Clinical Perspectives on the MIG

From the clinical perspective, the Minor Injury Guideline (MIG) in Ontario is a rather blunt tool. While a more precise tool is being prepared for use, it is not available yet, and we are likely to need to deal with the current construct for another year. As of the writing of this article, we still have been provided no guidance from arbitration decisions or other authoritative sources of how this guideline will be interpreted. Insurers do not know the extent of the possible exposure, and clinicians do not know whether their professional opinions will be validated or set aside. This is the nature of a new administrative guideline of this kind.

“The SABS and the MIG are intended to encourage and promote the broadest use of the Guideline, recognizing that the majority of people injured in car accidents in Ontario sustain minor injuries for which the goods and services provided under the MIG are appropriate.” FSCO’s statement sets the stage for Ontario’s attempts to manage costs related to minor injuries. There are few who dispute this statement, but the effect of this Guideline extends beyond the obvious, so a look at some of the twists and turns experienced with the MIG is in order.

The MIG is more inclusive than prior guidelines such as the Pre-Approved Frameworks. They include a sprain, strain, whiplash associated disorder (WAD), contusion, abrasion, laceration or subluxation and includes any clinically associated sequelae to such an injury. While this appears to be clear and simple, there are some surprising issues that may arise particularly looking at the clinical sequelae to WADs – these can include impairments commonly identified as neurological, such as dizziness, tinnitus, headache and memory acuity. Differentiating whether these are associated with the minor injury or with something else is typically the task of medical professionals.

A cerebral contusion is technically a Mild Traumatic Brain Injury (MTBI), with symptoms described often as post-concussive. A plain and simple reading of the MIG would argue against this ever being captured within the MIG, but our experience is that this may warrant more nuanced consideration. Arguably, MTBI should be demonstrable on imaging as an organic injury and concussion is more of a functional head injury without actual “brain injury”, but experts and organizations seem to disagree on this. Is this a minor injury? Does it automatically disqualify a person from treatment within the MIG? The role of loss of consciousness is disputed and forms a grey area within expert opinion as well.

Some say that when no treatment is prescribed for this injury, and since time is all that may be needed for resolution, it should not exclude a person from the MIG, provided obvious minor (MSK) injuries predominate (more on this later). While the cognitive sequelae are generally anticipated to resolve spontaneously, there may be long-term implications of pain-related post-concussive symptoms that persist in 10-15% of cases. These would clearly demand removal from the strictures of the MIG, but this may not become evident until later in the case. Moving to secure an earlier expert opinion is recommended when these issues arise, or do not quickly diminish and create exposure.

There is an explicit assumption that “psycho-social” matters will be handled within this Guideline, and according to FSCO (Bulletin No. A-02/11) to be completed within the $400 available for supplementary goods and services. There is also an implicit assumption that psychosocial matters for those who suffer minor injuries will also be minor in nature and importance.

Psychology and psychiatry professionals have certainly struggled with the MIG construct. They are asked to make determinations comparing physical issues with psychological issues – there is little guidance in the literature for this activity. In a conference (“Before the MIG hits the Fan” 2011, LifeMark/Centric Medical Assessments) psychiatrist Dr. William Gnam noted that minor accidents are anticipated by many to produce only minor injuries, but unfortunately the literature does not support this assumption – a minority of persons sustaining minor physical injuries will go on to develop mental disorders that will not be adequately addressed by treatment within the MIG, based on current evidence-based treatment guidelines.

For those who do not have a major mental disorder after an accident, their psychosocial needs can likely be addressed fully within the current provisions of the MIG. There is no compelling evidence-based case for prolonged psychosocial treatment if psychiatric symptoms do not attain disorder status. It is a minority of people involved in minor accidents that go on to develop major mental disorders, but these individuals are of significant concern to the industry.

The time courses of PTSD, phobias, and major depression arising from MVAs appear to differ, but risk of chronicity exists for each, and when one sees the possibility of chronicity arising, this is of great concern to insurers and medical professionals alike! It is in everyone’s interest to avoid chronicity, and the MIG is a relatively focused program with expectations and hopes for quick termination and closing of the file both from the medical and the adjusting point of view.

Lastly among inclusions is the continuing whiplash associated disorders question – it does not seem to have changed substantially from the PAF days. The Guideline defines the MIG to include the traditional WAD I and II definitions but not the WAD III and IV. We still see many OCF-18s referencing WAD III, without identification of the objective, demonstrable, definable and clinically relevant neurological signs to justify this diagnosis. Challenging any unsubstantiated claims and securing an independent diagnosis is a continuing necessity, given the potentially serious nature of this condition.

The exclusions within the MIG are more constrained than previous guidelines. As long as the injuries fall within the definitions of minor, there is only one identified – “if the insured person’s impairment is predominantly (emphasis added) a minor injury but, based on compelling evidence provided by his or her health practitioner, the insured person has a pre-existing (emphasis added) medical condition that will prevent the insured person from achieving maximal recovery from the minor injury if he or she is subject to the $3,500 limit …”.

As a result, there is no allowance for the funding for assessment or treatment outside of the minor injuries that may have arisen from the accident, or other conditions that may come to light after the accident, but within the MIG treatment period. This also seems to exclude all but the most basic of psycho-social interventions, and certainly advanced diagnostics (MRIs or CT scans) to verify conditions such as full ligament tears or TBIs are expensive enough to be practically excluded from the MIG on the treatment side.

This leads to one of the more difficult matters for clinical professionals: how do we consider both physical/medical impairments principally referenced in the MIG with the psychosocial or the mental/behavioural elements? This issue is basically mirrored in the catastrophic injury rating discussions, and is part of the consideration of the “predominantly” minor injury question.

How does one define “predominantly”? Is predominance measured by the number of observed minor injury impairments as a factor of the total number? By the impact on treatment needs and costs? By the impact on function? After all, the MIG is essentially a functional restoration program. Who should evaluate predominance – physical providers or psychiatric providers? Both together?

With the MIG and a focus on diagnosis and causation of accident-related impairments, there has been a return to use of the more traditional medical assessor. GPs are now more frequently used for this purpose as their scope of practice is extremely broad. However, not all are willing to go out on a limb to comment on mental disorder
s, and comparison of physical and mental conditions are dealt with in an understandably inconsistent fashion, given the lack of guidance from the literature. Our experience has been that results are most reliable and defensible when both sides are involved together. This way, the professionals can come to a common understanding of which impairments should be considered to be “predominant.”

On the one hand, the job of a clinical professional is to consider these matters carefully and render a reasoned, evidence-based and understandable judgement – but that judgement is based more on medical considerations than administrative, adjusting or cost-control considerations. It is the somewhat difficult spot medical professionals find themselves when dealing with administrative guidelines that involve legal or administrative definitions as much as medical ones.

On the other hand, some insurers, without medical input, are making the decisions about whether a case should be handled as MIG – basically a “medical” decision, to some extent anticipated by the Superintendent’s Bulletin A-02/11. The impact of this is not yet clear, but it has some associated risk.

A final issue with the MIG is related to access to Income Replacement benefits. While the previous Pre-Approved Frameworks were linked to limited IRB funds, the MIG is not. This concern was predicted by many when the MIG was implemented. What are we to do when a person has legitimately suffered minor injuries, is provided with excellent care as recommended in the Guideline, but was involved in a heavy duties job to which s/he needs to return at full capacity? The $3500 is (well) spent but this person legitimately still cannot manage the full duties, and needs some work hardening or conditioning. We have seen numerous situations where the insurer is exposed to ongoing IRB payments, and the claimant, whose responsibility is to engage in treatment to mitigate the injuries and maximize progress, is not able to access required funds to do so to complete the process within the MIG. It is a classic catch-22 situation that the medical professionals cannot solve, and it ends up as an adjusting issue.

A contract has recently been awarded to Dr. Pierre Côté for creation of the Minor Injury Treatment Protocol (MITP). According to FSCO, scientists and other experts will contribute to the development of an evidence-based protocol that will form the basis of a new MIG. We hope that this new protocol will meet its objectives and solve some of the issues described above. But we will inevitably be faced with a new construct that will require consideration, thoughtful implementation and a whole new round of interpretive exercises.

Until then, it is clear that individual cases continue to require individual consideration. The majority of MIG cases are easily identified and proceed with little problem, but a minority of cases fall into a grey zone and risk seems impossible to avoid with these cases. As always, a clear diagnosis and medical/psychiatric opinion has its place, as the principal issue in determination of whether a person belongs in the MIG remains a clinical decision.

Dennis Giesbrecht is manager, clinical intake and client services for Centric Health Medical Assessments.