Exercise & Sports Science Australia’s submission to the National Disability Insurance Agency

General issues around the implementation and performance of the NDIS: Impact for ESSA professionals

27th March 2018

Dear Mr De Luca,

Thank you for the opportunity to submit feedback to help inform the National Disability Insurance Agency (NDIA) regarding issues arising for Accredited Exercise Physiologists delivering services within the NDIS.

Exercise & Sports Science Australia (ESSA) is a professional association representing over 7,000 members, including university qualified accredited exercise scientists (AESs), accredited sports scientists (ASpSs) and accredited exercise physiologists (AEPs). Given the unequivocal evidence supporting clinical exercise interventions as a valid prevention, treatment and management tool for a myriad of chronic diseases^[4, 5], coupled with the cost-effectiveness of AEP-led interventions^[6], it is expected that demand for an AEP’s unique technical and clinical skills will continue to increase.

The following comments are for your consideration and address issues that negatively impact the access and provision of exercise physiology services within the NDIS, and consequently, the performance of the NDIS and consumer health outcomes:

Thank you for providing ESSA with the opportunity to submit feedback regarding workforce issues impacting the performance of the NDIS. We please request the opportunity to discuss the aforementioned concerns and recommendations further with you. Please don’t hesitate to contact me via email or on (07) 3171 3335 to arrange a meeting time of your convenience.

1. Exercise physiology services are not listed in therapeutic category (item 3.15) and only in improved health and well-being (item 3.12).

AEPs are recognised under other government schemes (e.g. Medicare, Department of Veteran Affairs, State WorkCover Authorities) as allied health practitioners eligible to provide chronic disease management and rehabilitation services. AEPs are highly trained allied health professionals who provide clinical exercise interventions aimed at primary and secondary prevention; managing sub-acute and chronic disease or injury; and assist in restoring optimal physical function, health and wellness. Currently exercise physiology services are only listed in the improved daily skills (item 3.12) and AEPs providing services under the NDIS are unable to claim the provision of services under therapeutic categories or improved daily skills (item 3.15). AEPs however have the skills, knowledge and scope to provide workplace assessments and functional capacity assessments (currently performed under therapeutic support) as well as provide exercise rehabilitation as a therapeutic service. In light of the recent Independent Pricing Review and NDIA’s response, ESSA is concerned regarding a number of recommendations:

Recommendation 17 and the implementation of a tiered approach to therapy. The exclusion of exercise physiology services in the therapeutic category limits the ability for consumers to exercise choice and control as well as limits the opportunity to progress via social and recreational based activities.
Recommendation 18 and the inclusion of exercise scientists as part of the tier 2 approach is supported by ESSA. However ESSA requests that the NDIA recognise the difference between AEPs and AESs and ensures that AEPs be include as a tier 1 therapy alongside other allied health professional groups such as physiotherapy, speech pathology and occupational therapists.

In 2016, ESSA commissioned Deloitte Access Economics^[1]^ to identify the financial investment associated with engaging the AEP workforce from the perspective on the consumer. Deloitte identified that exercise interventions delivered by AEPs are efficacious and highly cost effective for Australians living with complex chronic

disease. On average the overall benefit for consumers receiving AEP exercise

interventions is estimated to be $6,562, with a net benefit of $5,938 (overall benefit

minus the cost of treatment), benefit to cost ratio of 10.5 (for every AUD spent the

consumer will receive a $10.5 return) and approximately 25% of direct out-of-

pocket expenses saved.

ESSA please requests that AEPs are recognised as allied health providers and

can supply therapeutic services to further support the consumer centred care

approach of the NDIS.

2. Discrepency of pricing between allied health practitioners.

There is a discrepancy of pricing between allied health practitioners even within the improved health and well-being category (e.g. dietitian consult = $178.98

compared to exercise physiology = $145.63; group classes dietetics = $59.67

compared to exercise physiology groups = $48.54). Additionally, allied health practitioners providing services under improved daily living skills (individual

assessments) are receiving $175.57. AEPs are having to perform individual

assessments as well, yet pricing does not reflect the value in services.

Like other allied health professionals, AEPs have completed a university qualification, are recognised by the Australian Government and are subject to a

robust self-regulatory system (which includes code of conduct, ethics and

disciplinary processes etc). Furthermore, in 2007 the Department of Health and

Ageing released the Quality Assurance Requirements for Privately Insured

Services[2]. The framework identified that “the exercise physiology industry meets all of the requirements of an allied health profession that is eligible for the provision of health insurance benefits” [2].

AEPs working within community health settings, where multidisciplinary practices

occur, are also concerned with the disparity between pricing of allied health

practitioners. The current NDIS fee schedule places AEPs at a disadvantage in

community health as the fees per hour of service are lower for both individual and

group services. This has resulted in some other allied health professionals

providing exercise based treatment as their value for service hour is higher, yet

they may be not the most appropriate professional to deliver this specialised

service.

Given the recent Independent Pricing Review, ESSA supports a national pricing guide but ensuring that all therapies are included as part of the pricing guide.

ESSA please requests parity and consistency in the application of pricing

allocated to services provided by allied health professionals within the NDIS.

3. Previously approved services have been denied or placed in different

   categories. There is misunderstanding from many planners on the

  nature of AEP services, resulting in services being listed in wrong plan

  (as above).

Consumers who have previously had exercise physiology services or who have requested these services are being denied and are receiving services under

different categories that AEPs are unable to provide services with. For example:

a. Functional Capacity Evaluations (FCEs) / Work Place Assessments (WPAs):

AEPs have been asked to provide these services under NDIS, however the

 plans approved have these services listed under therapeutic support and
 subsequently the AEP cannot provide or claim for the service.

b. Group therapy:

AEPs are working within multidisciplinary settings (e.g. CPL, community

 health practices, GP super clinics) and provide collaborative group therapy

 (code  15_044_0128_1_3)  which  also  includes  exercise  physiology

  services. Currently AEPs are unable to claim under this code.

c. Exercise therapy: Consumers are requesting exercise physiology services and are receiving

 plans that have exercise physiology and appropriate key outcome milestones

however the service is being listed under therapeutic codes or improved daily

  living codes, neither of which AEPs are currently listed in.

Exercise therapy provided by AEPs has a positive impact within interprofessional

practices and is an essential resource in interventions designed to combat all

chronic and noncommunicable diseases[4]. However, exercise physiology is

currently an underutilised discipline[4] . The positive impact of exercise therapy

on managing and improving movement and functional deficits related to disabilities and chronic conditions is proven in multiple studies[5-12] and clients

are requesting AEP services in their NDIS plans.

ESSA recommends that planners be educated about the benefits of all allied

health providers to ensure that consumer centered care is achieved.

Involvement of an allied health or medical professional at the planning level

will ensure a thorough assessment of the consumer’s needs, an

understanding of the condition and progression of the disease and

appropriate treatment and support required.

ESSA is able to provide the resources and support to NDIA in further

educating planners on the role of AEPS in the treatment of chronic conditions

and disabilities (for example, facilitating a workforce or professional

development opportunity).

4.  Inclusion of AEP services on a patient plan have been denied, and

  consumers are asked to use alternative health services.

In many instances, consumers have been asked by planners to utilise their health

services (i.e. Chronic Disease Management (CDM) Plans and Private Health

Insurance cover) before receiving exercise physiology services within the NDIS.

CDM plans only provide 5 services in one year and are spread across all allied health

professionals recognised under Medicare. Many consumers only receive 1-2

sessions of this plan which doesn’t adequately address their multiple chronic

diseases and/or co-morbidities and are often used within the first few months.

In 2016, ESSA commissioned Deloitte Access Economics to identify the financial

investment associated with engaging the AEP workforce from the perspective on

the consumer[1]. Deloitte identified that exercise interventions delivered by AEPs

are efficacious and highly cost effective for Australians living with complex chronic

disease. The net benefit per person per year, include:

$2,820 for people living with type 2 diabetes
$5,467 for people living with depression
$7,606 for people living with cardiovascular disease
$6,629 for people living with chronic obstructive pulmonary disease
$241 for people living with asthma.

On average the overall benefit for consumers receiving AEP exercise interventions

is estimated to be $6,562, with a net benefit of $5,938 (overall benefit minus the

cost of treatment), benefit to cost ratio of 10.5 (for every AUD spent the consumer

will receive a $10.5 return) and approximately 25% of direct out-of-pocket

expenses saved[1].

In addition to consumer savings, improving access to AEPs has significant

implications for the Australian economy, positively contributing to workforce

participation and reducing hospital expenditure associated with overnight and

extended stays. A summary of the benefits and costs of AEP interventions per

person, for the conditions analysed by Deloitte in their 2015 report are outlined in

the table below. Deloitte also identified that clinical exercise interventions were

also cost effective for chronic back pain, osteoarthritis and rheumatic diseases[3].

Estimated benefits and costs of AEP interventions per person

Condition	Benefits ($)				Costs ($) (E)	BCR
	Health system (A)	financial & other financial (B)	BoD (C)	Total wellbeing (D=A+B+C)
Pre-diabetes	1,977	1,520	2,617	6,115	580	6.0^
Type 2 diabetes	5,107	NE	2,860	7,967	580	≥8.8^
Mental health (depression)	330	1,909	NE	2,239	824	2.7^
Chronic disease (cardiovascular)	NE	NE	11,847	11,847	1,903	6.2

Note: BoD is ‘burden of disease’, NE is ‘not estimated due to lack of available data’, ^ BCRs (Benefit to Cost Ratio) for pre-diabetes, type 2 diabetes and mental health (depression) are reported as the ratio of financial benefits (health system and lost productivity savings) to costs. The BCR for chronic disease is relative to the burden of disease. BCRs which contain NE elements are reported on a ‘greater than or equal to’ basis, as it is assumed that the NE components would add to the benefits. Source: Deloitte Access Economics (2015)[3]

ESSA please requests justification around the denial of AEP services under

NDIS for consumers who require more consistent exercise rehabilitation

and progression.

5. Service provision by Allied Health Assistants prioritised over university

   qualified exercise physiologists.

ESSA is concerned that in some cases allied health assistants (AHAs) have been

inappropriately brought into some consultations to continue management or

substitute supervision by an AEP for client exercise & rehabilitation

programs. ESSA acknowledges and supports the value of AHA roles within

healthcare and encourages the development of appropriate models of care for AEPs

working with AHAs. However, the variability in the AHA workforce qualifications,

training and skills can make delegation of an AEPs duties challenging[13].

Broadly speaking, an AHA will undertake tasks that can be described as “assisting,

supporting, monitoring and maintaining” while allied health professionals, such as

AEPs will “evaluate, assess, diagnose, plan and implement”[14]. An AHA can assist an

AEP by undertaking less complex tasks (both clinical and non-clinical) that will

allow the AEP to focus and manage consumers with more complex needs and

provide care to a greater number of consumers. An AEP will be responsible for the

assessment, interpretation of diagnostic testing to inform clinical reasoning and the

overall care and treatment plan of a client while delivery of the care and treatment

plan may be undertaken by an AHA[15].

However, an AHA is not an “autonomous practitioner and must work under the

overarching auspice and clinical oversight of the allied health practitioner”[16]. For

example, it is not appropriate for an AHA to supervise treatment plans for

consumers with complex and chronic conditions, particularly those that are not

self-managed.

Services provided by AEPs are more effective than non-university qualified

professionals or unsupervised exercise alone, partly attributed to an AEP’s ability

to account for the potential risks and likelihood of the presence of comorbidities in

populations with chronic disease[1]. Further, an AEP’s unique skills in exercise

prescription for chronic and complex populations cannot be delegated (i.e. ability

to conduct ongoing risk stratification, monitor symptomology, and adjust the

prescription based upon complex interactions of diagnosis, exercise tolerances and

medication regimes).

ESSA supports that:

The overall responsibility for the management and care needs of a

client remains with the AEP, regardless of what tasks are delegated.

 An AEP must be satisfied that appropriate-levels of supervision are

  provided to the AHA to ensure they can perform the delegated task in
  a competent manner.

An AHA possesses a minimum level of qualifications, training and

skills that allows them to competently and safely complete their role

 and delegated tasks (i.e. Cert IV allied health assistant or equivalent).

 ESSA also supports the inclusion of degree qualified AESs to fill the

  roles of AHAs as outlined in the recommendations by the

  Independent Pricing Review.

The AEP is responsible for determining which tasks can safely and

competently be delegated to an AHA. ESSA supports the utilisation of

existing delegation and supervision frameworks developed by state

health authorities to assist with this decision-making and into the

future, working in collaboration with authorities to ensure these

 frameworks remain contemporary and reflect industry best practice.

An AEP establishes clear reporting methods and lines of communication with an AHA to ensure quality and safety of the

healthcare services provided.

EXERCISE & SPORTS SCIENCE AUSTRALIA

THE VALUE OF ACCREDITED EXERCISE PHYSIOLOGISTS TO CONSUMERS IN AUSTRALIA

BENEFIT TO COST RATIO OF AEP TYPE 2 DIABETES INTERVENTIONS FOR T2DM AN AUSTRALIANS PER DOLLAR SPENT

e Depression 10.8 j seta vecment -e« CVD 12.1 © — 68% of direct out-of-pocket -COPD 265 scm ere -¢ Asthma 13 <> physiologist interventions OVERALL BENEFITS AVERAGE = ESTIMATED TO BE $3,1 97 <= $10.50 4 Nemec e*eenvreeeeneeeeeneneeeeneeeeeeeneeeneeeenee

DEPRESSION © — Net benefit $5,467 (overall beneht ~ cost of treatment) © Benoit to cost ratio 1:10,8 {lor every AUD spent $10.80 back)

20% of direct out-ol-pocket expenses can be saved by accredited exercise physiologist imerventions estimate Tose 90,029

ASTHMA

Net benefit $241 (overall bonelit - av cost of treatment}
— Benefit to cost ratio 1:1.3 (for every AUD spent $1.30 back) OVERALL BENEFITS ESTIMATED TO BE $1 075 ey AVERAGE SAVINGS FOR CONSUMERS © Net benefit $5,938 (overall benelit - cost of treatment) ¢ Benefit to cost ratio 1:10.5 {for every AUD spent $10.50 back) © 5% of direct out-ol-pocket expenses can be saved by accredited CARDIOVASCULAR DISEASE (CVD)
— Net benefit $7,696 {overall benefit cost of Ireaiment} Benefit to cost ratio 112.10 {for every AUD spent $12.10 back} ®@ OVERALL BENEFITS NU) estimated to be $8 293

eeneeeveeeeveeseeeeeeeeeeeeeeeeee CHRONIC OBSTRUCTIVE 8 PULMONARY DISEASE (COPD) s..-J fowl ™(4,

= Net benefit $6,623 (overall benefit — cast of Ireatment} * — Benefit to cost ratio 1:26.5 (for every AUD spent $76.59 back) exercise physiologist interventions esTiMaTED TOBE 90,09 estimated tose 90,002 Reference: Deloitte Access Economics (2016) The Value of Accredited Exercise Physiologists to Consumers in Australia a ha jE” &}

References

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