You are in: eMedicine Specialties > Physical Medicine and Rehabilitation > OCCUPATIONAL MEDICINE Workers' Compensation SystemArticle Last Updated: Jun 15, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 9
  Author: Kelly L Allen, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Lourdes Regional Rehabilitation Center, Our Lady of Lourdes Medical Center Editors: Patrick J Potter, MD, FRCP(C), Director of Spinal Cord Injury Program, Associate Professor, Department of Physical Medicine and Rehabilitation, Parkwood Hospital, Lawson Health Research Institute; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Richard Salcido, MD, Chairman, Erdman Professor of Rehabilitation, Department of Physical Medicine and Rehabilitation, University of Pennsylvania School of Medicine; Denise I Campagnolo, MD, MS, Director of Multiple Sclerosis Clinical Research and Staff Physiatrist, Barrow Neurology Clinics, St. Joseph's Hospital and Medical Center; Investigator for Barrow Neurology Clinics; Director, NARCOMS Project for Consortium of MS Centers, Phoenix; Consuelo T Lorenzo, MD, Consulting Staff, Department of Physical Medicine and Rehabilitation, Alegent Health Care, Immanuel Rehabilitation Center Author and Editor Disclosure Synonyms and related keywords: workman's compensation, disability evaluation, independent medical examination, work-related injury INTRODUCTIONSection 2 of 9
  The workers compensation system is a form of social insurance that provides injured workers with medical care, income (or a percentage of income), and survivor benefits in cases of fatalities. The worker, in turn, waives the right to sue his or her employer under common law. HISTORY OF WORKERS' COMPENSATION SYSTEMSSection 3 of 9
The history of workers' compensation systems has been reported back to ancient time. In 1908, the United States enacted the Federal Workers' Compensation Act (FECA). Individual states followed soon after, with New York in 1910 and New Jersey in 1912. In the late 1940s, Mississippi was the last state to develop workers' compensation legislation. Many European countries had addressed the need for a no-fault workers' compensation program prior to the United States. Occupational claims and legislation regarding such claims did not come into favor in the United States until approximately 1917. Prior to workers compensation legislation, both the employee and employer could be affected by a claim. The employee could potentially lose his or her job, income, and the ability to receive medical treatment. The employee would often have to fund his or her own legal defense (which could potentially become quite expensive) and prove in a court of common law that the employer was negligent. The employer was also at a significant risk because lawsuits were costly (even with a favorable outcome) and the results unpredictable. WORKERS' COMPENSATION SYSTEMS IN THE UNITED STATESSection 4 of 9
Federal workers' compensation programs
State workers' compensation programs State workers' compensation statues provide guidelines for most, if not all, injured workers not covered by the federal programs mentioned above. The differences in legislation from state to state include, but are not limited to, issues related to benefits, waiting periods, choice of physicians, physician fee schedules, occupational exposures, schedules of awards, and administration of the system (ie, court vs special state agency). Many states also have legislation protecting employers from liability and medical expenses related to hiring a prospective worker who has a preexisting disability. These programs are often referred to as the Second Injury Fund or the Special Disability Trust Fund. THE INJURED WORKERSection 5 of 9
Work-related injuries are classified as either accidental traumas or occupational diseases. Generally, the injured worker has the responsibility to report the injury in a timely fashion. The reporting of injuries or occupational exposures usually has a statue of limitations. This may vary from state to state and within the federal systems. All injuries or occupational diseases deemed compensable must "arise out of" or occur "in the course of" employment. This confirms the idea that the work-related injury or occupational exposure would not have occurred had the employee been engaged in non–work-related activities. For example, if an employee slips and falls while in the course of his or her employment and sustains a laceration of the head, this would be compensable. Alternatively, if an employee with a balance disorder simply falls with no known cause and sustains a laceration to his or her head, this may not be considered compensable. Most often, the situations are not so clear-cut. Once an injury or occupational disease is considered compensable, most systems require the employer to provide medical treatment, rehabilitation, and a percentage of prior earnings (usually two thirds of the employee's salary, up to a maximum value amount). Medical treatment is either employee or employer directed depending on individual state or federal statue. Treatment is usually continued until the worker has reached maximum medical improvement (MMI) or maximum medical benefit (MMB), whereby no further therapeutic interventions or diagnostic testing will improve the worker's subjective complaints. This is most likely determined by the treating physician, but it also may be a question addressed in an independent medical evaluation (IME). In some cases, palliative care may continue beyond a point of MMI or MMB. In addition, employees may enter into a compensable injury with preexisting conditions. For example, an employee with a long history of back pain, including a prior surgical procedure, "re-injures" his or her back in the course of employment. This may represent an increase in the employee's prior condition and, therefore, fall under the categorization of an "activation, acceleration or exacerbation" of a preexisting disorder. This also can become very complicated, particularly when no diagnostic studies preexist the injury that would provide a baseline for a certain condition. Apportionment is determining what portion of impairment preexisted the injury in question versus what portion of impairment is directly and objectively related to the injury in question. This can be very difficult to determine and may also be an indication for and IME. INDEPENDENT MEDICAL EXAMINATIONSSection 6 of 9
A physician who has not previously treated the employee usually performs the IME. Normally, no doctor-patient relationship exists between the examiner and employee. Occasionally, physicians may be asked to take over treatment. Numerous indications exist for IMEs within workers' compensation systems, which include, but are not limited to, the following:
IMPAIRMENT/DISABILITY RATINGSSection 7 of 9
Impairment is defined by the World Health Organization as any loss or abnormality of psychological, physiological, or anatomical structure or function. The American Medical Association (AMA) defines impairment as loss; loss of use; or derangement of any body part, system, or function. Disability is defined by the World Heath Organization as any restriction or lack of ability (resulting from an impairment) to perform an activity in the manner of within the range considered normal for a human being. The terms impairment and disability are often interchangeable in workers' compensation systems. However, the AMA has determined that impairment and impairment ratings are more appropriate. Most states require examiners to use the AMA guidelines (Guides to the Evaluation of Permanent Impairment, fourth or fifth edition) to determine accurate impairment ratings. The AMA guidelines were developed to limit the wide range of impairment values reported by different examiners. The AMA guidelines stress a limited amount of inter-rater discrepancy (no more than 2.5%) when determining impairment ratings on the same individual. In reality, this does not always occur. ROLE OF THE PHYSIATRISTSection 8 of 9
Physiatrists are in a unique position to evaluate impairment and permanency. They are trained in musculoskeletal medicine, orthopedic rehabilitation, neurological rehabilitation, rheumatologic rehabilitation, spinal cord injury, brain injury, amputation, and workers' compensation injuries. They are also trained in electrodiagnostic medicine, which is particularly useful when dealing with carpal tunnel and radiculopathy claims. Physiatrists are experts in disability and long-term management. Ergonomics and biomechanics are also stressed in training, which are helpful in determining work restrictions and preventive measures. REFERENCESSection 9 of 9
Workers' Compensation System excerpt Article Last Updated: Jun 15, 2006 |
