About 2.5 million people apply to the Social Security Administration (SSA) each year for disability benefits. About 22 percent of all applicants appeal their cases to ALJs; about two-thirds of all claimants whose claims are denied at the DDS reconsideration level appeal to an ALJ. Differences in Decision Results Are Long-standing

The differences between DDS and ALJ results are a long-standing problem contributing to the growth in OHA backlogs and increased case-processing time, according to our 1996 report on SSA’s efforts to reduce backlogs in appealed decisions. To respond to the first objective, we divided the possible contributing factors into three types: (1) factors related to differences in RFC assessments made by DDSs and ALJs, (2) procedural factors that contribute to differences in decisions, and (3) use of quality reviews to manage the process. These data indicate that ALJs are significantly more likely than DDS medical consultants to find that applicants have very limited work capacity. This study found that DDS and ALJ adjudicators reached different results even when presented with the same evidence. Such an opinion might include, for example, a statement that a claimant “cannot stand or walk for more than two hours total in a day.” In the disability determination, adjudicators must give controlling weight to these treating source opinions provided they are (1) well supported by medically acceptable clinical and laboratory diagnostic techniques and (2) consistent with the other substantial evidence in the record. As a result, ALJs often cannot rely on the evaluations as developed by the DDSs. Although claimants have the right to representation, SSA relies on the ALJ to fully document the case, considering the claimant’s as well as the government’s best interests. SSA’s Planned Improvements in Procedures

SSA plans to take several actions so that DDS and ALJ procedures better ensure decision-making consistency, including requiring more detailed DDS rationales, returning selected appealed cases to the DDS for consideration of new evidence introduced at ALJ hearings, and using a “predecision interview” by a disability examiner. Quality Reviews Do Not Focus on Inconsistency Between DDS and ALJ Decisions

SSA could use its ongoing quality reviews to better focus on differences in DDSs’ and ALJs’ assessments of functional capacity and of procedures to improve its management of the decision-making process and reduce inconsistent decisions between DDSs and ALJs. Such a focus would be necessary for both identifying and reconciling differences in decisions. As envisioned, disability examiners and physician consultants as well as reviewing judges will review ALJ awards. The agency has not explicitly established this as a goal, however. SSA has developed process unification initiatives that, if implemented, could significantly improve the consistency of decisions. Competing workloads at all levels of adjudication, however, could jeopardize progress in this important area. SSA has not established explicit outcome-oriented goals or measures, however, to assess its progress in achieving consistent decisions. In addition, we recommend that, given the magnitude and seriousness of the problem, the Commissioner should, under the Results Act, articulate the process unification results that the agency hopes to achieve and establish a performance goal by which it could measure and report its progress in shifting the proportion of cases awarded from the ALJ to the DDS level.
Why GAO Did This Study

Pursuant to a congressional request, GAO reviewed the Social Security Administration's (SSA) decisionmaking process for disability determinations and efforts to improve the process, focusing on: (1) factors that contribute to differences between disability determination services' (DDS) and administrative law judges' (ALJ) decisions; and (2) SSA's actions to make decisions in initial and appealed cases more consistent.

What GAO Found

GAO noted that: (1) ALJs made nearly 30 percent of all awards in 1996; (2) because two-thirds of all cases appealed to ALJs have resulted in awards, questions have arisen about the fairness, integrity, and cost of SSA disability programs; (3) differences in assessing applicants' functional capacity and procedural factors, as well as weaknesses in quality assurance, contribute to inconsistent decisions; (4) ALJs are far more likely than DDSs to find claimants unable to work on the basis of their functional capacity; (5) this outcome has occurred even when ALJ and DDS adjudicators review the same evidence for the same case; (6) most notably, DDS adjudicators tend to rely on medical evidence such as the results of laboratory test; ALJs tend to rely more on symptoms such as pain and fatigue; (7) DDS and ALJ decisionmaking practices and procedures also contribute to inconsistent results because they limit the usefulness of DDS evaluations as bases for ALJ decisions; (8) in addition, SSA procedures often lead to substantial differences between the evidentiary records examined by DDS and ALJs; (9) specifically, ALJs may examine new evidence submitted by a claimant and hear a claimant testify; (10) as a result, even with a well-explained DDS decision, ALJs could reach a different decision because the evidence in the case differs from that reviewed by the DDS; (11) SSA has not used its quality review systems to identify and reconcile differences in approach and procedures used by DDSs and ALJs; (12) the quality review systems for the initial level and appeals levels of the decisionmaking process merely reflect the differences between the levels; they do not help produce more consistent decisions; (13) although SSA has not managed the decisionmaking process well in the past, its current process unification initiatives, when fully implemented, could significantly help to produce more consistent decisions; (14) competing workload pressures at all adjudication levels could, however, jeopardize SSA's efforts; (15) as a result, SSA, in consultation with the Congress, will need to sort through its many priorities and be more accountable for meeting its deadlines and establishing explicit measures to assess its progress in reducing inconsistency; and (16) this may include, for example, setting a goal, under the Government Performance and Results Act, to foster consistency in results, set quantitative measures, and report on its progress in shifting the proportion of cases awarded from the ALJ to the DDS level.