Wednesday, September 15, 2010

Entitlements High and Low

James Ledbetter at Slate describes the explosion of Social Security Disability Insurance coverage in recent decades, to the current rate of 4% of the potentially working population, as high as 6% in some states. The two most common kind of conditions covered? Mental disorders and musculoskeletal injuries (think lower back pain), both of which are notoriously elastic. Both are often quite real and severe, but surely these soaring disability rates are driven by non-clinical factors as well.

I work at one clinic at which virtually all the patients (or "consumers" as they are designated in the community mental health setting) either have disability status or are assiduously seeking it. They openly compare notes on how best to get a "crazy check" and to retain it long-term (patients often resist reduction or removal of medications in the belief that it may make them appear less disabled). Before they learn the system they are surprised to learn that I am not directly involved in the process--Social Security has its own protocol for determining disability. The bar is set apparently high--people are often turned down multiple times over a period of years, but repeated appeals especially with legal support usually seem to succeed, and once attained, disability is rarely lost, at least in the population I see.

Obviously many warrant disability support whatever the circumstances. But even among the questionable ones it is no simple matter of conscious malingering. Between $500 and $1000 per month isn't much, but it compares well with full-time minimum-wage work, which is the best that many disability candidates could hope for. And as Ledbetter mentions in his piece, disability rates may reflect long-term weakness in the job market that could be worse than feared. If someone with any mental symptoms whatsoever is chronically unable to find a job, his/her natural inference may come to be that s/he is disabled by those symptoms. Certainly I have seen this deduction at work (so to speak) in many young, quite able-bodied men in rural areas who have lost once abundant construction jobs. I was pleased to see that Ledbetter also produced the argument (as I did in a post last week) that increasingly technical jobs may be out of reach of a greater fraction of the labor pool.

Meanwhile, at the other end of the socioeconomic spectrum, NPR's health blog, citing a JAMA study, looks at reasons why doctors accept pharmaceutical company perks despite well-known concerns about conflicts of interest. The most common reason appears to be that they believe that they deserve them. This sounds familiar from my years of trying educate residents and medical students about the ethical issues involved. The latter just could not compete in general with their conviction that as they were working hard and--at that point in their careers anyway--not mind-bogglingly well-compensated, they were in fact entitled to a free lunch. One man's entitlement is another man's just deserts (or just desserts as the case may be).

The suppression of freeloading is the ultimate evolutionary game of whack-a-mole.


Anonymous said...

There are strange universes within universes where evolutionary logic inverts and twists itself to eke out the gnarled inexistences of the unfittest survivors.

Dr X said...

A few years ago, a local attorney who has a practice concentrated in social security disability tried to convince me to provide assessments for his clients. Payment would come after benefits were secured, which is how he got paid, as well.

I wouldn't agree to it because of the perverse financial incentive. As a private practitioner, I wouldn't get paid unless I found disability. These individuals were probably working with an attorney because the existing medical/psych record didn't establish eligibility. My suspicion was that that half or more of the cases would involve conscious or unconscious malingering, or more likely that hazy area in between knowing and not knowing.

It hadn't occurred to me that disability claims would increase substantially during times of high unemployment. Might be a boon to attorneys working in this area, but it would only make the job of the clinician more difficult.

Novalis said...

Wow, talk about a conflict of interest...