Concerns Regarding Recent NDIS Independent Review Recommendations

I write to voice my concerns regarding the recent NDIS independent review recommendations coming from this review.

I run 4 allied health practices and provide services to a significant number of participants in the NDIS. Please see an outline of my concerns regarding the recommendations that are potentially going to be implemented from July 2018.

Recommendation 17

Therapy price caps have been $178.98 for early intervention and $175.57 otherwise. NDIA will split professions into 5 different levels with 5 difference prices. Detail on this has not been released. Psychology has a higher price than ‘physical therapy’ supports including physio, OT, speech pathology.

NDIA will decide how ‘simple’ or ‘complex’ a participant’s needs are, and allocate them to a pricing level

• Level 1 - $110 - $120
• Level 2 - $140 - $150
• Level 3 - $180 - $190 Details on who would make that decision is unclear, however it would need to be at the planning stage so our best guess is that it would be the Local Area Coordinator who does your planning meetings, or they would be bringing in Independent Assessors in addition to your therapists and LACs.

RESPONSE:

1. Everyone deserves a high level of skilled, experienced care

    a. Price savings for people with less complex needs are that they require fewer hours to achieve their goals
    b. However they should still receive a high level of skilled and experienced care to do this
     c. An experienced therapist will still be more effective with people with 'milder' levels of disability than a less experienced therapist
    d. Children with cerebral palsy GMFCS I and II appear to be put into Level 1 according to the table 5 in the pricing review.. This is still a complex condition, involving multiple systems of the body, with complex interactions between the person,
            condition, physical and social environments as illustrated by the World Health Organisations' International Classification of Function - Children and Youth. While the functional level of a child with GMFCS I is higher, the interplay between the many factors that are affecting their function and participation are not simple. They have the right to seek out a more qualified and experienced professional if they wish to, and that professional has the right to be paid an appropriate wage.
      e. No Awards pay therapists different wages depending on the complexity of the work they are doing. There is no reason why the NDIS ought to
          f. GPs are not paid less for seeing someone with a cold than with a complex medical condition. Health professionals are paid for providing the best possible service.

2. Comparisons to other schemes reported in the review do not hold true for physiotherapy
     a. The pricing review and NDIA responses report that other comparable schemes pay lower rates for 'simpler' cases and higher rates for more 'complex' cares.
    b. This is not true for physiotherapy, and that can be verified by publicly available pay scales. I have not investigated OT, speech or psychology.
     c. What the TAC and WorkSafe do is support people after workplace and motor vehicle accidents. You can have someone with a relatively 'simple' bone fracture, or you can have more 'complex' rehabilitation from an Acquired Brain Injury or multi trauma

d.

they pay for 20 minute review physiotherapy consultations for ‘simple’ cases, and for longer appointments for more ‘complex’ cases. They have set forms and rates for reports which are very specific and quick to fill out.

e.

where there are further complexities for a case, as in occupational rehabilitation, they pay in 7 minute blocks for phone calls, meetings etc

f.

physiotherapists working with these case loads typically see 2-4 patients per hour. Even at the ‘simple’ rate this adds up to above the current $175.57 or $178.98 price caps for NDIS physiotherapy, not less. Group rates also add up to higher than the NDIS rates. In the current NDIS group rates of up to 3 clients at once add up to less than the 1:1 rate!

g.

The TAC also allow physiotherapists to charge their usual market rates with prior agreement, as market rates are typically higher than the TAC rates. The NDIS pays only up to the capped rate.

h. WorkSafe allows health services to charge their usual rates to clients, who then are

reimbursed a set rate. That means clients may have a gap to cover to see their preferred provider. The NDIS does not allow gap payments to be charged to participants.

i. in short, TAC & Work cover DO NOT actually pay physiotherapists less for ‘simpler’

cases as is reported in the pricing review; they are paid more than under the NDIS; and they are able to charge market rates.

3. Who is going to decide which participant falls into which ‘complexity’ level?

a. details have not been released however it appears this will be done in the planning stage

b. difficulty in predicting a participant’s needs and the level of funding required has already provided challenging for planners (eg. LACs, Early Childhood partners), while many families needing reviews of their plans

c. adding another decision about how ‘complex’ a person’s needs are without an easy review or appeals process is concerning

d. what counts as ‘complexity’?

e. What about someone with GMFCS 1, MACS1, CMFM1… but who is struggling to function due to lack of therapy for a decade and has complexities with their care needs, and who needs intervention to prevent a loss of independence?

f. What about a child with CP hemiplegia who has GMFCS 1 or 2 and MACS 1 or 2 but who really wants to learn to ride a bike? You need skilled physios to do that, it’s a really tricky area, and it is not sustainable at $110ph. It might take 6-8 hours to give that child a skill they will use their whole lifetime, that has carryover to other areas of their life, that gets them participating and joining in with their family and friends,

to sets them up for an active future. That is a fantastic outcome for a very small outlay of funds if we are paid appropriately.

g. what are the risks of introducing tiered funding for different people?

h. it still costs the service the same amount of money to provide the service

i. we at Physiotherapy could not provide aquatic physiotherapy at lower rates than the NDIS currently pays

j. will this cause further inequity with services having to make horrible ethical decisions? We go into health because we want to be helpful, and no one is in it to earn huge wages! But we can’t provide services at a loss. That would be a terrible situation to be in to make that decision.

4. The report notes that most providers are charging at or near the price cap

3

a. that is because that is what our services are worth, or because we usually charge higher than that rate. This is easily verified by looking at prices charged by other schemes (TAC, WorkSafe, Medicare as described). In private practice, services under these schemes are generally provided by physios, OTs and speech pathologists at less than the usual rates i.e. the schemes all pay less than market value, and the new NDIS rates even lower.

b. that is an argument for remunerating us fairly, so that we can provide high quality services. c. therapists do not go into work in the disability sector for the money. Disability has historically been one of the most poorly paid sectors in health and we have all worked in that environment for many years. We go into this area because we are passionate about doing meaningful work that makes a tangible difference to the lives of the people we support. d. but that does not mean we shouldn’t be remunerated fairly for our expertise working in a specialist, complex and challenging area. e. remember that therapists don’t have the therapy rate going in to their pocket for 40 hours per week. The organisation might bill 20-30 hours per week per therapist, who generally work well above full time hours, to cover: therapist wages and super; admin support; book keeping and accounting; time to do continuing professional development; cost of professional development; equipment, rent and utilities; insurances and registration; non - contact time that is not billable, including hours interacting with the NDIA attempting to recover payment, and so on. This is already proving challenging at the current prices and will be not possible at new rates without major changes. f. the “greedy provider” narrative is inaccurate and shows a lack of understanding. It drives a wedge between providers, participants and the NDIA when we should be cooperatively forming partnerships to support independence, choice, control and participation. g. misinformation about what the costs of providing therapy involve; and questioning the intention of therapists who are speaking up. Yes we are speaking up to allow us to continue to support people with disabilities to participate in life in the way they want, by working in an area we are passionate in. We are advocating both for our client group and for ourselves. Without advocating for ourselves as well, we will not be able to provide sustainable services for participants.

5. Providers are already struggling to remain viable under the transition to NDIS a. Many provider organisations have folded under NDIS pressures, or are struggling, or have de - registered as NDIS providers. b. Examples of issues have been: i. high cost of registration, and concerns about now having go through a new expensive process in the 18-19 financial year as we move to a national commission ii. adjusting to unit price costs iii. planning ahead for how participants wish to use their funds to achieve their goals, and providers being realistic about what they can achieve within a certain allocation of hours iv. challenges of using the NDIS portal and communicating with the NDIS and planners. I personally have not met an organisation who has not spent significant hours (at huge staff cost)

Providing certainty to providers

Providing certainty to providers has been a priority of the NDIS to grow a stable and effective work force

a. Sudden changes to remuneration provide an unreliable environment where they are making significant outlays in preparing to meet NDIS demand. This is in contrast to the planned development of the NDIS reported in July 2015: b. There is no way for providers to plan their budgets and staffing levels to the support NDIS participants, where the NDIA makes sudden and significant changes to policies and pricing.

Recommendation 21

SUMMARY:

The NDIA should only allow providers to charge participants for the time spent writing reports that are requested by the NDIA. A new line item should be introduced for tracking purposes. No detail has been released on when reports will be mandated, what they are to include, or how much providers will be paid for doing them.

RESPONSE: 1. It is our understanding that no reports are currently mandated, rather they are provided in response to participant request. This is in contrast with other schemes, we are required to send in reports at certain time points and these are attached to funding 2. Families / participants have been exercising “choice and control” in when they wish to have reports done. We do certainly prefer to write one for participants when they are preparing for their planning review meetings, to demonstrate their goals, how they have used their funding, how their goals have been achieved, and the goals they wish to work on next 3. Families / participants have also often asked for other reports such as: a. applying for equipment b. advocating for a review of the NDIS plan where there were gaps in funding c. advocating for reviews of decisions not to provide equipment d. communicating with the participant’s team to facilitate working together to support them in a coordinated way 4. Is there a potential for bias? 5. If you don’t want to know about something, don’t pay for a report? 6. What if no reports are requested because they don’t want to see evidence of therapies’ efficacy because they want to reduce cost? 7. What if they only ask for an early intervention keyworker’s report, and not those from the rest of the AHPs involved, therefore not showing marvellous gains or raising issues that need to be addressed in the next plan? 8. If providers cannot be paid to write reports to support and advocate for participants in appealing decisions, is that bias? Does that prevent appeals? Does that lead to appeals with less evidence to back them up? Does it lead to further inequality where participants who can afford to pay for advocacy reports can receive them? Or are therapists expected to volunteer their time?

• If you want to minimise funding, do you pay only a small amount for reports to you get a bare bones summary with little evidence from providers? (Or expect providers to volunteer their time to provide more comprehensive reports?)
• How and when will the NDIS request reports? Will they give us quick turnaround times making production of a quality report challenging?

Hopefully this highlights some of the issues for providers and participants working within the NDIS are likely to be presented with if the recommendations from the independent review are accepted and implemented. Providers working in the disability sector are absolutely committed to improving the lives of their clients, but need a system that allows them to do the required work within a fair and reasonable framework.