National audiences enthusiastically received our message that driving accurate impairment ratings is one of the best opportunities for effective management of impairment ratings and also the right thing to do. In this special edition we want to share with you the message that others found so valuable.

Christopher R. Brigham, MD, Chairman of Impairment Resources, LLC, and Senior Contributing Editor to the Sixth Edition of the AMA Guides to the Evaluation of Permanent Impairment was a featured speaker at the National Council of Compensation Insurance's (NCCI) annual meeting in Orlando on May 7, 2009 and the National Council of Self-Insured's (NCSI) annual meeting in La Quinta, California on May 19, 2009. In these presentations he discussed the concepts of impairment and disability, explained the evolution of the AMA Guides, provided insights to the reasons why the majority of impairment ratings are erroneous, described how errors can be resolved, defined best practice in the assessment of impairment, and explored the future. He passionately articulated the tragedy of needless impairing and disabling and the need for a positive focus on restoration of function.

Dr. Brigham explained that impairment should be considered as a failure, i.e. a failure that there was injury or illness that should have been prevented; a failure that we are considering a process (such as aging) that is not a workers' compensation injury; or a failure to mitigate the impact of the injury or illness - in returning the injured worker to full function. Over time, with improved medical and surgical outcomes we should expect impairment and disability to decrease. He explained why the most recent Sixth Edition of the AMA Guides is a significant improvement. Much of the criticism of the Sixth Edition relates to no longer receiving high impairment ratings for spinal surgical procedures; previous assignment of impairment for these procedures is not supportable - the goal of all treatment should be to improve function and to decrease impairment. Therefore, the focus needs to be on the end result, not the treatment.

Many of the attendees had suspected that the error rate among ratings was high; however they had not collected the data which has been obtained by Impairment Resources, LLC which reveals that the majority of ratings are incorrect and typically these errors are missed by physicians, adjusters, and attorneys. The experience of our clients is that our reviews have been far more reliable than those performed by others, since our focus and expertise includes both several years of experience with the Guides and unparalleled medical expertise. Once errors are identified there are a number of strategies that will result in driving an accurate rating and ultimately improving the accuracy rate.

This message was received well - there were standing ovations at both sessions. An example of the feedback is the email from an attendee (the Executive Director of a large state security fund):

The NCCI presentation was discussed by the press, including in a May 8 article by National Underwriter Property and Casualty (http://www.property-casualty.com/News/2009/5/Pages/Most-Dr-Comp-Injury-Assessment-Faulty-MD-Says.aspx) which explained:

More than 75 percent of workers' compensation physical impairment ratings are incorrect because doctors "are not held accountable," an expert told an industry conference here... Most ratings are incorrect, he said, because grading impairment is a tedious process that most physicians have not studied and are ill equipped to perform...

He said critics of the latest American Medical Association guide who score changes for certain injuries fail to take into account advances in treatment and that "certain stakeholders" in the comp system resist science and data. A survey of reaction to the new AMA Guide and whether it is an improvement, he said, found... most lawyers strongly disagreed and most doctors agreed it was an improvement.

In the comp impairment area, the doctor said he sees many physicians who are "self-fulfilling prophets of doom and attorneys who use their clients as pawns." He urged his audience to focus on creating a positive attitude toward worker injury impairment to "change the future in the workers' compensation field." Dr. Brigham added, "Needless impairing is occurring all too often in the workers' compensation arena." He called for a stand to be made for a focus not on disabling but rather empowering injured workers.

The presentation was also referenced in the popular blog by Joe Paduda, Managed Care Matters (http://www.joepaduda.com/archives/001518.html#comments):

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...

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 physical 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.

His blog resulted in the following comment by Peter Rousmaniere, a leading national expert on workers' compensation and columnist for Risk and Insurance.

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.

Impairment Resources, LLC is dedicated to driving accurate impairment ratings - through every action we take - including the services we provide and education. Our dedication is to integrity and excellence - leading to transformation of the workers' compensation system. We are pleased to assist you by reviewing all impairment ratings received to assure their accuracy and assisting you in correcting erroneous ratings. We are also passionate about getting the message out that needless impairing and disabling is not to be tolerated and these challenges can be managed. If you are interested in more information about our services or booking Dr. Brigham or one of our other talented speakers for your meeting or organization, please contact us. We appreciate the opportunity to be of service, to you and the field.