Will the I-CAN miscalculate budgets and encourage fraud on NDIS?

This reform is an attempt to implement Recommendation 3.4 from the 2023 Independent Ministerial Review namely, that NDIA introduce a new ‘needs assessment processes to more consistently determine the level of need for each participant and set budgets on this basis.’ 

A shift to some form of a needs-focused assessment is warranted as the current system which funds participants goals rather than their needs, is illogical and opaque–  goals bear little correlation to the level of supports required. The current goals reporting system also requires multiple reports, which makes it too complex and time consuming for most disabled participants to navigate, causing undue stress – and overwhelms and disadvantages intellectually disabled participants who are unable to organise the paperwork. The current system also results in inconsistent budget allocations between planners and enables biases, for example: the plans of male participants are larger than women's across-the-board.

Rapid growth in the scheme to 720,000 participants has overwhelmed NDIA administratively, despite a doubling the number of NDIA bureaucrats to 10,000 in the past 5 years (Fin. Review 7/11). The Agency is no longer unable to read the multiple long reports they request in a timely manner, which causes unacceptable processing delays, forcing participants to wait six to nine months for plan changes which breach of NDIAs statutory timeframes. Such delays force vulnerable participants– 77% of whom are unemployed–to pay their care costs out-of-pocket or face neglect.

Limitations of the I-CAN Assessment Tool

So some kind of new needs assessment process is required to simplify and standardize the assessments process, remove disadvantage to the intellectually disabled, as well as speed it up. However, in the selection of any new standardized needs assessment tool, several factors must be considered: 

■ Any new assessment tool must be universally applicable and cannot disadvantage NDIS participants with certain classes of impairments. As a questionnaire, the I-CAN relies exclusively on self-reporting, which very clearly disadvantages participants who are:

• Intellectually disabled or have cognitive difficulties (including autism); 
• Non-verbal or have difficulties with communication
• ESL: participants for whom English is a second language

The above participants may be unable to answer ICAN questions accurately or at all. Restricting evidence gathering for the I-CAN assessment to verbal self-reporting, will prevent many participants from being accurately assessed for the very conditions they seek supports for– which is illogical and unjust. The I-CAN will have a discriminatory impact on participants with intellectual disabilities, cognitive difficulties, communication issues or those who are ESL. This is over half the scheme, which throws into question the suitability of the I-CAN as a standalone assessment tool. Second-hand accounts of capacity by family members— who may be unavailable, not involved/engaged, or suffer mental health challenges or cognitive impairments of their own (impairments are often hereditary)— cannot be relied upon as accurate proxies for gauging capacity by NDIS, especially if the result determines budgets.

Even the common strategy of ‘masking’ employed by autistic participants– which includes scripting conversations– as individuals unsure what the ‘right thing’ to say is, provide scripted answers to mask their social shortcomings, would prevent accurate assessments. Autistic participants may claim ‘they can get ready independently’, but in reality, may require multiple prompts in order to do so which would render the results inaccurate.

ESL participants may struggle to comprehend the questions or communicate their answers effectively, which will result in inaccurate responses and invalidate the results.

The I-CAN also discriminates against participants who have fatigue-related conditions as they are unlikely to have the energy required to complete the three hour survey, resulting in affected participants struggling to answer correctly towards the end or complete the survey at all. Fatigue is a very common symptom for NDIS’ severely affected participants, so any new assessment process needs to accommodate fatigue disorders.

■ Inaccurate:  given the I-CAN's multiple shortcomings outlined above, it comes as no surprise that the I-CAN has a low rate of accuracy only 53% in early testing (according to Gerry Humphris Emeritus  Professor of Health Psychology at the Medical School at University of St. Andrews, Scotland, see post below)– which gives participants only a one in two chance that their needs will be accurately captured, much worse for minorities. 

According to Larry Cashion, a Consultant Psychologist at Enable Plus who has reviewed the I-CAN, is of the opinion that the accuracy of the new assessment tool is likely to be even lower than 1 in 2  in the real world where it will be administered by non-clinicians: ‘There's no reliability or validity data for non-clinical administration which is very likely to (further) diminish (accuracy).’ In short, the accuracy of the I-CAN's, which is already unacceptably low, would be further reduced in a real world setting in unprofessional hands. This throws the suitability of the I-CAN as an assessment tool on NDIS into question.

Encourages Fraud: However, most concerningly for NDIA is fraud. If the I-CAN questionnaire determines funding, will participants be motivated to answer truthfully? Likely not.

If the I-CAN assessment determines budgets, participants will be motivated to exaggerate their capacity limitations in order to maximise their care budgets. Unfortunately, the self-reporting– which the I-CAN exclusively relies on– enables participants to exaggerate capacity limitations easily. For NDIA, the ease of fraud that the I-CAN will enable should be of grave concern– especially given the level of fraud currently plaguing the scheme. 

It should be noted that the reliability of self-reporting– utilised by I-CAN– has not been tested where participants are motivated by an economic outcome– which will skew results. Any budget related assessment conducted by NDIA requires that the Agency independently verify the information provided, to ensure its reliability and accuracy: afterall, a needs-based budget allocation cannot be accurately determined without credible and verifiable evidence. Self-reporting is not credible evidence as it cannot be verified: without substantiation, any claim can be made in pursuit of more funding. A wave of fraud will be inevitable and enabled by the I-CAN's inadequate design.

In summary, the I-CAN falls short of being non-discriminatory, accurate or fraud free– core requirements of any new assessment process, due to its exclusive reliance on verbal self-reporting which has: a discriminatory impact on participants who are ESL or have certain classes of impairments, is inaccurate and enables fraud.

Liability for NDIA

Failure by NDIA to accurately assess a participant's needs due to the I-CAN's:

• Sole reliance on verbal self-reporting, which discriminates against participants with certain classes of impairments and ESL;
• Low rates of accuracy;
• Absence of an assessor who is professionally qualified in functional capacity assessments, which further lowers the accuracy of the assessment.

May result in the miscalculation of participants' budgets. Liability may arise for NDIA where participants suffer harm due to the miscalculation of care budgets resulting from the Agency's use of an inadequate assessment process or unqualified assessor. For example, if an NDIS participant suffers an accident or deterioration in health or capacity, due to the miscalculation of supports which results in additional costs for the participant, such as medical bills or out-of-pocket care costs, NDIA may be liable.

As it is reasonably foreseeable that NDIA's conduct could cause harm to participants, and there is proximity between the parties, a duty-of-care under common law exists for NDIA to take reasonable care to avoid acts or omissions that could foreseeably cause harm to its participants. Therefore, Agency executives must exercise a standard of care that a reasonable person would in the selection and development of any new assessment process– which includes both acts and omissions– to avoid harming its participants and therefore liability. When determining the standard of care, courts consider the level of risk which is likely to be very high for severely disabled people.

So in order to effectively manage liability alone, NDIA will need to ensure that the new assessment process is:

■ Accessible and uniformly applicable across different types of disabilities: so does not discriminate or disadvantage people with classes of impairments or ethnic minorities.

■ Uses only allied-health professionals qualified in Functional Capacity Assessments to conduct assessments: so occupational therapists only. While dietitians or counselors are currently allowed to conduct I-CAN assessments–they would be very unlikely to clear the standard of care required by common law for assessments, as they increase the inaccuracy of assessments and are unable to pick up on red flags such as masking behaviours, cognitive or communication difficulties and intellectual impairments.

■ Accurately assesses and provides for the needs of its disabled participants: to ensure they are not harmed by miscalculated supports. 

To ensure compliance with torts law, a more robust and multifaceted approach to assessments, than the narrow Q&A format that I-CAN provides, is required. It would also necessitate that I-CAN assessors are allied-health professionals qualified to conduct functional capacity assessments to ensure nothing is missed– so an occupational therapist, rather than a dietitian or counselor.

Adjudicating budgets using a tool which employs only one assessment method–that discriminates against participants with classes of impairments– is unlikely to satisfy the duty-of-care that NDIA owes its participants. The I-CAN also suffers from low rates of accuracy– only 53% in early published testing the I-CAN (according to Gerry Humphris, Emirates Professor of Health Psychology at the University of St Andrews, Scotland, see statement) – which makes harm highly foreseeable, further increasing liability for NDIA. The miscalculation of NDIS’ participants' care budgets is dangerous and potentially fatal as participants are severely disabled.

To manage liability effectively when assessing participants' care budgets, NDIA will  require an additional and accurate non-verbal assessment tool, such as directly witnessing participants performing the daily activities– or an approximation of them– that NDIA are determining funding for.

Only part of the solution 

While the customizable I-CAN can form a part of a new needs assessment process for domains suited to the Q&A format– such as non-physical domains like relationships and behaviour– it cannot be relied upon as a standalone assessment tool, particularly when assessing the impact of a participant's physical impairments on their daily support needs.

So the physically-focused I-CAN domains of mobility and self-care cannot be assessed verbally through I-CAN questionnaire due to:

• the inability participants who are ESL or certain have classes of impairments to report accurately or communicate effectively; and 
• the inability of NDIA to verify information provided through self reporting– as it will inform budgets.

An additional non-verbal assessment tool– which involves NDIA directly witnessing the impact of a participant's impairment on their ability to carry out daily activities– is required in order to correctly assess the nature and extent of supports required for daily living without relying on verbal communication which is unreliable (or at least to verify the accuracy of self reported claims).

The following daily activities activities need to be viewed by NDIA directly, and scored quantitatively, in order to accurately determine funding:

■ transfers        ■ ability carry out personal hygiene tasks

■ mobility           ■ eating

■ bathing           ■ pouring a drink

■ dressing         ■ preparing a light meal ■ laundry

There are two ways of assessing a person's functional capacity non-verbally, both involve direct observation:

1) The direct witnessing and scoring (on a standardized metric) a participant’s ability to perform the essential daily activities outlined above, as part of their normal routine to a reasonable standard by an occupational therapist. This can be achieved in an efficient timeframe (60-90mins) by directly observing a participant's morning routine: from when they get out of bed– until they are out the door, as this encompasses most daily living activities including: mobilisation, washing, dressing, meal preparation, eating, organisation and multitasking.

2) Devising a Standardized Functional Capacity Assessment, which involves a series of standardized physical tasks which approximate the daily living activities that NDIA funds supports for. Such an approach would offer a direct standardized non-verbal method for the Agency to assist participants' capacity in relation to their daily care needs, in a short space of time. Additionally, participants could be asked to copy a movement routine demonstrated in a video in order to gauge basic physical capacity such as: range of movement, coordination, balance, reach-and-grasp etc…in a standardized way.

See Table 1: Standardized Functional Capacity Assessment for an example of a series of standardized tasks that would assist in determining the extent of supports required. Whether the participant can perform these standardized tasks to a reasonable standard would determine whether or not they receive funding for the daily living activity that the activity relates to.

Both of these direct observational assessments– which must be conducted by an occupational therapist only– eliminate the disadvantage posed by verbal self-reporting by participants with intellectual, cognitive or communication difficulties as well as ESL participants (who come from ethnic minorities). Directly witnessing participants performing the daily activities which NDIA are determining supports for, would ensure that the assessment is accurate thus guard against exaggeration enabled by self-reporting, therefore fraud.

In-built Fraud Prevention Measures: The best way to guard against fraud and ensure honest and accurate assessments, is to ensure that the participant's own occupational therapist (OT) is present along with the NDIA assessor, both of whom observe and score participants ability to perform essential daily activities on a standardized metric such as an expanded Care and Needs Scale (C&NS) (which is currently relied upon by NDIA to assess applicant's eligibility for the scheme, as the C&NS identifies whether a participant's impairment impacts their capacity to perform daily living activities). The presence of the disabled participant's own OT guards against any exaggeration of physical limitations in an attempt to maximise budgets. It would also ensure that participants' needs are accurately captured and that nothing important is missed. Intellectually disabled or cognitively impaired participants cannot be relied upon to give accurate responses. Using two assessors–one from NDIA, the other the participant's own– to double-score the standardized Functional Capacity Assessment– would also help eliminate low balling and high balling– there by removing bias from the assessment– so long as the two assessment scores are required to be within an acceptable range of each other (ie. 20%).

A direct observational assessment of capacity can be used in tandem with the I-CAN questionnaire which can be tailored by collapsing unwanted domains– domains unsuited to or likely to be inaccurately gauged through Q&A self-reporting format (such as mobility and self care)– and substituted with a non-verbal assessment. The I-CAN can continue to be used to assess the remaining 8 I-CAN domains suited to a Q&A format– such as intellectual capacity and relationships– as well as to verify the frequency of supports required.

As NDIA allocates funding for supports based on whether individuals are able or not able to perform a daily living activity, it is important that these attempts are witnessed directly by the Agency, rather than determining funding for daily care support via an algorithm and a loose aggregate score which is unlikely to correlate with the supports required. The first hand witnessing of daily living activities by NDIA would not only ensure the accuracy of the assessments, but prevent discrimination against ethnic minorities and users with certain classes of impairments, as well as prevent fraud.

Another Way Forward: Integrating Co-design into the Development Process

The NDIS Ministerial Review was right– a consistent needs assessment process needs to be introduced onto the scheme, as the current goals-based funding model is complex, opaque and administratively unworkable at scale– and delays access to funding.

However, exclusive reliance by NDIA on the I-CAN questionnaire is an extreme response to the Ministerial Review's directive of introducing a consistent needs assessment process and demonstrates:

■ an excessive drive towards administrative efficiency at the cost of participant welfare; and 

■ an inability of cloistered Canberra bureaucrats to understand how fraud happens on-the-ground.

■ no understanding or working knowledge of how Functional Capacity Assessments are conducted or the information required to accurately gauge capacity.

Hard-and-fast application of the I-CAN questionnaire– which is not designed to accommodate multiple classes of impairments and suffers from large error margins– as the sole standardized assessment tool will miscalculate care budgets and butcher the disabled– who are by-enlarge low-income and unable to privately fund care support. The combination of the I-CANs poor rate of accuracy with the discriminatory impact of the verbal Q&A format on ethnic minorities and users with certain classes of impairments, makes it a potentially dangerous tool for determining care budgets. This policy disaster could in-part have been averted had co-design been integrated into development of any new assessment process, rather than just being tokenly sought by NDIA. To correct this, two fold action by NDIA is now required:

• Contract for the development of an additional non-verbal assessment tool to supplement the I-CAN (in domains relating to physical capacity such as mobility and self-care) in order to directly, accurately and even-handedly assess disabled users' functional capacity in relation to daily living activities. This would remove the discrimination embedded in the I-CAN against classes of impairments and ESL speakers, as well as ensure accuracy of assessments and reduce fraud.

• An independent study of the I-CAN (not by Melbourne University who have a commercial imperative to report good result as it is already-contracted-for), with participants' I-CAN results benchmarked against standard FCAs conducted by independent occupational therapists is required if the I-CAN tool is to be in any way relied upon by NDIA to determine budgets. Given the existing shortcomings of the I-CAN, including low rates of accuracy, an independent study is necessary in order to ensure that the I-CAN has acceptable rates of accuracy prior to its use by NDIA has an assessment tool to determine budgets, in order to avoid both harm to participants and liability to the Agency.

The I-CAN represents a sharp and experimental departure from the tried-and-tested non-verbal Functional Capacity Assessments currently relied upon by NDIA to assess users' budgets and therefore gambles with the health and safety of NDIS’ severely disabled participants. It is far safer to modify and expand existing instruments with a proven track record than to ambitiously reinvent the wheel.

Expanding Trusted Tools

The Care and Needs Scale (developed by University of Sydney), which is already relied upon by NDIA to gauge participant's capacity during the admission process, could be expanded by researchers to include standardized assessment tasks which would non-verbally assess participant's capacity to perform the key daily living activities assessed in the Care and Needs Scale, (which is structured around daily living activities– which is how NDIS presently determine participant's care budgets).

The accessibility of any new assessment process can be contractually insisted upon by NDIA by stipulating that the new assessment tool must be uniformly accessible across different classes of impairment as a term in any contract. NDIA could also contractually require a minimum number of workshops with: a representative group of occupational therapists and peak disability groups, in order to ensure their assessment tool is accessible across a wide range of disabilities as well as has real world application and is not susceptible to fraud. NDIA should also require that assessment tools are tested with an economic motive in play to ensure that the tool is viable where budgets are being determined. 

Agency Knowledge Gaps

This mishandling of the selection of the new needs assessment tool demonstrates the vast knowledge gaps plaguing NDIA executives as to how the scheme works at the coal-face or what the complex realities of disability care actually are. Both are caused by a lack of working knowledge of disability, as well as no hands-on experience using NDIS. And herein lies the problem, NDIA bureaucrats are not by-enlarge disabled, don't use the scheme, and so are simply unaware of:

• the real-world accessibility challenges that any new assessment tool needs to overcome;
• the information required to conduct an accurate assessment; or
• how fraud happens on-the-ground.

Consequently, NDIA have lazily reached for the most administratively efficient assessment tool– one which makes the Agency's life easier – at the cost of accessibility, accuracy, fairness, safety and participant welfare. At this point, it is unclear who the new assessment tool is for? Certainly not NDIS’ severely disabled users.

Merely outsourcing the matter carte blanche to siloed academics – who have not tested how economic motives distort participant responses and are unaware of how fraud happens on NDIS– does not get NDIA off-the-hook liability-wise. As the National Disability Insurance Agency, NDIA are responsible for ensuring that any new assessment tool they contract for is: 

• compatible with the functional impairments of scheme users;
• accurate; and
• reduces fraud on NDIS– rather than increasing it. 

Reining in Fraud

Fraud on NDIS is of great concern to Australian taxpayers who foot the sizable $46B bill for the scheme and whose confidence in NDIS is fading fast, in-part due to high levels of fraud plaguing the scheme. As public servants, it is a key responsibility of NDIA bureaucrats to ensure that any new assessment tool is both designed and tested for fraud, rather than carelessly enabling the practice. The extensive efforts of NDIA's $30mil per annum Fraud Fusion Taskforce and 700 dedicated fraud staff (7/11 Fin.Review) are in vain, if the policy tools that the Agency unwittingly selects for green-light fraud.

Conclusion 

With a recent string of harmful policies, including I-CAN, NDIA have demonstrated that they lack the working knowledge of either disability or fraud required to independently choose a workable needs assessment tool. Until political leaders wake up and smell the mismanagement, the disability community will need to actively lobby against mishandled policies such as the I-CAN, which are both discriminatory and pose great risk to the scheme’s vulnerable and disabled users– and propose viable policy alternatives themselves.

To this end, a petition for a Parliamentary Inquiry into the new needs assessment process has been opened, so that the many issues surrounding how participant budgets on NDIS are to be calculated can be opened to public scrutiny- especially in the absence of a White Paper prior to legislating for it, which is standard practice. Please click here to sign the petition and comment below to publicly register your views on the I-CAN so journalists, NDIA and political leaders become aware of your concerns.

In light of NDIA’s mismanagement, the disability community must now coordinate its activism in order to raise the standard of policy on NDIS themselves, to ensure that the scheme is accessible, safe and fair – not just efficient.

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