IMEFriend or Foe?

Warren Silverman MDApril 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 Scientistor 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. Non-

scheduled

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