Submission to:
The role of pricing and payment approaches in improving participant outcomes and scheme sustainability
July 2023
Introduction
Music therapy is an evidence-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 a AQF9 level qualification and are accredited nationally by the Australian Music Therapy Association (AMTA). There are currently nearly 800 music therapists registered with the AMTA.
RMTs are allied health professionals with expertise in using music engagement to activate complex neurological structures. RMTs design and deliver individualised music-based interventions that support social, communicative, sensory, emotional, cognitive and behavioural skills.
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. 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 will continue to hear and value the voices and skills of allied health. AMTA has tried to limit this submission to focus on new information and content, noting that in the past, many issues have remained unheard and unresolved.
Finding 1: Opportunities to improve NDIS pricing arrangements
Price caps and ‘preferred provider’ arrangements
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.
Our members are disappointed to be faced with statements suggesting inefficient pricing of therapy supports. Our members expend up to 50% their hourly rates on business costs, excluding 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. 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’.
AMTA has serious concerns about ‘preferred provider panels’. AMTA is concerned about the impact of preferred provider panels on smaller-scale providers who may be less able to compete on price (but who may deliver excellent quality services). AMTA is opposed to service providers’ actively competing on cost; quality should be the primary measure used for therapy providers. Competition based on pricing may negatively impact the sustainability of smaller providers, particularly in rural and regional areas.
Finding 2: Focussing on volume of supports, rather than outcomes
Outcome-based and blended payments, perverse incentives
AMTA acknowledges the government’s concerns about the ‘sustainability’ of the NDIS. We support a focus on value-based supports and ensuring that providers are delivering outcomes to NDIS participants.
AMTA would welcome greater focus on Scheme outcomes and evaluation. However, 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. 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. NDIA and the NDIS Review will need to collaborate with participants, their support people and providers about what constitutes positive outcomes from the Scheme and codesign a framework for appropriate outcome indicators and measures.
Prior to any associated payment changes, the NDIS Review and NDIA will need to understand the real costs of therapy supports, the differences between types of supports, and the outcomes that can be expected for different participants.
Finding 3: Improving transparency around pricing, volume, quality and outcomes
Market monitoring, price disclosure and provider performance
AMTA members believe that NDIA does not understand the costs associated with providing services. We would welcome a process that collects and provides the NDIA with detailed and accurate data on the true costs of service delivery. This would include costs outlined above (see Finding 2). This process must involve AHPA and its members in its development, to ensure it accurately reflects the costs of NDIS therapy providers.
AMTA does not agree with the notion of providers competing based on price. Service quality is a better driver of improvement in this instance and should be the aim for all therapy providers. Self-regulating professions already have in place accreditation and registration processes that ensure participants are receiving supports from appropriately qualified and professional providers. Outcome and performance measures would provide the NDIA with more information about the quality of supports (if appropriate outcome and performance measures are selected, in conjunction with participants, support people and providers).
We would caution against the use of systems such as the Star Rating System for aged care which currently provides little in the way of quality information for older people and their families.
Finding 4: Aligning incentives, participants, providers and governments
Informed choices, active consumers, competitive pricing
AMTA has repeatedly raised concerns about limited ‘choice and control’ for participants in the NDIS, and the inconsistent approach to music therapy approvals in the NDIS. Our members continue to witness participants’ being disempowered to make their own choices and decisions due to administratively-driven processes within the NDIA. AMTA members hear too many reports of planners disregarding the choices and opinions of participants, carers and support people. Transparent and collaborative decision-making would enable participants and providers to question decisions, troubleshoot, and work together with the NDIA to develop a plan that truly meets participant needs.
We welcome increasing transparency to enable choices about support quality. We would be pleased to support the NDIA to ensure participants, carers and support people have access to information about:
- various therapy supports available,
- evidence available for these supports
- how certain supports can enable goal achievement.
AMTA does not agree that providers should be competing to deliver the ‘cheapest’ service, but instead be focussed on high-quality supports and outcome achievement. Again, AMTA asserts these outcome measures must be selected with AHPA and its members. AMTA cautions against use of outcome measures that would disadvantage those participants with more profound needs. Any proposed funding model should consider the potential impact on participants, and equitable access to supports.
GST as a cost for providers
Due to their GST status, RMTs experience increased administrative and cost burdens in their private practices and small businesses. After deducting GST, RMTs significantly lower payment than their GST-exempt allied health colleagues. This disparity has the potential to impact market availability in the NDIS negatively. AMTA has repeatedly spoken and corresponded with government officials, Treasury, and the Minister about issues relating to the GST in the NDIS. Any consideration of costs in the NDIS must take into account the disparity between GST-exempt and non GST-exempt providers as well as the costs of GST administration in a service.
Music therapy’s GST status impacts participants’ fund expenditure, complexity for planners, parity with other allied health, sustainability of small practices and workforce availability.
AMTA acknowledges and welcomes further consultation on the role of pricing and payments on the sustainability of the NDIS and most importantly on the focus on outcomes for participants. We trust that this consultation is genuine. We look forward to working together with participants, providers, the NDIS Review and NDIA to continue to improve the NDIS for participants, carers and their support people.
Contact: Bridgit Hogan Chief Executive Officer Australian Music Therapy Association Inc. E. ceo@austmta.org.au M. +61 438 444 439 www.austmta.org.au