California Physicians: Adjusting to AMA Guidelines

Saturday, November 8, 2003 | 0

The "Garamendi Plan", second phase, envisions a restructuring of the permanent disability rating system, and it is highly anticipated that a new permanent disability rating system will adopt the widely used (in 40 states) American Medical Association's Guide to the Evaluation of Permanent Impairment (currently in a much criticized 5th Edition) as the basis of a new PD rating system. This portends several changes for California workers' compensation physicians, not the least of which is an entirely new 'language' for the description of loss of body part function.

Perhaps the most dramatic change that this restructuring will create is that the physician will no longer be describing a disability, but rather an impairment, which is then translated to disability.

The difference between an impairment and a disability is that an impairment describes the inability of a certain part of the body to function properly. A disability occurs when the impaired bodily function inhibits personal, social, or occupational demands. The AMA Guidelines assist in the description of an impairment, but workers' compensation systems that have adopted the Guidelines as a dollar for dollar system of rating disability have been widely maligned as failing to adhere to the concept of the AMA Guidelines. The Guidelines specifically provide:

"The physician does not determine industrial loss of use, economic loss, or any other type of loss giving rise to disability payments."

The concepts of 'employability' and 'incapacity' are not the tests for the assessment of impairment and non-economic loss. Translating impairment into money is the product of a legally defined disability. The Guidelines specifically provide that they are NOT to be used for the purpose of compensation for disability.

On Page 13 of the Guides it states; "Impairment percentages derived from the Guides criteria should not be used as direct estimates of disability. Impairment percentages estimate the extent of the impairment on whole person functioning and account for basic activities of daily living, not including work. The complexity of work activities requires individual analysis. Impairment assessment is a necessary first step for determining disability."

For example, under the AMA guidelines, the loss of five fingers on one hand would be an impairment of 90% of that extremity. Additionally, this would represent a 54% whole-person impairment. If the injury occurred to a professional piano player, then it would seem obvious that such an injury should represent a 100% to that person. On the other hand, a long distance runner would not be so affected and thus the impairment of a loss of five fingers would represent a significantly lower disability.

According to the AMA Guides, there are two ways in which to evaluate individuals with an injury. The primary method is called the DRE method, which stands for Diagnosis-Related Estimate method. The other method is called the ROM method, which stands for Range-of-Motion method. The Guides state that the ROM method should only be used when the impairment is not caused by an injury or when an individual's condition is not well represented by a DRE category. The ROM method is also now used to evaluate individuals with an injury at more than one level in the same spinal region and in certain individuals with recurrent pathology.

No longer would an assessment of permanent disability be based on subjective factors or work restrictions, and in addition, the Guidelines provide that impairment is based on a "whole body" factor, meaning that no one can have a combined total impairment in excess of 100% combined of all impairments taken together. The question, of course, is whether the law will permit someone to have greater than a 100% disability.

Adoption of the AMA Guidelines as a part of a permanent disability rating system in California will require an entirely new outlook, and a lot of education, on the part of professionals in the work comp system, and in particular physicians, who will be called upon to operate in an entirely different, albeit well tested, environment.