Disability Impairment Trends

34 Pages·2015·0.84 MB·English

American Osteopathic College of Occupational and Preventive Medicine
2015 Mid Year Educational Conference, Ft Lauderdale, Florida
Impairment
anylossorabnormalityof:
MimmsJMabee,DO,MA,MPH,
FAOCOPM
COL(ret)USArmy
DisabilityImpairment- Psychological
AnArmyperspective
Physiological
Anatomical structure or function
Disability WhoCompensates?
Inabilitytoengageinanysubstantial,
gainfulactivitybyreasonofanymedically Workerscomp
Determinablephysicalormental Privateinsurancepolicies
impairment(SSA)
Stateprograms
ADAsays:limitinaleast1majorlife SSAbenefits
activity,recordofimpairmentORbeing Govt.&VA
regardedasimpaired!
Challenges CredibilityConclusions
Lackofconsistency Allegations are credible
ASingleidenticalcasewassentto65IMEsand
Allegations are partially
resultingawardvariedbyupto85percentile
points! credible
Physiciansarereluctanttoreportinconsistencies
shownbythepatientduringexam Allegations are not credible
F-1
American Osteopathic College of Occupational and Preventive Medicine
2015 Mid Year Educational Conference, Ft Lauderdale, Florida
APGARTool
A=ifjobisnobetterwhatwillyoudo?
Areyousatisfiedwithyourjob? USARMYdisability
P=paindrawing system
Painbehaviorscore(AMAguidestable18-5)
MEBorMedicalEvaluationBoard
G=gut tothe PEB
orPhysicalEvaluationBoard
credibilitytool,intuitionofeffort,andduration
A=acting(distraction,Wadells,griptesting)
R=reimbursement(compensation/litigation)
VAdisabilityvs.Armydisability
VAlooksatlifelong
impairment
Armylooksatcurrent
impairmentandabilitytodo
job
LessonsLearned
Lostartofmedicine-
Fearofgivingopinionssuchasmalingeringor
exaggeratedresponsetotesting
productivityrequirements
Casereturns
TDRL
F-2
097129-DisabilityMed-Sept01 12/4/01 11:25 AM Page 1
Vol. 1 No. 2 September–December 2001
DDIISSAABBIILLIITTYY MMEEDDIICCIINNEE
The Official Periodical of the American Board
of Independent Medical Examiners
Editorial Board Contents
PAGE
Disability Medicine -
Editor-in-Chief
The Quest Continues
Mohammed I. Ranavaya, MD, MS, FFOM, 3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
FRCPI, FAADEP, CIME
General Information
Assistant Editors . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
Thomas A. Beller, MD, FAADEP, CIME
Motivation Determination
J. True Martin, MD, CIME, FAADEP
(Sincerity of Effort): The
Rebecca McGraw-Thaxton MD
Performance APGAR Model
5
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Editorial Advisory Board
Alan L. Colledge, MD, CIME Mild Traumatic Brain Injury
Stan Bigos, MD An Overview of Pathophysiology,
Biomechanics and Evaluation
Chris Brigham, MD, CIME 19
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gordon Waddell, FRCS, Glasgow,UK
Book Review
Charles N. Brooks, MD, CIME
Risk and Disability Evaluation
Pete Bell, MD, CIME
in the Workplace
25
Peter Donceel, MD, Belgium . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sigurdur Thorlacius, MD, PhD, Iceland
Letters to the Editor
Clement Leech, MD, Ireland 27
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Jack Richman, MD, Canada
Cristina Dal Pozzo MD, Italy ABIME Certification Review and
AMA Guides to the Evaluation of
Richard Sekel, MD, Australia
Permanent Impairment
William H. Wolfe, MD, MPH, FACPM, CIME 5th Edition Training Course
Charles J. Lancelotta, Jr., MD, FACS 2001-02 29
. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Kevin D. Hagerty, DC, CIME
Sridhar V. Vasudevan, MD
Frank Jones, MD, CIME
Alex Ambroz, MD, MPH, CIME
William Shaw, MD, MPH
Jan von Overbeck MD, Switzerland
James Becker, M.D.
Altus vanderMerwe MD, Switzerland
Jerry Scott, M.D.
Chet Nierenberg, MD
Charles Clements, M.D.
Mitch Shaver, M.D.
Brian T. Maddox,Managing Director
American Board of Independent Medical Examiners
097129-DisabilityMed-Sept01 12/4/01 11:25 AM Page 2
AMA Guides ad
PDF File furnished
full page
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097129-DisabilityMed-Sept01 12/4/01 11:25 AM Page 3
Disability Medicine -
The Quest Continues
BOARD OF DIRECTORS
Thomas A. Beller, MD, CIME
President
Kansas City, Missouri
The response to the inaugural Issue of
Mohammed I. Ranavaya, MD, CIME practitioner of disability medicine are
President Elect/Secretary
Chapmanville, West Virginia Disability Medicine was both positive and
without border and that our colleagues
Paul R. Bell, MD, CIME
Denver, Colorado overwhelming. From your mail and
performing Independent Medical
Donald L. Hoops, PhD
Prospect Heights, Illinois personal conversation it was obvious
Examinations and impairment and
John D. Pro, MD, CIME
Kansas City, Missouri that there is a great interest in a
disability assessment down under and
Brian T. Maddox
Executive Director periodical that focuses on the issues
elsewhere in the industrialized world
Barrington, Illinois
facing the field of Disability Medicine in
face some of the same issues as we deal
BOARD OF ADVISORS
Christopher R. Brigham, MD, CIME general and the Independent Medical
Chairman of the Advisory Committee with regularly including controversial
Portland, Maine
Examinations in particular. Every article
Robert N. Anfield, MD, JD diagnoses, misuse and abuse of benefit
Chattanooga, Tennessee
of the Inaugural issue received
Stan Bigos, MD systems and legal challenges.
San Diego, CA
comment. Obviously the article on
Niall J. Buckley, BSc, MD, CIME
Halifax, Nova Scotia, Canada The more recent attention by public and
Fibromyalgia received the most
Pieter Coetzer, MB, ChB, BSc, CIME
Capetown, South Africa legislators in some jurisdiction regarding
attention, as there is passion on both
Paul W. Goodrich, Esquire
Boston, Massachusetts Independent Medical Examinations
sides. Impairment and disability
J. Frederic Green, MD
Moline, Illinois about all aspects of these examinations
resulting from the claims of these
Jane C. Hall, RN, MPA, CCM
San Francisco, California including qualification and credentials
various controversial diagnoses
Clement Leech, MD
Dublin, Ireland of examiner, fee structures, ethics- shows
continues to be a challenge for
Christine M. MacDonell
Tucson, Arizona Independent Medical Examiners that the subject stirs up deep emotions
Presley Reed, MD, CIME
Past President because of the polemic nature of the because it affects the way the resources
Boulder, Colorado
Lester L. Sacks, MD problem. Everything about these various of benefit systems are distributed, and it
Hartford, Connecticut
William Shaw, MD, MPH controversial diagnoses engenders affects our perception of fairness and
Denver, CO
Alfred Taricco, MD controversy except for the suffering it justice.
Manchester, Connecticut
Gordon Waddell, DSc, MD, FRCS causes. It is my sincere hope that
Glasgow, Scotland In this regard, I should note that a sense
John J. Wertzberger, MD colleagues from all sides of debate
Scottsdale, Arizona of trust and open communication are the
Karen Wielde, RN, BSN, CCM would not loose sight of the isolation,
Marietta, Georgia essential ingredients in gaining
frustration, and marginalization of these
acceptance for the IME process. There
patients, which need to be addressed by
obviously is a distinct need for
the clinicians.
education and credentialing of the
Independent Medical Examiner. What is
Some of the comments from our
needed above all is an unbiased, evenly
international readers, particularly from
balanced process and a dialogue
Europe and Australia underscored my
between industry, politics, and the
conclusion that the challenges facing the
3
097129-DisabilityMed-Sept01 12/4/01 11:25 AM Page 4
public. The ultimate aim of helping petitioned the Board of Directors in the continuous education and training. This
people and serving society must never past for an alternate pathway for re- new pathway would be an alternate
be lost from sight. certification without examination. After option to the current re-certification
considerable deliberation the Board of examination, which would remain
The past decade has shaped our
Directors in its recent meeting available. The details will be available
organization and made it what it is
unanimously agreed to an alternate shortly.
today. We can look back with pride on
Re-certification pathway without
our relatively short past, which has Mohammed I. Ranavaya, M.D., M.S.,
examination. The initial certification by
shown that the American Board of FRCPI, FFOM, FAADEP, CIME,
ABIME would still require certification
Independent Medical Examiners has Professor, Marshall Univ.
examination; however, the 5-year re-
always adapted itself successfully to the Joan C. Edward, School of Medicine,
certification process would have an
demand of the evolving environment of Huntington, West Virginia
alternate pathway without examination
Disability Medicine. In this regard,
but with rigorous requirement of
ABIME’s certified doctors have
General Information – Disability Medicine, Volume 1, Number 2
Disability Medicineis an educational publication of the US per year (individual copies $15 each); for outside professional textbooks or professional journals,
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Examiners reserves the right to decline any
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097129-DisabilityMed-Sept01 12/4/01 11:25 AM Page 5
Motivation Determination (Sincerity of Effort):
The Performance APGAR Model
Abstract:
Alan L. Colledge, MD, FAADEP Conclusions: The authors conclude
Medical Director
that the Performance APGARmodel
Labor Commission of Utah Background:Making an objective
Salt Lake City, Utah provides clinicians a new, easy method
determination of the amount of effort
Sports Medicine and Orthopedic
to uniformly measure patient
Associates an individual expends to recover from
Provo, Utah motivation and effort. Performance
injury or illness is an essential
APGAR scores can be measured at each
Edward B. Holmes, MD, MPH component in making stability and
Chief Medical Consultant visit, over a series of visits or at final
capability statements. Individuals,
Utah Disability Determinations Services
impairment rating. The authors feel
for Social Security whose effort and motivation are less
University of Utah that further research will validate the
than optimal may over use treatment,
Rocky Mountain Center for
proposal that motivation and effort are
Occupational and Environmental Health have increased medical costs, more
Salt Lake City, Utah key factors in predicting recovery and
disability payments, and a prolonged
Send Correspondence to:
RFC.
9581 Hillsborough Heights Rd. recovery. This paper presents a new
Sandy, Utah 84092
standardized reporting methodology, Introduction:
[email protected]
801-321-6522 referred to as the Performance APGAR,
that is a comprehensive summary of Physicians are more frequently being
E. Randolph Soo Hoo, MD, MPH, FACOEM
Chief Medical Consultant, Arizona DDSA current methods used to measure the asked to determine an individual’s
Regional Medical Director, Union Pacific amount of personal commitment and physical, mental or social abilities, for
Railroad
Tucson, Arizona effort the patient has expended to either temporary or permanent
improve their condition. conditions. Those requesting this
Richard E. Johns Jr., MD, MSPH,
information include: Social Security,
FACOEM, FAADEP, CIME
Methods: Various experts in the field
Medical Director State Welfare, Employment Security,
Alliant Techsystems of impairment and disability evaluation
Labor Commissions, Vocational
Professor (Clinical)
did an extensive literature review and
Department of Family & Preventive Rehabilitation, Driver’s License
Medicine developed a consensus method to
Divisions, employers, insurance
University of Utah School of Medicine
better evaluate the motivation and
Salt Lake City, Utah companies, workers’ compensation,
effort of the patient and the role of that
short and long term disability, and loan
John Kuhnlein, DO, MPH, FACPM,
effort in determining Residual
FACOEM deferment plans among others. The
President ORCA, PC Functional Capacity (RFC) and
ability to accurately measure the
Corporate Medical Consultant predicting recovery.
IBP, Inc. amount of effort expended by a patient
Fitness for Duty Medical Director
Results: The authors developed the to improve their condition is a critical
Union Pacific Railroad
Omaha, Nebraska Performance APGARmodel as an determination. It is particularly critical
acronym that provides an easy to that medical providers quantify a
Scott DeBerard, PHD
Assistant Professor remember method to estimate patient patient’s effort so that administrators
Department of Psychology
motivation, credibility and effort. can appropriately allocate limited
Utah State University
Logan, Utah disability funds. In 1996, direct medical
5
097129-DisabilityMed-Sept01 12/4/01 11:25 AM Page 6
costs for persons with disability were shown to be a significant part of the injured elite athlete and other patients.
estimated to be $260 billion.1As the treatment for an injury or illness, even As a general rule, elite athletes with
applicant pressures increase for benefiting patients suffering from severe joint injuries are highly
different disability policies, there is a chronic pain.6,7,8,9 Conversely, motivated to return to full functional
growing and significant need for a prolonged time away from work makes capacity. On the other hand, some
comprehensive instrument that reliably recovery, and eventually returning to injured individuals, for various reasons,
measures effort. In 1992 there were work progressively less likely.10,11 have less motivation to return to full
approximately 3,200,000 individuals in Studies have shown that workers who functional capacity in a timely fashion.
pay status under the SSADisability return to their original employer are
Areview of the medical literature
Insurance program. By the first of 2001, usually better off financially than
demonstrates that compensation
this number had grown to workers who choose other options,
benefits alone can significantly affect
approximately 5,100,000.2 US such as alternative vocational
motivation toward recovery.15,16,17,18,19,20
employers have seen their costs for rehabilitation plans that include
All parties involved in the recovery of a
work-related injuries and associated retraining or new job placement.12,13
patient receiving compensation, should
disabilities increase from $2.1 billion in Effective accomplishment of returning
recognize the unique set of
1960 to an annual estimated total cost of impaired individuals to work often
expectations, critical periods and
$171billion a year.3 Currently the requires the combined efforts, of the
specific needs that must be met to
average cost of a lost-time work related individual, health care provider, and
attain return-to-work status. Current
injury is more than $20,000.4 Medically employer, to carefully evaluate the
research has shown conclusively that in
determined physical abilities statements patient’s ability and then, if necessary,
cases of delayed recovery, nonphysical
are the first step toward the final consider efforts to provide reasonable
factors are often present directly
administrative disposition as to accommodations.14 In order to
impacting the injured individual’s
whether a person is determined complete accurate fitness for duty
motivation.21,22,23,24,25,26,27 There might be
qualified for some type of disability reports, stability statements, and
a single factor or a combination of
benefit. These ability decisions carry residual functional capacity (RFC)
factors present, i.e. social, emotional,
heavy legal and ethical responsibilities determinations, clinicians need to
neurotic, economic and even
as fitness for duty decisions are often consider and report the motivation and
sometimes-vindictive motives. Beneath
directly related to the individual’s effort of the patient. All experienced
this lies the original physical complaint
earning capacity and/or disability clinicians have noted that the same
that maintains the disability
benefits. In making capability physical condition or impairment can
compensation payment.
statements, physicians should be cause widely divergent levels of
cognizant that returning individuals to functional loss in different individuals. Epidemiological studies reveal distinct
gainful employment is one of the most This difference in functional loss among characteristics in the occupational and
potent therapeutic and rehabilitative individuals can often be attributed to psychological profiles of people
modalities available. Work promotes motivation and patient effort. Many disabled by soft tissue injuries,
independence and is essential to a clinicians have noted with particularly low back pain.28,29,30,31,32,33,34,
person’s self-respect and quality of life.5 consternation the difference in recovery 35,36,37,38,39,40,41,42 For example, job
Resumption of work has also been times and final capability between an dissatisfaction, monotony and stress are
6
097129-DisabilityMed-Sept01 12/4/01 11:25 AM Page 7
common characteristics. Persons facing In order to simplify and justify nature of the mental, social and
these problems are more likely to suffer assessments of motivation, effort and physical demands of work; objective
from depression, anxiety, credibility, the authors have developed measurement of effort and motivation
hypochondriasis and hysteria. These the Performance APGAR. Originally is a difficult task. Effort measurements
nonbiological factors have an even developed by Virginia Apgar in 1951, to are particularly important for those
greater impact on motivation when the measure a newborn’s health, others in patients who receive compensation, are
patient retains an attorney and becomes the literature have built on this model victims, or in some way perceive
a legal claimant.43,44 Once this happens as a basis for other types of themselves as entitled to compensation
the patient is obligated to prove and measures.46,47,48,49 Bigos et al concluded for their physical condition.54, 55 For
preserve injury or illness. To improve that a simple work APGAR score such individuals, research has
physically jeopardizes the ability to yielded significant predictive validity demonstrated a more prolonged
prevail in a suit. Additionally, the with regard to future reports of back recovery,56,57,58increased disability
patient’s own credibility is placed at pain.50 Most APGAR models are rated cost,59,60,61,62and decreased potential to
risk. Hence, the impairment continues on a scale of 0-10, with 10 representing return to work.63,64
and may even worsen throughout the normal. As with others, this
On the other hand, caution is given to
litigation process, even in the absence Performance APGAR score is scaled from
clinicians who draw unwarranted
of any objective medical basis for the 0 to 10 and can be used to quantify
conclusions about a patient’s
impairment. effort at the initial visit, as a summary
motivation, in that they may be
of progress at subsequent visits, or on
In addition to motivation and effort, “violating the rights of the person being
the final determination of RFC.
disability programs such as social tested,” with the potential for the report
security have attempted, through Motivation Determination to be emotionally and financially
policy, to determine the actual – The Performance APGAR devastating.65 This is particularly true
credibility of the alleged pain or when an undiagnosed physical
Motivation and effort can conceivably
limitations and their legitimate effect on condition is later discovered that was
be plotted along a continuum with the
RFC.45 Although the authors feel the truly limiting performance.
physiologic bone ligament complex
determination is probably better labeled
Currently, a number of procedures are
responses to loading conditions51,52and
a “consistencyassessment”, the term
promoted for a clinician to objectively
with psychosocial factors determining
“credibility” will be used in this paper
assess motivation, including Waddell’s
how one performs in relationship to
since it is used in the Social Security
non-organic signs66, dynometric grip
these physiological limits. Elite athletes
Administration (SSA) regulations. In
strength variation67, bell-shaped force
perform much closer to their
the context of this paper and in SSA
curves68, Rey 15-Item Test for
physiological limits than most persons.
regulations, credibilityrefers to the
Malingering69, and rapid exchange
degree to which the statements of
Effort has been shown to be influenced
grip.70 Other evaluations include the
symptom-related functional restrictions
by multiple factors, including illness,
correlation between musculoskeletal
are believed. Credibility does not refer
injury, personality, coping style, self-
evaluation and functional capacity
to the integrity of the individual.
esteem, associates, environment and
evaluation71, documentation of pain
self-confidence.53Due to the complex
behaviors and symptom
7
097129-DisabilityMed-Sept01 12/4/01 11:25 AM Page 8
magnification72,73, and the ratio of heart published as the BICEPS model.75After motivation, and a score of 0-3 suggests
rate to pain intensity.74 The Social further review, research and poor patient motivation to improve
Security Administration uses an consultation, the Biceps model has been their functional abilities. The
assessment of the credibility of modified by the authors to the Performance APGARscores can be used
allegations in their overall disability Performance APGARmodel. Like the for many different types of
evaluation process. Table 3 provides an infant APGAR, which is given at birth, impairments. Performance APGAR
example of a tabular assessment of the Performance APGARis a composite scores can be given at each visit or over
credibility for use within the summary of methods used to determine a series of visits and provide the reader
Performance APGAR. patient motivation level and is rated on with an indication of the motivation a
a scale of 1-10. Ascore of 8-10 is patient is currently expending to
An attempt to develop a comprehensive
consistent with what is optimally improve their condition.
performance model that considered the
expected from a motivated patient, a
above components was recently
score of 4-7 indicates concern about
Table 1
Credibility Assessment Tool:
Use this table to make an assessment of allegation credibility for thePerformance APGAR score.
Not consistent with the Partially consistent with the Fully Consistent with
objective evidence objective evidence and/or expected the objective evidence
and/or expected outcome/severity and/or expected
outcome/severity (1 point) outcome/severity
(0 points) (2 points)
Impact of symptoms or
condition on ADL’s
Type, dosage,
effectiveness and side
effects of medications
Treatment sought and
received
Opinions about function
given by other treating
and examining sources in
the file
Inconsistencies or
conflicts in the
allegations, statements
or medical evidence in
the file
Total Credibility score=______________
(0-10)
Credibility Determination: Result of Credibility
Total Credibility Score of 0-3= Not credible Determination to be
Total Credibility Score of 4-7= Partially Credible used in the APGAR
Total Credibility Score of 8-10= Fully Credible table
Table 3. Each of the 5 areas should be scored 0, 1 or 2 points. The 5 area scores are then totaled for an overall credibility score of x/10. This
score is then used in the credibility section of Table 1 (Not, Partially or Fully Credible).
8