Transcript What is an IME?

IME
Friend or Foe?
Warren Silverman MD
April 2006
What is an IME?
(A definition by description)
•
•
•
•
•
•
•
It is a tool for you to use
It is a second opinion
Is it really independent?
Who orders them?
Who supplies them?
Who does them?
What are the qualifications?
BIAS
•
•
•
•
•
•
Financial
Initial assumption of “questionablity”
Never see the “yesses”
Should one seek out biased IME’s
Should an IME succumb to bias
What is court? And where does it
happen?
Goal Oriented IME
“Not sure what is going on!”
Ask an IME!
• Need a good historian
• Can be used when the
claimant is not supplying
medical records or there
is a suspicion that there
is something out there to
be learned
• Ask for a comprehensive
history and physical
Methodology
• Reconstruct the narrative
– Take a great and comprehensive history
– Get (ask for, be provided with) every bit
of medical that you can and read it
– Begin at the beginning and reestablish
chronologic events
– Reconstruct the incident
– Determine if the mechanism of injury is
capable of causing the biomechanical
events
• A good IME
can be like
investigating a
car accident,
except that the
claimant’s
body is one of
the vehicles.
What is a bad IME
• One who reviews and summarizes the
file offering no expertise, automatically
agreeing with everything without
explanation
• One that makes no logical sense
• One that is clearly biased
• One that does not respect the
claimant
• One that becomes political One
who fails to identify inaccuracies
and unsupported medical facts
• One who colludes with any party
and loses independence
• For the claimant, this is often a hostile
environment
• Many times they are not even sure
what the purpose of the exam is
• This can affect the outcome
• On the other hand sometimes they are
prepped or prepared
Is a thumb sprain totally
disabling? Or
How to influence your
outcomes
Use an IME to affect
Behavior
• Embarrass the provider into the
standard of care : peer pressure
• Educate the provider and the claimant
• Provide alternative realistic options for
the employer to act upon
• Clarify degree of disability
• Provide an endpoint in permenant
disability
On the other side of the coin
• If the care is appropriate and the
treatments justified, say so and
educate the requestor about the
medical details of the case
• Express to the provider when things
are correct
• Do not be afraid to offer medically
sound suggestions in the name of
helping the claimant to become well
Use an IME to separate
causally related medical
conditions from non-causally
related issues
Is this connected?
•
•
•
•
•
The ever growing injury
The very expanding treatment
Medication use
Pre-existing
Psych?
But did we do it?
The big “C”
Please determine causality!
• 29-year-old woman from Cairns,
Queensland Seeking:
• looking for causal relationship.
The IME as Scientist
or Forensics 101
• Understand the anatomy and physiology
• If not sure, research the established body of
medical science
• Read the observations of other observers
including the history that they had to work
with at the time* and the physical
examination
• Look for patterns
• Create a differential diagnosis
• Stratify the conclusions based
upon factual data
• Establish if the test of “reasonable
degree of medical certainty has
been met”
• Provide the conclusions that can
be best defended upon inquiry and
rest closest to truth
Please determine
“Degree of Disability”
• Temporary vs.
Permanent
• Partial vs. Total
• Scheduled vs. Nonscheduled
Toxic injury
• Identify the toxin
• Identify the health effects of the toxin
• Identify the claimants health
complaints
• Confirm exposure
Special Injuries
• Happened at work
– Falls : Idiopathic vs. causally related
– Cardiac: Stress vs. Natural
– Failure to take precautions
– Substance abuse: sole cause of injury
– Stress Claims
– 207a and 207c
Request
• Failed Back
• Positive Diskogram
• Request IDET procedure authorization
– Is this procedure indicated
•
Intradiscal electrothermal therapy for the treatment of chronic
discogenic low back pain.
Saal JA, Saal JS.
The early studies on IDET are very promising. IDET offers patients with
chronic discogenic low back pain an option other than chronic pain [figure:
see text] management or spinal fusion.
IDET
•
•
Spine. 2005 Nov 1;30(21):2369-77;
A randomized, double-blind, controlled trial: intradiscal electrothermal therapy
versus placebo for the treatment of chronic discogenic low back pain.
Freeman BJ, Fraser RD, Cain CM, Hall DJ, Chapple DC.
• This study demonstrates no significant benefit from
IDET over placebo.
• f/u:
• At 1-year post-IDET, half of patients were
dissatisfied with their outcome. The percentage of
patients on disability remained constant. The
estimated proportion of patients undergoing fusion
was predicted to be 15% at 1 year and 30% at 2
years.
What about the Diskogram?
•
Spine. 1995 Sep 15;20(18):1997-2000;
•
Outcome of unoperated discogram-positive low back pain.
•
Discogenic low back pain improved in patients without psychiatric
disease. Older age at onset and shorter duration of low back pain
were favorable indicators. These results are comparable with or
better than those reported for surgical treatment of this condition.
•
F/U:
Painful disc injections are poor independent predictors of
subsequent LBP episodes in subjects initially without active lower
back complaints. Annular disruption is a weak predictor of future
LBP problems. Psychological distress and preexisting chronic pain
processes are stronger predictors of LBP outcomes.
Dueling IME’s
Treatment Recommendation
• A reasonable way to affect movement
in a stalled case
• Bringing in the right specialist when
the care is being handled by the
wrong specialist
How to order an IME
•
•
•
•
•
•
What do I really want to do here?
Who is the right person to do this job?
How should I write up the request?
What should I provide?
What outcomes can I expect?
How will I use the information?
What about the testimony?
• Feedback after deposition
– Was the IME Credible
– Was there good preparation
– Was the IME a good communicator
– Did the IME defend the assessment
effectively
– Was the IME consistent with the report
What is it like to testify?
• I’m not on trial!! Whew
• Truth is not the mutually agreed upon
outcome
• Truth, however, is a very strong
weapon
• For the IME, testimony is a duel with
Medical knowledge armour versus
legal knowledge armour
Cultivating your IME network
• Spectrum of options:
• Low cost vendors vs.. premium
network “You get what you pay for”
• Individual providers
• Word of Mouth
Special Requests
• 15-8 - a section of law which gives the carrier reimbursement
from Special Funds — Does not effect the amount of
payment to the worker, but can have an impact on the
eventual settlement value, as Special Funds tend to low-ball
a settlement.
• 25-A Under Workers' Compensation Law § 25-a, liability for
further compensation will be shifted to the Special Fund and
away from a workers' compensation carrier when seven
years have passed since the date of the claimant's injury and
three years have lapsed since the claimant was last
compensated