Tag Archives: poverty

An Evolving Perspective of Whole Patient Medicine


Evelyn Figueroa, MD

Zoe,* a 35-year-old law student, often missed and rescheduled appointments for her toddler Elias.* I have supervised Elias’ visits with the residents since his first newborn visit 2 years ago. Although I have only seen them with the residents, Zoe identifies me as their primary care physician and has always scheduled Elias’ visits during my teaching clinics. I have examined this cute little guy at every visit and thought I knew this family well.

I knew that Zoe and Elias were struggling because of the issues we discussed at every visit: finishing law school 90 miles away, struggling to maintain her breast milk, and single motherhood. Zoe’s tired face showed determination despite her challenges. Little Elias, in a loose diaper, always clung to Zoe’s tiny frame, a fact that initially made me think he was simply on the small side. Despite multiple no-shows, we gathered enough data to construct a disappointing growth trajectory. Was it failure to thrive or constitutional small stature? Medical advice typically consisted of dietary counseling aimed at boosting calories and more frequent follow-up.

Recently, I recognized Elias’ name on a resident’s schedule. Anticipating their typical tardiness, I asked the front desk to register Elias regardless of arrival time. When they came a little late, they were quickly ushered into to an exam room. The resident reported that although Elias had normal development, his weight remained below the first percentile.

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SSI/SSD: What Is Our Role as Family Medicine Educators?

Colleen Fogarty,

How do we as family medicine educators work with residents or students who come to precept saying, “I don’t think this patient is disabled but…” or “What am I supposed to do with this long form?”

As a family physician who has spent my career practicing and teaching in community health centers, I have come to recognize the importance of Supplemental Security Income (SSI) and Social Security Disability Insurance (SSD) to many of my patients who are out of options. In our annual community medicine rotation, I co-teach a session with a local lawyer to help our residents understand some of the elements of disability determination so they can effectively manage requests for information and advocate for patients as suitable.

SSI, or Title XVI, is a needs-based federal benefits program for poor adults who are over 65 or disabled, and children under 18 who are disabled and whose families are poor. In contrast, Social Security Disability Insurance—or Title II—is an insurance program for disabled adults (wage earners) who have contributed into the Social Security system (FICA). This distinction is as important as it is confusing.

Why should we as family medicine educators know the details about these programs? In a word, poverty. Many of our patients with complex medical needs may be unable to engage in “substantial gainful activity” (SGA), the social security administration’s term for “work for a living.” Many poor individuals and families qualify for county-based programs such as Temporary Assistance for Needy Families (TANF) or Safety Net assistance. These programs are administered at the county level; benefits vary among states, or—in some states—don’t exist at all. Typically, clients must re-apply every 6 months and must participate in some type of work, training, or rehabilitation. Since “Welfare Reform” in 1996, time limits have been imposed.

Given the increasing burden of public assistance, many counties are trying to shift clients off the local “welfare rolls” to SSI, a federal program. Having a reliable source of income adds a measure of stability to people’s lives and keeps them from continually running to the public assistance office, which in many counties can be chaotic and difficult to navigate. Now, when I say “reliable source of income” I am by no means implying that SSI is a gravy train. Just the opposite; SSI determines a set amount per recipient that is based on living arrangements and any other income. In New York in 2012, this comes to approximately $780 per month for the maximum benefit, for a total annual “income” of less than $12,000 per year. Many of my patients on SSI cannot afford to purchase routine hygiene products but are able to afford a low rent and reliably make their payments.

Importantly, SSI comes with health insurance. In two thirds of states, including New York and New Jersey, SSI recipients are automatically eligible for Medicaid. SSD recipients are automatically eligible for Medicare 24 months after receiving their first payment. Even with the imperfections and gaps in coverage of Medicaid and Medicare, having health insurance can mean the difference between getting needed health care and not.

Who is eligible for SSI or SSD?

The SSA Standard for Disability reads: “Inability to perform substantial gainful activity by reason of a medically determinable physical or mental impairment, or combination of impairments, which has lasted or is expected to last at least 12 consecutive months, or end in death, taking into account the individual’s age, education, and work history.” The SSA website http://www.ssa.gov/ contains a wealth of information and can facilitate online applications.

Disabled individuals who have enough work history and FICA contributions may be eligible for SSD. Chronically poor individuals without work history who have a disability expected to last 12 months may be eligible for SSI disability benefits.

Who determines disability, and how can I maintain an effective doctor-patient relationship?

I never promise a patient that she/he will qualify for SSI or SSD. I discuss the patient’s situation with them; in many cases they will have applied and been denied several times. Recommending a skilled disability lawyer is useful. I tell my patients that I will do a full clinical evaluation and provide the information requested to SSA or their lawyer. The Commissioner of Social Security determines disability, not the clinician. This is an important boundary for us to establish with our patients; it provides me a way to stay connected with my patient, honest with my findings, and advocate or not as appropriate to the clinical scenario. I don’t use the word “disable” as a verb, as in “I’ll disable you on this form.” In fact, I don’t tell them that at all, I simply do a full evaluation and document my findings, taking into account contributing factors such as mental illness, learning disability, and educational attainment.

SSA will consider the opinion of the treating source, that is, the primary clinician, as “controlling” if our documentation is well supported and not contradicted. This means that our words as primary care clinicians should carry more weight than consultative examiners or SSA clinicians. Our role is to write and record the patient’s history, diagnosis, limitations, and functional capacity to our best judgment.

At a practical level here are the things I do in practice to assist with these applications:

  1. Book an extended appointment with the patient, specifically to discuss the condition for which they claim disability.
  2. Ensure the patient has signed an appropriate release of information.
  3. Discuss with the patient the SSA definition of disability, my role in the process, and let them know I will provide them and their lawyer with a copy of the visit note documenting my findings.
  4. Use the electronic record to fully document the visit, listing the diagnoses evaluated and billing according to the level of service, usually 99214 for an established patient.
  5. Elicit and document a full occupational history, if not already done. Many of my patients have spotty work histories, based on prior or current mental health problems or other problems. Others have always done physical jobs and have no other skills to bring to the work force.
  6. Elicit and document an educational history. Was the patient diagnosed with a “learning disability” as a student? Have they attempted a GED course and exam? Is there other evidence of a learning problem? What about the possibility of a low IQ?
  7. Include in the assessment/plan a statement of functional limitation and residual functional capacity (eg, how much can the patient walk, stand, sit, lift, carry, bend, handle? How reliable is the patient with:
    1. Understanding, remembering, and carrying out simple instructions?
    2. Making simple work-related decisions?
    3. Responding appropriately to supervision, co-workers, and usual work situations?
    4. Dealing with changes in a routine work setting?
  8. Provide a copy to the patient, or send it directly to the lawyer or SSA address designated by the patient.

The National Health Care for the Homeless council has published two useful publications, one on general tips on documenting disability and an updated version geared for persons with substance use disorders and co-occuring impairments.

In summary, SSI for eligible individuals can make the difference between a reasonably stable chronic poverty and homelessness, and between access and non-access to health care. As advocates for improved health care, family medicine faculty should have some familiarity with their county social service benefits as well as federal programs, such as SSI and SSD. Family medicine residents need to learn to document and advocate for these programs as appropriate and recognize that certain vulnerable members of our communities may be disabled and thus eligible for available public assistance.

The author thanks Catherine M. Callery, Esq, for her educational contributions to our residency program and for reviewing this essay.