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- Author or Editor: Steven D. Feinberg x
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Abstract
Many states have benefit programs (e.g., special fund, second injury fund, subsequent injuries fund, special disabilities trust fund) for people with significant pre-existing impairment and/or disability who are injured. Each fund has different rules and regulations. Some of these funds provide benefits to the injured worker, while others reimburse eligible employers and insurers. Physicians need to understand the specific requirements of benefit programs in their states. Evaluating physicians who understand the uniqueness of these programs will be better able to provide valuable services. This article provides insights into one such program, the subsequent injuries benefits trust fund (SIBTF) in California. To be eligible for SIBTF benefits, the injured worker must meet an “overall threshold” and an “industrial threshold” of disability to qualify for benefits. If these thresholds are met, the injured worker may receive additional compensation based on pre-existing (labor-disabling) disability. The pre-existing disabilities can arise from any source, including congenital, developmental, or acquired disease, prior injury, war injury, non- industrial injuries, or prior industrial disabilities.
Abstract
This article describes special aspects of addressing and defining substantial medical evidence, causation, and apportionment in the California Workers' Compensation system. Substantial medical evidence is framed in terms of reasonable medical probability, and the opinion must be based on fact and not be speculative. The issue of whether the injury occurred in the course of employment is left to the Trier of Fact (WCAB judge). The issue of arising out of employment is a medical issue left to the physician. Apportionment applies to both the industrial and nonindustrial cause of the disability.
Abstract
Who is in the better position to evaluate, the treating physician or an independent medical examination (IME) physician? A treating physician has a patient-advocate role because he or she has a doctor-patient relationship with the patient/claimant. Unlike the treating physician, an IME physician does not have a doctor-patient relationship, and can, therefore, provide an impartial evaluation necessary to assess the extent to which the patient/claimant is impaired or disabled from functional activities of daily living.
Abstract
Assessing impairment and/or disability in the pain patient often is difficult due to both administrative and clinical issues; in addition, the terms impairment and disability are misunderstood. Chronic pain complaints may be associated with significant disability, but typically the physician defines clinical issues, functional deficits, and, when requested, impairment; disability most often is an administrative determination. The biopsychosocial approach currently is viewed as most appropriate perspective for understanding, assessing, and treating chronic pain disorders and acknowledges a complex and dynamic interaction among biological, psychological, and social factors. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Sixth Edition, discusses the assessment of pain and eligibility requirements for pain-related impairment (PRI). Some physicians feel that the AMA Guides’ approach to PRI does not adequately address the “disability” and functional loss caused by some chronic pain states, but the AMA Guides is limited, mostly, to describing measurable objective changes or impairment. The AMA Guides is not intended to be used for direct estimates of loss of work capacity (disability), and impairment percentages derived according to the AMA Guides criteria do not measure work disability. Impairment ratings in the AMA Guides already have accounted for impairment-associated pain, including that experienced in areas distant to the specific site of pathology.
Abstract
Assessment of impairment and disability experienced by patients with chronic pain is challenging. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) assesses impairment primarily based on objective findings, but pain is subjective. The sixth edition of the AMA Guides provides a pain-related impairment (PRI) of up to 3% in rare situations. Otherwise, pain is considered to be reflected in the conventional impairment rating system. There are still many unanswered questions.
Abstract
Complex regional pain syndrome (CRPS) is characterized by chronic spontaneous and/or evoked regional pain disproportionate in severity, distribution, and/or duration to that typically experienced after a similar injury or illness. The pain may also begin without a known precipitant. While various authors have questioned the validity of the diagnosis, physicians will be asked to perform impairment ratings on patients diagnosed with CRPS. Hence, it is important to understand the issues associated with this syndrome; the diagnostic criteria for it, including the need to rule out other diagnoses that may explain the patient's presentation; and how to rate CRPS. The AMA Guides to the Evaluation of Permanent Impairment, Fifth Edition, provides approaches to assessing CRPS impairment that are refined in the Sixth Edition.
Abstract
Causation analysis involves determining what conditions are related to a compensable injury or illness; apportionment is the allocation of responsibility among two or more probable causes; and assessing impairment is based on the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). These three are separate activities, but sometimes all three must be addressed in a single evaluation and may be required for a specified jurisdiction (eg, California). Evaluators thus must ask if jurisdictional issues dictate or influence the approach to causation and apportionment; which edition of the AMA Guides to use; and how to approach causation and apportionment in the present case example: A 63-year-old woman with rheumatoid arthritis and systemic lupus erythematosus is assessed by an orthopedic surgeon who is the agreed medical evaluator (AME). In addition to her pre-existing rheumatoid arthritis and lupus, the individual also had Sjogren's syndrome, osteoarthritis, degenerative disc disease, left carpal tunnel syndrome, osteopenia, and obesity. She has undergone multiple surgical procedures, and treatment for her collagen vascular disease includes leflunomide (immunosuppressant), hydroxychloroquine, and prednisone. In this case, impairments were not the result of “cumulative trauma” but rather were secondary to underlying chronic inflammatory disease, and her occupational permanent impairment rating accordingly would be zero.
Abstract
When they apportion impairment in musculoskeletal cases, evaluators encounter a variety of unique issues and problems. The first step in apportionment is scientifically based causation analysis. Arbitrary or opinion-based unscientific apportionment estimates that amount to little more than speculation should be avoided. The AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), Fourth and Fifth Editions, are similar in their assessment of orthopedic impairment, but significant differences exist between these and the Sixth Edition. Individuals may experience impairments on several occasions. For example, if the first injury was rated using an earlier edition of the AMA Guides and a second injury occurs and is rated using a more current edition, then the most recent edition in the current jurisdiction is used to recalculate the rating for the first injury. Regarding which edition of the AMA Guides to use, evaluators should be aware of the jurisdictional requirements and also the timing to ensure that the individual is at maximum medical improvement. If the issue to be determined is apportioning the cause of the injury and not the impairment rating, then different criteria are used and the AMA Guides to the Evaluation of Disease and Injury Causation, Second Edition, is an invaluable resource. Extensive sidebars discuss qualitative vs qualitative apportionment and steps that evaluators can take to ensure that body regions and conditions are not confused (ie, that an apples-to-apples comparison is taking place).
