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Thus began a posting discussion on the Work Comp Analysis group of LinkedIn. Several workers' comp experts weighed in on the subject, all with the same basic message: Inaccurate assessments of injured workers due to a lack of understanding and/or training on the Guides is resulting in unnecessary costs to employers, especially in California.

The American Medical Association Guides to the Evaluation of Permanent Impairment were designed to offer a standardized, objective approach to evaluating medical impairment once an injured worker has reached maximum medical improvement. Most states use some version of the Guides to help determine monetary benefits for permanent partial injuries.

Pearlman's comments concur with a 2010 study by San Diego-based Impairment Resources that found an error rate of 78 percent based on an examination of more than 6,000 impairment ratings. It appears the problem is not going away.

"Of the impairment rating reviews and permanent disability ratings this year alone the error rate is 74 percent," Brasseur wrote. "Of that 74 percent, over 90 percent assigned too high of a rating."With an average cost of each mistake totaling at least $15,000 per claim and with roughly 600,000 ratings done each year, that adds up to big bucks for the workers' comp system.

The problem. Inaccurate assessments are especially problematic in California, a situation that's been exacerbated by a couple of recent legal decisions. "There's been encouragement by the applicants attorneys' bar in California to be extremely creative in the use of the AMA Guides," said Dr. Christopher Brigham, chairman of Impairment Resources.

Brigham said that some states use the Guides better than others. In Hawaii, for example, there is a high degree of reliability of ratings because the state trains physicians on the reporting requirements.

"If the ratings are done appropriately, what it permits is to have decisions made in a more consistent manner with reduced costs, both financial and human," Brigham said. "That permits earlier claim closure and permits people to go on with their lives."

In general, however, the ratings are performed by people untrained on the Guides. The experts say physicians are not accomplished report writers.

"Beyond impairment ratings, my observation as a report 'grader' for our WorkCompCentral education courses on report writing is that the vast majority of physicians, at least ones getting into the system and required to take this course, just have no clue, or don't take the time to understand, the reporting requirements per regulation, nor what is or can be (or more importantly, what isn't) substantial evidence," wrote David DePaolo, president of WorkCompCentral. "Too many I have to fail and have them try again, and many push back."

Brigham concurs. "Most evaluations I review (particularly California reports) are poorly done -- inadequate histories, record reviews and physical examinations, unsupportable conclusions (often ignoring the facts in the case and current science -- particularly as it relates to causation, apportionment, impairment and disability), and poorly written," he wrote. "This misinformation negatively impacts the workers' compensation system, including the injured worker."

Solutions. Getting accurate, objective assessments is critical for proper use of the Guides. "The key is to have a physician write a neutral report meaning they are not applicant or defense. The exam is the exam," Pearlman said.

To enable untrained physicians to do that, Pearlman and his company have developed a web-based system that will allow physicians to perform impairment ratings. With a planned launch date this summer, the software guides physicians through the process in accordance with the 5th edition of the Guides, which is used in California. Pearlman says he's also been asked to modify the system for use in Georgia.

Brigham says having a trained person do the assessment is vital, whether that means training physicians or employing an outside resource. He sees a significant opportunity to improve causation.

"If somebody has acute trauma, causation is clear," Brigham said. "But in many cases where we see something attributed to cumulative trauma, it's not so clear if it is work-related or not. So physicians don't learn the skills of causation or apportionment."

Brigham is hoping that states such as California take steps to ensure the Guides are used as intended. "I hope there would be changes if they continue with the 5th edition [of the Guides] to require training and a process of monitoring physicians to ensure they perform [the assessments] correctly," Brigham said. "Also, I'd suggest moving from the outdated approach -- the 5th edition -- to the 6th edition of the AMA Guides. It reflects the current science, knowledge and evolution in impairment."

Read more at the WorkersComp Forum homepage.

May 31, 2011

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