Driving Accurate Impairment Ratings - natcouncil.com

Driving Accurate Impairment Ratings:

New AMA Guides to Evaluation of
Permanent Impairment – Sixth Edition

Christopher R. Brigham, MD
Senior Contributing Editor, AMA Guides, Sixth Edition
Chairman, Impairment Resources, LLC

Impairment – In Perspective

• Impairment reflects a failure
– a failure in preventing an injury
– a failure in assessing a condition as work-related, when it
is not
– a failure in mitigating the impact of injury – i.e. not
achieving restoration of function

• Goal of all stakeholders should be an accurate, unbiased
assessment of impairment via efficient means

• Development of the new Sixth Edition and the reaction to it
exemplifies challenges core to workers compensation –
issues even more important than the numeric value assigned
to an impairment

• Driving accurate impairment ratings reflects both doing what
is right and a superb opportunity for cost containment

2

Today we will explore

• Impairment rating reality
• Impairment facts
• Best practices in impairment rating management for self-

insured organizations
• New paradigm in impairment assessment – Sixth Edition
• Reaction to the Sixth Edition
• Future

3

History of the Guides: 1971 to Present

4

© 2009 Impairment Resources, LLC www.impairment.com

Impairment Rating Reality

• Impairment ratings are a significant issue – they are a
significant cost driver and reflective of significant
underlying issues.

• Directly impacted permanent partial benefit costs
constitute approximately 20% of total benefit costs.

• Reassessment by experts of referred impairment ratings
reveals the majority of ratings are erroneous and rated
substantially higher than is appropriate - review of
consecutive non-selected cases reveals similar findings.

5

Impairment Rating Analysis – Original vs. Corrected

Group Cases Percent Average Average
Incorrect Original Corrected
All Rating
California Rating

3756 76% 20.9% 8.1%

866 83% 23.8% 10.3%

National Insurer 112 77% 19.6% 7.0%
(California
cases –
sequential)

6

Comparison of Impairment Ratings:

Corrected vs. Original

7

Impairment Rating Reality

• California 2008 Analysis (866 cases)
– 83% of impairment ratings incorrect
– Average difference between original and corrected
rating is 13.5% WPI
– When other factors are taken in consideration an
average cost of $1325 per WPI percentage.
– The estimated cost per erroneous case averages
$17,888.
– Opportunity of $1.4 M per 100 PD Cases

• Therefore driving accurate impairment ratings is both the
right thing to do and also results in cost containment.

8

Systemic Approach Drives Accuracy:

Comparison of Geographic Regions

Data based on the 9 9
location of the
doctor confirms
observations that
Los Angeles and
San Jose regions
are problematic.

© 2009 Impairment Resources, LLC www.impairment.com

Systemic Approach Drives Accuracy:

Comparison of Jurisdictions

California - Unmanaged Hawaii - Managed

10

Data analysis raises several questions.

• Why are most impairment ratings erroneous?
• Why do error rates vary geographically, even when the

same Edition is used?
• Why do error rates vary by type of rater?
• Why do error rates vary by diagnosis? (Why rates higher

if the diagnosis is more subjective?)
• Why have we not effectively managed this process?

11

Impairment Facts

• Impairment is not synonymous with disability

– Assessment of both are associated with significant
challenges

– Impaired may not be disabled
– Disabled (or those that perceive themselves as disabled)

may not be impaired
– Comparison of exceptionally abled vs needlessly disabled

provides insights to the “crippling of America”
– Risk factors for disability relate primarily to

biopsychosocial, personality and psychological issues
– Issues of whether disability or not, relate more to

perceptions, than to measurable impairment
– Impairment, however, is an important first step

12

Impairment Facts

• Over time we should see (and embrace) a reduction in
impairment and disability

– Medical / surgical treatment should result in improved
functioning and reduced impairment (yet in the past
impairment ratings were higher if there was surgery)

– Overtime, assuming medicine is improving, impairment
values should decrease (e.g. surgical outcomes for
procedures such as joint replacements should result in
less impairment now then several years ago)

13

Impairment Facts

• Physicians, attorneys, and patients often resist science
and guidelines

– Many practitioners actively resist scientific knowledge
because they like having the freedom to practice any way
that they want.

– Participants often prefer to define their realities consistent
with their belief systems and what provides them with the
highest personal gain

– Much of the practice of medicine is not based on science –
this is particularly true in workers compensation and
litigation where health outcomes are much worse than in
other arenas

– Many attorneys appear to prefer ambiguity
– Design of workers' compensation and disability insurance,

thwarts getting well

14

Impairment Facts

• Many assumptions in workers’ compensation have been
clearly proven to be wrong – i.e. not supported by
science – yet still part of our false belief systems –
impacting care and impairment assessment.

• Examples of false beliefs:

– Degenerative disk disease is due to trauma
– Spinal imaging typically provides explanation for back pain
– Carpal tunnel syndrome is caused by typing
– CRPS is an injury related condition
– Head trauma causes prolonged headaches
– Mild brain injury (concussion) causes prolonged

impairment

15

Impairment Rating Management - Proactive

Drive Identify &
Accurate Manage
Ratings Erroneous
Ratings

Analyze
Data &
Assure Best
Practices

16

Proactive Impairment Rating Management

• Manage impairment ratings as you manage other issues:
defining best practice strategies, assuring accuracy and
efficiency, using data for total quality improvement and
not tolerating mediocrity or fraud.

• Early in claims cycle:
– Identify claims likely to result in impairment
(permanent partial disability)
– Determine probable date of maximal medical
improvement (MMI) and probable impairment
(reserving)

17

Proactive Impairment Rating Management

• At Maximal Medical Improvement (MMI):
– Provide guidance to treating or other rating physician
on how to perform an accurate rating – enlist them in
the goal a reliable, unbiased, efficient rating.
– Encourage physicians to be trained and certified in
assessing impairment
– Select physicians who have demonstrated the ability
to perform unbiased, quality evaluations (based on
prior performance, monitoring and data)

18

Proactive Impairment Rating Management

• When rating received:

– Use normative data and expert technology systems to
identify which ratings are likely to be erroneous

– Use dedicated experts on the Guides to audit and
critique (as appropriate) all ratings

– If rating is erroneous, manage the error

– Provide feedback to physician

– Challenge the error (evidence, cross examination)

– Capture data on ratings (including diagnostic and
physician quality information)

– Assess final case outcome (capturing data)

– Modify interventions to assure accurate ratings and

most effective return on investments (ROI have ranged

from 4:1 to 20:1) 19

AMA Guides Sixth Edition

• Responded to Prior Criticisms and
Concerns
– Did not provide a comprehensive,
valid, reliable, unbiased, and
evidence-based rating system
– Did not adequately or accurately
reflect loss of function

20

© 2009 Impairment Resources, LLC www.impairment.com

Impairment Rating Considerations

1. What is the problem?
2. What difficulties are reported?
3. What are the exam findings?
4. What are the results of the clinical

studies?

21 21

Sixth Edition Five Axioms

1. Adopt methodology of International Classification of
Functioning, Disability and Health (ICF)

2. Become more diagnosis-based, with diagnoses being
evidence based

3. Give priority to simplicity and ease
4. Stress conceptual and methodological congruity
5. Provide rating percentages that consider clinical and

functional history, examination and clinical studies

22

International Classification of Functioning,
Disability and Health

Health Condition,
Disorder or Disease

Body Functions Activity Participation
and Structures No Activity Limitation
No Participation
Normal Variation Restriction

Complete Impairment Complete Activity Complete Participation
Environmental Limitation Restriction

Contextual Factors

Personal

23

Example – Spine, Chapter 17

• Diagnosis-Based Impairments (DBI) expansion of
Diagnosis-Related Estimates (Injury) Method of 4th and
5th ed.

• Range of Motion no longer used, either as examination
finding or determinate (not found to be reliable)

• Unreliable findings (i.e. spasm and guarding) no longer
used

• Surgery no longer increases impairment

24

Example: Cervical Fusion

(Single-Level, Resolved Radiculopathy)

• History: Cervical injury resulting in C5-C6 disk
herniation and Left C6 radiculopathy. Underwent
anterior cervical fusion at C5-C6.

• Current Symptoms: Minimal neck pain only
with strenuous activity. No radicular symptoms.

• Functional Assessment: PDQ 50
• Physical Exam: Mild motion deficits and slight

weakness of wrist extensors (although no
evidence of radiculopathy)
• Clinical Studies: Pre-op MRI showed disk
herniation at C5-6, left. Post-op healed fusion.

25

Fourth Edition: Injury Model

• Table 73 DRE Cervicothoracic Spine Impairment
Categories(4th ed, 110)

• Category III = 15% WPI

“With the Injury Model, surgery to treat an impairment
does not modify the original impairment estimate,
which remains the same in spite of any changes in
signs or symptoms which follow the surgery and
irrespective of whether the patient has a favorable or
unfavorable response to treatment” (4th ed, 100)

26

Fifth Edition: Diagnosis-Related Estimates
Method

• Table 15-5 Criteria for Rating Impairment Due to
Cervical Disorders (5th ed, 392)

• DRE Cervical Category IV = 25% - 28% WPI
• Favorable outcome = 25% WPI
• Multilevel fusions rated via Range of Motion Method
• Below Knee Amputation = 28% WPI

27

Sixth Edition: Diagnosis-Based Impairment

• Table 17-2 Cervical CLASS 1
Spine Regional Grid
45678
• Category: Motion Intervertebral disk herniation or documented
Segment Lesions / AOMSI at a single level or multiple levels with
Intervertebral disk medically documented findings;
herniation and/or with or without surgery
AOMSI
and

for disk herniation with documented resolved
radiculopathy or nonverifiable radicular
complaints at the clinically appropriate levels
present at the time of examination

28

Sixth Edition: Summary

Diagnosis-Based Impairment

Grid Class 0 Class 1 Class 2 Class 3 Class 3

Diagnosis / Table 17-6 No problem Mild Moderate Severe Very
problem problem severe
Criteria problem problem

Adjustment Factors – Grade Modifiers

Non-Key Grid Grade Grade Grade Grade Grade
Factor Modifier 0 Modifier 1 Modifier 2 Modifier 3 Modifier 4

Functional Table 17-6 No problem Mild problem Moderate Severe Very severe
History Table 17-7 No problem problem problem problem
Table 17-8 No problem
Physical Mild problem Moderate Severe Very severe
Exam problem problem problem

Clinical Mild problem Moderate Severe Very severe
Studies problem problem problem

29

Sixth Edition: Calculation

CDX GMFH GMPE CMCS
1 1 1 2

Net Adjustment Calculations

(GMFH-CDX) 1 -1 =0
(GMPE-CDX)
(GMCS-CDX) 1 -1 =0
Net Adjustment
2 -1 =1

= +1

Result is class 1 with adjustment of +1 from the
default value C which equals grade D = 7% WPI

30

Sixth Edition: Diagnosis-Based Impairment

• Net Adjustment CLASS 1
+1
45678
• Move 1 to the Intervertebral disk herniation or documented
right of the AOMSI at a single level or multiple levels with
midrange default medically documented findings;
with or without surgery

and

for disk herniation with documented resolved
radiculopathy or nonverifiable radicular
complaints at the clinically appropriate levels
present at the time of examination

31

Survey of Users of Sixth Edition

• Internet based survey with invitations sent to
approximately 900 individuals requesting participation by
those who are using the Sixth Edition

• 47 individuals reported having performed or reviewed 10
or more Sixth Edition ratings
– Majority (62%) were physicians

• Small sample however provides some insights

32

Most physician respondees agree “The Sixth
Edition reflects overall improvement.”

100% Physicians
90%
80% Chiropractors
70%
60% Plaintiff
50% Attorneys
40%
30% Plaintiff Attorneys
20% Chiropractors
10% Physicians
0%
Strongly Agree

Agree

Neutral

Disagree

Strongly
Disagree

33

Physician Response to Sixth Edition

Statement Agreement
More reasonable impairment values 66%
Clearer process 62%
More internally consistent 62%
More reliable 59%
Errors Less Likely 52%
Easier to use 41%
Litigation Less Likely 28%

34

Challenges with the Sixth Edition

• No beta testing, only peer review
• No analysis of impact of change in impairment rating

values
• Layout and formatting could be improved
• Corrections and Clarifications were required, and

necessitating reprinting of the Sixth Edition

35

Physician Respondees Prefer Sixth Edition

Edition Preference

Sixth Edition 66%

Fifth Edition 31%

Fourth Edition 3%

36

Future

• Use of best practice approaches and guidelines based
on science (rather than faulty belief systems) for clinical
care, assessment of causation and apportionment, and
the assessment and management of impairment and
disability

37

Future of Impairment Evaluation

• Refinement of approaches provided in Sixth Edition
• Evolution to systems that are evidence-based with goal

of accurate, reliable ratings
• Recognition and management of root causes for

erroneous ratings results in improved accuracy,
decreased conflict, reduced costs and prompter case
resolution
• Proactive management of the assessment process –
providing guidance to practitioners to promote accurate
impairment ratings
• Review of all impairment ratings to assure accurate
ratings on each case and to provide data essential for
total quality improvement

38

Future, beyond impairment rating

• Recognition and promotion of human potential rather
than focus on deficits

• Changes in incentives to drive changes in behavior
– Example, providing incentives for improved function.

• Accountability of all stakeholders
• Minimizing impairment and disability – maximizing

human potential

39

Thank you

Chris Brigham, MD
[email protected]

www.impairment.com