NEWS & COMMENTARY

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References & Links

Journal of the American Medical Association (JAMA)
jama.ama-assn.org

Occupational Health and Safety Administration (OSHA)
www.osha.gov

American College of Occupational and Environmental Medicine (ACOEM)
www.acoem.org

A special communication in the January 26, 2000 issue of the Journal of the American Medical Association (JAMA) calls for significant changes in the AMA’s Guides to the Evaluation of Permanent Impairment, Fourth Edition. The article, entitled "Recommendations to Guide Revision of the Guides to the Evaluation of Permanent Impairment" was authored by Emily A. Spieler, JD, Peter S. Barth, PhD, John F. Burton, Jr., PhD, LLB, Jay Himmelstein, MD, and Linda Rudolph, MD, MPH, and makes nine major recommendations for revision.

The Guides are used in some fashion for assigning benefits in over 40 state workers’ compensation systems. Some states, most notably California, do not use them. The JAMA article addresses the criticism that the Guides have too many internal deficiencies to be valid. The study concluded: "The poor reliability of the American Medical Association Guides’ spinal range of motion model can result in marked variation in the percentage of whole body impairment. These findings have implications for compensation bodies in Australia and other countries that use the AMA Guides’ procedure to estimate impairment in chronic low back pain patients."

Comment: This is an extremely thoughtful commentary on a very serious problem which affects occupational medicine. One hopes that the committees that develop the Guides will be able to integrate the recommendations. The Guides deficiencies are glaring. As it stands now, competent physicians, carefully applying the Guides, frequently arrive at widely varying impairment ratings. I’m sure that makes observers question whether any of us know what we are doing. - William L. Newkirk, MD (wln)

On January 17, 2000, the web site of the American College of Occupational and Environmental Medicine published a new position paper on "Spirometry in the Occupational Setting." The paper, developed by the Occupational and Environmental Lung Disorder Committee of the ACOEM, chaired by James E. Lockey, MD, MS, recommends that the NHANES III equations be considered for general use in the occupational setting.

In spirometry, predictive value equations are used to determine whether a person’s pulmonary function results are normal. Over the years, several versions of the equations have been used.

In occupational medicine, Knudson’s 1976 prediction equations have been widely used because OSHA mandated these equations for the Cotton Dust Standard. They were the only equations available at the time that studied both males and females, were based on non-smokers, and measured only Caucasians. When these were applied to workers in the cotton industry, healthy African-American workers were frequently found to have abnormally low lung function. To correct for this, OSHA mandated an ethnic adjustment (multiplying the FEV1 and FVC by 0.85) although OSHA recognized that the correction was not precisely correct.

In 1981, Crapo published a different set of predictive equations which have been adopted by the American Medical Association (AMA) as the standard reference in the AMA’s Guides to the Evaluation of Permanent Impairment, Fourth Edition. The Knudson data were re-analyzed in 1983 and new equations were developed.

In January 1999 John Hankinson and colleagues published new equations based on the National Health and Nutrition Examination Survey (NHANES III). These data allow new reference equations to be calculated separately for Caucasians, African-Americans, and Hispanics. ACOEM recommends that the NHANES III equations be considered for general use in the occupational setting.

Comment: It will take some time before all spirometry machines used in occupational medicine reflect the recommended equations. It will be good to finally have race-specific equations so that the practice of across the board, often inaccurate, ethnic adjustments can stop. wln

On March 24, 2000 physicians performed the first surgical procedure to implant the SB Charite III disc prosthesis in the U.S. The prosthesis consists of a polyethylene core that slides between two metal endplates, and has been in use outside the United States for more than 10 years. The surgery was performed on a 31-year-old male. The patient has suffered from low back pain for two years. He injured himself while lifting a heavy object.

Ten investigational sites will be conducting FDA-approved trials of the device in the U.S. Patients included in the FDA study must have single level degenerative disc disease with back pain, rather than leg pain, as the major complaint and be 18-60 years of age. This pain should have persisted for at least six months without resolving while under the care of a physician. Each patient will be followed for a minimum of two years. The investigative study will compare the SB Charite III device to lumbar fusion, the procedure currently performed to treat this type of back pain problem.

Dr. Scott Blumenthal, the study’s lead investigator, said: "Every 10 to 15 years there is an evolutionary step in spine surgery and the artificial disc may be the next step. This development is similar in importance to the first artificial joint replacements done 20 years ago."

Comment: Dr. Ulf Fernstrom implanted the first artificial disc in the 1960s. The prosthesis consisted of a steel ball which was placed between the vertebrae to maintain the separation or height, while maintaining mobility. There were long term problems with these implants — the steel balls would migrate into the adjacent vertebrae. The SB Charite disc is the most frequently implanted artificial disc in the world. A study of 50 implant patients by Zeegers and colleagues from the Department of Orthopaedics, Maasland Hospital, Sittard, The Netherlands, found that 70% have a satisfactory clinical result at two years follow-up. They concluded that "in patients with severe isolated symptomatic discopathies that are resistant to conservative treatment, a mobile disc prosthesis is worth considering ...." The FDA implant study bears watching because of the large number of patients with chronic back pain due to discopathy seen by occupational medicine clinics. wln

On Friday, March 3, 2000 California’s Insurance Commissioner, Chuck Quackenbush, took control of Superior National Insurance Group, one of California’s largest workers’ compensation insurers. The state’s financial assessment of Superior National revealed that the company was in "hazardous financial condition and was severely under reserved."

"The workers’ compensation insurance market here in California is fiercely competitive. A by-product of that reality is the possibility of circumstances arising such as these, where a carrier cannot remain competitive and financially solvent at the same time,’’ said Commissioner Quackenbush. "Superior National faced unforeseen loss ratios and an adverse claims history that has resulted in a significant shortfall in reserves. Superior National must be conserved in order to ensure that claims will be paid.’’

The Superior Group is comprised of five companies with assets of $730 million and a 1999 premium income of $240 million. Four of the companies have been seized by California regulators.

Comment: The recent article critical of workers’ compensation in Consumers Reports maligns the improved profitability of workers’ compensation insurers as it relates to workers’ rights and benefits. This is the other side of the story. The seizure of Superior National demonstrates what happens when insurers are not profitable. wln.

The February 2000 issue of Consumer Reports contains an analysis which is critical of the impact of recent changes in state workers’ compensation systems. The report concludes: "Workers deserve more help from the workers’ compensation system than they are getting."

The report states that the new laws that states passed in the early 1990s "generated profits for insurers and savings for employers mainly at the expense of injured workers.’’ Workers’ compensation reforms also reversed the steady increase in the percentage of payroll devoted to workers’ compensation. Starting at less than 1% in 1960, the percentage peaked at over 2% in 1993. Workers’ compensation benefits paid by insurers and employer premiums, as a percentage of payroll, fell by more than 20% from 1992 to 1996.

Among other things, the article calls for Congress to revive standards set by the National Commission on State Workers’ Compensation Laws to raise benefit caps to 100% of the state’s average weekly wage.

D.W. (Bill) Schrempf, President and CEO of National Council on Compensation Insurance (NCCI), responded to Consumer Reports: "Your recent report on the status of workers’ compensation was disturbingly one-sided and did not address the realities of the entire system. In fact, many of the factors impacting claims payments are not individual decisions, but are instead driven by regulation and the structure of the workers’ compensation system itself."

Comments: The Consumer Reports article does not cover any new ground. But it is interesting from another perspective. The predictable response to the article from NCCI illustrates the debate between controlling employers’ costs, on the one hand, and increasing workers’ compensation benefits, on the other, that has been with us for decades. The sweeping legislative reforms of workers’ compensation laws in the early 1990s reversed the long-term trend of increasing benefits and raising employer costs. These laws emerged amid great acrimony. Many states’ legislatures are wary of discussing the topic again. The importance of this article it that it represents an attempt to re-energize the debate from the labor perspective. This debate will never end. What  will be interesting is whether these groups can muster the strength to get state legislatures to change course. wln.