Double Whammy for Insurers from Tasmanian Impairment Guidelines

The WorkCover Tasmania Guidelines to Impairment Assessment that modify the American AMA  (4th Edition) Guides are used to assess impairment of Tasmanian workers.

Without going into some more fundamental issues about the use of impairment assessment systems (such as the validity of any system that attempts to quantify injury in percentage terms or the reasons for exclusion of pain as a separately assessable impairment), there are two areas of current concern about the Tasmanian Guides.
Perhaps the issue of greatest concern is the effect that a spinal impairment rating can have on an insurer’s willingness to approve spinal surgery procedures.

With the latest editions of the Guides (Version 2 & 3) fusion or disc replacement surgery is considered to meet the criteria for ‘multilevel structural compromise”. This automatically is rated as DRE category IV or V. This is 20% and 25% Whole Person Impairment (WPI) respectively in the lumbar spine and 25% and 35% WPI in the cervical spine. In the absence of surgical intervention most spine injuries are rated at 5% or 10% WPI and only the most severe injuries with associated spinal cord damage are rated above that level.

Under Tasmanian workers compensation legislation there is a threshold for access to Common Law. Workers with injuries rated at 20% WPI (previously 30%) and above have access to common law damages. Insurers considering a recommendation to fund spinal fusion or disc replacement surgery are faced with the potential double whammy’ of the not insignificant costs of the surgery and the prospect of a higher impairment rating opening the door for the worker to common law entitlements and higher lump sum payments for permanent impairment. In addition, there are often concerns that the surgery may not have a positive outcome in terms of getting the worker back to work. Understandably insurers hesitate to fund spinal surgery.

My concern as a doctor managing work injuries is that the current impairment guidelines for assessment of spinal impairment can create a barrier to appropriate surgical intervention in some cases. The solution lies in a review of spinal impairment criteria, that recognises the effects of fusion and disc replacement on the structural integrity of the spine, but does not equate a more functional spine post operatively to an impairment category higher than that of a dysfunctional spine prior to surgery. This might require both a review of spinal impairment ratings for spinal conditions associated with disabling pain who have not had such surgery and spinal conditions where surgery has been undertaken. The important issue is that WPI ratings per se should not act as a disincentive to insurers to approve necessary spinal procedures. Spinal surgery should only be considered on the medical merits of the proposed procedure.

The other issue of concern is the assessment of impairment associated with Complex Regional Pain Syndrome (CRPS), previously known as Reflex Sympathetic Dystrophy (RSD). The WorkCover Guides have strict criteria before a worker can be assessed using the specific methodology for assessing impairment associated with CRPS. The diagnostic criteria in the guides are not based on the internationally accepted diagnostic criteria for CRPS. Only severe cases of CRPS meet the criteria. The most common scenario is that the clinical diagnosis of CRPS is clear, often agreed by both the treating practitioners and independent assessors, yet the prescribed methodology for assessing the disorder cannot be used. This is a situation where the Guidelines do not align with current clinical practice. This results in artificially low impairment ratings for a disorder which can result in a permanent disorder with a very high level of disability. The solution here is clear, the diagnostic criteria for CRPS included in the impairment guidelines should be brought into line with current clinical practice.

While I am not as familiar with the WorkCover Impairment Guidelines in other states (Victoria does not have statutory guidelines, only AMA4), I suspect the same issues might arise there too.

 

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About Tasworkdoc

As an occupational physician in private medical practice in Hobart, Tasmania - the southernmost state of Australia, I see workers referred by their general practitioners with various types of work-related injuries and diseases. These are mostly musculoskeletal injuries, both of traumatic and gradual onset as well as various associated psychological disorders. With interaction with patients for treatment and providing advice about rehabilitation, I have the opportunity, first-hand, to observe interactions between individual patients and compensation systems. I also conduct independent medical assessments, including impairment assessments for musculoskeletal injuries and asbestos-related disease compensation. This provides another perspective of workers within compensation systems.
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6 Responses to Double Whammy for Insurers from Tasmanian Impairment Guidelines

  1. Soula says:

    I have a pudendal nerve injury (that you’ve heard about Peter but I’ll repeat for new readers). The injury is referred to as Pudendal Neuralgia and for those unfamiliar with the nerve it’s the biggest pelvic nerve that controls signals and function within our pelvis (toilet/sex). It also has roots that extend up into the lower spine so it leaves you feeling you’ve damaged your core. The system was unable to diagnose me and it took my searching for 4.5 years to find my diagnosis that the system did not recognise. I am proof the Guidelines and system fails in diagnosing and acknowledging this issue and its disabling impact. I can’t drive, can’t lift over a couple of kilos and sitting is always painful. I can’t lie on my back either and I daily require my husband’s help. I’ve had nothing but denial from the Agent and have not until recently had a little recognition for the issue in the form of a Medical Panel Opinion (no, sadly no compensation in fact I’m battling for medicals and weekly benefits now). What I’ve learned is that when the Guidelines fall outside of clinical practice like mine, the system fails the injured worker almost totally. Our invisible injuries end up being taken advantage of to benefit the insurer and ultimately get the Workers Compensation System (that as a self insurer I contributed to myself) easily out of its responsibility… and they have absolutely no qualms about what state the injured worker is left in. It really is unbelievable.
    Thank you for your blog and fabulous words Peter. I hope your efforts lead to change, my ranting certainly hasn’t, I just get told my advocacy is noted and get shut out of WorkSafe’s facebook page!

  2. Kerrie Daly says:

    I read Soula’s webpage which is where I found this link,I have cervical, thoracic, lumbar, tmj, and knee injuries and PTSD following an MVA coming home from work,I am in NSW and about to lose my pay thanks to legislation from the just resigned Barry O’Farrel, I finally know why I was never operated on and left in pain and pins and needles all this time without proper explanation and continuously fighting this adversarial system while not well enough, I was also diagnosed with CPRS and after years of depression and giving up my neck and arms are worse, got an mri after many years and need an operation facet joint narrowing c5/c6 leaning bilaterally on nerves, I am in for a bigger fight but at least now I know why,thank you Doctor. I need help but dont know where to go from here.

    • Tasworkdoc says:

      I am not familiar with the details of the NSW Workers Compensation and Motor Accident Schemes, but the factors that operate in Tasmania might be relevant.

      • Kerrie Daly says:

        i have to see a neurosurgeon shortly, thank you for your reply, I want at least better function regarding neck and arms although the rest gets me down. As our premiere was just found lacking at the corruption investigations and he rammed more adversarial insurance nightmares into injured workers lives I guess we await whether they can be peeled back under the circumstances (corruption and all!) but regardless of government or insurance interference into injuries we want to get better if at all possible, thank you for writing this blog very enlightening and answered questions that have stress-fully run around and around in my head for years since the injuries:)

  3. Tasworkdoc says:

    Thanks for your feedback Kerrie, Unfortunately I can’t see any real changes to the system on the horizon, but the more people who raise the issues the better!

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