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Workers comp Impairment ratings

If you thought the first few posts from NCCI were esoteric, here comes one that makes them look amazingly general. You’ll either yawn or be right on the edge of your chair…
Chris Brigham, MD, senior editor of the AMA Guides to the Evaluation of Permanent Impairment (the Guides), had the coveted post-lunch speaking slot at last week’s NCCI meeting on Thursday. For those not conversant with this issue, the Guides are used in workers comp to determine when, and how much, a person’s medical condition is a disabling condition.
Note that Brigham, and the new edition of the Guides, are controversial and the object of assault by many who claim to be on the side of the claimant (I’m not saying they’re not, I’m saying that’s what they purport to be. I have no opinion re the utility or appropriateness of the Guides).
Brigham started off by noting that most of the initial impairment ratings he reviewed were subsequently corrected. And in the vast majority of cases, the original rating was an over-rating of disability. That is, the subsequent review showed the person was not as disabled as the original impairment rating asserted. Brigham used a database comprised of 866 California cases, out of which 83% were incorrectly rated, at a cost of over $15,000 per case (cost is the award amount for the initial impairment rating v the subsequent rating).
Notably, impairment ratings in Hawaii tended to be more consistent than in California – a lot more consistent.
Errors in CA were overly concentrated in LA, less so in others. There is also a variation in ratings done by different types of physicians and for different diagnoses.
A couple key concepts – impairment is not the same as disability. Impairment is the result of the medical condition – what physicial impact occurred. Disability is somewhat more subjective, as it addresses what that person can do. For example, Steven Hawking (the brilliant physicist) is completely impaired due to ALS. He is also a prolific author and practices his craft every day. Thus he is ‘impaired’ but not ‘disabled’.
To paraphrase friend and colleague Jennifer Christian, MD, “there is no medical condition that is so disabling that there is not a person in this country with that condition working full time and being paid well.”
The new Guide was developed in an effort to add consistency across the ratings, a response to criticism of past editions. The new Guide is more diagnosis based, using evidence to substantiate the diagnosis, and provides rating percentages that factor in clinical and functional history as well as an exam of the patient. It also factors in new, more current medical research and clinical studies.
According to Brigham, the new Guide eliminates such historical factors to rating including the occurrence of surgery and range of motion for spine patients, as the clinical research indicated no linkage between those ‘factors’ and actual impairment.
Notably, physicians polled for their reactions to the new edition were generally favorable, while plaintiff attorneys and chiropractors were not.

What does this mean for you?

Expect the use of the new Guides will be controversial, and will likely be subject to legal action in many jurisdictions due to the changes, and stakeholders’ reactions to those changes.

One thought on “Workers comp Impairment ratings”

  1. I’ve been looking at and writing about the impairment rating controversy since the current 6th edition of the AMA guides was published. This topic is both arcane and at the heart of the workers compensation experience, which sometimes I think of as an ongoing conversation about fairness in American society. The ultimate arbiter of if and how Stephen Hawkings is disabled is what legislatures croakingly call out as the voice of the people. To present Stephen Hawkings (and the some 50,000 workers who get permanent disability awards each year, plus or minus) to this jury, we need consistently applied and valid reports on functional impairment. the 6th edition is an advance. Claimant bar does not like it because the ratings tend to be less than in the prior editions. The net reduction in impairment ratings result, Brigham says, from better measurement of functions after today’s medical treatment. I am sympathetic to Brigham’s point of view.

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Joe Paduda is the principal of Health Strategy Associates



A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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