Podcast: Permanence and Whole Person Imparment

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Cory: 00:00 Right before we go into this totally unrelated question, why is the perception that all doctors have crazy handwriting?

Dr. Alchemy: 00:10 Yeah, I think it just happens to be some type natural selection for them.

Cory: 00:16 It’s, if you, if you always have had crazy handwriting than I did it, it raises the possibility that you’re going to be a doctor.

Dr. Alchemy: 00:24 It highly increases the probability you will become a doctor. That’s right.

Cory: 00:29 Yeah. Welcome back to the California work comp report. Today is Wednesday, August 7th, 2019 I’m your host, Corey Olsen here with Dr. John alchemy to discuss permanence and whole person impairment. Recently somebody emailed one of the re-pass accounts and it was a patient who is not one of our patients or, or one of John’s patients asking. They had somewhere in the range of 10 to 15 WPI and they asked what does that mean? And that was the only question they asked. Simple as that. I have 12% WPI. What does that mean? So today we’re taking a look at WPI or whole person impairment and deconstructing it and seeing what it means and what it means to the, to the stakeholders in the claim. So John, do you mind telling me what is WPI?

Dr. Alchemy: 01:17 Yes, the WPI is a term that was actually coined by the American medical association when they first founded the concept of the guides to permanent impairment. And it was basically a universal way of communicating loss on an individual for their condition. So the WPI came about because of that and, and became basically the currency of,injury determination when calculate getting permanent impairment. So it’s a term that runs from 0% to 100%. When I’m trying to explain this to either doctors or patients or insurance adjusters, attorneys, et cetera. I always use this term that a 0% means that you have had no impact from your condition with regards to function, imiting pain, things that you do around the house. Your physical exam is normal. Appropriate diagnostic tests are either non-contributory or have minimal or negligible findings. So all of those things must be met for you to be a 0%.

Dr. Alchemy: 02:20 Now as you range or move up through the WPI percentage points up toward 100 as you get to 100% the AMA guides actually says that this person is nearing death. So that basically means that you need help with literally everything to live. So you need to be fed, you need to be bathed, you need help with toileting. You can, sit very well, stand very well, walk very well., there’s 34 things at the aim make guides in the fifth edition that we use. And also mostly in the sixth that we use that,that discusses or talks about what the other end of the spectrum is. So just to back up and clarify the zero means everything’s all good patients feeling and functioning well. All the diagnostic tests are green and go and a a hunDr.ed means you’re not doing very well at all. You’re having, lot of problems. You need a lot of help. You may have a lot of pain or you just, you can’t, can’t do what you need to do with that particular organ system. Be it, uper extremity, lower extremity psychiatric skin and what have you. You’ve got some serious, serious problems when you’re getting up toward 100% whole person impairment.

Cory: 03:29 Just a as sort of review when people reach their permanent impairment in a workers’ comp claim, that means you’re as good as you’re going to get. And then we’re going to kind of give your injury of final grade as to how much your injury affects your life at this point, which turns out to be the WPI, the WPI ranges from zero to a hunDr.ed zero being you pretty much walking away from your injury as if it never happened in a same way. You’re, you’re, you’re just as good now that you’ve recovered as, as before 100% is, yeah. Your in serious need of help and, and will be more or less. Henceforth, quick question. Do different injuries give a kind of a cap for different WPIs? Like, say I injured the, the, the say like the tip of my finger or the, just, just cut it off or something.

Cory: 04:16 And, and it w I could, I didn’t have the top of my finger anymore, but it healed up. There’s no, it didn’t get gang green or something like that. There’s kind of a cap to how much WPI that could be. Right. It wouldn’t be wouldn’t ever get to a 100% WPI just missing like the tip of my finger or, or even even more so say like a chemical burn or something like that that I only got on a certain part of my arm that healed all the way up or, or something like that. There’s, there’s, there’s no real way that an injury like that would, would be 100% WPI versus if you were to get like a serious spinal injury that is way more likely to give you that. Or are there, are there cases where we’re a smaller injury would lead to something like that?

Dr. Alchemy: 05:03 Well, it’s an interesting question and basically, WPI has made up, depending on what body part you’re looking at, a of possibly some, some lesser impairment currencies if you will, like four quarters make up a dollar or in clinicals make up a dollar, et cetera that you have, percentages for upper extremity that are then converted to whole person impairment. Similarly for lower extremity and, they have a percentage value too, like a, a whole person. So for instance, if you have, if you have a 10% lower extremity impairment, well the lower extremity is worth 40% of a whole person point. So, that’s basically four bursts, 4% whole person impairment. So, injuries at the particular level of the body may have these subcomponents of impairment that are calculated first for that body part and then they’re, they’re combined or added together and then they’re converted to a whole person impairment. So there’s this little bit of a hierarchy, if you will, for the whole person impairment as sort of a graduated process, if you will. Now other things like the spine for instance, those are just calculated straight out and whole person impairment. So they’re a little bit different but, but the end game is always getting the whole person impairment for the stakeholders and for the patient. That is going to be the building block and the starting point for your case. Settlement.

Cory: 06:26 You answered my question too. I was going to ask next what happens when multiple body parts are injured? So, so they’re kind of added together for the whole person impairment because there’s separate ratings. There are separate impairment ratings for multiple different body parts that are injured. Say in the same instance, if somebody got injured and they broke multiple parts of their body, they’ll whole person impairment would come together for all of the injuries put together.

Dr. Alchemy: 06:50 Yeah, that’s right. Th the whole person impairment system actually has something called the combining table and the combining table was designed so you could have multiple conditions but it would never exceed that 100%. So it’s a special table in the back of the book. It takes into account or person impairments from different body systems. And then they’re all ultimately, while that body system is rated, then it’s combined with the next combined with the next combined with the next step. So they slowly start approaching a hunDr.ed but the formula that’s used, it doesn’t allow any combination of numbers between zero and 100 to ever exceed 100% so. So it’s sort of an interesting approach that they’ve devised on how to prevent someone from becoming 101% impaired.

Cory: 07:35 So it seems like a lot of patients come in asking the question, I have 13% whole person impairment, I have 26% whole person impairment. What does that mean? And I’m, I’m wondering why, why do patients ask this question kind of also, why don’t doctors just say what that means to the patient? What is it that’s leaving them kind of clueless about it?

Dr. Alchemy: 07:57 Well, I think we’ll answer those questions in order. The first thing is the patient has to questions because probably no one’s ever discussed with them what it means. It’s just a strange and foreign term and it’s an integral part of the settlement of their claim. They’ve had this industrial claim, they’ve been seeing, a doctor through the work comp system for awhile and maybe a couple months, maybe a couple of years. And then this number shows up somewhere, usually in a letter from insurance companies saying your doctor is for farmed impairment rating and it’s determined your impairment loss is, 22% totally out of the blue. And the patient, may not have been educated by their doctor at all. And to be honest, the Dr.. May not have a very good firm understanding of what it means. Either they say, Oh, I don’t know, I use this book and I try to find where, you’re best placed in it.

Dr. Alchemy: 08:41 And, it gives me a, a number to choose from and I pick a number, that’s, how many doctors view generating a whole person impairment. We can talk about the accuracy and the correctness or incorrectness of, of how it’s done. But to answer the question, it’s a foreign term that patients don’t understand. So it all, so comes on the heels of being told that their, case has been made stationary. That puts a lot of fear into patients because they don’t understand that term either. We’ve adDr.essed that in prior podcasts, but, but people have a hard time coming to terms that this is as good as I’m going to get and how can my case be closed when I’m still having problems or not able to go to work.

Cory: 09:21 I see, I see. So it’s sometimes not only just what is, what does this mean? It’s sort of like trying to wrap their head around the fact that, Oh my goodness, I’m not who, I’m kind of not who I was before this all happened. So that’s sort of a rude awakening. I’m sure it’s somebody that’s sort of launched into the work comps veer by getting injured at work. They didn’t expect to walk out of it knowing this sort of, this, this magical number that told them what they would be like, how they are now that they’ve, they’ve recovered. It’s like you can’t, you haven’t recovered all the ways. So this is the WPI.

Dr. Alchemy: 09:49 Yeah. Yeah, I agree. I think the other big issue is that the patients are never given context for their numbers. So, does is a 15% whole person impairment for your back really makes sense. I mean, if someone feels that they can’t go to work and they have severe pain, I mean they’re probably thinking their back pain is 100% in pear impairment, and without someone explaining to them what the scale is, the real only reference they have is their personal experience. And that’s not really a good way to look at it because that’s not how the system is designed, ? So I think that’s the biggest thing that that people without that proper information or introduction to the system and to the value of the whole person impairment in the concept, they’re just kind of left to their own to figure out, does this make sense to me or not? And if it doesn’t make sense, who can I turn to or do I need to get an attorney?, all these things. I’m start to go through their mind. And, patients panic sometimes and I totally get it. Again, they’re in a system where they know very little about it and they’ve been doing their best to comply with it and, and now they’re, they’re given a determination that they don’t understand,

Cory: 10:55 Talked about before. The fact that it’s strange that, I mean it’s strange and understandable at the same time that workers are kind of launched it in the system, they don’t understand it and everything. It would be very helpful if they had some sort of pamphlet or some sort of brochure or guide that walks them through the terms that they’re being told and all the things that they more or less should be expected out of a work comp point. They’re all different, but they all sort of follow a certain formula they’re going to be, rated and everything like that. But it comes as no surprise that there isn’t something like that for patients because there’s not even something like that for doctors. So it just still makes so much sense. Why is why the injured worker just doesn’t know what’s going on so often and then has to turn to a company that does workers comp software and things like that to ask us, what does this mean, what is this number

Dr. Alchemy: 11:45 Or is it correct? Exactly. Yeah. There’s really a lot of interesting layers, around it that makes it difficult for, for a lot of stakeholders and no getting back to, to try and to get some type of pamphlet if you will, or educational process. Personally, I’ve been continually disappointed in California, at least with the division of workers’ comp, the, the language they use, the terms they use just are not accessible for most injured workers to understand. And I think workers’ comp needs to kind of go through this revolution, that privacy statements in terms of use have recently gone through in Europe. And now, in the U S where when you give someone a terms of use and it’s 30 pages long, is it really understandable and is it a natural language or is it in very technical language and, and a lot of legal terms, I think that probably needs to happen to help injured workers become more educated. And in fact, almost maybe something like the Miranda rights when you have a work that, you’re a male, here is how this system works. Here’s how requests for treatment are handled. Here’s how your case is going to be rated your our, your rights. Here’s the insurance company’s rights, here’s the QME process. And unfortunately that just doesn’t happen. And I think once we get to the point where that does happen, I think the system hopefully would move along a little bit with less

Cory: 13:07 Reading, reading the laws, the work comp laws. It’s just very confusing. These sort of law law of documentation. I’m not the kind of person that that that can read some very heavy legal legal documentation and sort of just be like, Oh, I get it., totally get what you guys are going for there., I’ve moved to me. Okay. Moving along, John, how is the WPI generated and how does the doctor create it? We heard that you put together multiple injuries when you have multiple injuries and that kind of cumulatively makes your WPI, but how is any of those independent WPI numbers, how are those numbers generated?

Dr. Alchemy: 13:47 The numbers are generated in a process that is called, at least in California, the [inaudible] report or the impairment report. And basically what happens is that the doctor has to do an exam, do a history, interpret diagnostic tests, and then generate a report and then reference the, the administrative rule set, which is the fifth edition AMA guides in California, and then write it all up., and that’s a tall order because there’s a lot of moving parts with that. Now when I’m, when I’m talking to stakeholders and they want to know why, why these reports are accurate or inaccurate, I like to liken it to a tax return. So, you go out, most people don’t do their own taxes and they go out and they get a CPA or a bookkeeper and the bookkeeper does their taxes and the accuracy of their tax return is based on two items basically.

Dr. Alchemy: 14:35 One is, how, how well does the provider that’s writing a report really understand the system? Okay, that’s, that’s very paramount. What do they do? They really know what they’re looking at. Do they know what they should be asking, et cetera, et cetera. The second point is how good is the data that they’re working with? So you can have a very deep and solid understanding of the system and the way to generate these whole person impairments, but you might have a really bad dataset, and that introduces a second problem. Just like the bookkeeper may not have all the receipts, I mean couldn’t imagine if the bookkeeper didn’t have your W2 or, didn’t have your mortgage statement, all those things yet you still have to turn in by April a 14th or 15th, you still have to turn in your tax return and so, you’re [inaudible] you’re still going to turn it into a tax return.

Dr. Alchemy: 15:24 It just may not be that accurate. And so these are really the two big key items that get overlooked. And often it’s a combination of both. It’s the provider not having a good or solid understanding or being rushed or just not wanting to do it. And then number B, the exam being done is not in not in good compliance with the, with the AMA guides. So it’s really, really difficult to get a good solid rating out of that. Now it can, it can still be done or at least the best rating based on available information. But it’s those two key factors that really determine if that number is correct or not. That’s going to settle the claim.

Cory: 16:03 I picture anybody that’s listening to our podcast, it’s probably listened to more than two or three episodes is probably just banging their heads against the goat steering wheel or their, whatever it is. Just just being like, why is it like this? It says in, it’s in, it’s not anybody’s individual fault, it’s just set up in a certain way where even oftentimes the, the, the doctor doing the rating or the, the administrative person doing the rating is not understanding these things and then they have to give it to somebody. Like the patient doesn’t understand it either, but who might just say, Hey, something’s wrong. Like, who might, who might have been even worse who might have it worse than the rating. Reed’s who’s, their, their whole person impairment might be a, as we’ve talked about before, their whole person impairment rating might be 0% when they’re walking around with a limp now or something.

Cory: 16:49 , Just, just something like that. Kind of leading to the next question, what if somebody doesn’t like the result of their WPI? What if they look at it and say, I mean, I would imagine in most cases they don’t like the result because they feel that that that result is actually lower. I can’t imagine a circumstance where they’re given 50% whole person impairment. And then, they, they, they don’t feel that bad and they’re just saying, Oh, it’s not as bad as that, but I’m sure that happens as well. Well, it

Dr. Alchemy: 17:18 Puts the patientin a tough spot or the insurance company because if someone doesn’t like it, they have to understand why they don’t like it. And then B, they have to understand the avenues that they can pursue to get it fixed. So, for most people, insurance adjusters and patients alike, they get this report and they don’t really know what they’re looking at. The only thing they can focus on is the number and they decide if that number is adequate or not because they can only react to the value of the settlement amount. And, and, and they, they can’t really understand the number they’re looking at is a correct value or not. And that’s a big, big problem because, the whole system, the whole linchpin of this thing is the WPI. And so if you have a bunch of,stakeholders who are trying to figure out if this is the right number, they don’t know what they’re looking at.

Dr. Alchemy: 18:07 They don’t know the terms that are used to generate it. More importantly, they don’t know what was in or left out of the report that could have value., that’s why we, we’ve created rate fast to allow insight into that process and give it some transparency. But, without a tool like rate faster, basically I’m left up to your own devices and you’re trying to figure out this very, very complex tax code, if you will, on your own and without a guide. And it’s very fragmented to try to find someone who, has a comprehensive hands of understanding and they can look at a report and say, yep, this is a, this is a solid a plus report or this is an F minus report. We’ve talked in prior podcasts about completeness and data integrity and all that, which we don’t need to get in. But, it’s a real problem when you think about it. And if you don’t like something but you’re not quite sure why that’s even a more difficult problem to solve. You have no idea where.

Cory: 19:01 Let’s start as, as we’ve talked about so many times, anytime there’s any sort of dispute from any of the stakeholders, whether it be the, anybody, whether it’d be the patient, whether it be the physician, whether it be the insurance company, there is going to be a down in the claim. There’s going to be something that happens in a lot of the time that results in. Yeah. Getting a lawyer involved to getting a nurse case manager involved, things like that.

Dr. Alchemy: 19:24 So, and in getting the attorneys involved doesn’t always solve the problem. It feels like you’re doing something, proactive or doing something. But, attorneys are like any other tool in the system. They may be a benefit. They may be a hazard. They, they may not understand the system very well other than the portion that they process and work with. So it’s, it’s a complex system and that’s, that’s why the industry is so big

Cory: 19:46 As a [inaudible]. One captain Picard of the USS enterprise said to a [inaudible] data during a game of chess, I believe, and I’m paraphrasing, you can, you can make no mistakes and still lose. Yes. I like that. That’s an accurate statement. I read that one just yesterday and it kinda kinda hit me a little bit. John, what are the remedies to when somebody doesn’t understand their whole person impairment or when they don’t agree with their whole person impairment? Well, the, if you’re an injured strict

Dr. Alchemy: 20:19 Worker, you have a couple of remedies. One is if you’re unrepresented, meaning you don’t have an attorney, you can always take the report into,one of the state offices for worker’s compensation called the disability evaluation unit. And you can share that with, with a unit there and they can look it over and help you understand what to do next with your report. The other thing that, a injured worker can do is they can talk to their doctor about it and sit down and go in and have another visit and really go through about how this rating value was created and why that particular number was selected as their settlement. The other thing they can do, again, they don’t have to be represented as, they can request a qualified medical exam. And that’s where the state of science and other doctors to look over their case in their medical records. That’s usually going to ask, adda three to six months, to te [inaudible].

Dr. Alchemy: 21:08 But for some patients it’s worth it, they go and they have this they, they have this evaluation, then a report gets written and,and then again, the state will look at the two reports and seeing was the one your doctor gave you or the one the QME gave you the, the more accurate of the two reports. And that’s usually a decision based on, e, the, the actual data in the report. So usually the report with the most compelling data, the most complete and detailed data will become via will become the report of record for the settlement.

Cory: 21:38 This question is definitely more for the most of the, the content of the podcast so far has been actually geared towards the injured worker who’s been asking this question, but I think that this one is a little bit more for the physicians, but it is for the injured worker who wants to kind of cover their own butts and make sure that the physician is doing everything right. How does one ensure an accurate whole person impairment or WPI for their claim?

Dr. Alchemy: 22:02 Excellent question. How does that happen? In my opinion, the most consistent way is a standardized approach to looking at reports, how the exams are done or as the reports being generated. Having a tool that helps guide you through the process so you’re asking the right questions, doing the right measurements, and interpreting the AMA guides and looking at the right tables. Those are the main things. Now, back when we first founded Ray fast, that’s exactly what we did. We created a template where you could select a body part and it would basically be a menu Dr.iven tour, if you will, the GPS through navigating the impairment report and generating the correct impairment report and apportionment for the stakeholders. That’s the ideal way and the most consistent way to do it. So you get the same approach, the same level of detail, the same level of quality from exam to exam.

Dr. Alchemy: 22:54 Is that the way that it’s done? In reality? No, it’s not. And, and my hope is that, as, as systems become,more mechanized and easier to use that system such as rate fast or, other systems, ill become adopted to help solve this problem. Because really what we want to solve is the inaccuracy and the delay and the expense to the system., all those things are detrimental to business, to injured workers, getting back to work, to the whole system in the, in the costs, around all of this. So, mechanizing the system, having having a digitized approach to claims, being able to reproduce, reorts from examiner to examiner or from data set to data set. Those are really the real keys. We’re getting closer, but, a lot of this is just still done on pencil and paper.

Dr. Alchemy: 23:46 I mean, imagine trying to balance your checkbook using a pencil and paper doing it long hand [inaudible] that’s basically how most of these increment reports are turned in in the state or they’re just guesstimates wild guesstimates that the providers just think that, Oh, my experience, this person’s a 10 or 15. And I’ve looked at a lot of QME reports even in they, they just throw a number down, but it’s never really substantiated and it never really says why they selected 13 or why they selected 10. It’s quite amazing that this level of, of work or lack thereof in reports can go on and be processed and settled. But, that’s the way it’s done right now.

Cory: 24:23 I read recently that the fellow that kind of came up with the calculations for weather prediction, knowing the, the forecast and everything like that, he could calculate what the forecast would be an hour from that moment, but it would take him six weeks in order to make the calculations to get the estimate for what would be an hour ahead and in, in the, in, in the cast and everything. Also, similarly there, 20 years ago it would, if I, if I had to send you a written document, it would take a couple of days., you’re, you’re, you’re in California. I’m in Pennsylvania. Now, now it’s literally the press of a button. Th there was nothing stopping aside from a huge, sort of sort of, wwhat am I thinking? An infrastructural kind of change that would take everybody to, to kind of put all of their resources into being able to just digitally plug your numbers into a machine.

Cory: 25:26 And then it just pops out a very accurate whole person impairment as well as many to all of the other measurements that it would take in order to take examinations and get permanent impairment and everything like that. It’s just a matter of those things being allowed to enter the, the sphere of, of, of medical and workers’ comp and everything. And it’s just, it’s amazing how some of these systems are still not implemented yet. And you could see why they’re not, we talked about fax machines and everything last week and why exactly those are last last month. And, and why those are still being used and everything. So it’s understandable in a lot of ways, but it’s really makes you wonder how, what is, what is so crucial about the systems that are in place when things are taking an extra six weeks and everything like that. And we just have to accept it. So it’s just, it’s strange. John, do you have anything else to say about whole person impairment? Anything for any of the, the patients or the physicians wondering about it out there and people, things that could, I don’t know, give people a little more insight to it. The only thing else

Dr. Alchemy: 26:24 Is, is that a try to understand the number that you’re looking at and try to understand some type of context. If you haven’t been given a context for your number and you need to go back to the person that generated the report and get some more education, I think that’s step number one. Step number two is I think it’s also important to try to understand, what the underlying information was used to generate that number. And, and again, that’s really a question for the evaluator that writes the report. If, if both of those answers are unsatisfactory, o you as a stakeholder in the system, then I think you need to access the state resources that being the, dpartment of, thDEU with the state of workers’ comp, the disability evaluation unit. It could be a consultation with an attorney, either a defense if you’re in an employer or or a carrier or an applicant attorney if you’re an injured worker.

Dr. Alchemy: 27:21 Trying to get some Infor information that way. And like I said, if everyone’s on board,Hey, go get a QME and get the case you done. But, I will warn everyone here that the QME reports are not necessarily going to be better, easoned or more accurate or more detailed than what the primary treaters are already turned out. And I know that from experience we’re looking at reports. So, it’s kind of like a buyer beware type of situation, but those are some of the basic, reources I think that the stakeholders can use to try to better understand what is the WPI and is my WPI correct. Hmm. Thank you so much for your time today, John. Hey, always good to chat. Thanks Cory.

Cory: 28:05 For more and whole person impairment, visit our blog@blogdotrate-fest.com. And to learn more about reach fast visit rate-fest.com.

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