november 2021 extra

  • AMA Guides Updates 2021 & 2022 - Background

Dr. Maggie Cook-Shimanek called a meeting of interested parties regarding the potential of adopting the 2021 revisions and potentially the 2022 revisions to the 6th Edition of the AMA Guides to Impairment and Disability (the Guides) on Friday November 12.

Earlier this year, Dr. Cook-Shimanek arranged for a briefing session with the AMA to go through the changes. At that September 22 meeting, the AMA went through the changes they had proposed to the 2008 6th Edition of the Guides, shared that it is their intention to update the Guides on an annual basis and to make them available only through an electronic subscription service. Up to this point, the Guides had been published in hard-copy. Since that meeting the 2022 revisions to the Guides have been drafted.

I arranged for MSIA members to have access to the actual changes in the Guides language as a result of the updates. That access may have been terminated by the AMA at this point. However, here is the link to a layman’s explanation of the 2021 and the 2022 updates.

The Guides are used in over 44 states in one form or another as the primary base for identifying impairment ratings within those states’ workers’ compensation systems.

At this most recent meeting of Montana stakeholders individual medical providers, the Montana Medical Association, AFL-CIO, MSIA, MCCF, MSF and others from ERD attended. We had been asked to be prepared to discuss the following questions, as sent out prior to the meeting by Dr. Cook-Shimanek:

1.      Your perspective on how the recent and proposed updates to the AMA Guides will impact workers’ compensation in Montana – in terms of the updated medical content, magnitude of impairment ratings, or other factors.

2.      The advantages and disadvantages of a subscription-based approach to the AMA Guides and the associated fee as compared to the 2008 hard copy current version.

3.      The Department’s assessment that legislative change would be necessary to implement the 2021 version of the AMA Guides to the Evaluation of Permanent Impairment, based on review of MCA 39-71-711.

4.      Next steps.

MSIA Meeting Wednesday 11/10 to Identify Our Position

MSIA members met on Wednesday November 10 to discuss our potential response to the questions. All members were invited and we had a good turn-out as well as some emailed perspectives on the changes. We determined at that meeting the law likely required a change to adopt anything other than the 6th Edition as published in 2008 (there have not been any updates until this year). We also adopted the general position that the system is best served by the most current evidence-based medical thinking available.

Claims management members shared the nightmare we would incur in changing the Guides every year. We would have to deal with the different injury dates and applicable law, different impairment rating dates and having to constantly confirm each claim/injury referenced the correct version of the Guides. Those are just the simple issues we would have to address. We were also operating under the impression that the medical providers we work with in the system would support a desire to have the most current evidenced-based medical thinking as the basis for impairment ratings, and importantly, that these updates represented those changes. 

MT Meeting on Friday 11/12

Remember what “assume” means? We were wrong. The physicians at the meeting could not identify any significant changes to the practice of medicine in these 2021 or 2022 revisions of the Guides.

Those providers who participated in the meeting were Dr. Petrisko of the Billings Clinic, Drs. Owens and Schwertz of the Billings Clinic in Bozeman and Dr. Schumpert with REOH in Missoula. They all agreed:

o  there is no new medical thinking of significance in these proposed changes they could identify;

o  they found use of the subscription service clunky, clumsy and difficult;

o  the subscription service created additional annual costs for (currently) no discernable benefit (and would likely increase over time);

o  the references and tables are difficult to find and, if there is a calculator to help determine different aspects of an impairment rating, it is difficult to find – if it exists

o  the subscription service system does not provide for bookmarking, note making within the system and is difficult if not impossible to share with injured workers and others as the current hard-copy is (they shared that a “show and tell” with injured workers is very important in explaining impairment ratings); 

Dr. Petrisko offered that it seemed to take about four times as long as using the book to arrive at an impairment rating. Dr. Schumpert went so far as to reference the updates appeared to be a marketing effort by the AMA to generate more fees by charging $275 per year for an updated subscription service. In contrast he claimed a used copy of the current book could be purchased for $100. He went further in identifying the subscription service requires internet access - which many of the places physicians work from during off hours do not have. (Think about heading to your cabin to get away from everything and review notes and dictate findings). 

The group could not identify benefits to injured workers or the workers’ compensation system these two revisions provided. Certainly if none could be identified, there was no desire to make any changes.

There was some discussion of the potential of the update from the DMS-IV to DSM-V as being potentially significant, but no one on the call had enough information about the changes in the psychological practices to adequately address the question. Dr. Cook-Shimanek reported eight states had already adopted the changes; I shared the basis for those changes were specific statutory language requiring adoption of the most recent revisions of the Guides.

Next Steps

Dr. Cook-Shimanek will contact the AMA and IAIABC (the state WC regulators association) to see what kind of experience other states may have had with the new revisions of the Guides and what kind of input and response they have had from their medical communities.

Cook-Shimanek will also check with some Montana psych providers to see if they feel there is a significant difference in the DSM-IV versus the DSM-V, which may be the only significant medical change in the revisions.

I will work with the National Council of Self Insurers for the same kind of feedback – if any – those who manage claims and work with physicians creating impairment ratings might have.

At this time, there does not appear to be any interest in pursuing a change in the edition of the AMA Guides the Montana workers’ compensation system references.

As things continue to progress, I will keep you updated.