GAO: Action needed to assist SSA staff in understanding policies related to prescription opioid misuse
Wednesday, March 11, 2020

GAO: Action needed to assist SSA staff in understanding policies related to prescription opioid misuse

By Payroll and Entitlements Editorial Staff

Currently, the United States is in the midst of an unprecedented opioid epidemic. Opioids are prescribed to treat conditions such as chronic pain. However, opioid misuse can lead to addiction, disability, overdose, and death. Prior GAO and other reports have discussed the use of prescription opioids within federal programs, particularly Medicare. Less is known about the use of opioids in relation to the SSA’s Disability Insurance (DI) program. The GAO was asked to review any correlation between prescription opioids and rates of DI claims, and any related challenges for the SSA.

The report examines (1) what is known about the relationship between trends in prescription opioids and DI claims, and (2) how the SSA considers potential prescription opioid misuse in its DI eligibility decisions. The GAO analyzed county-level data on opioid prescriptions and DI claims from 2006 through 2017; interviewed program staff involved in DI eligibility decisions in Alabama, Kentucky, and West Virginia, selected because of their high rates of opioid prescriptions and percentage of the adult population on DI; and reviewed case files for DI beneficiaries identified by the Centers for Medicare & Medicaid Services as being at risk for prescription opioid misuse or abuse.

What the GAO found. The numbers of opioid prescriptions and claims for the SSA’s DI program have each declined nationally in recent years, but rates vary widely across the country. National trends show both peaking between 2010 and 2014 and then declining. The GAO’s analysis shows counties with the highest rates of both were concentrated in the Southeastern United States. After accounting for economic, demographic, and other factors, the GAO found that counties with higher rates of opioid prescriptions tended to have higher rates of DI claims from 2010 through 2017. These rates also were correlated with other factors. For example, counties with higher rates of each tended to have higher poverty rates. However, the GAO was unable to determine whether there is a causal relationship between rates of opioid prescriptions and DI claims or other factors, given readily available data.

SSA program staff are required to evaluate and document substance use disorders (including opioids not taken as prescribed) when making certain DI eligibility decisions. Specifically, staff are required to evaluate potential substance use disorders for certain DI claims and deny benefits, for example, if the claimant would not be considered disabled if they stopped using drugs or alcohol. In addition, staff are generally required to document the rationales for their decisions so that another reviewer can understand how they made them. However, staff in five of the six offices the GAO visited in three states were confused about when to evaluate substance use disorders, and nine of 15 case files that the GAO reviewed in which an evaluation was conducted did not have a documented rationale. SSA officials acknowledged the need to clarify policies on when to evaluate substance use disorders, and that a poorly documented rationale could lead to reversals or remands of decisions. Without ensuring that the SSA’s policies are understood and that staff document their rationales, the agency may expend resources reworking cases and, in turn, delay benefits to individuals eligible for assistance.

What the GAO recommends. The GAO recommends that SSA (1) clarify policies and procedures to help staff better evaluate substance use disorders, and (2) ensure staff document their rationales. The SSA agreed with the GAO’s recommendations.

For more information. For additional information, contact Elizabeth Curda at (202) 512-7215 or [email protected] (GAO-20-120, January 2020).

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