Opinion ID: 1280719
Heading Depth: 2
Heading Rank: 2

Heading: Why the Guides are at issue

Text: This case turns upon the propriety of the Commissioner's adoption of what the parties refer to as the Guides,  as the standard by which permanent impairment shall be determined. The full name of this publication is, The American Medical Association's Guides to the Evaluation of Permanent Impairment, Fourth Edition, and we shall refer to it simply as,  Guides, Fourth  in the text of this opinion, so that it is not confused with earlier or later editions of the same publication. [4] The Guides, Fourth are at issue in this case by virtue of the Legislature's delegation of authority to the Commissioner, and a rule issued by the Commissioner adopting the Guides, Fourth for certain purposes. Before addressing the application of this publication to examinations of spinal injuries, we first explain how it is that this publication is at issue in the cases below. As we have discussed in previous cases, the Legislature made significant changes to the workers' compensation system in 1995. On February 10, 1995, the West Virginia Legislature passed and enacted Committee Substitute for Senate Bill 250, which comprehensively revised numerous aspects of West Virginia workers' compensation law. The purported goal of these sweeping reforms envisioned ameliorating the workers' compensation fund's fiscal crisis and restoring its financial integrity. See State ex rel. Blankenship v. Richardson, 196 W.Va. 726, 729-31, 474 S.E.2d 906, 909-11 (1996). State ex rel. ACF Industries, Inc. v. Vieweg, 204 W.Va. 525, 529, 514 S.E.2d 176, 180 (1999) (footnote omitted). Of specific importance to this case is that the Legislature altered the way in which one discovers the extent of an injured worker's permanent partial disability; under current law, one determines the level of permanent disability by first finding the worker's degree of whole body medical impairment. The Legislature also granted the Commissioner authority to establish standards for the determination of that impairment: [T]he degree of permanent disability other than permanent total disability shall be determined exclusively by the degree of whole body medical impairment that a claimant has suffered.... The workers' compensation division shall adopt standards for the evaluation of claimants and the determination of a claimant's degree of whole body medical impairment. Once the degree of medical impairment has been determined, that degree of impairment shall be the degree of permanent partial disability that shall be awarded to the claimant. W. Va.Code ง 23-4-6(i) (1999). [5] Of course the ultimate question being asked is, how much, if any do we (the State) owe the injured worker? Before 1995, our system took into account factors beyond medical impairment when making a determination about permanent partial disability. As Justice Starcher explained in a concurring opinion, Prior to the Legislature's amendments in 1995, the Workers' Compensation Act distinguished between impairment, which is a medical question, and disability, which is a legal question. To determine impairment, a doctor would examine the claimant and render a scientific opinion regarding how much a claimant's physical functions were impaired by a work-related injury. The Workers' Compensation Commissioner would then determine disability by looking at the doctor's opinion on impairment, and mix that opinion with the evidence of the claimant's earning capacity, the effect of the impairment on the claimant's efficiency at work, and the effect of the impairment on the claimant's pursuit of normal everyday living. From a mix of these factors, the Commissioner would compute the claimant's percentage of permanent partial disability. The Commissioner's permanent partial disability award would, in theory, only partially take into account the doctor's determination of impairment. In 1995 the Legislature amended W. Va.Code, 23-4-6(i) to state that the degree of permanent disability other than permanent total disability shall be determined exclusively by the degree of whole body medical impairment that a claimant has suffered. This amendment altered the Workers' Compensation Act in two ways significant to this case. First, after 1995 doctors are to make impairment evaluations using a standardized, whole body impairment rating systemโin other words, they are to use the American Medical Association's Guides to the Evaluation of Permanent Impairment, Fourth Edition (1993). Second, the Commissioner is to make permanent partial disability awards solely on the basis of the doctor's impairment evaluation. Put another way, the percentage of medical impairment now equals the percentage of permanent partial disability, and the Commissioner cannot take into consideration any other factors. Wagner v. Workers' Compensation Div., 205 W.Va. 186, 191-92, 517 S.E.2d 283, 288-89 (1998) (per curiam) (Starcher J., concurring) (footnote omitted). Moreover, the Commissioner has equated an impairment rating conducted under this standard to be the equivalent of a disability rating for permanent impairment. The authors of The Guides themselves urge against any system that equates medical impairment with disability. As we noted in a case challenging the constitutionality of the 1995 changes: See 85 CSR 16-3.4 (defining permanent impairment and impairment, according to the Guides, and indicating that [a] claimant's degree of permanent whole body medical impairment is to be determined in keeping with the determination of whole person permanent impairment as set forth in the Guides. Id., in relevant part.) The exclusive use of the Guides for evaluation of impairment and, therefore, permanent partial disability, is not recommended by its author: The critical problem is that no formula is known by which knowledge about a medical condition can be combined with knowledge about other factors to calculate the percentage by which the employee's industrial use of the body is impaired. Accordingly, each commissioner or hearing official must come to a conclusion on the basis of assessment of the available medical and nonmedical information. The Guides may help resolve such a situation, but it cannot provide complete and definitive answers. Each administrative or legal system that uses permanent impairment as a basis for disability ratings should define its own means for translating knowledge about an impairment into an estimate of the degree to which the impairment limits the individual's capacity to meet personal, social, occupational, and other demands or to meet statutory requirements. It must be emphasized and clearly understood that impairment percentages derived according to Guides criteria should not be used to make direct financial awards or direct estimates of disabilities. Id. at 1/4-1/5 (bold provided [in text of Guides ]). In light of the AMA's admonition against the exclusive use of its Guides for evaluation of permanent disability, we question the Commissioner's wisdom in adopting them. State ex rel. Blankenship v. Richardson, 196 W.Va. 726, 735-36, n. 13, 474 S.E.2d 906, 915-16, n. 13 (1996) (quoting Guides, Fourth, emphasis in original). While we still have our concerns about a system that makes a one-to-one correlation between impairment and disability, and while we continue to question the wisdom of employing the Guides, Fourth in a fashion contrary to the intent of the authors, neither issue is squarely before the Court today. What is before the Court, is whether the adoption of the Guides, Fourth as a mandatory set of instructions for performing an examination of a claimant with a spinal injury is consistent with our workers' compensation law. Pursuant to the W. Va.Code ง 23-4-6(i) (1999), the Division [6] issued a rule that established standards for determining an injured worker's degree of permanent impairment: ง 85-16-4. Adoption of Standards. 4.1. Except as provided for in section 6 of this rule, on and after the effective date of this rule all evaluations, examinations, reports, and opinions with regard to the degree of permanent whole body medical impairment which a claimant has suffered shall be conducted and composed in accordance with the Guides to the Evaluation of Permanent Impairment, (4th ed.1993), as published by the American Medical Association. If in any particular claim, the examiner is of the opinion that the Guides or the section 6 substitutes cannot be appropriately applied or that an impairment guide established by a recognized medical speciality group may be more appropriately applied, then the examiner's report must document and explain the basis for that opinion. Deviations from the requirements of the Guides or the section 6 substitutes shall not be the basis for excluding evidence from consideration. Rather, in any such instance such deviations shall be considered in determining the weight that will be given to that evidence. An example of an acceptable recognized medical speciality group's own guides is the Orthopaedic Surgeons Manual in Evaluating Permanent Physical Impairment. 85 C.S.R. ง 85-16-4(1996)(emphasis added) [7] . We find it extremely important to note that the rule commands a doctor to conduct the examination and compose the report in accordance with the guides and not simply to use the models or suggestions contained in the publication. Indeed, the basis of the appellees' argument is that, minus the exceptions specified in the rule, the whole of the Guides, Fourth, including the DRE section, must be followed by any doctor performing an examination on a claimant. As a result of this phrasing, the Division has essentially incorporated by reference into the rule, the entirety of the Guides, Fourth. While the publication runs some three hundred pages and encompasses all aspects of impairment of many bodily systems, we are concerned in this case with injuries of the spine. In the section dealing with spinal injuries, the Guides, Fourth describes two methods of determining impairment. One is called the ROM, or Range of Motion Model. The other is called the DRE, or Diagnosis-Related Estimate Model, or simply, the Injury Model, and was newly introduced in the fourth edition of the Guides. [8] We shall make reference to either ROM or DRE for the remainder of this opinion.