NDIA Accountability Project

Submission 1 — Australian Music Therapy Association (AMTA) — NDIS Annual Pricing Review 2022-23

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Submission to:

2022-2023 NDIS Annual Pricing Review (APR)

April 2023

Introduction

Music therapy is a research-based practice and allied health profession and in Australia is delivered by registered music therapists (RMTs). Allied health professions all require a minimum AQF7 university-level education. Current RMT graduates have achieved an AQF9 level education and are accredited nationally by the Australian Music Therapy Association (AMTA). There are currently nearly 800 music therapists registered with the AMTA.

RMTs design and deliver individualised music-based interventions that support social, communicative, sensory, emotional, cognitive and behavioural skills. RMTs are allied health professionals with expertise in using music engagement to activate complex neurological structures.

For NDIS participants, music therapy can significantly impact mood, cognition, behaviour, communication and mobility, and increase independence and community participation. RMTs are recognised therapy service providers for the NDIS and provide crucial and life-changing supports for people with disabilities and their carers.

AMTA is the national peak body for music therapy in Australia, and is responsible for registering RMTs, accrediting music therapy courses and maintaining professional standards and ethics. AMTA is a member organisation of Allied Health Professions Australia (AHPA) and the National Alliance for Self-Regulating Health Professions (NASRHP). Membership of NASRHP requires all RMTs across Australia to meet 11 regulatory standards to ensure consumers receive quality and safe services from qualified and certified RMTs.

AMTA acknowledges and welcomes this consultation on NDIS annual pricing review. We have raised our priorities with Minister Shorten in January 2023 and via numerous prior submissions, including the recent NDIS Independent Review. We trust this consultation prefaces a smooth transition into the next funding period - in contrast with previous years when significant funding and pricing changes were made without consultation, or changes were required after publication. AMTA has tried to limit our feedback to focus on new information and content, noting that in the past, many issues have remained unheard and unresolved.

Pricing arrangements for therapy supports ensure participants receive value for money, while providers strive to improve quality of service and increase efficiency

Quality and safety

AMTA strongly supports the NDIA’s focus on providing high-quality and safe services to NDIS participants. Music therapy delivers significant and meaningful outcomes for NDIS participants, including achievement of specific communication, movement and mental health goals, as well as supporting the independence, social and economic participation of people with disability.

AMTA values the focus on quality and safety evidenced by NDIS registration processes, however note the significantly lesser focus on quality and safety when unregistered NDIS providers deliver supports. We advocate for a system that ensures the qualifications and accreditation of allied health professionals, regardless of provider registration status.

AMTA’s professional self-regulation processes safeguard NDIS participants regarding registration and ethical and safe practice by RMTs. We recommend NDIA works together with the existing professional bodies to minimise duplication and reduce the unpaid (and costly) workload of allied health professionals relating to NDIS registration.

Testing some assumptions underpinning the NDIS APR Consultation Paper

The Consultation Paper highlights increases in therapy support payments between December 2021 and December 2022. AMTA suggests using Dec 2021 numbers as a comparator with caution due to the ongoing impacts of COVID-19 in the Dec 2021 quarter. Our members assert increases in therapy support payments since December 2021 have been the result of numerous interacting factors:

  • Increasing provider numbers are a longstanding trend within the NDIS. Historical data (2018-2019) suggests provider numbers increased by 6% per quarter (19% per annum). The growth rate of 15% in provider numbers from December 2021-22 suggests a consistent growth rate of provider numbers compared to previous (pre-COVID) years. The allied health growth rate nationally sits at approximately 4-7% per annum – the entry of early career providers new to the NDIS may account for some of the provider growth rate in the NDIS.
  • Increasing therapy rates may reflect context and point-in-time changes. In December 2021, many members were still experiencing lower therapy engagement rates due to COVID-19. Our members perceive increasing therapy rates as a readjustment post-COVID-19. Some participants who had achieved goals and improved social and economic participation pre-COVID-19 have since required rehabilitation to re-establish skills or develop new systems for support in a world living with COVID-19. Additionally, some participants experienced loss or trauma during COVID-19 peaks in Australia and require further supports.
  • Participant knowledge, choice and control may impact how participants invest their funds. As participants have more experience in the NDIS, they are more able to identify, prioritise and communicate their preferences and elect to expend funds on therapy supports to achieve their goals.

Cost drivers for NDIS therapy supports

In the case of the NDIS, practitioners often provide unpaid or underpaid labour to subsidise a participant’s plan. Items such as consumables, non-client-facing time, and additional consultation for people with complex needs are often absorbed by NDIS providers as a part of delivering ‘best practice’. Despite suggestions from the NDIS about overpriced therapy supports, our members report that up to half of these hourly rates cover costs of running a business in the NDIS (without therapy staffing costs).

Cost drivers listed by members include a range of increasing costs associated with running a business and NDIS-specific costs:

  • Higher business running costs, e.g., rent, utilities, petrol for outreach services, and insurances. One member cited a rent increase of 32% over twelve months.
  • Increasing administrative costs, e.g., accounting, practice management software, and telehealth platforms. Inconsistencies in GST exemptions and inclusions add to an already administratively complex system. Some members have employed administrative staff in their practices to manage the complex pricing and billing arrangements for the NDIS.
  • NDIS-specific costs, e.g., audit costs, and registration with the NDIS (in addition to profession-specific registration with AMTA). These costs are proportionately more significant for small and solo practices.
  • Indirect costs associated with providing high-quality supports to clients with complex needs, including program evaluation and resource development.

Staffing costs include insurances, Workcover, superannuation and salaries. Importantly, whilst RMTs have applied CPI to their staff salaries, NDIA has not applied indexation to therapy supports for three years.

While AMTA does not have specific data about the proportion of revenue derived by RMTs from the NDIS, AMTA’s workforce survey undertaken in 2022 provides some insights into the nature of RMT practice and funding sources. RMTs work across several employment settings, with 38% working with more than one employer. Private practice is a primary employer for RMTs, together with disability services, education and early childhood, public health and residential aged care. AMTA’s survey results suggest the three primary funding sources for RMTs in 2021-22 were NDIS, self-funded clients and public hospitals (322 respondents). Members providing NDIS supports report they are charging the same hourly rate for all clients.

Comments about ‘sustainability’ of the Scheme

AMTA acknowledges the government’s concerns about the ‘sustainability’ of the NDIS. While the NDIS is titled an insurance scheme, it has significant differences that must impact the approach to financial sustainability. We note here from the Insurance Principles and Financial Sustainability Manual:

… in seeking to manage financial sustainability, the Agency should be seeking to influence the perceptions of both participants and contributors (including broader community attitudes), through evidence of independence, outcomes and social participation, and both the immediate and longer term financial outlook of the scheme.

Our members note that outcomes measurement is often ableist/normative and focused on function rather than participation. Generalised outcome measures often do not adequately capture outcomes for people with complex needs. That said, AMTA would welcome greater focus on Scheme outcomes and evaluation. Our members caution the NDIA not to oversimplify outcome measurement and goal achievement. A simplistic approach to outcomes-based funding may act as a disincentive for practitioners to support more complex clients with profound disabilities. AMTA hopes to collaborate with participants, their support people and the NDIA about what constitutes positive outcomes from the Scheme and codesign a framework for appropriate outcome indicators and measures. AMTA would suggest NDIA consults with AHPA in the first instance.

Inconsistencies and the GST

AMTA has repeatedly spoken and corresponded with government officials, Treasury, and the Minister about issues relating to the GST in the NDIS. Unlike other therapeutic supports, music therapy is not GST-exempt within the NDIS (except when delivering early intervention supports or supports in residential care services). Music therapy’s GST status impacts participants’ fund expenditure, complexity for planners, parity with other allied health, sustainability of small practices and workforce availability.

Music therapy is not a GST-exempt health service within the Other Health Services listed under s38-10 of Division 38 of the GST Act. This issue has arisen because music therapy was omitted from the table referred to in paragraph (a) of subsection 38-10(1) of the GST Act in 1999. The evolving nature of health care, growing evidence base and professionalisation of various health professions since that time has made this list outdated and no longer informed by evidence.

Music therapy is a GST-free support within the NDIS when delivering early intervention supports or supports in residential care services. These arrangements result from A New Tax System (Goods and Services Tax) (GST-free Supply—National Disability Insurance Scheme Supports) Determination 2021.

AMTA has serious concerns about the impact of music therapy’s GST status within the NDIS:

  • GST payable for RMTs comes from NDIS participant funds, reducing their available plan funds and access to music therapy.
  • Inconsistencies in GST exemptions add complexity for planners, who need to determine the funding value for participants’ plans. The planning process is more complex when planners are negotiating both GST-exempt and GST-inclusive services.
  • Inconsistencies in GST exemptions bring complexity to service purchasing by participants. Current GST rules result in price changes for individuals over time (for example, as a child turns eight, their music therapy will no longer be GST-exempt). NDIS GST rules also impact individual participants across services (for example, a participant accessing physiotherapy and music therapy will be paying two different hourly rates - one GST-exempt and one GST-inclusive).
  • Disparity in GST exemptions results in an uneven market, where some therapy supports (our allied health colleagues) are funded at the $193.99 rate (GST-free). For music therapy, $193.99 is the GST-inclusive rate.
  • In multidisciplinary care settings, participants may be charged GST for one practitioner (e.g. RMT) but not for another (e.g. physiotherapist).
  • Due to their GST status, RMTs experience increased administrative and cost burdens in their private practices and small businesses. After deducting GST, RMTs receive the equivalent of 2018 therapy support prices from the NDIS - significantly lower payment than their allied health colleagues. This disparity has the potential to impact market availability in the NDIS negatively.

The disparity in GST exemption for different participant groups has the potential to skew the market towards early intervention and make it increasingly difficult for older children, young people and adults to access music therapy, limiting participant choice and control.

AMTA acknowledges and welcomes consultation on the Annual Pricing Review. AMTA has been consistently involved in past NDIA consultations; however, many of these past consultations resulted in no change or reflection of the content of submissions. We trust that this consultation is genuine and will deliver meaningful recommendations for change.