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Section 6 Recommendations (and Benchmarking)

By Jeffrey Shaw,2014-05-07 15:49
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Section 6 Recommendations (and Benchmarking)

Section 6 Recommendations (and Benchmarking)

The findings (“best practices”) from this Study in conjunction with practices of the

    specialty of Occupational Medicine, and certain procedures of other Federal Agencies

    who purchase CE-type examinations, collectively suggest that several improvements to

    the CE process are feasible. However, attempts at standardizing - or “benchmarking” -

    CE’s will have to be compatible with SSA and State resources, (i.e., dependent on CE

    budgetary, personnel, and management constraints).

Medical Consultants should review all CE requests

    The decision to purchase a CE should involve the DDS Medical Consultant (MC). Such

    involvement should include a documented process whereby the MC considers whether

    any specific issues or questions should be posed to the CE provider. (For example, how many severe asthmatic episodes or seizure episodes occurred within the past year; or

    what specific daily activities aggravate or ease back pain and how much; or are

    medications taken as directed and are there any side effects? These types of questions

    were rarely posed, or addressed in the CE’s reviewed). All relevant MER should be

    forwarded to the CE provider, and to avoid wasteful activity - irrelevant MER not

    forwarded. Here, again, the MC can be helpful in “sorting” the MER. (Of note, DI

    22510.26B1a and b, e.g. for neurological allegations, requires that MER be forwarded.)

    SSA should require that the items of MER reviewed by the CE provider be listed in the

    CE Report. Any time devoted to review of MER should be included in the time duration

    SSA expects the CE provider to devote to the claimant, and it should be considered in

    setting the CE provider’s fee. For childhood claims, e.g., relevant MER could include

    Teacher Questionnaires, as well as the SSA 3820.

The CE provider should clarify ADL’s with the claimant

    Input obtained by SSA related to the claimant’s ADL’s should be a regular component of

    the CE provider’s packet. Such information lessens the time the CE provider has to

    devote to this issue, and more importantly, also informs the CE provider about the

    claimant’s alleged functional limitations. However, whether or not the CE provider

    obtains previously collected ADL data from the DDS, the CE provider should discuss

    ADL issues directly with the claimant, especially since ADL data collected by SSA might

    be 30 to 60 days old.. The review of ADL’s with the claimant should be described in the

    CE Report. The CE provider should also routinely clarify whether the claimant’s

    diagnosis and severity level are consistent with his/her allegations.

Greater use of specialist CE providers, including generalists who can become

    “specialists” for CE purposes The data collected in this Study strongly suggest that claimants with musculoskeletal

    complaints are often referred to CE providers who do not have specific expertise with the

    types of impairments that the claimants allege. This issue can be addressed in one of two

    ways. A concerted effort could be made to recruit more orthopedic surgeons, physiatrists,

    occupational medicine specialists, etc. for CE panels. It is not clear if this would require

    fee adjustments, given California’s experience. However, even in California., some

    claimants with these allegations are referred to generalists. This implies there is a

recruitment obstacle for specialists here, too. This approach might also require more CE’s,

    since many claimants have additional impairments also requiring a CE. The Department

    of Labor’s Office of Workers Compensation Programs (OWCP) appears to take this

    approach.

On the other hand, the Veterans Administration’s approach might be more practical. Here,

    the Agency simply stipulates through the use of Templates (as some DDS’s also

    apparently do occasionally) the minimum data inputs (clinical findings) it expects from

    the CE provider concerning a particular impairment. Generalist providers, as licensed,

    often residency-trained physicians, should be capable of obtaining specifically requested

    data, especially if SSA adopts an intensive approach to training providers regarding the

    specific types of observations it is seeking, and attempts to refer similar types of

    impairments to the same providers.

Treating Sources as CE Providers

    A significant difference between the standard IME and the CE is that SSA allows

    claimants in many, but not all instances to have a CE performed by their treating

    physician (TS). Based on the E-Files reviewed by COMS, TS’s appear very reluctant to

    perform this service for their patient/claimants, or even to simply provide an MSS.

    Furthermore, this reluctance appears to hold true as much for claimants with qualifying

    impairments as it does for less severely afflicted ones. The basis for this behavior was not

    evident in the E-Files and probably should be explored by SSA. One possible

    contributing factor is the format DDS’s use to request a CE from a TS. More direct

    (phone, E-Mail) contacts with TS’s, especially by MC’s, and especially if the MC personally is acquainted with the TS, might improve the frequency of TS CE’s. However,

    many treating sources, especially if they are not confident that their patient/claimants will

    receive a favorable decision from SSA, will simply be reluctant to be placed in an

    adversarial relationship with their patients. SSA should further explore the reasons why

    TS’s are reluctant to perform CE’s for their patient/claimants.

    Standardized Templates It should be noted that several States (DDS’s) have made some efforts to standardize CE

    findings for some body systems. These include chest pain and neurological

    questionnaires, and ROM, hand function, and back-related Charts. Other States have a set

    of “boilerplate” physical finding requests, i.e., “one size fits all,” whenever the

    musculoskeletal or neurological body systems are implicated. But none of these

    approaches are consistent throughout SSA, and they also do not reach the level of disease

    specificity expressed in VA clinical worksheets, especially regarding Medical History

    items. Instituting such worksheets in SSA, however, will likely improve CE quality only

    modestly, unless CE providers are “oriented” to acquire the data sought, e.g., a detailed

    pain history or confirmed straight leg raising test or completely examined knee or

    shoulder (for stability, anatomically specific tender sites, and specific muscle group and

    dermatomal findings, etc.). It should also be noted that for mental health-related

    impairments, a Template approach alone might not adequately capture (i.e., be too

    superficial) all relevant and valid clinical findings.

Greenbook Guidelines

    If a claimant alleging a chronic respiratory impairment, e.g., COPD, is referred to a

    pulmonologist for a CE, or to an internist for a “Respiratory” CE per Greenbook, SSA

    expects that, in addition to addressing the requirements for an Internal Medicine CE, the

    CE provider should ask the claimant about cough, dyspnea, etc., and note any use of

    accessory muscles of respiration, the presence or absence of adventitious breath sounds, etc. However, under the same guidelines, if the same claimant is referred to an internist

    for an “Internal Medicine” CE because s/he also suffers from potentially disabling

    rheumatoid arthritis, the requirements per Greenbook are expressed only in “general

    terms,” such as “factors” which increase the “problem or impairment” and pertinent physical “aspects of the examination dealing with ... the complaints,” though in

    “particular detail” to be sure. Similar comparisons can be drawn between rheumatology

    CE’s and IM CE’s or even orthopedic CE’s and IM CE’s regarding osteoarthritis for example. Even without adopting the VA’s approach using disease-specific Templates, the Greenbook should be modified so that specific allegations are addressed similarly

    regarding the HPI and physical examination irrespective of the examining CE provider’s specialty. COMS is aware that SSA occasionally orders orthopedic CE’s, e.g., from

    generalists. However, this did not appear to be a common approach in the CE’s reviewed

    as part of this Study. Differences in requirements between POMS directives and the

    Greenbook for CE Report contents should also be reconciled.

Deficient CE Reports

    SSA should standardize criteria for review and approval/rejection of CE Reports prior to their use in claim adjudication. This step is needed so that deficiencies can be “corrected” while the findings are still “fresh” in the CE provider’s mind or – in very rare circumstances the claimant can be recalled, if necessary, and also so that the

    additional/corrected information can contribute to a correct claim decision. Despite DI

    22510.020 B.2. ([CE] Report Inadequate), correction of deficiencies other than obtaining signatures was rare in the CE Reports reviewed by COMS.

Standardized review of CE Reports for quality

    DDS policies regarding review of CE Reports for quality per se vary, although essentially the quality of each CE Report is obviously noted by the actual user of the Report. All CE

    Reports should receive a Quality Rating, and Ratings (and the types of deficiencies noted)

    should be tracked. However, given the IT resources available to SSA, and the availability

    of CE Reports in electronic format, it would be prudent to utilize IT-based procedures to

    evaluate and expedite CE Report processing, as well as to develop Program oversight

    tools for senior management.

One approach might be to follow the VA’s lead and develop quality indicators linked to

    specific items/responses in disease specific, impairment specific, or body system specific

    Templates. A “quality score” would be assigned to a CE Report based on the presence or absence of the quality indicators, with cumulative scores maintained for each provider.

    Some quality indicators would be generic (e.g., providing all vital signs), while others

    would depend on the specific diagnosis/impairment at issue (e.g., a longitudinal history of symptomatic episodes of a recurring disorder (e.g., asthma, epilepsy) or verifying a

“positive” Straight Leg Raising test by various additional maneuvers). (See Appendix K

    for examples of potential quality indicators for two types of allegations: Obstructive Lung

    Disease and Diabetes Mellitus). A review tool could also be developed that linked

    authorization for payment to a satisfactory CE Report score. Finally, in the era of pay-for-

    performance healthcare reimbursements, payment amounts might even be linked to

    cumulative “quality scores.” A need for “remedial” training – or other appropriate

    administrative action - could also thereby be identified.

MC review of all requested ancillary studies

    Another component of management of the CE process that should be standardized is the

    ordering of ancillary studies, particularly X-Rays. Based on MER, a DDS could

    reasonably conclude that a particular ancillary study is indicated. However, whenever a

    clinical CE is indicated to assess properly a claimant’s allegation(s), the need for

    ancillary studies should be confirmed based on the findings obtained from the medical

    history and physical examination, as occurs in non-emergent medical practice in the

    community. Even if studies appear indicated based on MER alone, it would usually be

    prudent to defer ordering them until the claimant has been evaluated by the CE provider,

    assuming of course that the CE provider is assessing the same clinical issue for which the

    ancillary study is indicated. Appropriate views to obtain in an X-Ray study, e.g., could

    easily change as a result of the clinical CE findings. Furthermore, DDS MC’s should be

    involved in all decisions to purchase ancillary studies so that performance of unnecessary

    studies is minimized. However, if ancillary studies are deferred to a greater extent than

    currently i.e., until after the clinical evaluation, a procedure (communication with the CE

    provider) is needed to maximize the likelihood that indicated studies, and only indicated

    studies, are performed.

Improve the timeliness of CE requests and durations of CE Exams

    It is not clear from the E-Files reviewed or the DDS questionnaires how much of the

    delays across the country in obtaining CE’s are due to internal DDS issues as opposed to

    CE provider availability. Given that E-Files record the dates at which the various steps in

    the CE procurement process are completed, it might be reasonable for Regional Offices

    to monitor the timeliness of CE procurements and offer assistance as appropriate when

    indicated. Regional Office medical consultant staffs represent a broad spectrum of

    medical specialties, and such consultants might be able to help DDS’s recruit hard to

    obtain CE specialists.

COMS reviewed SSA CE policy guidelines provided in DI 22510 Development of

    Consultative Examination and DI 39545 Purchased Medical Services. These Sections

    provide guidance to the DDS’s and FO’s on the overall administration and execution of

    the CE process. However, when COMS analyzed these policy areas for guidance on the

    duration of CE’s (DI 22510.015A3 and DI 39545), we identified multiple areas

    discussing “scheduling intervals.” Clarification is needed in DI 39545.020 which notes

    “the purpose of … minimum scheduling timeframes is to ensure that CEs are complete

    and sufficient time is made available to obtain the information needed to make an

    accurate determination.” In this Section, timeframes are provided for various types of

    exams (i.e. general medical, psychological, etc.), however, it is unclear if these

    timeframes are intended as scheduling intervals between CE’s or the actual time the provider is expected to devote to the claimant.

    .

    The expected exam intervals defined in current policy are fairly short, e.g., “comprehensive” musculoskeletal or neurological exams can be scheduled at 20 minute

    intervals. But if a provider schedules “comprehensive general medical examinations” every 90 minutes, but only “sees” the claimant for 20 minutes, the guidelines are satisfied. To be sure, there is an admonition in DI 39545.250A that the guidelines are not meant to limit the “actual duration” of the CE. Thus, a provider is perfectly free to take 45 minutes to perform each examination and simply let claimants scheduled at shorter intervals, but later in the day progressively “wait” longer times for their CE’s (unless there are “no-

    shows”).

    The POMS directives regarding the expected durations of various types of CE’s should be changed to clearly emphasize expected (actual) CE durations in addition to guidelines for scheduling intervals. In this regard, the wider use of body system Templates will help to standardize further exam times (including the “interview” phases), and also to forego collecting unnecessary data. A rational “no-show” policy, however, should also be

    instituted.

Prognostic estimates

    All stakeholders understand that a prognosis is only an estimate or prediction, subject to unexpected change. CE providers, as physicians who have voluntarily agreed to examine claimants for SSA, should possess sufficient expertise in the types of impairments they are willing to address to be able to - and be expected to - offer a prognosis, when appropriate. When not possible or appropriate, the basis for not providing a prognosis should be clearly stated in the CE Report.

Inclusion of Medical Source Statements (MSS’s)

    DDS’s should ensure that Medical Sources Statements are included in CE Reports and that these Statements are completed in accordance to current policy guidance. When formulating an MSS, it is reasonable to request that all elements of the standard MSS be addressed, noting, when appropriate, those that are not applicable or relevant. CE providers should also address items outside the standard MSS, but relevant to an RFC, if they possess the expertise for doing so. An example of the latter would be a pulmonologist CE provider who should describe appropriate environmental and work exposure restrictions for a claimant with asthma.

    An inadequate or inappropriate MSS, however, poses a dilemma for SSA. In 1997, the GAO reported that the seminal explanation for the relatively high rate of claim allowances at the ALJ level was that ALJ’s frequently estimated claimant functional capacities as being more restricted than did initial adjudicators. This conclusion allowed for any interim progressions in impairment severity levels (50). In a follow-up Report in 2004, GAO continued to hold that SSA had not adequately addressed this situation (51). Thus, for a disability claim at Step 4 or 5 of the sequential process, an accurate and well

documented RFC “as is possible” is an indispensable requirement for a correct and

    supportable claim decision not only initially, but also, if necessary, on appeal.

The initial RFC is formulated at the DDS based on the totality of evidence in the

    claimant’s file. The findings from a CE, however, including any judgments in the form of an MSS should if reasonable materially influence the RFC subsequently developed.

    On the other hand, an inappropriate MSS, given that it has been produced by a clinician who has actually examined the claimant, creates a dilemma for the DDS. An RFC

    incompatible with the MSS will now have to be produced by a DDS MC who, though

    s/he might possess more expertise in the type of impairment at issue, will not have

    directly evaluated the claimant. Any functional capacity estimate produced at the ALJ level, by contrast, will also have been based in part on a face-to-face claimant interview. Thus, MSS’s formulated by CE providers who have discussed symptoms and ADL’s with

    the claimant directly, have personally physically examined the claimant, and who also have significant experience and expertise in the impairment posed by the claimant would seem to add value to the CE process and thereby provide an important service to the DDS and SSA.

Enhancement of CE provider recruiting

    The recruitment of appropriate CE providers poses one of the greatest barriers to CE quality. Current efforts at recruitment are obviously not satisfying SSA’s needs. A more structured approach to the CE process along the lines of the VA’s approach - might

    help to alleviate this problem somewhat. However, more effective provider recruitment is also needed. SSA should consider involving its current medical consultant staff (at all levels) in recruitment efforts (specialist to same specialist). Every effort should be made to maximize the participation of Board Certified providers, specialist or generalist, in the CE process. Also, Medical Consultants can be helpful with respect to contacting treating sources to request their participation in the CE process (to perform CE’s or just provide MSS’s).

Training for CE providers

    There needs to be more intensive training of CE providers, and this training should recur as necessary to keep providers informed of Disability Program changes. But because CE providers are independent vendors, and not government employees, such training has to be mindful of the sensitivities in this relationship. Some approaches to consider are case banks, video demonstration materials, and in some instances, one-on-one encounters

    utilizing established experts as trainers. SSA’s Office of Training should partner with the Regions and States to develop a more formal CE provider training methodology as well as a defined schedule for regular follow-up training. The emphasis must be on obtaining the specific types of observations SSA requires, especially regarding supportable MSS’s. Some degree of training should be mandatory. If CE provider performance is substandard, the amount of mandatory training should be increased.

    Conduct an outreach panel to explore “best practices” in CE-type examination procedures and identify workable improvements to the CE process SSA should consider convening a Conference with invitations given at a minimum - to the Compensation and Pension Service of the VA, OWCP (in DOL), a sample of DDS’s,

    the AMA (Disability Guides experts), several private insurers who underwrite disability

    policies, and clinician scholars with expertise in the clinical assessment of disability

    applicants and beneficiaries. The aim of such a Conference would be to identify “best

    practices” regarding the performance of CE-type medical examinations (including those

    involving mental health), and determine which ones would be appropriate for adoption by

    SSA. SSA might want to extend this outreach to claimants and advocates to obtain their

    perspectives on improvements to the CE process. At a minimum, SSA should request a

    briefing from the VA on the details of its Compensation and Pension Exam Program.

    Conduct a review of claims at the ODAR level for CE quality Finally, the inability of COMS to review ODAR claims represents a shortfall in achieving

    the goals of this Solicitation. COMS was thus unable to assess the quality of CE’s

    purchased by ALJ’s, and also the influence of any CE’s purchased earlier in the

    adjudicative process on subsequent ALJ decisions. Such research is recommended. Given

    the rates at which ALJ’s order CE’s, it would be appropriate to assess whether

    improvements in the quality of CE’s performed during initial adjudications might lessen

    these rates. It would also be reasonable to assess how CE’s, ordered both initially and at

    the ODAR level, influence the setting of RFC’s by ALJ’s.

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