I think that the system for medical disability is a mess. Too often I see patients who should be granted disability unable to get it and too often I see patients who should not have been granted disability get it.
A big part of the reason that the disability system is a mess is because it's run by lawyers and the government. Nothing good comes to mind when you mix the two together.
Disability is of course a legal term. It is determined by the court system. A doctor never determines if a patient is disabled or not. Disability is very subjective which explains why two patients with the same condition may have one labeled as disabled but not the other one.
The doctor determines a patient's impairment rating which is based upon objective exam findings. There exists a published guideline to allow a concise number to be obtained which is called an impairment rating. This rating is a percentage with the maximum being 100%, say if someone is completely impaired from quadriplegia, and can range to less than 1%, say in the case of the loss of a little toe.
While one could argue the validity of the relative percentages assigned to different physical limitations, the important point is that these numbers have great reliability amongst different examining physicians. Consistency is a hallmark in impairment ratings but not so in disability ratings.
The disability rating, which is determined by the legal/government system, takes into account the impairment rating along with the patient's age, education level, ability to continue in his chosen profession and other factors. For example, a construction worker and a computer programmer would have the same impairment rating from the loss of a leg, but the former would have a much greater disability based on their ongoing ability to perform their current jobs.
Unfortunately, anyone can apply for disability at anytime. This process sets off a time consuming and expensive cascade of events that may involve an application, a review of same, a request for medical records, a review of same, a physical examination by a physician, a referral for additional diagnostic tests, a referral to a specialist, and finally a review of all the preceding information. The taxpayer pays for all these services regardless of how legitimate the claim for disability is.
The government pays a pittance for the amount of work required by a physician to review the records and perform a history and physical examination on the patient who is applying for disability. Thus, these exams are often performed by under trained and underpaid physicians who don't have the ability or communication skills to provide better employment opportunities.
A good rule of thumb is that everyone gets denied disability when they first apply. I have personally never heard of anyone receiving disability without retaining the services of an attorney first. I suppose this deters to some degree the people who shouldn't be applying in the first place, but not until the previously listed process is gone through. It does however also deter many deserving patients of this determination.
There is a reason you see ads on television for lawyers who specialize in disability claims. There is money to be made from people that deserve disability but cannot get it without an attorney's intervention on their behalf.
Too often a patient will come in and request disability papers be filled out and not be interested in nor having had pursued any treatment for the perceived disability. These patients, much like those that are in the process of suing someone over an accident, are not motivated, some consciously some subconsciously, to get better.
The rare but unfortunate case is the patient who has a condition that can be successfully treated and wants to be treated, but cannot afford the care required to treat and sometimes cure their disability. Once disability benefits, including health insurance, are granted, this patient will aggressively pursue treatment. The more frequent case is that of the patient who would rather maintain the disability, receive benefits, and eschew treatment.
Just like the welfare system used to reward mothers for having children out of wedlock and penalize women who married, so too does the disability system reward people for not working and penalize those who do try to work.
We are all aware of the patient who is on disability for a physical condition, but can golf, Jet Ski, and do any number of physical activities except work for a living. I remember a fellow resident who talked to first grade class about careers. He asked the students what they wanted to do when they grow up and one child said he wanted to be on disability, just like his dad. Sad, but true.
People should not be able to self-refer for a disability evaluation. Only doctors should have that right. And once a patient is referred the process should be streamlined and not require the patient to hire a lawyer to get disability benefits. If the evaluating physician thinks that an impairment and subsequent disability exists, then a lawyer should not be necessary. If the evaluating physician thinks that an impairment doesn't exist or doesn't merit disability, then a lawyer and court should not be allowed to overrule.
Although certain conditions are diseases and are disabling, they are also completely preventable. No one should be permitted to receive disability payments for obesity, alcoholism, or drug abuse.
If disability is granted, it should be determined whether it will persist despite treatment, it will persist only if treatments are discontinued, or it will not persist once a finite treatment is provided. This triage system would allow an appropriate and cost effective approach.
An example of the first case would be a person with quadriplegia. Although treatment can prevent complications from developing, the underlying problem of paralysis will not change. This person would require medical benefits and living expenses. All patients in this class should be re-evaluated annually to determine if any new treatments are available that could improve their underlying disability.
A patient in the second group would include someone with seizures. This person would require medical treatment to control his disability and should be provided medical benefits only once the seizures are controlled to the point where employment would be viable. An annual re-evaluation would determine whether medical benefits needed to be continued, or if the patient could now coped with his ongoing medical expenses on his own or through private insurance.
The people in the last class would include someone with severe hip arthritis. This condition is curable through surgery and medical benefits should end once that person has fully recovered and is able to return to full active work activities.
If someone has an impairment that prevents certain work, then they should be expected to work at a job that can perform with their disability. If this causes an income discrepancy from their pre-morbid state, then the difference can be provided. This makes much more sense than not allowing a partially disabled person to work full time if able.
When it comes to determining medical disability, the lawyers should be removed from the process. The government's role should be limited in the process. Disability benefits should be available on an "as needed basis" for an "as long as needed basis" as determined by a physician.
