So good afternoon, everyone, and welcome to the session on AMA guides, the history updates and where the future is heading. My name is Dr. Doug Martin, and I'm joined on the stage today by Ken Eichler from the AMA. So without further ado, I have the pleasure of introducing Ken Eichler from the AMA guides. Ken and I have known each other for 25 years or so, a long time. I think that's what that counts. We both have been involved in AMA guides development on multiple different levels, both within the AMA, previous organizations, and so forth. So at this point, I will turn it over to Ken. Here we go. And if it seems a little awkward with us juggling back and forth, originally we had requested a table and we thought it was going to be a little more conversational, so I apologize if it's at all choppy. I want to thank everyone for joining us today. We really appreciate your time. I know there are a lot of really top-notch sessions, and the fact that you're joining us means something. We greatly appreciate it. I want to thank you for being with us today, a little bit on credentials. Obviously, Dr. Martin has top billing credentials here as an op doc. On behalf of the AMA, I want to thank him for all the work he's done for us and on behalf of the industry. It's funny, because Doug and I met roughly 25 years ago when we were both testifying at a Senate hearing in Nebraska, and it was the first time we got a chance to meet, and I've had the pleasure of collaborating since. We do have to give a disclosure that Doug Martin is the co-chair of the AMA editorial panel, and I'm the senior product manager for the AMA guides. No actual potential conflict of interest specific to this presentation. I want to get a quick survey, just to get a sense of who the audience is. Neither of us are people who overly work from a canned presentation, so we want to be able to tweak it for your needs accordingly. How many folks in the audience here are either a treating practitioner, still treating patients? Wow, this is great. That's not the usual raise of hands we see. How many folks are doing IMEs as well? So it's about two-thirds or so. And how many people are doing both? It's the same population. Okay, great. How many of you are in an independent or a small practice? Okay. Anyone in a larger regional practice? Corporate medicine? One. Okay. So we've got a mix of docs, and that's really nice, because we're seeing a lot, we're seeing less docs and more medium-sized practices, and we're seeing more go to the larger practices. Pretty cool. Anyone multi-state? You're all sole state? Who's in a state that is currently using the AMA impairment guides? Okay, don't be surprised if in the next year or so you're going to be using a new impairment guide, as we're updating the guides, and many states are interested in the updates. How many of you do not have any experience with the impairment guides? Okay. Everybody's got some. Just a reminder, the guides are an excellent revenue stream for you and your private practices, and we're going to talk about some one-step-off. My background, by the way, as far as the one-step-off, is I did own a very successful boutique, IME company in New York, and we learned to listen to the market and listen to our client needs, and that's hopefully something that we'll help share today to bring revenue into your practice. Referral relationships. How many of you have relationships with an employer in your area? Just most. Insurance carriers, as far as referring cases, Welfare Workers' Comp, great. And how many of you have somebody doing marketing to bring the business in for you? Okay, so we've got a good mix of everything. The AMA's mission, basically stated here, we believe in fair and equitable permanent impairment ratings. The AMA believes in applying the best available science and evidence-based medicine. But I'll give everyone a second to just kind of look at the mission statement. Consultative resource approach. I know the billing in the presentation didn't necessarily cover this, but we want to discuss alternative ways of bringing in revenue. And one of the things we encourage is you build and invest in the relationships as a team member. If you're not working directly with employers, I encourage you to reach out to your local employers. Get to know them. Build the relationship. Give them a little bit of your time, free of charge. Get to know the workplace. An example years ago, there was a drive train manufacturer in upstate New York, and how did docs get really in there? Well, one doctor's practice that also happened to have some OTs on staff, went in and said that in order to do IMEs or in order to treat their patients, they wanted to understand the workplace. So that if you see a company or an organization that's giving you volumes of work or that has the potential to, I'd encourage you to reach out. Go in. Sit at the different job stations. See what goes on. Analyze the ergonomics. Hear and see. You're going to see it's going to give you a different perspective. You'll be able to reflect that in your reports, but it's also going to build that relationship as a valued partner, either as a treating physician or as a consulting physician. And also, I encourage you to discuss return-to-work opportunities, because we often know, and I think you'd agree, return-to-work in some form is a lot healthier for the patient than having them sit at home. Learn about the work performed and do your site visits. Has anyone done that, by the way, in this room? Very cool. I'm impressed. This particular organization, Upstate New York, the employer got so into it that they took pictures of the jobs of the different workstations and created a binder for the docs. And the docs then cited that in their reports, and when they went to testify, boy, did they knock it home, as well as improve the outcomes. Develop with innovation and convention. Become a valued asset as a consultant, IME, consultative coaching. That's often very helpful. I suggest making yourselves available to the attorneys and educate them, which will also help your testimony, as well. Traditional evaluations for end-of-case assessment. But something that we're looking at now as an innovative use is to look at a case from the AMA Impairment Guide's perspective, or if you're in a state that uses their own impairment ratings, don't wait until the end. Because what happens when you wait until the end? Think about it from the claims perspective. All of a sudden, a dollar figure pops up, a settlement value pops up. And that could be four figures, it could be five figures, it could be six figures. You don't know what it's going to be. But from the insurance carrier or the employer perspective, that's a number they didn't set reserves for. And when they get hit at the end with a large number, the reserves are skewed, which is considered poor claims practicing. So what do we suggest here? Is if you start to look at using the, and I'm bringing this up in the beginning so as you look at the guides a little bit, it may change the perspective. If you're able to look at the guides as a tool to project out what the potential exposure could be for worst-case scenario or likely-case scenario of an impairment rating, a carrier or employer can set the reserves for that. Put the money aside and project it for the cost of the claim. There are two other pieces that are really important. Think about this. You want to proactively throw treatment at the injured worker, correct? We want to give them whatever we can as quickly as possible. And you may be getting some pushback along the way, especially if there are treatment guides in place, that you've got to follow the treatment guides, which are different than the impairment guides. But if you're able to show by proactively treating the patient, throwing the appropriate care and doing soft evaluations of what permanent impairment will be, you're able to document that with appropriate care, if you did that soft evaluation on the front end, you give appropriate treatment, and that rating starts to come down. It substantiates the care that you're doing because it's a benchmark to show that you got the improvement. By doing so, you'll also find your carriers and your employers are going to approve things quicker for you, and it'll help develop your business. Does that make sense to folks? It's a nontraditional use, but it's using the tool to look on the front end rather than the back end. Stakeholders, you've got all the different groups there, the physician, the patient, the regulator, labor, employer management, legal community, insurers. We have to find the common ground to bring everyone together. And you're going to see specific to the guides, that's going to become very relevant in the coming year, being that we are doing significant updates, and many of the jurisdictions, including the two biggest jurisdictions in the country, California and Texas, are actively looking at the guides and are engaging with us as we move forward. Doug? Thanks, Ken. So, along the way, the journey has been quite interesting. And just to kind of give you a flavor of how we are improving the AMA guides with the new additions and new updates, there are certain things that are foundationally important to understand, right? And I think most people, and by the way, I see a lot of familiar faces in this audience is from like 20 years ago, when I first started to do a lot of teaching on the AMA guides. So it's refreshing to see that. But just understanding the concepts of impairment and disability, if you've heard me talk before, you know that I pound this into people, that these are two different things, right? Impairment is what's wrong with the person, disability is the outcome with respect to what's wrong with the individual. We talk about the mission of the AMA guides. I think it's important to understand the history and historical background of where we've been and how we've gotten here. Really, the real focal point of what we're doing on the AMA guides panel and trying to improve things going forward is this number four, and that's the importance of using the most current medicine. We're not going to sit here and tell you that we've got perfect medicine with all of these issues with regards to impairment ratings, because that would not be the truth. But we do have better medicine than what we had 15, 20 years ago with some of the other previous iterations of the guides. Also, going to a digital product has been a really focal point of the AMA. We've heard over and over from people how it's easier in this day and age to integrate the digital processes with electronic health records and all of those types of things and not having to carry around the old books that, frankly, you know, fall apart and are difficult to deal with. And then also implementation. Of course, you know, if you don't have an implementation plan, all of the work kind of goes astray and doesn't really mean anything. But then also how to get people involved in the process as we go forward. So I want to talk a little bit about that. Ken, if you don't mind, I'll just run through these, if that's okay. So it's a proactive tool, right? So you heard from Ken about how the rating is important for case closure, and we all know how that goes, right? The workers' compensation programs that are set up within our state jurisdictions and the federal jurisdictions all have a process, right, for rewarding the injured individual if they have a permanent problem. And of course, the impairment rating is the thing that starts that ball rolling, so to speak. It does help insurance carriers for reserve-setting purposes to try to get an idea of how that is. Benchmarking and improvement on outcomes is very, very important. One of the things, and we'll talk about this in a little bit, is that we're really focusing on that outcomes measurement tool aspect of it, because that becomes critical in trying to improve the guides going forward. Also evaluating the effectiveness of care, now you might say, well, you know, the impairment rating process really doesn't have a lot to do with the care process. But when you think about it, it does. Because what you're trying to do is you're trying to get the best outcome for the injured worker that you possibly can. So when you use a guides process that incorporates some of that into the information process, obviously it becomes a win-win type of situation. The key, of course, is to try to get people back to work as fast as possible and get them rehabilitated from their injuries and illnesses as quickly as possible. And then also that closure for the injured worker. Nobody likes to have the long, drawn-out claim. That doesn't really help anybody. None of the stakeholders involved like that. So if there is a process that we can try to improve to make that go a little bit quicker, that, of course, is a move in the right direction. Now this is the slide that I like to call the patchwork quilt of AMA Guides Edition Utilization in the United States. And you can see that there's many different colors here. We still have a process in the U.S. where we have different states that use different editions. And there's no uniformity to this. And we're trying, obviously, to make this whole picture look purple. So that's what our goal is here. If you look at my jurisdictional area, which is the Sioux City, Iowa area, that's where Nebraska, Iowa, and South Dakota all come together. At one point in my career, I had three different editions that I had to use. South Dakota, previous to 2016, was a fourth-edition state. Iowa continues to be a fifth-edition state. As you can see, Nebraska, they don't have a specified statutorial rule. However, with regards to their case law, most of the judges in the Nebraska Workers' Compensation System like to see sixth-edition ratings. So I had to have all three of those things disposable to me. I can tell you all kinds of wonky stories about how things have changed over time, about how workers would live in one state and work in another state, and how the state Supreme Courts got in arguments with each other about which edition should be used. And there are several cases that I can tell you where I had to rate an individual using three different guides for the same injury. Just goofy stuff, right? So none of this makes any sense, by the way. Why can't we get people together that get a uniform idea here as to what to do? And oh, by the way, why don't we use the best science in doing it? You know, if you're using the fourth edition, or if you're Colorado or Oregon and you're using the third-edition revised, just think about what it would be like today if you had to practice medicine with the knowledge that you only had in 1970. Does that make any sense? It makes absolutely no sense. Because you have terminology in some of these previous editions of the guides that isn't even relevant anymore. But statutorily, you still are kind of mandated to do that. So that's what we're trying to change. We also have other states that have their own state-specific guides. Long history and tradition behind why that is. A lot of it is steeped in political stuff, as I like to say it. You know, I'll scratch your back if you scratch mine kind of stuff. Okay, well, I get that. I get the politics. Isn't this really something that we should be focusing on the science instead? Yeah, I think we kind of should. You know, we're physicians. We promote evidence-based practice. That's really what we should be doing with that. It is not true that this is my book, but it's close. This is... It is a real doctor's book. It is a real doctor's book. That's right. Mine does have duct tape, and it is gray. Mine has pages that are falling out. So, you know, you get to the point of saying, okay, well, what's the best way to, you know, promote the communication, to provide reference tools for people, et cetera, et cetera. Clearly, we live in a digital age, right? So the way to do this is obviously to give people a digital product, right? And by the way, if you do a digital product, that also sets the stage for it to be updated more frequently and more periodically. It's really a hassle to publish a book, to be honest with you. I've been through it myself a couple of different times. It's not fun, right? And it's true, you know, you've always heard the statement that the minute that you publish a medical textbook, it's out of date instantaneously. There's a lot of truth to that. So if you have a digital format that you can continue to update, it makes a lot more sense. And we already do this with an occupational medicine, right? That's the way the ACOM Practice Guidelines is done. That's digital, updated all the time. ODG the same way, MD Guidelines the same way. So we have sort of a template here to follow with respect to this information. It's really important that we do that. Where did we come from? Way back in 1958 in the Journal of the American Medical Association, we had the first article that talked about this whole concept of impairment rating. Over the years, there were more guides on more organ systems that were published and put together. The iteration of the different guides, additions, starting with the first edition, which by the way, I was able to finally find a copy of the first edition of the AMA guides to add to my collection. And I'm proud to say that I have every single one of these books now. But I'm kind of a weird person in that respect. So anyway, don't try to follow me along the lines. But if you look at the improvement in iteration as how things went from guide edition to edition to edition, you get a good understanding of how this has been looked at historically. You know, at the very beginnings, people kind of had a concept of what impairment was about, but it wasn't really formulated very well. We kind of had an understanding that we needed to compensate people for their injuries, but we really didn't have a good way or pathway that was well described for that. But as time has gone on, of course, we've gotten better and better. Big thing with the sixth edition in 2008, which I think most people know, is we went to a diagnosis-based system. Previous editions, it was not that. So I think that was a big foundational step in the right direction. And basically, the premise of the AMA guides from going forward now is all going to be based upon that diagnosis-based approach. So we're using the sixth edition as sort of the foundational, if you will, bottom of the pyramid to continue to grow with future editions and iterations of the guides. So again, the sixth edition features are the diagnosis-based impairment perspective. The goal of the sixth edition when it was put out was to try to improve that inter-rater reliability, and I do think that it did that to a large degree, but it wasn't perfect. There are many things, even in the sixth edition book, that, you know, still was open to interpretation from examiner to examiner. And I'll talk a little bit about some of the things that we've done on the panel to try to improve that in some of the organ systems here going forward. So what does the iterations look like now? Well, you might be saying, okay, well, you know, why do we continue to hold on to the nomenclature of the 6th edition? Again, that's the foundational thing for all future editions are going to be based upon. So, early on, the guides editorial panel decided that the way that we were going to identify these things by nomenclature would be by yearly updates. So, for example, AMA guides 6th edition 2021. The next iteration was AMA guides 6th edition 2022. The next iteration after that will be 2023 and so forth and so on. So, the messaging on that was to tell people the 6th edition is the baseline, but we're making improvements on a yearly basis as we go forward. If I could jump in for one second there. On the nomenclature as far as how we name the guides, one of the complicating factors is that guides are generally cited in regulations and or statutes. So, that we're trying to work with the jurisdictions to get the smoothest transition possible. Hence, if we keep guide 6 and the regs don't stipulate what version, it opens the door a little bit. Also, for the states that say most current, it allows us to move forward in a more concise basis. The other thing to remember also is depending upon the jurisdiction, the version that's applied when you do your evaluation varies. Some jurisdictions, it's based upon date of injury as it is with treatment guidelines where it's whatever the guidelines or guides were in at the time of the injury. However, in other jurisdictions, it's based upon date of evaluation. Our folks in the audience experiencing that in some of your jurisdictions, I see some head nods. So, it's a juggling game to try and figure out which version is the most accurate. One of the other things that's very important and you may say, why are we updating, why are we updating? The AMA is committed to serving physicians. You are our population that we serve. And we believe what we're hearing from physicians is physicians are not comfortable using outdated information, as Dr. Martin said. So, when we're out there advocating in the states, this is not a money grab. We are a not-for-profit. And this is a particular product line that is designated at the AMA as a mission product, meaning it's purely there to serve the mission of physicians and the communities they serve. So, I don't want you to think that we're changing it. Oh, you change versions so we can sell more books. That's not the case at all. So, as we go forward in the jurisdictions, we're hoping to have you engaged and we'll touch that a little further down the road. You bet. Thank you, Counselor. So, I think it's important to understand the content of what we're trying to accomplish. You see that there are several things on this slide as far as using best medicine. And we're going to talk a little bit about the editorial process and how we've changed that to a, I think, a best transparency or best practice type of situation. And then I'm going to talk a little bit about the things that we've already adopted as new and sort of things that are in the pipeline to do here into the future. So, one of the things that I will tell you that the co-chair, Dr. Melhorn and myself were very clear to the AMA when they first came to us and said, would you consider being co-chairs of this panel? We told them that there's no way we're going to do this unless you change to a more transparent model. Previous editions of the AMA guides, not much transparency. Basically, the way that this worked in the past is they would assign content editors. Those editors would work sometimes with a work group, that sort of thing, come to a general editor. Things would be looked at. Things would be published. And it was really a very close-knit group. Very little input from any type of outside stakeholder, outside specialty organizations, or these types of things. And we wanted to change that. We wanted to make this a situation where all of the stakeholders involved in the process could have a voice in the process, okay? And the AMA said, sure, we're going to do that for you. And I'm proud to say that this editorial process now is very transparent. What happens is, is that we actually ask for content developers to give us input and to give us proposals, okay? Now, that can come from an individual. It can come from a specialty organization. It can come from any stakeholder group. We don't really care within the editorial process who is giving us the proposal information. But then there's a series of steps that has to happen. Obviously, first of all, we look at that proposal to see if it cuts the mustard from the standpoint, from a scientific perspective, you know, from a iterations perspective. I mean, is it really talking to the issues of impairment? If the panel, and I'll show you who makes up the panel here in just a little bit, if that panel then decides that this is a proposal that needs to go forward, what happens is, is that that proposal is accepted, but it's accepted for review and comment, all right? So, it's not just a, like, we propose this and we vote on it and we're all happy and then we go home. No, it's much more of a bigger deal than that. So, we actually go through a public comment period. Our meetings of the editorial panel are open to the public, and we encourage people to participate in that particular process. And I can tell you that the members of the editorial panel really pay attention to those public comments and outside stakeholder perspectives on things. And in many cases, in the things that we have already adopted, we have changed things because of that type of public comment and input on the process. If I could jump in on the transparency as well, the participation from the outside is so important. And what we're hearing from regulators, which is much different, as you gather, I do the advocacy for the guides, and I'm out meeting with the regulators, legislators, and the stakeholders. But what they're telling us is due to the transparency that we have now, they can proactively plan for the future. So, we've got the medical directors from many of the jurisdictions silently dialing in or listening in to the calls so that they know what's going on. They're able to give input. They're able to help us formulate, not only from the scientific and objective perspective, but for the real use in practice. So, that communication is so important to us. And those of you who perform evaluations, you are the folks that are doing it. So, the more we can hear from you about what's happening in your jurisdiction, and for those of you who are multi-jurisdictional, give us the feedback. Let us know the problems. Let us hear what you're hearing and know your issues so we can make the guides work better for you. That's who we're committed to. Right. So, throughout the process of sort of assimilating the public comments, oftentimes what happens is that then there's several different changes or edits that are made to the proposal. That goes back to the editorial panel again for more review. Sometimes we're happy with that. Sometimes not. Sometimes we'll send it back to the proposers and say, hey, you know, we think we need to change this because of that input and that public comment that we've received. So, frequently the cadence now with regards to time of proposal to time of adoption oftentimes is a year. And you might say, well, gosh, that's an awful long period of time to engage somebody. And you're probably right. But we want to make sure that we do it the right way. Okay. We don't ever want to be in a situation where we can't say to somebody, hey, we kind of shortcut the process or we didn't listen to organization XYZ or we blew off this particular individual. We don't want to be in that position. We want to make sure that everybody has a voice and everybody has a due process situation here so that they can contribute to things going forward. All right. So, please understand that there's a standardized methodology for assessing permanent impairment. I think most of you here probably know this. An impairment rating is oftentimes just one component of a more complex disability determination and compensation calculation. The AMA guides are an assessment and a rating tool that is focused on the fair and objective standardization process for evaluating individuals that have these related injuries and illnesses. And many jurisdictions do then use the impairment rating to convert into a financial or other type of compensation situation. Jurisdiction is very widely on this. I mean, you do have some state workers' comp processes in the United States where the impairment rating directly is translated to a dollar figure. You have other jurisdictions where there's a variety of variable factors or other things that come into that particular process. So, every state's different. Every jurisdiction is different. We are trying to say that the impairment rating process should be the same for everybody. And then what the jurisdiction decides to do with regards to the monetary value, that's an individual state's determination. And when the panel is working on the guides, we stay blind and silent about anything financial associated with the guides. The guides are supposed to purely and objectively evaluate function and the loss thereof. Right. I should say impairment rather than function. So, what are some of these considerations? Well, obviously, when you're using a diagnosis-based model of impairment assessment, you have to know what the diagnosis is, right? So, you've got to figure out what the problem is. That's kind of a foundational type of thing. You might think that that's silly. I will tell you in doing a number of impairment ratings over my career, that is not necessarily done well because if you don't have the right diagnosis, it's not going to lead you to the right conclusion. Some things are obvious, right? I mean, we can see obvious type of injuries, but some things are not so easy, especially in the so-called cumulative trauma disorder world or some of the more difficult syndromes that we deal with in trying to figure out exactly what's going on. And then what difficulties are reported? You know, when you're trying to figure out from that individual, you know, the actual problems, the functional limitations that the people report, whatever that might be, trying to then march that along and try to tie that to what the actual injury is sometimes is not as easy as you might think. What are the exam findings? You know, it isn't like we've casted the physical examination to the side here. As a matter of fact, if there's anything that I really kind of like tote the banner on is like, have we forgotten how to do a good history and physical exam? I really worry about that. I mean, I have to tell you, in addition to doing a lot of impairment evaluations, I get to review other people's impairment evaluations. And I read through the physical exam and I go, my God, did this person fall asleep that day in medical school or what's going on here? I mean, I don't get good range of motion values when they're appropriate. I don't have any idea of what their neurologic exam is. They tell me that they test reflexes, but they don't tell me of what. And their radiation scale is some scale that I've never heard of. And it's like, okay, well, what has this person actually done? I know that's a very frustrating thing, but it's really important to understand that the exam findings have to meet with what we know the diagnosis is intended to reflect. And then, of course, we do use clinical studies, right? I'm not suggesting that we throw those out the window. We don't. But you have to understand that you use the relevant clinical studies. Those of you in the audience that do spine ratings, you know exactly what I'm talking about, all right? The diagnosis is not herniated nucleus pulposus. That's an MRI finding, okay? The diagnosis might be L4 radiculopathy if the person has the physical examination findings that match that and has a correlative finding on an MRI scan that matches that condition, okay? So these things become really, really important as we go on. Let's talk about impairment classes, okay? Doug, could we stop for a sec there? Yeah. I've got a question for you, going back to the practice of using the guides. How many of you actually take the time and the person who's referring to you and paying a fee of, what, $500, $1,000, $2,000, $5,000 for an exam, how many folks actually take the time and review the report with the party you're sending it to? Okay. I've got less than five hands up. Think about the impact it can have on your practice and the impact on how you can empower the attorneys and the adjusters if you took the time to explain the report to them. You'll be able to give them the golden nuggets that they may not see there and coach them through it. And again, sometimes this is billable, sometimes it's not, but it's part of the relationship building and it's part of giving the attorney and or the adjuster and or the employer, especially if it's a proactive, self-insured employer, the ability to understand, better utilize the tools, and better build the relationship with yourselves. Very good. You bet. Do you have time for those $5,000 in the jurisdiction? There are lots of jurisdictions. If you saw some of the numbers that I've seen on impairment ratings, I've seen them go up well above that. And what about our experts age? It depends upon the relationship in the jurisdiction and the type of case. If you're being hired by the attorneys or by the claims adjusters, most jurisdictions will allow you to communicate with them. And I see some heads nodding because what you're doing is explaining your report to them. But again, I'm not sure what jurisdiction you're in, but you've got to really know your jurisdiction. Okay. California is- As we like to say, California is not a state, but it's a state of mind. But I'll tell you, there are employers I know of in California that, even if it's not on a specific report, they'll have the docs explain, they'll have them understand. And also, California, for those of you who don't know the California market, it functions almost as three to four different markets with very different flows and outcomes in each of the areas. Years ago, when we were looking at the opioid issue, this was prior to AMA when they were looking at the drug formulary. Friend of mine is in advertising, and we knew what the patterns were as far as drug use. We could see where the scripts were done. And she went and I said, do me a favor, run an analysis of advertising by time slot and by category of advertisers. And sure enough, the advertising patterns on TV match up exactly with the opioid use in the state. The L.A. basin lit up like flashing red when we did a heat map on it, when you matched up the advertising of the drug companies and the attorneys compared to drug use and other treatments. Same thing with certain diagnostic procedures. Yeah. I think the bottom line that Ken is trying to say, and I reiterate all the time, you've got to understand what your rules are. You can't play the game unless you understand the rules. And every jurisdiction is different. I'm old enough to have been in front of the California Applicant Attorneys Association meeting right after California adopted the fifth edition. I just about didn't leave with my life. I'm surprised that you did walk out. So, I mean, despite we got up there and said, don't kill the messenger. We're here just to tell you what this is all about. They wanted to kill the messenger. Okay. So I've been through all that history. I understand that there are challenges, right? Every jurisdiction is different. Sometimes you can talk to some people. Sometimes you can't. Sometimes your report gets to be shared with others. Sometimes it isn't. Sometimes you have to have it done in a certain amount of days. Sometimes not. All of these things are important to understand because your state jurisdiction, or if it's a federal system, they all have rules that surround that sort of thing. So, let's talk a little bit about sixth edition. If you're unfamiliar with how this works, the classification system basically works like this. Okay. You find a diagnosis, and then you find a diagnosis-based impairment grid or table, if you will. It basically looks like this. Class zero means it's asymptomatic. It's not a problem. Those people don't get any impairment, all the way to class four, which is severe. So, the idea here is to go from mild, moderate, severe, very severe. That's basically the concepts, right? Within each class, you have five different grades, typically. Those grades are A through E, A being a good outcome, E being a not-so-great outcome. All right. They're not all chapters like this. Some chapters you'll know only have a three-grade system. I'll talk a little bit about the three-grade system here in a little bit. So, just to give you an idea, this is not intended to be educational about how to do a knee rating. That's a different course. But just to give you an idea here of what the tables look like, this is for the knee, right? So, if you had a person that had a partial medial meniscectomy before a meniscal tear, for example. Maybe they twisted their knee, bang, had swelling, had problems, and they had to go and have that arthroscopically taken care of. You would find meniscal injury in the knee category, right? So, you see meniscal injury there under the diagnostic criteria. Then you would have to figure out which class actually applies in this situation. And let's say that this person had a partial meniscectomy and, you know, they recovered fine and they did okay. And, you know, maybe they have a little bit of an ache or a pain or whatever. But for the most part, they're doing pretty well. That would be definitionally under Class 1. Of course, you see the circle there. That's intended to identify like the middle of the range value or the grade C value, if you will. The sixth edition has a process where you think about grade modifiers to move that either up or down. Those grade modifiers are functional history, physical examination, and clinical studies. Again, this is not intended to try to teach you how to do impairment ratings. That's a different class. But based upon those grade modifiers, you would then figure out, hey, is this a grade A? Is it a grade B? Is it a grade C? D or E? If you decided that it was a grade C, 2% of the lower extremity would be the impairment rating. And there you go. Okay. So it's a pretty straightforward type of system. Again, based upon that diagnosis-based classification. All right. This is what I've already said. So the thing is based upon no symptoms at all, mild, probable, moderate, severe, very severe as far as how the class system goes forward. Could you talk for a minute about the transition that's going to happen? Yes. So I was going to get to that, but thank you for reminding me. So one of the things that we are thinking about, and let me go back to this slide here. One of the things that we are thinking about, which has been a real focus within the GUIDES editorial panel, is to try to even improve the inter-rated reliability more than what the sixth edition already did. Some of you that have done a lot of sixth edition ratings recognize that when you go through this gradation system, very rarely do you wind up with a grade A or a grade B. Have you all noticed that? All right. Now, some people that are cynical would say, well, patients in the work on system, they're going to have worse outcomes anyway. Okay, maybe. There's some truth to that. but even internally, when you go through the process of looking at the physical exam and the clinical studies, rarely are you going to get to the grade A, grade B system. So we looked at that as a panel and said, well, maybe we shouldn't have five grades. Maybe we should have three grades, and instead of looking at the middle grade being the average, maybe we should look at it as the foundational grade is a baseline, and then we give people additional impairment if the thing is a lot worse than what we expect. So we've already done this, interestingly, for the revisions in the neurology or CNS chapter. This is something that we're going to continue to think about in the musculoskeletal chapters going forward. So it's very likely that what you'll see is, is in the future iterations and revisions to the musculoskeletal chapters, there won't be five grades anymore. There will only be three. We think that that's going to improve inter-rater reliability even more. And of course, this is still an iteration process. We're still at the infancy with those three musculoskeletal chapters. So if you all think that's great, we need to hear that input. If you all think that we're crazy and nuts, we need to think that, you know, get that from you too as well. So thanks for that. Okay, so what have we done, and what's in the pipe, okay? So in 2023, the guides actually adopted the new content for the nervous system, and that's effective for those states that use the most current 6th edition. I have to tell you that this is one of the things that I really carried the banner on. Most of you who interact with the CNS system prior to this change know that there was a great degree of range that was available to the examiner for certain neurological conditions without any guidance as to what number to pick, okay? You actually had classes in the old neurology versions where Dr. Durand, my good friend from Lincoln, might have examined the patient and said, it's 10%. The same person gets sent up to Sioux City and sees me, and I say, it's 25%. Is Dr. Durand right? Am I right? The answer is we're both right because that class in the old version would say that the range is from 10% to 25% without any guidance as to what that number actually should be, okay? So new proposal. What did that new proposal say? We're actually going to give you numbers, and oh, by the way, we're going to give you classes that make sense. So we're going to redefine some of these neurological conditions so it actually makes sense from a diagnostic standpoint, and we're only going to give you three grades. We're going to try to make it super simple for you, all right? So now, when that same person goes and sees Dr. Durand, and he says 17%, and he comes to Dr. Martin, and Dr. Martin says, hey, Dr. Durand's right, it's 17%, win, right? Okay. So that's what we're trying to do to try to improve the process. So that's a big deal right here for the central nervous system for sure. What's coming down the pipe? In 2023, meaning like right now, we have workgroups that are working on the spine, the upper extremity, and the lower extremity chapters, okay? There's no question that those are the three most common chapters that are used in AMA guides. Probably 85% of claims all come from those three chapters. We recognized early on that if we're going to make a change, we better make that change all at the same time. It would make absolutely no sense to one year change the upper extremity, and then wait for the second year to change the lower extremity. That's not going to work very good, okay? So we figured out that we need to kind of do them all at the same time. The other important part about this is, is they're working on the PROMs, the patient reported outcomes measures. Now those of you that have used the 6th edition know how difficult this is. For lower extremity ratings, you can't even get the AAOS lower limb instrument anymore. It's gone. But yet the 6th edition talks about it, right? There's been a lot of discussion about, well, is the QuickDash really the best tool for the upper extremity? Is the pain disability questionnaire really the best tool for the spine? The answer to that is probably not. It might have been the best tool in 2008 when the thing was published, but better research has told us that it isn't the case anymore, okay? So there's an example of using the best medicine, right? We want to make sure we're using the best medicine in the impairment rating process, so that's all going to be changing here in the near future as well. Now again, this is all based upon a transparent process. We have gotten the information back from the stakeholders about this, okay? This hasn't been done in some, you know, back room, smoke-filled room in Chicago that nobody knows what in the heck's going on. Oh, come on, Doug. The Get Smart Dome? Yeah, right. Right. The Dome of Silence that comes down, which is not the case at all. Oh, yeah, that, well, anyway. Yeah. So we hope to have those things done in 2023. It's aggressive, admittedly, to maybe have these things ready to go for the 2024 edition, but that's what our goal is, okay? The situation, it continuously is looking for best practices, so, you know, it's not that we're only focused as the editorial panel on those three chapters, because those are the three proposals that we have in line right now, but we're more than happy to accept other proposals on other organ systems as things come along. On the updates, there are two sides to the equation. There's the medical side, which is the objective evaluations, but there's also the regulatory side. That's used in the jurisdictions. If anyone in, has anyone in the room been involved in a jurisdictional change in one area or another? For those gathering not, it's not a fun process. It's a complicated process. It's a costly process. For a state to adopt the newest version, you've got to get stakeholder buy-in. You then have to get buy-in of the regulatory agency. You then, in most cases, even in the states that are on, quote, most current, the regulations have to be updated, and you often have to go in front of the legislature. You've also got to look at the financial impact of it, because it's going to have an impact, and how is it going to impact the individual stakeholders? So what we've done is we've reached out. Some of the states have their own rating agencies, such as California. California has CWCI, the California Workers' Compensation Institute. CWCI and the DWC in California have agreed to look at the impact. They're going to look at how this will impact the ratings. NCCI, the National Council of Compensation Insurance, handles close to 20 or more states on the rate setting. NCCI is also going to work with us in looking at the impact, and what they said, again, both of these organizations, is don't give it to us in dribs and drabs. Give us the total piece, and they listen into our calls, so that they hear what's going on in the process. They've also told us that between the four body parts, being nervous system this year, spine, upper, and lower extremity, that depending upon the jurisdiction we're speaking about, that will represent somewhere between 70 and 80 percent of the total impairment ratings done in the jurisdiction. So whereas in the past, when it was a drib or a drab, they wouldn't go through the process, states are interested in doing it, NCCI is interested in doing it. Now, something that you may question in your mind is what's the impact of changing the rating system? The percentages may change. In the process, we have to stay blind to that. We cannot look at the financial impact, because that would be skewing it, rather than doing it on pure medicine and medical principles. So the way it's been agreed, and we've looked at similar models, where if you change something that's going to impact dollars, how does it work through? So the closest comparison we found is fee schedules. You want to have new fee schedules come out in your jurisdictions, and somebody's going to complain that there's either too much going, being paid, which is usually the payer community, or the provider community is going to pay, complain that the numbers are going down based upon the new fee schedule. How do they level the field? With modifiers, such that they'll have the new fee schedule, and they'll add a modifier to get it to the same point. So as we're out speaking with the jurisdictions, we're encouraging them to stay blind to the percentage of the ratings, as long as they're objective. But then you can take their new rating, compare it to the old rating, figure out what the differential is, and then add a modifier. Because otherwise, you're going to have one side, plaintiff's bar or defense, complaining on one side, and we think we can level the playing field, even to the point in California. Fingers crossed. We hope we can get CAH, which is California Applicant's Attorney Bar, which is mighty powerful, even get them to agree. Does that make sense to folks? If you think there are holes in the bucket, please, shoot the holes. Share it with us so that we can address them now. So just to finish up, again, all this is transparent. The editorial panel is online. You can participate. We publish our meeting dates, so we have an area for comment. We have an area for questions. We're more than willing to accept all information. Dr. Murray, if we could go back one slide for a second. One thing to comment, folks are, as we've come out with the digital version, some of the response, I'm going to be real candid, is this is just a grant to sell subscriptions. Not the case. It's a tool that's important. With the anticipation of moving to a more current version of guides in many jurisdictions, you're going to need to be able to toggle back and forth between the versions. You'll be getting ratings in certain states, as I said, based upon date of injury, not date of exam. So whether it's a matter of trying to get all the different versions with different books or different supplements or whatever you're looking for, versus on the platform, you're able to toggle between and do a comparison if you need or get to any version that's the snapshot in time, and that'll be consistent. I know a lot of folks will be, oh, my God, it's going to cost me thousands of dollars. It's under $300 a year for a subscription, and I'll call out the secret that nobody wants to discuss. Think about the cost that you get for one impairment rating compared to $279 for a tool that you're going to use all year, that you'll be able to copy and paste from. The other thing I'll mention, I was just on some meetings recently about new AI, artificial intelligence. When you're working on your reports and your exams, take a look at some of the tools that are out there in artificial intelligence. The ability to take records, scan them, and in a matter of moments have all your records fully digested, fully organized, and fully cited. There may be an investment, but it may pay off. There are different ways of doing things, and from what I'm hearing, industry is not going to expect doctors to lower their fees for using technology. Very good. Just to talk a little bit about what the digital subscription gets you. I think one of the coolest things for me is having the ability to do two things. Number one, to research the AMA guides newsletters, which used to be a separate thing by itself in addition just to the guides itself. Now we've integrated that all together. The second thing that I would tell you is a searchable database. There's a type in search tool on this. If you're interested in thoracic compression fracture, type in thoracic compression fracture. It's going to take you to all the references of all the editions of the guides. It's going to take you to the guides newsletter articles that have been published on that topic. It has saved me a ton of time, believe me, as far as the way that I used to do it, which was all by hand, which didn't really make much sense. All these things are available to you digitally. Ken has talked about the subscription. I don't need to reiterate that. I think that's a move in the right direction. Yes, it is a time saver. The copy and paste function from the standpoint of creating reports has been a huge plus, I think, for most people. There's no question about that. You do have options, right? If you want just the digital access to the six, that's great. If you want just the newsletter, that's great. If you want everything, that's great, too. We try to give you a menu here that you can select from. Official qualifier. This is not a sales pitch, but we felt it was necessary when we were asked to provide people with information where the guides are available. All right. A few people to thank. I want to thank my co-chair, Dr. Mark Melhorn. If you don't know Mark, he's a hand surgeon by training. He is an ACOM member, Wichita, Kansas, has been at this for a long period of time. We're going to go back a slide for a second. Oh, we are? Okay. I want to give a heartfelt thanks to Dr. Martin and to Dr. Melhorn. Dr. Martin, in particular, has become ... Dr. Martin is not only a great value to the AMA and obviously to this association, but he's committed, he cares, and he's making a difference here. Doug, thank you for your service and thank you for your friendship. I appreciate it. You're welcome, Ken. Thank you very much for those kind words. I get into this because I'm just trying to make things better. That's my focus. I do want to give a shout out to the editorial panel members. Some of these folks are probably familiar to you. We have ... Goodness, I don't know how many ACOM members do we have here. One, two, three, four, five. We have five ACOM members that are on the panel. They're not all representing ACOM, understand. These folks have been chosen because of their interests, their expertise. You'll see that we have panel advisors that include two judges. Again, got to get all the stakeholders involved in this process. Judge Bishop and Judge Langham, in particular, have been very helpful throughout this process giving their insight on the things. Dr. Brigham, who is the editor of the newsletter, very important. Abby Hudgens, who's from the administrative world, former director of the Tennessee Workers' Comp System. Dr. Jelena, who's our international representative from Canada, who tells us all about the wonky things as how the guides are used in Canada, which is crazy. Then we have folks from the physical therapy world, people from the nursing world. Again, we're really serious about this being a transparent process involving all the stakeholders. This is the new editorial panel. Dr. Curtais, stand up please. Dr. Curtais is on the editorial panel. He represents psychology. Thank you. Again, I just want to give a shout out to all of our panel members because they've been an invaluable resource. Interestingly enough, we all get along, which is sort of like a nice thing, too. If I could give one other shout out to somebody who's in the audience here today, who's one of my former collaborators and somebody who helped me grow in this industry and has really helped not only the impairment guides indirectly, but the treatment guides incredibly. I want to acknowledge Lucy Shannon, who's in the office, from Regroup, who publishes the AECOM guides. Lucy and I have worked together for how many years, Lucy? More than we'll admit to. From the days of when New York first decided to have treatment guidelines and challenged us to develop a product for it. Regroup, especially its new iteration, is going to be doing some exciting things. We hope to be collaborating with them as well. Great. How can you get involved? Attend panel meetings. Give us your feedback. Submit a proposal to update the guides. Peruse the guides' digitals and give us important feedback about that. Stakeholder groups. I think AECOM has been fairly transparent about what our AECOM folks have been doing in this process, and then pay attention to a lot of these summaries. I've left a little bit of time for Q&A if anybody has any questions. And I'd ask you to come to the, what is there, only one microphone in this room? I guess to the one microphone. Any feedback for us? Any comments? Any things that you think we should be considering that we haven't kind of touched base in a bigger picture? Oh, good, we've got somebody. David Duran, Lincoln, Nebraska, Occupational Medicine. Doug, you mentioned new guidelines for the neurologic system. I have an old sixth edition book. Do I need to get on the website and get the new guides? Yes. Yes, I encourage you to do that. I think, David, what you'll find is that it's a refreshing change that makes it more clear and will drive you to a number that makes sense. There's also one other, there's another alternative other than the platform, which is e-books. So, we still have some print books. We're printing the older versions now, so there will be supply for at least another year or two. But the e-books are also a value, and I think they're underrated. On an e-book, and we showed you the picture, and that was a real picture. That was the green book with the duct tape on it. That was a doc sitting next to me in a training session. I go out to observe the training. But on the e-books, you can download the e-book or you can leave it online. You can take notes on your e-book. You can bookmark the pages. You can fill out forms and charts. For those of you who have kids or grandkids that are in high school or college, ask them about e-books. I know I resisted until I had a younger family member take me through and play with it. The other advantage of an e-book in addition to the platform is an e-book can be downloaded locally. I'm not sure how many international folks we have here, but with the use of the guides in South Africa and through other parts of the world where there's not consistent internet access, the e-books are a great alternative. It's easy to print out and print sections for citations as well. Other questions or comments? Okay. Well, seeing none, again, thank you for your attendance. We're just going to go to the last slide, which has our contact info if you need anything. Don't forget about the contact slide. You can contact any of us for stakeholder communications and whatnot. We can share our information. Do the phone numbers not go through? I don't know. Okay. We got Oz. Thank you so much, folks. Take care.

AMA guides

history

updates

future direction

Dr. Doug Martin

Ken Eichler

development

transparency

classification system