The field of physical medicine and rehabilitation (PM&R) is primarily devoted to the clinical evaluation and treatment of disabling consequences to those individuals who have illness, injury, infirmity, or deformity at some point in their lives. As such, PM&R physicians can expect, from time to time, to be called on to make formal assessment of the disability to their patients. Furthermore, the face of medicine continues to undergo changes brought about by the aging Baby Boomer generation; by advances in medical and surgical technology, as well as health awareness that help people live longer and survive even after catastrophic trauma or illnesses; and by continuing casualties of global conflict and other cataclysmic events. According to recent estimates, approximately 57 million Americans are currently living with disabilities, and these numbers can be expected to continually increase during the coming decade. By 2030, an estimated 37 million Baby Boomers will have more than one chronic condition. This impending shift in demographics affords additional opportunities for PM&R specialists to adapt their practice to optimally address the health care needs of patients, through acquisition of a greater understanding of the conceptual foundation and terminology of disablement and application of the same to the practices of impairment rating and disability determination.
This chapter is intended to provide the reader with a brief historical perspective of disability evaluation; a conceptual foundation for understanding the current models of disablement; a descriptive overview of key features and nuances of the various U.S. disability systems; a working vocabulary and practical application of tools available and procedures to follow for proper and valid performance of impairment ratings and disability determinations, including use of the most relevant physician guides; and a heightened awareness of the medicolegal framework, pitfalls, and ramifications of such undertakings.
Terminology and Conceptualization of Disablement
During much of the nineteenth and twentieth centuries, disability was conceptualized in terms of a “medical model” of disease, whereby causation was viewed as directly linked to some underlying pathologic condition potentially identifiable at a histologic and physiologic level and arising out of illness or trauma. Because the diagnosis and treatment of disease was the purview of physicians, diagnosis and treatment of the resulting disability also fell within their expected domain of expertise. With the advent of the stethoscope, microscope, x-ray, and other technologies, the physician was armed with instruments of precision and objectivity with which to rate severity of impairment (at an organ system level) and hence objectify the associated disability. The model worked well for disease entities that were relatively devoid of diagnostic ambiguity and where the disease was well understood, as well as for treatment goals and expected therapeutic end points. Today, the medical model still serves as the fundamental basis for Social Security disability determinations and for physician-rating schedules that remain largely anatomically and diagnostically based.
A “social model” of disability grew out of the advocacy movement of the 1970s and 1980s, making society accountable for disability in the face of disease through its failure to accommodate the special needs of individuals with disability in terms of environmental access, availability of adaptive equipment, discrimination, prejudicial thinking, and other attitudinal barriers at the time. A better documentation and understanding of the role of social barriers to functioning has helped foster strategies and tactics to neutralize the same and to enable and empower the members of our society with disability.
A “biopsychosocial model” of disability is now the preferred model and has gained wide acceptance when disability is conceptualized. The biological component refers to the physical or mental aspects, or both, of an individual with a given health condition; the psychological component recognizes personal beliefs, coping strategies, emotional, and other psychological factors that may affect functioning; and the social component recognizes contextual, infrastructural, and other environmental factors that may also affect functioning in any given case.
From Classification of Causes of Death to International Classification of Functioning, Disability, and Health
The World Health Organization (WHO) has created an international classification system of diseases and of disablement whose origins can be traced directly to the publication of Bertillon’s Classification of Causes of Death (1893) and, subsequently, the International Statistical Classification of Diseases, Injuries, and Causes of Death. By 1948 the WHO began leading this effort and ultimately created the International Classification of Impairments, Disabilities, and Handicaps (ICIDH), which is reproduced in simplified form in Figure 5-1 .
This system was an attempt to relate the pathologic features of a specific disease or trauma to the resulting impairment (physiologic consequences in terms of signs and symptoms of dysfunction at an organ system level), disability (functional consequences of impairment in terms of abilities lost in one’s personal sphere), and handicap (social and societal consequences, freedoms lost in terms of role fulfillment). The relationship lends itself to being depicted in a simplified linear manner, which implies unidirectional nature and causation, and fails to adequately account for confounders of a personal and environmental nature. More recently, the ICIDH has been replaced by the International Classification of Functioning, Disability, and Health (ICF), reproduced in modified form in Figure 5-2 .
The ICF system more aptly displays the interactive (i.e., nonlinear) relationships between the impairment that an individual afflicted with a particular health condition might face; the potential functional consequences of impairment with respect to that individual’s personal and social sphere; and the contextual factors that may mitigate or amplify these consequences, including environmental factors, personal experiences, and choices. By taking environmental and personal factors into account, the ICF has adopted the biopsychosocial model of disablement discussed earlier. The components of disablement according to the ICF classification system include the following:
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Body functions and body structures: Physiologic functions and body parts, respectively
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Activity: Execution of a task or action by an individual (typically functioning within their own personal sphere)
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Participation: Involvement in a life situation (typically within one’s social sphere)
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Impairments: Problems in body function or structure, such as a significant deviation or loss
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Activity limitations: Difficulties that an individual may have in executing activities
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Participation restrictions: Problems that an individual may experience in involvement in life situations
Americans with Disabilities Act and Implications
With the passage of the Americans with Disabilities Act (ADA) in 1990, Americans with disabilities were guaranteed equal rights to employment opportunities, transportation, and public access. The ADA has its own key terminology and defines disability as “a physical or mental impairment that substantially limits one or more of the major life activities of such individual, a record of such impairment or being regarded as such impairment.” Although it is broad and somewhat imprecise, this definition is narrowed under “Title 1” of the ADA (Employment) to recognize employment as a major life activity and views disability within the context of performance of the essential functions of an employment position with or without reasonable accommodation . Reasonable accommodation can include structural modifications of the work site to improve accessibility; availability of modified duty options; and acquisition of adaptive equipment or devices to enable an otherwise qualified worker with a disability to perform the essential functions of the job. Accommodations exempted under ADA include those that pose “undue hardship” to the employer in terms of cost or feasibility of implementation or those that would pose a “direct threat” to the health and safety of the individual with a disability and/or co-workers.
As can be seen from the preceding ICF discussion, accommodation under the ADA is a fundamental social environmental modifier mandated by statutes to mitigate the disabling consequences of impairment in the workplace, in terms of accessibility with respect to activity limitations and participation restrictions. The ADA perspective can be further conceptually integrated with this broader ICF terminology and definitions by viewing impairment, reasonable accommodation, activity limitations, and participation restrictions in relation to a major life activity (work functioning), according to Tables 5-1 and 5-2 . According to Table 5-1 , if the impairment potentially interferes with activities of daily living (ADLs) in the context of one’s workplace that requires accommodation and if that accommodation is provided, no disability in terms of activity limitations need exist. If accommodation is not judged reasonable or otherwise cannot be provided, then disability in terms of activity limitations exists. According to Table 5-2 , if the impairment potentially interferes with the ability to safely and efficiently perform the essential functions required of the job and for which specific accommodation is required and can be provided, no disability in terms of participation restrictions need exist relative to that job. If the accommodation required is not reasonable (poses undue hardship or direct threat) and is thereby denied, then disability in terms of participation restrictions exists relative to that job. Although participation restrictions in the workplace can arise out of impairment, they may not be determined solely (or for that matter, primarily) by the impairment itself because other contextual factors might be the primary determinant of disability in any particular case. Consider, for example, the vastly differing work-related consequences of a partial foot (e.g., first digital ray transmetatarsal) amputation to a ballerina who must perform “on point” and to a construction worker who habitually wears steel-toed work boots on the job. The former amputee might face career-ending changes, whereas the construction worker could arguably experience minimal participation restrictions for the same level of impairment by using minor footwear modifications.
| Impairment Potentially Interferes with Activities of Daily Living | Accommodation Needed | Accommodation Provided | Participation Restrictions |
|---|---|---|---|
| Yes | Yes | Yes | No |
| Yes | Yes | No | Yes |
| No | No | No | No |
| Impairment Potentially Interferes with Essential Functions | Accommodation Needed | Accommodation Provided | Participation Restrictions |
|---|---|---|---|
| Yes | Yes | Yes | No |
| Yes | Yes | No | Yes |
| No | No | No | No |
Although the ADA helps to ensure that individuals with disabilities cannot be discriminated against in the workplace and that reasonable accommodation in terms of access must be provided to avoid such discrimination, the workers’ compensation system is not presently directly accountable to this legislative mandate. However, the physician examiner seeking to return an injured worker safely to the workplace is well served to review the worker’s formal job description and to tailor the ensuing therapy treatment plan to the specific material handling and activity requirements listed according to the essential functions therein; in addition, return-to-work decisions can be driven by the claimant’s observed performance in therapy according to these essential functions, thereby releasing the claimant to return to work when the worker’s physical performance meets or exceeds these requirements, or by recommending restricted duty and suggesting accommodations when they do not. However, the employer is ultimately responsible for determining reasonable accommodation. It is not the responsibility of the disability-evaluating physician to determine the essential functions of a job, to devise accommodation, or to determine reasonableness of any accommodation proposed by the employer.
Relating Impairment to Disability and Compensation Formulas
Although the major current disability systems of the United States and elsewhere exhibit significant differences from each other (discussed later), they all share a common mandate according to their design and intent to compensate individuals financially for losses due to their qualifying disablement. The challenge becomes one of providing fair and equitable compensation for losses that typically can be expected to occur in three major domains: work disability, nonwork disability, and quality of life (QOL), as depicted in Figure 5-3 .
An impairment rating provides an objective measure of severity of disability in terms of organ system disease and associated loss of structure and function. As such, it is a keystone to any disability determination but not the sole or necessarily adequate determinant of losses to the affected individual. Metrics also exist to calculate losses to the impaired individual in terms of work disability (loss of earnings or earning capacity) and are commonly applied when actuarial analysis takes place. Less obvious, and perhaps less accessible, are metrics to assess avocational (e.g., nonwork) disability, such as losses in ability to pursue hobbies and recreational activities, and QOL disability, such as losses in terms of medical burden of care and overall life satisfaction. In reality, these more complex domains of disability are typically overlooked for the sake of expediency, simplicity, and practicality, and are often gratuitously (rather than empirically) accounted for. A procedural short-cutting typically takes place whereby the impairment rating becomes a surrogate for the disability rating according to a predetermined formula whereby the impairment percentage is multiplied times a number of weeks arbitrarily established as the “worth” of the whole person times a percentage (usually two thirds to three quarters) of the average weekly wage (up to a cap) to generate a lump sum payout.
In summary, impairment rating is important to the categorization of disablement for the following several reasons:
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It serves as a standard reference point in terms of linking a specific diagnosis to an associated percentage of physical and functional loss in compensable injury claims.
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It enables the impaired individual to exit the system of temporary disablement (e.g., temporary total or permanent partial disablement under workers’ compensation) at. maximum medical improvement (MMI).
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It provides a diagnosis-based classification of severity to segue to alternative systems management of long-term disablement.
Major U.S. Disability Systems Compared with Attention to the Role of the Examining Physician
The physician who deals with claims of impairment and disability and issues regarding return to work or staying at work should become familiar with the multiple U.S. compensation systems, which exist both at the federal and state levels, to provide economic and other benefits to claimants experiencing work incapacity because of injury, illness, or aging. Chief among these are the Social Security Administration (SSA), federal and state workers’ compensation systems, the Veterans Benefits Administration (VBA), personal injury claims, and others. A physician working within the jurisdictional boundaries of any of these systems plays a critical role and is expected to diagnose the problem, opine as to the causation of an injury or illness (particularly in a workers’ compensation setting), provide care, and assess the work fitness of the injured claimant for “modified” duty or return to full duty during recovery. Therefore the physician must also become familiar with the definitions, eligibility requirements, and rating criteria of each particular system and must follow the system-specific rules and procedures prescribed in each particular case.
Social Security Disability Insurance and Supplemental Security Income
The SSA is the largest U.S. disability system, providing assistance to approximately 33% and 50% of all persons who qualify as disabled. The SSA offers two separate disability programs: the first, Social Security Disability Insurance (SSDI), provides benefits to those individuals who have worked in a qualified job for a requisite period, paid into the Social Security system, and subsequently become disabled before age 65 years. SSDI is funded by payroll deductions that, in combination with deductions for old age insurance, comprise the Federal Insurance Contribution Act (FICA) tax, with matching contributions from the employer.
Eligibility for SSDI requires that a “medically determinable impairment” be established whose resulting incapacitation is so severe that it prevents the affected individual from 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.” SSDI also requires that the individual has worked in a qualified job for at least 5 of the 10 years before onset of disability.
SSDI benefits are provided to those considered totally incapacitated and extend to their surviving spouse and children. Benefits are paid as a monthly stipend, and beneficiaries may receive payments until age 65 years, after which they are eligible for Social Security retirement benefits.
The second program, Supplemental Security Income (SSI), provides income for medically indigent persons who are blind, are disabled, or are older (>65 years of age). SSI also provides assistance to children if they have “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.” SSI operates as a federal-state partnership that is jointly funded through general revenue (federal and state income tax). Eligibility is determined according to a means test and does not require a work history. SSI also requires that a “medically determinable impairment” be established.
When an applicant submits an SSA application and nonmedical eligibility has been established, the application is forwarded to their state Disability Determination Service (DDS) for further medical review. The SSA has its own set of medical criteria, the “listing of impairments,” which, if met or equaled, will result in an automatic award of benefits. 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 on the basis of “residual functional capacity.”
Physicians, including the patient’s treating physician, who assist applicants when filing for SSDI or SSI disability should be familiar with the “five-step” appeals process and the listings themselves. They may be asked to provide the DDS evaluating team with a statement about the patient’s ability to do work-related activities and backed by objective evidence. They may also be asked to comment on an applicant’s physical and psychological capacities and limitations and, in the event that the condition in question does not meet or equal the listings, to assist the DDS evaluating team in estimating the claimant’s “residual functional capacities.”
Federal Workers’ Compensation Systems
In the United States, the workers’ compensation laws originated both at the federal and state levels at the beginning of the twentieth century and have evolved over the past 100 years into the current programs to provide no-fault–based compulsory broad coverage of injuries and illnesses arising out of and in the course of employment.
The major federal workers’ compensation programs are administered by the Office of Workers’ Compensation Programs; an agency within the U.S. Department of Labor. One of the major federal programs, the Federal Employee’s Compensation Act covers 2.9 million federal employees in more than 70 different agencies along with a number of other worker groups adopted by Congress in various acts of expansion of the federal authority. In addition, the Longshore and Harbor Workers’ Compensation Act, Energy Employees Occupational Illness Compensation Act, and Federal Black Lung Program (coal mine workers’ compensation) are other federally mandated compensation acts administered by the Office of Workers’ Compensation Programs. The U.S. Department of Labor maintains exclusive jurisdiction over these programs subject to judicial review. These four major federal workers’ compensation programs provide wage replacement benefits, medical treatment, vocational rehabilitation, and other benefits to injured workers that experience work-related injury or occupational disease, or their dependents.
Other federally mandated workers’ compensation programs include the Federal Employers Liability Act commonly known as the railroad worker act; the Jones Act (Merchant Marine Act); and the Defense Based Act (DBA). The DBA provides workers’ compensation protection to civilian employees working outside the United States on U.S. military bases or under a contract with the U.S. government for public works or for national defense.
State Workers’ Compensation Systems
At the individual state level in the United States, each state has enacted a workers’ compensation law that protects the injured worker for injuries arising out of and in the course of employment. Each jurisdiction has its own nuances; however, the following fundamental features are common to all of these statutory schemes :
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Compulsory insurance is required for employers with very few exceptions.
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A no-fault system exists for injuries arising out of and in the course of employment.
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Expedited benefits are included for medical and rehabilitation treatment and for wage replacement.
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Benefits also include compensation for permanent partial and permanent total disability.
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The law ensures access to an exclusive source of remedy for employees for work-related injuries/illnesses with few exceptions.
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The injured worker retains the right to sue any third party liable for injury.
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Disputes are usually resolved through administrative law adjudication with less rigorous rules of procedure and evidence.
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Administration is through a state agency designated to oversee workers’ compensation law.
The physician examiner can play a variety of roles in the work-related injuries associated with workers’ compensation claims. There are four possible phases of involvement, including (1) initial evaluation and treatment of injury either as an approved and designated attending physician or as an authorized consultant; (2) overseeing rehabilitation, including return-to-work or staying-at-work issues; (3) determination of any residual impairment (permanent) or disability (work restrictions); and (4) estimating long-term care needs in catastrophic injuries (e.g., limb amputations, spinal cord injuries, major multiple trauma), including participation in life care planning. The PM&R physician can be particularly successful in meeting the needs of the workers’ compensation system by maintaining functionality as his or her key focus when setting treatment goals and monitoring progress toward the same; by enabling a return-to-work treatment focus that holds both patient and employer accountable; and by exercising appropriate control over the duration of treatment before an MMI determination is made (discussed later) to help ensure optimal results for both the patient and the system. The physician may choose to participate only in the selected phase, such as impairment and disability evaluation, which requires an understanding of the process of an independent medical examination (IME), as well as application of the appropriate impairment rating guidelines that may vary by jurisdiction.
Compensation and Pensioning Under the Veterans Benefits Administration
In 1953, the VBA was created within the Veterans Health Administration (VHA) to administer the GI Bill and the U.S. Department of Veterans Affairs (VA) Compensation and Pension Service (C&P) and Programs.
Eligibility for VA disability benefit 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 as nonservice 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.
Disability compensation is paid as a monthly stipend to veterans who are disabled because of 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. Benefits may also 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 wartime. Other benefits include insurance benefits, specially adapted housing, motor vehicle modifications, and durable medical equipment.
VA C&P examinations may be performed by physicians, nurse practitioners, physician assistants, psychologists, optometrists, audiologists, and “other qualified” clinical personnel. The VHA oversees and ensures that C&P examiners are adequately qualified, and all C&P examination reports must be assigned by a physician or psychologist. The physician examiner is asked to render an opinion as to diagnosis of the ratable condition, to address permanency of the condition, and to opine as to whether the individual with the condition is considered totally disabled (fails to meet minimal employability criteria), which is defined as physical inability to be employable at a sedentary level, or psychiatric or psychological inability to be employed in a loosely supervised situation with minimal exposure to the public.
Physician disability evaluations are generally performed at VHA facilities with the Automated Medical Information Exchange (AMIE) data processing system and associated Disability Examination Worksheets and the VA’s Schedule of Rating Disabilities.
Personal Injury Claims
American law recognizes physical or psychological injury as a personal injury for which monetary damages can be awarded under the law of torts. A claim is usually made against the defendant for personal injury arising out of negligence and in some instances an intentional act. Common examples include those claims arising out of motor vehicle accidents, slip and fall claims against property owners (both private and business), defective products, medical negligence, hospital and nursing home negligence, assault claims, as well as work-related injuries outside of the aegis of workers’ compensation. Plaintiffs are entitled to monetary awards for both actual and general damages (e.g., pain and suffering, nonpecuniary damages). The severity of the injury is the main driver for the compensation and physician-independent medical examiners (as expert witnesses) are retained by both sides to evaluate the plaintiff’s claims of personal injury. The physician typically is required to evaluate the causation, the nature, and the severity of the injury, the exacerbation or aggravation of the preexisting pathologic condition, if any, as well as apportionment. In some instances, the physician may also be called on to comment on the necessity of the treatment previously provided or future treatment proposed for the condition under question.
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