Draft: The role of health professionals in informing insurers' earning capacity decisions in the CTP scheme

This advice relates to the Motor Accident Injuries Act 2017 (the Act) and the Motor Accident Guidelines (MAGs) issued by the State Insurance Regulatory Authority (SIRA). It provides information and guidance for insurers and health professionals on the role and requirements for health professionals in supporting insurers to make decisions about the pre-accident earning capacity and/or post-accident earning capacity of an injured person (earning capacity decisions) in line with Schedule 1 of the Act and Part 4 of the MAGs.¹

Health professionals and earning capacity decisions

‘Health professionals’ are:

• health practitioners as defined by the Health Practitioner Regulation National Law, and
• other health service providers who work within the CTP scheme, including rehabilitation counsellors.

In determining a person’s entitlement to statutory benefits under Part 3 of the Act, the CTP insurer is responsible for making earning capacity decisions.

In making these decisions, the insurer must consider all relevant information regarding the person's capacity for work including that provided by health professional/s.² An insurer may make a decision about the pre-accident earning capacity or post-accident earning capacity of a person at any time. In determining the amount of weekly payments under s3.8 in respect of the period after week 78 after the motor accident, insurers are to determine ‘employment reasonably available’³ to a person.

Information that an insurer may use to determine earning capacity

When making an earning capacity decision, insurers consider evidence about factors including:

• Employment reasonably available⁴, including:
  • the nature of the person's injuries
  • the person's age, education, skills and work experience
  • rehabilitation services that are being or have been provided
  • the nature of the person's pre-injury employment
• Fitness for work⁵, including:
  • the nature of the injury and the likely process of recovery
  • treatment provided and rehabilitation undertaken and the potential for further treatment and rehabilitation
  • the person's training, skills and experience; and age.

The sources of this evidence can include:

• assessments relating to an injured person’s functional capacity for employment and vocational match with the labour market
• the claimant’s Certificate of Fitness and other medical records.

Where a report is requested by an insurer, it is expected that a health professional with the appropriate skills, qualifications and experience will issue the final report provided by an organisation to support the insurer’s decision-making on earning capacity.

Required qualifications

When undertaking assessments or preparing reports which are relevant to an insurer in making an earning capacity decision, the following qualifications and registration are required.

• For health professions regulated by Australian Health Practitioner Regulation Agency (AHPRA): AHPRA registration (excluding student or provisional registration)
• For all other health professions not regulated by AHPRA:
  • full accreditation (not student or affiliate) by relevant professional body eg Exercise & Sports Science Australia (ESSA), Australian Association of Social Workers (AASW)⁶, or
  • if the relevant professional body does not accredit members, full membership of the relevant professional body eg Australian Society of Rehabilitation Counsellors Ltd (ASORC)
  • Exercise physiologists also require ESSA certification to deliver workplace/functional assessments.

These qualifications are consistent with the Heads of Workers Compensation Authorities (HWCA) Guide: Nationally consistent approval framework for workplace rehabilitation providers (HWCA Guide) and the NSW Supplement .

Required skills

For the purpose of any assessment or other task which could inform an earning capacity decision, the following skills are required.

Skills required to assess a person’s capacity to undertake certain tasks/duties

• Ability to clearly articulate functional capacity
• Ability to objectively measure functional capacity to assess performance of actual or simulated work tasks to determine work capacity for actual job demands
• Ability to identify the critical physical, psychological, social, environmental and organisational demands of all relevant work tasks.

Skills required to assess a person’s transferable skills

• Interviewing skills, including asking specific questions about tasks in a job description
• Analytical skills such as reasoning/logic, critical thinking, and specifically including: Ability to analyse work profile which includes a description of transferable skills, abilities, aptitude, interests, preferences, restrictions and work capacities
• Ability to analyse job options with consideration of factors such as work environment, work requirements and culture to identify a match, also considering pre-injury wage and status
• Ability to identify if testing or further investigation is required and to know what the standard test/investigation is required
• Report writing
• Content knowledge of job market
• Understanding of the Act eg reference to person’s ‘training, skills and experience’

Skills required to assess a person’s skills for seeking and gaining employment

• Interviewing skills to test motivation
• Ability to differentiate between practical and theoretical jobseeking skills
• Ability to undertake a labour market analysis
• Knowledge of specific local labour market, including availability and stability of employment
• High level of research skills to determine options available in the market, including contacting employers and undertaking site visits where required to understand logistical and cultural barriers and enablers
• Knowledge of specific industries and other factors related to industry demands eg age, gender.

Skills required to undertake job matching

• Ability to consider appropriate and realistic vocational options, including understanding of supply and demand
• Ability to consider whether the person’s skill set matches suitable options in the market

Required experience

For the purpose of any assessment which could inform an earning capacity decision, the following experience is required.

• Recent relevant professional experience (within three years)
• A minimum of 12 months of relevant experience
• Demonstrated success in placing people in sustainable employment with injuries or disabilities similar to the person being assessed (when providing opinion relating to a person’s ability to work in an appropriate labour market)
• When assessing people with the following diagnoses, specialised knowledge and durable sustainable placement experience are required:
  • traumatic brain injury
  • spinal cord injury
  • Post Traumatic Stress Disorder.

Health professionals who meet the relevant skills and qualifications outlined above, but lack the required experience, may be engaged, provided there is guaranteed access to supervision/mentoring/peer review eg co-sign mechanism by a health professional who meets all qualifications, skills and experience requirements.

Notes:

1. These decisions are not medical assessment matters as defined by Schedule 2 of the Act or medical matters under clause 18 of the Motor Accident Injuries Regulation 2017
2. Insurers may also use other relevant evidence – for example, in labour market analysis.
3. As provided for in clauses 7 and 8 of Schedule 1 of the Act.
4. See clause 4.55 of the MAGs.
5. Clause 8(3) of Schedule 1 of the Act.
6. AASW is also developing further accreditation for social workers specialising in disability (as at January 2019); such a credential would be highly regarded for social workers providing earning capacity assessments.