persons who are sick or disabled return to work, and (2) a noncontributory non-means-tested provision, DLA, which provides cash payments for the extra costs of disability.
Aspects of Fast-Track Processes
This section discusses selected aspects of fast tracking presented earlier for the countries included in the sample. The environment in which FT procedures operate is examined along three dimensions: (1) the administration of disability claims, (2) the integration of FT (including the role played by technology) into the determination process, and (3) claimant sequencing throughout that process.
Administration of Disability Claims (including Fast Tracking)
Nearly two decades ago, an International Social Security Association study contained the observation that the responsibility for both eligibility and assessing the degree of disability is generally assigned to an individual decision maker or to a team committee (Bloch 1994). Based on the review of the five countries examined in this article, that statement still appears relevant today. However, systemic changes are evident, at least for countries in the sample. New technology-based initiatives—QDD and CAL in the United States, those pending in Australia, and others that are underway in Israel—are transforming the decision maker's role where fast tracking is concerned, redefining responsibilities that involve more systematic verification of data related to disability assessment rather than requiring the more traditional approach to disability determination. In addition, the types of inputs required for determining disability claims in certain countries appear more in line with an automated environment designed to lead to faster processing and greater efficiencies. Evidence from the implementation of predictive modeling in the United States and the recent introduction of a new Health Professional Advice Unit in Australia suggests those new frameworks are providing assessors with an opportunity to clarify/confirm diagnoses that allow decision makers to make disability determination decisions more quickly; where additional information becomes available, such decisions may become better informed.
At the same time, nongovernment involvement is evident in the private-sector medical assessment process, which is contracted out in the United Kingdom. It is also evident with the partnership arrangement that Service Canada is conducting with clinics and hospitals for its Terminal Illness Application pilot, which involves document preparation prior to the application stage for those identified as terminally ill in Canada. While those developments, both technological advancement and nongovernmental involvement, suggest an evolution in fast tracking the disability process, it is not clear from the small five-country sample the extent to which such trends may be significant worldwide.
Integrating Fast-Track Procedures into the Disability Claims Process
Fast-track procedures vary as far as national program-driven details are concerned, but there are at least two trends at work that suggest how those procedures are being integrated into the overall disability claims process.
First, this research finds that there appears to be some convergence in terms of FT-related technology, at least in certain countries. As automation increases, we may see more of a technology-driven dichotomy consisting of claims processes that identify (flag) conditions versus a more probabilistic approach. Pending technological advances in Australia appear to be moving in the direction taken by SSA—in terms of the agency's sophisticated software, including electronic claims processing. SSA initiatives compare closely with what Australia is in the process of implementing under the new disability reform and what Israel appears to be moving toward over the next 10 years.
In the context of fast tracking claims, increased automation could be expected to increase efficiency in several ways. First, it could permit better identification of an alleged or reported medical condition(s) for screening claims when fast tracking, increasing the potential for greater efficiency with the implementation of updated impairment listings on a flow basis. In addition, software innovations, similar to predictive modeling and electronic claims processing, might enable greater flexibility in disability management, as observed in the United States, with the ability to adjust criteria using FT procedures to redirect managed caseloads across the entire disability system.
Second, this research also finds that the placement of FT in the claims process is broad-based both in terms of type of initiative and time horizon. This is most evident in the case of Canada (using relatively less technology), which (like the United States) has implemented reentitlement FT procedures, but is also currently testing a unique FT procedure on a pilot basis to help terminally ill individuals complete their application materials more quickly. The Terminal Illness Application pilot advances the time horizon of the claims process forward and is indicative of Canada's "client centric" approach demonstrated for some time in its early client contact policy. In the United Kingdom, FT processes are also at work with a DLA benefit for the additional expense associated with care and mobility of disabled persons. DLA complements the standard disability benefit that had been available through the Incapacity Benefit, now replaced by ESA (since October 2008).
Processing Sequence Encounteredby Disability Applicants
The countries under study for this research differ in terms of how their disability programs interact with the claimant, passive versus active approaches. At one extreme is Canada—with its Terminal Illness Application pilot, the early client contact policy of walking "clients" through the entire claims process, and the reapplication and reinstatement FT options for claimants with recurring disabilities. The fact that those FT processes in the CPP-D program rely less on technology may not be a coincidence because the close relationship between "customer/client" and government service delivery does not appear to be necessarily consistent with a high-tech, arms-length relationship. SSA is somewhat different, operating a more high-tech approach with its FT processes at the DDS level, but also incorporating a mixture of automation and face-to-face activities in its handling of the majority of claims at the field office level.47 Between those two polar cases are approaches adopted by disability agencies in the United Kingdom, Australia, and Israel, which are harder to categorize. Noteworthy, however, is the up-front availability of the employer-funded and administered SSP benefit and 13 weeks of an assessment-rate benefit in the United Kingdom that would seem to diminish the urgency for fast tracking claims from a humanitarian perspective.
Finally, the outcomes associated with FT processes are clearly successful in achieving more timely decisions for persons who qualify, though it is less clear how those processes affect overall operations. Faster processing times are achieved for the most part, with overall accelerated time horizons ranging from 48 hours (Canada) to about 3 weeks (United States and Israel). As mentioned earlier, the United Kingdom appears to attain lower processing times for FT claims, supplemented by other income support programs. Data on lower processing times are not available for Australia's manifest grants, but reduced times are claimed by agency staff in that country. While increased efficiency and productivity of the disability process because of FT procedures may help free up resources to allow disability agencies to better cope with all claims, the more direct impact on disability applicants who fall outside the scope of FT procedures is uncertain and not addressed in this article.
The information collected from countries participating in this study indicates that FT procedures reflect country-specific goals and standards. Although the small sample size restricts the potential for making global assertions about FT procedures, some insights can be discerned.
The following list contains some of the most important lessons learned from this research:
- FT procedures do not appear widespread among public long-term disability programs throughout the world. For purposes of this study, efforts to identify such processes led to the discovery of only six potential candidate countries, other than the United States, and sufficient information on which to draw comparisons was available in only four countries, other than the United States.
- FT procedures are rather diverse, but share a common goal of helping persons most likely to need (and to be eligible for) assistance. As observed in this article, FT procedures do expedite the determination process for certain disability claimants. Comprising an array of guidelines, protocols, and processes, those procedures aim to shorten the disability determination process for selected claimants, but strive to accomplish that goal in the following four ways:
- Technology-intensive emphasis on computerization and software
- Online application and posting of documents electronically
- Personal contact via telephone and face-to-face meetings
- Manual or automated applicant screenings designed to shorten the duration of case processing
- Among the countries identified as having disability programs using FT procedures, one observes a tendency to focus on claimants with many of the same medical conditions for accelerated processing, to emphasize similar operational guidelines, and to establish the goal of significantly decreasing processing times in those cases. However, some special approaches are worth mentioning. One example is Canada's recent initiative to assist potential beneficiaries (diagnosed as terminally ill) by providing hands-on assistance to guide the claimant in completing a new and much-abbreviated application package. Another example is the supplemental disability benefit allowance provided in the United Kingdom to help beneficiaries deal with the extra costs of living with a disability. A final example is the postentitlement opportunity for individuals who return to work and then become unable to work again to more quickly reclaim their disability benefits in both the United States and Canada, without having to go through a lengthy reapplication process.
- FT procedures generally affect a relatively small proportion of the overall disability applicant pool. According to the data available, the share of cases qualifying as FT typically hover around 5 percent of disability claims in a given year. Differences within this narrow range are generally not great despite the disparity among national disability approaches documented in this study, which may reflect a trade-off between accuracy and processing speed. Specifically, there may be a limit on the number of fast-track claimants that disability systems can handle without sacrificing some degree of precision in determining eligibility. In that context, concurrent income support program strategies in some countries (for example, the United Kingdom's 3-day waiting period followed by an issuance of benefits that can last as long as 13 weeks before determination)—strategies unavailable in the United States—appear to reduce the urgency of FT procedures.
- Most countries included in this sample have recently concluded or are in the process of expanding their use of FT procedures through pilot projects or disability program reforms. For example, SSA continues to use sophisticated software to expedite an increasing share of disability cases, whereas other countries—Australia, Israel, and the United Kingdom—are employing FT procedures more frequently to identify and move cases quickly through the determination process, but with less-intensive technological methods. Canada, in particular, has successfully implemented a variety of FT procedures, which have reduced processing times without relying on high-end technology. Given the small sample of disability systems and fast-track outcomes examined in this article, one cannot predict whether more sophisticated computerized procedures are the wave of the future. While high-tech approaches appear to be gaining traction in some countries, there may be many other countries outside this sample reflecting an opposite trend.
- Countries desiring to explore and use FT processes can learn from other countries about the methods that work and the medical conditions that might be targeted. In fact, cross-country fertilization of FT practices may occur, as documented in this research, when countries take into account the relevant experiences abroad. For example, in the process of conducting this research, FaHCSIA staff in Australia learned about and subsequently incorporated SSA's Compassionate Allowance listing of conditions into their modified Disability Support Pension FT process, which became effective on July 1, 2010.
The evidence collected for the five countries included in this study indicates that FT procedures concern only a relatively small percentage—around 5 percent—of the overall pool of disability applicants. However, it is clear that SSA, as well as the other national disability agencies analyzed here, place great importance on diminishing human suffering by moving quickly to address the claims of persons with terminal illnesses and other conditions deemed to merit special handling. Defining and identifying those disability applications that are most likely to satisfy the criteria for FT handling is also, by necessity, an on-going challenge as new information comes to light regarding medical diagnostics and treatment.
Even the limited number of countries selected for this study demonstrates that national social security systems may develop FT procedures in a variety of ways, with some countries placing considerable importance on setting time frames within which decisions are made and applicants are notified of the outcomes of their claims. Some countries, notably the United States, are investing increasing resources into the development of sophisticated electronic processing procedures designed to single out the most likely applicants for FT handling. Within that group of countries, increased automation appears to raise the potential for efficiency gains in disability case management at the same time that it transforms the role of the decision maker. As the goal remains the same for all national systems, namely, to handle those cases as quickly as possible when it is evident that delay would pose a burden on potential beneficiaries (and their families), it is self-evident that countries have a great deal to learn from each other regarding this aspect of social security policy and practice. Indeed, this research indicates how the spread of these techniques and strategies across national boundaries may occur; the modeling of Australia's FT procedures along the lines of SSA's Compassionate Allowance initiative serves as an example of such cross fertilization.
Finally, this analysis shows how FT processes interact with evolving national disability programs. New or expanded impairment listings and efforts to update older disability claims processing guidelines appear to be the norm in recent years for all countries surveyed in this article. As technology becomes available to improve the identification of serious impairments, on a probabilistic or nonprobabilistic basis, the role of decision makers and medical support personnel will also change in the assessment of disability claims.
Appendix: Questionnaire–Letter Circulated
The US Social Security Administration is looking for ideas to streamline and improve its process for determining whether applicants for disability benefits meet the requirements of our program, and we hope that you will be able to help us.
Our Social Security Disability Insurance (SSDI) program has over 7 million beneficiaries and receives over 2 million applications per year. We have recently implemented a new procedure, the Quick Disability Determination (QDD) process, in an effort to better serve benefit applicants. QDD uses a sophisticated screening tool to identify applicants who are highly likely to meet entitlement requirements. The screening tool rapidly searches the application and other documents for key words and other information that have been demonstrated to indicate a high probability of entitlement. Cases identified for QDD are sent for accelerated processing that may enable us to allow the claim quickly—often within 10 days.
We are also testing a similar procedure, Compassionate Allowances, which is designed to quickly identify diseases and other medical conditions that invariably qualify for benefits based on minimal objective medical evidence. For example, individuals with catastrophic congenital abnormalities such as the most common form of Down syndrome, acute leukemia, amyotrophic lateral sclerosis and pancreatic cancer would likely fall into this category. We believe that many of these claims could be allowed based on confirmation of the diagnosis alone.
The SSDI program is neither a temporary nor permanent disability program. Most disability beneficiaries continue to receive benefits until they reach retirement age or die. However, some return to self-supporting employment and, in other cases, the beneficiary's impairment improves to the extent that he no longer meets the requirements of the program. Beneficiaries who have an impairment that is expected to improve, or an impairment where improvement is possible, are scheduled for periodic continuing disability reviews (CDR), which include a medical examination. If it is determined, following a CDR, that the beneficiary is no longer disabled, benefits are terminated.
We would be appreciative if you could provide us with the following information: Does your disability program include any procedures similar to those described above? If so, could you provide us with a detailed description of the procedure(s)?
Thank you for your cooperation in this matter.
1 In the Unites States, the term "fast track" is used by the Social Security Administration to denote the Quick Disability Determination and Compassionate Allowance procedures. In this article, however, the term fast track is employed in a more general sense.
2 Significant increases in new disability claims for Social Security Disability Insurance and Supplemental Security Income since 2008 can also be attributed to worsening overall economic conditions and rising levels of unemployment. See Szymendera (2011) for a more complete discussion of those and other factors affecting the growth in disability applications.
3 SSA staff also provided suggestions to the author about official contacts in some cases.
4 Because there is no international inventory of national disability agency personnel available, the author consulted the staff listings posted online for member countries of the International Social Security Association in Geneva, Switzerland, http://www.issa.int. The author initially tried to contact international liaison specialists for each country and pursued any recommendations made for staff names or departments of national disability agencies to locate sources familiar with a particular national disability program; this was done with knowledge of whether some type of FT procedure was in operation. On November 3, 2009, the survey questionnaire was e-mailed to subscribers of the Syracuse University–based Global Partnership for Disability and Development (GPDD) listserv; GPDD is a major forum for the dissemination and discussion of global disability issues. The GPDD effort did not result in any new contacts of significance. Additional leads (contact names of staff and departments) arose in the course of this search process. In each case, e-mailing the survey questionnaire served as the initial step in attempting to contact a potential respondent.
5 Negative (no FT procedures presently operating) responses to the survey questionnaire were received from Austria, Finland, Japan, Mexico, Netherlands, Portugal, Sweden, Switzerland, and Taiwan. Attempts to contact staff with disability agencies were unsuccessful in Belgium, the Czech Republic, Egypt, France, Ireland, Italy, New Zealand, and South Africa—resulting in a nonresponse rate for the questionnaire of roughly one third.
6 This figure represents expenditures only for Social Security Disability Insurance, the major long-term disability program; it does not include costs for the Supplemental Security Income program, which is discussed briefly in the next section.
7 Comparable data for the share of fast-tracked claims in Israel are unavailable.
9 Contributions are based on employee earnings (or earnings of a spouse or parents). Dependents may also be eligible for benefits based on an employee's earnings record.
10 As a prerequisite, US applicants must also have worked for a certain period of time, or have a specified amount of covered earnings in a year as measured in quarters of coverage (depending on age) of at least 1 quarter of coverage for each elapsed year from age 22 to the age of disability onset. (A minimum of 6 credited periods up to a maximum of 40 quarters are required for fully-insured status.) In addition, there is a recency of work test in the United States: Applicants must have 20 quarters of coverage in the 40-quarter period ending in the quarter in which they became disabled; or, if aged 32 or younger, one-half of the quarters must have elapsed since the attainment of age 22. Individuals younger than age 24 need 6 quarters of coverage in the 12-quarter period ending in the quarter in which they became disabled.
12 The evaluation process is based on the answers to five questions taken in order: (1) Is the individual working and earning more than the SGA amount? If yes, the person is not disabled no matter how severe his or her medical condition(s). If no, then ask the following question. (2) Does the person have a medical condition that is "severe" enough to interfere with basic work-related activities? If no, the person is not disabled. If yes, then go to the next question. (3) Does the individual have an impairment that meets the criteria for one of the impairments listed in the regulatory Listing of Impairments or one that is just as severe? If so, then the claim is allowed; if not, then proceed to the next question. (4) Can the individual perform the work he or she previously did? If so, the person is not disabled. If the answer is no, then go to the final question. (5) Can the individual do any other type of work? If not, the person is disabled; otherwise, the claim is denied. For more information, see SSA (2009a and 2011b).
13 The Listing of Impairments describes, for each major body system, impairments considered severe enough to prevent an individual from doing any SGA.
14 Fast-track procedures in the United States also apply to SSI children under the Code of Federal Regulations. This shorter sequential evaluation process for children is accessible online, http://www.socialsecurity.gov/OP_Home/cfr20/416/416-0924.htm.
15 Under DI, statutory blindness is a disability category, while under SSI, it is a category separate from disability.
16 A discussion of the historical background preceding SSA's launch of the electronic disability claims process in 2004 is available from the General Accounting Office (GAO 2003).
17 Older paper-based evidence is converted to scanned documents. Once SSA meets all of the requirements set forth by the National Archive and Records Administration for the retention and security of the electronic records, the electronic folder will become the official file and all information needed to document the disability case will be stored and maintained in an electronic format.
18 As mentioned earlier, the term "fast track" at SSA refers specifically to two recent hi-tech procedures. However, this analysis employs for all countries, including the United States, the more common usage of the phrase.
19 In New England, where the QDD process was first tested for the period from August 2006 through October 2006, slightly less than 3 percent of all new disability cases were identified as QDD cases; 97 percent of those cases identified were decided within 21 days, with an average decision time of 11 days.
20 The number of CAL conditions listed was expanded in fiscal year 2012. Thirteen new conditions were added to the CAL list on December 10, 2011, bringing the number of conditions up to 113. Those conditions involve neurological, mental, and immune system disorders.
21 Additional information about CAL conditions and processing applicable cases is available online, http://www.socialsecurity.gov/compassionateallowances/.
22 In March 2010, the Department of Veterans Affairs (VA) proposed its own fast tracking of veterans' claims processing for service-connected presumptive illnesses that were due to Agent Orange exposure during the Vietnam War (VA 2010). The VA hopes to migrate from manually processing those claims to an automated process for adjudicating them, involving military and private medical records and the scheduling of medical examinations. With this new approach, the VA expects to shorten the time it takes to gather evidence, which now averages more than 90 days. Once the claim is fully developed and all pertinent information is gathered, the VA will be able to more quickly decide the claim and process the award, if granted.
23 A contract was awarded to IBM in September 2004 to develop a predictive modeling tool for the QDD process, which became operational on a pilot basis in July 2006 and has been maintained by IBM since that time.
24 This arrangement permits SSA to manage the disability caseload of a particular DDS.
25 SSA regulations effective November 12, 2010, temporarily permit designated disability examiners in all of the DDSs to issue "fully favorable" determinations for most adult claims adjudicated under the QDD and CAL procedures. The authority applies to those cases at the initial level and to CAL cases at the reconsideration level. Regardless of the basis of the determination, medical or psychological advisor sign off is not required for a fully favorable determination. Disability examiners may confer with those consultants, but generally are not required to do so.
26 Although a QDD indicator cannot be manually added to a case, this is possible with CAL. Disability Determination Services, the Office of Quality Performance, and the Office of Disability Adjudication and Review all have the capability to manually add cases to CAL processing.
27 Centrelink is one of six service delivery agencies responsible for delivering services and welfare payments to individuals throughout Australia, as negotiated with policy departments in the Human Services Portfolio.
28 The description in this section draws heavily on personal communication between David Rajnes (the author) and FaHCSIA staff, FaHCSIA's website (http://www.fahcsia.gov.au/Pages/default.aspx), and Clayton and Honeycutt (2005).
29 The Age Pension retirement age for women is currently 64 and 65 for men. Those ages are both scheduled to rise to 67 by 2023.
30 Where multiple medical conditions impact one body system or structure, then a single score is assigned that reflects the combined functional impairment on that body system or structure. Where multiple body systems are affected by one or more condition(s), ratings may be assigned on all relevant tables, and the total impairment rating should reflect the overall level of the applicant's impairment (Clayton and Honeycutt 2005).
31 On July 1, 2011, current contracts for job capacity assessors were terminated and Centrelink became the sole provider.
32 The description in this section draws heavily on personal communication between David Rajnes (the author) and Service Canada officials and from Service Canada website descriptions, http://www.servicecanada.gc.ca.
33 If the applicant has not contributed to the CPP for enough years, certain provisions of the law may help them qualify. For example, the general drop-out provision excludes 15 percent of a person's lowest earnings to help offset periods of low or no earnings, such as those incurred during unemployment, illness, or schooling. In addition, the child rearing provision excludes from the calculation of benefits the periods during which contributors have remained at home, or have reduced their participation in the workforce, to care for children younger than age 7. Under credit splitting or pension sharing, married or common-law spouses may either share their retirement pensions (where the union is intact) or split their pension credits (where the union has ended). If the claimant has not worked recently because of a medical condition(s), the late applicant provision helps contributors who meet all conditions of eligibility, except that their contributions were made too long ago to meet the minimum qualifying period to be eligible for benefits. Applicants must have been continuously unable to work in any job from the date the applicant is deemed to have become disabled to the present and into the future. The incapacity provision may help patients who are unable to apply for benefits on their own because of their medical condition(s)—patients with a loss of cognitive function because of a severe stroke, for example. Personal representatives can use this provision to apply for CPP disability benefits on the patients' behalf at a later date.
34 They decide first whether the client's medical condition(s) meets the severe criterion as outlined in the 1966 Act to Establish a Comprehensive Program of Old Age Pensions and Supplementary Benefits—also known as the CPP Act. If it is determined that the severe criterion is met, then the medical adjudicator will determine if the prolonged criterion is also met. However, if it is determined that the severe criterion is not met, then the medical adjudicator will not review to determine if the prolonged criterion is met.
35 This section is based on CPP-D (2010).
36 The national terminal illness policy (updated March 2010) did not address the complexity of the initial application kit nor the amount of potentially unnecessary information asked of dying claimants (for example, would they be interested in vocational rehabilitation?).
37 By June 2010, applications totaling 309 were received using the new process. Service Canada evaluations indicate that it is taking approximately 1–1½ days for all sections of the TIA (including medical report) to be completed and faxed to the mail processing center. Once the application is received in the processing center, 81 percent of all files are adjudicated in fewer than 10 calendar days, including 61 percent adjudicated in fewer than 5 calendar days.
38 The description in this section draws heavily on personal communication between David Rajnes (the author) and National Insurance Institute staff, as well as the agency website, http://www.btl.gov.il.
39 According to the National Insurance Law, amended on August 1, 2009, this means entitlement to a disability pension for at least 60 out of the 80 months that preceded the amendment (that is, in the period between August 1, 2002, and July 31, 2009).
40 This is a medical disability of at least 75 percent, or a 40 percent impairment for a psychotic disorder or "mental retardation."
41 These special documents have been prepared by the Israel Cancer Association and by the Atlas Association (caring for ALS patients). These documents meet NII requirements.
42 The pension may be granted later on a permanent basis, and assessments are no longer made. Under rules introduced in August 2009, an NII claims officer may reopen the discussion of a disabled person's medical degree only if the medical condition(s) deteriorated before the end of the temporary period. A reduced medical degree may be determined after the end of the temporary period (NII 2010).
43 The description in this section draws heavily on personal communication between David Rajnes (the author) and Department for Work and Pensions staff from the Disability and Carers Division; Thomas (2008); Lewis (2009); Mitra, Corden, and Thornton (2005); European Union of Medicine in Assurance and Social Security (undated and unpublished document, http://www.eumass.com); and United Kingdom government websites, including http://www.Newcastle.gov.uk.
44 The government has proposed to replace the DLA with a new benefit, the personal independence payment, in the 2013–2014 period. The new benefit will continue to be a non-means-tested, extra-costs benefit. According to the government, this new disability benefit would be easier for individuals to understand and would address individual circumstances rather than the health condition itself (DWP 2010).
45 Schlumberger Group Medical Services, a multinational corporation, provides medical services (advice and examination reports) nationwide to the DWP, under contract for more than 200 full-time medical advisers. Because of the high workload, Schlumberger subcontracts services for another 3,000 part-time physicians (chiefly general practitioners) to conduct medical examinations (European Union of Medicine in Assurance and Social Security, undated and unpublished document, http://www.eumass.com).
46 The HCPs who provide those services are experienced in assessing disability, capacity for work and care needs, and mobility for entitlement to the Employment and Support Allowance, Disability Living Allowance, Attendance Allowance, and Industrial Injuries Scheme Benefit.
47 However, less face-to-face contact is anticipated at SSA. Current agency goals call for 34 percent of disability applications to be online claims in 2011, and 38 percent in 2012.
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