Evaluation of impairment, disabilty, and workers’ compensation

1

Distinguish between impairment, disability, and handicap.

An impairment is the “deviation of an anatomic structure, physiologic function, intellectual capability, or emotional status from that which the individual possessed prior to an alteration in those structures or functions or from that expected from population norms.” (1)

A disability is the “inability to complete a specific task successfully that the individual was previously capable of completing or that most members of a society are capable of completing owing to a medical or psychological deviation from prior health status or from the status expected of most members of a society.” (1) In other words, a disability is the inability to perform a specified task because of an impairment.

An impaired individual is considered to have a handicap if there are obstacles to accomplishing life’s basic activities that can be overcome only by compensating in some way for the effects of the impairment. In this context, a handicap represents an impairment that is mitigated by the use of an assistive device or a task modification that allows an individual with an impairment to complete a task.

An example contrasting impairment and disability serves well. Consider a person who sustains a cervical fracture with spinal cord compromise. There is loss of motor and sensory function in the upper and lower extremities with bowel/bladder dysfunction. That person has an impairment, or a deviation from normal anatomy and function. If the person were an accountant, this medical impairment may not translate into disability, and therefore not impact normal travel and work duties. On the other hand, if the person were a professional basketball player, the same medical impairment creates total disability. Thus, disability is task specific, whereas impairment merely reflects an alteration from normal body functions. Furthermore, the accountant may be considered to have a handicap, because they use a wheelchair, assistive equipment, and a specialized van to travel to work.

2

What is an impairment evaluation?

An impairment evaluation is a medical evaluation that aims to define, describe, and measure the differences in a particular person compared with either the average person (e.g., an IQ of 86 compared with the expected average of 100), or that person’s prior capability (e.g., a preinjury IQ of 134 compared with the current level of 100). Such differences may take the form of anatomic deviations (e.g., amputations), physical abnormalities (e.g., decreased ROM of a joint, decreased strength surrounding that joint, or abnormal neurologic input), physiologic abnormalities (e.g., diminished ability to breathe, electrical conduction disturbances in the heart), or psychological (e.g., diminished ability to think, reason, or remember).

3

Who performs an impairment evaluation?

Impairment evaluations should be performed only by professionals with a medical background. Doctors of medicine and osteopathy are the logical choices. Other professionals, including chiropractic doctors, dentists, optometrists, psychologists, and physical therapists, also possess such training and background and often perform impairment evaluations. Further, an impairment evaluation should be performed only by professionals qualified by training or experience to assess the organ system that needs evaluation. Ideally, a neurologist should evaluate neurologic impairment, not cardiac impairment. However, many specialties cross boundaries so that an occupational medicine specialist or physiatrist can also evaluate orthopedic impairment, not just orthopedic surgeons.

4

How does an impairment evaluation differ from a standard history and physical examination?

Several important differences are seen when these types of examinations are contrasted: the goal of the evaluation is different, the patient may be defined differently, and the opportunity for reevaluation is limited in impairment examinations.

The goal of an impairment evaluation is to define deviations from normalcy. Having or arriving at a specific diagnosis or diagnoses is helpful. However, a specific diagnosis is not the end result in an impairment evaluation, unlike in the standard history and physical examination. Both evaluations require an appropriate educational background, skill, thoroughness, and dedication. In a standard history and physical examination, there is a doctor-patient relationship and the physician attempts to diagnose and determine any required treatment. In an impairment examination, the evaluator determines and quantifies deviations in the examinee’s health status and does not enter into an active doctor-patient relationship.

The results of the standard history and physical belong to the person being evaluated (although not always, as in the case of a child). The results of an impairment evaluation are usually provided to the requesting source, such as an attorney, insurance company, or governmental agency (e.g., workers’ compensation boards or the Social Security Department). This point raises an interesting legal concept. Physicians are not allowed to disclose medical information to anyone but the patient. To whom does such confidentiality apply in an impairment evaluation? Usually it exists between the physician and the referring agency or party, as opposed to the person evaluated.

Another basic difference is that the impairment evaluation report focuses on and addresses the questions asked by the referring party. For example, if the physician is asked to evaluate a person for a specific injury, such as an amputation or dysfunction of an arm, the entire evaluation focuses on the arm. The end result is a report that describes the injury, the differences in the function of the injured arm from a normal person’s arm (or the individual’s arm function prior to the injury), and provides a prognosis for future recovery. This information is then used by other parties to determine appropriate compensation. Other diagnoses discovered during the evaluation may be irrelevant. Other issues, such as causation, apportionment, and diagnostic or therapeutic recommendations, may or may not be desired. If these issues are not requested, they are not included in the report.

Lastly, impairment evaluations are generally limited to a single encounter with the examinee.

5

How does a disability evaluation differ from an impairment evaluation?

A disability results from a medical impairment that precludes a specific task. Generally, during a disability evaluation, that task will be the examinee’s job. A disability evaluation is comprehensive and based on various factors. One of these factors is the medical impairment. Other factors may include a person’s age, educational background, intellectual capabilities, and social factors. Such elements are used by the system to which the worker has applied for relief. For example, a person whose right arm has been amputated may be capable of entering the work force in some other capacity. If the person is young enough, smart enough, and sufficiently motivated, he or she may be capable of performing remunerative activities in some other job market. The referring agency uses such factors when determining whether a person is totally or partially disabled and which benefits are applicable. Thus in a disability evaluation, the physician must not only identify and quantify the impairment but address additional issues such as:

• What tasks is the examinee capable of performing?

• Can the examinee attend work?

• Are job modifications an option?

• When will the examinee reach maximum medical improvement (MMI)?

6

Define what is meant by causation and identify criteria used to determine causality in relation to the evaluation of impairment.

Causation refers to the legal or administrative system determination of the cause or causes of the injury or illness that has resulted in a temporary or permanent impairment. (2) According to the American Medical Association Guides to the Evaluation of Permanent Impairment, Sixth Edition (3), causality requires determination that each of the following has occurred to a reasonable degree of medical certainty:

• A causal event

• The patient experiencing the event has the condition (e.g., impairment)

• The event could cause the condition

• The event caused or materially contributed to the condition within medical probability

Reasonable degree of medical certainty is generally interpreted in the setting of an impairment evaluation to mean that 50% or more of the evidence supports the determination of causality (i.e., “more probable than not” or “more likely than not” standard). If evidence is less than 50%, the degree of probability of an event’s occurrence is merely a possibility, and does not establish causality.

7

What is the definition of apportionment?

Apportionment means that something is divided based on a specific issue. Causation can be apportioned. For example, if a person has arthritis in his knee, how much of the arthritic changes were caused by occupation, age, and prior meniscectomy? An impairment rating can be apportioned. If a person has a rating of 12% impairment because of a herniated disc with radiculopathy and low back pain, and also had three separate injuries to the same body area, how much of that impairment was caused by the first, second, or third injury? Treatment costs can be apportioned to both the old and the new injuries, and different employers. Most jurisdictions have their own rules as to whether apportionment is used and in which circumstances. A great deal of skill and expertise is needed for an examiner to apportion an individual’s current condition to all the causative factors, including the normal aging process.

8

Distinguish between exacerbation and aggravation of a prior condition.

An exacerbation is a temporary worsening of a prior condition by an injury or illness, with an expectation that the condition will eventually return to baseline. An example of an exacerbation is a temporary increase in symptoms based on increased activity. This contrasts with an aggravation, which describes a permanent worsening of a prior condition by a specific event or exposure. This distinction may have important legal consequences. For example, if a work injury aggravates a preexisting condition, the employer may become responsible for both the second injury and the preexisting condition.

9

What is meant by maximum medical improvement, and permanent and stationary status?

The concept of MMI, when used in impairment evaluations, means that a person’s condition has achieved a state where no further substantial improvement is anticipated with time and/or additional treatment. Treatment may include medications, surgery, physical therapy, or other types of rehabilitation. Most impairment systems require that the person achieve MMI before a final impairment rating can be given. This rating is used as a basis for the final disability settlement. Note that this concept does not consider whether the individual will worsen with time. Further, the concept of MMI usually allows for an individual to accept further treatment (with MMI determined after an appropriate recovery time following that treatment) or to decline further treatment (in which case they have attained MMI). In other words, an individual may decline treatment that might mitigate the current level of impairment (as well as the impairment rating).

The concept of permanent and stationary (P&S) is generally synonymous with the concept of MMI. Legally, the terms are the same in the state of California. Other similar terms vary by state and statute, and include “medical stability,” “medically stationary,” “medical stabilization,” “fixed and stable,” and “of healing.”

10

List some of the major compensation systems which provide economic and other benefits to claimants who experience work incapacity due to injury, illness, or aging in the united states.

Major compensation systems in the United States include:

• Social Security Administration system

• Federal and state workers’ compensation systems

• Veterans Benefits Administration

• Personal injury claims

• Private disability systems (e.g., long-term disability insurance purchased through employer)