disability medicine

35 Pages·2005·0.36 MB·English

Vol. 4 No. 1 January - March 2004
DDIISSAABBIILLIITTYY MMEEDDIICCIINNEE
The Official Periodical of the American Board
of Independent Medical Examiners
Editorial Board Contents
PAGE
Editorial:
Editor-in-Chief
Ipse Dixit
Mohammed I. Ranavaya, MD, MS, FFOM,
FRCPI, FAADEP, CIME . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
IAIABC Supplemental Guides for
Assistant Editors
Rating Permanent Impairment:
Thomas A. Beller, MD, FAADEP, CIME
Current Status
Steven Mandel, MD
Rebecca McGraw-Thaxton MD, CIME IAIABC Supplemental Impairment Guides©
IAIABC 2004
Editorial Advisory Board . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Rory Wagon MB, BS, CIME, Australia Malingering in
Prof. John B Walden, MD Low Back Pain Assessments
Presley Reed, MD, CIME . . . . . . . . . . . . . . . . . . . . . . . . . . 28
David E. Brown, DC, CICE Book review
Richard Sekel, MB.BS, CIME, Australia Writing and Defending Your IME
Niall J. Buckley, BSc, MD, CIME, Canada Report: The Comprehensive Guide
Gordon Waddell, DSc, MD, FRCS, UK . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Lester L. Sacks, M.D., Ph.D., FACOEM
CME Question Answers
Randall L. Short, DO, CIME
. . . . . . . . . . . . . . . . . . . . . . . . . . 31
Robert L. Nierenberg, MD, CIME
Book review
Alfred Taricco, MD, FACS
Gerontological Rehabilitation
Jalees K Razavi, MD, Saudi Arabia
Nursing
Clement Leech, MD, DMA, Ireland
Stan Bigos, MD . . . . . . . . . . . . . . . . . . . . . . . . . . 32
William S. Shaw, MD, CIME Book review
David P. King, BSc, MD, CIME, Canada DeLee and Drez’s Orthopedic
Jan Von Overbeck, MD, CIME, Switzerland Sports Medicine Principles
Sigurdur Thorlacius, MD, PhD, Iceland and Practice
Yat Cho Chu, MBBS, MSc(O.M.)(London), CIME, . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Hong Kong
Prof. Zaliha Omar MD, CIME, Malaysia
Mohammed Azman B. Aziz Mohammed, MBBS,
LFOMRCP, CIME, Malaysia In The Next Issue:
Rahman Gul, MBBS, MFOM RCP (Ireland), Guest Editorial on
CPrIMofE. ,RMobaelaryt sBia Walker, MD, CIME Use bayn dP rMofi.sGusoer doof Wn Wadaddedlle’sl l,Signs
Kathleen M. Bernett,Managing Director DSc,MD,FRCS
American Board of Independent Medical Examiners
E :
D I TO R I A L
Ipse Dixit
Physicians have traditionally been regarded as opinion must be supported by scientific
BOARD OF DIRECTORS an authority in their craft and are accustomed evidence or they risk loosing credibility.
Thomas A. Beller, MD, CIME
President to getting their opinions accepted as the final
Kansas City, Missouri The standards for the admissibility of the
Mohammed I. Ranavaya, MD, CIME truth. However, in a legal proceeding the Ipse
President Elect/Secretary expert testimony to provide medical and
Chapmanville, West Virginia
Dixitof the physician can lead to challenges
Alex Ambroz, MD, MPH, CIME scientific evidence have been around in
Donald L. Hoops, PhD
Prospect Heights, Illinois and cause needless frustration and anxiety for American Jurisprudence since the Frye case in
John D. Pro, MD, CIME
Kansas City, Missouri the physician. 1920s, which established the test of “General
Kathleen M. Bernett
Executive Director acceptability by the scientific community” for
Barrington, Illinois The long held notion by the public that the
admissibility scientific opinion of an expert
BOARD OF ADVISORS
doctors know the best has led them to believe
Rory Wagon MB, BS, CIME,
Australia witness. U.S. congress in 1975 codified the rules
that medicine is based on high level of
Jalees K Razavi, MD
Saudi Arabia for expert witness testimony in rule 702 of
certainty and therefore, every opinion and
Presley Reed, MD, CIME
Boulder, CO federal rules of evidence, which essentially
David E. Brown, DC, CICE assertion by medical professionals whether
Charlottesville, VA means that if scientific, technical or other
Rebecca McGraw, MD, CIME proven or not is generally accepted as a fact.
Morgantown, WV specialized knowledge will assist the judge or
Richard Sekel, MB.BS, CIME This has led some to conclude that physicians,
Redfern, NSW Australia jury to understand the evidence or to
Niall J. Buckley, BSc, MD, CIME fearing the loss of positive reinforcement
Halifax, NS, Canada determine a fact in issue, a witness qualified as
Gordon Waddell, DSc, MD, FRCS resulting from the public’s lack of confidence in
Glasgow, UK an expert by knowledge, skill, experience,
Lester L. Sacks, M.D., Ph.D., FACOEM the doctor’s abilities, have been disinclined to
Laguna Niguel, CA training or education, may testify to these
CRhaanpdmalla Ln.v iSlleh,o Wrt,V DO, CIME expose the limits of our actual scientific issues in the form of a expert opinion
Robert L. Nierenberg, MD, CIME
Honolulu, HI knowledge and abilities. As today’s media testimony.
Alfred Taricco, MD, FACS
Manchester, CT savvy health care consumer increasingly
Prof. Zaliha Omar MD, CIME, The rule 702 was recently modified in
Malaysia questions the science behind the doctor’s
Clement Leech, MD, DMA December of 2002 in light of the U.S. Supreme
Dublin, Ireland assertions and as the ivory tower image of
Stan Bigos, MD Courts decision of Daubert vs Merrell Dow
Seattle, WA medicine fades, doctors are increasingly faced
William S. Shaw, MD, CIME Pharmaceuticalsand its progeny (General Electric
Denver, CO with the challenge of an informed consumer
David P. King, BSc, MD, CIME vs Joiner and Kuhmo Tire Company vs Carmichael).
Yellowknife, NT Canada demanding second or even third opinions.
Jan Von Overbeck, MD, CIME This body of the U.S. Supreme Court case law
Zurich, Switzerland
Evidence based medicine has become part of
Sigurdur Thorlacius, MD, PhD now codified under modified rule 702 sets the
Reykjavik, Iceland
media buzz words. No longer it is satisfactory
Yat Cho Chu, MBBS, MSc(O.M.) appropriate review standards for the federal
(London), CIME
Kowloon, Hong Kong to either an informed consumer or to a court of courts with regard to the admissibility of the
Prof. Robert B Walker, MD, CIME
Mohammed Azman B. Aziz Mohammed, law when the doctor offers an opinion as a fact scientific and expert opinion. These legal
MBBS, LFOMRCP, CIME
Kuala Lumpur, Malaysia and says it is so because I said so. Physicians standards make the judge responsible for
Rahman Gul, MBBS, MFOM RCP
(Ireland), CIME providing Independent Medical Examinations insuring that the scientific evidence proffered
Ipoh, Malaysia
Prof. John B Walden, MD and expert testimony must be aware that their in the form of expert testimony is reliable and
2
reproducible. Everything from AMA a nonexclusive list of tests so they can Subsequent U.S. Supreme Court
Guides and standards of impairment determine whether the scientific theory decision such as Kuhmo Tire Company vs
and disability to Causality Opinions in of methodology underlying the opinion Carmichaelfurther clarifies this authority
Toxic Exposures claim are fair game for of expert witness before them was and extends the Daubert’sapproach to
challenge under these standards. One reliable. Dauberttests included peer other kinds of expert testimony
should remember though that these review of the method, testability and including medical testimony.
federal rules of evidence do not general falsifiability (known error rate) of the
What does this all mean to us, the
apply in the state and other court scientific theory and finally the judge
independent medical examiners offering
systems. may still consider “General acceptance”
medical expert testimony in legal
by the scientific community, the old
With regard to the admissibility of proceedings? U. S. Supreme Court said
Frye test.
expert opinion and scientific evidence it best in General Electric vs Joiner “the
few cases have been as widely feared Even though Daubertbroadened the court need not accept testimony of an
by experts and equally widely scope of the judge’s authority by adding expert which is connected to existing
misunderstood and misused as Daubert, several other tests, it must be recognized data only by the Ipse Dixitof the expert.
which simply was the U.S. Supreme that tests for admissibility of expert
Court’s attempt to provide a broad opinion or scientific testimony given in
Mohammed I. Ranavaya, M.D., M.S.,
discretionary gate keeping power to Daubertare not a “definitive checklist”
FRCPI, FFOM, FAADEP, CIME,
federal trial court judges by giving them but rather general guidance. Editor in Chief
General Information – Disability Medicine, Volume 4, Number 1
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3
IAIABC Supplemental Guides for Rating Permanent
Impairment: Current Status
IAIABC Supplemental Impairment Rating Guides IAIABC 2004
©
Editors note:
The cost of workers compensation insurance (IAIABC) has introduced supplemental Annual Convention, and the Iowa
is on the rise in general and the insurers guides to the evaluation of permanent Workers’Compensation Symposium. To
are assigning blame on many factors impairment which currently are in the draft date, the best practical application of these
including the escalating cost of impairment form and are published here in installments guides is in the State of Utah. In ma n y
and disability compensation. For example, with permission from IAIABC for comment respects, the IAIABC Guides res e m b l e the
data gathered by the National Council on and discussion purposes. administrative rules Utah adopted for the
Compensation Insurance, Inc. (NCCI) and rating of permanent injuries. This is the
Since their draft release in 2002, the
the Kentucky Department of Workers’ seventh year that Utah has used such sup-
IAIABC Supplemental Guides for Rating
Claims recently resulted in NCCI request- plemental guidelines, with continuous
Permanent Impairment have generated
ing an average increase of 20.5% for work- refinements. Less than one percent of claims
much interest. Part 1 (General Guidelines)
ers’compensation rates in that state.1The with permanent disability have been liti-
and Part 2 (Spinal Impairment) have been
request cited one reason as being; “The gated, which has produced a dramatic cost
revised several times by an open committee
recent changes in American Medical savings to the Utah Labor Commission.
of expert physicians, made available on the
Association guidelines for evaluating per-
IAIABCWeb site (among the most fre- As the AMAconsiders their 6th Edition of
centages of impairment, potentiallyres u l t i n g
quently visited/downloaded pages on the the Guides, the IAIABC and the AMA
in additional compensation available for
site). Additionally, the American Medical continue extensive, ongoing talks with
pain disability have increased the overall
Association (AMA) and the IAIABC have hopes of collaboration to evolve guides that
cost. While the estimated impact of the
kept open dialogue about the prospects of have more sensitivity to injured workers.
new fifth edition of the American Medical
collaborating on future editions. The
Association Guides to the Evaluation of As for the IAIABC Supplemental Guides,
IAIABC strongly supports a consistent
Permanent Impairment was estimated at comments and additional input are still
message to doctors on how to conduct
1 percent, the observed impact has been as desired. The IAIABC is actively collabo-
impairment ratings.
much as 5 percent.”2 This contrasts with rating with Medical Directors in state
what is happening in states who have The purpose and background of the agencies, trade and medical associations,
adopted the 5th Edition of the AMA IAIABC Guides was formally presented at and practitioners in occupational medicine.
Guides or who are working with the 2nd, several conferences during 2003. Dr. Alan It is hoped that the publication of draft of
3rd or 4th Editions. College, Chair of the Committee that over- these supplemental guides would generate a
sees development of the guides, presented dialogue resulting in a consensus document.
International Association of Industrial
them to attendees at the IAIABC Workers’
Accident Boards and Commissions Editor
Compensation College, the IAIABC
4
International Association of Industrial Accident Boards and Commissions
Supplemental Impairment Rating Guides
®
IAIABC Supplemental Impairment Rating Guides©IAIABC 2004
IAIABC Executive Office
5610 Medical Circle, Suite 24
Madison, WI 53719
Phone: [phone]
Fax: [phone]
Web: www.iaiabc.org
You can view and download all the IAIABC Guides at: http://www.iaiabc.org/Impairment/Impairment_index.htm
Questions? Contact:
Alan College, MD, Medical Director, Utah Labor Commission, [email protected]
Melissa Wilson, Education & Publications Manager, IAIABC, [email protected]
Acknowledgments
The report is the result of many dedicated people who want to improve the functioning of the workers’ compensation system.
In particular, the contributors share a passion for delivering fair compensation to injured workers under the laws of their jurisdiction.
Fairness has many dimensions, but this committee had a particular interest in, and competency on, the reliable and valid measurement
of bodily impairments due to work injury.
This work was produced by the Occupational Impairment Rating Committee of the International Association of Industrial
Accident Boards and Commissions (IAIABC). Since its creation in 2000, this committee has been led by Alan L. College, MD,
Medical Director of the Utah Labor Commission. Current members of the committee are found in Appendix D .
Table of Contents
Chapter One: Introduction
Section Subject
1 Introduction 3.5 Capabilities Assessment
1.1 American Medical Association Guides 3.6 Future Medical Treatment
1.2 IAIABC Guides 3.7 Patient Declining Surgical, Pharmacological, or
Therapeutic Treatment of an Impairment
2 Legal and Historical Background
2.1 Overview of Occupational Benefits 4 Administrative Issues
Table 1: Workers’ Compensation Cases in the United 4.1 Who Is to Perform Impairment Ratings
States, 2000 4.2 Forms
2.2 Measuring Permanent Loss from Injury 4.3 Billing for Impairment Ratings
2.2a Impairment/Disability Relationship in Workers’ 4.4 Billing for Impairment Ratings Done by the Treating
Compensation Physician
2.2b Problems with Impairment Ratings Table 3: Current Existing Non-specific Procedure
Codes that Can Currently be Utilized When
3 General Guidance for Raters Submitting Billings for Impairment Rating
3.1 Duties of Rating Physician or Rater Procedures
3.2 What Metric to Use? Table 4: Specific Codes Submitted to the AMA’s CPT
3.3 The Medical Report at Stability Code Committee for Adoption
Table 2: Variations in the Standards for the End of Table 5: Billing for Impairment Ratings Done by
Healing or Maximum Recovery from Injury Someone Other than the Treating Physician
3.4 Time Periods for Certain Conditions to Reach 5 Summary to Chapter One
Medical Stability
5
Chapter Two: Pain and Apportionment 5 Schedule Forms
5. 1 Form for Computing Spinal Impairments - Schedule I
Section Subject
5.2 Form for Computing Surgical Spinal Impairments -
1 Pain Schedule II
1.1 Pain Rating Guidelines and Examples of Application
1.2 IAIABC Recommended Practices 6 Examples of Spine Impairment
1.2a Subjective Pain Only 6.1 Example 1: Mechanical Back Pain
1.2b Objectifiable Pain Normally Associated with an Injury 6.2 Example 2: Mechanical Back Pain
1.2c Extraordinary Chronic Pain 6.3 Example 3: Mechanical Back Pain
6.4 Example 4: Mechanical Back Pain With Referred
Table 6: Extraordinary Chronic Pain Conditions
Pain
1.2d Rating Extraordinary Chronic Pain
6.5 Example 5: Mechanical Back Pain With Referred
Table 7: Whole Body Impairment Percentages
Pain And With Prior History
Associated with Scores on the I3Score
6.6 Example 6: Cervical-Thoracic Pain Without
Table 8: Factors to Consider in Evaluating
Radiculopathy
Extraordinary Pain
6.7 Example 7: Cervical-Thoracic Pain Without
Radiculopathy And With Clinical
2 Apportionment Manifestations Of Overt Pain Behaviors
2.1 When and How Impairments are Apportioned 6.8 Example 8: Low-Back Pain With Radiculopathy (No
2.2 The Schedule to Use When Apportioning Surgery)
Preexisting Conditions 6.9 Example 9: Low-Back Pain (Post-Surgery)
Table 9: What Schedule to Use When Apportioning 6.10 Example 10: Low-Back Pain With Radiculopathy
(Post-Surgery)
Prior Ratable Conditions
6.11 Example 11: Low-Back Pain With Foot Drop (Post-
Surgery)
Chapter Three: Spinal Injuries and Conditions 6.12 Example 12: Spondylolisthesis Without History
6.13 Example 13: Spondylolisthesis With Radiculopathy
Section Subject
And Without Prior History
1 Introduction
6.14 Example 14: Spondylolisthesis With Radiculopathy
And With Prior History
2 Spine and Pelvis Conditions 6.15 Example 15: Prior History Of Disc Problems
2.1 Apportionment of Soft Tissue Impairment Requiring Surgery And Now With A
2.2 Spine Impairment Concepts Recurrent Disc Herniation, Needing
Another Surgery
3 Spinal Translocation, or Isolated Spinal Segmental 6.16 Example 16: Second Disc Injury, Treated Non-
Instability (ISSI) Operatively
6.17 Example 17: First Industrial Disc Injury, Second Disc
3.1 Determinations of ISSI
Herniation Requiring ASecond Surgery
3.2 Measuring Impairment Related Secondary to ISSI
6.18 Example 18: Disc Injury, Undergoing Three
3.3 Schedule A. Stand Alone Ratings
Surgeries, Including AFusion
6.19 Example 19: Degenerative Disc Disease With Two-
4 Schedules
Level Decompression
4.1 Schedules
6.20 Example 20: Compression Fractures With Prior
4.2 Schedule II. Surgically Treated Spine Conditions History And Rating
4.3 Schedule III. Radiculopathy Schedule 6.21 Example 21: Burst Fracture Requiring Fusion
4.4 Schedule IV. Vertebral Fractures 6.22 Example 22: Coccygodynia
4.5 Schedule V. The Pelvis 6.23 Example 23: Prior Non-Industrial Injury With Two
4.6 Schedule VI. Severity Indexing For Apportionment Industrial Injuries And Ratings
of Schedule I 6.24 Example 24: Prior Industrial Rating With Another
System, Now With ANew Injury
4.7 Schedule VI Notes
6.25 Example 25: Prior Industrial Rating With Another
4.8 Schedules for Calculating Neurological Loss
System, Now With ANew Injury
4.9 Spine with Associated Severe Neurological Injuries
6.26 Example 26: Impairment Related To One Event And
Operation On Two Discs
6
Chapter Four: Upper Extremity 4 Lower Extremity Painful Organic Syndromes
That are not otherwise accounted for within these Guides
Section Subject
or the AMA5thEdition
1 Introduction to Upper Extremity
4.1 Schedule XI. Lower Extremity Painful Organic
Syndromes
2 2003 IAIABC Upper Extremity Rating Guidelines
Worksheet
5 Lower Extremity Impairment Rating Example
Table 10: Schedules in AMA5th Edition Not to Be
Used for Rating Impairments in the Upper
References
Extremity
Appendixes
3 Upper Extremity Rotator Cuff Impairments A State Specific Use of The AMAGuides
3.1 Schedule VII. Upper Extremity Rotator Cuff B Jurisdictional Impairment Rating Laws
Impairments C Nature and Type of Rating
D Development and Review Subcommittees
4 Distal Clavicle Resection
Glossary of Terms
5 Upper Extremity Neuro-Muscular Impairments
5.1 Upper Extremity Neuropathies
5.2 Schedule VIIIa. Guidelines for Placement of Patients
Chapter One: Introduction
Within Schedule VIII
5.3 Schedule VIIIb. IAIABC’s Specific Upper Extremity
Impairments Due to Entrapment Physicians or those who make impairment ratings should
Neuropathy
understand the basic and universal principles of workers’
5.4 IAIABC’s Upper Extremity Strength Evaluations
compensation law to respond to the clinical and procedural
5.5 Constrictive Tenosynovitis
demands of rating the permanent residual consequences of
6 IAIABC Specific Upper Extremity Painful Organic
work-related injury or disease. This introduction covers this
Syndromes
That are not otherwise accounted for within these Guides essential background. In addition, it explains the purposes
or the AMA5thEdition and use of this supplemental guide.
6.1 Schedule IX. IAIABC Specific Upper Extremity
Painful Organic Syndromes In some countries, government insurance programs cover
occupational and non-occupational disability with the same
7 Examples of Upper Extremity Impairment Ratings
7.1 Example 1: Rotator Cuff Repair administrative and benefit laws. However, in some countries,
7.2 Example 2: Shoulder Fracture
particularly Australia, Canada, and the United States,
workers’ compensation uses its own distinct approach to the
Chapter Five: Lower Extremity
compensation of occupational disability. In these places where
Section Subject
1 Introduction to Lower Extremity: AMA 5thEdition separate workers’ compensation laws exist, there is
Chapter 17 commonly a legal process for qualifying and quantifying
certain injuries for a class of benefits for “permanent
2 2003 IAIABC Lower Extremity Rating Guidelines
Worksheet disability.” This process is distinct from other social insurance
Table 11: Schedules in AMA5th Edition Not to Be
programs covering disability, private disability insurance, or
Used for Rating Impairments in the Lower
damage measurements made in connection with civil legal
Extremity
3 Lower Extremity Arthroscopic Cartilaginous Impairments proceedings. Thus, the measurement of total disability for US
3.1 Schedule X. Acute Arthroscopic Osteochondral
Social Security disability qualification has no relation
Lesions
whatsoever to a permanent total disability rating in workers’
7
compensation. Private disability compensation. Indeed, there is much advisory. In other cases only parts of
insurance claims adjusters, while they diversity among jurisdictions in the the AMAGuides are used, or are
may ask about permanent physical loss, fundamentals of how and when benefits supplemented with jurisdiction specific
are mainly concerned with vocational should be paid. This is especially true guidance. Many US states do not
and job performance issues. concerning approaches to measuring recognize the AMAGuidesfor rating
and compensating the injured worker impairment and have instead developed
Knowing that it has its own distinct
for the lasting, or permanent, their own internal standards or guides
system, with enforced rules of
consequences of an industrial injury. to raters.
adjudicating claims, may prevent the
physician/rater from consciously or This guide is provided as an option for TheAMAGuidesattempt to provide a
unconsciously misapplying techniques the IAIABC’s respective jurisdictions to reasonable method to evaluate
or methods used for evaluating other consider for adopting all or part as able. impairment and attempt to minimize
kinds of permanent injury or disability. Below is a brief introduction to the inter-rater variability. Each chapter in
This guide focuses on issues specific, or AMAGuides, followed by a statement theAMAGuidesfocuses on a single
particularly common, to occupational of how this supplement interacts with organ system and provides a description
injury. impairment rating guides published of the diagnostic and evaluative
by the AMAor jurisdiction-based methods for assessing specified
Workers’ compensation is a system
impairment rating systems. impairments. Each impairment is
based on a heterogeneous collection of
assigned a rating, expressed as a
national and sub-national (individual AMAImpairment Guides
percentage of loss of function for that
state and provincial) laws. There are
Originally published as a series of system. Organ-based ratings are then
no binding national or international
articles in the Journal of the American translated into impairment ratings for
st a n d a r ds for how workers’ compensation
Medical Association, the AMAGuides the whole person. The AMA
impairment ratings are to be done. To
have been revised periodically, and are methodology is not universally accepted
illustrate the wide range of government
now in the 5thedition. As shown in and is based largely on consensus rather
insurance systems in the United States
Appendix A, 35 US states reference than scientific evidence (Holmes, 2002).
alone that have their own rating systems
some version of the AMAGuides in
for occupational disability: Those jurisdictions that utilize the AMA
their workers’ compensation law
Guidesnote difficulty and confusion in
•Black Lung Benefits (Brigham, 2002). Other sources site a
coming to a consistent rating between
• Lo n g s h o r e and Harbor Workers Prog r a m slightly different usage (AMA, 2000;
different raters for the same condition
•Railroad Workers Program Bavon, 1993). Acurrent listing of each
(Texas Monitor, 1999). This difficulty
•Veterans Benefits state and what they currently require for
provokes calls for revisions of the AMA
•Federal Employees Compensation Act the impairment calculation is found in
Guidesto address this issue (Barth,
(civilian) Appendix C at the end of this document.
Burton, Himmelstein, Rudolph &
TheAmerican Medical Association Guides TheAMAGuidesare a tool that can be Spieler, 2000; Stern, Peterson, Reville &
to the Evaluation of Permanent Impairment used to convert medical information Vaiana, 1997). Some jurisdictions
(AMAGuides), for reasons explained about permanent losses into numerical disallow parts of the 4thedition of the
below, fall short of a guide for workers’ values. Sometimes the AMAGuidesare AMAGuidesin that it violates their
8
compensation laws (BNA, 1997). claims payers and system admin- time and medical expertise by disability
Additionally, a number of studies istrators in rating permanent impairment. and workers’ compensation claims
demonstrate poor reliability The IAIABC contacted the AMA, seeking processors. It explains benefit types and
(reproducibility of results) of the to work with them in this endeavor. nomenclature.
methods used in the AMAGuides, The AMAresponded favorably to the
Overview of Occupational Benefits
especially relating to the spine. In request and expressed hope of future
fairness, these studies have dealt with coordination. The categories listed below describe
older editions of the AMAGuides.3 benefits payable under workers’
After reviewing current impairment
compensation. Terminology may differ
IAIABC Guides rating systems, the Committee developed
from jurisdiction to jurisdiction, but
the present supplemental guide specific
Most jurisdictions that utilize some most recognize these four broad
to problem areas in workers’ compen-
edition of the AMAGuidesfor injured divisions of claims and their common
sation. These guidelines do not fit all
workers’ impairment ratings note abbreviations:
administrative situations. Each juris-
unnecessary physician/rater reporting
diction has a significant history of •Medical-only
variability in the impairment rating for
legislation, rules, and case law that will •Temporary disability, for wage loss
what appears to be the same physical
require these guidelines to be adjusted indemnity (TTD)
loss. This variability creates unnecessary
for parts of the rating process, or in •Permanent disability, divided into
patient anger, suspicion, hostility,
specific injuries. This work is provided Permanent Total (PT) and Permanent
litigation, and costs that are attributed
as model for jurisdictions to consider as Partial Disability (PPD)
to several non-medical factors. These
their particular jurisdiction needs develop. •Death (including burial)
factors include the individual examining
The Committee’s vision is to evolve
physicians, lack of knowledge and skills Most workers’ compensation injuries
toward the best practices in rating
by physicians, difficulties in diffe r en t i a t i n g require only medical attention and do
methodology. Additional supplemental
not involve lengthy time away from
subjective complaints from objective
bulletins or guides will be periodically
work, nor do they leave residual effects
findings, confusion between the concepts
issued as medical science evolves and
on the worker. In the United States,
of impairment and disability, bias, poor
updated by the IAIABC for the
“medical-only claims” are about 72
quality medical reports, determining
voluntary use by member organizations.
percent of all compensable injuries
causation analysis, and the apportionment
(Telles, 2001). These are claims that do
processes. Members of the IAIABC Legal and Historical
not involve compensation for lost work
Occupational Impairment Rating Guide Background
time, only medical expenses related to
Committee (Committee) believe that by
an injury. The percentage of medical-
im p r oving the rating criteria req u i r em e n t s , Processing claims information can be
only claims in a jurisdiction is a function
physicians/raters can reduce variability extremely frustrating and time
of the quality and speed of medical care,
for the impairment ratings. For this consuming for physicians/raters and
the length of lost time required before
reason, the IAIABC Executive Committee, their support staff. This section reviews an injury qualifies for indemnity
in October of 2001, commissioned the legal and administrative issues that benefits, and how scrupulously
Impairment Rating Committee to addres s equip physicians and staff to better employers report claims as workers’
the needs of workers’ compensation respond to the demands made on their compensation.
9
Under workers’ compensation, when Fortunately, claims for death benefits are permanent injury benefits, yet they
the injured worker has missed a relatively infrequent. In 1999, there produce about two thirds of the cash
predetermined amount of time from were 6,023 fatal work injuries out of 5.7 benefits paid. Of the $25.3 billion in
work4, he/she is eligible for wage million Occupational Safety & Health cash benefit payments going directly to
indemnification, with the amount Administration (OSHA) reportable injured workers in 1999, nearly $19
determined by each jurisdiction. Wage injuries (.1%) (NASI, 2001). billion were for compensation of
loss benefits continue until the disabling permanent injury.
As Table 1 below shows, about a quarter
condition either permits a return to work,
of claims in the United States involve
or reaches a plateau where healing ends
Table 1: Workers’ Compensation Cases in the United
and no significant improvement is likely.
States, 2000
The concept of “maximum medical
improvement” will be discussed at
Type of Workers’ Percentage of Percentage of
greater length in a later section. When
Compensation Claim Cases Cash Benefits
this occurs, the injured worker may be Temporary 72% 25%
Permanent Partial 27 62
entitled to another class of benefits to
Permanent Total 1 13
compensate for any permanent residual
Source:National Academy of Social Insurance,
loss, i.e., PPD or PT.
Workers’Compensation:Benefits, Coverage, and Costs, May 2001
Most state, provincial, and national
How the award is calculated for these blinded in both eyes or suffer major
systems make some allowance in the
law for payment of cash benefits upon permanent claims differs from amputations in two limbs.
proof of objective or reasonably inferred jurisdiction to jurisdiction. In some •Award a fixed number of weeks of
permanent injury to a worker. A jurisdictions, permanent injury benefits permanent disability benefits
permanent injury is one that causes are awarded only on the direct physical following certain treatments even
damage to an organ or bodily system loss. Other jurisdictions compensate to though the outcome is perfectly
that reduces its function and is expected some measure for expected wage loss, satisfactory to the physician and the
to last for life. These permanent injury the loss of employment options, extra patient.
benefits presumably compensate the expenses from accommodating the •Limit or disallow awards for certain
worker for likely or inferred loss of disability, or perhaps an implicit award conditions, such as tinnitus or
income from the bodily injury. This tie- for psychological loss and pain. Once psychological conditions.
in between income loss and permanent again, the laws in each jurisdiction differ
disability benefits is approximate and in philosophy and practice.
Ad d i t i o n a l l y , regulations or case law may
highly inconsistent from jurisdiction to
constrain or define how multiple injuries
In some jurisdictions, the permanent
jurisdiction. It is worth noting that
benefit is statutory and has no medical may be combined for losses to the body
some jurisdictions do not compensate
or clinical basis. Examples of the latter as a whole, or how preexisting conditions
for objective permanent injury to the
statutes are those that: should be apportioned to the loss.
body, only for permanent wage loss due
to the injury or likely to ensue from the •Declare a worker totally and In summary, several different classes of
benefits are paid under workers’
injury. permanently impaired if they are
10