IOM Sides with Psychological Science

In an April 10, 2015 report, Institute of Medicine (IOM) authors sided with psychological science saying that not only should psychological testing be routinely performed in many types of Social Security Disability claims, but that the use of symptom validity testing in particular is needed when there are questions of credibility.

The IOM’s findings are another volley in the now decade-long debate between psychological scientists and policy makers at the Social Security Administration (SSA). The IOM began its review in 2013 after members of Congress and the Office of Inspector General put pressure on the SSA to change its policy. Instead of complying, the agency said it disagreed and would seek out an independent review from the IOM. If the SSA follows the IOM recommendations it could save taxpayers between $20 billion and an estimated $68 billion or more, per year.

At the center of the debate is New Orleans clinical neuropsychologist, Dr. Michael Chafetz, one of a small group of psychological scientists around the country who began to notice disturbing patterns as he went about performing routine disability evaluations as a consulting psychologist. The controversy hinges on the agency’s steadfast resistance to using modern psychometrictools to measure malingering despite the consensus in scientific circles these tools are needed for accuracy. This position also runs counter to other federal agencies and private industry.

On the surface of the issue, the debate has involved the use of symptom validity tests, known as SVTs, in disability evaluations. But underneath, the politically sensitive and disturbing problem of malingering in disability claims is at issue. As psychological science has improved its methods, research with SVTs has shown that up to 40 percent or more of claims include some level of malingering. This can be an especially thorny issue in claims of mental impairment (low IQ), in emotional disorders such as depression, and in some physical claims, such as chronic pain. 

In the IOM report, titled Psychological Testing in the Service of Disability Determination, authors recommend the use of standardized psychological tests, administered and interpreted by psychologists, for mental disorders and whenever somatic complaints are not fully supported by physical test results. They also recommend the use of SVTs when needed for accuracy. Chafetz and colleagues collected archived data to understand the accuracy of their results, also called validity, research that the SSA does not do for itself. But the reception for their efforts has not always been welcoming.

In 2007 Dr. Michael Chafetz and coauthors published the first peer-reviewed research article about malingering in Social Security claims, “Malingering on the Social Security Disability Consultative Examination: A New Rating Scale,” in Archives of Clinical Neuropsychology.

Prior to this, in 2003, Chafetz had shared his research with the local Disability Determinations Service (DDS) for a training workshop, “Malingering on the DDS consultative examination in psychology.” The DDS coordinator congratulated him on his research efforts and thanked him for the workshop, according to internal emails obtained by the Times.

But after publication of the 2007 article, DDS severed their relationship with Chafetz. He had previously performed almost 1,000 disability evaluations for the agency over the years, without complaint. According to emails obtained from DDS, the officials were concerned about the article and study of claimant results, and were in contact with the regional office about what to do about Chafetz. The emails were not specific on the reason for his release. Chafetz has repeatedly declined to comment on this issue, saying that it is private and that the agency had the right to discontinue with him at any time. However, along with colleagues in other areas of the country, Chafetz continued to do basic research, using anonymous claimant data, and in particular, the use of SVTs. The researchers began to see troublingly high “base rates.” As part of a series of research articles, researchers have found base-rates of malingering in social security claims of 41.8 percent. This is higher than the 30 percent that is typically found in legal cases.

Researchers have also demonstrated that malingering is “dose dependent.” There are higher levels of malingering in those seeking the higher benefits or compensation, and also higher levels when the claimant is seeking federal dollars. Chafetz has also described malingering by “proxy,” where children were coached to fake by a parent.

One of SSA’s complaints is that low-IQ individuals, those seeking benefits for intellectual disability, are unfairly labeled as malingering. However, in a study titled, “To Work or Not To Work: Motivation (Not Low IQ) Determines Symptom Validity Test Findings,” Chafetz and colleagues Drs. Erica Prentkowski and Aparna Rao cast doubt on this concern. They compared three groups of low IQ individuals. One group was seeking disability benefits, another group was seeking employment, and a third group was trying to get custody of their children. Only those seeking compensation scored high on malingering. Chafetz and colleagues have published 15 articles on the topic. He has presented his work repeatedly, including at the American Psychological Association and the Louisiana Psychological Association (LPA). Recently Chafetz has authored Intellectual Disability: Criminal and Forensic Issues, published by Oxford Press, which includes many of these issues.

However at one point, officials at DDS sent a letter to all of its consulting psychologists cautioning them about the content of a presentation by Chafetz, hosted by LPA. DDS officials were not willing to provide comment on the matter.

Psychologists have had little success influencing SSA positions. In 2008 the president of the National Academy of Neuropsychology, president of the American Academy of Clinical Neuropsychology (AACN), and others, joined in signing a letter by Chafetz sent to SSA advocating the use of validity tests. According to Chafetz, shortly after that the AACN created a committee on the issues and held a teleconference with SSA to discuss the issues. In 2010, the neuropsychology division of the American Psychological Association also created a task force that then provided guidance on new SSA rules.

By 2012 U.S. Senator Tom Coburn became involved in trying to update procedures at the SSA. Coburn, now retired, is known for his efforts to uncover government waste. In 2011, through the U.S. Senate Permanent Subcommittee on Investigations, committee on Homeland Security and Governmental Affairs, Coburn was studying problems with backlogs in disability appeals. Appeals rose from 12,000 in 1999 to 817,000 in 2012, according to the U.S. Budget Office. The increase had to be processed by Administrative Law Judges (ALJs) who were struggling with extremely high case loads causing years long wait times for decisions.

Coburn’s research found errors rates of 25 percent and insufficient evidence in decisions by ALJs. Some judges approved appeals simply because they did not have time to study the case, according to a report by the Cato Institute. Senator Coburn was referred to Chafetz by an ALJ, Chafetz explained to the Times. And in September 2012, Chafetz provided a special presentation in the public interest for Coburn’s office, through the Louisiana Psychological Association Online Academy.

By January 30, 2013, Coburn wrote to SSA Commissioner, Michael Astrue, asking that the agency fund psychological tests that measure malingering.

“… the agency’s decision stands in stark contrast to current scientific research and findings,” Coburn said and pointed out the support for use of symptom validity tests to identify malingering in psychological evaluations. “In fact, there is broad consensus within the medical community that malingering is a problem and must be addressed,” he wrote.

Coburn noted that there could be $20 billion in a single year of benefits for “malingered mental disorders alone.” He also said, “Translating these base-rates of malingering to benefit payments is alarming.” And, “If one considers that ‘disability,’ which is defined as an inability to work, can be feigned no matter what the illness, then the agency spent approximately $68 billion (or 40 percent of $170 billion in total net benefit payments) in 2011 on disability beneficiaries who were likely malingering.”

Coburn criticized the SSA, saying “… the agency has no idea of its inability to measure the impact of the fraud occurring under its own roof.”

In March 2013, Chairman for the U.S. Committee on Oversight and Government Reform, Darrell Issa, wrote Acting SSA Commissioner Carolyn Colvin. Issa pointed to a number of OIG recommendations that SSA had not implemented. These included improvements to continuing disability reviews, reporting to Congress, conducting of additional work related reviews, revisions to benefit payments, and prosecuting false applications. According to Issa’s letter, the recommendations either had not been implemented or the outcome was unknown. Issa and coauthors also sited Coburn’s findings and the agency’s failure to address “insufficient, contradictory or incomplete evidence,” in disability claims.

In April 2013, Chafetz was asked to present for the Inspector General’s Office (OIG) and by September 2013 the OIG released a report pointing to flaws in SSA’s policy. In “Congressional Response Report: The Social Security Administration’s Policy on Symptom Validity Tests in Determining Disability Claims,” the OIG investigators said that the SSA runs contrary to scientific and medical consensus, other federal agencies such as Veterans Affairs, and standard practice in the private insurance sector, when it refuses to allow the use of SVTs.

The OIG concluded, “While SSA does not allow the purchase of SVTs for its disability determinations, we found that medical literature, national neuropsychological organizations, other Federal agencies, and private disability insurance providers support the use of SVTs in determining disability claims.”

The SSA was still resistant. Their response was authored by a CPA and Financial Manger, Mr. Gary Hatcher.

Mr. Hatcher wrote, “We believe that tests cannot prove malingering, as there are no tests that conclusively determine the presence of inaccurate patient self-reporting. We do not give greater weight to a test than to other symptom validity factors.”

“In addition,” Hatcher wrote, “we plan to seek external expertise on psychological tests from the Institute of Medicine [IOM] to include an examination of published research and studies on SVTs, including those published by Dr. Chafetz. Our goal is to determine the effectiveness and costs of requiring and purchasing SVTs under our disability programs, as well as their applicability to anyone who claims they are disabled.”

Hatcher concluded, “We provided technical comments and listings from medical literature on the shortcomings of SVTs at the staff level.” And, “We have no further comments,” he said.

Last week the Times asked the IOM if there was a committee or other action to address the report findings and the IOM said that while they work closely with SSA, this has not been addressed as yet. As of this date, the Times has not found any public response from the SSA about the April report.

IOM Recommendations

1. The SSA should require psychological testing for “all applicants” when claims relate to either a) mental disorders unaccompanied by cognitive complaints; or b) claims where “somatic symptoms are disproportionate to medical findings.” Statements of validity should be included, which “could include” symptom validity tests.

2. The SSA should require standardized cognitive testing for “all applicants” when claims do not include objective, medical evidence. Again, a statement of validity should be included, and could include performance or symptom validity testing.

3. The SSA should require that testing be performed by “qualified specialists properly trained in the administration and interpretation of standardized psychological tests.” The IOM says the specialist must be licensed or certified to administer and interpret psychological tests.

4. The SSA should conduct research to investigate the “accuracy and consistency of SSA’s disability determinations with and without the use of recommended psychological testing.”

5. The SSA (in collaboration with other agencies) should evaluate the impact of these recommendations on its outcomes, including backlogged cases, time delays, number of appeals, accuracy, and “Effect on state-tostate variation in disability allowance rates…” 6. The SSA and other agencies should support a program of research to “investigate the value of standardized assessment, including psychological testing, in disability determinations.”

[Editor’s Note: The IOM report can be obtained from the Academy of Sciences at IOM website under the section on reports. See Dr. Chafetz’s book reviewed in this month’s Bookshelf. Also see “OIG Shakes Its Finger at SSA,” and “Did SSA Try to Kill the Messenger,” in October 2013 issue of the Times (Vol. 5, No 2).]

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