RateFast Podcast: Almaraz-Guzman: Your Opinion Matters

Dr. John Alchemy outlines the Almaraz/Guzman II ruling in respects to California workers’ compensation, detailing when it should be applied, how it should be applied, and why it’s so important for both physicians and injured workers.

If you’re a workers’ compensation provider, or are interested in getting started with workers’ compensation, check out our product, RateFast Workers’ Compensation Software Suite, as well as RateFast Express 3 Day Impairment Rating service.

Transcription of Podcast:

Cory Oleson (Host): Welcome to the California Work Comp Report Podcast. It’s Thursday, March 11, 2021. Today we speak with Dr. John Alchemy about the Almaraz/Guzman decision and how it applies to California workers compensation cases.

Today we are discussing Almaraz/Guzman and the Almaraz/Guzman law and how it applies to workers comp claims in California. Again this is your host, Cory Oleson, here with the other host – I don’t know about host, or co-host, what is what, but – I am here with Dr. John Alchemy. How are you, John?

Dr. John Alchemy: Doing well, Cory, how are you doing?

Cory: Doing good, doing good. Yeah so if I understand Almaraz/Guzman correctly, in California the way I would describe it, as a non workers comp professional, who’s reading into this, it’s essentially a law that allows for workers comp physicians and professionals to give an impairment rating that is different from the rating that is calculated based on the AMA guides. So if you do a calculation for the impairment based off the AMA guides, and you determine that your patient has 3% whole person impairment in a certain body part, but you as the physician, the professional who’s basically seen the patient through the course of the claim, you think it might be more than that, or even less than that, then you would therefore invoke Almaraz/Guzman. Am I understanding that correctly, John?

Dr. John Alchemy: Yeah, the Almaraz/Guzman dates back to around 2009, when there were a couple of cases that came up and basically the doctors who were doing the ratings thought that the chapter rating, or the “four corners” as they refer to it, and I like to point out that the AMA guides actually has eight corners on it, but we call it four corners. But within those four or eight corners there are chapter ratings and you follow the directions and you get a rating value.

And these particular doctors in these particular cases decided that the ratings should be higher, or more than what the standard AMA guides did. And remember, the AMA guides in California came in around 2005 into existence, and these didn’t come around until 2009. Which is a little bit amazing to me because really, what took so long, for this whole idea to come up and get formalized? But that’s probably another story. But that’s right. So the doctor does not think that the book gives the injured worker enough impairment.

Cory: Just leading off with this, because the outcome of the Almaraz/Guzman case kind of reminds me of a quote from a film made by a very large film company, it’s a film about some pirates. And when questioned about the code of pirates, the captain of one of the ships says “those are more like guidelines.”

And I think about the AMA guides as it relates to this case because that’s kind of what’s been determined with the Almaraz/Guzman is one of the strict measures of the AMA guides is that this rating is law, but as you said and as it’s sort of apparent, you can’t really confine the infinitesimal things that can happen in a work comp case to what it says in this book. And the fact that it took four years to implement that is kind of crazy. So the AMA guides – we’ve discussed this before, but it must have slipped my mind – were invented around 2004, 2005, did California have its own rule set before that or was it a former version of the AMA guides it was working off of?

Dr. John Alchemy: No they did, and some states still do, have their own rules for creating disability injuries and work comp injuries, and California had its own, and it went bases on pain, and frequency, and the objective findings, and functional loss, as far as work restrictions and things like that. That for the most part has kind of been phased out, we don’t do those ratings unless it’s under extremely special circumstances, if there’s an original claim that needs to be revisited. But most of our claims are issued over to the AMA guides.

And getting back to the Almaraz/Guzman, the Almaraz/Guzman really addresses two flavors of situations and I think it’s good for the listeners to understand this. One is, when the rating value simply doesn’t match the patient’s functional loss, that’s one of them.

And the other one if you reads some of the determinations, the other application for it is when you’re trying to do conditions that the AMA guides simply do not list. It’s not a rate-able condition. It’s under those two situations that Almarz/Guzman comes into play for the most part, in my experience from what I’ve seen and reviews I’ve done, it’s usually been that the doctor for some reason doesn’t feel like the AMA guides fifth addition rating is an accurate rating of the individual’s loss. That’s usually what it is, 9 times out of 10.

Cory: And as we’ve discussed before, the fifth addition isn’t even the most recent version of the AMA guides, so it’s an inevitability that as the field of medicine evolves, and that will certainly be intertwined with the law, and Almaraz/Guzman is essentially an inevitability, as far as it looks, based off that. So now as a work comp physician, if you run into a case where you need to, I’m using the word “invoke” – I’m not even sure if that’s the proper wording for it, but what is involved in doing so? Do you have to alert the insurer that you’re doing so? Do you have to give a special section of the report that outlines that? What does it look like?

Dr. John Alchemy: Yeah, so, if you look at the Almaraz/Guzman, the doctors really have instructions to do four steps. The first step is, you have to do the standard rating before anything else. So you do the rating. And then you have to make some type of argument, or comment, or statement, as to why this strict rating does not apply to the individual. So it doesn’t apply because of a, b, or c.

Next, you then have to provide an analysis about what your alternative rating is going to be. Something different. And then the fourth thing that you have to do is explain how you got there. And this, as a physician this is one of the more frustrating aspects of the Almaraz/Guzman, is that they’ve given us this tool or this option, but it’s not a very good tool, because there are no instructions on how to do it.

Whenever you set up a rule with no clear instructions, you’re gonna get ten different people trying to approach it ten different ways. And to me the most disappointing Almaraz/Guzman is when the doctor writes, “In my medical opinion, of twenty years as a blah blah blah, I think it should be seventeen instead of six.” And that to me is not really any type of explanation as to why you’re picking that number. But you see that if you look at reports, and maybe they get approved, maybe they don’t. But so far that is the most disappointing one.

Now the classic one is when the doctor says their patient has problems with their back. So if I do the strict rating, it’s 6%. But I know that for instance let’s just say I know they can’t do heavy lifting. So then they go off into the hernia chapter. They say hey look, if you had a hernia, and you can’t do any heavy lifting, you get a WPI of X, therefore my patient with a back injury that can’t do heavy lifting, must have a rating of at least X. And you know that’s come up and I think it’s been played and accepted, but the point is you want to stay focused on the actual body part and the chapter where that body part is supposed to be rated. And kind of do your thinking, and your conceptualizing in that chapter. Because you don’t want to start wandering around and having that number in mind, and then you’re just looking for an explanation for it. That’s what they don’t want, and I totally get that and I totally agree with it. So you want to stay in the chapter where the body part resides because those are all of the critical elements that pertain to that body part if that makes sense. So that’s another thing you’re going to read about. They’re going to ask why you went out of the chapter and ecetera, ecetera.

Again, since we weren’t really given any instructions on how to do this, you’re going to get all kinds of responses. So it makes it frustrating, it makes it very open ended, and in some ways, it makes it a little contentious. Because everyone’s right. If you’re going to pick a number different than what the book tells you, that’s going to be open to interpretation and criticism. Which is fine. We’ve gotta have some discussions about things in order to move the ball forward.

Cory: There’s no way to improve without criticism.

Dr. John Alchemy: Absolutely. So that does come up and it’s commonly contested and I think that people see opportunities from all sides as why or why not the Almaraz/Guzman would be best for their client and their case.

Cory: It’s kind of funny how these sorts of things work, when you introduce something into the law that’s supposed to make it in favor of the possibility that things will even out, and things aren’t so strictly adhering to these laws, as the science behind medicine evolves and new things come to light. And it does introduce by way of that, things get a little more complicated.

Now you had mentioned that it’s probably best practice for doctors to stay within the chapters that they’re working with and everything and I can’t help but imagine that even when all of those bases are covered, when an insurance adjuster sees the Almaraz/Guzman thing, that it just sort of, like we said, increases the likelihood of confusion overall, or is it more of a case that’s understood now that it’s law, you know, it flies by a little easier. Or does it always complicate things more when Almaraz/Guzman is used?

Dr. John Alchemy: I think it’s seen as a red flag for parties when they look at the report and see an Almaraz/Guzman being used because they think, what are we missing? What are we looking for in the report? Where’s the bright line in here that caused this to be triggered? And then the next thing is, I’m going to have to see if they can sell me on this or not, essentially is what it comes down to.

Cory: The Almaraz/Guzman was a decision of two separate cases and it was actually in the Guzman case that the person that brought the final impairment rating of the case, wasn’t really in alignment with what the actual impairment may be, was introduced actually in AME. It was the person who you bring on to double check everything said, this doesn’t match up. It is the second opinion that is saying this is outside of the guide. So I think that’s sort of a win in a way, because you don’t have an AME jump on the case unless there is contention or it’s something that needs to be examined by another medical professional.

Dr. John Alchemy: Yeah I mean, the AMEs come in for multiple reasons. But to check the ratings, all these things, they’re used a second check. And sort of a little bit of personal comment here – unfortunately, I think that the marketplace has seen some of the AMEs and QMEs have a better or more complete or more expertise in impairment ratings, and I’ve said this on previous podcasts, it’s absolutely not true. These QMEs and AMEs have no tests in competency in AMA writing any more than the primary treating physician. Nor is there any requirement by the state to show any competency in writing impairment ratings.

So unfortunately I think this has just kind of become folklore to some people. To think well I am getting a QME rating, it’s going to be better than the one my primary treater is giving me. And it’s absolutely not true. I’m wandering a little bit off topic, but we have to remember the Almaraz/Guzman came up during an AME exam way back when, and they’ve visited Almaraz/Guzman multiple times, I think we’re on version three right now, V3.0 or something, so it gets a little bit more consideration and refinement. But the main things we’re talking about here really haven’t changed.

Cory: Okay so, there’s a little bit more refinement until the next person has an issue, and then it goes back to court, until the end of time.

Dr. John Alchemy: Yep, you’re right, run through it again, and see what types of things can be fine tuned on it.

Cory: I mean, that’s built into bureaucracy as we know it. As soon as you get bored with one thing, you bring up another.

So yeah, this was a thing that I was wondering, as you’ve mentioned, you are a very busy person, and there were a few years there in between before they implementation of the AMA guides and Almaraz Guzman, and it makes me wonder, there are states that are still using the third addition of the AMA guides, things like that. And it makes me wonder if those types of protection are in place for people in other states. And the inevitability that they’ve been using the AMA guides for much longer and if people have any sort of protections out there. Now, like I said you’re a very busy person in that regard so I don’t know if you would know if other states have a similar thing or not.

Dr. John Alchemy: To be honest, I don’t know what alternative measures they have for assigning claim values in other states. But if you follow the AMA guides, and this was something I wanted to bring up as well in the talk, the AMA guides have provided this scenario like the Almaraz/Guzman but have stated it slightly different. And again it totally amazes me why it took so long for this to come up formally in the courts. When it was written in the AMA guide’s fifth addition off the press back in 2003 or whatever year it was originally published. But if you go to page five of the AMA guides fifth addition, it clearly defines what a 0% whole person impairment is for an individual. We’ve talked about this in some other podcasts, but it’s at the bottom of the page, left column. And just to paraphrase, it says “if you’re going to give someone a 0% whole person impairment rating, they cannot have any limitations in the performance of their activities of daily living.”

Cory: So they’re just as good walking out of the claim as they were right before they got into it.

Dr. John Alchemy: So the point is that the AMA guides knew there were situations where the function does not match the whole person impairment rating, which is simply a reflection of the function. But the AMA guides also fall short because it doesn’t say how to reconcile that. And this has been one of the great mysteries of worker’s comp and impairment rating for many years.

Now, when we created RateFast we came across this early on and decided we needed to come up with something that was analytic, objective, and reproducible. Again if you read the book you’re going to come away seeing that there are different grades of impairment purity. And the first one is the patient’s actual functional loss and documenting that. And then being able to come up with a chapter rating which the Almaraz/Guzman says you have to do. And then all it really comes down to is comparing two numbers. So if you know what someone’s functional impairment rating is, based on their pain, the frequency, their tolerance for activities, endurance of a particular ADL, and if you know what that impairment rating is and you know what the chapter rating is, it becomes a very simple exercise to know if someone comes in with the AMA guides on their rating.

But again the problem is that no one has ever really formalized that. And we’ve done that at RateFast for some time now. So all of our ratings get checked against the functional ratings. So if you get a back rating of 7, we do a functional rating on you, and we simply compare the two numbers. And on page 20 it says step two, everything needs to be within 10% of each other. So if the two numbers are within 10%, the “four corners” rating is good. You’re good to go. If your “four corners” rating is not within the 10% acceptable tolerance of the AMA guides, meaning that the functional rating is more than what the chapter has allowed you, then you use Almaraz/Guzman. And it’s very simple. Unfortunately not everyone uses RateFast or understands the level of detail or objectivity we’ve gone to. We’re hoping more stakeholders adopt it or think like we think.

Cory: We hope you do, we hope you make the decision!

Dr. John Alchemy: That’s right! What’s really interesting is once you set up the matrices on these and the thresholds, you can not only say when someone’s case is an Almaraz/Guzman, but you can also calculate what we call the overage. So we can say, this is 5% over the tolerance for the AMA guides chapter four corners, or 22% over. And then what we do is simply adjust the rating accordingly. And I personally have had very good luck while doing this. And for me personally, this is my opinion, body parts have maximal values. And they’re simply not going to be exceeded. Because the AMA guides have set up the upper bounds for the body part.

So let’s say your elbow. If you go to table 1618, page 499. You’re going to see that the value of the entire elbow is 42% whole person impairment. So to try to give someone an Almaraz/Guzman of 56% whole person impairment just doesn’t make any sense. Because if you’re trying to go above the maximum value, the amputation value if you will, really what are you doing? Why even have a book if we’re going to be going above the amputation value?

The book has given us boundaries of what the upper and lower body parts are, it’s in the chapter of the body part being considered. And you simply need to address it and scale it appropriately for what the maximal body part is. And I have never had any problems in depositions or discussions with the adjusters or patients, other doctors, using that method. Yet a lot of Almaraz/Guzman reports are meandering and they’re looking for a result that the doctor has in mind but maybe not sure how they’re going to support it or why they want to support it but they just feel like the number they have is too low. And sometimes that’s right, and sometimes it’s not.

It’s really interesting because once you start reading these reports, the numbers that are generated are 50, 60, 20, and they try to analogize them with something in the book that demonstrates an ADL that the table says you get for a certain impairment and you tie it to that. So it’s been a little frustrating for me with the Almaraz/Guzman to see a lot of this go on because it’s like guys, we should have figured this out a long time ago. And again this is my opinion, but we can’t have a system that says you can do something, but there are no instructions on how to do it at all. That’s where the Almaraz/Guzman really falls down in my opinion.

Cory: And that goes to show, as we mentioned earlier, you kind of complicate things when you introduce a new variable, with respects to the Almaraz/Guzman. But at the same time you are saying what has been defined needs to match up with the AMA guides and that is not contentious. It doesn’t exist to create complications, it’s just the fact that Almaraz/Guzman, as you extrapolate it to work comp law, it’s just a thing that doesn’t have the sort of documentation. It isn’t written down somewhere where someone can go and reference it and adequately perform for the claim. Again just pointing out inherent problems in the workers comp system. Now, it’s sort of our goal to take care of these things, so look out for a RateFast blog post clearly outlining Almaraz/Guzman in the most non confusing way possible.

One of the things that I’m thinking about right now is, I wonder if anybody is listening in, that is a physician, that wasn’t aware of Almaraz/Guzman. If they tell you about or not when you’re getting your work comp approval. But if you’re just finding out about this now, spin this one back and give it another listen. Because it’ll help your practice.

So, John, in depositions for RateFast users, how do you handle questions from attorneys regarding RateFast ratings that invoke Almaraz/Guzman?

Dr. John Alchemy: This Almaraz/Guzman comes up with standard ratings, too, and I did a deposition not long ago where the attorney was trying to understand how a whole person impairment skin condition was arrived at and how it was done. And I spent some time going through the basics, saying here’s how we bound things, here’s how we interpreted, weight averaging is basically the bread and butter of the AMA guides, it’s cited all over, between the two covers, and here’s how we do it. And the attorney seemed a little perplexed as to how we do it, and how this whole thing works. The attorney was able to grasp, and even understand and agree with the basic tenants that I outlined. You lay it out all nicely for them. And at the end of the day there’s still this inquisitional look over at me, like, why are you using RateFast?

Cory: Well first off, because I made it! Is what you could say.

Dr. John Alchemy: Well that’s the reason it was created. Because these ratings are complicated, numerically. And the answer I always give the attorney is when was the last time you balanced your checkbook manually? When was the last time? For me, the last time was probably 1993. That was the last time I sat down and balanced my checkbook. And I’m okay at math, but I would never get my checkbook to balance. It would take me three or four times, and the mistake was always mine. So the bigger question to the attorney in that particular situation is why would we ever depend on a doctor long handing it to try go figure out what someone’s impairment rating is when we have a system that has already done it? That’s why we have computers, and it’s why we have technology.

Cory: Well yeah, and if answer is that things are better done in a traditional sense, there’s nothing that’s being done in a more traditional sense. We live in a time where everything is different than it was five years ago. So I’m with you on that. There’s no reason one should be doing something by hand, especially in work comp, every stakeholder is occupied right now and even if the entirety of the system was automated, they would still be occupied. It almost seems like a profession in which every stakeholder is constantly catching up to the last thing that happened. So it’s absolutely necessary to use something such as RateFast as we highly recommend.

Dr. John Alchemy: You know and the bigger question is, why did I choose the inputs that I did for RateFast as opposed to why do I use RateFast? RateFast is a tool to improve accuracy and consistency with ratings. The bigger question is why did you choose a 5/10 pain and why did you say it was frequent and why did you say 7 ADLs were limited and only 4 were pain only? Those are the real questions that belong in the discussion and you just have a tool like RateFast because you want to make sure the outcomes are correct, if the inputs are correct.

So it’s the same old thing, garbage in, garbage out, if you’re looking for garbage in, have discussions about what’s going in, not why we’re using technology to achieve more accuracy and efficiency. I just don’t really think that’s much of a discussion, but some people get confused by it I think.

Cory: Yeah, it’s the attorney that walks to the courthouse instead of taking a car.

Dr. John Alchemy: And in the attorney’s defense, attorneys don’t go home as far as I know, and study the AMA guides. They need help learning those, and the doctors need help understanding the different work comp labor codes. Again, we did a great podcast on depositions not long ago. And again it’s just an opportunity to learn and teach each other and not get too contentious about it.

Cory: Absolutely. John, any final words on Almaraz/Guzman?

Dr. John Alchemy: Well, I’ll just recap again so we can all hear it again, but the Almaraz/Guzman was set up when the doctor believes that the injured worker has crossed beyond the threshold of what the AMA guides have provided the individual and when that happens the doctor has to first simply give the “four corners” rating whether that be 0 or some other number and then they have to give an alternative rating. Then they have to go on and explain why that alternative rating is a, valid and b, reasonable to fit the injured worker’s functional loss.

And I’ll close, and I try to say this in podcasts as much as I can, impairment rating is all about functional loss, and a whole person impairment is nothing more than a reflection and an accurate reflection of the functional loss. Those two things don’t always line up for whatever reason. Then you’re looking at this situation of the Almaraz/Guzman, but in the AMA guides it’s already understood that this comes up, so it’s already been thought up and put out there by the AMA guides. Unfortunately there hasn’t been a very good standardized system. And at the end I’ll give a pitch saying RateFast has made a very good attempt at standardizing function ratings to compare to the “four corners” and it’s just a standard part of every single rating we do. It’s just the bread and butter of the impairment rating and it’s just business as usual for us to calculate that.

Cory: We do it well, so you don’t have to.

Dr. John Alchemy: Indeed we do.

Cory: Well thanks again, John. And we will have a blog post pretty soon on Almaraz/Guzman, that outlines it really well. Hopefully we can make something that will be a nice companion to doing impairment ratings, and if you’re using this companion and it works out for you and you still find yourself spending a lot of time on it, and you think your time could be used otherwise, you can always use RateFast.

Thanks again, John. We will talk to you next time.

Dr. John Alchemy: Thanks, Cory.

Cory: For more information on the Almaraz/Guzman decision, as well as how it applies to RateFast and RateFast Express rating services, visit our blog at blog.rate-fast.com. And try RateFast Express today at ratefastexpress.com.

RateFast Podcast: Practical Advice for Depositions

Dr. Alchemy and Cory discuss what to expect as a work comp physician when being deposed by an attorney. This month’s podcast is filled with anecdotes, practical advice, and cautionary tales that you don’t wanna miss!

If you’re a workers’ compensation provider, or are interested in getting started with workers’ compensation, check out our product, RateFast Workers’ Compensation Software Suite, as well as RateFast Express 3 Day Impairment Rating service.

Transcription of Podcast:

Cory Oleson (Host): Welcome back to the California work comp report. Today is Tuesday, January 26, 2021 and the topic of today’s discussion is what the work comp physician should do when they receive a deposition. We go over some helpful tips and tricks as well as some examples of “good” and “not so good” interactions between doctors and attorneys. Without further ado, here we go.

 

We are back in the studio today. It’s me, Cory Oleson, and I’m here with Dr. John Alchemy. How are you, John?

 

Dr. John Alchemy: Hey, Cory! I’m doing great, how are you today?

 

Cory: I’m doing good. Today our topic is on depositions on impairment ratings and what to do when you, a work comp physician, gets a deposition from an attorney. And I guess we will lead off with why would an attorney give a deposition to a physician? And am I saying that right? Is the attorney giving the deposition to the physician?

 

Dr. John Alchemy: Indeed they do. And the person who is being deposed, the physician in this scenario, is called the deponent. So the deponent is being asked questions by the attorney and usually there are two attorneys there, one for the applicant and one from the defense. And sometimes there’s a third one there, and we will talk a little more about that in the podcast. 

 

Cory: And is it generally – I’m guessing that an attorney will come in and depose a physician when there is something about the claim that – isn’t necessarily suspicious – well I guess maybe suspicious. I guess if you have an attorney on the line there is probably something suspicious that needs to be very much clarified in the eyes of the law. 

 

Dr. John Alchemy: Well these depositions can come about for a variety of reasons. The most common one is to clarify the report that is served by the doctor and this can be a primary treating physician that gets deposed, it can be a qualifying medical evaluator, or an independent medical evaluator or whatever the equivalent is in whatever state.

 

But attorneys are usually deposing because there is an applicant and a defense, meaning the injured worker has become represented, the claim is getting to the point where it’s ready for settlement, they’ve likely  reached maximum medical improvement as they will in our scenario today, because we’re talking about impairment ratings, but they can also be called if there’s a question about causation. The doctor can say, hey there’s this condition of rheumatoid arthritis that was flared by the work environment, so it’s not like they’ve fallen down and hurt their back. That’s usually pretty straightforward. But sometimes the causation will be cause for deposition as well. 

 

Cory: I see. So, hi doc, this is the attorney, I was just curious because your client has rheumatoid arthritis in their hands and they only work with their feet. So things like that. 

 

Dr. John Alchemy: There you go!

 

Cory: Our “f” word – fraud! A lot of what they’re checking for. But not everything. 

 

Dr. John Alchemy: No, not everything. 

 

Cory: Okay. So you’re a physician. Or a physician gets the deposition. What kind of questions so the attorneys ask in the deposition?

 

Dr. John Alchemy: Well you know usually, they start out and it really depends who is asking the questions, and what they’re really looking for. Sometimes it’s just a fact finding mission. They’ll always open it up. It’s just like you’re in court, so you have to raise your right hand and say you’re going to tell the truth and you answer your questions. 

 

And they usually then want to go in and find a little bit about your credentials so they might ask you about where you went to residency, what specialty you do, maybe how many depositions you’ve done in the past. So they’re trying to get a feel of how seasoned you are, as a deponent and that will kind of set the tone of how much the process will get explained to you. So for instance if you’ve been in many depositions they may just say I’ll waive the details on my rights as a deponent, but if you’re brand new to it they’ll usually just walk you through it. It’s not contentious at that point.

 

Cory: Yeah, you’re not a nemesis of all parties or anything, it’s not a chess game. 

 

Dr. John Alchemy: Yeah. And most of the time to be clear, these are very straightforward depositions. People aren’t out to make each other look bad. It’s not a friction situation – although they can turn that way sometimes – for the most part they are just trying to get more information to fill in the blanks and hopefully come up with some better terms for settlement and agreeing on a settlement price. 

 

Cory: Definitely, definitely. So you have your general questions that the attorney will ask but then after those questions are out of the way, then you begin to get questions that are a bit more specific to the claim. What would those questions entail?

 

Dr. John Alchemy: Commonly they will start by asking how long you’ve known the patient and what the relationship is. Are you a primary treater, are you a QME, if you’re a QME how many times have you seen the patient, what’s your recollection of the last visit? They will commonly start asking questions about the providers or the doctor’s take on what kind of historian the patient is. Do they seem to be consistent with the information they’ve been providing you throughout the visits you’ve seen them? 

And your take on their level of sincerity and accuracy of the reporting they do to you as a doctor. Does their pain tend to make sense with what you’re finding on physical exams? What they’re telling you is consistent with what they can do at home and at work and those types of things. 

 

So it’s just sort of a little setting up of everything so everyone can understand. Maybe you’ve only seen this person once as a QME, or maybe you’ve been seeing them five years as their primary physician. They might ask questions like do they miss their appointments, are they punctual, how do they behave in the exam room? And those can obviously vary, like if you’re seeing someone for their back, the questions will be very different than someone who’s claiming post traumatic stress. There would obviously be a lot more behavioral questions around that. 

 

Cory: Of course, absolutely. Because most of the time all the insurance has to go off of the patient is what you put in your reports.

 

Dr. John Alchemy: Yes, that’s absolutely right. 

 

Cory: So what we’re very familiar with is that some of the data is inconsistent. And maybe part of that can be on the doctor for maybe being in a hurry or not understanding the AMA guides, maybe also received earnest or dubious information from the patient that just kind of slipped under the physician’s radar. And it could have just been the patient’s memory or something, that just flew under everyone else’s radar. But it’s the insurance’s job to catch that.

 

Dr. John Alchemy: Well there’s definitely all of that and there’s cases of information that the doctor isn’t aware of, like maybe the patient had a preexisting condition or risk factor that they didn’t think to tell you about. Or you didn’t think to ask. There’s some of that that goes on, too. All of these are preparatory questions to make sure everyone’s on the same playing field. And then we start digging into the impairment report which is our focus here today. 

 

Cory: Man it would be really nice if the physician and insurance adjuster and the injured patient could just go to the bar and get a beer and get to know each other. 

 

Dr. John Alchemy: I think that would bring its own set of issues. 

 

Cory: It really would. So with the wide variations of types of reports, like we’ve talked about before and even in our most recent episode, the specific language that doctors use – there’s going to be variation as to again – a very similar relationship between the patient and the adjuster – the relationship between the adjuster and the physician. The adjuster’s not going to call up the physician prior to the deposition and ask how well they know the guides. But that might be something that the attorney asks and is that something that they ask? And how does that go?

 

Dr. John Alchemy: Well it’s definitely a question that comes up, particularly when there is a disagreement about the impairment rating, which is frequently. And remember we’re at a table with three people. We have the deponent, the doctor, the applicant and the defense attorney. And it’s very likely that all three have different understanding of the AMA guides. 

 

So for instance the attorneys might be pretty familiar with multiple chapters in the AMA guides just because of the scopes of their practice and the types of injuries that they represent or defend against. And the doctor may be very narrow in his or her understanding of the AMA guides. Maybe they’re a spine surgeon or a hand doctor. So they’re not going to know about pulmonary function tests in the pulmonary chapter or rating vertigo, or the ear/nose/throat chapter. 

 

So everyone comes to the table with a very different background. And then there’s a little bit of question/answer about trying to figure out where we all are in our understanding of the AMA guides. There are sometimes some questions about California for example, they want to know if you know the labor code and so forth. Of course you usually do. I personally just like to, you know if I get asked that by an attorney, I politely just ask, well I’d like you to clarify for me your understanding on how to answer the question in the context of labor code. 

 

And so it’s more of an educational relationship than cross questioning – you don’t know this – so therefore your answer doesn’t count. We try to avoid that situation. So if you’re going to be asked a question in the context of labor code, it’s more than acceptable to ask the attorneys to clarify. And they don’t want this thing to drag out any longer than it has to. And they want to make sure they can get the most valid answers out of the deponent. Most of the time they’re going to do everything they can to make sure you understand labor codes. 

 

Cory: You know, I’m having a really hard time wrapping my mind around people having a disagreement regarding different interpretations of a standardized text. That’s sarcasm of course, it happens all the time. And that extends to all different subjects. It’s quite relevant to the news and things like that. 

 

Dr. John Alchemy: Well it’s a tall order. And the book is confusing. It’s not very well written.

 

Cory: Yeah, and then you have to learn a new version of it every couple years, depending on what the state decides to do.

 

Dr. John Alchemy: That’s right. But in general there is usually a little question and answer to get each other’s level of understanding of the AMA guides. And that usually takes about ten or fifteen minutes. 

 

Cory: Sure. I’m sure there’s some sort of ancient word for that sort of thing. And if I remember it by the next episode or if anyone knows it, feel free to email us at c.Oleson@rate-fast.com

 

Dr. John Alchemy: Bring it on.

 

Cory: We would love to get some listener mail or something! Ask a question, we will do a whole segment on the episode.

 

Dr. John Alchemy: We can make a whole podcast out of it if it’s a good one.

 

Cory: Oh yeah! So you’re here with the attorney and you’ve discussed your understanding of the AMA guides and now how do you, I guess, present the impairment rating to the attorney and how would you walk them through the process of how you did it?

 

Dr. John Alchemy: So the process of walking them through it, the way I do it and the way I recommend it’s done, is you basically start in the same order as your impairment report. So there’s usually an intake about the pain and symptoms and how the patient was asked those questions and how you scored their pain. And in some of the other podcasts we have talked about pain scoring and the process I use. 

 

But you want to start and talk about what the patient told you, and they said it’s 5 out of 10. And because it’s 5 out of 10 this is what it tells me about their ability to do things and how it impacts them. And then take them through the concept of frequency. So if they have a 5 out of 10 pain and it’s 50 percent of the time, walking down that and giving a brief overview of it. And if the attorneys have questions they will stop and ask those and get it clarified. Next, a big hurdle sometimes is activities of daily living. There’s usually a couple of stops in that section. 

 

They want to know how you came up with this or what the concepts are. And we’ve done some podcasts about activities of daily living and those are important to listen to if you’re a doctor and you’re doing work comp. Because those are probably the first and most important sections to show a solid understanding to the attorney, that you know what you’re talking about, you’ve done this before, you didn’t guess at these numbers. 

 

The stuff you wrote down was not an estimate, it was what your medical opinion is and what you’re standing by in the report going into this. And the basis of the impairment rating and the adjustments that they will be asked about later. So it’s really important in this foundation that you’re getting that pain and the ADL out there and you make it clear to them that this is a systematic approach and this is not something you just threw together, threw a dart at the board and came up with a number.

 

Cory: And if you’re a work comp doctor, and you don’t feel comfortable about the activities of daily living, first off, get comfortable with them.

 

Dr. John Alchemy: Get really comfortable with them.

 

Cory: And boy do we have good news for you. Just go to our blog! If you never went to a day of medical school, you’ll probably still know ADLs like the back of your hand if you spend an hour on our blog at blog.rate-fast.com. So now the attorney has an understanding of your process and we’re all on the same page with the AMA guides, they’ve given you the questions so they know how you do it and they know your relationship with the client. So now you’ve walked them through the report. So do they go back to their office and then the Jeopardy music starts playing and then you see what happens at that point? What’s usually next?

 

Dr. John Alchemy: The next step is moving into the physical exam. And here’s really where I see a lot of gaps in the understanding of attorneys in these depositions because the AMA guides have a very specific way and a very specific level of detail that measurements are supposed to be obtained and organized. What that data set looks like to validate. 

 

So for instance if you’re doing a wrist you want measurements on the other side, you want at least two measurements, but the attorneys don’t always understand that. They may have read it in the AMA guides but they’ve never actually seen it in practice. Or maybe they don’t stop to think that all the measurements on the wrist end in 0 and 5 and maybe they aren’t actual measurements and maybe they are visual estimates. And they are obviously supposed to be actual measurements. So it’s very rare if ever that you find the perfect data set in an impairment report. And that’s okay as long as it’s disclaimed and understood by everyone that the numbers we’re looking at may not be perfectly brought down from the mountain and here’s how they were done. And here’s how I interpreted them for the ratings. 

 

So when you’re going through the ratings and when I’m listening to the types of questions that attorneys are asking when we’re moving through the physical exam, it tells me a lot about their understanding, their overview and their grasp on the actual – what I call the “rateable data set” in the report. Because in the report, there’s so much stuff that’s sort of there, and I don’t want to say it’s window dressing, but it’s stuff you’re doing in the exam that really doesn’t have anything to do with the impairment report or the whole person impairment value at the end of the day. So when you’re dealing with someone who knows their stuff, they’re going to zero in on the errors or incompleteness of the data that should be there but it’s not. 

 

So for instance if you’re doing a wrist, someone who has a really strong grasp on the AMA guides may say hey, I see you got some x-rays here that you ordered, I noticed that they’re not clenched fist. Meaning that the patient has x-rays taken when they’re making a firm grasp, because that can reveal gaps in the bones that aren’t there when you just take a normal hand x-ray. And that’s one of the pieces of rating for a wrist rating, is a clenched fist x-ray. But you don’t know to look for that unless you know it should be there before you look at the report.

 

Cory: Absolutely. 

 

Dr. John Alchemy: So there are all these little things. Like I said, everyone has a different level of organization and understanding. But as you move further through the report, it becomes very clear who at the table has a good understanding of the impairment report and who does not. 

 

And we will talk a little bit about that at the conclusion because when the discussion starts, that’s really the time you want to start walking through them through some of the finer details of the impairment report impairment rating. Because remember that initially when people look at an impairment report, and it can be an attorney, a doctor, an adjuster, a patient – they have an emotional relationship with that whole person’s impairment. This is too high, this is too low, this is wrong, this is right. And when you get to the end of this discussion, you want to be able to tell them that this number that we have before us is not too high, not too low, it is the exact rating that this individual deserves. Because there are a lot of little offshoot questions about all these things that start to swirl. But if you can walk them through how you got to this particular number and why it was chosen, it really tends to abort a lot of that horse-trading that can go on at the end of these depositions. 

 

Cory: You need to walk with confidence in it. And have this stuff in your impairment report, you can’t just fake it until you make it with the impairment report. But yeah, definitely, because it’s naive to think these things are emotionless interactions. There is going to be somebody who takes the lead and that’s going to be the person as you said with the most knowledge in the subject. 

 

Just curious, does it reflect – say you’re a physician that gets deposed, and you have the meeting where you walk the attorney through and you walk all parties through, I mean you just demonstrate yourself to be the he who knows about the AMA guides and everything. Are you then less likely to be deposed in the future, because the adjuster has in their notes that you are legit? 

 

Dr. John Alchemy: Yeah, you’ll be recognized for your level of impairment rating and then of course for your ability to do depositions and your reputation will become known depending on how long you’ve been in business with different law firms and so forth. How well you know your stuff, how well you depose and how accurate your reports are at the end of the deposition. One thing I will caution doctors listening to this, if you haven’t done depositions in the past, one of the most dangerous things you can do is come in with the attitude of “my impairment rating is perfect.” 

 

Because that is not going to set a good tone or build any collegiality for the deposition. You don’t want this to be adversarial, although certainly I’ve been in some where the one is less than friendly. But for the most part you want to appear that this is my humble opinion, this is the way I did it, this is how I organized it. If there’s a mistake then own up to it, if there’s a mistake then own up to it, if you misinterpreted something then you own up to it and that gets everyone’s defenses down. 

 

Cory: Listen, I am not, as I’ve made clear many times, a doctor. But I can tell any doctor who might not have heard this, out of life experience, what you don’t want is a severe act of hubris on your own turf. Because that’s debasing. It’s scarring for life. So be humble when you’re getting deposed. 

 

Dr. John Alchemy: I started way back when, fortunately, I had a good attorney mentor and his advice was always make these educational. Always be in there to be teaching and to be helping others learn and you’re really not going to go wrong, if that’s your intent going into it. Don’t be defensive, don’t be angry or passive aggressive, be open and honest and be helpful, and ask for help when you need help. 

 

I think that’s the thing with these impairment ratings, particularly in these depositions, if you’re being asked a question and the attorney is saying, well what about page blah blah blah. I always say great, let’s open up the book and take a look at this together. Because sometimes it’s been read out of context or they don’t understand what it was, and it’s not what you thought it was, and I’m still learning, having done many depositions and many impairment reports. I’m still learning the new parts of the guides. And sometimes it says this on this page and then you go one chapter up and it says something else. 

 

Cory: For better or for worse. You said what I was thinking as well, which is you were saying prepare to teach and them to learn. And you said it before I did, but be prepared to learn also. The deposition isn’t an affront to your character as you mentioned. A different context of the way you said it, but it is an emotional decision making process and sometimes we make decisions with strong emotions. 

 

If you’ve never been deposed before, you’re a brand new work comp doctor, you’re kind of winging it because you haven’t discovered the majesty of RateFast Express yet, and then you get deposed, you might feel some type of way if you’ve never had to communicate with an attorney pointed at you instead of you them. Be prepared to learn.

 

Dr. John Alchemy: Yeah. It can be very overwhelming, the doctor just needs to remember that it’s your report, you’re an expert in your own report, you wrote it, but you’re not an expert in all things so you have to be like I said willing to accept some other points of view and be willing to say hey I don’t know. The other thing that I think gets forgotten a lot by doctors is, if there’s a problem in your report and something was missed or needed to be considered, A) you can always take time out of the deposition and look at it off record and I think that that gets forgotten sometimes, and B) you can say, write that down, send it to me and I can clarify that in a supplemental report. And you move on. 

 

Because not everything can or should be settled right at the time of the deposition. So give yourself time to think about it, to step away from it for a while, to completely understand what the question is, have the attorneys write it down in a letter and send it out and don’t forget that’s a great tool to use to put the brakes on a situation where you’re saying things you shouldn’t say or you’re talking about things you don’t understand that well, so keep that in your pocket. 

 

Cory: Okay, so in this scenario everybody’s on the same page now. And so what does wrapping up the deposition entail?

 

Dr. John Alchemy: Well, wrapping up the deposition, after you’ve walked everyone through the report, maybe you’ve talked about something in future care that you think is important that the patient needs and why, you kind of bring everyone to your conclusions, there will be some silence sometimes and then the questions will come out about the impairment value. Why is it this? Why is it 17? Why wasn’t it adjusted? 

 

All of these questions but if you’ve done a good job of laying down your underlying support as you’ve gone through it, those questions will still come but they’ll be very easy to answer. So if you’ve educated the attorneys on how the ADLs are scored and why they’re given the weight they are, the question about is this person eligible for a pain add on which commonly you will get that from both sides, the applicants will want to add on more pain, and the defense does not. This is what these people do. 

 

And so you have to be able to answer that question of this person is getting a 1 out of 3 because their pain scored moderate when it was averaged across the whole day, or the whole week, or something with substance to it. What you don’t want to say is well I think this person seems like they should get a pain add on. And sort of the standing answer has usually been “well it’s my medical opinion.” And I always get a little frustrated when I hear that in depositions or when I hear doctors say that because it’s not a real answer, to say someone should get an add on of 2% because you’ve been a doctor for 1 year, 10 years, 15 years, and that’s your opinion. It just doesn’t make any sense. Yet it gets used over and over. 

 

Cory: I had an analogy to use that was going to be delivered innocently but now I feel like the analogy would just make us enemies. But yeah definitely. Again, this is just one of those life experience things. If one party says it’s just my opinion as a doctor, or something like that, then you’ve seen movies where this happens, where someone says “this is my opinion as a lawyer, I’ll see you in court.” 

 

Dr. John Alchemy: It plays both ways, for sure.

 

Cory: And we were going to get into what happens in the case of an Almarez Guzman, which is something I’m still learning about, feel free to be as descriptive as you want about that.

 

Dr. John Alchemy: Yeah so the real common questions at the end become reasons for a pain add on and then the reasons for an Almarez Guzman which, the Almarez Guzman is California’s way of saying could this person’s injury exceed the values that the AMA guides have written in the pages. It’s pretty simple. It can be made confusing by putting in a lot of labor codes and case law and stuff but that’s basically all it is. Is this person’s WPI an accurate reflection of what they’ve lost as a result of this injury and if it’s not, how much should it be? How much should be added on? And that’s pretty much the same thing as the pain add on. There are just some different ways of doing it. 

 

Cory: Yeah, so that generally happens after the claim is closed?

 

Dr. John Alchemy: No, it’s something that needs to be addressed after the rating has been provided. So you do your AMA rating, you get a number, off the table, but then you have to look at the impact of the injury and say is this number really reflective of how this patient is able to function or not function, and then Almarez Guzman allows you to adjust that and that opens up a whole can of worms because there’s no rule on how to do the adjustment, just that you can do an adjustment. And that makes it really messy, often.

 

Cory: You’re in the mind palace of interpretation at that point. 

 

Dr. John Alchemy: Well that’s the way it’s seen many times. But if you have a systematic approach, and the approach we use in RateFast is these questions are no longer subjective they’re objective. And it’s very simple to answer yes or no to do they get a pain add on. Do they get this, and in fact you can even say what percentage they were above or below the threshold for these which is impressive for people to hear. They were under the threshold by 30% or over the threshold by 70%. These values become very easy if you have a system to operate in that makes sense and is consistent. 

 

Cory: Yeah so we have this, it sounds very mysterious to me just by the name, but what is “third attorney”?

 

Dr. John Alchemy: Well the third attorney is something that I think is not seen very often in work comp depositions so as I said at the beginning you usually have two, the applicant’s attorney and you have the defense attorney, but everyone in the deposition is allowed to be represented. So the doctor who is the deponent can bring their own attorney in and the attorney will sit with the doctor as the doctor is being deposed and help them with questions or clarify questions. 

 

For instance, sometimes it’s around trade secrets, because people don’t think of impairment ratings as something the provider may have trade secrets or patent pending on their methods. And there are certain things that can not be disclosed for the sake of protecting intellectual property. Sometimes the attorney is there to help the deponent when they think the question is over broad and just doesn’t think that they should answer it. 

 

So it’s nice to have an attorney with you as a deponent, it’s someone else to bounce ideas off of, it’s someone to keep everyone in line so to speak, like I said most of the time it’s pretty collegial and it’s a positive environment, but if it gets ugly for some reason or if someone’s having a really bad day, it’s good to have an attorney there as a deponent to try to settle things down or say hey, we’re not going to go in that direction right now, or we don’t need to do this. Or if you really think this is important let’s bring it in front of the judge and have them help us out. 

 

And it’s a good insurance policy for the deponent, the doctor, to have, because remember this is not a malpractice case against you, it’s an informational safari if you will, for everybody. Sometimes it just needs to be settled down a little bit, or you go in with your attorney and you say this is what I think are the key points, and you can get a little bit of a strategy going into the deposition and remember you can be deposed 2, 3, 4 times on the same case. Just because you’re deposed once doesn’t mean that it’s over. 

 

Cory: Definitely. Because if the deposition went badly, then it’s more likely to happen again. 

 

Dr. John Alchemy: Or maybe it’s just a complex case and there’s all types of things to be considered. But that basically wraps it up from top to bottom about what I think about the depositions, the kinds of questions and education I give, and how I like my depositions to go, being a doctor on the stand.

 

Cory: Yeah, so you know, as a recap, an attorney will come in and depose you for reasons, to clarify parts of your report, then you will get together with the attorney and the adjuster and go over the AMA guides and get the clarification of your understanding. I forget which one comes first, you go over the report, and then you go over the AMA guides – 

 

Dr. John Alchemy: Yes.

 

Cory: Then they will peruse the report, make sure everyone’s understanding is the same, there might be some waiting in between. And kind of the best thing to do is just give the best possible answers you can, be humble, and remember that it’s not a personal attack on you, it’s an attempt to get clarification. And I’d say I would leave this up to you to give a definitive answer on, but if it’s looking serious, grab your attorney, but maybe get an attorney no matter what when you get deposed especially if you have insider trade secrets?

 

Dr. John Alchemy: For sure. If you’re dealing with a lot of intellectual property it’s always good to have an attorney there to help draw that bright line between explaining and being educational and divulging trade secrets that are protected for your company. That’s a common reason why I bring an attorney in but like I said it’s always good to have a partner there, someone you can bounce ideas off of and someone who understands the legal aspects better than you as a physician.

 

Cory: Yeah. I just need to get this off my chest. I don’t know how my imagination thought this up but we were talking about the third attorney, and this mysterious entity, and how the insurance adjuster has an attorney, and how the injured worker has an attorney and my mind just thought of how you wouldn’t run into a Pokemon battle between two people with your fists blazing, you would throw out your own Pokemon. 

 

Dr. John Alchemy: The Pokemon attorney!

 

Cory: That’s right. You’ve heard of detective Pikachu. People who are listening to this know who Pokemon is, we’ve probably got some big fans in the audience. Again, write in to us! If you’re a big fan of Pokemon. I’ll do an episode on that.

 

Dr. John Alchemy: We will do an impairment rating on your Pokemon. Send a card in.

 

Cory: Absolutely, they battle all the time.

 

Dr. John Alchemy: They have to have some injuries. 

 

Cory: Exactly. Well alright John, that was a great talk. Hopefully people learned a lot and details about where you can find more about this will be at the end of the episode. And happy 2021!

 

Dr. John Alchemy: And people, email us those questions in. Cory, give them the email again, and give them the RateFast website.

 

Cory: So I gave my personal email earlier which, write me anytime. It’s c.Oleson@rate-fast.com but also you can just as reliably write into info@rate-fast.com. And we will talk to you next time.

 

Thanks for listening. For more information on best practices for physicians who received depositions, visit our blog at blog.rate-fast.com and try out RateFast Express at RateFastExpress.com.

 

The RateFast Express Impairment Report Form Makes Life Easier

Dr. John Alchemy and Cory Oleson discuss the RateFast Express Impairment Report form, and how it takes the guesswork, and the make-it-up-as-you-go-work out of workers’ comp impairment report writing.

If you’re a workers’ compensation provider, or are interested in getting started with workers’ compensation, check out our product, RateFast Workers’ Compensation Software Suite, as well as RateFast Express 3 Day Impairment Rating service.

RateFast Podcast: The Pain About… Pain!

Dr. John Alchemy and Cory Oleson discuss the proper way for a workers’ comp physician to measure patient pain, and some of the common mistakes made in measuring pain that extends work comp claims longer than they need to be.

For more information on this episode, and other helpful tips about workers’ compensation, visit the RateFast Blog.

If you’re a workers’ compensation provider, or are interested in getting started with workers’ compensation, check out our product, RateFast Workers’ Compensation Software Suite, as well as RateFast Express 3 Day Impairment Rating service.

RateFast Podcast: The RateFast Parity Calculator – Harmony and Dissonance in Work Comp Reports

Dr. John Alchemy describes the new feature of RateFast: the Parity Calculator, and illustrates the importance of keeping congruence between objective findings and subjective measurements when writing a workers’ comp report.

Try RateFast Express at https://ratefastexpress.com

Try RateFast Workers’ Compensation Software Suite at www.rate-fast.comAnd check out our blog at https://blog.rate-fast.com

 

RateFast Podcast: The RateFast Parity Calculator – Harmony and Dissonance in the Work Comp Reports

Cory Oleson (Host): Welcome to the California Work Comp Report. Today is Monday, July 27, 2020. This is your host, Cory Oleson, here to bring you the topic of today’s show, the RateFast Parity Calculator. Let’s hear what Dr. John Alchemy has to say about this exciting new feature to RateFast.

Cory: How are you doing today, John?

Dr. John Alchemy: Hey Cory, I’m doing great, thanks for asking. 

Cory: So today we are talking about the RateFast Parity Calculator. The RateFast Parity Calculator is another key module in the magic formula that helps make RateFast a great tool for workers compensation. John, can you tell us a little about the RateFast Parity Calculator features?

Dr. John Alchemy: Yes, the RateFast Parity Feature – we’ve been working on this for quite some time. It’s a tool that we use that basically compares the internal accuracy of a report, and answers the age long question of which information in the report is most correct, or is the data aligned between what the patient reports for pain and symptoms and function, verus what is found on the physical exam, diagnostic tests, the procedures they’ve had, and all of the information that goes into the ratings for the individual’s body part.

Cory: It seems like there is a tug of war between the objective and the subjective findings that determine the outcome of the report. How does the Parity Calculator make additional accuracy on top of all the accuracy that RateFast already does?

Dr. John Alchemy: Well, within a report there is this invisible understanding of internal consistency. And obviously if you’re getting a report, you want internal consistency between the factual information the patient is reporting to you and you want it to be credible, and the objective findings that are documented in the report like the physical exam, the range of motion, strength, etcetera. And ideally you want those two to be equal and most importantly reflective of one another and as accurate as possible between. 

So for years, I can’t tell you how many times state holders, employers, attorneys, patients, everybody in the work comp system that has to deal with the Parity Report, which is everyone, they struggle with this concept of: this is not an accurate reflection, or my exam doesn’t really show what my pain is, or vice versa. And there’s this ongoing issue that no one has ever really done anything about it. 

Unfortunately because of lack of a tool like this, cases go through multiple iterations of exams, more tests, more documentation, and so forth. What the Parity Calculator serves to address is how much alignment or misalignment is here in this report that we’re looking at. And really what the most accurate rating should be, all the information is in and it’s been considered and rated. That’s basically what the Parity Calculator does. 

Cory: What are some of the basic AMA principles used in the Parity Calculator?

Dr. John Alchemy: Well that’s an excellent question. Just to start off, this is a great podcast, and I think it’s going to be groundbreaking in taking parity rating to the next level that’s going to help standardize and help create insight into the data in a way we haven’t seen it before. As I’ve said it’s required a lot of investment, it’s a really detailed tool – I won’t go into the math and the statistics but it’s very comprehensive and extremely educational once you understand what it does. 

Now, in order for us to use it, we are obviously using the AMA guides and administrative ruleset, and because of that it is founded on the premise of some of the basic AMA recommendations. I’m going to just read through a couple of them and give just a brief interpretation of what it means and why it’s important when we’re talking about something like data parity. Also in this podcast I’m going to use it and refer people to it when they have questions or are trying to understand data parity because questions are always good. It helps me understand what the marketplace is thinking about, what they’re having a hard time understanding, and what they value. So, I’ve selected just a few key elements out of the AMA guide that I’m going to read to you. Like I said I’ll make a brief comment about why or how it’s important as to how the RateFast parity calculator looks at data. 

Starting way back in chapter one of the philosophy purpose and appropriate use of the guides on page two, it simply says, “an impairment may lead to functional limitations or the inability to perform.” Pretty straightforward. 

Next, what is an impairment evaluation supposed to do? Page three. It says, “an evaluation (rating) a permanent impairment, is a medical appraisal of the nature and extent of the injury or disease as it affects an injured employees personal efficiency, again, in the activities of daily living, such as self care, communication, normal living postures, traveling, non specialized activities of bodily members, the arms and legs.” So again, it says, it’s an appraisal of function. So that is again, a second swing at the plate, and it’s saying impairment is about ADL function.

 Okay, page four. The whole person impairment percentage is listed in the guide’s estimate of the impact of impairment, and again impact is reported in percentages of zero to one hundred, of the individual’s overall ability to perform activities of daily living excluding work. That’s listed in table 1-2. That is the main reference table for the 34 activities of daily living in the AMA guides.

 So I think one of the most important things that this particular passage says, and what I want to impress upon the listener, is that the whole person impairment result of the rating is a reflection of the individual’s ability to perform activities of daily living. It is not the reverse. The findings in the whole impairment rating does not dictate what the patient’s function is. The whole person impairment rating is supposed to reflect the loss of function, and this is very important. And as you can see, up until this point as you can see with these three simple passages, we can understand there is a very tight and direct connection between a whole person impairment rating and an individual’s activity of daily living. Any questions on that so far, Cory? And then I have one more citation. 

Cory: Well I certainly see how the three go together to determine the impairment based off of the function of loss and things like that, and I can also see how the three could definitely get confused in the process amounting to a whole person’s impairment. Baking those things in together, there’s a lot of margin for error. This is a long shot, but it kind of reminds me of – I saw this chart recently that was pictures of different cookies, and the only one that looked right was the first one, and the others just looked different and weird. Then it says, “there’s too much egg in this one” or “no flour in this one.” And I’m picturing that as a lot of impairment reports, are these weird looking cookies.

Dr. John Alchemy: Absolutely. And the frosting needs to match the cookie. That kind of thing. What I’m trying to build here for the listener is the understanding that we have our activities of daily function or the functional loss. And that whole person’s impairment is to be a mirror as accurate as possible that serves to describe that. 

Cory: Instead of imagining that the patient’s exaggerating – not saying that the doctor would think that, but it’s as if someone else was reading the report saying that might not be true, it can’t hurt that bad. It was just their finger. Or something like that. Versus the recording of it not being accurate to the amount of agony being caused or not. Or maybe sometimes it’s even more exaggerated. Maybe the reading comes out and shows that the pain is worse than the patient is thinking or would confess to it being. 

Dr. John Alchemy: Well each stakeholder has a different take on how they’re seeing the impairment report. I’m not going to say one is better than the other, I’m just saying that people look at this through different lenses. Our job is not to say if the patient is being truthful or if the exam is being truthful. But the Parity Calculator goes in and takes a look and says, okay, what was actually said, much of the interview and history that’s supposed to be there is there, and how much functional loss is there in relation to reported whole person impairment. So, we’re basically an objective system that takes a look at it and says, does this report make sense or not? And if not, then why? And if not then what does the corrected data look like? 

So that’s really what the Parity Calculator is all about. Now I’ll say this. I’ve been citing these citations I have here, and about this point in the discussion, I usually get “well, I kind of get it, but how do we know it’s really a 1:1 relationship?” Great question. One is the AMA guide goes out of its way to define both ends of whole person impairment which are defined with numbers with following definitions, that a zero percent whole person impairment is assigned to someone that has no organ loss or functional consequences and does not limit the performance of the common activities of daily living. That’s on page five. 

Cory: Zero percent one PI is, I’m healed. I’m good. 

Dr John Alchemy: Yes, it means, I’m as good as before. And it’s interesting because if the AMA guide goes out of its way to find two numbers of impairment, the first one is zero, and the second one is one hundred, and one hundred is an individual that is dependent on others for basically all functions and even says approaching death. So this is someone in a coma, and that’s 100%. And so if we think about our function and our zero to hundred spectrum of impairment, these are what the functional expectations are bounded as. Perfect, no problem, to I can’t do anything for myself. 

Cory: And someone else is probably having to tell you that they can’t do anything for themselves. 

Dr. John Alchemy: That’s right. So the final passage that I read is the following. And this really nails it in the AMA guides. This is also the basis of the Parity Calculator. It says on page five, “for an example an individual that receives a 30 percent whole person impairment due to pericardial disease, is considered from a clinical standpoint to have 30 percent reduction in general functioning as represented by a decrease in the ability to perform activities of daily living.” It can’t be any clearer than that, there is a perfect 1 to 1 ratio of whole person impairment to percent of functional loss. End of story, it’s pretty clear. So the Parity Calculator uses all of these definitions to understand the data. Very impressive.

Cory: Yeah, absolutely, I mean it makes you wonder why the two numbers aren’t the same number in the first place. I understand they’re kind of different, like different points or stages in the report, that the information reflected by one of those numbers isn’t necessarily reflected in the other, but it does make you wonder, who thought up this system?

Dr. John Alchemy: Let me just say again, because I think part of our problem and our bias as individuals when we read a report, is that the ranges of motion, the circumference of the arm, the strength testing, the findings of the x-ray, are very concrete findings that we hold as valuable. As we should. What’s less tangible, however, is the interview of the patient, and the completeness of the data, having the patient describe how the condition is affecting their ability to function. 

I can tell you that after looking at thousands of these reports, we get very detailed reports, or sometimes the report just says “Patient with pain. Physical exam.” Or sometimes it says “Patient can’t work. Physical exam.” And sometimes the physical exam is great, or sometimes the physical exam just says “pain when bending forward.” It doesn’t say how far they bend forward, doesn’t say what level the pain is, so this is the major problem that we have throughout the industry. It’s the bias, I think, that most people believe that the WPI is derived entirely from objective findings. And it’s our inability or our blind spot to really understand how much data is missing inside of the report. 

We’ve talked about this with other tools, with data quality that we have and so forth. This tool, this parity, really brings it all together, lines it up and makes it very simple to understand how good the report is, and if we only have this information in front of us, what should the rating be? How far out of line is the subjectives with the objective findings? It’s as simple as that. 

Cory: So that which comes out of the Parity Calculator is basically the synthesis of the most important parts of the report, or the emphasis on the most important part of the report, which is the functional findings. 

Dr. John Alchemy: Right. And when the Parity Calculator finds a report that’s in parity – again, how do we know it’s in parity? We look at the AMA guides, page 20 says that it’s valid if it’s within 10 percent of one another. We look at the parity scores for the objectives, the function, and we look at the parity score of the physical exam WPI, an dwe compare those two. If it’s within ten percent, great. You get a green light, and that’s it. 

But when it doesn’t, that’s where the Parity Calculator is equally helpful. And it takes a look because there’s this tug of war of data accuracy and data completeness, going on constantly. Was the history accurate? Was the physical exam accurate? Was something missing here or there? So when things are out of parity, two numeric representations or as we refer to as scalers, the magnitude of these two things are not in alignment, we have to find the in between.

Where is the true midpoint between these two now conflicted elements? We know it’s conflicted, but that may or may not be apparent to the reader. But it is apparent to the calculator because it queries very specific information to determine the completeness, the accuracy, and also the weight of each of these objects. 

Cory: Absolutely. And I’m sure a lot of that isn’t clear to the less adept professional as well. Maybe this is something that they aren’t seeing or understanding the marriage of the two. 

Dr. John Alchemy: And I will tell you even over the 20 plus years I’ve been doing this, it is very sobering once you have a corrective tool to look into your own report and say, wow, that was missing there, this was missing here, the data was out of alignment this much, and being able to take that information and either repair it with another report or do a better job on the next one. It’s a tool of understanding and guidance, consistency and making the rating overall more accurate in a way that’s never been seen before. 

Cory: Honing in on that perfect impairment rating that RateFast has been doing the whole time. So that brings us to the next question, John. If you’re reading a report, and it’s talking about parity, what am I supposed to be learning from the report?

Dr. John Alchemy: The main thing that the reader should understand from the report.. So the report’s going to have the standard rating report in it, so let’s say the rating of the low back is 7 percent, whole person impairment, and then it’s going to have the parity analysis. And the parity analysis is very short and brief. It tells you this simple information: is the data in alignment for this rating? And if it’s yes, like I said that’s a good thing, if it’s a no, the question is how far out of alignment is the data? Is it 20 percent, 40 percent? 

This is reflected in something we call the Delta Score or difference. Delta is a term used frequently in math for determining the difference between two numbers or two objects. And so it’s this Delta Score that tells the reader, yep this has good parity or no it does not. Now if it does not have good parity, what it does is it finds the correct number set that best reflects evenly and accurately the two differences. It takes the objective and subjective findings, it weighs them based on their credibility and accuracy and completeness, and it reconfigures and enhances the data and basically re rates it. 

So if I’m coming into a 7 percent whole person impairment on my back, the Delta score said this information is 40 percent out of line. It’s going to give us what the rating should be. Sometimes it’s higher and sometimes it’s lower. But it’s what the data in the report best reflects. It could go to twelve, it could be down to three. It all depends on the sensitivity of the data. 

I always have to chuckle when organizations publish these tables saying the rating for a strain should be 5 percent. Or for a post surgical it’s supposed to be a 9 percent. These are in my opinion, completely ridiculous because as we know, until you understand the deficiencies and the accuracies of the data, the specificity of the measurements all taken into account, it just doesn’t mean anything. And tables like that are really what put the bias blinders on stakeholders because everyone thinks “I read this table from this organization and they said no knee should be minus three points from seven percent whole person impairment.” 

Anyway, it’s hard because people want things done simply and they want to be able to understand them, and that’s where the parity calculator comes in. We do all the work for you, we’ve done all the analysis, all the calculations, all the specifics, we just want to be able to tell you whether or not it’s a good report and here’s what the rating is based on best practices, for this individual.

Cory: What you’re describing reminds me of – and this is going to be a very paraphrased version – but you can’t begin to work on the problem until you’re aware of what it is. And I’m sure a lot of people aren’t even aware of the harmony and dissonance between the two items that come together that the parity calculator does. And by the way this is the PARITY calculator, not the PARODY calculator. 

Dr. John Alchemy: Yes, meaning consistency. And I’m going to piggyback on that analogy, and talk about the ways some of the stakeholders view these reports. I’m not saying it’s bad, it’s just what I’ve observed. 

There is this funny story that goes: a man lost a quarter in his basement, and he was found outside in the yard looking for it. And someone came up to him and asked what he was looking for, and he says he’s looking for a quarter that he lost in the basement. And the question is then, why are you out here in the yard and not in the basement looking for it, and his answer is “the lighting is better out here.” And we see that all the time, people go and try to make sense of the report somewhere else and it really has no realistic connection to what’s in the report. So the Parity Calculator is a flashlight you can bring into the basement to find that quarter. 

Cory: Absolutely. So we’re talking about the Parity Calculator, the thing that’s making everyone’s life easier, just to put it that way. So when do we see it in effect?

Dr. John Alchemy: Right now on the commercial platform for RateFast, it’s already there and working. So if you’ve submitted any cases to our platform after the beginning of July of this year, you will find a parity description in your work report. I’m very much looking forward to the questions and feedback that I’m going to get from stakeholders, and like I said, this is not something we made up, this is simply a deeper dive into the AMA guides to make understanding of impairment more accessible for stakeholders, that’s all it is. 

Cory: So I think at one point I called the Parity Calculator a new module that has been added to RateFast, which it very much is, a new algorithm that’s been plugged into the greater formula and everything. What it reminds me of, being a musician, I’m very much into synthesizers. There’s a type of synthesizer called a Eurorack, and what it does you take the little pieces of the synthesizer, the pieces that make different sounds. And the reason that I draw the parallels between RateFast adding new feature after new feature is because the way that a synthesizer works is on one end you get a degree of voltage, and that single thing of voltage travels through all of these modules and comes out the other end as a rich tapestry of sounds, even though it started out as one piece of data. And the way that RateFast relates to Eurorack in a way is that you always want to add more. More is always better. Especially because we are figuring out for you the things that you didn’t know that you needed. 

Dr. John Alchemy: Yes that’s right, because we are obsessed with accuracy and consistency. It’s as simple as that. 

Cory: Well that was the RateFast Parity Calculator. If you are a RateFast user look for that section in the report and if you have any more questions, I’ll be giving you contact information at the end of this episode. So thank you again, John, for joining us at the California work comp report.

Dr. John Alchemy: Cory, always a pleasure. 

Cory: For more information about the RateFast Parity Calculator, and how it plugs into the RateFast Workers compensation software suite, visit our blog at blog.rate-fast.com and to try the RateFast workers compensation software suite, or the RateFast express three day impairment rating writing service, visit our website at rate-fast.com.