Alive or dead: Validity of the Social Security Administration Death Master File after 2011.

OBJECTIVE: To determine the reliability of the Social Security Death Master File (DMF) after the November 2011 changes limiting the inclusion of state records. DATA SOURCES: Secondary data from the DMF, New York State (NYS) and New Jersey (NJ) Vital Statistics (VS), and institutional data warehouse. STUDY DESIGN: Retrospective study. Two cohorts: discharge date before November 1, 2011, (pre-2011) or after (post-2011). Death in-hospital used as gold standard. NYS VS used for out-of-hospital death. Sensitivity, specificity, Cohen's Kappa, and 1-year survival calculated. DATA COLLECTION METHODS: Patients matched to DMF using Social Security Number, or date of birth and Soundex algorithm. Patients matched to NY and NJ VS using probabilistic linking. PRINCIPAL FINDINGS: 97 069 patients January 2007-March 2016: 39 075 pre-2011; 57 994 post-2011. 3777 (3.9 percent) died in-hospital. DMF sensitivity for in-hospital death 88.9 percent (κ = 0.93) pre-2011 vs 14.8 percent (κ = 0.25) post-2011. DMF sensitivity for NY deaths 74.6 percent (κ = 0.71) pre-2011 vs 26.6 percent (κ = 0.33) post-2011. DMF sensitivity for NJ deaths 62.6 percent (κ = 0.64) pre-2011 vs 10.8 percent (κ = 0.15) post-2011. DMF sensitivity for out-of-hospital death 71.4 percent pre-2011 (κ = 0.58) vs 28.9 percent post-2011 (κ = 0.34). Post-2011, 1-year survival using DMF data was overestimated at 95.8 percent, vs 86.1 percent using NYS VS. CONCLUSIONS: The DMF is no longer a reliable source of death data. Researchers using the DMF may underestimate mortality.

Social Security and Disability Due to Mental Impairment in Adults.

The Social Security Administration (SSA) oversees two disability programs, Social Security Disability Insurance (SSDI) and Supplemental Security Income (SSI). Adults with mental impairments represent a very large component of the programs. Policy makers and SSA are concerned about the accuracy of disability determination and also about low levels of labor force participation among individuals with disabilities. Adults with mental impairments are challenging to assess for work-related functional limitations. They are also a challenge to return to labor force participation. SSA has sponsored several demonstration research programs focusing on improving the accuracy of disability determination and on interventions in supported employment to return individuals with mental impairments to competitive employment. This article reviews the demonstration research focused on both entry into the disability system (at the "front door") and potential exit from it (through the "back door"). All of the research holds promise to "right-size" the SSA disability program.

Geographies of medicalized welfare: Spatial analysis of supplemental security income in the U.S., 2000-2010.

In the post-1996 welfare reform period in the U.S., disability assistance has become a significant source of government aid for low-income residents as other forms of public support have faced considerable reductions and restrictions. In order to qualify for Supplemental Security Income (SSI) - a means-tested assistance program that provides income stipends to qualified residents - working-age individuals with disabilities must have little income and resources, and procure medical documentation that confirms that they are unable to work due to a disability. The result of rising SSI enrollment in the face of cutbacks to other government programs is the increasing medicalization of welfare, whereby receipt of welfare benefits is contingent on a medical diagnosis of disability. Using county-level data from the American Community Survey and the Social Security Administration, this paper examines the changing spatial patterns of SSI participation of the working-age population in 2000 and 2010 across the U.S. in addition to the interconnections between disability, welfare, and poverty. Results from spatial analyses illustrate geographic variation in SSI prevalence, with distinctive spatial clusters of higher than average SSI participation in the southeast and Appalachian regions of the U.S. and in northern California. Multiple linear regression model results reveal that SSI participation is significantly correlated with disability, poverty, race, family type, and level of education in both 2000 and 2010. The findings suggest that spatial concentrations of disability, poverty, and underemployment persist in largely rural areas. The discussion explores the potential social and economic implications of long-term SSI clustering on localities and residents, and points to future research directions.

Reforming Access: Trends in Medicaid Enrollment for New Medicare Beneficiaries, 2008-2011.

OBJECTIVE: To evaluate whether aligning the Part D low-income subsidy and Medicaid program enrollment pathways in 2010 increased Medicaid participation among new Medicare beneficiaries. DATA SOURCES: Medicare enrollment records for years 2007-2011. STUDY DESIGN: We used a multinomial logistic model with state fixed effects to examine the annual change in limited and full Medicaid enrollment among new Medicare beneficiaries for 2 years before and after the reforms (2008-2011). DATA EXTRACTION METHODS: We identified new Medicare beneficiaries in the years 2008-2011 and their participation in Medicaid based on Medicare enrollment records. PRINCIPAL FINDINGS: The percentage of beneficiaries enrolling in limited Medicaid at the start of Medicare coverage increased in 2010 by 0.3 percentage points for individuals aging into Medicare and by 1.3 percentage points for those qualifying due to disability (p < .001). There was no significant difference in the size of enrollment increases between states with and without concurrent limited Medicaid eligibility expansions. CONCLUSIONS: Our findings suggest that streamlining financial assistance programs may improve Medicare beneficiaries' access to benefits.

First in line: prioritizing receipt of Social Security disability benefits based on likelihood of death during adjudication.

BACKGROUND: Given the complexity of the adjudication process and volume of applications to Social Security Administration's (SSA) disability programs, many individuals with serious medical conditions die while awaiting an application decision. Limitations of traditional survival methods called for a new empirical approach to identify conditions resulting in rapid mortality. OBJECTIVE: To identify health conditions associated with significantly higher mortality than a key reference group among applicants for SSA disability programs. RESEARCH DESIGN: We identified mortality patterns and generated a survival surface for a reference group using conditions already designated for expedited processing. We identified conditions associated with significantly higher mortality than the reference group and prioritized them by the expected likelihood of death during the adjudication process. SUBJECTS: Administrative records of 29 million Social Security disability applicants, who applied for benefits from 1996 to 2007, were analyzed. MEASURES: We computed survival spells from time of onset of disability to death, and from date of application to death. Survival data were organized by entry cohort. RESULTS: In our sample, we observed that approximately 42,000 applicants died before a decision was made on their disability claims. We identified 24 conditions with survival profiles comparable with the reference group. Applicants with these conditions were not likely to survive adjudication. CONCLUSIONS: Our approach facilitates ongoing revision of the conditions SSA designates for expedited awards and has applicability to other programs where survival profiles are a consideration.

The effects of health care benefits on health care use and health: a randomized trial for disability insurance beneficiaries.

BACKGROUND: Under current law, most Social Security Disability Insurance (SSDI) beneficiaries are not eligible for Medicare until 29 months after the Social Security Administration determines the onset of their disability. During this waiting period, >1 in 5 lacks health insurance. This study investigated the effects of providing health care benefits on the health, employment, and other services of uninsured beneficiaries. METHODS: New SSDI beneficiaries without health insurance were randomly assigned to receive health care benefits, health care benefits plus additional supports, or a control group. RESULTS: Compared with a control group, those provided health care benefits used more health care, had fewer unmet medical needs, spent less out of pocket on health care, and reported improved health. In addition, those provided the additional supports were more likely to look for work, but the supports did not affect work or SSDI benefits at this very early period. CONCLUSIONS: The results provide rigorous evidence that health care benefits can increase health care use and health outcomes. Longer-term follow-up is needed to fully assess the program's effects on its ultimate benefits and costs, including its long-term effects on health, employment, and benefit receipt.

Employment experiences of young Medicaid Buy-In participants with psychiatric disabilities.

OBJECTIVE: The Medicaid Buy-In (Buy-In) program allows people with disabilities to "buy into" Medicaid when their earnings or assets would typically make them ineligible. This program may be advantageous to youth with psychiatric disabilities by providing continuous health care coverage while they are employed. METHODS: State-submitted participant-level Buy-In enrollment data were linked with Social Security Administration data to identify the receipt of federal disability benefits, the primary disability used to determine eligibility, and annual earnings. We assessed the differences in employment outcomes between young participants (ages 18 to 30) with psychiatric disabilities versus young participants with other disabilities, including the likelihood of being employed, average earnings, and changes in earnings around the time of Buy-In enrollment. RESULTS: Young Buy-In participants with psychiatric disabilities were just as likely to be employed as those with other disabling conditions, although their average earnings were slightly lower. Both groups were similarly likely to increase their earnings around the time of Buy-In enrollment, but among participants who had such increases, the amount of the increase was higher for those with psychiatric disabilities. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: Young Buy-In participants with psychiatric disabilities achieve larger average increases in earnings around the time of enrollment in the program than those with other disabling conditions, though average earnings while employed are lower. This suggests that the coverage provided by Buy-In may be particularly beneficial for youth with psychiatric disabilities. Outreach to enroll these youth into the program may benefit this vulnerable group, who often lack other supports in the community.

Administering social security: challenges yesterday and today.

In 2010, the Social Security Administration (SSA) celebrates the 75th anniversary of the passage of the Social Security Act. In those 75 years, SSA has been responsible for programs providing unemployment insurance, child welfare, and supervision of credit unions, among other duties. This article focuses on the administration of the Old-Age, Survivors, and Disability Insurance program, although it also covers some of the other major programs SSA has been tasked with administering over the years-in particular, Medicare, Black Lung benefits, and Supplemental Security Income. The article depicts some of the challenges that have accompanied administering these programs and the steps that SSA has taken to meet those challenges. Whether implementing complex legislation in short timeframes or coping with natural disasters, SSA has found innovative ways to overcome problems and has evolved to meet society's changing needs.

The prospective role of personal health records in streamlining and accelerating the disability determination process.

BACKGROUND: The disability community could benefit significantly from the widespread adoption of health information technology, in particular from its ability to streamline and accelerate processing of the estimated 3 million disability benefits applications filed with the Social Security Administration each year. Disability determination is an inefficient, largely paper-based process requiring large volumes of clinical data compiled from multiple provider sources. That, coupled with a lack of transparency within the process, adds unnecessary delays and expense. OBJECTIVE: The objective of this paper is to outline the case for how personal health records, particularly those populated with information from provider-held electronic health records and payer claims data, offer a means to achieve financial savings from shortened disability determination processes, as well as a tool for disability health self-management and care coordination. METHODS: Drawing from research and policy forums and testimony before the American Health Information Community, the importance of including the disability community as the nation moves forward with health information technology initiatives is explored. RESULTS: Our research suggests that systemwide improvements such as the Nationwide Health Information Network and other such health information technology initiatives could be used to bring benefits to the disability community. CONCLUSIONS: The time has come to use health information technology initiatives so that federal policy makers can takes steps to reduce the inefficiencies in the Social Security Administration disability determination process while improving the program's value to those who need it the most.

Complying with federal guidelines: Medicare Prescription Drug, Improvement, and Modernization Act of 2003: amendments to Social Security Act.

The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 is the most comprehensive health legislation since the initiation of Medicare. It has many other ramifications in addition to establishing a prescription drug payment. This review outlines the prescription drug benefit and attempts to extract the topics important to practicing physicians from the other eleven titles. We will be seeing the effects of this act for years to come.

The Social Security Administration's Disability Service Improvement process.

Reprinted here in its entirety is Commissioner Jo Anne B. Barnhart's statement of June 15, 2006, to the Subcommittee on Social Security of the House Committee on Ways and Means. In her statement, Commissioner Barnhart outlines the improved disability determination process and how the changes to the process were decided. The key elements are collectively referred to as the Disability Service Improvement (DSI) and represent the most significant changes in the Social Security Administration's 50-year history of determining disability for workers seeking Social Security Disability Insurance benefits. Commissioner Barnhart's statement underscores that while the need for change in the disability determination process was clear, both she and SSA staff listened carefully to all points of view in the decisionmaking process. The end product of this outreach effort and deliberative process is the final rule that was published on March 31, 2006. The new procedures outlined in the final rule will take advantage of the new electronic disability claims system, or eDib, and will shorten times to make disability decisions and will allow benefits to be paid sooner to people who are clearly disabled. Key elements include a new Medical and Vocational Expert System to improve the quality and availability of such expertise at all levels of adjudication, review of state agency determinations by a Federal Reviewing Official to ensure more accurate and consistent decisionmaking earlier in the process, and a newly created Decision Review Board to identify and correct decisional errors and to identify quality issues at all levels. Two improvements underlying the new process at all levels include better documentation of the record and more effective quality feedback loops for continuous improvement. Read Commissioner Barnhart's statement for a further explanation of DSI, how the changes were decided, and her plans for implementation.

Workers' compensation, Social Security Disability Insurance, and the offset: a fact sheet.

This article offers a brief summary of the workers' compensation and Social Security Disability Insurance programs. Information highlighted includes the differences between the two programs' types and terms of coverage. It compares the differing patterns in workers' compensation and Social Security disability benefits as a percentage of wages over the past few decades and considers the potential causes for such trends. The article also explains the offset provision included in the 1965 Social Security Amendments, the intention behind the offset, and how and when offsets are applied.

The net effects of the Project NetWork return-to-work case management experiment on participant earnings, benefit receipt, and other outcomes.

The Social Security Administration (SSA) initiated Project NetWork in 1991 to test case management as a means of promoting employment among persons with disabilities. The demonstration, which targeted Social Security Disability Insurance (DI) beneficiaries and Supplemental Security Income (SSI) applicants and recipients, offered intensive outreach, work-incentive waivers, and case management/referral services. Participation in Project NetWork was voluntary. Volunteers were randomly assigned to the "treatment" group or the "control" group. Those assigned to the treatment group met individually with a case or referral manager who arranged for rehabilitation and employment services, helped clients develop an individual employment plan, and provided direct employment counseling services. Volunteers assigned to the control group could not receive services from Project NetWork but remained eligible for any employment assistance already available in their communities. For both treatment and control groups, the demonstration waived specific DI and SSI program rules considered to be work disincentives. The experimental impact study thus measures the incremental effects of case and referral management services. The eight demonstration sites were successful in implementing the experimental design roughly as planned. Project NetWork staff were able to recruit large numbers of participants and to provide rehabilitation and employment services on a substantial scale. Most of the sites easily reached their enrollment targets and were able to attract volunteers with demographic characteristics similar to those of the entire SSI and DI caseload and a broad range of moderate and severe disabilities. However, by many measures, volunteers were generally more "work-ready" than project eligible in the demonstration areas who did not volunteer to receive NetWork services. Project NetWork case management increased average annual earnings by $220 per year over the first 2 years following random assignment. This statistically significant impact, an approximate 11-percent increase in earnings, is based on administrative data on earnings. For about 70 percent of sample members, a third year of followup data was available. For this limited sample, the estimated effect of Project NetWork on annual earnings declined to roughly zero in the third followup year. The findings suggest that the increase in earnings may have been short-lived and may have disappeared by the time Project NetWork services ended. Project NetWork did not reduce reliance on SSI or DI benefits by statistically significant amounts over the 30-42 month followup period. The services provided by Project NetWork thus did not reduce overall SSI and DI caseloads or benefits by substantial amounts, especially given that only about 5 percent of the eligible caseload volunteered to participate in Project NetWork. Project NetWork produced modest net benefits to persons with disabilities and net costs to taxpayers. Persons with disabilities gained mainly because the increases in their earnings easily outweighed the small (if any) reduction in average SSI and DI benefits. For SSA and the federal government as a whole, the costs of Project NetWork were not sufficiently offset by increases in tax receipts resulting from increased earnings or reductions in average SSI and DI benefits. The modest net benefits of Project NetWork to persons with disabilities are encouraging. How such benefits of an experimental intervention should be weighed against costs of taxpayers depends on value judgments of policymakers. Because different case management projects involve different kinds of services, these results cannot be directly generalized to other case management interventions. They are nevertheless instructive for planning new initiatives. Combining case and referral management services with various other interventions, such as longer term financial support for work or altered provider incentives, could produc

Attrition in the new beneficiary survey and followup, and its correlates.

Panel surveys interview the same individuals more than once over a period of time. Attrition from the survey occurs when those individuals die, refuse to be interviewed again, or, for some other reason, cannot be contacted. If the original sample was representative of a specific population, then survey analysis may provide misleading conclusions about changes in population characteristics over time if these individuals leave the sample in a nonrandom way. Therefore, it is important to identify the characteristics of individuals who leave the survey for various reasons. This article explores the extent of and reasons for attrition in the New Beneficiary Survey (NBS) between the first interview in 1982 and the followup interview in 1991. Presented is a comparison of the characteristics of survivors (the reinterviewed sample) with attriters (those in the sample not reinterviewed) from the retired-worker and disabled-worker samples. The article explores a variety of potential determinants of attrition to the probability of attrition. These determinants are examined alone and in a multivariate framework. The NBS sample population is drawn from and linked to Social Security Administrative records, which have exact matched data on mortality as a cause of attrition. These data do not depend on survey-reported reasons for attrition; hence, it allows the examination of the differences in the patterns and predictors of attrition due to death and due to other reasons, primarily, the refusal to be interviewed. Attrition due to death must be identified precisely because misidentification of death as refusal to be interviewed may lead researchers to infer more selective attrition than might be the case. Different patterns of attrition are evident in the comparison of attrition levels and the determinants of attrition for the retired and disabled samples, both composed of persons with relatively high mortality risk. In particular, individuals' health, health insurance coverage, and level of education have different impacts on their likelihood of attrition. In general, it appears that refusal to be interviewed is more evenly spread across populations and characteristics than is death. The analysis shows that attrition due to death and attrition due to refusal are quite different processes, even though health conditions play a role in both processes. The results suggest that because attrition patterns (including death) may be quite different across population samples, sample-specific attrition patterns must be analyzed over the lifetime of any panel study. Long-term studies of panel attrition are necessary to provide researchers analyzing the data with information on potential biases due to nonrandom attrition.