Concerns Regarding NDIS Funding and Pricing for Exercise Physiology Services | External submission

NDIS General Issues Inquiry

Joint Standing Committee on the

National Disability Insurance Scheme

June 2023

EXERCISE & SPORTS SCIENCE AUSTRALIA (ESSA) SUBMISSION

RE: NDIS GENERAL ISSUES INQUIRY

Joint Standing Committee on the National Disability Insurance Scheme

Thank you to the Joint Standing Committee on the National Disability Insurance Scheme (“the Committee”) for the opportunity to provide feedback to the NDIS General Issues Inquiry.

Exercise & Sports Science Australia (ESSA) is the peak professional association for exercise and sports science professionals in Australia, representing more than 10,500 members comprising university qualified Accredited Exercise Physiologists, Accredited Sports Scientists, Accredited High-Performance Managers and Accredited Exercise Scientists.

Accredited Exercise Physiologists (AEPs) currently work within the National Disability Insurance Scheme (NDIS), by providing exercise physiology supports, while Accredited Exercise Scientists (AESs) provide supports as therapy assistants alongside allied health professionals, or as personal trainers, social engagement facilitators and support workers.

This submission highlights the concerning trend of unjustified reductions in exercise physiology and other allied health supports within the NDIS, and the negative impact it has on individuals. The NDIA’s cost-saving actions and lack of understanding of allied health professions have resulted in decreased funding for essential supports and ineffective therapy solutions. The accountability of NDIA planners in decision-making is insufficient, contradicting the core objectives of the NDIS. ESSA advocates for proper training and education of planners to ensure funding allocations align with participants’ needs. To address these issues, it is crucial for the NDIA to implement previous recommendations, intensify accountability measures, and recognize the value of exercise physiology through fair and equitable Pricing.

ESSA welcomes the opportunity to provide further detail or appear before the Joint Standing Committee on the NDIS if invited. Please contact ESSA Policy & Advocacy Advisor, Felix Meyer at felix.meyer@essa.org.au for further information or questions arising from this submission.

Yours sincerely, Policy & Advocacy Advisor Acting Manager, Policy & Advocacy ) Exercise & Sports Science Australia Exercise & Sports Science Australia

EXERCISE & SPORTS SCIENCE AUSTRALIA

1.0 ABOUT ACCREDITED EXERCISE PROFESSIONALS

Accredited Exercise Physiologists (AEPs) are at least four-year university degree qualified allied health professionals. They provide services to people across the full health spectrum, from the healthy population through to those at risk of developing a health condition, and people with a disability, aged related illnesses and conditions, including chronic, complex conditions and mental illness. Exercise physiology services are recognised by Australian compensable schemes including Medicare, the National Disability Insurance Scheme (NDIS), Department of Veteran Affairs (DVA), workers’ compensation schemes and most private health insurers. Australia’s exercise physiology profession comprises over 7,500 AEPs.

AESs are three-year university degree qualified professionals who deliver exercise programs to Australia’s well populations to prevent chronic disease, injury and disability, and improve health, fitness and performance. They empower, motivate and coach clients to adopt long-term behavioural changes. AESs work in numerous sectors spanning allied health as Allied Health Assistants (AHAs); the NDIS as Therapy Assistants; personal trainers in the fitness industry; coaches in sporting organisations; and as program coordinators in education and corporate health. There are more than 900 AESs working in Australia today.

2.0 SUMMARY OF RECOMMENDATIONS

Recommendation 1: The NDIA should collaborate with ESSA to integrate the Exercise is Medicine© program for NDIS planners. This initiative aims to enhance the workforce’s knowledge and health literacy, thereby providing better support for NDIS participants.

Recommendation 2: The NDIS should develop and implement an online platform that provides public access to data regarding participant plan budget allocation, expenditure on allied health therapies, and participant outcomes. This transparency would contribute to better understanding resource utilization and participant progress.

Recommendation 3: Encourage the CEO of the NDIA to release the comprehensive data underpinning the determination of price limits, specifically the data used in setting the price for exercise physiology. This step would enhance the clarity and transparency of the decision-making process.

Recommendation 4: Request an explanation from the NDIA as to why exercise physiology is the only therapy support with a differentiated price (excluding allied health assistant and counsellor with different qualification requirements).

Recommendation 5: Reinforce previous recommendations made by this committee and implement mechanisms for accountability.

Recommendation 6: The NDIA should put into action the recommendation from the 2021-22 Annual Pricing Review report calling for the establishment of NDIS price limits exclusive of GST.

3.0 ISSUES REGARDING UNJUSTIFIED REDUCTION IN SUPPORTS

The National Disability Insurance Agency (NDIA), tasked with assessments and delivery of supports considered “reasonable and necessary” for participants, has come under criticism due to a growing trend of unwarranted reductions in these vital services. Exercise physiology, in particular, has witnessed numerous such cases, leading to distressing repercussions for individuals with disabilities.

For instance, a 42-year-old man in Victoria, living with Chromosomal Deletion Syndrome — a rare disorder impacting both his physical and cognitive abilities — was one such victim of this alarming trend. After receiving support from an AEP since August 2021, he saw considerable improvement in his condition, in stark contrast to his previous unsuccessful attempts with basic exercises. Nevertheless, during a plan review in May 2022, his exercise physiology support was inexplicably withdrawn. This was done even in the face of a specialized recommendation emphasizing the critical nature of the exercise regimen and why it couldn’t be replaced with a support worker. During the appeal, the NDIA posited that the weekly exercise physiology support was neither reasonable nor necessary, and viewed it as redundant alongside physiotherapy. Even after health professionals presented evidence on how the two interventions were unique yet complementary, the NDIA proposed personal trainers or disability support workers as replacements. Now the participant is facing considerable deterioration of his condition while battling in an intensive appeals process.

In another instance, a woman in her 60s, who has been battling Multiple Sclerosis for over four decades, experienced a severe deterioration in her condition in the past year, which led to complete sensory loss in her limbs. The role of exercise physiology was pivotal in preserving her physical activity, social involvement, and mental wellbeing. Her exercise physiology team provided hydrotherapy, which noticeably mitigated her symptoms by reducing stiffness and enhancing muscle strength and flexibility. Regrettably, during her most recent plan review, her vital exercise physiology support was entirely discontinued. The justification given was that hydrotherapy was merely recreational and she had achieved sufficient capability to exercise independently. However, it is crucial to acknowledge that expecting her to exercise independently, given her complete sensory loss in the limbs, is not only unrealistic but also poses significant safety risks.

In another circumstance, a woman in her 70s, also diagnosed with Multiple Sclerosis, encountered additional health challenges such as pneumonia and breast cancer, complicating her overall health status. Exercise physiology had been instrumental in improving her muscle strength and mobility, especially after her stay in the ICU. Despite her declining health and the evident advantages of exercise physiology, the support she was receiving from this discipline was significantly reduced during her most recent review, without a clear explanation. It’s challenging to comprehend how someone in her condition could suddenly be deemed no longer needing such essential support. This decision left her in a strenuous appeal process while her health rapidly deteriorates.

These cases spotlight the power of exercise physiology when combined with other supports in improving physical and mental health, enhancing mobility, and increasing efficiency in daily tasks. However, they also show the unexpected reduction or complete withdrawal of this vital support, often contrary to professional recommendations, and without clear or logical justification, especially when concomitant with physiotherapy. As a result, these individuals are forced into challenging battles to retain the support crucial for their progress and independence.

A better understanding of the agency’s interpretation of therapeutic supports and the roles of each professional could have been achieved if the Committee’s recommendation #16 from the Committee’s 2021 report on NDIS Planning had been put into effect.[1] This recommendation urged the NDIA to share clear and comprehensive information about its Technical Advisory Branch and expert teams on the NDIS website.

Furthermore, the implementation of this Committee recommendations #18 and #19 could have entirely prevented these undesired outcomes, as it requested the NDIA’s CEO to consider any expert advice specifically tailored for a participant, and in cases where a participant’s plan does not echo the expert advice, a written justifications for this decision should be provided.[1] 4

4.0 NDIS PLAN REVIEWS

A concerning pattern of unjustifiable reductions in exercise physiology support during the review of the NDIS participant plans has been observed. Although certain planners are dedicated to ensuring the plan allocates adequate funding for crucial allied health support, others without a thorough comprehension of the extent of allied health professionals’ roles or the repercussions of these budget changes on participant health, prefer resource-sparing strategies that fail to offer secure or effective therapeutic solutions.

ESSA has already communicated serious concerns to the NDIA regarding the harmful consequences of these cost-saving measures on participant outcomes. NDIA’s argument is that AEPs should instruct support workers to implement clinical exercise physiology interventions. However, it’s crucial to emphasize that support workers lack the necessary expertise for clinical decision-making, and due to the participants’ varying conditions, it’s not always feasible to delegate these tasks. Additionally, there have been instances where planners incorrectly dismiss supports as redundant, particularly when the support merges physiotherapy and exercise physiology.

ESSA has identified a widespread lack of understanding among NDIS planners about the role and importance of allied health professionals. This deficit in understanding had led them to favour cost- saving alternatives without truly appreciating the value of different allied health professionals, leading to suboptimal outcomes for participants. Despite recommendation #21 of this Committee urging the NDIA to prioritize candidates with experience or qualifications in allied health or disability-related fields during planner recruitment, the problem persists.

The focus on cost-saving has resulted in overly rigid plans that fail to align with the recommendations of allied health professionals or meet the expectations of participants. ESSA supports the laws and regulations that hold NDIS providers accountable for the quality and safety of NDIS supports. Unfortunately, this accountability does not extend to NDIA employees such as NDIS planners, whose decisions have a profound influence on a participant’s life. NDIS planners who choose to reduce participant plan funding or limit resources, contradicting the evidence-based recommendations of allied health professionals and participant preferences, face no repercussions for the resulting harm or stress. This lack of accountability stands in contradiction to the National Disability Insurance Scheme Act 2013 Object (1)(e)[2], which seeks to empower individuals with disabilities to exercise choice and control in achieving their goals and in planning and delivering their supports.

At present, AEPs frequently take on the responsibility of educating individual NDIS planners about the crucial role and significance of exercise physiology. The NDIA has a duty to ensure that planners are trained on the scope of practice for all allied health professions, facilitating funding allocations that optimally benefit NDIS participants. While the NDIA has in principle agreed with this Committee’s recommendation #20 [1], which calls for transparency about the training provided to planners and Early Childhood Early Intervention partners on the NDIS website, the details currently available in their corporate plan and annual reports are inadequate for assessing the type or extent of training offered.

ESSA can assist the NDIA by providing training for planners about the scientifically validated benefits of exercise treatments for NDIS participants and the critical role of exercise physiology services. As part of this commitment, ESSA is offering a tailor-made Exercise is Medicine© (EIM©) Australia education program. Available as in-person workshops or online sessions, this program aims to enhance the knowledge of primary healthcare providers about the importance of physical activity in

promoting health, wellbeing, social inclusion, self-efficacy, and in the prevention and treatment of chronic disease.

5.0 TRANSPARANCY AND ACCOUNTABILITY

ESSA notes that the NDIA often report on broad expenditure of the scheme and participant plan budgets. It would be useful to obtain more detailed data. Specifically, ESSA is interested in how much funding is being allocated to exercise physiology by NDIS planners, as well as how much participants are spending on exercise physiology.

It would also be useful for the NDIA to publish data on the outcomes of participants against plan budget expenditure. This would evidence the value and effectiveness of various supports. For example, the sector would be able to understand the impact of funding capacity building supports, such as allied health therapies. If data was available on the allocation and expenditure of each NDIS support alongside participant outcomes, ESSA believes that this would enhance accountability and help drive better performance.

6.0 EXERCISE PHYSIOLOGY PRICE LIMITS DETERMINATION.

Exercise physiology, one of the most important tools in Australia’s healthcare system for managing and rehabilitating chronic conditions and injuries, has not received the recognition and support it deserves within the NDIS. Even though it was included in the Medicare Benefits Schedule (MBS) in 2006, it wasn’t until the release of 2020/21 NDIS Price Guide that exercise physiology was finally recognised as an allied health therapeutic support by the NDIS. Despite this recognition, exercise physiology has been the only field consistently singled out for a lower price limit in the NDIA’s therapeutic supports.

Despite its integral role in the NDIS, exercise physiology continues to grapple with inadequate support, leading to limited access for participants and financial difficulties for providers. In the 2021/22 NDIS Pricing Arrangements and Price Limits, exercise physiology services were not duplicated into core supports as were other allied health services, further limiting its accessibility. Notably, despite the NDIA’s goal to have a specific price limit for each support, set at the 75th percentile of the private market billing distribution, only three rates have ever been set: psychology at $214, exercise physiology at $166.99, and all other allied health professions at $196.99. Although counsellors and allied health assistants also have different price limits, they do not share the same qualification requirements and, in this instance, are not comparable.[3]

During the most recent Annual Pricing Review (APR), ESSA outlined how exercise physiology supports have been unjustly undervalued, with historical price limits being consistently 14% lower than equivalent allied health supports. The latest APR report established that the fully loaded hourly cost for allied health services increased from $172 to $189 over the last 12 months. Still, exercise physiology price limit has remained below the estimated cost, at $166.99, for many years now. ESSA also underscored the glaring

disparity with equivalent national and regional schemes, where fees for allied health supports are set all at the same rate and at a much higher level (MBS at $197.55/h, DVA at $203.85/h, SIRA at $204/h, Workers Compensation WA at $211.7/h, ComCare’s at $240/h).[4]

The figure below shows the Exhibit 28 published by in the 2021/22 APR report highlighting the price limit evolution in the NDIS. Exercise physiology was excluded from this analysis. ESSA added exercise physiology prices in red for comparison.

Figure 1. Exhibit 28 from 2021/22 Annual Price Review. Exercise physiology prices added in red for

reference.[5]

[Image not converted to Markdown – “Exhibit 28: Therapy support price limits by geography from FY16 to FY21 chart” – check the source PDF page for the actual content]

7.0 PREVIOUS JOINT STANDING COMMITTEE RECOMMENDATIONS.

The unjustified reduction in supports described in this submission highlights the failure of the NDIA to address previous recommendations from this Committee. These recommendations were put forward to better understand and prevent such distressing scenarios. Below is a short list of relevant recommendations made by this Committee on its 2019 NDIS Planning report [1] and the NDIA’s response:

Recommendation #1 called for the provision for a fully costed, detailed draft plans to be provided to participants one week prior to their plan review. While the NDIA supported this recommendation in principle, it is still waiting for the NDIS Independent Review report in 2023. The delay in implementing this recommendation has deprived participants of the opportunity to review and provide feedback on

Recommendation #16 urged the NDIA to publish clear and detailed information about its Technical Advisory Branch (TAB) and expert teams on the NDIS website. The NDIA merely noted this recommendation and stated that TAB advisors are internal enabling teams, providing guidance to assist NDIA planners in making informed decisions. By not providing transparent information about these advisory and expert teams, the NDIA has limited the understanding of participants and stakeholders, hindering their ability to engage effectively with the decision-making process.

Recommendation #18 required the NDIA’s CEO, or its delegate, to consider any expert advice developed specifically for a participant when deciding on the effectiveness and benefits of a support. The NDIA acknowledged this recommendation, but it is still waiting for the NDIS Independent Review report in 2023. Failing to prioritize the consideration of expert advice undermines the expertise of professionals and disregards valuable insights that could greatly inform decision-making for participants.

Recommendation #19 emphasized the importance of the NDIA providing written reasons, one week prior to the planning meeting, when a participant’s plan does not reflect expert advice developed specifically for them. The NDIA acknowledged this recommendation but highlighted its requirement to consider the “reasonable and necessary” criteria. The lack of written reasons hampers transparency and accountability, leaving participants without a clear understanding of why their expert advice has been disregarded.

Recommendation #20 called for the publication of information about the training provided to planners, local area coordinators, and Early Childhood Early Intervention (ECEI) partners. The NDIA supported this recommendation but the available information in its corporate plan and annual report is not detailed enough to be relevant. The absence of published information on training impedes transparency and raises concerns about the qualifications and preparedness of those involved in making crucial decisions for participants.

Recommendation #21 advocated for a preference for allied health professionals when recruiting planners. The NDIA supported this recommendation in principle but explained that its recruiting is based on APS principles. The implementation and extent of this recommendation remain unclear, leaving room for ambiguity and potential gaps in the expertise of planners.

Recommendation #34 proposed the development and publication of de-identified summaries of key themes arising from settlement outcomes in the Administrative Appeals Tribunal (AAT). The NDIA noted this recommendation and stated that settlements are not precedent setting, while recognizing that past decisions can provide guidance for future decision-making. By failing to publish de-identified summaries, the NDIA misses an opportunity to enhance transparency, correct inadequate trends – as seen with exercise physiology supports - and promote consistency in decision-making processes.

Recommendation #35 suggested the creation of a more detailed checklist of documents that participants can provide as evidence for the supports their request before their planning meeting. The NDIA acknowledged this recommendation but claimed that they already fulfill this requirement. However, without clear and accessible information on the documents that participants should provide, there may be inconsistencies and uncertainties in the planning process, leading to potential gaps in the understanding of participants’ needs and disregard for specialized reports supporting participant’s Requests.

Recommendation 5: Reinforce previous recommendations made by this committee and implement mechanisms for accountability.

8.0 THE GST-INCLUSIVE PRICE GUIDE

The 2021-22 NDIS Annual Pricing Review report endorsed the concept of an “off-plan” GST payment process that would set up GST-exclusive price limits.[5] This proposed model would have NDIS participants paying a GST- exclusive price for exercise physiology services, with the GST component being billed separately to the NDIA by the service providers. This approach carries a multitude of advantages including boosting participant independence, simplifying the planning process, and avoiding unnecessary price limit increases. By utilizing this model, the NDIA could resolve issues faced by exercise physiology professionals and guarantee NDIS participants’ access to necessary services.

Unfortunately, this recommendation has not been implemented yet. The latest Annual Pricing Review paid no attention to the GST challenges affecting a wide range of allied health services, exercise physiology included. It is crucial that the NDIA expedite the implementation of the “off-plan” method to ensure fair and consistent NDIS price limits across all taxable and non-taxable services.

Recommendation 6: The NDIA should put into action the recommendation from the 2021-22 Annual Pricing Review report calling for the establishment of NDIS price limits exclusive of GST.

9.0 CONCLUSION.

This submission highlights the negative effects of unjustified reductions in exercise physiology and other allied health supports on those individuals who rely on them. Exercise physiology has proven to enhance the physical and mental health, mobility, and autonomy of participants. Despite this, exercise physiology supports are consistently being reduced without justified reasoning, indicating a troubling pattern of cost-cutting practices that disregard expert insights from allied health professionals and the participant preferences.

The accountability mechanisms primarily focus on NDIS providers, leaving out the planners who make critical funding decisions. This oversight contradicts the NDIS’s central aim: to empower individuals with disabilities to exercise choice and control over their support planning and provision. ESSA has expressed concerns regarding the deterioration of participant outcomes due to the perverse impacts that cost-cutting measures have on individuals with disabilities.

To rectify this situation, it’s essential for the NDIA to address the earlier recommendations made by this Committee, which could have prevented or mitigated the circumstances outlined in this submission. ESSA is also proposing that a suitable training program for NDIS planners on the scope of allied health services be implemented to ensure funding allocation matches participants’ needs.

Despite its critical role in managing chronic diseases and injuries, exercise physiology continues to be undervalued within the NDIS. The lower price limits and the exclusion from core supports have hindered service access to participants and the financial viability for professionals. The NDIA needs to rectify these discrepancies, ensuring fair and equitable price limits to support participants access to quality care.

10.0 REFERENCES.

Joint Standing Committee on the National Disability Insurance Scheme, General Issues 2021. 2021: Camberra.
National Disability Insurance Scheme Act 2013. 2013: Camberra.
National Disability Insurance Agency, NDIS Pricing Arrangements and Price Limits 2022-23. 2022.
National Disability Insurance Agency, NDIS Annual Pricing Review 2022-23 - Final Report. 2023.
National Disability Insurance Agency, NDIS Annual Pricing Review 2021-22 - Final Report. 2022.