Current Scheme Implementation and Forecasting for the National Disability Insurance Scheme (NDIS)

Joint Standing Committee on the National Disability Insurance Scheme (NDIS)

Submission by the Australian Physiotherapy Association

February 2022

Authorised by: Anja N kolic, Chief Executive Officer, Australian Physiotherapy Association, Level 1, 1175 Toorak Rd, Camberwell VIC 3124, Phone: (03) 9092 0888, www.australian.physio

Introduction ………………………………………………………………………………………………………………………. 3
Background: Physiotherapy and Disability …………………………………………………………………………. 3
Response to the Terms of Reference ………………………………………………………………………………….. 4

a. The impact of boundaries of NDIS and non-NDIS service provision on the demand for NDIS funding, including: ………………………………………………………………………………………………………………………………………. 4

b. The interfaces of NDIS service provision with other non-NDIS services provided by the States, Territories dand the Commonwealth, particularly aged care, health, education and justice services; …………………………… 5

c. The reasons for variations in plan funding between NDIS participants with similar needs, including: ….. 5

d. How the NDIS is funded, including: …………………………………………………………………………………………… 5

e. Financial and actuarial modelling and forecasting of the scheme, including: …………………………………… 6

f. The measures intended to ensure the financial sustainability of the NDIS (e.g. governance, oversight and administrative measures), including: …………………………………………………………………………………………………. 6

g. The ongoing measures to reform the scheme including: ………………………………………………………………. 8

h. Any other related matters. ……………………………………………………………………………………………………….. 8
About the Australian Physiotherapy Association ……………………………………………………………….. 9
Appendix 1 – Physiotherapy: a path to better care (extract) ………………………………………………. 10

www.australian.physio 2 of 12

Introduction

The Australian Physiotherapy Association (APA) thanks the Joint Standing Committee on the National Disability Insurance Scheme (NDIS) for providing an opportunity to provide further feedback on the Current Scheme Implementation and Forecasting for the NDIS.

The APA welcomes the Committee’s interim report and supports the Committee’s recommendation for the inquiry to be reinstated in the 47th Parliament.

The APA also takes the opportunity to commend the Committee on its report on Independent Assessments, particularly the recommendation to embed co-design with people with a disability as a policy approach and the support for holistic and multidisciplinary approaches to assessment (9.39). We thank the Committee for noting that it didn’t find evidence of so-called ‘sympathy bias’ (9.41), the public debate around this notion that questioned allied health professionals’ professionalism was undignified and hurtful to our members who possess strong work ethics.

In this submission, and in response to the terms of reference, we have provided further feedback—where relevant—in addition to our comments included in on our initial submission to this consultation (submission 28).

Background: Physiotherapy and Disability

Physiotherapy is a highly trained, Ahpra regulated discipline with expert knowledge, skills and training in understanding how people move and learn to move, and the development of movement, specifically, as these relate to the health, well-being and quality of life of people of all ages. Physiotherapists are trained in the biomechanics of movement, combining knowledge of physics, physiology and anatomy to analyse movement and determine movement difficulties.

Physiotherapists are movement and participation experts in disability who provide expertise in improving function, participation and building capacity. Physiotherapists analyse an individual’s quality of movement, identify motor impairment, and investigate the interrelationship between movement and other neurological and physiological factors such as sensory perception and pain.

Physiotherapists are committed to providing evidence-based, patient-centred, safe and high-quality care to people with disability and contributing to an effective and equitable disability sector.

Physiotherapists promote social inclusion through optimising a person’s function and encouraging participation and inclusion in the economic and social life of the community.

Within the NDIS, a physiotherapist’s scope of practice is very broad. Physiotherapists work in multidisciplinary and transdisciplinary teams to support capacity building goals and the functional and participation outcomes for all their participants. These supports will often occur in natural environments such as homes, day care, work places and in the community, in order to achieve participation outcomes, one of the pillars of NDIS’s insurance-based approach. Often supports will require communication with both a participant’s family, carers, and their formal supports. All this service provision occurs in addition to the face-to-face services that a participant receives.

Response to the Terms of Reference

Preliminary comment:

The APA would like to reiterate our support to the National Disability Insurance Scheme (NDIS) and its benefits to people living with disability. We want the NDIS to be resourced to perform at its best and deliver on its promise so people living with disability can achieve their goals while providers receive fair remuneration for the supports they provide.

a. The impact of boundaries of NDIS and non-NDIS service provision on the demand for NDIS funding, including:

i. the availability of support outside the NDIS for people with disability (e.g. community-based or ‘Tier 2’ supports), and

ii. the future of the Information, Linkages and Capacity Building grants program;

Access to health care in Australia remains a challenge for many, especially for the most at risk cohort, including people living with a disability. Access to affordable physiotherapy can make a massive difference in building capacity and improving mobility for people living with disability. We need Primary Care and Prevention strategy reforms with improved referral pathways and expanded allied health MBS items to make physiotherapy accessible and affordable.
The recently released Senate Community Affairs References Committee report on the Purpose, intent and adequacy of the Disability Support Pension (DSP) provides insights on access to support outside the NDIS and the link between NDIS and DSP. Another reference on the topic is Professor Madden’s response to the annual NDIS Financial Sustainability Report (particularly on page 18).1
The view of the APA is that mainstream services haven’t reached the level of inclusion expected and required for the NDIS to operate in an appropriate ecosystem. We would like to refer the Committee to Eddie Bartnik’s remarks in DSC’s podcast Disability done differently on the philosophy, implementation and challenges of local area coordination and their impact on the NDIS.2

b.

The interfaces of NDIS service provision with other non-NDIS services provided by the States, Territories and the Commonwealth, particularly aged care, health, education and justice services;

c.

The reasons for variations in plan funding between NDS participants with similar needs, including:

i. The drivers of inequity between NDIA participants living in different parts of Australia, iI. whether inconsistent decision-making by the NDIA is leading to inequitable variations in plan funding, and iii. measures that could address any inequitable variation in plan funding;

The APA reiterates that an effective way to limit inequitable variations in plan funding is through adequately resourced, trained and skilled planning workforce, with participants e empowered to make informed decisions on how best they can achieve their goals.
In relation to assessments, the Committee noted in its report on Independent Assessments (9.31)

“However, the committee also emphasises that consistency does not necessarily mean equity, and that people with disability continue to need supports that reflect their individual circumstances.”

Equally, variations are also to be understood in the context of individual circumstances and personal goals. It is critical that despite the variations in plan funding that may occur, nO participant Is ‘worth off’, and all participants have the resources to meet their goals.

In Physiotherapy: A path to better care$ , APAs pre-budget submission and federal election statement, we are calling for funding for the training and upskilling of NDISA planning workforce so that participants’ understanding and decision-making processes around how they can best achieve their goals with physiotherapy is supported by a skilled NDIA workforce.

d.

How the NDIs is funded, including:

i. The current and future funding sources for the NDI5, iI. the division of funding between the Commonwealth, States and Territories, and iii. the need for a pool of reserve funding;

Any conversation about the funding and sustainability of the scheme must be based on sound, transparent and publicly-available analysis and we call for the public release of the data on public spending related to disability before and after the implementation of the scheme.
Beyond the enormous benefits to participants, the Australian economy also sets to benefit from proper funding to the NDIS. FALSE ECONOMY: The economic benefits of the National Disability Insurance Scheme and the consequences of government cost-cutting, a Per Capta report commissioned by National Disability Services4, shows that funding to the NDIS positively impacts employment directly and indirectly, has a multiplier effect of about 2.25, and estimates that the economic contribution of the NDIS in 2020-2021 was about $52.4 billion.
Likewise, the report indicates that the introduction of the NDIS was supposed to reduce costs in other areas of governments (such as the National Disability Agreement, Home and Community Care, etc.) and states “Only the Federal Government have the data to produce an analysis of the cross-budgetary savings stemming from NDIS spending. (…) To truly understand the NDIS from a cost benefit perspective, such an accounting exercise is essential.” A comprehensive and fully transparent cost-benefit analysis of the NDIS would allow for an informed conversation around the funding of the scheme. e. Financial and actuarial modelling and forecasting of the scheme, including: i. the role of insurance-based principles in scheme modelling, and ii. assumptions, measures, and methodologies used to forecast and make projections about the scheme, participants, and long-term financial modelling; The APA finds Professor Madden’s response to the annual NDIS Financial Sustainability Report provides useful insights on this matter. 5f. The measures intended to ensure the financial sustainability of the NDIS (e.g. governance, oversight and administrative measures), including:i. the role of state and territory governments, and the Disability Reform Ministers Meetings, ii. the arrangements for providing actuarial and prudential advice about the scheme,

iii. the way data, modelling, and forecasting is presented in public documents about the NDIS, (e.g. NDIS Quarterly Reports and Reports by the Scheme Actuary), and

To ensure the sustainability of the NDIS, a whole-of-government approach to build a really inclusive Australia for all people with disability is critical. The NDIS doesn’t operate in a void, it’s across all portfolios, and all tiers of government that efforts need to be made to insure inclusion for all.

iv. measures to ensure transparency of data and information about the NDIS;

Our comment in our initial submission on the lack of responsiveness of the NDIA on request for data stands. Here are our initial comments below in blue:
We need the NDIA to be much more responsive to tailored data requests. To inform our policy and advocacy work, the APA has submitted a request for tailored data aiming at understanding spending across the four physiotherapy specific NDIS pricing items. Here is a timeline of our request:
17 June 2021: first email submitting a tailored data request using the form available on the NDIA website
21 June: we are advised that our request has been received but was submitted with an obsolete form and that we need to make a new request
10 August: we submit our request again using the new form-a much more complex form as it is designed for research requests
8 September: our request is being acknowledged and we are informed it will be assessed at the next Research and Evaluation Data Management Committee meeting to be held on 1 October
12 October: after follow-up from our part, we are told that our request has been reviewed but a decision is still pending. The email indicates ‘The general estimated timeframe for reaching a decision is 6-8 weeks (from the date the request is received).’

At the time of writing this submission, we are still waiting.

Since then:

29 November: our request is approved.
30 November: we are told that ‘The estimated timeframe for data production following approval is four weeks, but this varies depending on the complexity of the request.’

At the time of writing this submission, we are still waiting for the data to be sent to us. In the meantime, The NDIS Pricing review is ongoing and we are missing an important piece of information for our advocacy.

g.

The ongoing measures to reform the scheme including:

i. The new early childhood approach, including whether or how early intervention and other supports intended to improve a participant’s functional capacity could reduce their need for NDIS funding, and ii. planning policy for personalised budgets and plan flexibility; and

h. Any other related matters.

NDIS Pricing review

The APA has been closely involved in the latest National Disability Insurance Scheme (NDIS) Pricing review. We have contributed a written submission, and members and representatives participated in workshops organised by the NDIA.
While the review was ongoing, we have seen the suitably of NDIS pricing for providers, including physiotherapists, being questioned.
The APA is not questioning the current price point but wishes to see ongoing increases in line with CPI, recognition of the highly regulated environment physiotherapy already operates within, the reduction in unnecessary red tape, and any additional compliance burden to be taken into consideration to avoid ongoing ‘admin creep’ currently experienced.
In compliance with the NDIS pricing guide, physiotherapists can charge up to $193.99 for one hour of service, pro rata, to a NDIS participant. It has been reported that this is higher than what is usually seen as the fee of a single physiotherapy session for private patients, or for participants in other care schemes. It is inferred that the services are comparable however the comparison is erroneous.
Providing supports and services in a social model of care differs from the often ‘hands on’ and medicalised provision of services in a health context. NDIS participants have complex needs and require specifically tailored services. Physiotherapists focus on capacity building approach and functional outcome in the participant’s environment, and work with participants, families and carers.
Many NDIS services require specific training, different working space, more intense and longer sessions, and better and more expensive equipment-some equipment is not used by physiotherapists for other patients. Further, NDIS’s requirements on accreditation, registration, administration for claiming, reporting, and compliance, come at a cost both in time (non-billable hours of work) and actual money (for example, cost of registration and auditing, investment in software for compliance and reporting).
Standard appointments in the physiotherapy sector are charged by session whereas NDIS services are provided on a time dependent basis. Comparing NDIS pricing with other schemes, misses the point that many of these schemes remain underfunded: it’s not the NDIS pricing which is too high but other schemes that are too low-APA members report having difficulties to accept participants in those other schemes because the fee is unsustainable for their practice. So the question shouldn’t be why are fees in the NDIS so high, but why are fees in other schemes so low.
Systemic underfunding of some schemes has resulted in challenges to the provision of difficulties to accept participants in those other schemes because the fee is sustainable for their practice. So the question shouldn’t be why are fees in the NDIS so high, but why are fees in other schemes so low.
Systemic underfunding of some schemes has resulted in challenges to the provision of high-value quality care to participants and the APA has been advocating for appropriate fees across all sectors for many years.

Regulation alignment across the care sectors

The APA welcomed the Government’s focus on aligning regulation across the aged care, disability and veterans’ care sectors as announced in Budget 2021-2022 and is currently participating in the consultation led by the Regulatory Alignment Taskforce.
We have identified a number a solutions that can be implemented in the short term and without delaying them until the release of the medium and long-term roadmap the Taskforce is working on.

These recommendations include:

Map the overlap in registration processes among the schemes including the duplication of reporting; complaints processes, and the duplication and cost of auditing. Where similarities are identified, work with the sector to align the requirements to reduce overlap. Where individual requirements relate to a particular sector are deemed necessary these should be reviewed by experts to determine if these issues are worth the extra administrative workload vs the benefits to patients and participants.
Address inconsistencies such as different waiting times for police checks. Identify mechanisms to enable police check information to be stored in a central data base that can be shared across sectors.
Collect one set of health care provider data for use across all sectors and commit to releasing this data to providers for their use to improve the quality of their services and allow for workforce, training and contingency planning.
Create a simplified and transferrable registration pathway for Ahpra-registered practitioners in recognition of the stringent registration process they have already undertaken under Ahpra to ensure suitable training and qualifications to practise, and ongoing ethical conduct.
Create a consistent and largely transferrable registration process across sectors recognised when applying to a different sector.
Implement digital solutions to ‘sync’ cross sector portals; and/or export then import data from one portal to the other; get consistency in the data required (labels, frequency, units of measure, etc.).
Streamline reporting and information sharing to ensure providers report to one body.

About the Australian Physiotherapy Association

The APA is the peak body representing the interests of Australian physiotherapists and their patients. It is a national organisation with state and territory branches and specialty subgroups representing more than 30,000 physiotherapists who conduct more than 23 million consultations each year.

The APA’s vision is that all Australians will have access to quality physiotherapy, when and where required, to optimise health and wellbeing.

www.australian.physio 9 of 12

Appendix 1 – Physiotherapy: a path to better care (extract)

Source:

APA. (2022). Physiotherapy: A path to better care. Available at https://australian.physio/sites/default/files/submission/APA%202022%20Federal%20Election%20Statement.pdf

Physiotherapy: A path to better care is APA’s pre-budget submission and federal election statement 2022.

Priority 3.2 | Disability

Delivering on a promise

Physiotherapists are movement and participation experts in disability who provide expertise in improving function, participation and building capacity. They provide important support services to people with disability but the disparate and uncoordinated way disability services are funded significantly limits this care. While there are major challenges within the National Disability Insurance Scheme (NDIS) that extend from a limited funding pool, a key concern is that mainstream supports outside of the NDIS remain on the whole inaccessible to people living with a disability.

NDIS reform

Action: Properly fund the NDIS to meet its stated functions.
Action: The Government to map and publish public costs savings across all areas of government thanks to the implementation of the NDIS.

The objective of the Government’s NDIS plan is to deliver a world leading NDIS that improves outcomes for all Australians with disability, their families and carers. In delivering on this promise, and as an insurance scheme, ensuring the NDIS remains on a solid, sustainable standing should be of interest to all Australians. To achieve this, funding arrangements must better reflect the insurance principles of the scheme, encompassing required flexible or pooled reserves (Productivity Commission, 2017). Despite the narrative around the sustainability of the scheme, the NDIS is designed to operate in a manner that ensures its financial stability. We recognise, however, structural and regulatory impediments impact on its efficient operation.

Beyond the enormous benefits to participants, the Australian economy also sets to benefit from proper funding to the NDIS. FALSE ECONOMY: The economic benefits of the National Disability Insurance Scheme and the consequences of government cost-cutting, a Per Capita report commissioned by National Disability Services (Per Capita, 2021), shows that funding to the NDIS positively impacts employment—directly and indirectly, has a multiplier effect of about 2.25, and estimates that the economic contribution of the NDIS in 2020-2021 was about $52.4 billion.

Likewise, the report indicates that the introduction of the NDIS was supposed to reduce costs in other areas of governments (such as the National Disability Agreement, Home and Community Care, etc.) and states “Only the Federal Government have the data to produce an analysis of the cross-budgetary savings stemming from NDIS spending. (…) To truly understand the NDIS from a cost benefit perspective, such an accounting exercise is essential.” A comprehensive and fully transparent cost-benefit analysis of the NDIS would allow for an informed conversation around the funding of the scheme.

Action: Fund the training and upskilling of NDIA planning workforce.

Our vision for the NDIS is that participants’ understanding and decision-making processes around how they can best achieve their goals with physiotherapy is supported by a skilled NDIA workforce. It is critical that the National Disability Insurance Agency (NDIA) workforce that is involved in the drafting, planning, coordination and implementation of participants’ plans is properly trained and skilled to understand the value of physiotherapy for people living with disability, of how capacity building supports are provided by physiotherapists, the outcomes to be achieved by these supports, and the difference and complementarity of these supports with other supports available.

Support for those not eligible

Action: Fund preventive models including to support mobility and capacity prioritising an at risk cohort - those who are not eligible to the NDIS but are at risk of becoming eligible.

A social model of disability has to also factor those who currently fall outside of the system.

Mainstream supports outside of the NDIS remain on the whole inaccessible to people living with a disability. Further engagement with community organisations and industry is required to open up general opportunities for people with disability rather than paid NDIS supports. Currently, participants and their families could be reluctant to give up NDIS funding as community supports are generally self-funded. Without NDIS funded supports many people with disability are unable to fund these community based activities. This is further accentuated by many families of people with disability living in low income households resulting in limited ability to fund community supports (ACOSS/UNSW, 2018). There needs to be support and funding to strengthen access to peer network services. Many of those networks rely on individuals’ efforts and resources and need to be formally supported as part of the support a participant needs to reach their goal.

We call for funding and formal support for social prescribing of mainstream activities that can enhance people with disability’s social participation.

A consistent approach across the states in terms of linkages between health services, education services and social services, should also be a priority of the Government.

Another key concern is the inequity of access to capacity building, core supports, home modifications and assistive technology in the NDIS for someone with a newly acquired disability when compared to the same person acquiring the same level of disability after 65 years of age.

Action: Fund the immediate implementation of steps to align regulation across care sector that can be implemented now.

The APA welcomed the Government’s focus on aligning regulation across the aged care, disability and veterans’ care sector as announced in Budget 2021-2022 and is currently participating in the consultation led by the Regulatory Alignment Taskforce.

We have identified a number a solutions that can be implemented in the short term and without delaying them until the release of the medium and long term roadmap the Taskforce is working on.

These recommendations include:

Map the overlap in registration processes among the schemes including the duplication of reporting;

complaints processes, and the duplication and cost of auditing. Where similarities are identified, work

with the sector to align the requirements to reduce overlap. Where individual requirements relate to a

particular sector are deemed necessary these should be reviewed by experts to determine if these

issues are worth the extra administrative workload vs the benefits to patients and participants.
Address inconsistencies such as different waiting times for police checks. Identify mechanisms to

enable police check information to be stored in a central data base that can be shared across sectors.

Collect one set of health care provider data for use across all sectors and commit to releasing this

data to providers for their use to improve the quality of their services and allow for workforce,

training and contingency planning.

Create a simplified and transferrable registration pathway for Ahpra-registered practitioners in

recognition of the stringent registration process they have already undertaken under Ahpra to ensure

suitable training and qualifications to practise, and ongoing ethical conduct.

Create a consistent and largely transferrable registration process across sectors recognised when

applying to a different sector.

Implement digital solutions to ‘sync’ cross sector portals; and/or export then import data from one

portal to the other; get consistency in the data required (labels, frequency, units of measure, etc.).

Streamline reporting and information sharing to ensure providers report to one body.

Physiotherapy: A path to better care (extract)