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Abstract
The state of Illinois has undergone major workers’ compensation reform with the passage of House Bill 1698, and from September 1, 2011, one of the factors used to determine a permanent partial disability (PPD) rating is an impairment evaluation according to the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition. Previously, the Illinois Workers’ Compensation Commission used a body of case law that set forth general parameters to guide PPD assessment, and the Commission would not allow testimony for any doctor's opinion regarding the percent of disability. Adding the use of the AMA Guides should increase the reliability of these awards. Impairment rating is only one factor that will be considered in determining the level of PPD, and other factors include the injured employee's occupation; age at the time of injury; the employee's future earning capacity; and evidence of disability corroborated by the treating physician's medical records. No single factor should be the sole determinant of disability, and the fact finder must use judgment and must document the rationale for the decision. Basing the impairment rating on the AMA Guides as a starting point should result in both a more valid and more reliable process to determine PPD.
Abstract
Evaluating physicians may need to account for the effects of multiple impairments using a summary value. In the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, the Combined Values Chart provides a method to combine two or more impairment percentages based on the formula A + B(1 – A) = the combined value of A and B. Using the Combined Values Chart and this formula, physicians can combine multiple impairments so that the whole person impairment is equal to or less than the sum of all the individual impairment values. The AMA Guides, Sixth Edition, specifies that “impairments are successively combined by first combining the largest number with the next largest remaining number, and then further combining it with the next largest remaining number … until all given impairment numbers are combined.” Impairment values within a region generally are combined and converted to whole person permanent impairment before being combined with values from other regions. The article reviews the AMA Guides, Sixth Edition, approach to combining upper extremity impairments, lower extremity impairments, and combining spinal impairments.
Abstract
Physicians who perform impairment evaluations should base their ratings on the objective condition of the patient, along with credible subjective findings. In making interpretations and judgments, examiners have obligations that are distinct from the duty of care as a treating physician. An experienced attending clinician, for example, may be unfamiliar with the correct process of rating impairment or may not feel unbiased in performing the rating. If significant new diagnoses are discovered, the physician has a medical obligation to inform the requesting party and individual about the condition and to recommend or refer for further medical assessment. When the physician is uncertain about which method to use to calculate an impairment rating or if more than one method can accurately be used, the physician should calculate the impairment rating using different alternatives and choose the method or combination of methods that best represents the functional impairment of the individual. The attending physician often is the person most knowledgeable about the injured employee and is encouraged to render the final impairment rating, when possible. Depending on the jurisdiction, examiners may be required to comply with specific constraints and duties regarding the rating. Examiners should not question an individual's integrity but can appropriately comment on the person's credibility.
Abstract
A nationwide study in 2005 of 2100 cases referred for impairment rating review found 80% to be erroneous, and 89% of these erroneous ratings were higher than appropriate. Among whole person erroneous ratings (839 of 1037 cases critiqued), the original physician's rating averaged 15.5% whole person permanent impairment, but following rerating by physician experts, the corrected rating averaged 5.6%; only 7% of the cases were underrated. All ratings were based on the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides), Fifth Edition. Tables and figures show error rates according to portion of the body affected, expert vs original rating, and other explanatory variables. Two physicians who use the AMA Guides should arrive at similar conclusions about impairment ratings, but most physicians have not received instruction about assessing impairment, disability, or causation and lack an adequate ability to assess these issues. Causation requires a given cause and a given effect that are associated with a reasonable degree of medical probability and also requires documentation with appropriate scientific evidence (not self-reports or historical time frames). Those who prepare and review assessments of impairment should ensure that clinical causation assessments were accurate, that the rating was performed at maximal medical improvement, that examination findings were consistent, and that the individual's normal state was determined.
Abstract
This article continues a discussion of the results of a nationwide study that reviewed 2100 impairment ratings and found a large number of errors (see the May/June issue of The Guides Newsletter). Spinal impairment ratings, for example, often are erroneous. Although the AMA Guides to the Evaluation of Permanent Impairment, (AMA Guides) clearly specifies use of the Diagnosis related estimates (DRE) method, evaluators sometimes incorrectly use the range-of-motion (ROM) method, which is fraught with potential error and typically results in higher impairment ratings. The most common problem associated with rating the lower extremities is combining multiple duplicative impairments. Multiple impairments typically are combined rather than added because the latter usually results in overrating impairments. A sidebar highlights red flags to erroneous AMA Guides ratings, and evaluators can take a number of steps to ensure accurate ratings. The first of these is to ensure an unbiased rating, preferably by a board-certified physician who, ideally, also has certification in the performance of independent medical and impairment examinations. The client requesting the evaluation should provide a cover letter describing the specifics of the evaluation, and the evaluator's report should comply with standards defined in the AMA Guides. All submitted reports should be reviewed by a physician experienced in the use of the AMA Guides; this cannot be accomplished by a nonphysician reviewer.
