Archive for the ‘ Life Care Plan ’ Category

CMS Clarifies Its February Alerts Regarding Section 111, MMSEA Reporting

Russell S whittle, Esq VP MSP ComplianceOn February 28, 2014 the Centers for Medicare and Medicaid Services (CMS) published its formal notice of the change in the reporting threshold for liability (including self insurance) settlements, judgments, awards or other payments.  The notice follows the recent publication of two Alerts of February 18.   Those Alerts announced a potential change in the Mandatory Insurer Reporting obligations of Responsible Reporting Entities pursuant to the changes instituted by the Strengthening Medicare and Repaying Taxpayers (SMART) Act.

In the new notice, CMS has advised that an updated Non-Group Health Plan User Guide, Version 4.2 Chapters I – V, can now be downloaded to incorporate the change in the Medicare, Medicaid and SCHIP Extension Act (MMSEA) necessitated by its February 18 changes and the SMART Act requirements.

CMS has now determined that, for certain liability insurance settlements, judgments, awards or other payments:

  • The Current mandatory reporting threshold for liability insurance (including self-insurance) Total Payment Obligation to Claimants is $2000 for settlements, judgments, awards or other payments occurring on or after October 1, 2013.
  • For settlements, judgments, awards or other payments exceeding $1000 on or after October 1, 2014, reporting is required no later than the first quarter of January, 2015.  This is a change from the previously published threshold amount of $300.
  • Error Code CJ07 – where Ongoing Responsibility for Medical has not been accepted and where the settlement, award or judgment amount does not meet the reporting threshold – will still occur on claims submitted with a cumulative TPOC Amount less than $300.  It is expected to be changed to coincide with the new $1000 reporting threshold later this year.

As had been discussed in the wake of the February 18 Alerts, questions had been raised regarding the effective date of the changes and the ability of CMS, from a technical standpoint, to implement them. The notice now puts a clear timeframe on the applicability of the change, the settlements to which they apply and the anticipated technical Error Code update.

Gould & Lamb will incorporate the new changes into its Mandatory Insurer Reporting Services program for all settlements that are effected by the change and will also add the appropriate logic to ensure Error Coding is consistent with any CMS update.

Future Considerations for Controlled-Release Oxycodone

Oxycodone CR is a slow release opioid narcotic currently indicated for use in moderate and moderate-to-severe pain. When initially released to the market, the indicated use was for pain management in cancer patients and for control of postoperative pain. As the use of controlled-release Oxycodone expanded, problems with addiction and abuse escalated.

In an effort to bring the use of Oxycodone CR under more effective control, H.R. 1366 cited as the “Stop Oxy Abuse Act of 2013” was introduced March 21, 2013 “to direct the Commissioner of Food and Drugs to modify the approval of any drug containing controlled-release (CR) oxycodone hydrochloride, to limit such approval to use for the relief of severe-only instead of moderate-to-severe pain, and for other purposes”. The introduction of the bill followed a petition filed by Physicians for Responsible Opioid Prescribing (PROP) calling for the FDA to modify opioid labeling such that future approval would exclude the term “moderate” from an indicated use for non-cancer pain. As such, approval for use would be limited to severe pain only within this population. However, the bill does not restrict the drug’s use to non-cancer pain but, rather, seeks to limit approval for use to “severe-only pain” for any patient population.

If H.R. 1366 passes, it will operate to remove use of the controlled-release oxycodone drugs for management of any form of moderate pain type diagnoses as an approved indication by the FDA. The prescribing of Oxycodone CR for “moderate” or “moderate-severe” pain would then be considered an “Off Label” use. Within the world of Medicare Set-Aside, provision of controlled-released Oxycodone for such diagnoses would be excluded from the plan of care. Any continued use of Oxycodone CR would require medical documentation and diagnosis of “severe” pain.

Part II – Chronic Pain Conditions Impact on Future Care: Failed Back Syndrome

Patricia Rapson, RN, CCM, CLCP, CBIS, MSCCFailed back syndrome (also known as Failed Back Surgery Syndrome or FBSS) is not considered a diagnosis in itself, but rather a term often used to describe patients who have undergone lumbar surgery and continue to experience chronic and persistent pain syndromes with unsatisfactory outcomes. This condition it is characterized by severe, disabling chronic pain that is generally resistant to physiotherapy, pharmacological treatment and is associated with various degrees of functional disability.  It is estimated that this complication occurs in 5% to 10% of patients after spinal surgeries.

Failed back syndrome has many causes.  If surgery fails to adequately relieve pressure on the nerve or disc herniation recurs, ongoing pain can result.   What if the nerve sustained serious injury?  Full nerve recovery may not be possible, regardless of surgical intervention.  If spinal fusion was performed, incomplete healing of the bone graft and/or hardware failure (i.e. breakage) can lead to persistent instability of the spinal segments requiring additional treatment. The formation of scar tissue at the surgical site also presents challenges which need to be taken into consideration when addressing short-term and long-term future care.

Fibrosis and Adhesions

The formation of scar tissue is a normal part of the healing process.  When we are injured, our bodies launch a complex rescue mission, mobilizing specialized cells to stop the bleeding and lay down a matrix of collagen1.  Other cells (fibroblasts) reorganize these fibers eventually anchoring themselves into the matrix and pulling the wound edges together.  Every wound results in some form of scarring but we all scar differently. In some of us, scars are barely noticeable while in others the fibroblasts are overzealous, laying down excessive amounts of collagen which results in large raised (hypertrophic or keloid) scars.

Internal scar tissue also reflects the body’s natural healing abilities, repairing muscles and tissues injured or cut during a surgical procedure. Internal scar tissue differs from “normal” scar tissue in that it can create tethers, barriers and adhesions to internal body structures, pulling them out of place.

Epidural fibrosis occurs when fibrous tissue replaces the normal epidural fat adjacent to the dura  in the spinal canal. This tissue binds the dura2 and nerve roots to the surrounding structures.  Dense epidural fibrosis can cause nerve root irritation, entrapment, compression and restrict nerve root mobility. When encased in scar tissue, nerve fibers are subject to increased tension, impaired blood supply and a reduced capacity to transport substances along its length. Epidural fibrosis has been reported to be the cause of symptoms in 8-14% of patients with failed back surgery syndrome (FBSS) and is related to a poorer surgical outcome and increased complication rates in patients requiring reoperation.

Chronic Pain Conditions

Multiple treatment strategies have been researched in hopes of finding a way to prevent scar tissue from forming without compromising the wound healing process. A variety of materials have been implanted on top of the dura such as absorbable gelatin sponges and Gore-Tex membranes.  Chemical agents aimed at reducing scar formation suppress fibroblast proliferation after surgery.   Although some methods show promising results, researchers are calling for further studies to determine short- and long-term complications as well as the efficacy of these methods in clinical practice.

Scar tissue (fibrosis) generally forms between 6 weeks and 6 months after surgery, which may be why some individuals experience initial improvement of their symptoms, followed by a gradual return of back and/or leg pain. Undergoing additional surgery to remove scar tissue is not always recommended as the scarring tends to reform and can ultimately leave the patient worse off than they were before.

Some suggest that stretching the nerve root while the body is healing after back surgery can help limit epidural fibrosis from becoming a clinical problem.  The theory is that if the nerve is kept mobile while the wound heals, the nerve will not be bound down by adhesions and the scar tissue that does develop should be less problematic.

Spinal Instability

It is estimated that more than 300,000 spine fusions are performed annually in the United States which reflects a 76% increase in this procedure between 1996 and 2001.  The reasons for spinal instability are numerous and can be related to injury or disease of the bones, discs, joints or ligamentous support structures.

White and Panjabi described spinal stability as the ability of the spine, under physiological loads, to limit patterns of displacement so as to not damage or irritate the spinal cord and nerve roots and, in addition, to prevent incapacitating deformity or pain due to structural changes.  Conversely, instability refers to excessive displacement of the spine that would result in neurological deficit, deformity, or pain.  Instability can have an acute onset, as with spinal fractures or dislocations, or present as chronic conditions (i.e. spondyolisthesis3).

Depending on the circumstances, stabilization can be achieved externally or internally.  Chronic instability (and acute stable injuries such as fractures without displacement and/or nerve compression) can be stabilized with external bracing such as a cervical collar, halo brace or Thoracic lumbo-Sacral Orthosis4 (TLSO).  When applied, external bracing provides support which can improve posture and facilitate unloading of the compressive forces on the spine.  Bracing can also be used as a temporary means of stabilization, before fusion is undertaken or after surgery, until healing occurs.

Back Devices for Chronic Pain Conditions

Spinal fusion is an example of internal stabilization. This can be accomplished with bone grafting, hardware or a combination of both.  Many factors can adversely affect healing after fusion.  According to Pakzaban, these can include malnutrition, cortisteroid use, irradiation, cancer, diabetes, infection, osteoporosis and smoking. Of these, smoking is the most prevalent correctable risk factor.  There is growing evidence that cigarette smoking adversely affects fusion and disrupts the normal function of basic body systems that contribute to bone formation and growth.  In a study of patients undergoing lumbar fusion, the patients who smoked experienced failed fusions in up to 40% of cases, compared to only 8% among non-smokers.

Postoperatively, early mobilization is recommended as it expedites rehabilitation and can prevent complications associated with immobility (deep vein thrombosis, pneumonia etc).  If fusion is performed without instrumentation (hardware) an external support brace or orthosis is utilized until the fusion has matured.  If hardware has been used, an external orthosis may still be applied during healing to provide additional supplemental support for the hardware especially with more extensive procedures.  Although exercise therapy is often delayed several months, some studies suggest that an early home program focused on pain-contingent training for functional strength and endurance of back, abdominal and leg muscles, as well as stretching and cardiovascular fitness is beneficial.

As we all know, surgical fusion of the spine does not always result in relief of pain and FBSS often becomes a chronic condition. Conservative management includes the use of analgesics, anti-inflammatory drugs and physical therapy.  When depression is a factor, psychological intervention may be indicated.  Some physicians also advocate behavioral modification to address smoking cessation, weight loss or other lifestyle changes. Periodic epidural steroid injections or facet injections may be used to provide pain relief and increase functional activities.

Achieving the goal of improved function often involves a patient-centered, multidisciplinary approach.  Treatment planning and future care considerations need to address a biopsychosocial factors as well as spiritual and cultural issues.  With an emphasis on patient education, empowerment, self-management skills and lifestyle changes, the chronic pain sufferer is in a better position to regain control of their life.

In Part III of this series, Chronic Pain Conditions and their Impact on Future Care, we will explore the world of implantable devices used in the treatment of chronic pain conditions.  These include Spinal Cord Stimulators (aka Dorsal Column Stimulators) and Intrathecal Pain Pumps that deliver medication directly to the spinal fluid.

Gould & Lamb Medicare Compliance

1Collagen is any of various tough, fibrous proteins found in bone, cartilage, skin and other connective tissue.  Collagens have great tensile strength, and provide these body structures with the ability to withstand forces that stretch them.

2The dura mater or simply dura is the outermost membrane which envelopes and protects the spinal cord
3Spondylolisthesis is a descriptive term referring to slippage of a vertebra (usually forward) relative to another vertebra.  Spondylolisthesis is graded according to the percent of displacement
4The Thoracic Lumbo-Sacral Orthosis or TLSO brace stabilizes the spine with circumferential pressure. Whereas a Halo brace stabilizes the cervical spine with rigid hardware attached to the skull on one end and fixed to a vest (made of plaster or molded plastic) on the upper body.


1.    Skaf, G., Bouclaous, C., Alaraj, A., Chamoun, R., Clinical Outcome of Surgical Treatment of Failed Back Surgery Syndrome. Surgical Neurology.  64 (2005) 483-489.
2.    Rabb C. Failed back syndrome and epidural fibrosis.  The Spine Journal 10 (2010) 454-455
3.    Ullrich P.  Failed Back Surgery Syndrome (FBSS):  What It Is and How to Avoid Pain after Surgery. Updated 11/4/09.
4.    Ross J, Obuchowski N, Zepp R.  The Postoperative Lumbar Spine:  Evaluation of Epidural Scar over a 1-Year Period.  Am J Neuroradiol 19:183-186, Jan 1998.  
5.    Yildiz K, Gezen F, Is M, Cukur S, Dosoglu M., Mitomycin C, 5-fluorouracil, and cyclosporine prevent epidural fibrosis in an experimental laminectomy model.  Eur Spine J 2007 Sept; 16(9):  1525-1530 (
6.    Ulrich P.  Scar Tissue and Pain After Back Surgery.  Updated 3/6/02.
7.    Resnick et al, Guidelines for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 8:  lumbar fusion for disc herniation and radiculopathy.  J Neurosurg: Spine (2):673-678, Jun 2005
8.    Pakzaban P.  Spinal Instability and Spinal Fusion Surgery Treatment & Management.  eMedicine Medscape Reference. Updated Jun 7, 2010
9.    Deyo RA, Nachemson A, Mirza SK. Spinal-fusion surgery – the case for restraint. N Engl J Med. Feb 12 2004;350(7):722-6.
10.    Brown CW, Orme TJ, Richardson HD.  The rate of pseudarthrosis in patients who are smokers and patients who are nonsmokers:  a comparison study.  Spine 1986; (9):942-3
11.    Holten K, ed.  Managing chronic pain:  What’s the best approach? Family Practice  Dec 2008; 57(12): 806-811.
12.     Panjabi M. Clinical spinal instability and low back pain.  Journal of Electromyography and Kinesiology, 13 (2003) 371-379

Part I – Chronic Pain Conditions Impact on Future Care

An Introduction to Chronic Pain

Patricia Rapson, RN, CCM, CLCP, CBIS, MSCCChronic pain is an enormous topic and much has been written regarding its causes and management. An Introduction to Chronic Pain is Part One in a series of upcoming posts which will highlight injuries and conditions associated with chronic pain, look at their impact on future care, and identify some of the strategies used in long term management of these often complex conditions.

Pain affects millions of individuals each year, and is seen as a common theme in many types of claims. Pain affects more Americans than diabetes, heart disease and cancer combined and has been referred to as the most costly health problem in America. It is estimated that 50 million Americans are either partially or totally disabled due to chronic pain. Economically, for the individual, this translates into lost income and emotional / financial burdens. For the employer, the reduced annual productivity is estimated to be between $60 and $100 billion.

The American Society of Anesthesiologists defines chronic pain as “pain of any etiology not directly related to neoplastic involvement, associated with a chronic medical condition or extending in duration beyond the expected temporal boundary of tissue injury and normal healing, and adversely affecting the function or well-being of the individual.” (2010)

chronic pain conditions impactChronic pain differs from acute pain or recurrent acute pain. Acute pain is due to actual or pending tissue damage as seen with fractured bones, lacerations, or post surgical pain. An example of acute pain from pending tissue damage would be Chest pain (angina) due to lack of oxygen to the heart muscle. In this case, if circulation is not restored to the heart muscle, the involved area eventually dies resulting in infarction or heart attack. Acute pain improves as healing occurs. Acute recurrent pain refers to episodic pain associated with chronic conditions such as migraine headaches in which one may experience intense, sometimes disabling pain which then resolves and recurs with the next episode. Although acute pain can be intense, the perception and behavior associated with it tends to be short-term. Chronic pain, described above, tends to be long-standing and refractory to treatment.

Marchand (2009) noted that the mechanisms believed to be associated with the development and persistence of pain involves changes which occur at all levels of the central nervous system (CNS) when pain signals are transmitted from the body’s periphery (everything outside the CNS). Evidence-based research suggests that when acute pain does not resolve within a few months, continued activation of the nerves which transmit pain impulses may result in changes to the spinal cord and brain, eventually leading to the development of chronic pain and chronic pain syndrome. In addition, when our brains receive pain a message, the information is associated with the emotion and processed. Our resulting sensation therefore, has both physical and emotional components.

The “Terrible Triad”

Chronic intense pain can be overwhelming, interfering with work and normal activities. Often times the individual becomes so preoccupied with the pain, their appetite decreases. Physical activity exhausting and individuals sometimes fear it will worsen or aggravate the pain. As a result, they avoid activity, becoming more and more sedentary. Depression and irritability soon follow leading to insomnia. Lack of refreshing sleep causes fatigue; which can trigger more irritability, depression and pain.

This cyclic state is referred to as the “terrible triad” of suffering, sleeplessness, and sadness. Many individuals become so distraught and desperate that they will do anything to stop the pain. This can lead to drug-dependents; searching for multiple opinions, repeated surgeries and/or seeking relief via unusual or bizarre cures. Does this scenario sound familiar?

Biopsychosocial Model on Chronic Pain

Many factors contribute to the cause of chronic pain. These can include a variety of disorders such as arthritis, spinal compression fractures, fibromyalgia, faulty or poor posture, nerve injuries, cancer, irritable bowel syndrome and peripheral vascular disease, just to name a few. Some authors have suggested that a chronic pain syndrome represents a learned behavioral syndrome that begins with a noxious stimulus that causes pain. This pain behavior is reinforced either by external rewards (attention from family and friends, socialization with the physician, medications, compensation and/or time off work etc) or internal reinforces which provide relief from personal factors (guilt, fear of work, sex, responsibilities).

Richard A Sternbach, a researcher and program director at the Pain Treatment Center of California’s Scripps Clinic and Research Foundation, refers to the 6 D’s of Chronic Pain Syndrome. These include:

  • Dramatization of complaints
  • Drug misuse
  • Dysfunction/disuse
  • Dependency
  • Depression
  • Disability

When dealing with chronic pain, the burning question remains… Why do some individuals with serious injuries do so well that they defy the odds; while others experience prolonged recovery and /or long-term disability after seemingly minor injuries?

Weighill (1983) and Hanson-Mayer (1984) identified the following factors which contribute to delayed recovery: unconscious psychological conflicts; personal predisposition; pre-existing psychological disability; low work satisfaction; poor attitudes toward work and social responsibilities; family system homeostasis under threat; the accident as a “solution” to current life problems, no incentive for light duty; unions encouraging additional time off and others.

Headley (1989) notes that no personality cluster has yet been identified which, when subjected to an injury, produces delayed recovery. Hence “A” + “X” + “injury” = Delayed Recovery is too simplistic a formula by which to identify or intervene to decrease undesirable behavior. Instead, Headley recommends a biopsychosocial approach to understanding delayed recovery. She notes that a specific lack of certain coping skills; when combined with the physical aspects of pain (which are often unclear), social, industrial and medical factors, influence human functioning.

Chronic pain syndrome can be difficult to manage because of its complex natural history, unclear etiology and poor response to therapy. If at risk individuals can be identified, a proactive approach with early intervention, multidisciplinary treatment and an individualized care plan can made a difference. Consider the involvement of a qualified medical case manager. Although not appropriate for every situation, they can help to facilitate compliance, coordinate care and act as an intermediary between the involved parties so that these individuals don’t get lost in the system, treatment moves forward everyone is kept in the loop.

Overall the treatment goals need to be realistic and focused on the restoration of normal function to the extent possible, improved quality of life, reduction of medication and prevention of relapse. Efforts should be directed at making the individual with chronic pain self-reliant.

As we all know, despite the best efforts, some individuals will remain stuck in the cycle of chronic pain. In cases such as these life care planning for the future often occurs after pain clinic and surgical interventions have failed. When considering long term conservative care, multidisciplinary treatment programs can offer valuable resources. Typically the needs of the patient will require multiple measures to maximize the outcome of the patient’s ability to manage his or her own condition after a period of six months to a year. Most outpatient programs include a brief 1- to 2-month period of intense evaluation and management followed by a middle period of 3 to 6 months of continued weekly or monthly monitoring associated with the establishment of a management program tailored to fit the needs of the individual (Weed, Berens 2010). Identifying a primary treating physician who can provide ongoing long-term monitoring is optimal. Once the formal program is completed, long term cost estimates will include provisions for periodic reevaluation to assess and modify the program so that it remains appropriate and can address changing needs associated with aging. In addition, costs of medications and replacement/repair of any durable medical equipment should be evaluated and included.

Ultimately, the overall success of treatment is influenced by the individual’s compliance and ability to adopt new lifestyle measures and adjust and/or habituate certain aspects of their daily routine (i.e. Biofeedback, relaxation). The goal of chronic pain planning is not to reduce the pain to the level it was before the injury, as this is not always realistic, but to modify the pain and provide strategies which enhance quality of life and maintain a reasonable degree of function.

In treating one’s pain with medications, several options exist. First, we must try to differentiate between acute and chronic pain as length of time and types of medications differ. Acute pain is commonly treated for a short duration and with acetaminophen, NSAIDs (Ibuprofen) or even topical adjuncts (Capsaicin) for a short period of time. The treatment of chronic pain poses a greater challenge as it is commonly undertreated and medication usage may produce toxicities or addictive side effects when taken for long periods of time.


1. AAPM Facts and Figures on Pain. The American Academy of Pain Medicine.
2. National Centers for Health Statistics, Chartbook on Trends in the Health of Americans 2006, Special Feature: Pain. Nov 2006
3. Low Back Pain Fact Sheet. National Institute of Neurological Disorders and Stroke, National Institutes of Health. Updated Feb 18, 2011
4. Practice Guidelines for Chronic Pain Management. An Updated Report by the American Society of Anesthesiologist Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology 112:810-33. Apr 2010.
5. Marchand, Serge. “The Physiology of Pain Mechanisms: From the Periphery to the Brain.” Rheumatic Disease Clinics of North America 24 2 (2008): MD Consult. Elsevier, Inc. 5 Feb. 2009
6. Weighill VE. ‘Compensation neurosis’: a review of the literature.
J Psychosom Res. 1983; 27(2): 97-104
7. Hanson-Mayer TP. The worker’s disability syndrome. Journal of Rehabilitation, 50(3), 50-54, 1984
8. Headley BJ. Delayed Recovery: Taking Another Look. Journal of Rehabilitation, Vol 55, 61-66, 1989
9. Weed R, Berens D, Life Care Planning and Case Management Handbook: Third Edition, Chapter 17, Life Care Planning for People with Chronic Pain. CRC Press, Boca Raton, FL, 2010.

Please stay tuned for Part Two: Failed Back Syndrome. Also as part of our Chronic Pain Conditions Impact on Future Care series, William Bell, Jr. BSPharm, MBA, MSCC, Gould and Lamb’s Senior Clinical Pharmacist will weigh in on Pain Management Pharmacotherapy.


Considering Impairment, Disability and Functional Outcome when Projecting Future Care

Patricia Rapson, RN, CCM, CLCP, CBIS, MSCCThe concepts of impairment and disability are often confused and misunderstood.  Depending on the venue in which they are applied, there can be numerous accepted definitions for these terms. Understanding these terms and how they are interpreted by various organizations is vital in determining effective future care costs and projections.

Impairment is from the Latin impejorare, meaning to make worse.  The American Medical Association AMA defines impairment as a “significant deviation, loss, or loss of use of any body structure or body function, in an individual with a health condition, disorder, or disease.” Disability refers to “activity limitations and/or participation restrictions in an individual with a health condition, disorder, or disease.”¹   In other words, disability equates to the limitations and restrictions which result from an impairment.

The World Health Organization – WHO, which serves as the public health arm of the United Nations, considered a somewhat broader view of these terms.  WHO defines impairment as a problem in body function or structure.  Disability, on the other hand, is considered an umbrella term, covering impairments, activity limitations (such as a difficulty encountered by an individual executing a task or action) and participation restrictions (a problem experienced by an individual with involvement in life situations).  WHO recognizes disability as a complex phenomenon, reflecting the interaction between features of a person’s body and features of the society in which he or she lives.  In 2001, the 54th World Health Assembly endorsed WHO’s International Classification of Functioning, Disability and Health – ICF.  This is a classification of health and health-related domains which considers both body functions and structure as well as domains of activity and participation.  The ICF acknowledges that every human being can experience decline in their health and thereby also experience some degree of disability.  Disability is not seen purely as a “medical” or “biological” dysfunction, but a universal human experience in which environmental factors play an important roll in a person’s level of functioning.

In contrast, the Social Security Administration – SSA considers disability as it relates to employment and the inability to engage in any substantial, gainful activity by reason of any medically determinable physical or mental impairment(s).  Such impairments can be expected to result in death or have lasted or can be expected to last for a continuous period of not less than 12 months.  Because under SSA rules a person is either entirely disabled or not disabled at all, a rating system based on percentage of impairment is not utilized.  Instead, the SSA uses a sequence of evaluations and also considers an individual’s age and education in their analysis and ultimate determination.  When an individual is considered disabled under SSA, they may be eligible to receive cash payments as well as coverage under Medicare or Medicaid.

State and private insurance companies also offer a variety of disability plans in which qualification for benefits is not dependent on an on-the-job injury, however there may be provisions which require an initial period of disability prior to receiving benefits.  Many of these policies tend to be broader than those offered by Workers’ Compensation.

There are many definitions of disability under Workers’ Compensation, although, they typically include statements which refer to a reduction in ones wage-earning capacity as a result of an injury, illness, or occupational disease that arose out of, or in the course of employment.  In Workers’ Compensation, disability can be considered permanent or temporary, as well as partial or total.  Permanent impairments are those which have reached a state of Maximum Medical Improvement – MMI or are Permanent & Stationary – P&S.  At this point the impairment is considered static / stable, has had sufficient time to allow optimal tissue repair and is unlikely to change, despite further medical or surgical intervention.

The purpose for impairment rating is to represent the impairment by using a generally accepted system to estimate the degree to which illness or injury diminishes an individual’s capacity for daily activities. Impairment ratings are commonly used in a legal setting where they can help the parties understand the extent of an injured workers limitation and are also considered when determining compensability and settlement.

Impairment rating systems vary considerably depending on the state and/or jurisdiction involved.  While some states have specific statuary requirements regarding methods of permanent impairment rating – PIR, other states have abandoned the available guidelines in favor of developing their own rating standards.

The Impact of Individualized Future Care on Disability

Projecting Future CareImpairments, although they may be significant, do not necessarily equate into total and permanent disability.  Access to appropriate care and services after catastrophic illness or injury is imperative to achieving the highest functional outcome possible.  Accurate and comprehensive evaluation and interpretation of the medical records is a necessary step when considering the future care needs of claimants.  The impact of appropriate adaptive devices and/or services such as physical and occupational therapy can help to maximize function and can make the difference between dependence and independence in the ability to successfully perform activities of daily living.

Activities of daily living – ADL can be broken down into two groups or categories; basic and advanced (instrumental).  Basic ADLs represent those activities that are necessary for self care.  These include activities such as bathing, dressing, grooming, toileting, feeding oneself and mobility (standing, walking, transferring, etc.).  In other words, all those activities you independently performed prior to leaving the house for school when you were young.  Advanced (Instrumental) ADLs, although not vital for fundamental functioning, allow an individual to live independently in a community.  Advanced ADLs encompass activities such as shopping, planning and preparing adequate meals, housekeeping, laundry, using the telephone, accessing transportation, appropriately taking medications, and the ability to handle personal finances.

Consider a 24 year old man who has sustained a catastrophic injury, a complete spinal cord injury (permanent impairment) resulting in paraplegia.   After his acute recovery, he goes to in-patient rehabilitation where he receives intensive therapies and instruction.  It is not uncommon for an individual such as this to ultimately live independently; drive a vehicle adapted with hand controls, and work full time.   Mobility independence using a wheel chair is still considered independent mobility, albeit modified.  And with the appropriate equipment and training, the gentleman in this scenario remains modified independent with his ADLs.

When planning for future care, whether for a Life Care Plan, Medical Cost Projection or a Medicare Set Aside, it is important to understand and consider how the impairment and resulting disability impact the individual.  In addition, just as our needs change as we age, so do the needs of those with impairment and disability.  These are issues that must also be considered so that the items and services in the plan appropriately coincide with changing needs.   Effective future care planning involves the ability to understand and interpret the available information, physician recommendations and standards of care as well as the  knowledge, expertise and experience of the individuals who develop them.


¹Rondinelli R, Changes for the New AMA Guides to Impairment Ratings, 6th Edition:  Implications and Applications for Physician Disability Evaluations. PM&R, July 2009, Vol 1 (7); 643-656