At the Seekers Centre, we treat people with disabilities related to chronic pain. While this is our main focus, we also provide assessments for people who need an unbiased medical opinion for legal and insurance-related reasons. This is challenging work, but it has provided us with unique insight into the system that our patients depend on for their livelihood.
The American Medical Association Guides to the Evaluation of Permanent Impairment is considered the bible in the field. While this book is currently in its sixth edition, the province of Ontario still uses the fourth edition, which was published in 1993. This makes our system over twenty years old, which is a long time in medicine. This is especially concerning because the newer editions have made the methods used to evaluate impairment much more objective and fair. Hopefully we will see this change soon.
The laws that govern the auto insurance industry in Ontario are overseen by the Financial Services Commission of Ontario. They enforce the rules that are supposed to be followed by insurance companies, the people who buy insurance and the providers who look after their healthcare and other needs. These rules are supposed to be reviewed every three years, and the most recent version is due in the fall of 2014.
The way that impairment is rated is a very important aspect of this system. One of the most critical issues is whether or not someone’s impairment can be considered ‘catastrophic’. Doctors use a complex rating system to evaluate each system of the body and rate the impairment of that system as a percent of “whole person impairment”. If we assume that a normal healthy person has zero percent impairment, and someone who is completely paralyzed and in a coma is 100% impaired, each injured person will have an impairment that falls somewhere in between.
The musculoskeletal system is evaluated by adding up the limitations in the arms, the legs, the pelvis and the spine. This is mostly based on how well a person can move on their own, using special instruments to measure the exact range of motion of each joint. Amputation is 100% loss of that area, and every other problem is compared to that. Specific injuries of nerves, blood vessels deformities and muscle weakness are also evaluated here. It was eerie for me to realize that one amputated arm is worth 60% of the whole person but one leg is only worth 40%.
The nervous system is assessed in terms of the brain, the spinal cord and the nerves. As a pain specialist, it is tragic to see that pain is not considered an impairment, simply because it is impossible to measure. Many of my patients have no obvious nerve damage, but they live with constant daily pain that prevents them from doing basic things in life. One reason for impairment that is often missed is post-concussion syndrome from a mild traumatic brain injury. We also see many patients who have never been told that they suffer from complex regional pain syndrome, which is a legitimate impairment.
The mental and behavioural system is perhaps the most difficult to assess objectively. This includes post-traumatic stress disorder, depression and anxiety. In many cases, people have trouble proving that their problems are not due to pre-existing problems. One useful tool is to compare people’s level of function before and after an injury. We often see major changes in their ability to sleep, to go out, to talk to people, to drive, to concentrate or sit still.
While this is a rational approach, the current version we use has its limitations. Sleep disorders are often overlooked in this process, unless they are assessed by a specialist in the field. People who have suffered a concussion often have problems focusing their eyes and cannot read more than half a page, but these neuro-ophthalmologic disorders are not measured in the routine assessment of vision.
The other major issue with our current system is that the insurance industry has too much power and influence over the government that regulates them. While they make billions of dollars in profit every year, they oppose any rule that puts these profits at risk. They threaten to stop providing insurance, leaving the government with the obligation to set up their own insurance system like the one in Quebec.
While our emphasis has always been on healing, we have become involved with this system that includes lawyers and insurance companies, forms and letters. All the healthcare providers who work within this system are frustrated with it and want to see it change. While it has its problems, the reason we are willing to deal with them is that our patients have no choice. This is the only hope that many of them have of healing.
But it’s time to heal the system.