NDIS therapy funding to be reduced for many participants
NDIS therapy funding to be reduced for many participants:
Planners to decide how ‘complex’ participants’ disability and needs are, and allocate them to one of 3 pricing structures, from $110 to $190 per hour
The NDIS keeps changing. While ongoing change is tough, it’s good to have systems that keep evolving to meet needs of the community.
However the latest release from the NDIA has advised it will accept an independent pricing review’s recommendations which will reduce the funding for many people with disabilities accessing the scheme.
My summary of concerns is coming up below.
Why are we speaking up?
We advocate to address social, environmental, policy and institutional barriers to participation
One of our core values at Splash Physiotherapy is “We advocate to address social, environmental, policy and institutional barriers to participation” referencing the social model of disability, where a person is disabled by the structures of their community. I don’t typically make a lot of this work public, but felt this was an occasion where we need to share what is happening to encourage others to advocate as well.
Image description: Splash Physiotherapy value titled "We advocate to address social, environmental, policy and institutional barriers to participation - Social model of disability" under image of wheelchair basketballers, photo taken from above
How you can help advocate
I was a strong advocate for the NDIS which was initiated under PM Julia Gillard. I do believe it will end up being a fantastic support for people who have for too long been neglected. I understand that any new system is difficult to develop and implement.
However we need to remain engaged to ensure that we end up with a system that is in line with what we advocated for in the very beginning: a way to help people with disabilities have choice and control over their lives, and that helps them to achieve their goals and participate in everyday life.
Please join us by speaking up to help advocate for this.
OTA survey for health professionals:
UPDATE: this survey has now closed. Please write directly to your professional association with your concerns, case studies, supporting evidence.
[Occupational Therapy Australia is collating responses from anyone involved in allied health. They are partnering with the Australian Physiotherapy Association (where I am a member, and involved on the paediatrics and aquatics committees) and the Allied Health Professionals Association. These are all membership organisations, and the more feedback they receive the better. We are responsible for advocating for the families, children and adults we support, as well as for health professionals. Tip: cut and paste your answers into an email to your federal minister, the NDIA, and your professional associations.]
Ask the NDIA for the methodology of the pricing review to be released:
We in health know all about evidence informed care. Major decisions are being made based off the pricing review. However the review and the NDIA responses do not include much detail. We need to ask for the methodology and details of the pricing review to be released so we can understand where the conclusions have come from. And while you're there, tell them your concerns about the changes, and congratulate them on the changes you like! Email provider.support@ndis.gov.au and your local NDIA office.
UPDATE:
5/4/18 The NDIA released invitation to 'answer questions' in consultation regarding the review. Email Marketandsector@ndis.gov.au by Saturday April 14th to register your interest
You can also email your NDIS contacts, eg your LAC or planner
Providers have been also emailing provider.support@ndis.gov.au
Survey for participants and families, writing to the NDIA:
UPDATE: This has now closed. I have emailed the owner of the survey who has agreed to share results.
[Families who are concerned can advocate for themselves and their health professionals however they feel best. Examples could be: by writing to the NDIA, to professional associations, sharing information in parent / participant social media groups to encourage people to speak up.
Participants can complete this survey to say how they feel about the changes. This is for participants only, and is not affiliated with any provider groups. It closes 26th March 2018. Tip: cut and paste your answers into an email to your federal minister, the NDIA, and any of your contacts who need to know about the changes and speak up.]
Everyone can write to their ministers
The NDIS is federally funded. To find your local federal member, go to:
and put in your postcode in the search box near the bottom.
These are the Members of Parliament currently covering the NDIS to email, call, or write to
Hon Dan Tehan MP: Minister for Social Services and Disability Services
dtehan.mp@aph.gov.au (02) 6277 7560
Hon Jane Prentice MP: Assistant Minister for Social Services and Disability Services
jprentice.mp@aph.gov.au (02) 6277 4426
Hon Jenny Macklin MP: Shadow Minister for Social Services and Disability Services
jmacklin.mp@aph.gov.au (02) 6277 4305
Senator Carol Brown: Shadow Minister for Disability and Carers
cbrown.mp@aph.gov.au (02) 6277 3336
PO Box 6022 House of Representatives Parliament House Canberra ACT 2600
Use of social media:
I personally have been advocating within health professional and provider groups on social media for people to speak up directly to the NDIA and relevant professional associations. I am concerned about valid view points and content being lost on social media where it will not be considered by the NDIA. Sometimes it can feel as though we are advocating while remaining on social media, but I personally do not feel that is effective in this instance. Share and generate conversation by all means, but please then follow through with the survey and emails so your voice is heard.
Facebook groups for allied health professionals that are useful for staying up to date:
"Physiotherapists united in NDIS"
"Disability Community of Practice Australia: For Providers & Employees"
The context: choice and control
A key principle in the National Disability Insurance Scheme Act 2013 (the NDIS Act) of “enable(s) people with a disability to exercise choice and control in the pursuit of their goals and the planning and delivery of their supports”. (NDIS report on the principal of choice and control)
I believe any changes to the NDIS or participants’ plans needs to be viewed while considering choice and control.
The context: capacity building
A key principle of the NDIS is to build capacity of participants to participate in everyday life. This improves quality of life, well being, mental and physical health outcomes, engagement in community, education and work. The modelling that the NDIS was developed upon, showed how lifetime costs of supporting people with disabilities were reduced, and this is where the financial argument for the NDIS came in.
increased independence of participants and reduced cost of care
increased ability of participants to participate in the workforce
increased ability of carers to participate in the workforce
more proactive management of disability across a lifetime with fewer secondary complications and health risks
(Addition 10/3/18 in response to feedback)
Summary of changes and my responses
So here’s my run down of the items on the pricing review which are due for “immediate” effect from 1st July 2018, and my concerns with them. They are my personal opinions only. Submissions are rolling in to the NDIA and professional associations, so I encourage you to do the same.
I acknowledge the OTA survey whose questions I have used in structuring this article.
Recommendation 17
SUMMARY:
Therapy price caps have been $178.98 for early intervention and $175.57 otherwise.
NDIA will split professions into 5 different levels with 5 difference prices. Detail on this has not been released. Psychology has a higher price than 'physical therapy' supports including physio, OT, speech pathology.
NDIA will decide how ‘simple’ or ‘complex’ a participant’s needs are, and allocate them to a pricing level
Level 1 - $110 - $120
Level 2 - $140 - $150
Level 3 - $180 - $190
Details on who would make that decision is unclear, however it would need to be at the planning stage so our best guess is that it would be the Local Area Coordinator who does your planning meetings, or they would be bringing in Independent Assessors in addition to your therapists and LACs.
Addition of tables 10/3/18, taken from page 76 - 77 of the Independent pricing review
RESPONSE:
UPDATE 8/4/18:
My major concern is that it is discriminatory to put people into levels based on deficits. This sets the disability movement back decades and ignores the social model of disability. It is in complete contradiction to the World Health Organisation's International Classification of Function (WHO ICF), which considers the whole person, published 17 years ago in 2001.
I've previously written about the WHO ICF here, as we base all of our care around it, focussed towards participation goals.
It acknowledges that how someone participates in everyday life is a complex interaction between their environment, their personal factors, participation, activity, body structure and function, and disability.
To gain access to the NDIS, you already need to have a disability and needs that re 'complex' enough. Or, for babies and young children, you need to demonstrate developmental delay or a diagnosis. There is no such thing as 'simple' and 'complex' disability. Someone whose mobility is at GMFCS V might have a simple goal that can be achieved with 6 hours of therapy. Someone with mobility at GMFCS I might have a complex goal with many challenging interactions, that needs support from a team of therapists totalling 80 hours of support.
I believe that use of any levels is discriminatory. No one is 'worth' more or less per hour. No one is 'worth' seeing someone more or less experienced. The participant / their family gets to make the choice of who they want to see, and for what reason.
Instead of levels, each goal should be assessed based on how much support the participant needs to achieve it at this moment in time, considering the complex interactions as they are currently presenting. Some participants will need minimal support to achieve their goals, and others more. But that amount of support is not dependent upon what "deficits" they have, or what their diagnosis is.
Image description: World Health Organisation diagram of the International Classification of Function
a) Everyone deserves a high level of skilled, experienced care
price savings for people with less complex needs are that they require fewer hours to achieve their goals
however they should still receive a high level of skilled and experienced care to do this
an experienced therapist will still be more effective with people with 'milder' levels of disability than a less experienced therapist
children with cerebral palsy GMFCS I and II appear to be put into Level 1 according to the table 5 in the pricing review. This is still a complex condition, involving multiple systems of the body, with complex interactions between the person, condition, physical and social environments as illustrated by the World Health Organisations' International Classification of Function - Children and Youth. While the functional level of a child with GMFCS I is higher, the interplay between the many factors that are affecting their function and participation are not simple. They have the right to seek out a more qualified and experienced professional if they wish to, and that professional has the right to be paid an appropriate wage.
no Awards pay therapists different wages depending on the complexity of the work they are doing. There is no reason why the NDIS ought to
(addition in response to feedback 10/3/18): GPs are not paid less for seeing someone with a cold than with a complex medical condition. Health professionals are paid for providing the best possible service.
b) Comparisons to other schemes reported in the review do not hold true for physiotherapy
the pricing review and NDIA responses report that other comparable schemes pay lower rates for ‘simpler’ cases and higher rates for more ‘complex’ cares.
this is not true for physiotherapy, and that can be verified by publicly available pay scales. (Links to pricing schedules Worksafe and TAC). I have not investigated OT, speech or psychology.
what the TAC and WorkSafe do is support people after work place and motor vehicle accidents. You can have someone with a relatively ‘simple’ bone fracture, or you can have more ‘complex’ rehabilitation from an Acquired Brain Injury or multi trauma
they pay for 20 minute review physiotherapy consultations for ‘simple’ cases, and for longer appointments for more ‘complex’ cases. They have set forms and rates for reports which are very specific and quick to fill out.
where there are further complexities for a case, as in occupational rehabilitation, they pay in 7 minute blocks for phone calls, meetings etc
physiotherapists working with these case loads typically see 2-4 patients per hour. Even at the 'simple' rate this adds up to above the current $175.57 or $178.98 price caps for NDIS physiotherapy, not less. Group rates also add up to higher than the NDIS rates. In the current NDIS group rates of up to 3 clients at once add up to less than the 1:1 rate!
the TAC also allow physiotherapists to charge their usual market rates with prior agreement, as market rates are typically higher than the TAC rates. The NDIS pays only up to the capped rate.
WorkSafe allows health services to charge their usual rates to clients, who then are reimbursed a set rate. That means clients may have a gap to cover to see their preferred provider. The NDIS does not allow gap payments to be charged to participants.
in short, TAC & Work cover DO NOT actually pay physiotherapists less for 'simpler' cases as is reported in the pricing review; they are paid more than under the NDIS; and they are able to charge market rates.
c) who is going to decide which participant falls into which ‘complexity’ level?
details have not been released however it appears this will be done in the planning stage
difficulty in predicting a participant’s needs and the level of funding required has already provided challenging for planners (eg. LACs, Early Childhood partners), while many families needing reviews of their plans
adding another decision about how ‘complex’ a person’s needs are without an easy review or appeals process is concerning
what counts as ‘complexity’?
What about someone with GMFCS 1, MACS1, CMFM1... but who is struggling to function due to lack of therapy for a decade and has complexities with their care needs, and who needs intervention to prevent a loss of independence?
What about a child with CP hemiplegia who has GMFCS 1 or 2 and MACS 1 or 2 but who really wants to learn to ride a bike? You need skilled physios to do that, it's a really tricky area, and it is not sustainable at $110ph. It might take 6-8 hours to give that child a skill they will use their whole lifetime, that has carryover to other areas of their life, that gets them participating and joining in with their family and friends, that sets them up for an active future. That is a fantastic outcome for a very small outlay of funds if we are paid appropriately.
what are the risks of introducing tiered funding for different people?
it still costs the service the same amount of money to provide the service
we at Splash Physiotherapy could not provide aquatic physiotherapy at lower rates than the NDIS currently pays
will this cause further inequity with services having to make horrible ethical decisions? We go into health because we want to be helpful, and no one is in it to earn huge wages! But we can’t provide services at a loss. That would be a terrible situation to be in to make that decision.
d) The report notes that most providers are charging at or near the price cap
that is because that is what our services are worth, or because we usually charge higher than that rate. This is easily verified by looking at prices charged by other schemes (TAC, WorkSafe, Medicare as described) as well as at the publicly available Betterstart and HCWA rates. In private practice, services under these schemes are generally provided by physios, OTs and speech pathologists at less than the usual rates i.e. the schemes all pay less than market value, and the new NDIS rates even lower.
that is an argument for remunerating us fairly, so that we can provide high quality services.
therapists do not go into work in the disability sector for the money. Disability has historically been one of the most poorly paid sectors in health and we have all worked in that environment for many years. We go into this area because we are passionate about doing meaningful work that makes a tangible difference to the lives of the people we support.
but that does not mean we shouldn't be remunerated fairly for our expertise working in a specialist, complex and challenging area.
remember that therapists don't have the therapy rate going in to their pocket for 40 hours per week. The organisation might bill 20-30 hours per week per therapist, who generally work well above full time hours, to cover: therapist wages and super; admin support; book keeping and accounting; time to do continuing professional development; cost of professional development; equipment, rent and utilities; insurances and registration; non - contact time that is not billable, including hours interacting with the NDIA attempting to recover payment, and so on. This is already proving challenging at the current prices and will be not possible at new rates without major changes.
the "greedy provider" narrative is inaccurate and shows a lack of understanding. It drives a wedge between providers, participants and the NDIA when we should be cooperatively forming partnerships to support independence, choice, control and participation.
(This was edited 11/3/18 in response to observed informal communication about "greedy providers"; misinformation about what the costs of providing therapy involve; and questioning the intention of therapists who are speaking up. Yes we are speaking up to allow us to continue to support people with disabilities to participate in life in the way they want, by working in an area we are passionate in. We are advocating both for our client group and for ourselves. Without advocating for ourselves as well, we will not be able to provide sustainable services for participants.)
e) Providers are already struggling to remain viable under the transition to NDIS
Many provider organisations have folded under NDIS pressures, or are struggling, or have de - registered as NDIS providers.
Examples of issues have been:
high cost of registration, and concerns about now having go through a new expensive process in the 18-19 financial year as we move to a national commission
adjusting to unit price costs
planning ahead for how participants wish to use their funds to achieve their goals, and providers being realistic about what they can achieve within a certain allocation of hours
challenges of using the NDIS portal and communicating with the NDIS and planners. I personally have not met an organisation who has not spent significant hours (at huge staff cost) attempting to communicate with the NDIS to advocate for participants, or in attempting to be paid for services they have already delivered.
the ABC reported 28/2/18 that there is currently a $300 million debt to providers outstanding with the NDIS, and the NDIA have just released a specific team and email address to send payment issues to in response to this.
plans and service bookings can be changed by the NDIA without notice and this can lead to issues with being paid for services provided
supporting families who have struggled with organising their plans and interacting with the NDIS
Some of these pressures are recognised in the pricing review.
f) Providing certainty to providers has been a priority of the NDIS to grow a stable and effective work force
Sudden changes to remuneration provide an unreliable environment where they are making significant outlays in preparing to meet NDIS demand. This is in contrast to the planned development of the NDIS reported in July 2015:
“Providers, particularly existing providers, will need to develop an understanding of the cost of
doing business, especially the concept of unit pricing. It is important that pricing signals are
clear and timely so that providers can prepare for transition in a timely manner and invest
with certainty. For example, clear signals need to be provided about intended pricing policy,
regulatory and reporting requirements and publishing performance data of providers
operating in the NDIS.” (NDIS integrated market, sector and workforce strategy, July 2015)
There is no way for providers to plan their budgets and staffing levels to the support NDIS participants, where the NDIA makes sudden and significant changes to policies and pricing.
g) Having levels of "complexity" means advocating for yourself and demonstrating "how disabled you are "
In some funding schemes applications need to highlight the most negative aspects of a person's ability. Can't do this, can't do that, can't learn that either.
Therapists who work with children are often experienced in the differences between this and a Strengths Approach. What can you do? Great! What will you learn next?
Research in compensable claims has shown that people with legal claims tend to have poorer health outcomes and recoveries, related to repeatedly having to 'prove' their injury or disability in order to access the funds they need to support them.
In contrast, the NDIS has been focussed on capacity building goals and achieving them. It has been one of the joys or working with the NDIS. It makes sense clinically and with the evidence base. It feels like an up to date approach. It fits with our values at Splash! I for one do not want that focus to change.
h) Why are psychology services remunerated higher than other therapies?
I don't have much to add to that question! Why?
Recommendation 18
SUMMARY:
Therapy assistants are going to be paid at 2 levels depending on their qualifications.
The pricing recommendations states that Level 1 to be priced at $44.72 - $49.20 and Level 2 to be above level 1 and below the proposed price of level 1 therapy - $110 - $120.
Details have not been released on who would fall under which category.
“This recommendation is likely to result in an increase in the utilisation of therapy assistants” (OTA survey).
RESPONSE:
the way assistants are used in plans currently is often problematic
therapy assistants can be appropriately used where there are simple goals at an impairment level (eg increase strength, balance, range of movement) or where context specific repetitive practise is needed (eg walking from home to access the shops and practise existing strategies)
they are under the supervision and professional indemnity insurance of the supervising allied health professional (AHP, eg physio, OT, speech, psychology), who has to do all assessment, develop programs and plans, train the assistant, sign off on safety and efficacy, and regularly monitor and update, as well as hear back from assistants as they go, and reassess and report at the end of the plan, and address any issues that come up as the plan is implemented.
to do a good job in paediatrics, we need to get to know the child and family with a thorough assessment and at least some treatments to understand what progress is possible and how quickly
allied health professionals are skilled at moment to moment reassessment and adjustment of strategies being used within a session, always searching for that 'just right challenge'. In doing so, they are effective and efficient with their time. ie the client can be learning (neuroplasticity) and seeing change within and between sessions.
only once that learning is quite static would an assistant be appropriate, eg to build strength or endurance in an existing skill through a repetitive program. They cannot adjust or progress the program without the AHP's input.
most of the children we work with do not need exercise scientists or therapy assistants to achieve their goals - they need physiotherapists. When they need strengthening / balance / range of movement program, or support to transition to community based swimming lessons, therapy assistants work well. But most of the people we work with are still learning. They are still capacity building. They are still becoming more independent. And that's because of the detailed, specific, evidence informed, goal directed physiotherapy they are provided with. An exercise scientist or assistant just can't provide the same in that learning stage.
the current plans with assistants included that I have seen have few physiotherapy hours and lots of therapy assistant hours eg. 20 AHP and 120TA. This is a very poor ratio. On our information page about therapy assistants we write:
“Unfortunately some families have been given funding with very few allied health professional hours compared to many therapy assistant hours. If we do not feel we are able to provide a safe and effective service to your child / young person due to insufficient allied health professional hours, we will advise you of this.”
overuse of assistants undermines the effectiveness of AHPs and puts us in the role of a consultant, where we cannot provide the same level of support towards goals
the current rate of $41.71 of assistants is too low and we provide it at a loss for our existing clients who have moved to NDIS, so a price rise is well received
it is not clear what qualifications will count towards the two levels. We use final year physio students who provide excellent value for money as they are nearly qualified in this area.
increased use of assistants would appear to be a cost cutting measure, and inappropriate where further learning and capacity building is realistic and related to participant goals.
Recommendation 19
SUMMARY:
Travel for therapy will have the same policy as travel for attendant care.
This will allow “providers to charge up to 20 minutes at the hourly rate when travelling between participants. It is OTA’s understanding that travel will continue to be costed under therapy supports, but with no limit imposed. Participants will have choice of engaging a provider who needs to travel further and receive less therapy support as a result.” (OTA survey)
RESPONSE:
there are plusses and minuses with this recommendation
there is excellent quality of evidence for providing early childhood intervention services in “natural settings” such as children’s homes, childcares, playgrounds etc. Being able to provide a responsive services, that meets the NDIS principle of “choice and control” is linked to provision of therapy services in the community.
currently providers cannot charge for travel up to 10km. In metropolitan Melbourne where we work, 10km can easily take 30+ minutes, an that makes providing a visiting service very costly to organisations
so being able to charge for up to 20 minutes of travel is a great start, but does not go far enough. Are we to be paid to travel to a family’s home but we need to volunteer our time to drive back to the clinic? The therapists still need to be paid their hourly rate while driving, the admin team are still in the office supporting them…. i.e. the costs continue.
certainly it would be ideal for everyone to see therapists nearby in their community
however metropolitan Melbourne is huge!
and there are many areas where there are no local therapists with relevant skill and experience
it is difficult to find skilled and experienced therapists working in early childhood intervention without a waiting list
that disadvantages people based on where they live. That contributes to inequality in our community which has to fundamentally against the values of having a disability scheme.
for people working rurally & remotely, there are different recommendations. Please look at the review for that information - I am not commenting here as it does not currently apply to us.
Recommendation 20
SUMMARY:
“The cancellation policy for therapy should be amended so that up to a certain threshold, providers can charge against a participant’s plan for up to 90% of the scheduled service if the participant makes a short notice cancellation. A cancellation line item should be created as a governance mechanism for the NDIA.
Currently providers can charge up to 2 hours cancelled per year, therefore this is a significant change.” (OTA survey)
RESPONSE:
I have careful support for this recommendation
All service types should have been treated equally from the beginning. Therapy was not allowed to charge for short notice cancellations, until the 17-18 price guide where we could charge for up to 2 per year.
Therapists should absolutely be able to charge for late notice cancellations in this way.
It fits with common practise in health professionals, as well as in other service industries
It enables therapy services to not run at a loss. We still need to cover therapist wages, admin wages, utilities and venue hire, insurance etc even if someone does not attend. It covers the instances where people come down sick last minute, and responsibly cancel their appointment rather than spreading infectious illnesses.
We at Splash Physiotherapy have been devastated that our late cancellation rate roughly equalled our wait list in 2017. It is heart breaking to have families waiting for therapy when we technically have the time available to see them. Having fees for late cancellations provides additional incentive to give as much notice as possible, so we can fill places from our waiting list.
The threshold will be relevant, and the NDIA has indicated they will be supportive of participants who have frequent late cancellations due to complex medical needs. This is important. From an ethical point of view, we would not want to see a situation where people with complex medical needs are being turned away from services due to the financial loss that services have to wear through multiple late cancellations.
Recommendation 21
SUMMARY:
The NDIA should only allow providers to charge participants for the time spent writing reports that are requested by the NDIA. A new line item should be introduced for tracking purposes.
No detail has been released on when reports will be mandated, what they are to include, or how much providers will be paid for doing them.
RESPONSE:
It is our understanding that no reports are currently mandated, rather they are provided in response to participant request. This is in contrast with other schemes, we are required to send in reports at certain time points and these are attached to funding
Families / participants have been exercising “choice and control” in when they wish to have reports done. We do certainly prefer to write one for participants when they are preparing for their planning review meetings, to demonstrate their goals, how they have used their funding, how their goals have been achieved, and the goals they wish to work on next
Families / participants have also often asked for other reports such as:
applying for equipment
advocating for a review of the NDIS plan where there were gaps in funding
advocating for reviews of decisions not to provide equipment
communicating with the participant’s team to facilitate working together to support them in a coordinated way
Is there a potential for bias?
If you don’t want to know about something, don’t pay for a report?
What if no reports are requested because they don't want to see evidence of therapies' efficacy because they want to reduce cost?
What if they only ask for an early intervention keyworker's report, and not those from the rest of the AHPs involved, therefore not showing marvellous gains or raising issues that need to be addressed in the next plan?
If providers cannot be paid to write reports to support and advocate for participants in appealing decisions, is that bias? Does that prevent appeals? Does that lead to appeals with less evidence to back them up? Does it lead to further inequality where participants who can afford to pay for advocacy reports can receive them? Or are therapists expected to voluunteer their time?
If you want to minimise funding, do you pay only a small amount for reports to you get a bare bones summary with little evidence from providers? (Or expect providers to volunteer their time to provide more comprehensive reports?)
How and when will the NDIS request reports? Will they give us quick turn around times making production of a quality report challenging?
Please speak up to help build the NDIS that we envisioned and need!
I was a strong advocate for the NDIS which was initiated under PM Julia Gillard. I do believe it will end up being a fantastic support for people who have for too long been neglected. I understand that any new system is difficult to develop and implement.
However we need to remain engaged to ensure that we end up with a system that is in line with what we advocated for in the very beginning: a system that gives people with disabilities have choice and control over their lives, to achieve their goals and participate in everyday life.
Please join us by speaking up to help advocate for this.
Surveys: (UPDATE now closed)
Key references:
This post was updated 8/4/2018
