In her cover letter that accompanied the proposed changes, Minister Ecker stated that “the package of proposed reforms contains measures to expand the definition of catastrophic impairment.” The specific changes:
- Restrict availability of catastrophic impairment status to those having a Glasgow Coma Scale test result of 9 or less, as well as requiring a period of post-traumatic amnesia (PTA) of at least 7 days.
- Replace the Glasgow Outcome Scale outcome with Extended Glasgow Outcome Scale.
- Allow the use of analogous measures for children if the existing scales cannot be applied.
Recommendation Regarding Proposed Use of PTA (Proposal No. 1):
The group recommended that Proposal No. 1 be abandoned. This recommendation was made for several reasons, specifically:
- the PTA criteria was never recommended by the Committee formed at the request of David Young MPP to address changes to the catastrophic definition;
- Health Care Professionals do not generally chart post-traumatic amnesia;
- there is a high degree of subjectivity in determining when a patient first begins to recall events continuously, after a brain injury; and
- the proposal is unworkable.
Since PTA is not routinely measured or charted in clinical practice, a CAT DAC evaluation would have to conclude in all but the most rare cases, that the person had not provided sufficient or credible evidence to demonstrate at least seven days of PTA. As such, the person with an agreed “severe” brain injury based on applicable Glasgow Coma Scale criteria, would not be designated as having sustained a catastrophic impairment.
The group recommended that the current catastrophic designation, based upon a Glasgow Coma Scale score of nine or less, remain in its current form.
Recommendation Regarding Use of Extended Glasgow Outcome Scale (Proposal No. 2):
Health care professionals are familiar with the Glascow Outcome Scale and indicate that while the Glasgow Coma Scale Extended Version (GOSE) is more favorable than the Glasgow Outcome Scale, the GOSE reliance upon a structured interview for determination of impairment does not provide sufficient objective and observational data. Neuropsychological and occupational therapy assessments should be the primary determinants for catastrophic designation, in accordance with current CAT DAC protocol.
The GOSE was derived by dividing the Glasgow Outcome Scale’s three highest levels (severe disability, moderate disability and good recovery) into six levels, which are more descriptive and clearly indicated. As such, the GOSE is a more practical tool for categorization of impairment.
The group recommended that if an injured person scores five or worse on GOSE testing, he or she will be deemed catastrophically impaired.
Group Recommendations Regarding Inapplicability of Current Catastrophic Impairment Criteria for Children (Proposal No. 3):
The group recommended that children be deemed catastrophic in all cases and therefore entitled to an enhanced levels of benefits including case management, attendant care to a maximum of $6,000.00 per month to a lifetime maximum of $1,000,000.00 and medical and rehabilitation benefits to a lifetime maximum of $1,000,000.00.
Comment: Effect of Court/Arbitration Decisions Upon Assessment of Catastrophic Impairment and Reasonable and Necessary Treatment
Discussions continue about which approach should be taken in assessing the significance of non-accident related factors in determining benefit entitlements. Decisions such as Athey and Stargratt have established the principle that, if the injured person satisfies the DAC, arbitrator or a judge that the injuries sustained in the accident materially [significantly] contributed to the accident victim’s overall condition, the injured person is entitled to full compensation. If the injured person’s overall condition is deemed to be one of catastrophic impairment, the injured person may be entitled to catastrophic designation and enhanced benefits.