AMA Using More Open Process to Update Impairment Guides

Dr. Douglas Martin practices occupational medicine in Sioux City, Iowa. To evaluate the level of impairment for workers’ compensation claimants from his home state, he must use the fifth edition of the American Medical Association’s Guides to the Evaluation of Permanent Impairment.

But he also sees patients from across the Missouri River in Nebraska, which uses the sixth edition of the AMA Guides; and nearby South Dakota, which uses the fourth edition.

Martin is co-chairman of the AMA Guides editorial panel. He’d like to see all of the states on the same page to ensure that injured workers with the same level of disability aren’t rated differently depending on where they live.

“It’s difficult to explain to the patient and difficult to explain to an attorney,” he said. “That doesn’t make sense.”

The AMA has revamped the way it revises its impairment rating guides in an effort to persuade all of the parties involved in workers’ compensation — doctors, attorneys and regulators — to agree on a common methodology for rating the degree of impairment according to the best scientific evidence available. Revisions included in an update that took effect July 1 were the first changes to the guides since 2008.

For the first time, the AMA is allowing non-physicians to serve as advisors to the editorial panel. The panel is also holding regular public meetings to hear comments from interested parties about proposed revisions to the guides, much like the rulemaking process used by government regulatory agencies.

“In previous editions of the guides, it was left up to a bunch of physician editors to do the work,” Martin said. “It was published, and that was that. We felt there needed to be much more robust stakeholder involvement.”

Martin said a 2017 decision by the Pennsylvania Supreme Court that barred use of the AMA Guides Sixth edition to evaluate injured workers was part of the impetus to create a more open process. In Protz v. WCAB, the court ruled that state lawmakers had inappropriately delegated a legislative function to a private organization.

Martin said the AMA is also mindful of criticism by claimants’ attorneys that the sixth edition slashed benefits for injured workers by reducing impairment ratings for numerous types of injuries. He said the new update process gives attorneys an opportunity to point out deficiencies and propose changes.

The AMA adopted the more transparent update process in 2019 and used it while drafting the most recent updates.

The editorial panel made significant changes to the Mental and Behavioral Health chapter. Some of the more notable changes were elimination of the use of the Global Assessment of Functioning as an impairment rating method and adoption of the 5th edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Dr. Steven Feinberg, an editorial panel member who practices pain medicine in Palo Alto, California, said the latest revisions were made during a rigorous two-year process. He said the panel held monthly video meetings to discuss proposed changes and hear input from interested stakeholders.

“It was a lot of hard work,” he said.

Feinberg said the most controversial change was elimination of the GAF scale for rating psychiatric injuries, not because the methodology had many proponents but because it is relatively simple to use. The new psychiatric impairment rating method in the AME Guides Sixth 2021 uses an average of scores using the Brief Psychiatric Rating Scale and the Psychiatric Impairment Rating Scale.

Feinberg said the editorial panel had hoped to make many other changes, but ran of time. He said a deliberative process that entails making proposals, hearing public input and then revising those proposals to reflect a consensus of opinion is time consuming.

Martin said the editorial panel had 13 years of new medical knowledge to evaluate since the last revision. He said further updates will take some time.

“The process is very deliberative,” he said. “Some people say it may be slow. We want to make sure we do it right.”