Oregon Workers' Comp Division Provides Details on AMA 6th Edition Project

Oregon Workers' Comp Division Provides Details on AMA 6th Edition Project

The Oregon Workers' Compensation Division gave a presentation of the AMA Guides 6th Edition project at the May 15th meeting of the Medical Advisory Committee. A summary of the meeting notes is set forth below:

*    *    *    *    *

The Division stated how, since the publishing of the 6th Edition in December 2007 by the American Medical Association, some states have adopted the guides and some states are using study panels to decide their worth.

According to the Division, the Workers’ Compensation Management-Labor Advisory Committee (MLAC) had decided that the Medical Advisory Committee should look at the medical issues relating to the AMA Guides 6th Edition, resulting in the AMA Guides 6th Edition Charter. The Division plans to study the guides in a sequential approach:

  1. The medical policy issues;
  2. The administrative policy issues; and
  3. The benefits policy issues.

After each stage, the Division will make a decision if it is worthwhile to continue the study of adopting the AMA Guides 6th Edition.

For instance, if the Division decides the guidelines will be an improvement medically, it will then study the administrative rules. In turn, if the administrative rules prove to be workable, the Division will then study the benefits side.

The Division's presentation also covered the concern that the guides may lower ratings overall. To see if this concern is justified, the Division said that it might be beneficial to run a study where the DCBS Workers’ Compensation Division 35 Disability Rating Standards and the AMA Guides 6th Edition simultaneously looked at how benefits are affected. Then, if it proved to be good public policy generally, especially for workers, MLAC and the Legislature might want to adjust their benefit structure to take into account adopting the AMA Guides 6th Edition.

The Medical Advisory Committee asked if anyone had researched why some states declined to use the AMA Guides 6th Edition. The Division said there have been various reasons, including: legal, logistical (for instance, in Iowa rural providers were concerned that the steep learning curve for the AMA Guides 6th Edition would cause reluctance among them in providing ratings), and benefits reasons. Although, as far as a choice not to use the guides because of benefits reasons, the Division does not know if there have been vigorous studies that show if one were to take a number of claims, benefits would be aversely affected—which is the kind of study that the Division plans to carry out in the third phase of the project.

The Medical Advisory Committee also asked of the states that have adopted the AMA Guides 6th Edition, does the Division know how many of the attending physicians rate the worker. The Division replied that it could find out. According to the Division, the actual number of states that have adopted the 6th Edition is nine, and of those states, the attending physician rates most of them. Moreover, in Pennsylvania it has only been looked at for permanent total disability, not for generic ratings.

The Medical Advisory Committee wanted to know of those states that have adopted the AMA Guides 6th Edition, and of those who are the attending physician who actually rates the worker, how many have an IME process where the attending physician says he does not want to do it and to let the IME physician do it instead. It has been the experience that attending physicians prefer not to perform closing exams--they would rather someone else do it. In addition, for the rating part, some raters may not at look the guides at all, but just at what the Division gives them. The committee said that education would be an important part of any changes. The committee added that sometimes there is the opinion that once you have learned the Edition, there is a disincentive not to use it. The committee said that mostly everything in the AMA Guides 6th Edition book are now diagnostic based estimates with adjustment factors for clinical exams, clinical studies, and actually assessing a person’s function and symptomatic history. According to the committee, it is easier if physicians only provide impairment findings, while somebody else provides the rating. This is because sometimes all you need to know is the diagnosis, the worker’s history, if there are any positive objective clinical studies, and are there any relevant clinical exam findings. You do not need an inclinometer etc. You do not need to do some of the things you do now. It is an entirely different paradigm.

If the Medical Advisory Committee decides the AMA Guides 6th Edition are an improvement based on the given criteria, then it is going to require a shift in the administration and benefits side. It is not simply substituting one for the other; it comes at it from a different perspective. The committee said, as far as the rating goes, it would have to work out the administrative issue of the difference between the accepted condition and the actual diagnosis, because medical providers are going to rate on what the rating was for the final diagnosis. Therefore, if there is an overlapping diagnosis you will have to choose what was the single most disabling diagnosis for that body part and rate it accordingly.

Dr. Gary Rischitelli will chair a sub-committee composed of himself, Dr. Hans Carlson, and Dr. Frank Prideaux, that will answer the following questions:

  • Does the 6th Edition represent an evolution in medical knowledge?
  • Would use of the 6th Edition result in improved validity, clarity and inter-rater consistency as compared with Oregon’s current method for rating impairment?
  • Currently, insurers, based on medical findings and measurements, calculate ratings of impairment. Would this structure need to change with the adoption of the 6th Edition?
  • Could attending physicians readily interpret and apply the 6th Edition? If not, what would enable them to do so?
  • Who else could rate impairment using the 6th Edition?

Dr. Rischitelli said the sub-committee would have a report at the next Medical Advisory Committee meeting on September 18, 2009.

Source: Oregon Workers' Compensation Division, Medical Advisory Committee Draft Meeting Minutes May 15, 2009