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Driving Accurate Impairment Ratings: New AMA Guides to Evaluation of
Permanent Impairment – Sixth Edition
Christopher R. Brigham, MDSenior Contributing Editor, AMA Guides, Sixth EditionChairman, Impairment Resources, LLC
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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
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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
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History of the Guides: 1971 to Present
© 2009 Impairment Resources, LLC www.impairment.com
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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.
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Impairment Rating Analysis – Original vs. Corrected
Group Cases Percent
Incorrect
Average Original Rating
Average Corrected
Rating
All 3756 76% 20.9% 8.1%
California 866 83% 23.8% 10.3%
National Insurer (California cases – sequential)
112 77% 19.6% 7.0%
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Comparison of Impairment Ratings: Corrected vs. Original
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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.
9© 2009 Impairment Resources, LLC www.impairment.com
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Systemic Approach Drives Accuracy:Comparison of Geographic Regions
Data based on the location of the doctor confirms observations that Los Angeles and San Jose regions are problematic.
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California - Unmanaged Hawaii - Managed
Systemic Approach Drives Accuracy:Comparison of Jurisdictions
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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?
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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
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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)
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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
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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
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Impairment Rating Management - Proactive
Identify &Manage
ErroneousRatings
Analyze Data &
Assure BestPractices
DriveAccurateRatings
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• 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)
Proactive Impairment Rating Management
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• 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)
Proactive Impairment Rating Management
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• 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)
Proactive Impairment Rating Management
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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
© 2009 Impairment Resources, LLC www.impairment.com
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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?
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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 ease4. Stress conceptual and methodological congruity5. Provide rating percentages that consider clinical and
functional history, examination and clinical studies
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International Classification of Functioning, Disability and Health
No Activity Limitation
Complete Activity Limitation
No Participation Restriction
Complete Participation Restriction
Contextual Factors
Body Functions and Structures
Activity Participation
Environmental Personal
Normal Variation
Complete Impairment
Health Condition, Disorder or Disease
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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
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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.
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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)
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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
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Sixth Edition: Diagnosis-Based Impairment
CLASS 1
4 5 6 7 8Intervertebral disk herniation or documented AOMSI at a single level or multiple levels with 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
• Table 17-2 Cervical Spine Regional Grid
• Category: Motion Segment Lesions / Intervertebral disk herniation and/or AOMSI
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Sixth Edition: Summary
Grid Class 0 Class 1 Class 2 Class 3 Class 3
Diagnosis /
Criteria
Table 17-6 No problem Mild problem
Moderate problem
Severe problem
Very severe problem
Non-Key Factor
Grid Grade Modifier 0
Grade Modifier 1
Grade Modifier 2
Grade Modifier 3
Grade Modifier 4
Functional History
Table 17-6 No problem Mild problem Moderate problem
Severe problem
Very severe problem
Physical
Exam
Table 17-7 No problem Mild problem Moderate problem
Severe problem
Very severe problem
Clinical
Studies
Table 17-8 No problem Mild problem Moderate problem
Severe problem
Very severe problem
Diagnosis-Based Impairment
Adjustment Factors – Grade Modifiers
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Sixth Edition: Calculation
CDX GMFH GMPE CMCS
1 1 1 2
(GMFH-CDX) 1 - 1 = 0
(GMPE-CDX) 1 - 1 = 0
(GMCS-CDX) 2 - 1 = 1
Net Adjustment = +1
Net Adjustment Calculations
Result is class 1 with adjustment of +1 from the default value C which equals grade D = 7% WPI
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Sixth Edition: Diagnosis-Based Impairment
CLASS 1
4 5 6 7 8Intervertebral disk herniation or documented AOMSI at a single level or multiple levels with 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
• Net Adjustment + 1
• Move 1 to the right of the midrange default
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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
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Most physician respondees agree “The Sixth Edition reflects overall improvement.”
Strongly AgreeAgree
NeutralDisagree
StronglyDisagree
Physicians
Chiropractors
Plaintiff Attorneys
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Physicians
Chiropractors
PlaintiffAttorneys
34
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%
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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
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Physician Respondees Prefer Sixth Edition
Edition Preference
Sixth Edition 66%
Fifth Edition 31%
Fourth Edition 3%
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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
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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
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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
