NDIA Accountability Project

Regulation of the audiology profession and NDIS provider eligibility

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Submission No 178

INQUIRY INTO IMPLEMENTATION OF THE NATIONAL DISABILITY INSURANCE SCHEME AND THE PROVISION OF DISABILITY SERVICES IN NEW SOUTH WALES

Organisation: Independent Audiologists Australia Inc Date Received: 8 August 2018

P. O. Box 164 Turramurra NSW 2074

www.independentaudiologists.net.au

Director Portfolio Committee No. 2 Health and Community Services Parliament House Macquarie Street Sydney NSW 2000 PortfolioCommittee2@parliament.nsw.gov.au

9 August 2018

Dear Director

Implementation of the National Disability Insurance Scheme and the provision of disability services in NSW

Thank you for the opportunity to contribute to the Upper House inquiry into the implementation of the National Disability Insurance Scheme (NDIS) and provision of disability services in New South Wales.

Independent Audiologists Australia Inc (IAA) is a not for profit incorporated association with members who are university qualified audiologists who operate practices in which they have a financial interest. Our members offer audiological services across the full spectrum of diagnostic and rehabilitative audiology delivering services for auditory (hearing) and vestibular (balance) conditions for all ages (from newborns to the elderly) and for all degrees of complexity. Services are provided under a range of public and private funding schemes – including the Hearing Services Programme, Medicare, WorkSafe, Department of Veterans Affairs, National Disability Insurance Scheme (NDIS), private health funds and private fees.

IAA has contributed to inquiries into hearing services and the NDIS carried out by Federal government. We welcome this additional opportunity to share the experiences of our members with this NSW upper house inquiry.

The issues we raise cover points a, b, e, f, i and j in the terms of reference. However, many of the issues of concern cut across these points and so our submission is presented under the headings of NDIS providers, eligibility, participants (NDIS managed and self-managed) and regulation. We list proposed actions that the NSW government can take to ensure adequate service delivery across all NDIS participants as well as those who fall outside of the NDIS.

The mission of Independent Audiologists Australia is to promote and support clinical practices owned by audiologists.

NDIS Providers

Audiologists are excluded from registering as NDIS providers of hearing services. This decision has created confusion for providers and the public. Hearing service providers listed on the NDIS website include businesses that have little connection with audiology. Yet, audiologists, whose day to day work involves supporting those with hearing loss, have been told that registration as a hearing services provider under the NDIS is closed to them.

As the NDIS does not currently allow audiologists to register as NDIS providers of hearing services, the public is left confused as to who they can consult. The categories of NDIS provider under which audiologists can register – assistive devices and therapeutic supports are easily not recognised by planners or the public as being associated with hearing, when a separate category of hearing services exists in the list.

The NDIA staff have issued letters that show that they confuse the Hearing Services Programme (HSP) voucher scheme administered by the Commonwealth Department of Health with Australian Hearing, a for-profit government owned agency. This confusion is likely to be compounded by recent announcements of a partnership between Australian Hearingi and the NDIA to provide a single pathway for children up to 6 years of age. A common misunderstanding amongst planners is that they insist that NDIS participants (including those over 6 years of age) must go to Australian Hearing for hearing services and devices. Choice of provider is an element of both the HSP voucher scheme and the NDIS. NDIS participants on managed plans who are issued an HSP voucherii should be given full choice of contracted service providers under the hearing services programme scheme. Those deemed to have conditions too complex to be covered by the voucher have an option to be directed to Australian Hearing, but they also have the option to remain with their original provider of choice.

Proposed Actions:

  1. Education of NDIS planners and the public
  2. Hearing services NDIS provider category must be opened to audiologists and audiometristsiii, with specification as to what each can offer
  3. NDIS participants (over the age of 6 years in the case of hearing services) should be given choice of hearing services provider whether on managed or self-managed schemes.

Eligibility for the NDIS

The NDIS, despite declaring that its funding decisions are determined by function and need, applies an impairment measure to determine eligibility for those with hearing loss. Eligibility criteria have been set for the NDIS that are dependent on age and degree of hearing impairment. Those under 26 years of age are eligible for support from the NDIS, regardless of type or degree of hearing loss. For those over 26, only those with average hearing loss levels of 90 dB or higher in their better hearing ear (described as profound deafness) are automatically eligible for NDIS funding. Those with lesser degrees of deafness (65 dB to 89 dB in the better ear), if associated with other conditions may be eligible. By far most people with debilitating hearing loss fall outside of the range of those who are automatically covered by the NDIS.

Many people with so-called mild degrees of impairment may have major impacts on communication such that they must forgo employment due to the fatigue, lack of support and lack of adjustment to their needs in the workplace. Degree of impairment is arguably never a valid, indication of function and neediv. Impairment based eligibility criteria leave most people affected by hearing loss between the ages of 26 and 65 years without NDIS support. Those with articulate and strong advocates who can explain the impact of hearing loss on communication, psychological and social functioning, ability to work, impact on family and community, have a better chance of securing NDIS funding.

Little direct relationship exists between auditory impairment and the impact of that impairment on participation, therefore, eligibility for NDIS funding ought to be determined by the needs of each individual and an age-appropriate evaluation of function. Some auditory conditions do not lend themselves to an audiometric quantification (such as auditory processing disorders, balance disorders or tinnitus related distress).

The quantified impairment-based cut-off point adopted by the NDIS means that some Australians with milder impairments are being excluded from NDIS funding, despite substantially reduced ability to participate effectively in activities or perform tasks or actions without others learning how to adapt their communication whilst also using specialised equipment (implanted or wearable devices or a combination of these). Even with equipment, many with hearing loss, regardless of degree of impairment, have lifelong impacts on social participation and ability to work, which are lifelong, often with deterioration in both degree of hearing loss and function when communication situations become increasingly demanding. As audiologists, we acknowledge that we need to describe function and need, and not categorise those we serve into artificial and outdated impairment categories. Our profession worldwide is revising how terminology is used to describe hearing (dis)ability. However, even when those with significantly reduced capacity to participate in daily life apply for the NDIS, individual planners vary in whether they recommend NDIS support. We are aware of individuals who present very similarly in need, some of whom are funded by the NDIS and others of whom are not.

NDIA reliance on impairment cut offs poses a risk that Australia will lag behind the rest of the developed world in recognising the complex impacts hearing and balance disorders have on daily life. As we understand, state services are meant to provide support for those not covered by the NDIS. However, state funded services for those with hearing loss in NSW are lacking. State hospitals and rehabilitation programmes offer very few audiology services. NSW can develop world class audiological services for the one in six NSW residents living with hearing and balance disorders. Community based interventions such as appropriate town planning, public address systems, noise standards, audiology services in state hospitals and on all multidisciplinary healthcare teams are all areas that NSW state services can develop to account for those not covered by the NDIS.

Proposed Actions

  1. Education of NDIA staff and the public as to the difference between hearing impairment and hearing function and need.
  2. Development of NSW state services to ensure that those not covered by the NDIS are supported by individual services and community structures.

NDIS Participants

NDIS Managed Plans

The Commonwealth HSP voucher scheme has been adopted by the NDIS for those on managed plans, as an interim measure until 2019. The relationship between the voucher scheme and the NDIS beyond 2019 remains uncertain. The voucher scheme is designed primarily to distribute hearing devices to those on government pensions, with most voucher holders being on the aged pension. Vouchers are usually used to pay for a hearing assessment and either the provision of hearing devices (with a few rehabilitation sessions at the end of the hearing aid fitting process) or as an alternative, a short rehabilitation programme. However, NDIS participants are of working age and are being funded because of function and needs that are likely to require both devices and rehabilitation, along with additional support services in the community such as interpreters, notetakers, assistive devices and communication training for themselves and others.

Audiologists are well placed to deliver these services and for continuity of care and patient choice, these services should be funded for audiologists to deliver in addition to the device distribution and basic rehabilitation that is available through the HSP voucher scheme, a scheme not designed to support those in the workforce.

NDIS Self-Managed Plans

NDIS participants on self-managed plans are provided with funds and can choose their own providers, who need not be registered with the NDIS nor need be contracted service providers with the HSP. Those seeking their own provider might well consult lists provided on the NDIA website. Businesses are listed on NDIS provider lists, not practitioners.

In the absence of regulation of the audiology field, anyone can run a business that offers hearing services and sells hearing devices. The ACCC released a report into the sale of hearing aids in March 2017 prompted by media reports of sales targets, undisclosed commissions, and kickbacks that would be considered unacceptable in most healthcare delivery models. The ABC The Checkout segment on hearing clinics aired in June 2017, highlighting concerns about business ownership, commissions and qualifications of providers. Planners and participants might be enticed by advertising of cheap device costs, not realising that they need to plan for associated services in addition to cheaper devices, to overcome communication difficulties in everyday life. Importantly, necessary rehabilitation services will not necessarily be available from retail hearing aid outlets.

Those on self-managed plans face similar challenges in finding appropriate practitioners to address their needs, as do self-funded members of the public.

Proposed Action

  1. The audiology field needs regulation to ensure public protection and accountability in the delivery of hearing services.
  2. Education of NDIA planners and the public as to what constitutes hearing rehabilitation beyond the use of hearing devices.

Regulation of the Audiology Profession

In Australia, hearing services businesses can be owned by those with close business ties to hearing device companies, many of whom set sales targets for their staff, may pay commissions (hidden or disclosed). Some hearing clinics are owned by medical practitioners who may refer to practices they own. Audiologists and audiometrists are self-regulated if they voluntarily join a professional body, but this does not stop anyone from running a hearing related business in Australia, regardless of qualifications. Hearing services delivered by those who are under qualified or unqualified poses significant risk for participants in the National Disability Insurance Scheme (NDIS) and the public. Australia, without mandatory registration for both audiologists and audiometrists, currently compares poorly with many other countries that impose some form of mandatory registration for those delivering hearing services.

No clinical qualifications are required to contract to the HSP as a service provider. Multinational companies with close associations to the hearing device manufacturing and distribution industry form the majority of contracted providers. Hearing service providers who are not clinically qualified are required to employ qualified practitioners (audiologists or audiometrists) to attend to voucher patients, but this does not apply outside of the voucher scheme. NDIS participants who self- manage funds and the public may not be able to identify if providers are qualified or notv, in the absence of mandatory registration.

The ACCC report into the sale of hearing aids released in March 2017 highlights commissions and sales targets as inappropriate to healthcare, describing them as having the potential to cause widespread consumer detriment, especially for consumers who are vulnerable or disadvantaged. The Still Waiting to be Heard…. Presented to the federal parliament by Mr Trent Zimmerman MP called for the regulation of audiology and audiometry, whereby a board should be formed under Australian Health Practitioner Regulation Agency (AHPRA) with mandatory registration for audiologists, as applies to many other healthcare fields in Australia. Yet, to date, no announcement of the intention to regulate audiology and audiometry has been issued.

Limitations of self-regulation and implications for the NDIS

Proposed NDIS safeguards recommend that NDIS registered providers meet the requirements of the 2014 determination for allied healthcare providers. Yet, the NDIS lists businesses as providers, not individuals. Self-regulation by professional associations (as is the case for audiology and audiometry) does not extend to businesses as professional bodies can only regulate their own members and further the only sanction that can be applied is expulsion from the association.

NDIS participants who self-manage their plans are to select providers who are not registered with the NDIS for reasons shown above. We have been advised that currently relatively few NDIS participants self-manage, but taking the ACCC report into account, predatory sales tactics and aggressive marketing could influence NDIS participants to select to self-manage. Further, NSW has an obligation to protect not only NDIS participants, but also the many individual and families living with hearing loss who are not eligible for NDIS funding, and who must cope with finding and funding their own services.

A code of conduct for unregistered healthcare practitioners has been agreed by the Council of Australian Governments (COAG) to apply nationally. Codes of conduct for unregistered healthcare practitioners operate on a system of negative licencing, based on complaints. The NSW Healthcare Complaints Commissioner, in a presentation to members of Audiology Australia in 2011, advised that complaints investigated by their office are typically associated with patient death or disease progression. Types of practices that occur in the hearing industry might be considered a breach of the code of conduct for unregistered healthcare practitioners, such as business owners offering to supply patients in exchange for payment of a percentage of professional fees or device charges or who collect payment for devices and services as a third party. When challenged, at least one of those businesses identified their status as a business, not a healthcare practitioner, and stated that that as a business they were not subject to the code of conduct for unregistered healthcare practitioners.

Without mandatory registration for the audiology profession, the public (including NDIS participants) are at risk. Even the leading self-regulating professional body for audiologists, Audiology Australia, admits that they can only regulate the practices of their own members, not of the businesses employing them. Reports of sales targets, (undisclosed) commissions, preferred supplier arrangements as identified in the ACCC report - all practices that would be considered unacceptable in healthcare practices –are outside of the regulation of professional bodies because they can only regulate the practices of members, not of businesses practices set by those who are not their members. Neither self-regulation by professional bodies nor regulation of unregistered healthcare has worked to protect the Australian public, as evident in the recent inquiries into hearing health and wellbeing of Australians.

The practices reported by the ACCC have taken place under the watch of both self-regulation by professional bodies and the regulation of unregistered healthcare practitioners. We believe that the audiology field needs to be regulated within the system and standards already in place for registered healthcare practitioners, restricting the provision of services to those qualified to do so, with scope of practice for audiologists and audiometrists defined and enforced in keeping with their training. Our call for regulation of the audiology field is supported by audiologists and consumer and advocacy groups – including representatives of Self Help for Hard of Hearing (Shhh), Better Hearing Australia (BHA), Parents of Deaf Children and Aussie Deaf Kids.

Proposed Action

  1. IAA calls for reform in the regulation that applies to audiology and audiometry.

  2. IAA urges NSW to recommend a COAG decision to include audiology and audiometry as registered professions under AHPRA, affording protection of title, enforced professional boundaries and regulation by an appointed professional board.

In summary, we propose the following actions to be taken by NSW in relation to hearing services and the NDIS:

  1. Education of NDIS planners and the public about the effects of hearing loss

  2. Hearing services NDIS provider category must be opened to audiologists and audiometristsvi, with specification as to what each can offer

  3. NDIS participants (over the age of 6 years in the case of hearing services) given choice of hearing services provider whether on managed or self-managed schemes.

  4. Education of NDIA staff and the public as to the difference between hearing impairment and hearing function and need.

  5. Development of NSW state services to ensure that those not covered by the NDIS are supported by individual services and community structures.

  6. The audiology field needs regulation to ensure public protection and accountability in the delivery of hearing services.

  7. Education of NDIA planners and the public as to what constitutes hearing rehabilitation beyond the use of hearing devices.

  8. Reform in the regulation that applies to audiology and audiometry.

  9. COAG decision to include audiology and audiometry as registered professions under AHPRA, affording protection of title, enforced professional boundaries and regulation by an appointed professional board.

Thank you again for the opportunity to provide input into the inquiry into hearing service provision under the NDIS and provision of services in NSW. We welcome any further opportunity to discuss the NDIS and NSW services for those with hearing and balance disorders. We look forward to reading the final report and recommendations of the committee.

Yours sincerely

Dr Louise Collingridge B.Sc (Logopaedics) M.Sc (Audiology) PhD M.AudA (Accredited Audiologist) Chief Executive Officer

Notes

i Australian Hearing has historically been funded to provide hearing devices to Australians under the age of 26 who have permanent hearing loss and those who are government pensioners who have complex needs not covered by the hearing services voucher. The funding that was allocated to this community service obligation work has now been directed to the NDIS. Australian Hearing, in addition to its community service obligations, also competes with private providers in the provision of services to adults who hold vouchers.

ii NDIS participants on managed plans are issued an HSP voucher, which they can take to any contracted hearing services provider – of which Australian Hearing is just one. NDIS participants on self-managed plans are allocated funds, not a voucher, and have the choice to select the provider of their choice.

iii Audiologists’ postgraduate university qualifications prepare them to work with all ages and types of auditory and balance disorders. Audiometrists TAFE diploma qualifications prepare them to assess the hearing of adults for the purpose of fitting hearing devices.

iv The impact of auditory disorders on an individual’s participation in society and that of their family, communication partners, colleagues and associates is easily underestimated because hearing devices are advertised in ways that suggest that auditory conditions can be solved by technology. In fact, conditions managed by audiologists usually require long term support that adapts to changing needs over the lifespan (Claesen & Pryce, 2012). Hearing loss, if not adequately supported, can lead to social isolation which is directly associated with depression, anxiety and stress (Danermark, 1999). In children, auditory disorders can impact on the acquisition of language which may have consequences for learning and literacy (Fitzpatrick, Stevens, Garritty, & Moher, 2013). Auditory and vestibular conditions are not uniform and can range from the loss of ability to hear some sounds to an ability to hear but not recognise or understand sounds, to being intolerant of either sounds that occur in the environment or an internally generated sound (i.e. tinnitus). As hearing disorders affect communication, partners, families, colleagues and carers are typically the first to experience the effects of an unmanaged condition, meaning that comprehensive rehabilitation of auditory disorders is, of necessity, family or community centred and extends well beyond the individual (Davis et al., 2016).

Hearing thresholds (the decibel value of the softest individual tones just heard) are commonly used to quantify impairment (National Institute on Deafness and Other Communication Disorders, 2011), but hearing thresholds or averages are a poor indicator of the needs of any individual with an auditory or related problem (Hogan, Phillips, Brumby, Williams, & Mercer-Grant, 2015). Average hearing threshold level might provide information about degree of hearing loss, but quantifying impairment can be misleading as some averaging thresholds can mask difficulties experienced in everyday life. Audiometric quantification in the form of hearing thresholds provides no information about available personal, family or community resources or supports, the environment in which the individual communicates, or their communication abilities – all of which are determiners of the impact of any auditory disorder (regardless of degree of impairment).

Medicare does make a distinction between audiologists and audiometrists as relevant Medicare items can only be claimed if the allied healthcare provider (audiologist) is a university qualified (or equivalent) practitioner (i.e. audiologist) in their own right. The Health Insurance (Allied Health Services) Determination 2014 further requires audiologists who provide services funded by Medicare to be members of a self- regulating professional body and hold clinical certification.

Despite vastly different scopes of training, the HSP does not differentiate between audiologists and audiometrists in terms of how they are funded to provide rehabilitation to voucher holders as qualified practitioners. As a consequence, many business owners and some audiometrists choose to make little distinction between these two differently trained groups of professionals.

v Consequence of no mandatory registration for audiology is that privately funded devices / services can be provided by anybody in Australia, regardless of whether they hold qualifications in audiology/audiometry or neither or whether they belong to a professional association. Compliance with the national code of conduct for unregistered healthcare practitioners, that sets very general requirements for delivering healthcare, is the only regulatory structure in place. Very few private health funds specify that services to their members must be provided by a member of a professional body.

References

Claesen, E., & Pryce, H. (2012). An exploration of the perspectives of help-seekers prescribed hearing aids. Primary Health Care Research & Development, 13(03), 279-284. doi:doi:10.1017/S1463423611000570

Danermark, B. D. (1999). Hearing Impairment, Emotions and Audiological Rehabilitation: a Sociological Perspective. Scandinavian Audiology, 27 (4) (Suppl 49), S125 - S131.

Davis, A., McMahon, C. M., Pichora-Fuller, K. M., Russ, S., Lin, F., Olusanya, B. O., . . . Tremblay, K. L. (2016). Aging and Hearing Health: The Life-course Approach. The Gerontologist, 56(Suppl 2), S256-S267. doi:10.1093/geront/gnw033

Fitzpatrick, E., Stevens, A., Garritty, C., & Moher, D. (2013). The effects of sign language on spoken language acquisition in children with hearing loss: a systematic review protocol. Systematic Reviews, 2(1), 108.

Hogan, A., Phillips, R. L., Brumby, S. A., Williams, W., & Mercer-Grant, C. (2015). Higher social distress and lower psycho-social wellbeing: examining the coping capacity and health of people with hearing impairment. Disability and Rehabilitation, 37(22), 2070-2075. doi:10.3109/09638288.2014.996675

National Institute on Deafness and Other Communication Disorders. (2011). What the Numbers Mean: An Epidemiological Perspective on Hearing. Retrieved from https://www.nidcd.nih.gov/health/statistics/what-numbers-mean-epidemiological-perspective-hearing