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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.

 

UPDATE: Summary article 15/4/18 on how providers and participants can advocate is here

 

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

You can make a complaint directly to the NDIS 

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: 

https://www.aph.gov.au/Senators_and_Members/Guidelines_for_Contacting_Senators_and_Members 

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)

Read more about capacity building in the the legislation - NDIS Act 2013.

 

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

 

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