The removal of a metric for diagnosing mental disorders from the American Medical Association’s disability guide is a welcome change for those handling workers’ compensation claims for mental injury, experts say.
An analysis released Sept. 12 by the National Council on Compensation Insurance said the impact of changes made last year to the AMA’s guide is “uncertain” in diagnosing and determining disability. The Boca Raton, Florida-based credit rating agency said “the only significant changes to content and methodology were for mental and behavioral disorders.”
The changes appear in the sixth edition of the guide, which was last updated in 2008. The new version conforms to the “most current (guidelines) in medicine and provides a basis for fair and consistent evaluations and impairments.”;
Most states use the AMA Guide by law to determine comp-related disability.
The revision was proposed by the American Psychiatric Association and the American Psychological Association to align with the “Diagnostic and Statistical Manual of Mental Disorders,” or DSM, which is considered the authoritative guide for the diagnosis of mental disorders, according to the AMA.
The new guidelines, in both the DSM and AMA guides, eliminated the Global Assessment of Functioning scale as a means of determining impairment.
The GAF assigns a score between zero and 100 based on a person’s functioning—the higher the score, the higher the functioning—and the ratings are grouped into tens. Experts say the GAF is too imprecise and creates confusion and conflict in determining disability.
“From a clinician’s perspective, the GAF was always problematic,” said Mark Debus, Chicago-based clinical director of behavioral health at Sedgwick Claims Management Services Inc., adding that he expects little or no change in comp claims as a result of its adoption away. . “When they removed it, the therapists sighed very lightly because it’s just a silly result. To begin with, it’s extremely subjective.”
Les Kertay, a psychologist who helped draft the latest AMA guide and senior vice president of behavioral health with Axiom Medical in Chattanooga, Tenn., said the GAF was removed from the DSM because it “had some significant reliability issues” and that “removing it, especially because it was no longer in the DSM, made sense. If it’s bad enough that the American Psychiatric Association doesn’t want to use it anymore, then we probably shouldn’t use it.”
“You and I might have rated someone completely differently on the GAF,” he said, adding that the AMA still relies on other measures of diagnosis and disability determination for psychological injuries.
As part of their research, Kertay and other medical specialists investigated what disability would be without the GAF measurement. There were little or no differences in diagnoses and grades without GAF, he said.
While most states require doctors to rely on the latest AMA guide, California sticks to the earlier version, according to Ron Heredia, a psychologist and director and founder of Los Angeles-based Good Mood Legal, which specializes in reviewing psychology reports in insurance claims.
The GAF score is “another piece of information” for a claim and one of the reasons for the state’s adherence to the 5th AMA guide, he said.
Mr. Heredia agreed that the subjectivity of the score is a problem. When so-called “psych claims” are challenged, medical records are often found to lack concrete details — like what the injured worker is experiencing — and the GAF score leaves a lot out, he said.
“The GAF score is basically the doctor picking a number zero to 100, and if they wanted to, they could very well just pick a number out of a hat and say that’s the GAF score,” Mr. Heredia.
“And when they’re challenged by either a lawyer or even a claims adjuster about the GAF score that they assigned, the doctor just has to say, ‘Well, I gave that score because that’s my clinical judgment.'” And they could just repeat that as a ruptured disc. There’s really no rhyme or reason or formula that the doctor has to follow to arrive at the GAF score.”