Current American Medical Association Guidelines for Evaluating Musculoskeletal Impairment at Maximum Medical Improvement

Fig. 17.1

International classification of functioning, disability, and health

The components of disablement according to the ICF classification system include:

Body functions and body structures: physiological functions and body parts, respectively
Activity: the execution of a task or action by an individual (typically within their personal sphere)
Participation: involvement in a life situation (typically within a social sphere)
Impairments: problems in body function or structure, such as a significant deviation or loss
Activity limitations: difficulties an individual may have in executing activities
Participation restrictions: problems an individual may experience in involvement in life situations

Within this conceptual framework, the disabling consequences of impairment may be amplified or mitigated by factors unique to the individual with a health condition, interacting with their environment and according to personal choice.

Whereas the constructs of impairment and disability are central to any compensation scheme, they are frequently confused and confounded in practice. Figure 17.2 represents the domains of interest common to most disability compensation systems (McGeary, Ford, McCutchen et al., 2007). To the left is the domain of medical impairment, which describes physical or psychological pathology and dysfunction and which is typically defined and measured according to the medical model described above. In the middle is the domain of activity which describes the individual’s basic mobility and self-care abilities within their personal sphere, which can be defined and measured according to basic or advanced (instrumental) ADLs. Basic ADLs include self-directed activities, such as feeding, toileting, hygiene, bathing, grooming, dressing, and mobility activities, such as transfers (shifting one’s position at one point in space, such as lying to sitting, sitting to standing, etc.) or ambulation (moving oneself from one position in space to another such as walking, jogging, climbing stairs, etc.). Instrumental activities of daily living (IADLs) involve higher cognitive and intellectual skills in one’s personal sphere such as managing finances (e.g., balancing a checkbook), managing one’s medications, or preparing a meal safely. The impaired individual may or may not experience limitations to their ability to execute these activities due to their impairment. To the right are three domains useful to summarize functional losses pertaining to life activity and life satisfaction, potentially attributable to disability and therefore compensable. They include losses due to work disability, nonwork disability, and quality of life (QOL).

Fig. 17.2

Disabling consequences of impairment

The medical impairment rating provides an objective measure to substantiate and quantify the severity of disability in terms of its underlying organ system pathology and associated loss of ADLs. Therefore, it is a necessary component of any disability determination equation, but not necessarily the sole or adequate determinant. Other domains of disability deserve consideration, and suitable metrics exist to calculate losses to the impaired individual in terms of work disability (loss of earnings and/or earning capacity), but also for nonwork disability (losses in ability to pursue hobbies, recreation, etc.) and QOL (losses in terms of medical burden of care, life satisfaction, etc.). Unfortunately, several of these latter domains are generally overlooked since they are not systematically evaluated and cannot be easily and reliably measured by the physician examiner. Rather, they are often summarily accounted for by a procedural “shortcut,” whereby the impairment rating percentage becomes a surrogate for the disability rating according to a predetermined formula that multiplies the impairment percentage times a number of weeks’ wages (up to a cap) times a percentage (generally two-thirds to three quarters) of the average weekly wage (up to a cap), resulting in a lump sum payout. The adequacy of the impairment rating as an operational surrogate in such cases is the source of ongoing debate (McGeary et al., 2007; Rondinelli, 2009).

Thus, to summarize, the AMA Guides provides the physician examiner with suitable metrics to rate severity of impairment in terms of objective pathology and associated loss of functioning relative to basic ADLs [as noted on the left side of the ICF model (shaded area) depicted in Fig. 17.1 above]. The Guides’ focus is never on the right side of the model (loss of activity in terms of instrumental ADLs, loss of participation in major life activities) or the impact impairment has on broader issues such as on QOL. Therefore, it is not intended, nor should it be considered, to be a suitable, stand-alone metric for disability evaluations per se (Rondinelli, 2009; Rondinelli, Eskay-Auerbach, Ranavaya et al., 2012).

Major US Disability Systems Compared

Workers’ Compensation

Workers’ compensation systems in the United States are mandated by both State and Federal legislation in order to provide economic protection for workers who sustain personal injuries resulting out of, and in the course, of employment. Generally, this is accomplished through private insurance plans underwriting the risks of occupational injuries and diseases in return for a premium paid by the employer under the law. Few States serve as the insurer themselves. The need for workers’ compensation (WC) laws at the state level arose around the turn of the twentieth century in response to many factors including the societal change from an agrarian society to an industrial age resulting in catastrophic injuries causing several hundred deaths in a single incident, such as a mine explosion in West Virginia in 1907 as well as a New York sewing factory fire in 1911. The rise of labor unions and increasing awareness of workers’ rights were other major factors in the enactment of various workers’ compensation legislation. In addition, the only alternative legal remedy available to these injured workers, the common law of torts, was inefficient and ineffective in most cases due to its very lengthy and often expensive process, with several unique defenses available to the defendant. The workers’ compensation legislation sought to reduce this burden on the injured worker by providing all parties more expedited and responsive process and a no-fault system. Some of the common terms used are delineated next.

Entitlement: An injured claimant is entitled to benefits if his or her injury is determined to be compensable and can be shown to have arisen “out of and in the course of employment.” Historically, WC statutes were intended to cover injuries that occurred by “accident” (a chance, unexpected and unintended event) in the workplace at a specific point in time, as opposed to a “disease” entity or condition that arose gradually over time. In reality, this distinction often cannot clearly be made, and coverage is now typically extended to occupational “illness” or disease, as well as impairment resulting from “aggravation” of a preexisting and underlying condition (Novick & Rondinelli, 2000). All WC is predicated upon a “no-fault” concept whereby the employee needs not prove the employer is at fault. Instead, a determination is made that the injury or illness arose “out of and in the course of employment,” and a causal relationship is established whereby the injury or illness can be shown to have occurred while the employee was at work and actively involved in employment activity (Novick & Rondinelli, 2000). In addition, the resulting condition must persist for a sufficient duration to extend beyond any statutory waiting period (typically 0–7 days), and the injured worker is required to file a claim within specified time limits.

Benefits: An injured worker is entitled to three types of benefits: survivor benefits in the event of injury or illness resulting in death, medical and rehabilitation expenses, and wage-loss benefits. In the event of death, the surviving spouse and/or children are entitled to funeral expenses and a monthly pension (generally 2/3 of the average monthly wage at time of death up to a maximum cap) which terminates if the spouse remarries or, in the case of children, when they reach the age of 18 (or 22 if they remain a full-time student) or upon marriage. Coverage for medical and rehabilitative expenses is 100 % for authorized services. Wage-loss benefits are paid according to four separate levels of work disability. Temporary disability occurs for the duration of the treatment period and may be total (employee is incapable of any work) or partial (employee is allowed to resume “modified duty” with restrictions) (Novick & Rondinelli, 2000). Upon completion of the treatment phase, at the point of MMI and case closure, the employee may receive compensation for permanent total or partial disability, generally as a lump sum payout calculated according to a predetermined formula specific to each jurisdiction, which takes into account the value of the “whole person” as a number of weeks’ pay multiplied by the average weekly wage up to a cap and then multiplied by the impairment percentage of the “whole person.”

Physician evaluating and reporting requirements: Within the WC system, physicians may be asked to determine causality of a given impairment within medical probability. They may be asked to complete a work status report during various stages of treatment, indicating whether or not the employee is ready to return to full or modified duty, and to identify activity and material-handling restrictions where applicable. They will be asked to address when MMI has occurred, or is expected to occur, and to issue an impairment rating for work-related condition(s) if MMI has occurred.

Preferred rating guidelines: Jurisdictions vary in the use of rating guidelines, and physician raters must follow the directive of the WC jurisdiction within which they are working in this regard. The AMA Guides to the Evaluation of Permanent Impairment (various editions) is the most commonly used rating system, being mandated or recommended in at least 46 of the 53 jurisdictions at this time (American Medical Association, 2008).

The various workers’ compensation schemes at the US Federal level are distinct and distinguishable from the State workers’ compensation legislation and include the Federal Employers Liability Act (FELA) which is the sole remedy for the injured railroad worker against the railroad, and the Federal Employees’ Compensation Act (FECA) which is the sole remedy for job-related injuries and diseases sustained by federal employees, including postal workers as well as Peace Corps members against the federal government. Physicians seeking further information, as well as opportunities to provide services to these programs, should review the Federal Office of Worker’s Compensation Programs (OWCP) website at http://www.dol.gov/owcp/. The OWCP also manages the Long Shore and Harbor Workers Act, Federal Black Lung Program, and the Division of Energy Employees Occupational Illness Program.

Social Security Disability Insurance and Supplemental Security Income

The Social Security Administration (SSA) is the largest US disability system, providing assistance to between 33 and 50 % of all persons who qualify as disabled. There are two components of the system: the first, Social Security Disability Insurance (SSDI), exists to benefit individuals who have worked, paid into the Social Security system, and subsequently become disabled before reaching retirement age. The second, Supplemental Security Income (SSI), provides income for indigent individuals who have not worked and are disabled. SSDI is funded by payroll deductions which, in combination with deductions for old age insurance, comprise the Federal Insurance Contribution Act (FICA) tax, with matching contributions from the employer. In contrast, SSI operates as a federal/state partnership funded by general tax revenues (Robinson & Wolfe, 2000).

Criteria of eligibility: Both SSDI and SSI require that a “medically determinable impairment” be established according to accepted criteria and whose resulting incapacitation is so severe as to prevent engaging “in any substantial gainful activity (SGA) by reason of any medically determinable physical or medical impairment that can be expected to result in death or that has lasted or can be expected to last for a continuous period of not less than 12 months.” Eligibility for SSDI further requires that the individual has worked in a job covered by SSDI for a requisite number of years (at least 5 of the 10 years prior to onset of disability). In contrast, eligibility for SSI requires demonstration of low-income level and assets according to a means test (Robinson & Wolfe, 2000). SSDI benefits are provided to those considered totally incapacitated, surviving spouse, and children. SSI provides income support for indigent persons who are blind, disabled, or aged (over 65). SSI also provides assistance to children with “medically determinable impairments of comparable severity” to an adult’s and if the impairment “limits the child’s ability to function independently, appropriately, and effectively in an age-appropriate manner.”(Robinson & Wolfe, 2000)

Benefits: Benefits are paid as a monthly stipend of approximately $500.00 for >12 months. SSDI beneficiaries may receive payments until age 65, after which they become eligible for Social Security retirement benefits (Robinson & Wolfe, 2000).

Physician evaluating and reporting requirements: Once an applicant submits an SSA application and nonmedical eligibility has been established, the application is forwarded to the state agency, the Disability Determination Service (DDS), for a medical review. The SSA has developed its own set of medical criteria, the “listing of impairments” which, if met or equaled, will result in an automatic award of benefits (Social Security Administration, 1999). There are separate listings for adults and children arranged by body system. Each listing typically contains a diagnosis and some clinical markers of severity. If listing criteria are not met, the applicant can appeal based upon “residual functional capacity.” Physicians seeking to assist applicants who are filing for SSDI or SSI disability should be familiar with the “five-step” appeals process and the listings themselves (SS Ref). This includes the patient’s treating physician who may be asked to provide the DDS evaluating team with a clear succinct statement about the patient’s ability to do work-related activities as backed by objective evidence. They may also be asked to comment on an applicant’s physical and psychological capacities and limitations, in the event that the condition in question does not meet or equal the listings, in order to assist the DDS team in estimating the “residual functional capacities” (Robinson & Wolfe, 2000).

Compensation and Pensioning Under the Veterans Benefits Administration

In 1953, the Veterans Benefits Administration (VBA) was created within the Veterans Health Administration (VHA) to administer the GI Bill and the Department of Veterans Affairs (VA)’s Compensation and Pension Service (C&P) programs.

Criteria of eligibility: Eligibility for VA disability benefits is based on discharge from active military service (full-time service to the Army, Navy, Air Force, Marines, or Coast Guard or as a commissioned officer of the Public Health Service, the Environmental Services Administration, or the National Oceanic and Atmospheric Administration). Only honorable and general discharges (as opposed to dishonorable or bad conduct discharges) qualify. Entitlement to compensation is determined by the Adjudication Division of the C&P Service within the VBA and is classified as service connected if the disability relates directly to injury or disease incurred while on active duty or as a direct result of VA care or non-service connected if determined to have not been incurred while on active duty. Presumptive service connection applies to various conditions such as chronic diseases (e.g., hypertension, diabetes mellitus) or tropical diseases (e.g., malaria) and qualifies for compensation if such conditions manifest themselves within 1 year of discharge from active duty (Oboler, 2000).

Benefits: Disability compensation is paid as a monthly stipend to veterans who are disabled due to service-connected injury or disease. The amount of compensation received depends on the amount of impairment caused by the injury or disease, where the rating percentages themselves are expressed according to “the average impairment in earning capacity resulting from such disease and injuries and their residual conditions in civil occupations.” Disability compensation is not subject to Federal or State income tax; it varies according to number of dependents; and it is regularly adjusted to reflect changes in cost of living. Other benefits may include disability pensions for veterans of low income according to a means test, who are permanently and totally disabled and who have experienced 90 days or more of active duty, at least 1 day of which was during war time; insurance benefits; and specially adapted housing, motor vehicle modifications, and durable medical equipment (Oboler, 2000).

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