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By JOSHUA CLIFTON, a Chicago-based writer who covers workers' comp and disability issues

A leading member of Congress is raising concerns about the reliance of state workers' compensation systems on the American Medical Association's Guides to Permanent Impairment.

Among recent developments that merit attention, the chairwoman of the subcommittee pointed to the AMA's sixth edition of its guides, published in late 2007. The guides are used by physicians in a majority of state workers' comp jurisdictions as the sole protocol for measuring an employee's level of impairment due to a work-related injury. Woolsey focused on how the latest edition has become a hotbed of controversy, with states such as Iowa, Kentucky and Vermont choosing not to adopt them.

The sixth edition, she said, dramatically reduced impairment ratings for many types of conditions "without apparent medical evidence" and "without the transparency and consensus which should necessarily accompany the development of standards that will have widespread use by state governments."

Woolsey also took a shot at the physicians who developed the latest edition, alleging that they may have ties to insurance companies and are making a profit training doctors on how to use the guides, which she called "complicated" and "very difficult to apply."

Impairment Resources LLC in San Diego is among those companies that provide training, strategies and services related to the guides. Frederick Uehlein, director of the firm and chairman of Insurance Recovery Group, said that Woolsey's criticism is off base, although he's happy to see she is concerned about the disabled.

"Our company has conducted studies in Florida and Texas comparing ratings from the different AMA editions," he said. "We haven't found a dramatic change. The simplest explanation is that medicine is improving, which may cause the impairment which is prescribed to be less, but not dramatically less. However, if she is talking about a drop in payments, that's not something that is determined by the guide. The state legislatures can decide what they will pay for the disability."

The AMA concurred, saying that a recent study comparing ratings of the last three editions found no statistically significant difference in impairment ratings from the fourth to the sixth editions.

"Average values had increased from the fourth edition to the fifth edition for some spinal impairments based on the fact that surgery was performed, regardless of outcome," the organization said in a statement. "The authors of the sixth edition rectified these ratings to be based on functional outcomes rather than the fact that surgery was performed. There was not clear scientific rationale for inflating the fifth edition's ratings."

Uehlein--whose colleague at Impairment, Christopher Brigham, was the senior contributing editor for the AMA's sixth edition--also took issue with Woolsey's comments about the development of the guide.

"They looked to assemble the best of the best doctors from around the country," he said. "It was a significant group of experts, and anything but not transparent."

According to the AMA, the sixth edition allowed for greater transparency by including the input of more than 500 medical state, county and specialty societies, and additional impairment process stakeholders.

Woolsey also neglected to say that those same doctors who are providing training under the sixth edition are also providing guidance under the fourth and fifth editions, according to Uehlein. He noted that training is a good thing, pointing to previous studies by Impairment that have found that a large majority of impairment ratings are erroneous. For example, in a statistical analysis in California, the firm found that 82 percent of impairment ratings were incorrect, with the average rating being nearly three times higher than the appropriate level.

STILL SERIOUSLY FLAWED?

Uehlein, however, doesn't discount the notion that changes need to be made.

"What needs to be more clearly addressed by legislatures is the link between what a doctor delivers as a rating, or measure of functionality, and the ultimate determination about how much should be paid for a person's loss of earning capacity," he said. "In my opinion, the guides function well when dealing with the doctor portion, but more work has to be done on the other half of the equation. I think that's something that both Democrats and Republicans can agree upon."

John Burton, workers' comp guru and professor emeritus at Rutgers University and Cornell University, said that he doesn't necessarily think it is inappropriate for someone who has been involved in the guides to develop a training mechanism to ensure that the doctors applying them properly.

"I'm more concerned about the fact that the document is seriously flawed," he said.

A vocal critic of the guides in the past, Burton said that the fundamental problem is that, while the guidelines are supposed to rate impairments, the reality is that they have been used to determine the amount of cash benefits paid for disabilities.

"On one hand, the AMA can claim that they are pure on this issue," he said. "But they know very well that this is not the way these things are being used."

According to Burton, the AMA has a responsibility to put out a rating system that makes use of the available evidence and allows the guides to provide better information about the likely types of consequences for various types of injuries on peoples' disability.

"That's the frustrating part of all this," he said. "They claim in the sixth edition that such data on how various types of injuries translate into dollar losses and how they vary across different body parts isn't available. But I published a book on this in the 1980s, and there has been a whole lot of research conducted by RAND in the past 15 years that could be used to recalibrate the AMA guides in a way that serves the real purpose for which they are being used, and that's as a rating system for disabilities."

The AMA said that its goal is to develop an impairment rating system that is fair and equitable to all parties, and it looks forward to working with Congress and other stakeholders to resolve any pending concerns.

Read more at the WorkersComp Forum homepage.

December 1, 2010

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