There's an excellent website online published by a Dr. Holden, a former Disability Determination Services medical consultant. I couldn't help but comment on one of the good doctor's recent writings in which he makes several suggestions for disability evaluation reform. To get right to the point, Dr. Holden's reform ideas seem to strongly revolve around the notions of upgrading the salaries of disability examiners and instituting a better medical training regimen for these workhorses of the disability system.

Dr. Holden's points are, to some extent, on target. For starters, disability examiners don't get enough medical training. As a former examiner myself, I don't mind saying that. And I seriously question the entire concept of SDM's ("single decision maker" examiners who can slap decisions on cases without the input of their unit medical consultants----how crazy is that? Examiners are NOT doctors).

Dr. Holden also questions the soundness of utilizing lawyers--who are now wearing the hats of federal administrative law judges--to adjudicate "medical evaluation cases". Personally, I never really understood just why it is that an ALJ (someone with legal training, not medical training) is necessarily needed to preside over disability hearings. Judges are not medical professionals and disability hearings are not legal court proceedings in the strictest sense. In fact, this is exactly why non attorneys are allowed to represent claimants at such hearings.

I really have no major problem with any of Dr. Holden's core assertions. However, I guess it's true that we are all, to some extent, limited by our experiences and this holds true for MD's as well.

While Holden's suggestion for more indepth medical training for DDS examiners is a good one, his suggestions for overall reform miss the REAL PROBLEM (IMO - just my opinion) with DDS. What's that problem?

Here it is: DQB, or the disability quality branch. As all examiners, reps, judges, and CRs know, a percentage of completed DDS files are sent off to this unit to see if all the i's are dotted and all the t's have been properly crossed. And, interestingly enough, more cases that were MARKED FOR APPROVAL come back reversed i.e. overturned than vice-versa.

When a case is returned from DDS, it's like a black mark for the disability examiner because it directly implies that he or she flubbed up. It's a black mark for the unit supervisor because the return came back to his or her unit. And it's a black mark for the dds administrators because the more DQB returns you get, the worse it makes your agency look.

So, human nature being what it is, what is the outcome at all dds locations in the good old USA?

It means that supervisors tend to exert an iron grip over the examiners in their units. It also means that supervisors will always lean more toward denials rather than approvals. And...if a case is one of "those" cases that is right on the line, you can be sure that the disability examiner won't stick his or her neck out because the likelihood is that the unit supervisor will have to talk to the examiner about his or her decision-making ability, (i.e. imply to them that they better get in line with the program and/or potentially find a new job).

Now, this may not have occurred to Dr. Holden because he was not an examiner. And it may not have occurred to most reps because they, too, were never examiners (though some examiners later went on to become attorneys or non attorney reps). And it certainly would not occur to an SSA CR because, for all intents and purposes, they know very little about the actual disability evaluation process, aside from the mechanics of taking claims and then processing them once DDS is finished with the medical evaluation.

Of course, I am not saying that we need to fill the spots currently occupied by ALJ's with level 3 disability examiners or SSA Disability Case managers (that is, if they ever actually created such a DCM position). I'm not saying we should get rid of the SDM program (though it wouldn't bother me), or dispense with quality review. But, I do think it's pretty plain that external quality review has had an insidious effect on DDS claims processing-----with disability claimants coming out the clear loser.

So, what's the alternative to DQB? In all candor, I don't know. But, regarding such issues (disability system reform from a "structural perspective") perhaps that's something that the brighter heads in NADR and NOSSCR should ponder and make proposals toward.