Definitions

There is a certain amount of confusion about the role of the physician in determination of permanent disability and about the difference between impairment and disability. According to the sixth edition of the Guides to the Evaluation of Permanent Impairment, published by the American Medical Association (AMA), the following definitions apply :

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    Impairment: a significant deviation, loss, or loss of use of any body structure or body function in an individual with a health condition, disorder or disease

    
    
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    Disability: activity limitations and/or participation restrictions in an individual with a health condition

    
    
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    Impairment rating: consensus-derived percentage estimate of loss of activity reflecting severity for a given health condition, and the degree of associated limitations in terms of activities of daily living (ADLs)

  
  

Determining the difference between disability and impairment is challenging, if not impossible. In some conditions, there is a predictable correlation between the injury and the expected degree of functional loss (complete spinal cord injury). In other conditions, it is harder to predict (radial nerve palsy after humerus fracture). Disability is dependent on a number of nonmedical factors, among them the patients’ level of education, their work training and work history, their residual access to the workplace, and their socioeconomic background. Disability is context specific and can change over time. For example, an orthopaedic surgeon would be much more disabled by a finger amputation than an endocrinologist would be. If adaptations can be made to the work environment or task in question, a particular impairment may not limit an individual from performing the task. Physicians, in general, are considered experts only in the determination of impairment.

Impairment ratings enable the physician to estimate the quantitative losses to individuals as a result of their health condition, disorder, or disease. Impairment ratings are defined by anatomic, structural, and diagnostic criteria with which physicians are usually familiar. These ratings are determined by accepted diagnostic procedures. Most physicians, however, are not familiar with the full array of functional activities and participations that are required for comprehensive disability determinations. Impairment ratings are a physician-determined estimate that attempts to link impairment with a quantitative estimate of patients’ functional losses in their personal world of activity.

A permanent impairment exists when the patient has reached maximal medical improvement yet a loss or derangement persists. Maximal medical improvement has been achieved when the injury or illness has stabilized and no material improvement or deterioration is expected in the next year, with or without treatment. Many jurisdictions require that a year elapse after the injury or most recent surgery related to the injury before determining that maximal medical improvement has been attained.

Role of the Physician

According to the AMA guidelines, determining whether an injury or illness results in a permanent impairment requires a medical assessment performed by a physician. The functions evaluated in determining permanent impairment are those that allow the individual to perform common ADLs, excluding work. These include self-care, communication, physical activity (including sitting, standing, reclining, walking, and stair climbing), sensory functions, nonspecialized hand activities, travel, sexual function, and sleep. Because musculoskeletal injuries account for the majority of impairment determinations, orthopaedists are frequently involved in this process.

Depending on local regulations, the physician determining impairment may be the treating physician with whom the patient has an established doctor-patient relationship or an independent physician who examines the patient only for the purposes of determining impairment and is not otherwise involved in the patient’s care. In general, physicians acting as independent consultants for determination of impairment ratings do not establish a doctor-patient relationship with the patient being examined. If new diagnoses are uncovered during the course of an impairment evaluation, the physician has a medical obligation to inform the requesting party and the individual about the condition and advise the individual to seek appropriate medical treatment.

Third-Party Payers and the Workers’ Compensation System

The concept of compensation for personal injuries is not a modern one. Historical evidence shows that social justice and compensation systems for injured parties have been around since recorded history. These systems attempted to legislate the exchange of money for losses resulting from personal injury. The workers’ compensation system in the United States was started in 1906 with the passage of the first law covering federal employees. By 1917, workers’ compensation insurance was mandatory for a business to operate.

Prior to the passage of the workers’ compensation law, employees who were injured at work were required to sue and prove employer negligence to receive compensation. In essence, it is a form of insurance providing wage replacement and medical benefits to employees injured in the course of employment in exchange for mandatory relinquishment of the employee’s right to sue for the tort of negligence. The workers’ compensation system in the United States has evolved into a complex entity regulated by each state and representing approximately 1.5% of all employers’ compensation expenditures.

Impairment evaluations are most frequently requested by a third-party payer before settlement of a claim. The largest third-party payers are state workers’ compensation boards, private insurance companies, the Social Security Administration, and the Department of Veterans Affairs. Each of these groups has its own requirements for and definitions of impairment. Workers’ compensation laws vary widely from state to state, and federal agency regulations are amended yearly. The agency requesting the impairment evaluation should specify which rules apply in the specific case, and the reviewing physician should abide by the specified rules. In some cases, older editions of the AMA guides have been incorporated in state laws, in which case, the appropriate edition must be consulted. Tort law (civil litigation or lawsuits) in some states does not specify any particular body of rules; in these cases, the evaluating physician has considerably greater freedom to describe and quantify a given impairment.

Correspondence is between the physician and the third-party payer. Updates should be in the form of letters mailed directly to the representative of the third-party payer. The patient should not act as an intermediary, although the patient’s right to review his or her chart in the presence of the attending physician should always be honored.

Temporary Total Disability

In general, a patient is judged temporarily totally disabled if, in the opinion of the treating physician, the patient is incapable of performing any job, for any reasonable period of time, during the course of a workday. Note that, by this definition, a patient’s inability to perform his or her own job is not the primary issue. For example, a construction worker in a short arm cast for a distal radius fracture may well be incapable of his or her usual work but capable of sedentary or one-handed light work, so the worker is not totally disabled. Temporary total disability is also granted for patients whose pain is great enough to warrant regular narcotic use, whose mobility is so severely compromised as to make getting from home to the workplace unreasonably difficult, or who are hospitalized in an inpatient unit.

Patients are temporarily totally disabled from the moment of occurrence of a skeletal injury until they achieve a reasonable degree of mobility and independence, are able to perform their own ADLs to a reasonable degree, and are no longer dependent on narcotic analgesics. Obviously, patients who are hospitalized, are inpatients in a rehabilitation facility, or are homebound and require skilled nursing care are temporarily totally disabled. Patients who are dependent on crutches for ambulation are not necessarily totally disabled at all times unless they meet the other definitions of temporary total disability.

Periodic evaluation in the physician’s office is necessary during the period of temporary total disability. Most state workmen’s compensation laws mandate at least monthly visits during the period of temporary total disability, during which further documentation for ongoing temporary total disability status must be entered in the patient’s record.

Permanent Partial Disability

After maximal medical recovery has been achieved, the physician, possibly in cooperation with other occupational specialists, may be asked to recommend a permanent restricted activity level if the patient is unable to return to his or her original job. There are no widely accepted guidelines for determining the level of job restriction, but, in general, a patient who has any permanent partial impairment secondary to skeletal injury is unable to perform very heavy or heavy work safely. If the permanent partial impairment is greater than 25%, most patients are unlikely to perform successfully in any but part-time or home-based occupations at the sedentary level. Between these two extremes, the physician must decide what a reasonable expectation is for the patient, taking into consideration the type of injury and impairment and the sorts of activities that are likely to exacerbate persistent pain. The physician may use functional capacity evaluations performed in conjunction with a physical therapist as an objective measure of particular activities that an individual patient is capable of tolerating.

As an example, a well-healed 10% compression fracture of the lumbar spine with some chronic back pain may result in a 5% permanent partial impairment. The patient is likely to have exacerbation of pain with bending, twisting, stooping, lifting of more than 20 pounds, or prolonged overhead work. He or she would be qualified for a job involving light work, with the restrictions specified previously.

The physician assigns impairment and specifies work restrictions, but the responsibility for finding an appropriate job lies with the patient or the third-party payer. With more aggressive job retraining and work hardening programs, patients with significant impairment are now returning to the workplace. When an injured individual is declared disabled from injury, it is almost always economically unfavorable both for the individual and for society as a whole. If the physician performing the impairment evaluation is also the patient’s treating physician, it is often worthwhile for the physician to work with the social worker, nurse, or occupational therapist representing the third-party payer to find an acceptable job for the patient or to encourage occupational retraining when appropriate.