This is the accessible text file for GAO report number GAO-12-420 
entitled 'Modernizing SSA Disability Programs: Progress Made, but Key 
Efforts Warrant More Management Focus' which was released on July 19, 
2012. 

This text file was formatted by the U.S. Government Accountability 
Office (GAO) to be accessible to users with visual impairments, as 
part of a longer term project to improve GAO products' accessibility. 
Every attempt has been made to maintain the structural and data 
integrity of the original printed product. Accessibility features, 
such as text descriptions of tables, consecutively numbered footnotes 
placed at the end of the file, and the text of agency comment letters, 
are provided but may not exactly duplicate the presentation or format 
of the printed version. The portable document format (PDF) file is an 
exact electronic replica of the printed version. We welcome your 
feedback. Please E-mail your comments regarding the contents or 
accessibility features of this document to Webmaster@gao.gov. 

This is a work of the U.S. government and is not subject to copyright 
protection in the United States. It may be reproduced and distributed 
in its entirety without further permission from GAO. Because this work 
may contain copyrighted images or other material, permission from the 
copyright holder may be necessary if you wish to reproduce this 
material separately. 

United States Government Accountability Office: 
GAO: 

Report to the Chairman, Subcommittee on Social Security, Committee on 
Ways and Means, House of Representatives: 

June 2012: 

Modernizing SSA Disability Programs: 

Progress Made, but Key Efforts Warrant More Management Focus: 

GAO-12-420: 

GAO Highlights: 

Highlights of GAO-12-420, a report to the Chairman, Subcommittee on 
Social Security, Committee on Ways and Means, House of Representatives. 

Why GAO Did This Study: 

SSA administers two of the largest federal disability programs. GAO 
designated federal disability programs as a high-risk area, in part 
because eligibility criteria had not been updated to reflect medical 
and technological advances and labor market changes. Given the size 
and cost of its disability programs, SSA needs updated criteria to 
appropriately determine who qualifies for benefits. GAO has been asked 
to assess SSA’s efforts to update its medical criteria and develop a 
new occupational information system, and to identify other steps taken 
to modernize disability determination criteria. To do this, GAO 
reviewed relevant publications and federal laws and regulations; 
assessed agency plans, cost estimates, schedules, and other 
documentation against established project management criteria; and 
interviewed SSA officials, experts, and stakeholders. 

What GAO Found: 

The Social Security Administration (SSA) has taken steps that hold 
promise for improving the process for updating its medical criteria, 
but continues to face challenges ensuring timely updates. SSA now uses 
a two-tiered system for ongoing revisions to its medical listings. 
First, it completes a comprehensive review of all medical conditions 
listed within each of 14 body systems, making needed revisions. For 
subsequent updates for a body system, the agency uses a targeted 
approach, selecting for review and revision only those medical 
conditions most in need of change. To date, SSA has completed 
comprehensive revisions for 8 of the 14 body systems and now is 
reviewing conditions under them to determine where targeted revisions 
are appropriate. However, some of these targeted revisions have 
experienced delays. Moreover, SSA has yet to complete comprehensive 
revisions for six body systems that have been ongoing for 19 to 33 
years. SSA officials attributed delays to a lack of staff and 
expertise, along with the complexity and unpredictability of the 
regulatory process. 

SSA has embarked on an ambitious plan to design by 2016 an 
occupational information system for use in its disability decision-
making process, but has fallen short of best practices for estimating 
costs, maintaining a schedule, and considering risks and alternatives. 
SSA currently relies on occupational information developed by the 
Department of Labor which has not had a major update since 1977. In 
2008, SSA initiated a project to develop its own occupational 
information system (OIS), which SSA expects will provide up-to-date 
information on the physical and mental demands of work to support its 
decision-making process. To guide the creation of its OIS, SSA 
established an advisory panel, collaborated with outside experts and 
other agencies, and in July 2011 issued a research and development 
plan detailing relevant activities through 2016. SSA has made progress 
on some baseline activities in the plan. However, SSA’s cost estimate 
and schedule had key deficiencies, such as not including any estimate 
of the cost of producing, maintaining, and operating the system, which 
can inform design options. SSA also did not adequately consider 
inherent risks or potential alternatives, which could heighten the 
risk of additional costs or project failure. 

Consistent with modern views of disability, SSA has taken some 
concrete steps toward greater consideration of an individual’s ability 
to function with a disability but faces constraints in fully 
modernizing. SSA has incorporated some criteria into its medical 
listings to determine whether a claimant’s impairments result in 
functional limitations that can prohibit the ability to work. SSA is 
also sponsoring research through the National Institutes of Health to 
evaluate how functional abilities can further be considered in 
determining disability. One project aims to develop a computerized 
tool to assist adjudicators in evaluating how various impairments 
affect an individual’s function and ability to work. However, SSA 
officials maintain that other modern concepts of disability cannot be 
fully incorporated into SSA’s disability decisions. Specifically, SSA 
faces constraints considering the extent to which assistive devices 
and workplace accommodations can mitigate work disability, because 
these are not universally available and SSA lacks the resources to 
conduct individualized assessments. 

What GAO Recommends: 

GAO recommends that SSA (1) explicitly identify resources needed to 
achieve its 5-year time frame for updating its medical listings; (2) 
follow best practices in its cost estimate, schedule, and risk 
assessment for the occupational information system; and (3) conduct 
limited, focused studies on how to more fully consider assistive 
devices and workplace accommodations in its disability determinations. 
SSA agreed with the first two recommendations and disagreed with the 
third, stating that such studies would be inconsistent with Congress’ 
intentions. GAO continues to believe the recommendation has merit, as 
discussed more fully within the report. 

View [hyperlink, http://www.gao.gov/products/GAO-12-420]. For more 
information, contact Daniel Bertoni at (202) 512-7215 or 
bertonid@gao.gov. 

[End of section] 

Contents: 

Letter: 

Background: 

SSA Has Improved Its Process for Updating Medical Listings, but Still 
Faces Challenges with Timely Updates: 

SSA Has Begun an Ambitious Project to Develop Updated Occupational 
Information, but Many Uncertainties Remain: 

SSA Has Taken Other Steps to Modernize Criteria but Faces Limitations: 

Conclusions: 

Recommendations for Executive Action: 

Agency Comments and Our Evaluation: 

Appendix I: Objectives, Scope, and Methodology: 

Appendix II: Progress Updating Six Body Systems since Last 
Comprehensive Revision: 

Appendix III: Description of Cost Estimating Best Practices: 

Appendix IV: Description of Scheduling Best Practices: 

Appendix V: Comments from the Social Security Administration: 

Appendix VI: GAO Contact and Staff Acknowledgments: 

Tables: 

Table 1: Key Dates for Comprehensive Revisions to Body System Listings: 

Table 2: Status of Select OIS Activities as of May 2012: 

Table 3: Assessment of OIS Cost Estimate: 

Table 4: Assessment of OIS Schedule: 

Table 5: Six Sound Project Management Practices Used to Evaluate SSA's 
Efforts: 

Figures: 

Figure 1: SSA's Five-Step Sequential Evaluation Process for 
Determining Disability: 

Figure 2: Status of Comprehensive and Targeted Revisions for SSA's 
Body System Listings: 

Abbreviations: 

ADA: Americans with Disabilities Act of 1990: 

DI: Social Security Disability Insurance: 

DOT: Dictionary of Occupational Titles: 

Labor: Department of Labor: 

ICF: International Classification of Functioning, Disability and 
Health: 

NIH: National Institutes of Health: 

O*NET: Occupational Information Network: 

OIS: Occupational Information System: 

SSA: Social Security Administration: 

SSI: Supplemental Security Income: 

[End of section] 

United States Government Accountability Office: 
Washington, DC 20548: 

June 19, 2012: 

The Honorable Sam Johnson: 
Chairman: 
Subcommittee on Social Security: 
Committee on Ways and Means: 
House of Representatives: 

Dear Mr. Chairman: 

The Social Security Administration (SSA) manages two of the largest 
federal disability benefit programs--Social Security Disability 
Insurance and Supplemental Security Income--which together resulted in 
payments of $165 billion to almost 12 million beneficiaries and their 
dependents in 2010. Given the extensive size and cost of its 
disability programs, SSA must have current and appropriate criteria by 
which to assess whether an applicant's medical conditions affect his 
or her ability to perform work in the national economy. However, we 
designated federal disability programs as high risk, in part because 
the medical criteria and occupational information that SSA relies on 
to make benefit decisions were found to be out of date. Moreover, we 
and others have found SSA's disability programs--which historically 
have tended to equate severity of a medical condition with an 
inability to work--to be out of sync with a more modern concept of 
disability that considers the presence or lack of assistance that an 
individual with medical impairments might need to function more 
effectively in his or her environment. 

You recently asked us to assess SSA's plans and efforts for revising 
its disability criteria. Accordingly, we examined the status and 
management of SSA's efforts to update its medical listings to reflect 
current medical knowledge and develop a new occupational information 
system to reflect labor market changes, and we identified other steps 
taken by SSA to incorporate a modern view of disability into its 
eligibility criteria. 

To perform this work, we reviewed our prior reports and SSA Office of 
Inspector General reports; relevant federal laws and regulations; 
program documentation, including policies, procedures, strategic 
goals, and supporting project plans and cost estimates; relevant 
literature; and position papers and testimonies from disability groups 
and commissions. We interviewed SSA officials, key project contractors 
and stakeholders, disability experts, and representatives of other 
agencies that administer disability programs. We also evaluated SSA's 
plans to update its criteria against sound project management and cost 
estimating practices. We narrowed our scope to criteria used for 
initial adult disability determinations. See appendix I for more on 
our scope and methodology. 

We conducted this performance audit from April 2011 through June 2012 
in accordance with generally accepted government auditing standards. 
Those standards require that we plan and perform the audit to obtain 
sufficient, appropriate evidence to provide a reasonable basis for our 
findings and conclusions based on our audit objectives. We believe 
that the evidence obtained provides a reasonable basis for our 
findings and conclusions based on our audit objectives. 

Background: 

SSA administers two disability programs: the Social Security 
Disability Insurance (DI) program, enacted in 1956, and the 
Supplemental Security Income (SSI) program, enacted in 1972[Footnote 
1]. In order to be eligible for DI or SSI benefits based on a 
disability, an individual must meet the definition of disability for 
these programs--that is, they must have a medically determinable 
physical or mental impairment that (1) prevents the individual from 
engaging in any substantial gainful activity and (2) has lasted or is 
expected to last at least 1 year or result in death.[Footnote 2] 

To determine eligibility for both programs, SSA uses a five-step 
sequential process that is intended, in part, to expedite disability 
decisions when possible and limit administrative costs by conducting 
less intensive assessments at earlier steps (see figure 1).[Footnote 3] 

* At steps 1 and 2 of the process, SSA determines whether an applicant 
is working and meets income thresholds, as well as the medical 
severity of impairments. If not working (or not meeting income 
thresholds) and with the determination of a severe impairment, the 
applicant moves to step 3 of the process. 

* At step 3, SSA examiners assess the applicant's medical impairments 
against the Listings of Impairments, also known as the medical 
listings, which are organized into 14 major body systems for adults 
and reflect medical conditions that have been determined by the agency 
to be severe enough to qualify an applicant for benefits[Footnote 4]. 
When using the listings to determine eligibility, SSA generally relies 
on information on the applicant's diagnoses, including laboratory 
findings, diagnostic tests, and symptoms, as well as some limited 
consideration of the applicant's functional limitations. If the 
individual's impairment meets or is equal in severity to one or more 
of those in the listings, the individual is determined to have a 
disability at step 3.[Footnote 5] 

* If a disability determination is not made at step 3, SSA performs an 
assessment of the individual's physical and mental residual functional 
capacity[Footnote 6]. Based on this assessment, SSA determines whether 
the individual is able to perform past relevant work (step 4) or any 
work that is performed in the national economy (step 5). To inform 
determinations at steps 4 and 5, SSA uses a Department of Labor 
database--known as the Dictionary of Occupational Titles (DOT), which 
is an inventory of occupations performed in the national economy. At 
step 5, SSA also uses a set of rules and guidelines, referred to as 
the grid rules, to evaluate the combined effect of an individual's 
physical residual functional capacity, age, education, and work 
experience.[Footnote 7] 

Figure 1: SSA's Five-Step Sequential Evaluation Process for 
Determining Disability: 

[Refer to PDF for image: illustration] 

Step 1: Work test: 
Is the claimant's work earning more than the substantial gainful 
activity? 
Yes: Benefits denied; 
No: continue. 

Step 2: Severity test: 
Does the claimant have a severe impairment that significantly limits 
his or her ability to do basic work activities? And has the claimant 
had that impairment long enough to meet duration requirements?         
No: Benefits denied; 
Yes: continue. 

Step 3: Medical listings test: 
Does the condition meet SSA's medical listings, or is the condition 
equal in severity to one found in the medical listings? 
Yes: Benefits awarded; 
No: continue. 

Step 4: Previous work test: 
Can a person with the claimant's residual functional capacity perform 
the work the claimant did in the past? 
Yes: Benefits denied; 
No: continue. 
  
Yes Step 5: Any work test: 
Can the claimant perform other types of work that exist in the 
national economy? 
Yes: Benefits awarded; 
No: Benefits denied. 

Source: GAO analysis of SSA's evaluation process. 

[End of figure] 

While originally created for expediency,[Footnote 8] over time the 
medical listings used at step 3 were relied on less to make program 
determinations as they became increasingly outdated. In the early 
years of the program, more than 90 percent of cases were decided based 
on medical conditions specified in the listings; in 2010 only 47 
percent of allowances were made at step 3. Experts attribute the 
decline in allowances based on the medical listings to changes in the 
program, workplace, and medical treatment that the medical listings 
had not kept pace with. Since the 1990s, we, along with SSA's Office 
of Inspector General and the Social Security Advisory Board,[Footnote 
9] have expressed concerns that the medical listings being used no 
longer provide current and relevant criteria to evaluate disability 
applicants' inability to work. In 2003, we deemed SSA's and other 
federal disability programs as high-risk areas, in part, because their 
programs continue to emphasize medical conditions in assessing work 
capacity, without adequate consideration of work opportunities 
afforded by advances in medicine, technology, and changes in the labor 
market. 

In 2008, we reported that SSA had recently established a new process--
referred to by SSA as the "business process"--for revising the 
listings to better incorporate feedback into its continuous updates. 
[Footnote 10] This process, which has been in effect since 2003, 
incorporates feedback from multiple parties, including medical experts 
and claims examiners, to update the medical criteria. Under this 
process, SSA gathers external feedback from comments associated with 
regulatory actions, such as the publication of advanced notices of 
proposed rulemaking (advanced notices) and notices of proposed 
rulemaking (notices) in the Federal Register.[Footnote 11] In 
addition, this process includes conducting postimplementation reviews 
one year after a revision is made to assess the impacts of a revised 
listing, areas to improve, and whether expectations from the revisions 
have been achieved.[Footnote 12] 

With respect to information on jobs in the national economy that 
supports SSA's occupational criteria, we and others have reported that 
the DOT is outdated, although SSA still relies on it to assess 
eligibility at steps 4 and 5 of the process. The DOT has not had a 
major update since 1977[Footnote 13] and the Department of Labor 
(Labor) replaced it with a new database in 1998 called the 
Occupational Information Network (O*NET).[Footnote 14] However, SSA 
determined that O*NET is not sufficiently detailed for evaluating DI 
and SSI disability claims, so SSA has begun developing its own 
occupational information system to better reflect the physical and 
mental demands of work in the national economy. 

Beyond dated medical criteria and vocational information, numerous 
disability experts have expressed concern that SSA's disability 
programs--which statutorily require that an adult's medical condition 
prevents that person from engaging in substantial gainful activity--
have historically tended to equate the severity of medical conditions 
with inability to work and thus are out of sync with modern concepts 
of disability. Modern concepts focus on an individual's functional 
abilities in the workplace environment, including consideration of the 
presence or lack of assistance, for example, per the requirements for 
reasonable accommodation by the Americans with Disabilities Act of 
1990[Footnote 15]. These modern views are reflected in the 
International Classification of Functioning, Disability and Health 
(ICF), which is the World Health Organization's framework for 
assessing health and disability. This framework takes into account the 
interaction of health conditions and contextual factors, such as 
products and technology, attitudes, and services, on an individual's 
functional capacity, rather than viewing disability solely as a 
medical or biological issue. Along these lines, experts have 
recommended that SSA incorporate more consideration of individual 
function in its medical listings when doing so can improve their use 
as a screening tool for determining inability to work. Further, 
several groups, such as the Social Security Advisory Board[Footnote 
16] and the Urban Institute,[Footnote 17] have reported that SSA's 
disability programs should focus more on whether an individual can 
work given appropriate environmental or other supports, and that SSA--
through its demonstration authority or other means--could play a role 
in determining how. These suggestions are consistent with SSA's long-
term targeted outcomes, which include not only regularly updating 
regulations and policies to incorporate the most recent medical 
advances, but also making it easier for individuals with disabilities 
to return to work. 

SSA Has Improved Its Process for Updating Medical Listings, but Still 
Faces Challenges with Timely Updates: 

SSA Has Improved Its Strategy to Update Medical Listings: 

Since our last review in 2008, SSA has made several changes that hold 
promise for improving its medical listings updates. First, the agency 
is using a two-tiered system for ongoing revisions to the listings. 
Under this system, SSA first completes a comprehensive listings update 
for a body system, which entails reviewing all the diseases and 
disorders listed within that system and making necessary revisions. 
Second, following a comprehensive revision, SSA will pursue a more 
targeted approach--that is, SSA will conduct ongoing reviews and 
updates of a smaller number of medical diseases or disorders within 
that body system. Agency officials told us that targeted updates 
should be completed more quickly than comprehensive updates, allowing 
them to focus on the most critical changes needed.[Footnote 18] As of 
early March 2012, SSA had begun the ongoing review process to identify 
opportunities for targeted revisions for 8 of the 14 adult body 
systems that were recently comprehensively revised. 

Another change, according to agency officials, is that in 2010, the 
SSA Commissioner set a 5-year cycle for updating listings for each 
body system.[Footnote 19] Previously, SSA established cycles for 
periodically updating listings under each body system, ranging from 3 
to 8 years, but frequently extended them. SSA officials believe that 
conducting targeted reviews will generally allow the agency to 
conclude any necessary revisions prior to the 5-year period. 
Additionally, they expect that using the "business process," which 
requires early public notification of changes and obtaining necessary 
data and feedback from internal and external parties, should help keep 
continuous reviews on track. See figure 2 for the status and 
expiration date by which the listings should be reviewed and updated, 
if needed, for the 14 body systems undergoing review for either 
comprehensive or possible targeted revisions, as of early March 2012. 

Figure 2: Status of Comprehensive and Targeted Revisions for SSA's 
Body System Listings: 

[Refer to PDF for image: illustration] 

Six body systems still undergoing comprehensive revision: 
(Beginning to expiration)[A]. 

Special senses and speech[B]: 
* Speech (1979 to 2015); 
* Disturbances of labyrinthine-vestibular function (1979 to 2015). 

Neurological disorders (1985 to 2012). 

Mental disorders[C] (1985 to 2012). 

Hematological disorders[C] (1985 to 2012). 

Musculoskeletal system[C] (1985 to 2013). 

Respiratory system (1993 to 2012). 

Eight body systems now undergoing targeted revision: 
(Beginning to expiration)[A]. 

Skin disorders (2004 to 2012).     

Genitourinary impairments (2005 to 2013). 

Impairments affecting multiple body systems (2005 to 2013). 

Endocrine system (2011 to 2016). 

Cardiovascular system (2006 to 2013). 

Digestive system (2007 to 2012). 

Immune system (2008 to 2016). 

Malignant neoplastic diseases (2009 to 2017). 

Source: GAO analysis based on information provided by SSA officials. 

[A] For the two-tiered revision process, the beginning point is the 
date of the last comprehensive or targeted revision. 

[B] SSA officials told us they have grouped the disorders in the 
special senses and speech listings into two broad sections--vision and 
hearing--and two standalone medical conditions. SSA has not yet 
comprehensively revised the two standalone medical conditions that 
cover speech and disturbances of labyrinthine-vestibular function. The 
two sections have undergone comprehensive revisions and are undergoing 
reviews that began in 2007 for the vision section and in 2010 for the 
hearing section. Special senses and speech listings are set to expire 
in 2015. 

[C] According to SSA officials, SSA published limited revisions for 
the hematological disorders in 1988. It also published final rules for 
limited revisions for the mental disorders listings in 2000 and the 
musculoskeletal system listings in 2001. 

[End of figure] 

SSA has made another change by more extensively engaging the medical 
community to identify ways to improve the medical listings. For 
example, SSA contracted with the Institute of Medicine to study its 
medical criteria for determining disability and to make 
recommendations for improving the timeliness and accuracy of its 
disability decisions, resulting in a 2007 report with recommendations 
[Footnote 20] and a symposium of experts in 2010. SSA has addressed 
some of the Institute of Medicine's recommendations, such as making 
better use of its administrative data to update criteria and creating 
a standing committee through the Institute of Medicine to provide 
recommendations for listings revisions. In addition, through the 
Institute of Medicine, SSA created consensus committees to conduct 
research and provide other assistance with updating SSA's 
cardiovascular listings and its Human Immunodeficiency Virus (HIV) 
listing, which culminated in two reports with recommendations. 
[Footnote 21] 

SSA Has Experienced Delays with Its Revision Process: 

SSA has made progress, but continues to face delays in completing both 
comprehensive and ongoing targeted updates. As of early March 2012, 
SSA officials told us they had completed comprehensive revisions of 
listings for eight body systems, some of which resulted in significant 
changes. For example, in 2011, SSA removed the endocrine body system 
listings for all the adult disorders, such as diabetes, because they 
found that they were now generally diagnosed early and treated very 
successfully.[Footnote 22] Nevertheless, according to SSA, the agency 
still needs to complete the comprehensive revisions for listings of 
the remaining six body systems--a process that has been ongoing for 
the last 19 to 33 years, with numerous extensions beyond the original 
expiration periods (see table 1). For example, it has been at least 27 
years since SSA finalized comprehensive revisions for two of the six 
body system listings--mental and neurological disorders, which are 
among those SSA uses most frequently in its eligibility determination 
process[Footnote 23]. SSA has made progress on four of the six body 
systems set to expire in 2012, but will likely miss targeted time 
frames. SSA issued a notice of proposed rulemaking to revise its 
listings of mental disorders in 2010 and has told us that it plans to 
finalize this comprehensive revision by the end of 2012, after its 
current expiration date in July 201[Footnote 24]2. SSA is still 
developing notices for the neurological and two other body system 
listings, which are also set to expire in 2012. Because SSA has 
generally taken more than a year to move from publishing the notice to 
final revision and may also need additional time for any internal 
revision and review, as well as a review by the Office of Management 
and Budget, it is also unlikely that SSA will meet its planned 2012 
time frames for updating these listings. See appendix II for details 
on progress updating these listings. 

Table 1: Key Dates for Comprehensive Revisions to Body System Listings: 

Body system and section: Special senses and speech[C] sections: 
* Speech; 
* Disturbances of labyrinthine-vestibular function; 
Year of last comprehensive revision: 1979; 
Years initially set to review and revise: 8; 
Years since last comprehensive revision[A]: 33; 
Current expiration date[B]: 2015. 

Body system and section: Neurological disorders; 
Year of last comprehensive revision: 1985; 
Years initially set to review and revise: 8; 
Years since last comprehensive revision[A]: 27; 
Current expiration date[B]: 2012. 

Body system and section: Mental disorders; 
Year of last comprehensive revision: 1985; 
Years initially set to review and revise: 3; 
Years since last comprehensive revision[A]: 27; 
Current expiration date[B]: 2012. 

Body system and section: Hematological disorders; 
Year of last comprehensive revision: 1985; 
Years initially set to review and revise: 8; 
Years since last comprehensive revision[A]: 27; 
Current expiration date[B]: 2012. 

Body system and section: Musculoskeletal system; 
Year of last comprehensive revision: 1985; 
Years initially set to review and revise: 5; 
Years since last comprehensive revision[A]: 27; 
Current expiration date[B]: 2013. 

Body system and section: Respiratory system; 
Year of last comprehensive revision: 1993; 
Years initially set to review and revise: 6; 
Years since last comprehensive revision[A]: 19; 
Current expiration date[B]: 2012. 

Source: GAO analysis based on information provided by SSA officials. 

[A] According to SSA officials, SSA published limited revisions for 
the hematological disorders in 1988. It also published final rules for 
limited revisions for the mental disorders listings in 2000 and the 
musculoskeletal system listings in 2001. 

[B] SSA has continually extended the expiration dates of the listings. 

[C] The special senses and speech listings have two sections--vision 
and hearing--which have been comprehensively revised. 

[End of table] 

Updates using SSA's targeted approach seem to be moving at a faster 
pace than the comprehensive revisions, but some delays have occurred 
here as well, and more are expected. For example, SSA has already 
extended the expiration date for its targeted review of the 
cardiovascular system. According to SSA officials, it may also need to 
extend expiration dates for listings under two other body systems set 
to expire in 2012. Extensions may be needed because SSA has not yet 
published the notice of proposed rulemaking for those two body system 
listings and may not have time to publish these notifications, respond 
to comments, and complete the final updates by their current 
expiration date. 

At the same time that SSA has been experiencing delays completing 
timely revisions, agency officials reported challenges with other 
steps in the business process. Whereas SSA's business process includes 
a postimplementation review of case data at the 1-year mark to 
determine whether expectations from a revision were met, several did 
not undergo this review, such as those for skin disorders, 
genitourinary impairments, and impairments affecting multiple body 
systems. SSA officials told us they only began conducting these 
reviews in 2010, and to date, SSA has completed just one in 2011 that 
involved a targeted sample of 175 cases. SSA officials told us they 
are conducting or planning to conduct two more reviews at the 1-year 
mark in 2012. While disability experts we interviewed spoke highly of 
SSA's business and targeted review processes to obtain feedback early 
on and update the listings more promptly, ongoing delays raise 
questions about the agency's ability to fully follow its current 
business process while completing continuous and timely revisions for 
all 14 body systems.[Footnote 25] 

SSA officials offered two key reasons for the delays in updating the 
listings: (1) limitations in the number and expertise of staff and (2) 
the complexity and unpredictability of the regulatory process. 
According to SSA officials, revising the medical listings requires 
research, deliberation, testing, regulatory review, and consensus with 
many stakeholders, and consequently is difficult and time-consuming to 
achieve. According to an SSA official in the Office of Medical 
Listings Improvement, the office is short-staffed and there is a lack 
of expertise needed to perform this work. To address these 
constraints, SSA has contracted with the Institute of Medicine to 
review and develop recommendations for revising two of the body system 
listings. While not finalized as of March 2012, SSA officials reported 
that the agency plans to renew this contract after it expires in 2012 
and extend it to 2015. However, SSA has not yet determined how it will 
use the Institute of Medicine to revise the listings or the extent to 
which the contract will address staffing shortfalls. 

Also contributing to delays is the time required for internal review 
and public comment under the regulatory process, which depends largely 
on the number and the substance of comments received, according to an 
SSA official. Obtaining public comment is one way SSA receives 
critical information for identifying areas for revision and obtaining 
stakeholder consensus. As such, SSA reviews and responds to each 
comment that would result in a significant change, and the time 
required for doing so varies depending on the number of comments and 
resources. For example, SSA officials told us that the advanced notice 
of proposed rulemaking to the listings of mental disorders in 2003 
resulted in 500 comments, which took SSA 5 years to incorporate into a 
draft notice of proposed changes for regulatory review. SSA officials 
reported they have considered options for automating and thereby 
speeding up the process of obtaining and reviewing public comment. For 
example, they told us that they eventually plan to use a web-based 
tool to obtain early public feedback on medical listing updates to 
help target their limited resources and more quickly make changes. 
According to an SSA official, the agency plans to retain its optional 
use of the advanced notice of proposed rulemaking because it can also 
help to identify appropriate areas to focus on to ultimately make 
timely updates.[Footnote 26] 

SSA Has Begun an Ambitious Project to Develop Updated Occupational 
Information, but Many Uncertainties Remain: 

SSA is Designing a New Occupational Information System, but Has Fallen 
behind with Some Activities: 

In 2008, SSA began a multiyear project to research and design a new 
source of occupational information that will replace the outdated 
information currently being used to determine if claimants are able to 
do their past work or any other work in the national economy. Since 
the 1960s, SSA has been using the DOT, which contains a list of job 
titles found in the national economy and had a last major update in 
1977.[Footnote 27] The DOT provides SSA with descriptions of the 
physical demands of work--such as climbing, balancing, and 
environmental requirements--for each of the more than 12,000 
occupations listed.[Footnote 28] According to SSA, these descriptions 
have been essential to its evaluations of how much a claimant can do 
despite his or her impairment and whether this level of functioning 
enables the claimant to do his or her past work or any other work. 
After its last limited update, Labor decided to replace the DOT with 
O*NET, which has far fewer occupational titles compared with the DOT 
and has served Labor's purposes more efficiently. According to an SSA 
report, after investigating potential alternatives, SSA decided that 
O*NET and other existing databases with occupational information were 
not sufficiently detailed and not able to withstand legal challenges 
for use in its decision-making process. SSA further decided to develop 
its own occupational information system (OIS), which would contain 
detailed information as in the DOT, but would also include additional 
information, such as the mental demands of work. In addition, SSA has 
determined that the OIS will (1) meet its legal, program, and data 
requirements; (2) be flexible enough to incorporate changes in its 
policies and processes; and (3) be able to be updated to reflect the 
evolving workplace environment. 

In 2008, SSA began taking steps to guide the development of its OIS. 
SSA created an internal office and working group, as well as an 
Occupational Information Development Advisory Panel. While the number 
of panel members has fluctuated over time, in April 2012, 14 external 
experts were serving on the panel and represented various 
affiliations, such as medicine, disability law, rehabilitation, and 
industrial organizational issues.[Footnote 29] The advisory panel 
holds quarterly public meetings and has several subcommittees that 
review material and make recommendations to SSA on developing various 
components of the OIS. For example, in a 2009 report, the advisory 
panel supported the need for SSA to develop a new source of 
occupational information, rather than adapt O*NET, and recommended the 
type of data SSA should collect, as well as approaches for classifying 
occupations. 

To further inform its efforts, SSA has sought input from agencies or 
organizations that either collect occupational information or also use 
the DOT. For example, SSA officials held initial meetings with Labor 
and U.S. Census Bureau officials to gain information on sampling 
methods used for O*NET, the Occupational Employment Statistics 
program, and U.S. Census Bureau's household surveys[Footnote 30]. 
Additionally, since February 2011, SSA and Labor have been in the 
process of approving a memorandum of understanding to formalize their 
collaboration efforts on the new OIS. According to an SSA official, as 
the OIS project progresses, SSA plans to convene ad hoc roundtables 
with experts and other agency officials to explore specific subject 
areas, such as sampling issues. Besides working with Labor and U.S. 
Census Bureau officials, SSA officials and panel members have sought 
input from other experts and current users of the DOT, such as SSA 
disability adjudicators and external rehabilitation professionals. SSA 
officials conducted a user needs analysis in 2009 and have presented 
on the OIS project at events and conferences. 

In July 2011, SSA published a detailed research and development plan 
outlining all activities related to researching, developing, and 
testing the key components of the OIS in order to implement it by 2016 
at an estimated total cost of $108 million. For example, the plan 
includes several baseline activities to identify and study other 
occupational information systems and various approaches for analyzing 
occupations that may inform or could be leveraged in SSA's OIS data 
collection. The plan also includes activities to identify the primary 
occupational, functional, and vocational characteristics of current 
beneficiaries. Other key components of the plan include developing 
descriptions of work requirements, such as the physical and mental 
demands for jobs; developing data collection and analysis strategies; 
and identifying the occupations, categories, and definitions that will 
constitute the structure of the new OIS. SSA also plans to develop a 
strategy for piloting how it would ultimately collect data for the OIS 
nationwide within this time frame. 

As of May 2012, SSA had made progress on many of the baseline 
activities outlined in its research and development plan for the OIS. 
[Footnote 31] For example, according to an SSA official, its 
investigation of existing occupational information systems, now 
complete, resulted in useful information about design issues other 
organizations have confronted and mitigated when creating their own 
system. Additionally, SSA's preliminary analysis of its own 
administrative data identified the most frequently cited occupations 
and functional and vocational characteristics of disability 
applicants. SSA officials told us the agency will target the 
occupations identified in this analysis for its pilot studies of the 
OIS. Also in 2011, SSA completed a comprehensive framework for 
assessing an individual's capacity to work--key to informing the OIS 
content, according to SSA officials--which was based on 
recommendations of outside experts as well as SSA's policy and program 
requirements. 

While SSA has made progress on several key activities, agency 
officials delayed 2011 completion dates for certain activities and 
anticipate making additional changes to its timeline as a result of 
not meeting its staffing goals for fiscal year 2011 (see table 2). 
Some activities that were delayed by several months included 
finalizing reports for the baseline studies and conducting a 
literature review that would inform how occupations might be analyzed. 
SSA officials told us that they did not have enough staffing to 
complete all of the 2012 planned activities within the estimated 
schedule. Further, SSA officials said they did not have the budget to 
hire new staff in September 2011. To address this challenge, SSA 
officials hired consultants to meet some of their needs. SSA officials 
also met with the Office of Personnel Management to explore the 
possibility of an interagency agreement that would allow SSA to use 
one or two of the office's industrial organizational psychologists to 
help on a part-time basis. 

Table 2: Status of Select OIS Activities as of May 2012: 

Activity and objective: Investigate existing OISs. To identify lessons 
learned about features, requirements, processes, and options through 
the examination of the development and operation of existing domestic 
and international OISs; 
Fiscal year target: 2010-2011; 
Status: Completed in fiscal year 2012 (late). 

Activity and objective: Occupational and medical-vocational study. To 
identify and record the primary occupational, functional, and 
vocational characteristics of adult disability applicants at steps 4 
or 5 at the initial and hearings levels; 
Fiscal year target: 2010-2011; 
Status: In progress (late). 

Activity and objective: Job analysis methodologies (performed by 
contractor). To identify existing job analysis methods, their 
features, and their potential usefulness for OIS development; 
Fiscal year target: 2011; 
Status: Completed on time. 

Activity and objective: Business processes for recruiting, training, 
and certifying job analysts (performed by contractor). To identify 
existing business processes used to recruit, train, and certify job 
analysts and potential usefulness of these processes for OIS 
development; 
Fiscal year target: 2011; 
Status: Completed on time. 

Activity and objective: Identify OIS usability standards. To identify 
standards and criteria for assessing the operational usability of the 
new OIS and to incorporate those standards into OIS research and 
development activities; 
Fiscal year target: 2009-2012; 
Status: Completed 3 of 4 activities (one completed late). 

Activity and objective: Identify OIS scientific standards. To identify 
relevant scientific standards, guidelines, and best practices that 
enable SSA to meet its responsibilities under applicable federal 
requirements, and to incorporate those standards into OIS research and 
development activities; 
Fiscal year target: 2011; 
Status: Completed. 

Activity and objective: Identify OIS legal requirements. To identify 
standards for evaluating and ensuring that the new OIS accurately 
reflects the language and the intent of the vocational requirements of 
the Social Security Act; 
Fiscal year target: 2011; 
Status: Completed. 

Activity and objective: Identify OIS elements. To establish basic 
design parameters and requirements to ensure that OIS meets SSA's 
legal, scientific, and usability requirements for occupational 
information; 
Fiscal year target: 2012; 
Status: In progress. 

Activity and objective: OIS work taxonomy. To identify a comprehensive 
set of constructs that may form the basis of OIS. These constructs 
must reflect the physical and mental-cognitive requirements of work 
and context of work that can be objectively measured or delineated to 
develop an occupational classification; 
Fiscal year target: 2011-2012; 
Status: In progress. 

Source: GAO based on information provided by SSA officials. 

[End of table] 

SSA's Cost Estimate and Schedule Fell Short of Best Practices in Key 
Areas: 

Our Cost Estimating and Assessment Guide[Footnote 32] identifies a 
number of best practices for effective cost estimating and scheduling 
that should result in reliable and valid cost estimates that 
management can use for making informed decisions. Per these criteria, 
the success of any program depends in part on having reliable cost 
estimates and a reliable schedule. A reliable cost estimate provides 
the basis for informed investment decision making, realistic budget 
formulation and program resourcing, meaningful progress measurement, 
proactive course correction when warranted, and accountability for 
results. A reliable schedule defines, among other things, when work 
activities will occur, how long they will take, and how they are 
related to one another. As such, the schedule not only provides a road 
map for systematic execution of a program, but also provides a means 
by which to gauge progress, identify and address potential problems, 
and promote accountability. 

We compared SSA's cost estimate to three best practices for assuring a 
reliable cost estimate[Footnote 33] and found SSA only minimally or 
partially met each of these (see table 3). First, we found SSA's 
estimated cost of the OIS research and development phase--$108 
million--was not well-documented. For example, after reviewing all of 
SSA's documentation supporting this cost estimate as of December 2011, 
we did not find step by step documentation showing how the estimate 
was derived so that someone unfamiliar with the project could use the 
documentation to recreate the estimate and get the same results. Well-
documented cost estimates are considered a best practice and without 
good documentation, SSA is not in a position to defend the reliability 
of its estimate. Additionally, SSA only partially met the best 
practice of having an accurate cost estimate. While SSA provided 
documentation showing how some of their estimates compared to actual 
costs and the reasons for any variances, SSA did not provide adequate 
documentation for us to determine, for example, if the estimate took 
inflation into account or if there were any calculation errors. 
Generally speaking, in the absence of a detailed cost model, third 
party reviewers cannot be certain that cost estimate calculations are 
accurate and account for all costs. 

We also found the cost estimate was not comprehensive as it does not 
include any costs beyond the research and development phase, such as 
the costs of producing, maintaining, and updating the final data 
system, which could be significant. SSA officials told us that they 
are still in the process of determining what information will be 
included in the data system, how it will be collected, and how many 
occupations will be covered, each of which will influence the cost of 
developing and maintaining the OIS. As such, they maintain that it is 
too early to estimate the costs of the final system or the costs for 
maintaining the system. According to industry best practices, cost 
estimates should be comprehensive and include all costs necessary to 
achieve agency objectives and should be updated as the agency proceeds 
with the project and gains more information. At this point in the 
project, estimating total costs of options under consideration could 
enhance decision making by evaluating the potential tradeoffs of 
different designs. Without any estimate for the cost of producing the 
OIS, SSA risks designing a system that would not be a viable or 
affordable option to complete. Additionally, without maintenance cost 
estimates, SSA is at risk of designing a system that would be too 
costly to maintain on a regular basis resulting in outdated 
information. Other federal information systems provide some basis for 
estimating the cost of producing or maintaining an OIS. For example, 
Labor officials indicated that the cost of maintaining O*NET--an 
occupational information system that includes approximately 1,000 
occupations and uses a paper or web survey to collect data--is roughly 
$6 million a year.[Footnote 34] 

Table 3: Assessment of OIS Cost Estimate: 

Best practice: Well-documented; 
Extent best practice met: Minimally met. 

Best practice: Accurate; 
Extent best practice met: Partially met. 

Best practice: Comprehensive; 
Extent best practice met: Partially met. 

Source: GAO analysis of SSA's cost estimate for the OIS. 

Note: Not met--SSA provided no evidence that satisfies any of the 
criteria; minimally met--SSA provided evidence that satisfies a small 
portion of the criteria; partially met--SSA provided evidence that 
satisfies about half of the criteria; substantially met--SSA provided 
evidence that satisfies a large portion of the criteria; and met--SSA 
provided complete evidence that satisfies the entire criteria. See 
appendix III for more information on these best practices. 

[End of table] 

We also reviewed SSA's master schedule for the OIS against nine best 
practices for a reliable schedule, and found that SSA did not meet 
four and minimally met five of these practices (see table 4). For 
example, among those minimally met, we found a significant number of 
activities within SSA's schedule were not logically sequenced in the 
order that they were going to be carried out (best practice 2) and 
activities that were dependent on completion of a prior activity were 
not identified (best practice 5, 6, and 7). For example, SSA officials 
and experts acknowledged that activities associated with the "OIS work 
taxonomy" part of the research and development plan--activities that 
together determine which information should be included in the OIS--
are an essential building block that will inform other OIS activities, 
such as developing the "OIS work analysis instrument," which will 
determine how OIS information will ultimately be collected. 

Nevertheless, when we tested SSA's schedule for sequencing and 
linkages associated with the OIS work taxonomy activity, we found a 
significant delay of almost 1,000 days that should have significantly 
delayed the project actually barely affected the final completion date 
in the OIS project. Such missing links between key activities in the 
schedule represent broken logic that reduces the reliability of the 
forecasted dates. The OIS schedule also did not meet the best practice 
of conducting a schedule risk analysis (best practice 8), which is an 
essential tool for project managers to understand the most important 
risks to the project and focus on mitigating them. Based on the 
schedule provided to us, we do not have any indication that SSA has 
considered the vulnerability within its schedule for meeting time 
frames for individual activities which would in turn impact the time 
frames for the entire project. Without explicitly identifying risks to 
its schedule, SSA either does not know or is not conveying the 
probability of completing research and development activities on time, 
and its relationship to overall costs for this phase. However, in 
order to conduct a schedule risk analysis the schedule has to be 
properly sequenced and networked with all logic links in place for the 
analysis to produce credible results. 

Table 4: Assessment of OIS Schedule: 

Best practice: 1. Capturing all activities; 
Extent best practice met: Minimally met. 

Best practice: 2. Sequencing all activities; 
Extent best practice met: Minimally met. 

Best practice: 3. Assigning resources to all activities; 
Extent best practice met: Minimally met. 

Best practice: 4. Establishing the duration of all activities; 
Extent best practice met: Minimally met. 

Best practice: 5. Integrating schedule activities horizontally and 
vertically; 
Extent best practice met: Not met. 

Best practice: 6. Establishing the critical path for all activities; 
Extent best practice met: Not met. 

Best practice: 7. Identifying float between activities; 
Extent best practice met: Minimally met. 

Best practice: 8. Conducting a schedule risk analysis; 
Extent best practice met: Not met. 

Best practice: 9. Updating the schedule using logic and durations to 
determine dates; 
Extent best practice met: Not met. 

Source: GAO analysis of SSA's schedule for the OIS. 

Note: Not met--SSA provided no evidence that satisfies any of the 
criteria; minimally met--SSA provided evidence that satisfies a small 
portion of the criteria; partially met--SSA provided evidence that 
satisfies about half of the criteria; substantially met--SSA provided 
evidence that satisfies a large portion of the criteria; and met--SSA 
provided complete evidence that satisfies the entire criteria. See 
appendix IV for more information on these best practices. 

[End of table] 

Other Challenges with OIS Development Could Undermine the Project's 
Success: 

Beyond gaps in their cost estimate and schedule of specific 
activities, SSA faces broader challenges that could impede the success 
of the OIS design and implementation; however, SSA has not done a 
formal risk analysis of these challenges.[Footnote 35] While SSA 
officials said they had recently begun discussing various risks and 
how they might address them, they said it was premature to provide us 
with this information. Examples of potential challenges for OIS that 
experts and stakeholders we spoke with cited include: 

* SSA's lack of expertise with designing an OIS. SSA does not have 
prior experience with designing a complex and, in some respects, 
unprecedented occupational information system. As such, SSA will need 
to depend on many outside experts and contractors to complete the 
system. While the Occupational Information Development Advisory Panel 
members can provide some expert counsel, most of its members lack the 
technical and scientific background essential to informing this 
complicated effort. To help design the OIS, SSA recently hired a 
research psychologist and plans to hire two more individuals in the 
near future, but may need additional resources. In March 2012, SSA put 
out a request for information and, according to an agency official, 
received ideas from knowledgeable experts about how to move forward 
with technical aspects of the project. Until the agency secures 
required and sufficient expertise, SSA may not be able to move ahead 
with key technical decisions, such as defining the number of 
occupations to include and the data collection methodology, which may 
cause further delays. 

* Cost of maintaining an OIS. SSA has not yet made design decisions on 
the OIS that will ultimately define the overall cost of producing, 
implementing, and maintaining the OIS system. For example, SSA 
officials told us that they were not sure how many occupations they 
would include in the OIS, although they believe the total number will 
be somewhere between the number of occupations in the O*NET and the 
DOT, or between approximately 1,000 and 12,000 occupations. A 2010 
study conducted by the National Academy of Sciences reviewing Labor's 
O*NET cited the three major cost drivers of an occupational 
information system as (1) size of sample, (2) number of occupations, 
and (3) frequency of updates. This study noted that as the agency 
increases any one of these cost drivers, it does so at the expense of 
the others or of the overall cost. For example, if SSA chooses to 
frequently update the entire OIS, the agency may need to make 
tradeoffs with the number of occupations or sample size it chooses if 
it wishes to contain costs. 

* Managing large, multiyear projects. In the past, SSA has experienced 
difficulties managing complex, multiyear efforts. In prior work, we 
reported that SSA has canceled numerous demonstration projects due to 
limitations or weaknesses in design or implementation and lacked 
sufficient controls to ensure effective management of its 
demonstration projects.[Footnote 36] We have also reported on 
challenges that SSA faced managing two separate redesigns of its 
disability decision-making process.[Footnote 37] While the OIS project 
alone represents a complex effort, stakeholders have emphasized the 
importance of this project progressing in close concert with other 
ongoing research managed by another part of SSA, placing greater 
emphasis on broad and effective project planning.[Footnote 38] In 
light of past experiences and as SSA faces a potential change in 
leadership in 2013, the management shortcomings we identified increase 
the vulnerability of this complex project. 

Given the range of challenges and potential risks they pose to the 
success of the OIS project, it is important to identify and carefully 
explore feasible alternatives that may mitigate these risks. Examples 
of potential alternatives suggested by experts and other observers in 
the disability field include: 

* Leveraging O*NET. In a report issued in 2010, SSA's advisory panel 
found that it did not believe that O*NET would meet SSA's needs, in 
part, because it is not detailed enough. However, the National Academy 
of Sciences also issued a report in 2010 and concluded that O*NET 
could be altered to better meet SSA's needs for disability 
adjudication. SSA officials have told us that modifying O*NET would 
not result in savings for the agency, but they have not conducted any 
analysis to determine this. While most disability experts agree that 
O*NET in its current form would not be a suitable source of 
occupational information for SSA, the National Academy of Sciences 
study noted that there are potential linkages between O*NET and an SSA 
OIS that are worthy of more careful exploration on SSA's part and that 
leveraging one system to serve broader purposes could be most cost-
effective overall. 

* Adjusting the scope of the OIS. SSA could reduce costs by limiting 
the scope of the OIS. For example, the OIS could be designed to 
capture fewer occupations. SSA officials have told us that since they 
are early in their design, they do not know how many occupations will 
be included in their OIS. Since this decision is fundamental to 
informing the OIS data collection methods, feasibility, and cost, 
consideration of alternative scope should be given high priority 
attention. 

* Limiting data collection methods. Another key factor that SSA must 
consider is the method they will use to collect data for their OIS as 
some methods are more costly than others. For example, among the 
methods SSA is considering, conducting on-site job analyses of 
occupations would be more expensive than surveys, which are also more 
resource and time intensive than collecting information through 
telephone interviews. 

* Leveraging resources from other agencies and OIS users. Other 
federal agencies with experience in data collection and occupational 
information have resources that SSA could leverage. SSA officials told 
us that they have been considering how they could benefit from the 
infrastructure that other agencies such as Labor and the U.S. Census 
Bureau have for data collection, but that they have not identified 
specific ways to leverage those resources. Additionally, while SSA 
needs to assure the OIS serves its most basic needs, it may be 
appropriate for SSA to explore the possibility of cost sharing or 
applying users' fees with organizations that currently rely on the 
outdated DOT and could ultimately benefit from using a more modern and 
comprehensive OIS database.[Footnote 39] 

SSA Has Taken Other Steps to Modernize Criteria but Faces Limitations: 

SSA Has Taken Steps to Incorporate Modern Concepts of Disability into 
Eligibility Criteria: 

Although SSA's adult disability programs were initially built upon the 
assumption that certain severe medical conditions equate to work 
incapacity, through its medical listings updates and ongoing research, 
SSA has taken steps to modify its eligibility criteria. SSA now is 
taking a more modern view of disability that looks beyond the 
claimant's medical condition by giving greater consideration to his or 
her functional capacity, that reflects the International 
Classification of Functioning, Disability and Health (ICF) framework 
[Footnote 40]. According to the 2007 Institute of Medicine report, a 
modern concept of disability should recognize that disability is not 
just inherent in the individual and his or her medical condition, but 
is the result of complex interactions between the person, the person's 
medical impairments, assistive devices to which they have access, and 
features of his or her socioeconomic environment, such as the presence 
or lack of accessible transportation and workplace accommodations. 
Under this concept, as described in this report, two people with the 
same impairment might have different degrees of work disability for a 
variety of reasons. 

Updates to the medical listings have been one vehicle through which 
SSA can include an assessment of an individual's functional abilities 
to determine whether an impairment prevents work. For example, as part 
of SSA's comprehensive revision to the listings for the immune system, 
the agency included several functional criteria, such as performing 
activities of daily living, maintaining social functioning, and 
completing tasks in a timely manner despite deficiencies in 
concentration or persistence. Generally, SSA officials, adjudicators, 
and disability experts we spoke with support incorporating appropriate 
functional criteria into the medical listings to facilitate a more 
reliable assessment of an individual's ability to work. However, some 
have also noted that as SSA continues to more broadly incorporate 
functional criteria into listings updates, such efforts may result in 
a more subjective assessment by adjudicators that could increase the 
difficulty of making step 3 disability determinations. 

Since 2008, SSA has had an ongoing interagency agreement with the 
National Institutes of Health (NIH) to conduct short-and long-term 
research that has informed SSA's efforts to incorporate functional 
information into the disability criteria. For example, in its 2011 
annual report to SSA, NIH presented its findings on the use of 
functional criteria, as defined by the ICF, in the adult listings. The 
objective of the project was to quantify the comprehensiveness and 
consistency of functional criteria among the adult listings and any 
influence this has in determination of outcomes. NIH found that while 
the use of functional terms were particularly apparent in five body 
systems, nearly one-half of the 14 body systems did not capture the 
influence of health conditions and impairment on human functioning. 
NIH is currently working on another project, which examines the 
presence and consistency of functional terms in the listings criteria. 
It is estimated the project will be completed by 2013. 

Besides exploring how medical listings could further incorporate 
functional considerations, SSA is also sponsoring longer term research 
through the NIH to develop an automated method to more quickly and 
comprehensively evaluate a claimant's functional abilities for its 
disability determinations. Specifically, project researchers are 
developing a computer-based tool to rapidly and reliably assess the 
functional abilities of individual claimants considering their medical 
conditions[Footnote 41]. As envisioned, the claimant, a medical 
provider, or both would respond to a series of questions through the 
computer-based tool, which would likely take an hour to complete the 
entire battery, perhaps less if a more limited assessment is 
warranted. The project's intended scope encompasses six areas of 
function consistent with the ICF activity domain: (1) mobility, (2) 
interpersonal/social interaction and relationships, (3) self-care, (4) 
communication, (5) general tasks and demands (such as multitasking and 
carrying out daily routines), and (6) learning and applying knowledge. 
NIH researchers said they plan to consider the use of common personal 
assistive devices, such as wheelchairs, in developing the tool. As of 
April 2012, NIH had completed preliminary testing of instruments in 
two of the six areas--mobility and interpersonal/social interaction 
and relationships--with a sample of claimants and providers and had 
begun analyzing the data. SSA and NIH officials anticipate several 
benefits from the functional assessment tool, such as providing 
information on the impact of impairments more consistently, 
comprehensively, and early in the disability determination process. 
This information would help adjudicators more accurately assess 
whether a person can perform certain kinds of work given his or her 
functional and occupational capabilities. 

While this research is promising, there are several unknown variables. 
SSA officials said they have not yet determined when or how the tool 
will be integrated into the disability determination process. NIH 
officials indicated they believe that the tool may be most useful 
early in the determination process. SSA officials said they expect to 
pilot the functional assessment tool after all relevant domains have 
been tested and validated, which will likely be by 2016. Additionally, 
NIH researchers told us that, ultimately, this tool, which collects 
information on the applicant, would need to be aligned with the OIS, 
which collects information on the demands of work. SSA and NIH 
officials reported they have held meetings to share their progress to 
date, but both projects are in the early stages and additional 
coordination will be needed going forward. 

SSA is in the preliminary stages of taking additional steps to broaden 
its use of functional criteria throughout the disability determination 
process in response to other findings by NIH. Specifically, NIH 
evaluated a number of forms that SSA uses during the disability 
application and determination processes to determine how well these 
forms captured information on claimant functional activity as 
described by the ICF. The researchers found that current SSA 
assessment processes had major gaps in covering the ICF concepts. For 
example, SSA captured only limited information relative to sensory 
experiences, such as watching or listening, learning and applying 
knowledge, communication, and interpersonal interactions and 
relationships, all of which NIH considered particularly relevant to 
work. NIH concluded that the gaps need to be addressed in order to 
characterize individual functioning more comprehensively in 
relationship to the demands of the workplace. Another step the agency 
reports that it plans to take is the issuance of a Federal Notice of 
Solicitation of Collaboration from federal agencies in developing a 
standard for coding functional capacity in federal disability programs 
based on the ICF. The notice will explain that SSA believes using the 
ICF would help standardize how agencies describe and measure different 
aspects of disability, improve the clarity and comparability of 
research findings, and strengthen the base of scientific knowledge 
that guides public policies and health practices. In addition, SSA has 
asked the Institute of Medicine to plan an international symposium 
focused on how best to use and assess function in the disability 
determination process. SSA officials also stated that the agency may 
ultimately revise the residual functional capacity forms based on 
criteria from the ICF. 

SSA Faces Constraints to Incorporating Modern Concepts: 

Consistent with modern views of disability, a key consideration in 
assessing disability is that the environment can hinder or enhance an 
individual's ability to function. While assistive devices and 
workplace accommodations can play a critical role in an individual's 
ability to function in the work environment, SSA does not always 
consider them in its assessment of disability. Regarding the 
incorporation of assistive devices into the medical listings, SSA 
officials and experts we spoke with expressed concern about the extent 
to which specific technologies should be incorporated if they are not 
widely available. SSA officials told us that they currently 
incorporate assistive devices into the medical listings once these 
devices become standard in the medical community--a threshold that SSA 
officials described as generally involving some combination of 
availability, accessibility, and insurance coverage. After an 
assistive device, such as a prosthetic device for walking, is 
incorporated into a listing, adjudicators must evaluate the 
individual's ability to walk with the device being used. For example, 
evaluations of people who have had amputations involving a lower 
extremity or extremities are to be done with the prosthetic device in 
place. When we asked if wheelchairs are considered standard in the 
medical community, and whether SSA considers how individuals with 
wheelchairs might function in today's knowledge-based labor market, 
given their age and education, we heard conflicting information from 
SSA officials. Some explained that individuals in wheelchairs are 
generally allowed at step 3 on the basis of their underlying medical 
condition, without evaluating how their disability might be assessed 
at steps 4 or 5. Other officials maintained that according to SSA's 
policy, an individual in a wheelchair would be evaluated for upper 
body strength or other medical issues. However, SSA officials we spoke 
with said they have not evaluated these types of allowances 
specifically. 

Regarding workplace accommodations, SSA officials said their policy is 
to not consider them for several reasons. First, officials cited SSA's 
inability to ensure that workplace accommodations are provided by 
employers--a concern shared by other disability experts we 
interviewed. SSA officials also indicated the agency would be unable 
to assess the effectiveness of workplace accommodations for claimants. 
Further, officials noted that SSA already faces resource constraints 
managing its disability claims workload and expanding the scope of 
individualized assessments would exacerbate those constraints. 
Finally, they noted that data on the availability and use of workplace 
accommodations are lacking. 

SSA's policy notwithstanding, some opportunities exist for SSA to 
learn more about the availability of workplace accommodations. For 
example, developing the OIS may provide an opportunity to obtain some, 
albeit limited, information on workplace accommodations for the 
disability determination process. Specifically, while SSA officials 
reported that they do not plan to collect specific information on 
workplace accommodations as they develop the system, they may collect 
more specific information on the physical requirements of different 
jobs, such as options for sitting or standing. Some experts we spoke 
with agreed that while information on workplace accommodations would 
be immensely useful to include in the OIS, given the current scope of 
that project, they agreed collecting this information via the OIS 
would likely be too great a task for SSA to accomplish with existing 
budget constraints and time frames. However, another potentially 
viable option for collecting more information about workplace 
accommodations might be the Disability Research Consortium, which SSA 
is creating pursuant to section 1110 of the Social Security Act, as 
amended.[Footnote 42] SSA envisions the consortium as a 5-year 
cooperative agreement that will serve as a national resource for 
fostering high quality research, communication, and education on 
matters related to disability policy, such as identifying or 
eliminating barriers encountered by people with disabilities in 
returning to or maintaining work. 

Researchers and disability experts have commented on the limitations 
of SSA's current disability program eligibility criteria to fully 
consider whether an individual can function in the workplace due to 
limited consideration of assistive devices, including those in the 
workplace--limitations that we have also noted.[Footnote 43] Moreover, 
officials we spoke with from an organization of vocational examiners 
expressed frustration when they see young individuals who could work 
with minor accommodations being provided disability benefits likely 
throughout their working life, rather than receiving support to pursue 
work. Representatives of the organization added that minor 
accommodations can include a stool for sitting or devices to assist 
with vision impairments. Although giving broad consideration of 
assistive devices and workplace accommodations may be difficult to 
incorporate into the current disability criteria and process, 
considering how common and inexpensive workplace supports may affect 
work disability seems feasible and reasonable. 

Conclusions: 

SSA has taken important and concrete steps toward modernizing its 
disability criteria, but varied challenges may prevent the agency from 
achieving its goals. Specifically, SSA has a better process in place 
for updating medical listings but delays in meeting its own goals will 
likely continue unless the agency explicitly identifies and assigns 
the resources needed to achieve them. SSA is also taking bold and 
needed steps to replace outdated occupational information with a new 
OIS. However, especially in an era of governmentwide fiscal 
constraints, success of its OIS may hinge on SSA prioritizing its 
analysis of risks and feasible alternatives to address potential 
funding shortfalls and other significant challenges. Regardless of the 
shape and scope of the OIS, absent a complete, reliable, and 
transparent cost estimate and schedule, SSA risks schedule and 
performance shortfalls. Finally, SSA is sponsoring promising research 
to increase consideration of functional ability in its medical 
listings and other aspects of eligibility criteria--research that 
experts believe must be aligned with the design of SSA's new OIS 
system at the earliest opportunity to best serve the disability 
determination process. On the other hand, SSA is not considering the 
full range of assistive devices and workplace accommodations available 
today. While SSA and others raise valid concerns as to their universal 
availability and other considerations, in the absence of studies on 
how certain assistive devices and workplace accommodations are playing 
a role in helping individuals with impairments to stay at work or 
return to work, and their costs in comparison with potentially many 
years of disability benefit payments, SSA may be missing an 
opportunity to potentially assist individuals with disabilities to re-
engage with the workforce and to target finite resources efficiently 
and effectively. 

Recommendations for Executive Action: 

1. To achieve the goal of updating listings for each body system 
within SSA's 5-year time frame, we recommend that the Commissioner of 
Social Security explicitly identify the resources needed to achieve 
this goal, such as staff, contractors, and technology aids, and its 
plans to overcome any resource limitations. 

2. To ensure that its work to revise occupational information is 
feasible and cost effective, and to improve its chance for success, we 
recommend that the Commissioner of Social Security: 

* formally assess risks to the success of the OIS--addressing such 
challenges as related to controlling cost, acquiring expertise, 
managing project complexity, and coordinating with ongoing and related 
SSA research--and develop appropriate mitigation strategies, and: 

* develop a comprehensive and reliable cost estimate and schedule for 
the life cycle of the project, in accordance with best practices. 

3. To help ensure that SSA's disability decisions are as equitable and 
consistent with modern views of disability as possible, we recommend 
the Commissioner of Social Security conduct limited and focused 
studies on the availability and effects of considering more fully 
assistive devices and workplace accommodations in its disability 
determinations. 

Agency Comments and Our Evaluation: 

We provided a draft copy of this report to SSA and the Departments of 
Commerce, Health and Human Services, and Labor for review and comment. 
The Department of Commerce did not provide comments. SSA, Labor, and 
the Department of Health and Human Services provided technical 
comments, which we incorporated as appropriate. SSA also provided 
written comments, which are reproduced in appendix V. 

SSA agreed with the first two recommendations and disagreed with the 
third recommendation that the agency should conduct limited and 
focused studies on the availability and effects of considering more 
fully assistive devices and workplace accommodations in its disability 
determinations. SSA stated that conducting such studies is 
inconsistent with Congress' intentions. Specifically, SSA noted that 
the Americans with Disabilities Act of 1990 (ADA), as amended, 
addresses requirements for workplace accommodations. SSA referred to a 
1999 Supreme Court case which acknowledged the complexity of SSA 
involvement in determining the availability of reasonable 
accommodations and also noted that ADA determinations are separate 
from disability determinations under the Social Security Act. SSA 
asserts that because Congress has made no effort to change the balance 
between its disability programs and the ADA in the past 22 years, it 
would be inappropriate for SSA to spend its limited administrative 
resources on "an initiative that would undermine the balance Congress 
chose to strike." 

Notwithstanding SSA's response, we continue to believe that SSA should 
conduct limited and focused studies on the availability and effects of 
considering more fully assistive devices and workplace accommodations 
in its disability determination process. Although SSA asserts that 
workplace accommodations are addressed by the ADA, this act serves a 
very different purpose than SSA's disability programs. We do not think 
that the fact that workplace accommodations are addressed by the ADA 
would necessarily preclude SSA from potentially considering them in 
making disability determinations. Further, although we agree with SSA 
that Congress has not explicitly directed the agency to consider 
incorporating assistive devices and workplace accommodations into its 
disability determinations process, we also note that Congress has not 
explicitly prohibited SSA from making such considerations. Because the 
language of the Social Security Act is silent on this issue, and in 
the absence of clear Congressional intent, we think it would be 
reasonable for SSA to conduct limited studies on the feasibility of 
considering such factors. 

SSA further cites the 1999 Supreme Court decision in Cleveland v. 
Policy Management Systems Corporation to point out that assessing 
reasonable accommodation may turn on highly disputed workplace-
specific matters, and that an SSA misjudgment about that detailed 
matter could deprive a disabled person of the financial support the 
statute provides. While this is true, SSA fails to acknowledge that by 
not incorporating such factors, it may be providing benefits to 
individuals who are capable of working with accommodations, thereby 
potentially expending scarce government resources in a manner that may 
not be most appropriate. SSA's response acknowledges that the agency's 
resources are limited--a concern that we share. By conducting limited 
and focused studies on this issue, SSA would be in a better position 
to thoughtfully weigh the costs and benefits of these various policy 
options before deciding on an appropriate course of action. 

As we discussed in the report, SSA has avenues to research the 
availability of select devices or accommodations and the impact of 
their inclusion on disability determinations, such as through the SSA 
funded Disability Research Consortium, which is charged to conduct 
research to identify and eliminate barriers encountered by people with 
disabilities in returning to work or maintaining their ability to 
work. SSA could also incorporate discussion of assistive devices and 
workplace accommodations into its planned symposium with the Institute 
of Medicine that will assess the inclusion of functional measures in 
the disability determination process. Through these efforts, SSA may 
be able to identify certain common and widespread workplace 
accommodations that could be incorporated into the disability 
criteria, just as it incorporates certain medical treatments and 
assistive devices into the medical listings when they become a medical 
standard. Despite SSA's efforts to better address an individual's 
functioning in its disability criteria, without at least evaluating 
the costs and benefits of considering more assistive devices and 
workplace accommodations, SSA is likely to face ongoing barriers in 
its efforts to integrate a more modern concept of disability into its 
determination process. 

As agreed with your office, unless you publicly announce the contents 
of this report earlier, we plan no further distribution until 30 days 
from the report date. At that time, we will send copies of this report 
to the Commissioner of the Social Security Administration and the 
Secretaries of Commerce, Health and Human Services, and Labor; 
relevant congressional committees; and other interested parties. In 
addition, this report will be available at no charge on GAO's website 
at [hyperlink, http://www.gao.gov]. 

If you or your staff have any questions about this report, please 
contact me at (202) 512-7215 or bertonid@gao.gov. Contact points for 
our Offices of Congressional Relations and Public Affairs may be found 
on the last page of this report. GAO staff who made key contributions 
to this report are listed in appendix VI. 

Sincerely yours, 

Signed by: 

Daniel Bertoni, Director: 
Education, Workforce, and Income Security Issues: 

[End of section] 

Appendix I: Objectives, Scope, and Methodology: 

We were asked to assess the Social Security Administration's (SSA) 
plans and efforts to revise its disability criteria. Specifically, we 
examined the status and management of efforts to update its medical 
listings to reflect current medical knowledge and develop a new 
occupational information system (OIS) to reflect labor market changes, 
and we identified other steps taken by SSA to incorporate a modern 
view of disability into its eligibility criteria. For this review, we 
narrowed our scope to criteria used for initial adult disability 
determinations that involve the medical listings at step 3 or a 
medical-vocational assessment at steps 4 and 5 of SSA's five-step 
sequential process. 

To determine the status of activities to revise the medical listings 
and to develop the OIS, we reviewed our prior reports on the subject 
and SSA Office of Inspector General reports, relevant federal laws and 
regulations, and program documentation. This documentation included 
policies, such as those listed in SSA's Program Operations Manual 
System for examiners; strategic goals for fiscal years 2011 and 2012 
presented in the Agency Performance Plan for 2012; and other guidance. 
We also interviewed SSA officials from relevant offices with direct 
responsibility for revising disability criteria, as well as those 
offices that provide support for these efforts, and key project 
contractors and stakeholders. To obtain contextual information on 
modernization, we reviewed relevant literature, including studies, 
position papers, and testimonies from disability groups and 
commissions and interviewed disability experts. We assessed the 
reliability of data used in this report and found it to be 
sufficiently reliable for our purposes. 

To determine the extent to which SSA's efforts to revise its medical 
listings and develop a new OIS were anchored in sound project 
management practices, we first identified sound project management 
practices by reviewing A Guide to the Project Management Body of 
Knowledge, our guidance on internal controls, and the Government 
Performance and Results Act of 1993. We also identified our recent 
work (for fiscal years 2008, 2009, and 2010) that evaluated federal 
planning efforts. Through these efforts, we identified six practices 
for sound project management which we used as a framework for 
evaluating SSA's efforts to revise the medical listings and develop 
the OIS. Although there is no established set of requirements for all 
plans, we determined that these practices help implementing parties 
and decision makers effectively shape policies, programs, priorities, 
and resource allocations so that they can achieve desired results 
while ensuring accountability. While these practices may be organized 
in a variety of ways or use different terms, for the purposes of this 
report, we grouped them into six categories, from plan conception to 
implementation. Given the differences among SSA's efforts to update 
the medical listings and develop the OIS, we selected broad, higher-
level criteria that may apply to a wide variety of projects or plans 
(see table 5). 

Table 5: Six Sound Project Management Practices Used to Evaluate SSA's 
Efforts: 

Project management practice: Plan to identify problem, goals, and 
methodology; 
Description: In establishing the problem, goals, and methodology, the 
agency identifies the problem to be addressed and the causes of the 
problem, as well as the strategy, including goal and objectives, and 
the methodology for achieving these goals and objectives. 

Project management practice: Activities and timeline; 
Description: An agency should identify and document the specific 
activities that must be performed in order to complete the project. 
The agency should develop a schedule that defines, among other things, 
when work activities will occur, how long they will take, and how they 
are related to one another, as well as interim milestones and 
checkpoints to gauge the completion of the project. 

Project management practice: Resources; 
Description: The agency should identify the sources and types of 
resources or investments needed (e.g., budgetary, human capital, 
information technology, research and development, contracts) to 
complete project activities. If resource availability cannot be 
assured, the agency will need to establish alternate plans. The agency 
should develop a reliable estimate of the costs of these resources. 

Project management practice: Coordination; 
Description: The agency should identify stakeholders--individuals and 
organizations that are involved in or may be affected by project 
activities--and ensure that they are included in developing and 
executing the project plan, allowing them to contribute appropriately. 
In addition to internal communications, management should ensure there 
are adequate means of communicating with, and obtaining information 
from, external stakeholders that may have a significant impact on the 
agency achieving its goals. 

Project management practice: Risk; 
Description: Risk assessment generally includes estimating the 
significance of risks from both external and internal sources, 
assessing the likelihood of its occurrence, and deciding how to manage 
the risk. 

Project management practice: Performance evaluation; 
Description: The agency should describe how goals will be achieved and 
establish performance indicators to be used in measuring or assessing 
the relevant outputs, service levels, and outcomes of each program 
activity, and identify a process to monitor and report on progress. 

Source: GAO analysis based on Project Management Institute 
information, the Government Performance and Results Act of 1993, and 
GAO reports. 

[End of table] 

Additionally, we compared the cost estimate and schedule for 
completing SSA's OIS and related documents with best practices in our 
Cost Estimating and Assessment Guide. We compared these practices to 
the OIS project because it requires a significant commitment of 
resources and time by SSA to complete and will result in an end 
product. For SSA's OIS cost estimate and schedule, we scored each best 
practice as follows: 

* Not met--SSA provided no evidence that satisfies any of the criteria. 

* Minimally met--SSA provided evidence that satisfies a small portion 
of the criteria. 

* Partially met--SSA provided evidence that satisfies about half of 
the criteria. 

* Substantially met--SSA provided evidence that satisfies a large 
portion of the criteria. 

* Met--SSA provided complete evidence that satisfies the entire 
criteria. 

We provided the results of our schedule and cost analyses to SSA 
officials and met with them to confirm the results. Based on the 
interviews and additional documentation provided by SSA officials, we 
updated the results of our analyses, as needed. 

[End of section] 

Appendix II: Progress Updating Six Body Systems since Last 
Comprehensive Revision: 

[Figure: see PDF for image: timeline] 

Speech: 
Comprehensive update: 1978; 
Advance notice of proposed rulemaking (ANPRM) published: 2005; 
Expiration date: 2015; 
Years since last comprehensive review: 33. 

Balance: 
Comprehensive update: 1978; 
Advance notice of proposed rulemaking (ANPRM) published: 2005; 
Expiration date: 2015; 
Years since last comprehensive review: 33. 

Neurological disorders: 
Comprehensive update: 1985; 
Advance notice of proposed rulemaking (ANPRM) published: 2005; 
Expiration date: 2012; 
Years since last comprehensive review: 27. 

Mental disorders: 
Comprehensive update: 1985; 
Notice of proposed rulemaking (NPRM) published: 1992; 
Partial update: 2000; 
Advance notice of proposed rulemaking (ANPRM) published: 2003; 
Notice of proposed rulemaking (NPRM) published: 2010; 
Expiration date: 2012; 
Years since last comprehensive review: 27. 

Hematological disorders: 
Comprehensive update: 1985; 
Partial update: 1987; 
Notice of proposed rulemaking (NPRM) published: 2002; 
Notice of proposed rulemaking (NPRM) withdrawn: 2004; 
Expiration date: 2012; 
Years since last comprehensive review: 27. 

Musculoskeletal system: 
Comprehensive update: 1985; 
Notice of proposed rulemaking (NPRM) published: 1993; 
Partial update: 2002; 
Expiration date: 2013; 
Years since last comprehensive review: 27. 

Respiratory system: 
Comprehensive update: 1993; 
Notice of proposed rulemaking (NPRM) published: 1996; 
Advance notice of proposed rulemaking (ANPRM) published: 2005; 
Expiration date: 2012; 
Years since last comprehensive review: 19. 

Source: GAO analysis of interviews with agency officials and related 
documents. 

Note: SSA's special senses and speech listings include impairments 
associated with speech and balance (i.e., disorders of the 
labyrinthine-vestibular function). 

[End of section] 

Appendix III: Description of Cost Estimating Best Practices: 

Characteristic[A]: Comprehensive; 
Characteristic description: The cost estimate should include all costs 
necessary to achieve agency objectives including government and 
contractor labor costs as well as any necessary material or equipment 
costs. Comprehensive cost estimates should be structured in sufficient 
detail to ensure that cost elements are neither omitted nor double 
counted. Specifically, the cost estimate should be based on a 
standardized structure that allows a program to track cost and 
schedule consistently over time. Finally, where information is limited 
and judgments must be made, the cost estimate should document all cost-
influencing ground rules and assumptions. 

Characteristic[A]: Well documented; 
Characteristic description: The cost estimate should be supported by 
detailed documentation that describes the purpose of the estimate, the 
program background and system description, the scope of the estimate, 
the ground rules and assumptions, all data sources, estimating 
methodology and rationale, and the results of the risk analysis. 
Moreover, this information should be captured in such a way that the 
data used to derive the estimate can be traced back to, and verified 
against, the sources. 

Characteristic[A]: Accurate; 
Characteristic description: The cost estimate should be based on an 
assessment of most likely costs (adjusted for inflation), documented 
assumptions, historical cost estimates, and actual experiences on 
other comparable programs. Estimates should be cross-checked against 
an independent cost estimate for accuracy, double counting, and 
omissions. In addition, the estimate should be updated to reflect any 
changes. 

Source: GAO analysis. 

[A] We did not assess SSA's estimate on a fourth characteristic--
credibility--which evaluates any limitations of the analysis because 
of uncertainty or biases surrounding data or assumptions, as this 
criterion is most applicable to major capital acquisitions. 

[End of table] 

[End of section] 

Appendix IV: Description of Scheduling Best Practices: 

Best practice: Capturing all activities; 
Description: A schedule should reflect all activities defined in the 
program's work breakdown structure and include all activities to be 
performed by the government and contractor. 

Best practice: Sequencing all activities; 
Description: The schedule should be planned so that all activities are 
logically sequenced in the order they are to be carried out. 

Best practice: Assigning resources to all activities; 
Description: The schedule should realistically reflect the resources 
(i.e., labor material and overhead) needed to do the work, whether all 
required resources will be available when needed, and whether any 
funding or time constraints exist. 

Best practice: Establishing the duration of all activities; 
Description: The schedule should reflect how long each activity will 
take to execute. 

Best practice: Integrating schedule activities horizontally and 
vertically; 
Description: The schedule should be horizontally and vertically 
integrated--that is, it should link already sequenced activities with 
outcomes while also delineating the relation of supporting tasks and 
subtasks to upper-level milestones. Such mapping among levels enables 
different groups to work to the same master schedule. 

Best practice: Establishing the critical path for all activities; 
Description: The schedule should identify the critical path, or those 
activities that, if delayed, will negatively impact the overall 
project completion date. The critical path enables analysis of the 
effect delays may have on the overall schedule. 

Best practice: Identifying float between activities; 
Description: The schedule should identify float--the amount of time an 
activity can slip in the schedule before it affects other activities--
so that flexibility in the schedule can be determined. As a general 
rule, activities along the critical path typically have the least 
amount of float. 

Best practice: Conducting a schedule risk analysis; 
Description: The schedule should include a schedule risk analysis that 
uses statistical techniques to predict the probability of meeting a 
completion date. A schedule risk analysis can help management identify 
and understand the most important risks and focus on mitigating them. 

Best practice: Updating the schedule using logic and durations to 
determine dates; 
Description: The schedule should use realistic durations for 
activities and be monitored to determine when forecasted completion 
dates differ from the planned dates. This analysis can be used to 
assess whether schedule variances will affect future work. 

Source: GAO analysis. 

[End of table] 

[End of section] 

Appendix V: Comments from the Social Security Administration: 

Social Security: 
Office of the Commissioner: 
Social Security Administration: 
Baltimore, MD 21235-0001: 

May 30, 2012: 

Mr. Daniel Bertoni, Director: 
Education, Workforce, and Income Security Issues: 
United States Government Accountability Office: 
441 G. Street, NW: 
Washington, D.C. 20548: 

Dear Mr. Bertoni, 

Thank you for the opportunity to review the draft report, "Modernizing 
SSA Disability Programs: Progress Made, but Key Efforts Warrant More 
Management Focus" (GA0-12-420). Our response is enclosed. 

If you have any questions, please contact me at (410) 965-0520. Your 
staff may contact Amy Thompson, Senior Advisor for Records Management 
and Audit Liaison Staff, at (410) 966-0569. 

Sincerely, 

Signed by: 

Dean S. Landis: 
Deputy Chief of Staff: 

Enclosure: 

[End of letter] 

Comments On The Government Accountability Office Draft Report, 
"Modernizing SSA Disability Programs: Progress Made, But Key Efforts 
Warrant More Management Focus" (GAO-12-420): 

Recommendation 1: 

To achieve the goal of updating listings for each body system within 
SSA's 5-year timeframe, we recommend that the Commissioner of Social 
Security explicitly identify the resources needed to achieve this 
goal, such as staff, contractors and technology aids, and its plans to 
overcome any resource limitations. 

Response: 

We agree. 

Recommendation 2: 

To ensure that its work to revise occupational information is feasible 
and cost effective, and to improve its chance for success, we 
recommend that the Commissioner: 

* formally assess risks to the success of the OIS—addressing such 
challenges as related to controlling cost, acquiring expertise, 
managing project complexity and coordinating with ongoing and related 
SSA research—and develop appropriate mitigation strategies; and; 

* develop a comprehensive and reliable cost estimate and schedule for 
the life cycle of the project, in accordance with best practices. 

Response: 

We agree. We will explore the possibility of incorporating O*NET and 
resources from other agencies in order to advance the project. 

Recommendation 3: 

To help ensure that SSA's disability decisions are as equitable and 
consistent with modern views of disability as possible, we recommend 
the Commissioner conduct limited and focused studies on the 
availability and effects of considering more fully assistive devices 
and workplace accommodations in its disability determinations. 

Response: 

We disagree because we see such studies as inconsistent with Congress' 
intentions. The Americans with Disabilities Act (ADA) of 1990, as 
amended (See 42 U.S.C. § 12111) addresses the requirements for 
workplace accommodations. The Supreme Court recognized in Cleveland v. 
Policy Management Systems Corporation, 526 U.S. 795, 119 S. Ct. 1597 
(1999), that ADA determinations were separate from disability 
determinations under the Social Security Act, stating: 

... the ADA defines a "qualified individual" to include a disabled 
person "who ... can perform the essential functions" of her job "with 
reasonable accommodation." Reasonable accommodations may include: "job 
restructuring, part-time or modified work schedules, reassignment to a 
vacant position, acquisition or modification of equipment or devices, 
appropriate adjustment or modifications of examinations, training 
materials or policies, the provision of qualified readers or 
interpreters, and other similar accommodations." 42 U.S.C. § 
12111(9)(B). By way of contrast, when the SSA determines whether an 
individual is disabled for SSDI purposes, it does not take the 
possibility of "reasonable accommodation" into account, nor need an 
applicant refer to the possibility of reasonable accommodation when 
she applies for SSDI. 

The Court noted that SSA receives millions of claims for disability 
benefits each year, that our administrative resources are limited, and 
that "the matter of 'reasonable accommodation' may turn on highly 
disputed workplace-specific matters; and an SSA misjudgment about that 
detailed, and often fact-specific matter would deprive a seriously 
disabled person of the critical financial support the statute seeks to 
provide." Congress has made no effort to change the balance between 
our disability programs and the ADA in the past twenty-two years, and 
we do not think it would be appropriate for us to spend our limited 
administrative resources on studies to support an initiative that 
would undermine the balance Congress chose to strike. 

[End of section] 

Appendix VI: GAO Contact and Staff Acknowledgments: 

GAO Contact: 

Daniel Bertoni, (202) 512-7215 or bertonid@gao.gov: 

Staff Acknowledgments: 

In addition to the contact named above, Michele Grgich, Assistant 
Director; James Bennett; Kate Blumenreich; Tisha Derricotte; Jennifer 
Echard; Julie DeVault; Alex Galuten; Sheila McCoy; Patricia M. Owens; 
Carol Petersen; Karen Richey; Anjali Tekchandani; Kathleen Van Gelder; 
and Walter Vance made key contributions to this report. Also 
contributing to this report were Jaime Allentuck, Susan Bernstein, and 
Amy Frazier. 

[End of section] 

Footnotes: 

[1] The DI program provides monthly cash benefits to eligible 
applicants who have a sufficient work record. The SSI program provides 
monthly benefits to eligible applicants with limited income and 
resources who are disabled, blind, or age 65 or older. 

[2] 42 U.S.C. §§ 423(d)(1)(A) and 1382c(a)(3)(A). Substantial gainful 
activity is generally work activity involving significant physical or 
mental activities that are done for pay or profit, whether or not a 
profit is realized. 20 C.F.R. §§ 404.1572 and 416.972. In 2012, the 
substantial gainful activity threshold was $1,690 per month for blind 
recipients and $1,010 per month for individuals with other 
disabilities. 

[3] See 20 C.F.R. §§ 404.1520 and 416.920. 

[4] According to SSA officials, there are almost 300 medical 
impairments organized in 119 listings under the 14 major body systems 
for adults. 

[5] SSA has also implemented Compassionate Allowances to quickly 
identify diseases and other medical conditions that invariably qualify 
under the medical listings based on minimal, objective medical 
information. According to SSA officials, many of the Compassionate 
Allowances conditions are rare, and thus unfamiliar to examiners, such 
as certain cancers and early-onset Alzheimer's disease. In April 2012, 
SSA announced that 165 conditions would be on the list effective in 
August 2012, up from 113 conditions as of the time this report issued 
in June 2012. The Compassionate Allowances initiative is one of two 
parts of the agency's fast-track system for certain disability claims. 
When combined with the Quick Disability Determination process, which 
uses a predictive model to identify cases with a high likelihood of 
being allowed, Social Security reported approving more than 100,000 
fast-track cases in 2009, usually in less than 2 weeks. 

[6] SSA's physical and mental residual functional capacity assessments 
establish the extent to which an individual's medically determinable 
impairments, including any related symptoms, such as pain, may cause 
physical or mental limitations or restrictions that may affect his or 
her capacity to do work-related physical and mental activities. 

[7] SSA relies on the grid rules to represent the total number of 
unskilled jobs in the nation at three physical strength levels as 
classified in the DOT, and to provide for consistent "rulemaking" or 
application of case facts to help ensure uniform decisions. 

[8] Historically, SSA created the listings to have a clear set of 
medical conditions that, if present, would preclude work. This in turn 
would limit the number of cases requiring a more involved and 
individualized assessment of function. 

[9] In 1994, when the Congress passed legislation establishing SSA as 
an independent agency, it also created the seven-member bipartisan 
Social Security Advisory Board in part to advise the President, 
Congress, and the Commissioner of Social Security on Social Security 
and SSI policy. Pub. L. No. 103-296, § 103, 108 Stat. 1464, 1467. 

[10] GAO, Federal Disability Programs: More Strategic Coordination 
Could Help Overcome Challenges to Needed Transformation, [hyperlink, 
http://www.gao.gov/products/GAO-08-635] (Washington, D.C.: May 20, 
2008). 

[11] Any changes to the medical listings have to proceed according to 
an established process for rulemaking outlined in federal law. As 
such, when changes are made to the listings, a notice of proposed 
rulemaking must generally be published in the Federal Register with a 
public comment period before the final rule is issued. 5 U.S.C. § 553. 
Also, the Office of Management and Budget must review and approve any 
notice that is economically significant (i.e., has costs or savings 
greater than $100 million). 

[12] Such reviews typically rely on reviews of decision data as well 
as surveys of field staff responsible for applying the revised 
listings. 

[13] The DOT was updated in 1991, but for less than 20 percent of the 
occupations. 

[14] O*NET is a general purpose occupational information database used 
for workforce development, economic development, career exploration, 
and academic and policy research. Selected occupations within the 
O*NET system are updated each year. According to Labor officials, by 
July 2012, 900 occupations will have been comprehensively updated, and 
413 will have more than one update. 

[15] See, for example, 42 U.S.C. § 12112(b)(5). 

[16] See Social Security Advisory Board, The Social Security 
Definition of Disability (Washington, D.C.: October 2003). 

[17] David Wittenburg and Pamela Loprest, A More Work Focused 
Disability Program? Challenges and Options (Washington, D.C.: Nov. 1, 
2003). 

[18] Officials noted that these ongoing reviews could also result in 
major or even no changes, as appropriate. 

[19] The 5-year period will be applied to listings under a body system 
upon completion of their current revision. SSA began applying the 5-
year period in 2011 when it comprehensively updated the endocrine body 
system listings. For other body system listings updated prior to 2011, 
SSA generally assigned periods extending beyond 5 years. 

[20] Institute of Medicine, Improving the Social Security Disability 
Decision Process (Washington, D.C.: 2007). 

[21] For the reports, see Institute of Medicine, Cardiovascular 
Disability: Updating the Social Security Listings (Washington, D.C.: 
2010), and HIV and Disability: Updating the Social Security Listings 
(Washington, D.C.: 2010). 

[22] SSA officials noted that while the most common endocrine 
disorder, diabetes, can be disabling, this is due to its effects on 
other organs such as the heart or kidneys; as such, they can be 
assessed under listings for these body systems or the effects on 
functionality can be assessed at steps 4 or 5. 

[23] According to SSA officials, SSA made limited, but not 
comprehensive, revisions to the mental disorders listings in 2000. 

[24] See 75 Fed. Reg. 51,336 (Aug. 19, 2010). 

[25] According to agency officials, in addition to updating adult 
listings the agency must also update listings for children, which adds 
to its workload and resource needs. 

[26] Under the Administrative Procedure Act, a notice of proposed 
rulemaking is generally required for regulatory revision, but an 
advanced notice is not required. See 5 U.S.C. § 553. 

[27] The DOT provides a wide range of occupational information that 
could be used for job placement, occupational research, career 
guidance, labor-market information, curriculum development, and long-
range job planning. 

[28] In 1966, SSA contracted with Labor to produce a companion volume 
to the DOT entitled the Selected Characteristics of Occupations that 
provides measures for additional physical demands of work for DOT 
occupations, such as climbing, balancing, reaching, handling, special 
senses requirements (visual acuity, hearing, etc.), and environmental 
requirements (noise levels, exposure to cold, etc.). 

[29] The Occupational Information Development Advisory Panel was 
formed in December 2008 under the Federal Advisory Committee Act, and 
broadly includes representatives of organizations that have used the 
DOT or other occupational information systems, and subject matter 
experts. The panel was originally comprised of 11 members, including 
an SSA official. Over time, some members resigned and additional 
members were added. 

[30] The Occupational Employment Statistics program produces 
employment and wage estimates for approximately 800 occupations. The 
U.S. Census Bureau's household surveys include (1) the American 
Community Survey, which is an ongoing survey that provides annual data 
on demographics such as age, education, and disabilities, and (2) the 
Current Population Survey, which is primarily a labor force survey, 
conducted every month by the U.S. Census Bureau for the Bureau of 
Labor Statistics and provides data such as the national employment 
rate. 

[31] Some of the activities that were part of the research and 
development plan were completed in years prior to the plan's issuance. 

[32] GAO, GAO Cost Estimating and Assessment Guide: Best Practices for 
Developing and Managing Capital Program Costs, [hyperlink, 
http://www.gao.gov/products/GAO-09-3SP] (Washington, D.C.: March 2009). 

[33] We did not assess SSA's estimate on a fourth criterion--
credibility--which evaluates any limitations of the analysis because 
of uncertainty or biases surrounding data or assumptions, as this 
criterion is most applicable to major capital acquisitions. 

[34] O*NET's annual maintenance cost may constitute a lower bound 
estimate for the OIS, since SSA has considered more intensive data 
collections than a paper-or web-based survey questionnaire and a 
larger number of occupations. Another occupational information system 
maintained by the U.S. Bureau of Labor Statistics--the Occupational 
Employment Statistics program--costs around $30 million annually to 
maintain. This program also covers about 800 occupations predominantly 
using a mail survey, but may involve additional surveys, telephone 
interviews, or site visits to reach nonrespondents. 

[35] Risk assessment helps decision makers identify and evaluate 
potential risks to an agency's mission, so that countermeasures can be 
designed and implemented to prevent or mitigate the risks. As part of 
a risk assessment, agencies could identify alternatives to alter the 
likelihood or outcome of a high risk situation. 

[36] GAO, Social Security Disability: Management Controls Needed to 
Strengthen Demonstration Projects, [hyperlink, 
http://www.gao.gov/products/GAO-08-1053] (Washington, D.C.: Sept. 26, 
2008). 

[37] SSA's most recent redesign effort--the Disability Service 
Improvement initiative--was suspended in large part in 2007 by the new 
Commissioner, due to budgetary and other considerations. 

[38] Specifically, while the OIS is identifying functional 
requirements in the workplace, another SSA office is working through 
an interagency agreement with the National Institutes of Health to 
identify methods to more accurately capture the functional capacity of 
individuals. Both SSA and its advisory panel recognize that SSA's 
disability criteria must reflect both the capabilities of people and 
work demands, and that the OIS must be designed and developed to 
support SSA's process for assessing individual function. As such, some 
stakeholders believe it is critical that these two efforts be fully 
aligned for the overall success of the disability determination 
process. 

[39] Current users of the DOT include organizations in the private and 
public sectors, such as companies providing life insurance and short 
and long term disability insurance, and organizations providing state 
and federal vocational rehabilitation services, among others. 

[40] As noted earlier, the ICF focuses on ability to function despite 
a medical impairment, including taking into account the impact of 
environmental factors, such as products and technology, attitudes, and 
services. The World Health Organization developed the ICF as a 
universal classification of disability and health for use in health 
and health-related sectors, especially as a planning and policy tool 
for decision makers. All 191 World Health Organization member states 
endorsed the use of the ICF as the international standard to describe 
and measure health and disability. As a result, the international 
community now has classification schema that provides both a common 
language and underlying code for disability terminology. There are 
four basic ICF domains, with associated codes, in the ICF 
classification: Body Functions, Body Structures, Activities and 
Participation, and Environmental Factors. 

[41] Boston University's Health and Disability Research Institute is 
developing this tool under a subcontract with NIH. The tool is based 
on Item Response Theory using Computer Adaptive Testing. The tool is 
adaptive in the sense that each item that is administered is tailored 
to the unique level of functioning of an individual. The items are 
selected based on the individual's prior responses assessing that 
individual's level of function, while precision is gained regarding a 
person's placement along a continuum of functioning by asking more 
questions at the level that is appropriate for that individual. 

[42] See 42 U.S.C. § 1310. 

[43] GAO, SSA Disability Programs: Fully Updating Disability Criteria 
Has Implications for Program Design, [hyperlink, 
http://www.gao.gov/products/GAO-02-919T] (Washington, D.C.: July 11, 
2002). 

[End of section] 

GAO’s Mission: 

The Government Accountability Office, the audit, evaluation, and 
investigative arm of Congress, exists to support Congress in meeting 
its constitutional responsibilities and to help improve the 
performance and accountability of the federal government for the 
American people. GAO examines the use of public funds; evaluates 
federal programs and policies; and provides analyses, recommendations, 
and other assistance to help Congress make informed oversight, policy, 
and funding decisions. GAO’s commitment to good government is 
reflected in its core values of accountability, integrity, and 
reliability. 

Obtaining Copies of GAO Reports and Testimony: 

The fastest and easiest way to obtain copies of GAO documents at no 
cost is through GAO’s website [hyperlink, http://www.gao.gov]. Each 
weekday afternoon, GAO posts on its website newly released reports, 
testimony, and correspondence. To have GAO e-mail you a list of newly 
posted products, go to [hyperlink, http://www.gao.gov] and select 
“E-mail Updates.” 

Order by Phone: 

The price of each GAO publication reflects GAO’s actual cost of 
production and distribution and depends on the number of pages in the 
publication and whether the publication is printed in color or black 
and white. Pricing and ordering information is posted on GAO’s 
website, [hyperlink, http://www.gao.gov/ordering.htm]. 

Place orders by calling (202) 512-6000, toll free (866) 801-7077, or 
TDD (202) 512-2537. 

Orders may be paid for using American Express, Discover Card, 
MasterCard, Visa, check, or money order. Call for additional 
information. 

Connect with GAO: 

Connect with GAO on facebook, flickr, twitter, and YouTube.
Subscribe to our RSS Feeds or E mail Updates. Listen to our Podcasts.
Visit GAO on the web at [hyperlink, http://www.gao.gov]. 

To Report Fraud, Waste, and Abuse in Federal Programs: 

Contact: 
Website: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]; 
E-mail: fraudnet@gao.gov; 
Automated answering system: (800) 424-5454 or (202) 512-7470. 

Congressional Relations: 

Katherine Siggerud, Managing Director, siggerudk@gao.gov, (202) 512-4400
U.S. Government Accountability Office, 441 G Street NW, Room 7125
Washington, DC 20548. 

Public Affairs: 
Chuck Young, Managing Director, youngc1@gao.gov, (202) 512-4800
U.S. Government Accountability Office, 441 G Street NW, Room 7149 
Washington, DC 20548.