Submission to the Joint Standing Committee

on the National Disability Insurance Scheme

Market readiness for provision of exercise physiology services under NDIS

Beth Sheehan | Katie Lyndon Practice Innovation Advisor | Policy and Practice Innovation Manager Exercise & Sports Science Australia | Exercise & Sports Science Australia

13 February 2018

Dear Mr Andrews,

Thank you for the opportunity to submit feedback to help inform the National Disability Insurance Scheme’s (NDIS) market readiness for the provision of exercise physiology services.

Exercise & Sports Science Australia (ESSA) is a professional association representing over 7,000 members, including university qualified accredited exercise scientists (AES), accredited sports scientists (ASpS) and accredited exercise physiologists (AEPs). AEPs are recognised allied health professionals who provide clinical exercise interventions aimed at primary and secondary prevention; managing subacute and chronic disease or injury; and assist in restoring optimal physical function, health and wellness. AEPs frequently deliver services within NDIS, specialising in exercise prescription for individuals living with disability.

Given the unequivocal evidence supporting clinical exercise interventions as a valid prevention, treatment and management tool for a myriad of chronic diseases [1,2], coupled with the cost- effectiveness of AEP-led interventions[3], it is expected that demand for an AEP’s unique technical and clinical skills will continue to increase.

Please find below ESSA’s response to the terms of reference, as requested by the Joint Standing Committee. We look forward to hearing the outcome of the Inquiry. We welcome the opportunity to discuss this further, and appreciate your consideration of our feedback and recommendations.

If you require further information to support the review, please don’t hesitate to contact redacted

Yours sincerely,

Beth Sheehan Practice Innovation Advisor Exercise & Sports Science Australia

a. The transition to a market based system for service providers

ESSA supports the transition to a market based system as it emphasises consumer centred care and the ability for consumers to have informed decisions and choices available for the treatment and support systems relevant to their condition and needs.

Recently, ESSA surveyed 162 AEPs regarding NDIS, identifying:

52% were already registered to provide services to NDIS with 13% waiting on approval for their registration process,
56% were working in metropolitan areas, 32% in regional and 12% in rural areas, and,
53% rated their satisfaction with the NDIS process as low.

As acknowledged in the NDIS market approach statement of opportunity and intent, the supply of supports and services currently available must double by 2019-2020 to ensure demand is met. Identifying the ‘weak’ or ‘thin’ markets, particularly in rural, regional and remote areas will also highlight the importance of ensuring a thorough and inclusive transition across the market sector. Solutions to improve this transition, and ensure that consumer centred care is advocated for, needs to include education across the infrastructure and personnel of NDIA to enable appropriate planning and informed choice for consumers’ plans.

b. Participant readiness to navigate new markets

Whilst ESSA is supportive of the market based system and acknowledges the various tools and information sessions available to participants, feedback from AEPs working within the NDIS have reported:

Lack of consumer understanding around the types of services they are potentially entitled to under their plan.

PROPOSED SOLUTION: ESSA can collaborate with NDIA in the development of resources to be provided to consumers regarding the provision of AEP services within NDIS. Additionally, NDIA can take a more proactive approach in educating and empowering consumers with resources and knowledge to make informed decisions regarding their care plan.

Lack of planner understanding and knowledge regarding consumers’ conditions, needs and ability to access exercise physiology services. This has resulted in inconsistent advice

provided to service providers from planners, as well as incorrect decisions regarding exclusion of AEP services in plans.

PROPOSED SOLUTION: ESSA has in previous submissions to the NDIA, offered to supply resources (e.g. workshops) to assist planners across Australia understand the services that an AEP can supply, increasing positive outcomes for the consumer. ESSA would be happy to assist in the design and implementation of these resources in collaboration with the NDIA.

Some consumers are being asked to utilise other rebateable health services (i.e. Medicare Chronic Disease Management (CDM) Plans (item code10953) and Private Health Insurers) before receiving exercise physiology services within the NDIS. CDM plans only provide 5 services in one year and are spread across multiple allied health providers. Many consumers only receive 1-2 sessions of this plan which does not adequately address their multiple chronic diseases and/or co-morbidities and are often used within the first few months. The AIHW^[4] (2015) reported that 164 000 Australians (0.7%) have autisum, of which 88% have other disabilities. If these individuals were to spread their maximum 5 CDM services across the required allied health practitioners (e.g. speech therapist, dietitician, exercise physiologist), the ability to make significant changes to the health and wellbeing is limited to potentially only one session per practitioner. AIHW^[5] (2016) found that adults aged 18-64 with severe or profound activity limitation had a highler prevalence of overweight or obesity compared to those without a disability. These co-morbidites also highlight the need to have regular and monitored interventions, such as physical activity, to assist with management of co-morbidity impacts (e.g. psychological impacts such as self-esteem).

ESSA please requests justification around the denial of AEP services under NDIS for consumers who require more consistent exercise rehabilitation and progression. The potential refusal of NDIS relevant services could be detrimental to consumers and may be considered as a denial of human rights for people with a disability.

c. The development of the disability workforce to support the emerging market

ESSA has identified significant misunderstanding from many planners on the nature of AEP services. This has resulted in services being listed in incorrect item numbers (e.g. therapeutic codes) where AEPS are unable to provide services. Consumers who have previously had

exercise physiology services or who have requested these services are also being denied and are receiving services under different categories that AEPs are unable to provide services within, for example:

(a) FCEs/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) 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.

Evidently, these significant barriers are at odds with promoting workforce diversity to maximise choice and control for participants, visibility of providers across all allied health services and low provider barriers to entry to the NDIS, as highlighted in NDIS market approach report^[6].

PROPOSED SOLUTIONS:

Inclusion of NDIS modules and conditions within university allied health programs or as part of professional association Continuing Professional Development (CPD) requiements for members, ensuring that new graduates and the existing workforce are market ready.
Liaison with key allied health groups such as Allied Health Professions Australia (AHPA) to ensure the development of the workforce is collaboratively targeted.
Education and workshops available to NDIS planners to further educate on conditions, need and demand for services and the various allied health professionals’ roles within the treatment and management of conditions covered under the NDIS.
Whilst ESSA and other peak professional bodies play a supportive role in the upskilling anad preparation of the allied health workforce to operate in this space, NDIS need to take responsibility in providing training opportunities to ensure support of all AHPs with the skills required to effectively operate in this space.

d. The impact of pricing on the development of the market

Pricing has significantly impacted the ability for AEPs to both enter and remain competitive within the market. ESSA highlighted some of these issues in the recent independent pricing review.

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 the lower pricing for AEPs does not reflect the value in services as equal allied health providers.

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.).

ESSA please requests parity and consistency in the application of equal pricing models allocated to services provided by allied health professionals within the NDIS.

e. The role of the NDIA as a market steward

ESSA supports an approach where the NDIA will be actively involved in the NDIS market stewardship, but it will do so in collaboration with key stakeholders and on both the ‘supply’ and ‘demand’ sides of the marketplace.

As per the NDIS market approach statement of opportunity and intent, ESSA advocates:

Equal exposure to all allied health providers to enable and empower consumer choice to ensure a diverse, competitive and stable range of providers
Support for the broader workforce to achieve the desired goals and outcomes of the participants
Competitive pricing as opposed to disparency between allied health providers

f. Market intervention options to address thin markets, including in remote Indigenous communities.

ESSA strongly supports the development of industry to ensure healthcare access for all Australians, including rural and remote populations, Indigenous and other ethnic groups.

ESSA is currently designing a Reconciliation Action Plan to acknowledge the current discrepancies in access and servicing to the Aboriginal and Torres Strait Islander community. This will support further development of the skills, knowledge and cultural competencies of our professionals.

PROPOSED SOLUTION:

ESSA supports NDIA engagement with allied health organisations and industry bodies, to facilitate workforce development that addresses thin market opportunities within remote Indigenous communities and other disadvantaged groups across Australia.

This will be further supported by NDIA ensuring: consistent decision making by NDIS planners, and timely response and resolution to disagreements between NDIS and health services about service funding/provision to particpants (including resolving NDIA appeals).

g. The provision of housing options for people with disability, with particular reference to the impact of Specialist Disability Accommodation (SDA) supports on the disability housing market

No comment.

h. Impact of the Quality and Safeguarding Framework on the development of the market

As per AHPA’s submissions to the DSS ([rules and regulations](rules and regulations) and complaints), ESSA supports the emphasis on genuine accessibility, informed consent and the ability to exercise choice as major goals for the Scheme. ESSA, like AHPA, notes that these provisions have the potential to require significant resources both in terms of dedicated time spent with a participant and to have information available in a range of formats, unless there are limitations placed on how these requirements are applied to different types of providers.

ESSA requests that in order to continue to develop the market, that consistency in assessing provider profiles is determined to ensure that the process is not overly burdening for smaller providers, minimising barriers to market participation.

i. Provider of last resort arrangements, including for crisis accommodation

No comment.

Currently AEP services are only listed in the improved daily skills (item 3.12) and AEPs providing services under the NDIS are unable to claim services under therapeutic categories or improved daily skills (item 3.15). AEPs however have the skills and knowledge to provide workplace assessments and functional capacity assessments (currently performed under therapeutic support) as well as provide exercise rehabilitation as a therapeutic service.

In 2016, ESSA commissioned Deloitte Access Economics to identify the financial investment associated with engaging the AEP workforce from the perspective on the consumer ([see report](see report))⁷. 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 NDIA acknowledges that AEPs are federally recognised allied health providers, and as such ensure AEPs can supply therapeutic services within the scheme to optimise a consumer centred care approach of the NDIS.

The current pricing schedule includes Personal Trainers to assist with improving daily well- being and inclusion into mainstream community physical activity and sport.

Accredited Exercise Scientists (AESs) are professionals with university training in exercise and sports science. This equips AESs with the knowledge and skills to apply the science of exercise to develop services that improve health, fitness, wellbeing, performance, and that assist in the

prevention of chronic conditions. The aim of AES services is to provide physical activity and/or exercise programs for individuals or for the broader community.

ESSA requests inclusion of AES professionals alongside personal trainers within the Improved Health & Well-Being Category.

References

Soan, E.J, Brownie, S.M., Hills, A.P. (2014). Exercise physiologists: essential players in interdisciplinary teams for non-communicable chronic disease management. Journal of Multidisciplinary Healthcare, 7: 65-68.
ESSA and DAA. (2014) The collaboration of exercise physiologists and dietitians in chronic disease management. A joint position statement.
Tweedy, S. M., Beckman, E. M., Geraghty, T. J., Theisen, D., Perret, C., Harvey, L. A., & Vanlandewijck, Y. C. (2017). Exercise and sports science Australia (ESSA) position statement on exercise and spinal cord injury. Journal of Science and Medicine in Sport, 20(2), 108-115.
AIHW. (2017) Autism in Australia. Retrieved from https://www.aihw.gov.au/reports/disability/autism-in- australia/contents/autism
AIHW. (2016). Health status and risk factors of Australians with disability 2007–08 and 2011–12. Retrieved from https://www.aihw.gov.au/reports-statistics/health-conditions-disability-deaths/disability/reports
NDIS (2016). NDIS Market Approach: Statement of Opportunity and Intent. Retrieved from https://www.ndis.gov.au/medias/documents/h08/h2e/8799510396958/Statement-of-Opportunity-and- Intent-PDF-1.02MB-.pdf
Deloitte Access Economics. (2016). Value of accredited exercise physiologists to consumers in Australia. Canberra.