Welcome to the scientific session titled AMA Guides to Evaluation of Permanent Impairment Update on Musculoskeletal Chapter Changes for the Guides' 6th Digital Edition 2024. My name is Doug Martin, immediate past president of ACOM. I also serve as the co-chair of the panel, the AMA Guides editorial panel. Ken, you want to introduce yourself? Sure. I'm Ken Eichler. I'm hailing out of Florida currently, as you can tell from my speech, former New Yorker. I've been with the AMA now for three years. I'm responsible as one of the product owners for the AMA Guides. I also handle the advocacy. So if anyone's interested in helping us with advocacy in your states when it comes to the guides, please, we're looking for some grassroots help. There's a lot of training that's going to need to be done with the new guides and the like, so please feel free to approach me. The conference folks have also asked us to mention, to remind everyone, that if you want a copy of the slide deck, it's on the conference app. And the full slides are in there for you to reference back to it. And they also ask that you please do any evaluations and the like so that they can approve the conference for you in the future. So with that, I'll turn it over to Dr. Martin to start. Thank you, Ken. So don't let Ken fool you when he says he's been three years with the AMA. We've actually known each other for closer to 30, with various different projects and things that Ken has been involved with in the past. So after 30 years, I'd say we get along pretty well with each other still. We haven't gotten in each other's face a lot. So that's good. The funny thing is we both met each other when, at a, where was it, in Nebraska. Nebraska. Yep. Nebraska said it, both testifying. Yeah. So, go be red. Anyway, couple disclaimers. First thing that I want to cover is this activity is to inform you on some of the high-level changes to the AMA Guide 6th edition that are going to be coming later in 2024, specifically the three musculoskeletal chapters, upper and lower extremity and spine, and opportunities for content review. Ken in particular, I speak for him, are not medical experts, and he is unable to answer questions that are related to the practice of medicine. That's my role, and I'll try to answer those things that you have questions about to the best of my ability. Understanding that this is still a bit of a work in progress. It's not finalized. So some of the things, if you get really into the weeds, I may not be able to give you clear answers to, but I'll try to help you along. Asking questions via formal channels. There is a process that we have in place with regards to our AMA Guides panel that allows for public comment periods. We typically will have AMA Guides editorial panel meetings once a month. Sometimes that cadence gets off a little bit, and we'll skip a month here and there, depending on how much we have to do. But these panel meetings are open to everybody. One of the things that Dr. Mark Melhorn, who many of you know, who was my co-chair on this editorial panel, when we were asked by the AMA to be the co-chair of the panels back in 2019, both of us, one of our very strong messages to the AMA was, is we will do it, but we want to be open and transparent about the process. So historically, there have been some criticisms about that, but that was one of the things that we basically wanted to make sure was going to be true. And I think that we've been able to accomplish that. So let's talk about some of our objectives this afternoon. We're going to give a high-level overview of the musculoskeletal chapters, as we talked about. We'll provide additional information on timing, as far as when we think this is going to be ready for prime time. We'll talk about ways that you can contribute. Ken will talk about some of the implementation strategies and adoption methodologies that are occurring amongst our various different states and other agencies. And then we'll talk about some of the feedback that we can elicit from you to the AMA, and then also some ways to think about implementation of these changes in your individual jurisdiction. So I want to spend some time to set the stage a little bit. Ken, do you want to take over from here? Sure. I've got the, we're always required to discuss the AMA mission, and a two-second AMA pitch here is, we are the AMA. We, as the AMA, are here to service you as physicians and medical practitioners. We encourage you to get engaged. We encourage you to participate. The AMA, especially in the guides division, has become a lot more transparent, and we really want the engagement. We're engaging with regulators across the country, across the world, actually, at this point, and we're also hoping to get more engagement with physicians. But the AMA is committed to serving stakeholders, and our stakeholders include patients, physicians, and government, with fair and equitable. Fair and equitable, very, very important to the AMA. And when I first joined the AMA, I kind of laughed about the fair and equitable. I'm a hardcore New York guy, you know, fair and equitable, yeah, we do everything. But if you really dig into it, there's really strong meaning behind that, and it can apply to us in everything we do, in the delivery of medicine, the delivery of care, and how we treat people. And if you dig a little deeper, fair and equitable will really change the way you kind of look at the world. And I wasn't a believer, I truly am now, and it's not just drinking the Kool-Aid, it's seeing what it means. So we want fair and equitable permanent impairment ratings that can be completed promptly, without undue administrative burden. Make it easy, make it reproducible, make it consistent and accurate. By engaging the community of practice, the AMA guides editorial process incorporates the best available science and evidence-based medicine, reflecting medical advances and new insights. And it has been totally transparent. We've been open to the public. We take the comments, and as Dr. Martin mentioned, those are reviewed, and they're taken very seriously. And boy, did it really change the course of first drafts, and help it progress to a better product. Our AMA editorial panel, as you can see, you know, esteemed, esteemed, nationally and internationally known physicians, and these are all volunteers. I can't tell you how many hours these folks put in, and how much we at the AMA, and the constituents we represent, which is all of you and all the stakeholders across the country, truly appreciate it. The number of hours and commitment are beyond words, and these panel meetings are transparent. A lot of you probably know some of the folks there. Our AMA guides team, this is the core team that works on the product. We are on the product side, yet the physicians produce the content. So the content is physician-written, physician-driven, physician-evaluated, and it is our job to take that, distill it down into a distributable format, speaking of which, the new guides content are shifting, and we'll go up to that in a couple of minutes, to digital. Many of you know the books, and I wish we had a picture of a book when I first joined the AMA, and I went to one of the physician training classes, and what we should have had is a book taped together with duct tape. How many people have seen the duct tape books? Yeah? The judges joke about it all the time, because they're falling apart, and they're put together with duct tape. But now we've moved to digital. The digital platform has all the versions of the guides, plus the newest update, which will be 6th edition 2024, will only be available digitally, and there's been some pushback from the industry, but back when I was with MD Guidelines, and back when I was with ODG, we all went through the same process, only they did it 10 years ago, or 15 years ago, when everyone was abandoning paper, and had to move to digital. The AMA is now going to be moving to digital. The content's managed by our editorial panel. Our experts convene regularly, update, and it's physician-driven, as well as we also take external submissions for guides updates. The AMA guides editorial pass is open, transparent, and ensures collaboration, and 23-24 targeted releases include the biggest updates in 10 years. Last year, we did nervous system. Dr. Kramer and her team, as well as our team, worked together on updating the nervous system. What we're now doing this year is spine, upper, and lower extremity. So if you think about that, we went, anyone familiar with NCCI, National Council of Compensation Insurance, they're the ones who do the ratings of costs, and do impact analysis for many of the states. NCCI, as well as other organizations, have told us the new rating system will impact approximately 70-plus percent of the overall ratings, which makes sense because it's musculoskeletal. AMA guides, as I mentioned, are available digitally. The newsletters are also available digitally, and I encourage you, if you're going to be on the site, the newsletter's going to be key in helping to move to the new guides. We'll be having case studies, we'll be having other information, as well as there are additional studies that are soon to be released. They're under review right now, which we really can't discuss, but you'll see journal articles on the updates. Thank you. So one of the things, just to dovetail on what Ken said about the editorial panel and its makeup, there's a couple of things that you probably need to know as far as the selection process is concerned. Multidisciplinary representation, meaning that it's just not all musculoskeletal-based physicians. We have special senses represented, ear, nose, and throat, and psychologists to help us with the mental health part and that sort of thing, which is really important. And also, intentionally, it's not all people like me who have been involved with this for like 30 years. We have some newer folks, because we thought that we needed to have different perspectives and didn't want to get into an age categorization that only had old-school way of looking at things. And I will tell you that having this panel and this process in place now for five years, because of those two things, making sure that we have multiple disciplines that are represented and having various different demographics represented, has come a long way, I think, to make a better product. As you probably are aware, the current landscape of AMA Guides Edition use in the United States is a patchwork quilt, or a mosaic pattern, or whatever you want to call it. Of course, what we are trying to advocate for at the AMA panel level, and as is now policy of the American Medical Association, as adopted by their House of Delegates, is the most recent edition of the AMA Guides is the one that has the best science and the one that should be used. Obviously, when you look at this map and you see that there are some states that are still using fourth edition, which is now 30 years old, that becomes a little bit of a problem. Ask yourself the question if you would be wanting to practice medicine using things that you only knew in 1994 today. Obviously, there are lots of treatments that are different. I'll give you some classic examples. Rating occupational asthma. We did not have immunologic therapy for asthma back in 1994, so explain to me how you're supposed to rate occupational asthma today if that did not exist back in 1994 and you're trying to use 1994 standards. That's very difficult. That's just one example. As you can see, there are a fair number of states that do use the sixth edition. Those states, obviously, are easier to go and explain things to from the standpoint of updating information and so forth and so on. In addition, you'll see some of the states here that are black. Those are states that have their own individual state written guides or in some cases have some sort of a hybrid or a mixed pattern. North Carolina is a great example of that where they use the AMA Guides for certain diagnoses, but they have state-specific guides that they use for others. Our goal is to try to make this map all purple, obviously, because we think that the best science is the way to go. We also think that it would be helpful to have some universality with regards to the concept of how to go about ratings in the country to exist. Doug, if we go back for one second, one comment I'd like to make is what I neglected to do on this slide and we will be doing in the future is there are 12 or 13 states or jurisdictions that currently use most current in their legislative language. As the AMA updates, those states are supposed to update with us. Has anyone heard of the Protz case in Pennsylvania? Anyone? I've got a couple of hands up. Several years ago, when an older version of the AMA came out, and I'm bringing this to your attention to make sure that you can help us and help yourselves in your states. A state, when they're using an external entity to provide guidelines or references, the states have an obligation to do due diligence and verify that that is good for their jurisdictions. I'll take it away from medicine for a minute. Imagine if a state decided to upgrade or update their guides for engineering for building of bridges. The state said, go ahead, Bridge Builders Association, you guys set the standards. What does the state have to do? They have to review them to protect their constituents to make sure these are safe standards. Well, when the last AMA guides came out, Pennsylvania oopsed and they didn't review it internally. They just adopted it. The review is basically simple in most of the states. It's a quick, easy, you have to acknowledge it. What happened several years into it, a very clever attorney who represented an injured worker decided to sue the state and say you didn't go through the proper review process, and therefore it was what's referred to as unlawful delegation of legislative authority to an outside entity. This attorney sued, got his case overturned, and got hundreds if not thousands of other cases overturned with back pay and payouts, and they had to be re-rated. We are now on top of the states to remind them they must review the content and they must go through the promulgation process. Why do I bring that up? It's important in your states. When you're looking at potential updates, take a look yourselves. Have a voice. Don't stand back and moan and groan about it afterwards, but be part of the process. Very good. Thank you, Ken. So how do we go about achieving this transparency that I've told you is very important? There's several different ways. Obviously, when we think about content development and somebody comes to us with a suggestion to update the information, there is a peer review process by specialty experts that develop the editorial change proposal for consideration. In other words, we don't allow just like N of 1 submissions to go forth and stand alone by themselves. This goes through a significant subject matter expert peer review process. We have several different levels that have to go and be approved through our editorial panel process before it finally winds up as being in the final product. So it's not just a one-step-and-you're-done type of situation. This is done intentionally, okay? We have received some criticism that it's slow, but it's slow for a reason, because we want to make sure that we get it done accurately. So after we get a proposal that's presented to our editorial panel for approval, we make a judgment call, and this is a preliminary step, if you will, as to whether or not we believe that that proposal has enough scientific merit to be looked at and actually to be then further down the road for consideration. We then go through a rather extensive comment period, and we accept and encourage public comments from a variety of different stakeholders that are involved in the process. We have a methodology where the AMA contacts the various different state medical associations. They also contact the various specialty service societies, and that contact is not just one-and-done. It's a multiple-contact thing to encourage feedback with regards to the proposal that's been presented. We don't just stop with physician organizations, though. We also ask for allied health input, again, a very important part of the stakeholder process. Within the concept of looking at the musculoskeletal chapters, yes, we ask for chiropractic input. Don't shoot me, okay? But understand that in certain jurisdictions, chiropractors are allowed to do these examinations, right? So it's one of those things that we felt we had to entertain. Other ancillary organizations, physical therapists, occupational therapists, speech therapists, those are just examples of other groups who have provided comments to us. We also want to make sure that we include in that group, in the public comment period, any organization that touches the workers' compensation process. This includes administrators. This includes insurance companies. This includes lawyers. This includes judges. All of these different stakeholder groups have input in this situation, and it's very important to make sure that we have a wide swath of information that we are getting. We are not so blind as the editorial panel to think that the only input here that's important is from physicians, okay? Once that happens, the panel then looks at the various different comments, and we react to them, okay? Some comments are great, important, and need to be implemented, and that leads to various different updates, editorials made, changes made to the proposal. We oftentimes will send that back to the proposal group and say, hey, this is the comment that we've received. We need to have this updated. We need to have this changed. Some comments are not relevant, and that's great. You might think, you know, okay, well, what do we do with those? Well, we acknowledge and thank the commenter, but then we go back and we explain why, although we appreciate that comment, it really isn't appropriate to the change that we're talking about. So it's not just a one-way street. That's the point that I'm trying to make. There's a lot of ebb and flow, back and forth communication with the folks that are giving us these comments, because what we're trying to do is we're trying to create that document, and as Ken indicated, that's the best and fair and equitable that we can provide. Once that give and take has happened, and the edits have been made, then it goes back to the panel for formal approval and adoption, okay? So another step in the process that has to occur before it's ready to be put out there, and then we have a cadence that we typically try to follow for publication. Now, a little bit about that. We all recognize, right, as Ken has indicated, how often the impairment ratings are done from an organ system perspective. Clearly, the majority of the ratings are done for musculoskeletal conditions. Early on in the process, when we started to accept proposal changes for upper extremity, lower extremity, and spine, we determined as a panel that it was important to march those three things in cadence going forward. It would, for example, make no sense to publish an update to the upper extremity and then wait some two or three years later to do the lower extremity. Why? Because the methodology and the update is going to be exactly the same across those three chapters. The concepts are similar, the methodologies of looking at the diagnoses are similar, the classification system determination is similar, the grade determination is similar, and so forth, okay? So that was a conscious decision that was made. Doug, if I could jump in for a question. Anyone here do radios in California? Just a couple, just a few. Think about it, the impact it will have if upper and lower extremity are aligned as compared to the California rulings on use the four corners of the book. For those folks who don't know California, in California you can basically use any chapter of the guides to evaluate any body part, depending upon what the attorney is directing the doctor to evaluate to get the rating they're looking for. But now, with the new upper and lower being aligned, you won't see that as an issue as well. The other thing I'd mention as far as cadence and timing, yeah, the AMA is a publisher, and we try like publishers to stick on deadlines, but with the guides, the docs rule. We had targeted releasing guides content, what, a little over a year ago, and the docs turned to us and said, ah, it's not ready for prime time, we have to get it more fine-tuned, and they want to get it right, and get it right the first time. So we decided it was better to delay publishing, per the guidance of our physician advisory panel, Dr. Martin and the others, to get it right, and it'll be released within the next few months. Very good. Okay, so to give you some idea of the work that has been done by the editorial panel up until now, if you're not aware, the sixth edition book version was published back in 2008. Our editorial advisory panel was formed at the end of 2019. The first proposal that we entertained were changes to the mental and behavioral health chapter, which is chapter 14, and that was important, because it had nomenclature in it that no longer was relevant or in existence. The next thing that we dealt with were some changes to the foundations and principles chapters, which are the first two chapters of the guides, and that was completed in 22. Then the, I would say probably the first big change, if you want to think of it that way, occurred with the nervous system last year, and that was intentional, and dare I say, was sort of a banner carrier thing of mine, personally. As you probably are aware, in the sixth edition, the nervous system chapter was basically just a regurgitation of what was in the fifth edition, and although some people would say, well, what's the matter with that? We used to have a very difficult problem in the nervous system chapter with inter-rater reliability. The reason for that is is because under the methodology, you would probably be able to assign the proper class of impairment rating, but the numerical value that you would choose for that particular class was given to you in a range, with no instructions on how to pick a specific number. So, for example, you may have had a neurological condition that was a class one problem, and the guides' sixth edition 2008 printing would have told you, Mr. Dr. Rater, you have the ability to assign 10 to 25% whole person impairment for that condition, but would give you no clear guidance on which number to pick, okay? That's obviously a problem, because if I rated that individual and I said 10%, the doctor in the front row here said I rated that person, and I think it's 25%, and then you get into a legal system and somebody asks you the question, who is right? The answer under the old book is both of them. That doesn't work very well, especially in jurisdictions whose benefits hinge on a specific threshold, okay? Not to belabor the example, but one such state that I do ratings for, which is North Dakota, a threshold of 16% whole person impairment. If you're below that, regular indemnity benefits. If you're above that, a whole additional host of benefits kicks into the system. So obviously, when we're using the sixth edition, it's very important to figure out whether the 10 versus our other doctor's 25 is actually the one that is going to be accepted. As Ken indicated, and as I've indicated, we have 2024, later in the year, slated, hopefully, for adoption of the three musculoskeletal systems. Okay, so a little bit more information to share with you. Some specific changes about the mental and behavioral health chapter. The old printed version referenced DSM-IV. Obviously, we're not there anymore, so we had to move to DSM-V terminology and methodology. The old book version used the Global Assessment of Function or GAF scores as one of the three items that was assessed that led you to the impairment rating. And guess what? The American Psychiatric and Psychological Associations eliminated the GAF from their particular recommendations because they felt it was no longer representative or valid. So this became a problem, okay? So basically, what we had to do is we had to get rid of the GAF, and now the recommendation after the revision of the chapter is simply to use two methodologies as opposed to three in order to figure out the impairment rating. Those two methodologies are the brief psychiatric rating scale and the psychiatric impairment rating scale. So now, we don't take three different scales and look at that, we only have two different scales, and that's the way the methodology currently exists. As far as the updates that were made in 2022, again, I referenced that it was focused on the introductory chapters. This change did not lead to any changes in the impairment rating numbers, but it simply updated the language that described the new evidence-based editorial process and let everybody know about how the updates to the guides would occur into the future, right? And it also emphasized that documentation of the evidence and standards that are used to determine the impairment rating should be included in the impairment rating report. That's a fancy way of saying you have to show your work to get credit, okay? We'll take you back to elementary school, maybe that's not a great example. Let's talk about ninth grade algebra, right? Your ninth grade algebra teacher might have given you some credit if you got the right answer, but if you didn't show your work, you didn't get full credit. Same concept here, okay? This brings us to the reason that you're here today, and that is to talk about some of the updates to the musculoskeletal chapters, okay. Oh, I forgot about some updates to the ENT and some updates to the upper extremity. One of the things that I do want to mention that has been sort of a focus of attention, if you are knowledgeable about the sixth edition book version that was published in 2008, you'll know that one of the major changes was to the spine impairment rating systems, which got rid of range of motion methodology, okay? For the upper extremity and the lower extremity in the 2008 print version, it gave you an option, right? Diagnosis-based impairment method or range of motion method, okay? As more research has come in, we have also now found that range of motion is suspect for both the upper and lower extremity approaches just like we used the research to change that for spine in the 2008 edition. So, we had language that was added to de-emphasize range of motion-based impairments in upper and lower extremities and focus more on the diagnosis-based impairment methodology, okay. Other changes to the neurology chapter in addition to trying to eliminate this inner rater reliability problem, how did we do that? We went to assigning a grade system to the classes in the neurology chapter similar to how it's done in other sections of the guides, okay, so now in the updates to the neurology chapter, instead of having that range of 10 to 25% and saying, well, go figure it out yourself, we give you specific instructions at how to come up with a grade, right? Three grade system, which is another thing we'll talk about in a minute, but that individual grade has a specific number of impairment that you are going to use or assign. So now, when the doctor and I used to disagree between 10 and 25%, if we use the new chapter, we are probably going to agree that it's 16 or maybe it's 18, okay. So, no longer do we have this inner rater reliability issue. Why did we go from a five grade system to a three grade system? We get this question all the time. In the book version, we always had this process where we had a baseline or grade C impairment value for any particular diagnosis-based condition and we would apply the grade modifiers to that to adjust the grade. We had three grade modifiers before, one for functional history, one for physical exam, one for clinical studies. I always thought, and many others thought, how do you make a diagnosis? I don't know where you went to medical school, but where I went, which was Nebraska, I was taught to make a diagnosis by doing what? Taking a history, doing a physical examination, and using relevant clinical studies. So why should that be modifiers to a diagnostic process? Okay. So, what we did is we got rid of that philosophy and we went to a three grade system which is now based more just on the outcome of the individual from that particular perspective of their diagnosis. Now we include other things like burden of treatment and compliance, okay? And we have moved from the concept of having the grade C being the baseline value now to the grade A being the baseline value, grade B being a little worse outcome, grade C being a pretty significant outcome. Okay? So that's the thought and the process. And that particular movement from the grade process of going from five options to three options is going to be consistent, not only for the musculoskeletal chapters, but also for further changes to other chapters as well. It's no question that moving from a five grade system to a three grade system also improves inter-rater reliability which we've already talked about. That was an issue before. So, when we talk about fair, we talk about equitable, we talk about consistency of the impairment rating, this should all help in those processes. Okay? Clarify the burden of treatment compliance. Okay, so for example, any particular condition or diagnosis, what does that individual have to do from a medical perspective to maintain stability? Is there a burden of medications? Is there a burden of other medical things that the person has to do? Maybe this is an issue of an adaptive device. Maybe it's a prosthetic. Maybe it's a medication that they have to continue to take for the rest of their lives that have risks that are associated with it, or needs to have continuous monitoring of some sort. That's an example of a thing that we mean by burden of treatment compliance. Okay? All right, so, a lot of people ask the question, how is the sausage actually made? Okay? Understand that the goal here, right, is to enhance the science of the impairment evaluation. We have as a baseline that 2008 information from the published book, right? The Delphi method, which is the one that we adopt, requires a process of going back and forth at this level to review, develop, get feedback, analyze, go back and forth, back and forth, back and forth among subject matter experts about comments from the public, and making sure that those things are massaged so that everybody's input has been taken into consideration and that the eventual outcome is as evidence-based as possible. Once that occurs, then we ask for consensus of the group, right? That consensus, again, is by the editorial panel. Again, I've told you about what the makeup is, right? And that consensus-driven process eventually is the one that leads to the final product. All right, now, there are some key things that is important for you to understand in the development of these new musculoskeletal recommendations. Consistency is the driver here, okay? We wanted to make sure that the methodology between all three of those different musculoskeletal chapters was consistent, not only in the language of the written book, right? And then the process that would be the same, right? So regardless of whether it is an elbow problem or an ankle problem, the basic process would be the same. We used the existing sixth edition impairment values as our basis for any of those changes. So rumors that you might have heard like, oh, these new processes are going to drop impairment ratings by 50%. That's a bunch of hoo-ha, okay? I don't know where these things get started, but they do. That is not the case. We're not in the business of trying to slash impairment rating values for diagnosis. That's not what this is about, okay? We try, again, not to eliminate the history, the physical exam, or the clinical studies, but to focus on how consistent that is with regards to any particular diagnosis that we're using. In other words, when you're rating somebody for a particular diagnosis, the idea now is is to look at the history, conduct the physical, look at the clinical studies, and ask the question, is this a typical outcome for this particular diagnosis? If the answer to that is yes, that basically defines it at the grade A level. If they're a little worse, maybe that's grade B. If they're significantly worse, that's grade C. All right, now, the other thing about this is is that the ability to reference sections and tables will be significantly improved. One of the criticisms of the 2008 version is, is we have this diagnosis-based table. Then we got another table for grade modifier functional history. Then we got a different table for grade modifier physical exam. We got a third table for clinical studies. And there's a lot of this having to flip back and forth from pages to page, to table to table, and figure out how this is done. What does that do? All that does is lead to error. So instead of having four different tables to look at now for each diagnosis, we're gonna give you just one. And all of that incorporated information on functional history, physical exam, and clinical studies, you're only gonna have to look at one table and figure it out once. Doesn't that sound a lot better? I think so. You can ask all the questions you want, John. All right, so that was a debate, and that made Ken jump out of his seat. So Ken's got the proverbial answer for this. I've got the answer for that. If we were to come out with guide seven, it means every state would have to go to adopt guide seven, because it's got a different nomenclature, a different meaning to it. By going to the same guide six, and calling guide six 2024, the same way we did in the 2023 update, it saves the states the heavy lift of going through that. And this wasn't us manipulating in any way, shape, or form. We went after diagnosis regulators not in their heads. Because if we, you know, went to the states, this lift's revealed, we're gonna have to approve it anyway. But if you're renaming it, promulgation costs them anywhere from three months to two years, and you took anywhere from tens of thousands to hundreds of thousands of dollars to actually go through the process. All right, so again, just to review what the evaluation process is going to look at, we're gonna give you instructions at the beginning. That's not changed, right? We're gonna lead you to come up with a diagnosis, and the impairment's gonna be based on that diagnosis. We're gonna give you instructions on how to perform that impairment rating. The concepts of combining impairments and using conversions from, for example, upper extremity to whole person, that's not changed, that's the same. We're gonna drive you to these DBI, or diagnosis-based impairment tables, again, only have to look at one table now, not four different ones to come up with the final number. We have a section that is devoted still to peripheral nerves so that process is gonna be improved as well. No more modifiers to that. It's all gonna be in one table, easier to use. We've got other things that we have to deal with sometimes in the extremity like crypts, vascular issues, amputation, major trauma. Again, please understand we are going to de-emphasize range of motion in the upper and lower extremity chapter similar to what it already has been for spine. Just so everybody understands the process. Here's the step process. Confirm the diagnosis, establish MMI. That stuff's not changed. Determine the appropriate DBI table. That's the same. Determining the class is the same. Determining the grade, different method, still the process. Document the impairment value, document it in your report. If you have to convert that to regional level because of your jurisdiction, we will give you instructions on how to do that. So for example, if your jurisdiction doesn't deal with lower extremity impairments for a foot injury and they want that expressed in term of foot impairment, we will give you information on how to accomplish that. So again, just to review the highlights, we are going to a three grade system from a five grade system. As I said, ground aid will be the foundational or starting or typically normal grade that you will be looking at. You won't have to go back and forth between many different tables. It'll all be in one table. And again, I want to reemphasize, despite rumors that you may have heard otherwise, the impairment range values from the 2008 6th edition will be used as a guide based on the diagnosis. Can reference that there are some research papers that are in the pipeline of being published. One of those is going to be published in the Journal of Occupational Environmental Medicine very soon. I don't know exactly the date, but I know that very soon is accurate. All right. More, go ahead Ken, yep. Thank you. The process of the class establishment really is not changing. As part of the transition from five to three grades, we're not doing much of anything with the class system, right? Class zero is still going to represent that asymptomatic state where there's no impact on ADLs. That has not changed. Class one through four, if you want to think of it in terms of moving from a mild to a moderate to a severe to a very severe situation, you can still think of it that way. Having said that, I will tell you that there's a conscious effort to get away from using those subjective terms, mild, moderate, severe, very severe, that, oh, by the way, in previous editions the guys were never defined, and looking at it from a more objective perspective. So I have a couple examples here to demonstrate the process now. This is probably not what the final table is going to look like, so don't get all wonky if you look at it and say, geez, this doesn't look right. This is for illustration purposes only, all right? We have upper extremity condition. What is it? Healed, right? Soft tissue or skin injury that is dealing with a digit, and we are specifically dealing here with a tip injury, right? What's the definition of the diagnosis? Healed, right? Preventing nail abnormalities that involve greater than 50% of a nail secondary to trauma, residual distal pulp loss, or retained foreign body greater than three millimeter. Isn't that a lot more specific than what currently exists? Yes. What you'll find in the sixth edition currently, there's no reference to the 50%, there's no reference to the distal phalanx, there's no reference to a value on the size of the foreign body. So we're trying to drill this down, again, inter-rater reliability being the driver. So how would have this been approached in the previous sixth edition 2018 version? We may have had five different grades to consider. We may have had, this is just for example purposes, five different impairment rating numbers of the digit to consider, all right? This is the way that it used to look like, this is the way that it's going to now look like with the changes. We're going to give you the definitions, we're going to give you specific information clinically that's going to include the history, the physical, the clinical studies to allow you to put that person in either a grade A, a grade B, or a grade C, three different numbers to choose from, okay? Those three different numbers might be, again, don't kill the messenger, but you see how they were defined in the previous version? That means that grade A now might be eight, grade B now might be nine, grade C now might be ten. Okay? All right. Does everybody understand what the difference is here? Okay, so, for example, okay, we're going to tell you physical exam and clinical studies, if it's consistent with the diagnosis, right, that might be the basis for grade A. If we have additional things that make it look a little worse, that would be grade B. Really bad outcomes, okay, that might be C. All right? Pretty straightforward, right? So for example, if we have a situation that puts us in class 1A, we go into that table, again, only one table, right, and we know immediately what those values are going to be. Is it going to be seven, is it going to be eight, is it going to be ten? If we have a different example that's class 2A or 2B or 2C, we know exactly that that's going to be 16, 18, 22. We don't have to mess around with net adjustment formulas, taking the algebraic sum of the modifiers for physical exam, clinical studies, functional history. We no longer have to remember the rule that if the grade modifier for functional history differs by two or more from that of the clinical studies and physical exam, that it's invalid and gets thrown out. We don't have to remember any of that stuff. We just got to go to the table. You had a question? It's going to be clinical history, residual symptoms. See where it goes? Okay. So we're going to give you descriptors of what the typical symptoms for the diagnosis might be. Does that make sense? Yeah, because the reason why I was asking the question is, I do work as a comp in New York State. God bless you. The range of motion is, what ends up happening is, the clinical history of the diagnosis is going to be the same. It's going to be the same. I understand, okay, so we're not proposing with these changes that we disallow impairment ratings which currently exist in the 2008 version for your scenario that oftentimes leads to a one or two percent whole person rating. Now we can sit here and debate whether that's correct or incorrect, but there is a small, usually it's one percent, sometimes two, impairment rating that can be done for individuals who have a normal exam but say I hurt. Impairment ratings can't be used in New York. The AMA apparently does, right? I said, correct. I said, but if the impairment drivers are grading impairment, which is functional use as opposed to disability, and I'm going to get into that in a bit for this one. Here's the concept. Is it an impairment, if somebody does an impairment rating as a soft rating to measure progress, to document changes in impairment, It's sort of an outside-of-the-box way of thinking about it, right, but ... ... to potentially use those methodologies to physically evaluate the body part. And think of this as physicians. If you're seeing a patient and you're in a state where the ALJ is going to make a decision whether they're authorized or not authorized for treatment, if you can give the substantiation that's not just subjective, but objectively measured, your treatment is going to get authorized. As opposed to denied, which means better outcome, better the doctor for the service of the docs, but better for the patient. The quicker we can get them moving on, the less hassles in the process of getting authorizations, the better the outcome is going to be. I get a little passionate. This is the implementation plan that we have at the AMA. So there you go, Ken. And I'm conscious that we have seven minutes, so I'll go fairly quickly. I'll speak in New York speed. I have a time of 24 weeks with visions. As Dr. Martin said, that's evidence, that's science. We encourage you to join us on the panel. We're going to have a webinar for August 8th. I'll work with the organization here to see how we can get messaging out to everybody. And potentially through Wal-Mart. Not Wal-Mart, excuse me. Through ACOG. Jurisdictional review and adoption process is state-specific, training is state-specific. We'll help, but we can't do physical training. We have a definite, definite need nationwide for qualified physicians and caretakers. And it's not just for retirees. Adoption at the beginning of your... to squeeze the time in, have the ability to talk to a few representatives, but think about it. There are alternative ways to use it. We need the raters, and there's a strong demand. States will be doing individual training. The AMA is preparing for training direct. These are just a list of public comment. We are fully transparent, which is not the case in prior versions, but there's full transparency in this. And now we have educational modules. Again, we're not allowed to train. I'm here for any advocacy and adoptions. As I said many times, you are what we represent. We want to remove the obstacles, we want to lead the charge, and we want to drive medicine to the future. We want you to get involved if you will. And if you reach out to myself or anyone on our team, we'll help connect you. If you want to be national. If you know the stuff, and you get to the point where you can train others, that positions you as an expert in your market, which will then encourage... That being said, remember who your constituents are. We've got the physicians, the patients, the regular, the slaves. As far as it matters. With that, we have four minutes left for questions. We'll put up at the end there. Hopefully this has been informative. So, yes. course is the post-conference course on this on Thursday. If you're at all interested, there's still time to register. Dr. Seymour. Yes, thank you. So first, full disclosure, I was paid an ordinate amount of money to come here and hassle Doug. Two cents, two cents. But first, first thing actually, by your applause, who loves Doug's jacket tie and matching shoes? And then finally, we know there are people who will misuse and abuse the standards to increase percentages. No, we never see that. Could you sort of give us some things that we can look out for when we're seeing someone else's review that might tip us off that that's going on? Yes, so Dr. Seymour has expressed one of the things that I get involved in a lot and that's reviewing other raters reports and providing criticism and critiques. One of the things that are some tip-offs that perhaps the process has not been done correctly, incomplete physical exam is probably one of the bigger things in the musculoskeletal process as far as, you know, just typical things. Okay, measuring strength, measuring range of motion correctly. You know, there are certain things in the guides that still maintain, you know, validity, importance, information, like doing three trials of the range of motion to make sure that they're valid and that they're reproducible. I oftentimes do not see that. People will forget some of the weird rules that are involved. I mentioned one with regards to the grade modifier functional history. You know, if that's not valid, you don't include it in the rating process. Other things that I see are misapplication of appropriate diagnoses. One of the classic ones that I will tell you that remains an issue in my three-state jurisdiction is the distal clavicle excision that is done for rotator cuff disease. In the sixth edition, I mean, I don't know how much we can be more clear that that's not given a resection arthroplasty rating. Okay, it's incidental to the diagnosis. The diagnosis is rotator cuff tear, partial tear impingement syndrome, whatever. Okay, so just not understanding things. I would tell you that another pitfall that I see a lot in reports are people in their reports will say, well, this person is at MMI, but they're going to need medial branch blocks, chiropractic care, all kinds of additional things. Well, no. I mean, that's not the definition of maximum medical improvement. So, you know, if you don't think they're at MMI, you shouldn't be giving the rating. If you do think that they're at MMI, you shouldn't be making recommendations for service of care. So that's just a clear misunderstanding of the concept of MMI, which is one of those basic things that the rater should know. Yes, sir. Quick question. When you go to all electronic version, will all your prior versions, including all the sixth edition versions, also be on that electronic platform? You get the whole enchilada. I want a tamale, too. Yeah, okay. We'll give you that, too. The question is, is how is this going to go over in Washington State? I used to teach in Washington for Labor and Industries frequently, and as you know, it's a hybrid system between fifth edition and their state way of doing some things like spying and some other stuff. I think it's going to go quite well. I don't know. Ken has probably better insight on that that I do, but I think it's going to go quite well. All right, very good. Well, thanks very much for your attendance. Have a good evening. Thank you.

AMA Guides for Evaluation of Permanent Impairment

2024 edition

musculoskeletal chapter changes

impairment ratings

objective assessments

inter-rater reliability

physicians

stakeholders

medical evidence

consistency