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Driving Accurate Impairment Ratings
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 Resources, LLC
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Impairment – In Perspective
Driving Accurate Impairment Ratings 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 Impairment Resources, LLC
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Driving Accurate Impairment Ratings
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 Impairment Resources, LLC
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History of the Guides: 1971 to Present
AMA Guides to the Evaluation of Permanent Impairment - Sixth Edition Driving Accurate Impairment Ratings Sixth Edition of the AMA Guides and the State of Nevada NCCI - March 26, 2009 3/26/09February 2009 History of the Guides: 1971 to Present © 2009 Impairment Resources, LLC © 2009 Impairment Resources, LLC Impairment Resources, LLC
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Impairment Rating Reality
Driving Accurate Impairment Ratings 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. Impairment Resources, LLC
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Impairment Rating Analysis – Original vs. Corrected
Driving Accurate Impairment Ratings 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% Impairment Resources, LLC
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Comparison of Impairment Ratings: Corrected vs. Original
Driving Accurate Impairment Ratings Comparison of Impairment Ratings: Corrected vs. Original Impairment Resources, LLC
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Impairment Rating Reality
Driving Accurate Impairment Ratings 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. Impairment Resources, LLC
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Systemic Approach Drives Accuracy: Comparison of Geographic Regions
Driving Accurate Impairment Ratings 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. 9 © 2009 Impairment Resources, LLC © 2009 Impairment Resources, LLC Impairment Resources, LLC 9
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Driving Accurate Impairment Ratings
Systemic Approach Drives Accuracy: Comparison of Jurisdictions California - Unmanaged Hawaii - Managed Impairment Resources, LLC
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Data analysis raises several questions.
Driving Accurate Impairment Ratings 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? Impairment Resources, LLC
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Driving Accurate Impairment Ratings
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 Impairment Resources, LLC
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Driving Accurate Impairment Ratings
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) Impairment Resources, LLC
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Driving Accurate Impairment Ratings
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 Impairment Resources, LLC
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Driving Accurate Impairment Ratings
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 Impairment Resources, LLC
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Impairment Rating Management - Proactive
Driving Accurate Impairment Ratings Impairment Rating Management - Proactive Impairment Resources, LLC
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Proactive Impairment Rating Management
Driving Accurate Impairment Ratings 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) Impairment Resources, LLC
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Proactive Impairment Rating Management
Driving Accurate Impairment Ratings 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) Impairment Resources, LLC
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Proactive Impairment Rating Management
Driving Accurate Impairment Ratings 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) Impairment Resources, LLC
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AMA Guides Sixth Edition
Driving Accurate Impairment Ratings Sixth Edition of the AMA Guides and the State of Nevada AMA Guides to the Evaluation of Permanent Impairment - Sixth Edition 3/26/09February 2009 NCCI - March 26, 2009 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 © 2009 Impairment Resources, LLC Impairment Resources, LLC
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Impairment Rating Considerations
Driving Accurate Impairment Ratings Sixth Edition of the AMA Guides and the State of Nevada AMA Guides to the Evaluation of Permanent Impairment - Sixth Edition 3/26/09February 2009 NCCI - March 26, 2009 Impairment Rating Considerations What is the problem? What difficulties are reported? What are the exam findings? What are the results of the clinical studies? 21 © 2009 Impairment Resources, LLC Impairment Resources, LLC
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Sixth Edition Five Axioms
AMA Guides to the Evaluation of Permanent Impairment - Sixth Edition Driving Accurate Impairment Ratings Sixth Edition of the AMA Guides and the State of Nevada NCCI - March 26, 2009 3/26/09February 2009 Sixth Edition Five Axioms Adopt methodology of International Classification of Functioning, Disability and Health (ICF) Become more diagnosis-based, with diagnoses being evidence based Give priority to simplicity and ease Stress conceptual and methodological congruity Provide rating percentages that consider clinical and functional history, examination and clinical studies © 2009 Impairment Resources, LLC Impairment Resources, LLC
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International Classification of Functioning, Disability and Health
AMA Guides to the Evaluation of Permanent Impairment - Sixth Edition Driving Accurate Impairment Ratings Sixth Edition of the AMA Guides and the State of Nevada International Classification of Functioning, Disability and Health NCCI - March 26, 2009 3/26/09February 2009 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 © 2009 Impairment Resources, LLC Impairment Resources, LLC
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Example – Spine, Chapter 17
AMA Guides to the Evaluation of Permanent Impairment - Sixth Edition Driving Accurate Impairment Ratings Sixth Edition of the AMA Guides and the State of Nevada NCCI - March 26, 2009 3/26/09February 2009 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 © 2009 Impairment Resources, LLC Impairment Resources, LLC
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Example: Cervical Fusion (Single-Level, Resolved Radiculopathy)
AMA Guides to the Evaluation of Permanent Impairment - Sixth Edition Driving Accurate Impairment Ratings Sixth Edition of the AMA Guides and the State of Nevada NCCI - March 26, 2009 3/26/09February 2009 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. © 2009 Impairment Resources, LLC Impairment Resources, LLC
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Fourth Edition: Injury Model
AMA Guides to the Evaluation of Permanent Impairment - Sixth Edition Driving Accurate Impairment Ratings Sixth Edition of the AMA Guides and the State of Nevada NCCI - March 26, 2009 3/26/09February 2009 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) © 2009 Impairment Resources, LLC Impairment Resources, LLC
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Fifth Edition: Diagnosis-Related Estimates Method
AMA Guides to the Evaluation of Permanent Impairment - Sixth Edition Driving Accurate Impairment Ratings Sixth Edition of the AMA Guides and the State of Nevada NCCI - March 26, 2009 3/26/09February 2009 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 © 2009 Impairment Resources, LLC Impairment Resources, LLC
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Sixth Edition: Diagnosis-Based Impairment
Driving Accurate Impairment Ratings Sixth Edition of the AMA Guides and the State of Nevada AMA Guides to the Evaluation of Permanent Impairment - Sixth Edition 3/26/09February 2009 NCCI - March 26, 2009 Sixth Edition: Diagnosis-Based Impairment CLASS 1 4 5 6 7 8 Intervertebral 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 © 2009 Impairment Resources, LLC Impairment Resources, LLC
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Sixth Edition: Summary
AMA Guides to the Evaluation of Permanent Impairment - Sixth Edition Sixth Edition of the AMA Guides and the State of Nevada Driving Accurate Impairment Ratings 3/26/09February 2009 NCCI - March 26, 2009 Sixth Edition: Summary Diagnosis-Based Impairment Grid Class 0 Class 1 Class 2 Class 3 Diagnosis / Criteria Table 17-6 No problem Mild problem Moderate problem Severe problem Very severe problem Adjustment Factors – Grade Modifiers 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 Clinical Studies Table 17-8 © 2009 Impairment Resources, LLC Impairment Resources, LLC
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Sixth Edition: Calculation
AMA Guides to the Evaluation of Permanent Impairment - Sixth Edition Sixth Edition of the AMA Guides and the State of Nevada Driving Accurate Impairment Ratings NCCI - March 26, 2009 3/26/09February 2009 Sixth Edition: Calculation CDX GMFH GMPE CMCS 1 2 Net Adjustment Calculations (GMFH-CDX) 1 - = (GMPE-CDX) (GMCS-CDX) 2 Net Adjustment +1 Result is class 1 with adjustment of +1 from the default value C which equals grade D = 7% WPI © 2009 Impairment Resources, LLC Impairment Resources, LLC
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Sixth Edition: Diagnosis-Based Impairment
Driving Accurate Impairment Ratings Sixth Edition of the AMA Guides and the State of Nevada AMA Guides to the Evaluation of Permanent Impairment - Sixth Edition 3/26/09February 2009 NCCI - March 26, 2009 Sixth Edition: Diagnosis-Based Impairment Net Adjustment + 1 Move 1 to the right of the midrange default CLASS 1 4 5 6 7 8 Intervertebral 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 © 2009 Impairment Resources, LLC Impairment Resources, LLC
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Survey of Users of Sixth Edition
Driving Accurate Impairment Ratings 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 Impairment Resources, LLC
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Driving Accurate Impairment Ratings
Most physician respondees agree “The Sixth Edition reflects overall improvement.” Impairment Resources, LLC
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Physician Response to Sixth Edition
Driving Accurate Impairment Ratings Physician Response to Sixth Edition Statement Agreement More reasonable impairment values 66% Clearer process 62% More internally consistent More reliable 59% Errors Less Likely 52% Easier to use 41% Litigation Less Likely 28% Impairment Resources, LLC
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Challenges with the Sixth Edition
Driving Accurate Impairment Ratings 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 Impairment Resources, LLC
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Physician Respondees Prefer Sixth Edition
Driving Accurate Impairment Ratings Physician Respondees Prefer Sixth Edition Edition Preference Sixth Edition 66% Fifth Edition 31% Fourth Edition 3% Impairment Resources, LLC
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Driving Accurate Impairment Ratings
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 Impairment Resources, LLC
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Future of Impairment Evaluation
Driving Accurate Impairment Ratings 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 Impairment Resources, LLC
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Future, beyond impairment rating
Driving Accurate Impairment Ratings 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 Impairment Resources, LLC
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Driving Accurate Impairment Ratings
Thank you Chris Brigham, MD Impairment Resources, LLC
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