The American Medical Association (AMA) has gone digital with its updates to the sixth edition of the
AMA Guides to the Evaluation of Permanent Impairment (AMA Guides). This article examines the potential impact of recent updates on workers compensation (WC) indemnity costs.
Introduction
The
AMA Guides are the most widely used basis for determining impairment ratings in state WC systems. The National Council on Compensation Insurance (NCCI) monitors updates to the
AMA Guides that may impact WC costs. In addition to WC, the
AMA Guides are a resource for federal systems, automobile casualty, and personal injury cases.1
Permanent partial disability (PPD) benefit costs comprise approximately 15%2 of total benefits, on average, in states where NCCI provides ratemaking services. However, this proportion may vary significantly by state. Many jurisdictions use the AMA Guides to determine impairment ratings, which in turn are often a starting point in determining PPD benefit costs, although state statutes or regulations may differ as to which edition to use and how it is to be used.
There are a few states that not only require the use of the
AMA Guides, Sixth Edition, in determining impairment ratings but also have provisions in place so users rely on the most recent version after it becomes effective. The statutes are nuanced, but such states include Alaska, Illinois, Louisiana, New Mexico, Tennessee, and Wyoming.
Prior to the
AMA Guides, Sixth Edition, going digital in 2021, the last update was in December 2007 (it bore “2008” in its title). The update from the fifth to sixth edition had several major changes impacting impairment ratings,3 with numerous states ultimately adopting the sixth edition.
The 2021 and 2022 Updates to the AMA Guides, Sixth Edition
With the shift to digital, the AMA has changed the way it will update the
AMA Guides going forward. The
AMA Guides, Sixth Edition 2021, which became effective July 1, 2021, represents the first update to the AMA Guides since 2007. Going forward, the
AMA Guides, Sixth Edition, will be exclusively online and accessible by subscription only. Effective January 1, 2022, the AMA considers the
AMA Guides, Sixth Edition 2022, to be the most current version.4 The AMA expects that the next version will be available online in 2023.
Summary and Analysis of the AMA Guides, Sixth Edition 2021
While there were several changes included in the update from the
AMA Guides, Sixth Edition 2008, to the
AMA Guides, Sixth Edition 2021, the only significant content and methodology changes were for mental and behavioral disorders (M&BD).5 These changes, which aimed to provide clarification and updated terminology around mental and behavioral health concepts to improve interrater reliability, included:
- Updating terminology and methodology from the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) to the
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),6
- Newer editions of assessment tools and tests, and
- Elimination of the Global Assessment of Functioning (GAF) from impairment rating methods in Chapter 14 (“Mental and Behavioral Health”).
As described above, the
AMA Guides are used to determine WC impairment ratings in many states. However, the impact of the updates in the
AMA Guides, Sixth Edition 2021, would be limited to impairment ratings for mental injuries.7
The
AMA Guides, Sixth Edition 2021, adopted the terminology, criteria, and special features of the DSM-5. With the adoption of the DSM-5, the multiaxial system8 is no longer considered in mental health diagnoses.
When assessing the possible impact of the change from the DSM-IV-TR to the DSM-5, one field trial9 compared the prevalence of various mental illnesses between the two editions. This trial found there was a small decrease in prevalence between the DSM-IV-TR clinical screening diagnoses and the DSM-5 prevalence estimates. A small but significant decrease was noted for single sites studying schizophrenia, major depression, generalized anxiety disorder, post-traumatic stress disorder (PTSD), major neurocognitive disorder, borderline personality disorder, and bipolar II disorder. Another study,10 which focused on PTSD, concluded that the impact on prevalence from the switch to the DSM-5 is inconclusive. It should also be noted that the sample populations for both studies11 may or may not have been representative of WC claimants.
The elimination of the multiaxial system from the
AMA Guides, Sixth Edition 2021, could also impact impairment ratings for mental injuries. In the
AMA Guides, Sixth Edition 2008, the M&BD impairment rating was based on the median of three scales: the Brief Psychiatric Rating Scale (BPRS), the GAF, and the Psychiatric Impairment Rating Scale (PIRS). However, for the
AMA Guides, Sixth Edition 2021, the M&BD impairment rating is based on the mean (average) of the BPRS and PIRS.
The AMA’s 2021 Summary of Updates5 provided several examples of impairment ratings under both systems, with most examples unaffected by the methodology change. While the one example involving PTSD saw a change in the calculated impairment rating from 10% to 13%, this example was meant only to be illustrative.12
Overall, in the states using the
AMA Guides, Sixth Edition, to determine impairment, the direction and magnitude of the cost impact to the WC system associated with the updates included in the
AMA Guides, Sixth Edition 2021, is uncertain:
- Any impact on the WC impairment and disability ratings for mental injuries is unclear at this time
- The degree to which potential changes to indemnity costs offset or reinforce each other is uncertain
Other Considerations Related to the AMA Guides, Sixth Edition 2021 Update
There may be uncertainty as to how the change from the DSM-IV-TR to the DSM-5 for mental behavior and diagnosis will be interpreted and administered in a particular state, and to what extent and how quickly these changes will impact PPD benefits for mental injuries. The administrative, judicial, and regulatory environments across the states may affect the overall impact of adopting the
AMA Guides, Sixth Edition 2021, as well as the potential variability of impairment ratings amongst medical practitioners. The time frame in which physician practices will reflect a comprehensive understanding and accurate application of
AMA Guides, Sixth Edition 2021, and the extent to which impairment ratings will differ from current ratings, cannot be determined until implementation and application outcomes can be observed.
Summary of the AMA Guides, Sixth Edition 2022 Update
The 2022 updates were mostly administrative and editorial in nature. Per the AMA’s Summary of Updates, there were no changes to impairment ratings or methodology.13 As such, if a state were to move from the 2021 to the 2022 edition, there would be no expected impact on WC indemnity costs.
Concluding Remarks
Overall, a state’s adoption of the 2021 updates may impact overall WC system costs, although both the direction and magnitude of the potential impacts are uncertain. The 2022 updates are not expected to impact WC indemnity costs.
Going forward, the
AMA Guides, Sixth Edition, is expected to have annual electronic updates. These updates will not impact prior editions of the
AMA Guides. The AMA “has created the
AMA Guides Editorial Panel as a transparent process in which a broad spectrum of relevant professionals can consider, vet, and determine whether, when, and how the
Guides should be improved, enhanced, or revised.”14 In addition, it will deliver timely enhancements to the
AMA Guides that reflect current evidence-based medical practice.15
Editorial meetings that are open to the public will be held to discuss proposed changes to the
AMA Guides, Sixth Edition. Some topics being considered in future annual content updates are the inclusion of functional patient-reported outcome measures, or fPROMs, and changes to how impairment ratings are determined for tinnitus, spinal injuries, and neurological injuries.
NCCI will continue to monitor the annual electronic updates to the
AMA Guides, Sixth Edition, and how they may impact WC costs.
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