The American Medical Association (AMA) appreciates the opportunity to provide the House Committee on Veterans Affairs Subcommittee on Disability Assistance and Memorial Affairs with comments on reforming the Veterans Disability System.  Our comments follow our review of the Institute of Medicine’s (IOM) 2007 report entitled, A 21st Century System for Evaluating Veterans for Disability Benefits, which highlights the significant shortcomings of the current, antiquated veterans disability system.

The AMA supports reforms to the Veterans Disability System, as demonstrated in the AMA’s Guides to the Evaluation of Permanent Impairment, Sixth Edition (Guides), which was published in December, 2007.  This current edition defines a new international standard for impairment assessment.  A consistent, well-designed methodology was adopted and applied to each chapter to enhance validity, improve internal consistency, promote greater precision, standardize the rating process, and improve inter-rater reliability.  The goal is to provide an impairment rating guide that is authoritative, fair, and equitable to all parties.  The editorial process used an evidence-based foundation when possible and a modified Delphi panel approach to consensus building. Additionally, the editorial process was undertaken by a panel of experts and physician specialists in the field of impairment assessment.

The traditional model of disablement was based on the International Classification of Impairments, Disabilities and Handicaps (ICIDH).  This was a unidirectional model that does not address all facets of an injury experience. 

The AMA Guides methodology applies the current state of the art terminology and adopts an analytical framework based on the World Health Organization’s International Classification of Functioning, Disability and Health (ICF):

ICF Model of Disablement

In evaluating the severity of an illness or injury, a physician typically considers four basic points:

(1) what is the problem (diagnosis); (2) what symptoms and resulting functional difficulty does the patient report; (3) what are the physical findings pertaining to the problem; and (4) what are the results of clinical studies. These same considerations are used by physicians to evaluate impairment and, therefore, are used as a guiding construct for the Guides.  The Sixth Edition is designed to encourage attention to, and documentation of, functional consequences of the impairment as a part of each physician’s detailed history, to clarify and delineate key physical findings, and to underscore essential clinical test results where applicable. 

Based on the efforts of the AMA process, Diagnosis-based grids were developed for each organ system.  These grids arrange diagnoses into five classes of impairment severity, according to the consensus-based dominant criterion.  The functionally-based history, physical findings, and broadly accepted clinical test results, where applicable, are then integrated to determine severity grade and provide a corresponding impairment value.  Ratings are transparent, clearly stated, and reproducible. The basic template of the diagnosis-based grid is common to each organ system and chapter; thus, there is greater internal consistency, facilitating the application of this new method.

Each chapter in the Guides was written by a group of specialty-specific, expert contributors, developing their respective chapter within the scope of this established framework.   The Sixth Edition of the Guides reflects a significant revision and includes changes to all chapters. The three most common organ system claims seen in the Veterans Disability system— Orthopedics, Psychiatry, and Hearing—are all completely covered by the respective AMA Guides chapters.  Further, these specialty-specific chapters do not use any separate specialty-specific resource outside of the Guides in their fields. As an example, the common psychiatric claims for Post-Traumatic Stress Disorder (PTSD), other anxiety disorders, traumatic brain disorders, depressive disorders, psychotic disorders, are all evaluated with the use of the AMA Guides.

To assess impairment using the Mental and Behavioral Disorders chapter of the Sixth Edition, the clinician must first make a definitive diagnosis using standard psychiatric criteria, including history, and adjunctive psychological, neuroradiological, or laboratory testing.  The Sixth Edition also supports the use of well-standardized psychological tests that may improve accuracy and support the existence of a mental disorder.  The diagnosis (with the associated factors of prognosis and course) will form the basis by which one assesses the severity and predicts the probable duration of the impairment.  The Guides Sixth Edition also uses three scales by which mental and behavioral impairment is rated: 1) the Brief Psychiatric Rating Scale (BPRS), 2) the Global Assessment of Functioning Scale (GAF), and 3) the Psychiatric Impairment Rating Scale (PIRS). The BPRS measures major psychotic and nonpsychotic symptoms in patients with major psychiatric illnesses.  The GAF evaluates overall symptoms, occupational and social function. The PIRS assesses behavioral consequences of psychiatric disorders within various areas of functional impairment.  The purpose of including all three of these scales is to provide a broad assessment of the patient with mental and behavioral disorders as the individual scales focus on symptom severity and/or function.  The objective of making a reliable diagnosis and coupling it with the assessment of these three scales is to arrive at a strongly supportable impairment rating. 

Any model used to determine disability for veterans will require a comprehensive, regularly updated, commonly accepted rating method to diagnose medical impairments and link them to basic functional limitations.  The AMA Guides offers a methodology to achieve this.  Any physician trained and experienced in Guides methodology within or external to the VA can provide these assessments.  This information is a necessary first step in the comprehensive integrated determination of work disability, non-work disability, individual unemployability, and quality of life.

One of the most important changes to the Guides development process was the establishment of the Guides Advisory Committee. This advisory committee is composed of representatives from certification organizations, teaching organizations, workers’ compensation systems, or are members of the AMA’s policy making body known as the House of Delegates (HOD), which is comprised of representatives from 109 national medical specialty societies and all the state medical societies. 

The Guides Advisory Committee is ongoing and meets annually to discuss items of mutual concern and current issues in impairment and disability.  The Advisory Committee’s primary objectives are to:

• serve as a resource to the Guides Editorial Panel by giving advice on impairment rating as relevant to the member’s specialty;
• provide documentation to staff and the Editorial Panel regarding the medical appropriateness of changes under consideration for inclusion in the Guides;
• assist in the review and further development of relevant impairment issues and in the preparation of technical education material and articles pertaining to the Guides; and
• promote and educate the membership of representative organizations on the use and benefits of the Guides.

The Guides Advisory Committee will receive all recommendations for changes to future editions of the Guides. Based on current scientific and clinical evidence, the Advisory Committee members will help determine the scientific merit of each recommendation and use these to form the foundation for subsequent editions of the Guides. The goals of the new approach are to obtain broad input from stakeholders and to develop a process for defining impairment that is supportable, high-quality, efficient, and effective.  If the Guides were to be used within the VA system, the AMA would solicit representation from the Veterans Administration to ensure our responsiveness to any particular Veterans Administration need. 

In conclusion, there are significant shortcomings of the current, antiquated veterans disability system as highlighted by the IOM.  The current international science of disability places the World Health Organization model as the centerpiece to approaching this discipline.  The AMA Guides has been specifically developed to be at the forefront of the rating process and addresses the IOM reforms and virtually all of the recommended enhancements to the impairment rating process. As with all needed reforms to any aspect of our nation’s healthcare systems, the AMA is prepared to offer the resources of our organization to assist in the ongoing dialogue of implementation and improvement.