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| | California Is On The Brink Of Adopting The AMA Guides, Sixth Edition
By Jorge Alexandria - October 16, 2013
A lot of people, especially the California Applicants Attorney Association (CAAA), dislike the 6th Edition of the AMA Guides for the Evaluation of Permanent Impairment (hereafter referred to as the AMA Guides) for a whole lot of reasons. Chief among them is because almost all ratings under the 6th Edition (published December 2008) are lower than they are under the 5th Edition (published in November 2000). For those of you that are new to claims adjusting, the AMA Guides are used by several state workers' compensation systems as a way to determine permanent impairment and quantify the seriousness of injuries. The lower the rating the less money an injured worker receives. Conversely, the higher the rating the greater the compensation will be.
The current trend in the United States, and internationally (i.e. Canada, Australia, Netherlands, Hong Kong, New Zealand, South Korea and South Africa), is towards adopting the 6th Edition of the AMA Guides as the gatekeeper to receipt of permanent disability benefits. Now California seems to be on the brink of adopting the use of the 6th Edition of the Guides in spite of California’s Labor Code section 4660(b)(1) which specifically mandates use of the 5th Edition.
Allow me to explain. A recent Workers’ Compensation Appeals Board (WCAB) decision (dated 8/29/13), in a denied petition for reconsideration in the case of Edward Frazier v. State of California Department of Corrections (CDCR), permitted the agreed medical examiner (AME) to assign a whole person impairment using the 6th Edition of the AMA Guides.
Edward Frazier filed a claim against the CDCR (California Department of Corrections & Rehabilitation) alleging injuries to his cardiovascular circulatory system on a cumulative trauma basis through 7/06/10. Dr. Jonathan Ng, the internal medicine AME, in his maximum medical improvement report assigned a whole person impairment of 24% using the 6th Edition of the Guides.
The Claimant argued that under the criteria for rating cardiovascular disease under the 5th Edition of the AMA Guides would require nothing less than a 30% whole person impairment rating. Dr. Ng opined that if he assigned a 30% impairment it would not be an accurate representation of Mr. Frazier’s impairment.
The appellate WCAB agreed with Dr. Ng and stated, “The physician should be free to acknowledge his or her reliance on standard text or recent research data as a basis for his or her medical conclusions, and the Workers’ Compensation Judge should be permitted to hear that evidence”. The 6th Edition AMA Guides is a standard text and certainly provides more recent research data than the 5th Edition, setting the stage for those that contend that the 5th Edition is outdated and that the 6th Edition is better.
The undersigned has used both the 5th and 6th Editions of the Guides and I can attest that the 6th Edition is the more conservative of the two. In fact when rating certain body parts, under the 6th Edition it produces a rather low and to some, unrealistic rating that is not on par with an injured worker’s true level of disability. Using the case illustrated above, the 6th Edition disregards the comments made in the 5th Edition in regards to how serious and disabling heart disease and hypertension can be. Each successive edition of the Guides, starting with number 1, seems to reduce the whole person impairment rating with little explanation. This is a dangerous trend for injured workers. The latest [6th] edition of the Guides accelerates this decline. The most egregious take-away is the deprecation of pain as a factor in impairment ratings. The pain add-ons in the 5th Edition are no longer permitted in the 6th Edition. A pain add-on, according to this perspective, is double dipping. Other examples of rating reductions in the 6th Edition include but are not limited to the following:
• 15-9, region: elbow, class: 1, diagnosis: distal biceps tendon rupture, Sixth Edition impairment (WPI%): 4% Fifth Edition impairment (WPI%): 6%
• 15-12, region: Shoulder, class: 2, diagnosis: total shoulder arthroplasty, Sixth Edition impairment (WPI%) 13% Fifth Edition impairment (WPI%): 14%
• 16-5, class: 3 diagnosis: ankle arthritis, Sixth Edition impairment (WPI%) 10% Fifth Edition impairment (WPI%) 12%
• 16-6, class: 5 diagnosis: s/p total ankle replacement with poor result, Sixth Edition impairment (WPI%)24% Fifth Edition impairment (WPI%) 30%
• 16-11, class: 3 diagnosis: s/p Total knee replacement, Sixth Edition impairment (WPI%) 15% Fifth Edition impairment (WPI%) 20%
• 16-15, class: 3, diagnosis: hip fracture, Sixth Edition impairment (WPI%) 12%, Fifth Edition impairment (WPI%) 25%
• 17-3, region: cervical, class: 1, diagnosis: Intervertebral disk herniation or AOMSI at a single level (status posted herniated nucleus pulposus and anterior cervical diskectomy and fusion at C5-6 with intermittent left arm pain, Sixth Edition impairment (WPI%): 7%, Fifth Edition impairment (WPI%): 25%
• 17-4, region: cervical intervertebral disk herniation or AOMSI at a single level (cervical disk herniation with C8 radiculopathy), Sixth Edition impairment (WPI%): 12%, Fifth Edition impairment(WPI%): 18%
The biggest irony in all of this is that the editors of the AMA Guides (all editions) caution the user not to use the Guides as a stand-alone measure of disability but that is precisely what adjusters and attorneys do.
The process for developing the 6th Edition was driven by an Editorial Panel and an Advisory Committee. Perhaps the Advisory Committee will develop a 7th edition so whenever a party is displeased with the results of the 6th edition, the 7th edition can be deemed “recent research” and used to rate the impairment instead. Then they can develop an 8th Edition and so on. At $210 a book and an endless adjuster/attorney pool, it’s a good business to be in.
Jorge Alexandría
Jorge Alexandría is a U.S. Army veteran who received his B.A. in Political Science from Cal State Los Angeles, and graduated from Cal Poly Pomona with a Master’s in Public Administration.
He holds both a California Workers Compensation Claims Professional (WCCP) designation and the State of California’s Self-Insured Administrator’s License. He has more than 20 years of experience in claims handling, supervision, and risk management.
He currently practices federal workers’ compensation of maritime interest.
He can be reached at Riskletter@mail.com. The views and knowledge expressed in this article are Jorge Alexandría’s alone.
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