New Study Reveals 80% of Ratings are
Erroneous
Brigham and Associates, Inc., the nation’s
leader in impairment assessment, has completed a national
study of 2100 cases referred for rating review. This is a
crucial study since the AMA Guides to the Evaluation of
Permanent Impairment, Fifth Edition are widely used in
workers’ compensation, Longshore and Harbor Workers' Act,
automobile casualty and personal injury cases to quantify
permanent losses associated with injury or illness. The
results are very significant: 80% of all ratings are
erroneous, with 89% of the erroneous ratings being elevated.
This study involved the critique of 1445 cases and the
assessment of impairment on the basis of file review of 655
cases. Of Fifth Edition whole person erroneous ratings (839
cases of 1037 cases critiqued), the rating by the original
rating physician averaged 15.5% whole person permanent
impairment and upon re- rating the corrected rating averaged
5.6% whole person permanent impairment. Impairment ratings
must be based on objective data and assessed by skilled
independent evaluators. Therefore, all impairment ratings must
be critically reviewed. In a seven part series we will provide
you with a summary of the findings, present data regarding
typical ratings and errors, discuss the causes for erroneous
ratings, present “red flags” for detecting erroneous ratings
and provide specific effective strategies to manage impairment
evaluations.
The goal of our reviews is to determine if
ratings are accurate and the probable impairment based on the
available clinical information. If the original rating is
judged to be incorrect by the expert reviewer and there is
adequate clinical information to rate impairment, then the
case is re-rated using the Guides criteria and the data
provided. Each reviewing expert is a Certified Independent
Medical Examiner by the American Board of Independent Medical
Examiners, a Certified Impairment Rater, board- certified in
occupational medicine by the American Board of Preventive
Medicine, and has several years experience in clinical
medicine and ratings. Therefore, typically the expert reviewer
has considerable greater knowledge and skills in the use of
the Guides than does the original rater. Each critique results
in recording key data and preparing a written report. Although
this is not a random sample, this large unique national
database illustrates challenges encountered with ratings and
provides unique insight to these cases.
As of December 15, 2005, 2100 cases were
reviewed and entered into the database; 1445 (69%) of these
were critiques of ratings that had been performed by another
physician and 655 (31%) were independent ratings performed on
the basis of medical records. The cases included 1103 cases
reviewed in 2005, 602 in 2004 and 395 prior to 2004. Most of
the cases involved the use of the Fifth Edition, this
reflecting 1670 (80%) of all ratings reviewed or performed and
92% of the cases critiqued. The database was national and
included workers’ compensation, Longshore and Harbor Workers'
Act, automobile casualty and personal injury cases. Cases from
44 different states were reviewed; 45% of the cases were from
California (the Guides were adopted for use in workers’
compensation cases in 2005 as a result of workers’
compensation reform and enactment of California Senate Bill
899), 12% from Hawaii, 9% from Florida, and 37% from other
states. Depending on type of case and jurisdiction the final
ratings were expressed as a whole person or regional
impairment.
The vast majority (98% of cases) were
musculoskeletal impairment assessments, the most common being
spine (36%), followed by upper extremity (31%), lower
extremity (21%), and multiple musculoskeletal (12%). The most
common region rated was the lumbar spine (17% of all
cases).
Of the Fifth Edition cases critiqued 80% were
found to be erroneous and of the Fourth Edition cases
critiqued 79% were erroneous. Of the 567 California Fifth
Edition cases critiqued in 2005, 78% were erroneous, and for
non-California cases 84% were erroneous. Therefore the error
rate seen in California with the introduction of the Guides is
similar to that seen nationally; however 100% of the ratings
reviewed in January-February 2005 were erroneous, this
initially improved with error rates of 84% for March-April,
75% for May-June, and 73% for July-August, however then
worsened with error rates increasing to 84% for
September-October and to 87% for November-December. The error
rate for Florida cases was a staggering 94%. The vast majority
of Florida ratings were performed by treating physicians
typically prior to the probable date of maximum medical
improvement. Plaintiff-oriented physicians in Florida may be
inclined to report permanent impairment; if no threshold
injury is found, tortfeasors with personal injury protection
coverage are immune from liability for most tort claims.
(§627.737(1), Fla. Stat. (1995))
The error rate was higher as the value of the
original rating increased; for 1037 original ratings whole
person Fifth Edition ratings critiqued, for ratings under 5%
whole person the error rate was 57%, between 5% and 15% whole
person the error rate increased to 86%, and between 16% and
25% whole person the error rate was 94%, and over 25% the
error rate was 91%. Error rates for lower extremity ratings
were less (72% incorrect) than for spine (81% incorrect) and
upper extremity (80% incorrect).
In the next issue of the ezine we will present
more of the results of this landmark study. If you do not yet
subscribe to the ezine, visit www.impairment.com to subscribe
– it is valuable and provided as a public service.
Impairment Rating Review
