AUSTRALIAN PHYSIOTHERAPY ASSOCIATION - 2020-21 pre-budget submission - Treasury

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AUSTRALIAN PHYSIOTHERAPY ASSOCIATION - 2020-21 pre-budget submission - Treasury
2020–21 pre-budget submission
AUSTRALIAN PHYSIOTHERAPY ASSOCIATION - 2020-21 pre-budget submission - Treasury
Authorised by:
Phil Calvert
National President
Australian Physiotherapy Association
Level 1, 1175 Toorak Rd
Camberwell VIC 3124
Phone: (03) 9092 0888
Fax: (03) 9092 0899

                                       2020-2021 Pre-budget Submission • 2
AUSTRALIAN PHYSIOTHERAPY ASSOCIATION - 2020-21 pre-budget submission - Treasury
Introduction                                                                      4
Summary of recommendations                                                         5
1.0 Primary Health Care                                                         12
2.0 Prevention                                                                  18
3.0 Rural and Remote Health                                                    20
4.0 Aboriginal and Torres Strait Islander Health                               24
5.0 Aged Care                                                                   27
6.0 Allied Health Leadership and Innovation                                     31
Appendix                                                                        33

                                                   2020-2021 Pre-budget Submission • 3
AUSTRALIAN PHYSIOTHERAPY ASSOCIATION - 2020-21 pre-budget submission - Treasury
The Australian Physiotherapy Association (APA) is pleased to offer solutions
to support improvements in the efficiency and sustainability of our world class
health system. We welcome the sector wide reform that the government is
undertaking and commend the government on recognising the importance
of ensuring the allied health sector, representing a third of the workforce is
engaged in a meaningful way.

Physiotherapy is Australia’s largest allied health                                     Our recommendations in this submission offer
workforce, with 31,600 registered physiotherapists                                     an opportunity to begin further discussions with
working across all areas of the health system.1                                        government on how physiotherapy can help to
Physiotherapy represents the fourth largest health                                     deliver on Australia’s Long Term National Health
profession in rural Australia and has the greatest                                     Plan. We offer solutions that strengthen the
penetration of privately operated allied health                                        primary care sector and improve the affordability
businesses.2                                                                           of access to multidisciplinary care to all
                                                                                       Australians, and address the inequities that exist
Physiotherapists are key members of                                                    in pockets of our society.
multidisciplinary teams, making an important
contribution to health care through health                                             Australians living in regional, rural and remote
promotion, prevention, screening, as well as                                           Australia rely extensively on services provided
triage, assessment and treatment activities.                                           by both public and private physiotherapists, and
The skills and training of physiotherapists equip                                      have established strong relationships with these
them to work across a wide variety of conditions                                       practitioners, who are part of their community.
and disabilities to improve the health status of                                       Physiotherapists are an integral part of both
individuals across their lifespan. Physiotherapists                                    private and public systems and work closely with
also work with groups to deliver improved                                              other health professions.
population health outcomes within their local
areas.                                                                                 In rural and remote areas there are significantly
                                                                                       more potentially preventable hospitalisations than
Physiotherapists are perhaps best recognised                                           in metropolitan areas.
for the treatment of musculoskeletal conditions.                                       To reduce the additional burden on expensive
They also have a well-established role in                                              tertiary care in rural and remote areas, the
the treatment and maintenance of chronic                                               introduction of programs to improve the
conditions such as cardiovascular disease,                                             distribution of the physiotherapy workforce and
chronic obstructive pulmonary disease, diabetes,                                       better utilise existing infrastructure is vital.
osteoporosis, arthritis, obesity and hypertension.
The educative focus they adopt in areas such as                                        We offer opportunities to improve efficiencies in
chronic disease management, self-management                                            the system through the rollout of physiotherapy
techniques and lifestyle and physical activity                                         service provided through telehealth, allowing
counselling aligns well with the primary health                                        people all over Australia to access specialist
care philosophy of consumer and community                                              physiotherapy services. This means that the
empowerment.                                                                           farmer in Walgett can access the same high
                                                                                       quality, personalised care, as the lawyer in
Demand for physiotherapy services continues to                                         metropolitan Sydney.
increase due to the ageing population, population
growth, the rising incidence of chronic disease                                        We plan to strengthen primary care by reducing
and survival of accidents or illness.                                                  the burden on hospitals and better utilise the

1 & 2 Physiotherapy Board of Australia, Registrant Data June 2019. Accessed 20/08/19

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AUSTRALIAN PHYSIOTHERAPY ASSOCIATION - 2020-21 pre-budget submission - Treasury
existing investments in infrastructure in the           health environment allows this communication
physiotherapy sector. We believe there is scope         to be fed through to the GP in real time yet our
to use our expert diagnostic skills to triage and       system puts administrative barriers in the way that
treat minor injuries, particularly in rural areas and   costs patients in time, money and recovery.
in the after hours period where general practice is
already under pressure. This could mean that the        In addition, we would like the government to
parent of a child who has fallen from a bed and         better understand how the private physiotherapy
injured a wrist, can be safely reassured when an        sector relies on a myriad of complex funding
X-ray is not required.                                  mechanisms for its viability and sustainability,
                                                        with many practices relying on blended funding
We recognise the barriers of access to care for         from a number of sources such as private health
some patients are predominantly economical and          insurance, Medicare, compensable schemes
geographical, and we strongly believe that wherever     such as WorkCover, the National Disability
it is possible, these barriers must be removed. We      Insurance Scheme and aged care packages,
have identified many ways in which we see this can      while also needing to attract and compete for
be achieved.                                            consumer contributions. This means that minor
                                                        tweaks to policy can have a major impact on an
Our profession also wants to engage in health           individual practice, which in turn impacts on out
system stewardship in a meaningful way.                 of pocket costs to consumers thereby reducing
Our goal in treatment is to deliver recovery with       accessibility. For this reason we have made
minimum intervention and our expertise and              suggestions that support the efficient use of the
diagnostic skills in treating and managing              existing systems with some innovative solutions.
musculoskeletal disorders means that we know
exactly when it is time to refer to a surgeon           We trust that our recommendations will
or to recommend imaging.                                provide the government with sound, feasible
                                                        and cost-effective solutions, and that these
We would like to see the weekend soccer                 solutions represent a multidisciplinary, informed,
player who has come to a physiotherapist for            patient-centred approach that supports the
an assessment of their injury, follow a journey         implementation of the Long Term National
that represents best practice - whether that is         Health Plan.
conservative management, diagnostic imaging
or referral to an orthopaedic surgeon. Our digital

                                                                                   2020-2021 Pre-budget Submission • 5
AUSTRALIAN PHYSIOTHERAPY ASSOCIATION - 2020-21 pre-budget submission - Treasury

GOAL: Improve equity of access to primary health care for all Australians
through affordable high value physiotherapy


•   Allow direct referral to medical specialists and       the delivery of outcome driven, high value
    diagnostic imaging, within individual scope            physiotherapy care.
    of practice, under a clinical governance               Cost estimate: $100,000
    framework that recognises the role of
    physiotherapists as health system custodians       •   Improve access to After Hours care and
    in their area of expertise.                            reduce emergency department burden
    Cost saving: $13.6 million                             by piloting an innovative service model
                                                           for triaging and treatment of acute
•   Provide funding to pilot the expansion of              musculoskeletal injuries, which utilises the
    physiotherapy services, delivered through              existing physiotherapy sector infrastructure.
    telehealth to high need consumers, with                Cost estimate: $1 million
    proven safety and clinical equivalence to
    standard care, to evaluate cost-effectiveness.     •   Improve access to allied health services for
    Cost estimate: $1 million                              people with chronic and complex conditions
                                                           through the MBS by recognising the current
•   Investigate the cost-effectiveness of                  limitations and increasing the number of
    incentivised private health insurance rebates          available consultations and reducing the out
    for physiotherapy services that reduce out of          of pocket cost to consumers.
    pocket costs to consumers and promote

                                                                                 2020-2021 Pre-budget Submission • 6
AUSTRALIAN PHYSIOTHERAPY ASSOCIATION - 2020-21 pre-budget submission - Treasury

Goal: Enable access to funded prevention strategies where there
is evidence supporting both immediate need and cost-effectiveness


• Develop a service delivery model that utilises
  existing physiotherapy infrastructure to improve
  access to early intervention pain services.
  Cost estimate: $200,000

                                                     2020-2021 Pre-budget Submission • 7
AUSTRALIAN PHYSIOTHERAPY ASSOCIATION - 2020-21 pre-budget submission - Treasury

Goal: To bring equity of access to high quality physiotherapy for people
in rural and remote locations and areas of workforce shortage


• Recognise the higher costs associated with          • Provide ready access to high quality, affordable
  rural living and service provision by providing       education and training for both public and
  financial support to existing services and            private practice to attract and retain the rural
  support to attract and retain the physiotherapy       workforce. Cost estimate: $200,000
  workforce. Cost estimate: $3.75 million

• Promote viable rural markets by redirecting
  government programs towards enhancing
  utilisation of existing infrastructure, expertise
  and relationships, and stop the preferential
  incentivising of certain sectors, which creates
  an uneven playing fields, such as the General
  Practice Workforce Incentive Program.
  Cost estimate: neutral

                                                                               2020-2021 Pre-budget Submission • 8
AUSTRALIAN PHYSIOTHERAPY ASSOCIATION - 2020-21 pre-budget submission - Treasury

Goal: To reduce the current underutilisation of physiotherapy services
by Aboriginal and Torres Strait Islander peoples


• Provide funding to trial the impact of              • Provide funding for research into an evaluation
  embedding appropriately trained, culturally safe      of the barriers and enablers to appropriate
  physiotherapists into Aboriginal Community            utilisation of physiotherapy by Aboriginal and
  Controlled Health services. Cost estimate:            Torres Strait Islander peoples. Cost estimate
  $2.75 million                                         $150,000

• Enhance utilisation of existing Chronic Disease
  Management items in the Medicare Benefit
  Scheme, by providing a no gap physiotherapy
  consultation policy, similar to other Closing the
  Gap initiatives for Aboriginal and Torres Strait
  Islander peoples.

                                                                               2020-2021 Pre-budget Submission • 9
AUSTRALIAN PHYSIOTHERAPY ASSOCIATION - 2020-21 pre-budget submission - Treasury

Goal: To re-orient aged care services to evidence-based early interventions,
such as physiotherapy, to improve the quality and safety of care provided


• Provide a $1000 payment for physiotherapy-          • Establish an Aged Care Workforce Steering
  led restorative care for all new admissions into      Committee tasked with commissioning and
  residential aged care facilities to improve their     evaluating research into best practice workforce
  independence, reduce frailty and reduce the           models to ensure a viable, safe and sustainable
  cost burden on the aged care system.                  aged care workforce.

• In the Australian National Aged Care
  Classification (AN-ACC) system include a new
  funding layer for consumer directed wellness
  and reablement care to be delivered by allied

                                                                              2020-2021 Pre-budget Submission • 10

Goal: To understand and recognise the contribution of the allied health
sector to the health system and facilitate data driven future decision


• Develop an Allied Health Workforce Dataset
  that enables informed decision making and
  identifies opportunities for better workforce

• Appoint a Chief Allied Health Officer to inform
  decision making within the department.
  Cost estimate: $400,000

                                                       2020-2021 Pre-budget Submission • 11
Goal: Strengthen the primary care system and improve equity of access
to primary health care for all Australians through affordable high value

PROPOSED SOLUTION: Provide direct referrals for physiotherapist to medical specialists
and diagnostic imaging

We believe that to strengthen primary care in                                              This means that the patients of physiotherapists
Australia, improve efficiencies and enhance                                                in rural areas, who already have restricted
access to care for all Australians, all health                                             access to consultant medical specialists, have
professionals must take ownership of the                                                   an additional hurdle when accessing suitable
sustainability of our health system and should                                             medical practitioners.
consider themselves custodians, and be
empowered to act as such. In a contemporary team                                           Allowing for direct physiotherapy referral to
based health system, stewardship is not a role                                             specialist medical practitioners will better utilise
that can be designated to a single profession at                                           the existing workforce, cut red tape and free up
the exclusion of others. Not only does this suggest                                        GPs to dedicate more time to complex clinical
that other health professionals are not trusted to                                         care.
make sound decisions that are in the best interest
of their patients, but it also reinforces an outdated                                      For example, the Transport Accident Commission
hierarchy that devalues the contribution of other                                          (TAC) in Victoria has a Network Pain Management
health providers.                                                                          Program in Victoria that supports the principle of
                                                                                           early intervention and enables physiotherapists
The rationale for retaining general practitioners                                          to refer motor accident patients directly to pain
(GPs) as the primary source of referral has been                                           medicine specialists. Benefits of this program
the importance of continuity of care. However,                                             include:
recent research suggests that a significant
proportion of general practice care is delivered                                           • a single approval, which facilitates early access
away from ‘usual’ or home practices, with more                                               to healthcare
than one-quarter of the study’s sample attending                                           • access to a coordinated team of healthcare
more than one practice in the previous year.3 This                                           professionals, and
has potential implications for continuity of care.4
                                                                                           • access to pain management usually within 4
Within their scope of practice, optometrists,                                                weeks of approval.
dentists, midwives and nurse practitioners are
                                                                                           In contrast, the MBS requires a GP referral to
able to make referrals directly to consultant
                                                                                           consultant medical specialists, when in selected
medical specialists. The same principle needs to
                                                                                           cases a physiotherapist could safely and
apply to physiotherapists.
                                                                                           appropriately make the referral. This can create
One in 20 Australians lives in an area with                                                a circular referral pattern that delays necessary
severely reduced access to the services of a GP.                                           specialist treatment and generates unnecessary
In some of Australia’s most underserviced areas,                                           work.6 The use of interoperable information and
only half the number of GP services per person                                             communications systems (including My Health
are provided, compared with those provided to                                              Record) overcomes any sense of discontinuity
people living in metropolitan areas.5                                                      between providers and patients.

3 Haggerty JL Reid RJ Freeman GK et al. Continuity of care: a multidisciplinary review. BMJ. 2003 Nov 22;327(7425):1219-21.
4 Wright M Hall J van Gool K et al. How common is multiple general practice attendance in Australia? AJGP May 2018;47(5):289-96.
5 Duckett S Breadon P Ginnivan L. Access all areas: new solutions for GP shortages in rural Australia, Grattan Institute, Melbourne. 2013.

                                                                                                                                      2020-2021 Pre-budget Submission • 12
There is evidence to support that physiotherapists                                         changing current referral requirements, health
are capable health system stewards in hospital-                                            policymakers will streamline patient care,
based orthopaedic screening clinics. In these                                              facilitating faster diagnosis, improved patient
clinics, musculoskeletal physiotherapists screen                                           outcomes, quality of life, work productivity and
patients referred by GPs to an orthopaedic                                                 wider community benefits.
surgeon, filtering and treating patients who could
benefit from conservative treatment and reducing                                           A safety and quality framework already exists. The
the number of appointments on the orthopaedic                                              APA Code of Conduct is binding on all members
wait list.                                                                                 and requires physiotherapists to collaborate with
                                                                                           colleagues to promote safe, quality care. This
An analysis of physiotherapy-led orthopaedic and                                           will often involve collaboration with a GP, which is
neurosurgery screening clinics in Queensland                                               normal practice within the profession.9
found that 58% of the patients referred by a GP
did not require surgical consultations at all and                                          The Physiotherapy Board of Australia also has a
83% were referred for conservative physiotherapy                                           code of conduct that requires physiotherapists
management rather than surgery. The same                                                   to ‘recognise and work within the limits of their
review found that patients, GPs and medical                                                competence and scope of practice.’10 This
specialists had high levels of satisfaction with the                                       reflects the practice in the profession of referring
clinics.7                                                                                  patients to a GP if the aetiology of the presenting
                                                                                           condition is unclear or outside a physiotherapist’s
In 2013, the APA commissioned Griffith                                                     scope of expertise. However physiotherapists, as
University’s Centre for Applied Health Economics                                           experts in the management of musculoskeletal
and the Deeble Institute to conduct an economic                                            disorders, are well placed to determine the
evaluation to determine the costs associated with                                          relevant pathways for patients.
referrals. The research found if physiotherapists
were to receive Medicare rebates to directly refer                                         In addition, evidence suggests that
to a range of specialist medical practitioners,                                            physiotherapists are skilled at ordering clinically
there would be substantial savings:                                                        appropriate imaging. When magnetic resonance
                                                                                           imaging (MRI) was used as the gold standard,
                                                                                           the diagnostic accuracy of physiotherapists for
                                                                                           clients with musculoskeletal injuries was found to
  Savings to the MBS:                                        $13,641,362
                                                                                           be as good as that of orthopaedic surgeons and
  Savings to patients:                                         $2,175,407                  significantly better than that of non-orthopaedic
  TOTAL SAVINGS:                                           $15,816,7698
                                                                                           • Proposed Solution: Allow direct referral to
                                                                                             medical specialists and diagnostic imaging,
                                                                                             within individual scope of practice, under a
As shown in the figures above, the current referral                                          clinical governance framework that recognises
system can incur additional GP out-of-pocket                                                 the role of physiotherapists as health system
costs for patients. The imposition of additional                                             custodians in their area of expertise.
costs can lead patients to delay their care, or                                              Cost Saving: $13.6 million
worse, fail to follow through on treatments,
potentially creating a later acute episode. By

6 Wright Hall van Gool et al. op cit.
  aymer M Smith D O’Leary S. Physiotherapy screening clinic model improves neurosurgery and orthopaedic outpatient services, Queensland Government 2012.
  omans T Byrnes J Boxall A et al. Physiotherapist referral to specialist medical practitioners. Final Report. Griffith University Centre for Applied Economics and Deeble
 Institute. 2 September 2013.
  ustralian Physiotherapy Association (2017). APA Code of Conduct, p4, available at
10 Physiotherapy Board of Australia (2011). Code of Conduct for Registered Health Practitioners, p2, available at

                                                                                                                                      2020-2021 Pre-budget Submission • 13
PROPOSED SOLUTION: Provide funding for telehealth provided
physiotherapy services

We believe there is an opportunity to support the                                         is able to either provide direct patient care, or
implementation of the Long Term National Health                                           support the local practitioner to meet patients’
Plan to improve access to services through the                                            needs without the burden of travel.
rollout of telehealth.
                                                                                          Given recent technology advancements that
Telehealth is a proven, safe and cost-effective                                           have simplified the user experience and reliability,
strategy for increasing access to physiotherapy                                           telehealth is now an obvious solution to current
services for all Australians and there is a broad,                                        access issues and can be effectively used to
and rapidly increasing, body of evidence that                                             deliver many services, to review patient progress,
demonstrates this.                                                                        ensure effective services are delivered and
                                                                                          provide motivation for effective management
Reports suggest that sufficiently scaled home                                             programs. Telemedicine is also a proven cost-
telehealth implementation is an appropriate and                                           effective strategy for chronic pain management,
cost-effective way of managing chronic care clients                                       providing a solution the current opioid
in both urban and rural settings.                                                         dependence epidemic and extended wait lists to
                                                                                          access specialist pain services.
A systematic review that assessed the economic
value of video communication found that:                                                  We recognise that recommendations for
                                                                                          subsidised allied health teleconference
• 91% reported telehealth outcomes were at
                                                                                          consultations has been provided to the MBS
  least equivalent or better
                                                                                          Taskforce from the Allied Health Reference Group,
• 61% found telehealth to be less costly than the                                         and we would like to reinforce the importance
  non-telehealth alternative.12                                                           of enabling this to begin to address some of the
Difficulty in accessing physiotherapy services                                            inequities of access that currently occur in our
can be a result of multiple barriers, not only                                            system, particularly for people living in rural and
geographic. Video-consultations can lower                                                 remote areas.
the barriers for patients to receive advice and                                           Additional work to further support these services
support. This includes people living in rural                                             would be welcomed and should focus on the
locations, those who are homebound and older                                              collection of evidence of outcomes to form
people with limited capacity to travel to a clinic.13                                     national minimum
Frailty and immobility can reduce access at any                                           data sets.
distance and should not make vulnerable patients
ineligible – therefore we also believe that this                                          • Proposed Solution: Provide funding to pilot
has broader application and that the restrictions                                           the expansion of physiotherapy services,
should be based on clinical need, not geographic                                            delivered through telehealth to high need
location. However, we also recognise that the                                               consumers that have proven safety and clinical
most immediate access crisis is in rural and                                                effectiveness equivalent to standard care and
remote settings.                                                                            can demonstrate cost-effectiveness.
                                                                                            Cost estimate: $1 million
There are additional benefits if the patient is
in a rural or regional location and the treating
practitioner is an urban based specialist who

11 Daker-White G Carr AJ Harvey I et al. A randomised controlled trial: Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments. J
    Epidemiol Community Health,1999. 53: p. 643-50.
12 Wade VA Karnon J Elshaug AG et al. A systematic review of economic analyses of telehealth services using real time video communication. BMC Health Services
    Research 2010;10:233
13 Foley & Lardner LLP. 2014 Telemedicine Survey Executive Summary. Executive Summary November 2014. Chicago. USA.
    Summary.pdf (Accessed 1 October 2017)

                                                                                                                                     2020-2021 Pre-budget Submission • 14
PROPOSED SOLUTION: Support the delivery of high value care through
incentivised Private Health Insurance rebates

We believe there are opportunities in the current       quality across locations – we need the data
system to encourage consumer choice and                 to understand this better and the access to
support innovation, while ensuring there is a           resources to change it.
robust public and private health system that
delivers high quality care. We would like to see        A suggested introductory model, or interim
out of pocket costs to consumers reduced                model, is the provision of higher private health
so that access is improved, but quality is not          insurance rebates for acknowledged skills set or
compromised.                                            practice standards, which are passed on to the
                                                        consumer as reduced out-of-pocket expenses,
                                                        thereby encouraging the consumer to seek out
                                                        quality care.

                                                        This higher level of rebate could occur at two

                                                        • Practitioner (i.e. Titled physiotherapists)
                                                        • Practice (i.e. Have undergone QIP

                                                        This is an important point of difference from
                                                        preferred provider systems, which creates an
The health system is under constant pressure            uneven playing ground, and reduces the incentive
to provide more efficient, high quality care. Yet       for individual practitioners to invest in the system.
for physiotherapy, and allied health practitioners
in general, there is no effective way to either         It is an opportune time to identify the opportunity
measure this, or provide any incentives at the          for scaling and evaluation. Individual practitioner
coal face to extend beyond traditional practices.       credentialing already exists and there is
The ultimate potential of high value care and the       precedence for some insurers to recognise
link to accurate funding mechanisms to drive            this in their rebate structure. Quality assurance
this and support preventative health activities is      recommendations are best developed by the
underestimated.                                         individual peaks, who can inform government and
                                                        regulators of health service delivery.
It is now critical that the government acknowledges
this gap and develops frameworks that can               We believe this recommendation will support the
support the system to identify strengths and            Private Health Industry, allowing them to develop
weaknesses. We need to be able to understand,           a system that will engender consumer confidence
and where possible quantify, the quality of the         and improve health outcomes by allowing higher
service provided so that we can recognise the           rebates for outcomes based care.
provider for delivering cost-effective health care to
the system.                                             • Proposed solution: Investigate the cost-
                                                          effectiveness of incentivised private health
It is essential that we identify opportunities within     insurance rebates for physiotherapy services
the allied health sector to maximise efficiency,          that reduce out of pocket costs to consumers
reduce wastage, and identify and remove                   and promote the delivery of outcome driven,
perverse incentives to over-service. We know              high value physiotherapy care.
that there can be huge variation in practice              Cost estimate: $100,000

                                                                                  2020-2021 Pre-budget Submission • 15
PROPOSED SOLUTION: Improve access to After Hours care through a pilot
    triaging model for acute musculoskeletal care

    We see an opportunity to address some of the           services after hours. Many of the lower category
    inequities of access to care that currently exist in   presentations are minor traumas that would be
    our system while at the same time strengthening        better triaged or managed by a physiotherapist.
    our existing workforce by providing alternative
    access points that leverage existing infrastructure.   Studies in this area may show that rural access
                                                           issues could also be addressed this way.
    We believe there are opportunities for
    physiotherapists in rural areas to help reduce         There may also be opportunity to provide
    the number of unnecessary presentations at             certainty for local providers that rural practice
    emergency departments and the pressure on              is both sustainable and represents a sound
    GPs in rural areas.                                    investment.

    We would like the government to trial an after         Primary Health Networks (PHNs) provide an
    hours model for physiotherapists to use existing       ideal opportunity to work more closely with rural
    infrastructure to provide triaging and treatment       services and ensure that funding effectively
    for minor injuries, or other Category 4 and 5,         targets areas most in need.
    presentations.                                         • Proposed Solution: Improve access
    This could be extended to sociable hours triaging        to after hours care and reduce emergency
    opportunities.                                           department burden by piloting an innovative
                                                             service model for triaging and treatment
    These models have been explored through                  of acute musculoskeletal injuries, using the
    the Supercare Pharmacies model in Victoria               existing physiotherapy sector infrastructure.
    and some other Primary Health Network (PHN)              Cost estimate: $1 million
    initiatives. These initiatives looked at innovative
    collaborative models of care to address access to

“Those with existing businesses
already have the infrastructure
and business structures in place
and often just need some support
to expand into a multidisciplinary
practice model.”

APA member

                                                                                      2020-2021 Pre-budget Submission • 16
PROPOSED SOLUTION: Improve access to allied health services for people
with chronic and complex conditions through the MBS

We are keen to deliver on the nascent value within        We are aware from other research on the costs of
the Chronic Disease Management (CDM) items                physiotherapy services that the fee/benefit for the
in the MBS and to support the goal of the Long            CDM items is materially lower than the full average
Term National Health Plan to guarantee a secure           cost of providing the service on a sustainable
Medicare and a strong primary health sector.              basis. We anticipate there is an important financial
                                                          barrier for patients when accessing physiotherapy
We have a number of concerns about the model              subsidised by the MBS. This barrier is amplified
for the CDM items as currently enabled in the             for people with chronic diseases as they are likely
MBS. Clients often tell our members that they             to need an episode of care. Financial barriers are
have claimed all but one of their annual allocation       further exacerbated by variable bulk-billing rates.
of MBS-subsidised consultations with allied
health professionals prior to their first visit to this
physiotherapist. This creates a material barrier to
the clients attending for a sufficient ‘episode’ of
physiotherapy care.

Our members report they are advised by GPs
that referral to the physiotherapist is for a
single session, as the four remaining sessions
available under the MBS are to be used by other
allied health professionals (e.g. a dietician or
occupational therapist).
                                                          Our members have stated they do not receive
They also report that the structure of the CDM
                                                          referrals for the same person over multiple years
items departs materially from their usual practice.
                                                          despite the design of the CDM items pertaining
Independent research, commissioned by the APA
                                                          to the management of chronic conditions. Our
in 2017, indicates that initial consultations last, on
                                                          members report that there is a small number of
average, 40.29 minutes. This is more than twice
                                                          GPs who consistently refer patients who would
the threshold length of 20 minutes indicated for
                                                          not, in the view of our members, otherwise be
the service in the MBS. There is little variation in
                                                          eligible for these services. Our members have
this reported average length between urban and
                                                          been made aware that the decision is that of the
rural clinics and between sole traders and group
                                                          GP and the regulatory framework is such that the
                                                          decision is the GP’s.
This research also indicated that more than
                                                          The APA would welcome a tiered model proposal
a third of physiotherapists in Australia offer a
                                                          against current chronic disease items to provide
bulk-billed initial consultation on referral from a
                                                          additional allied health visits. This shift aligns
GP. Across the states, Western Australian (WA),
                                                          with the literature and the need for a long-term
Queensland (Qld), Victoria (Vic) and the Northern
                                                          multidisciplinary management plan for effective
Territory (NT) have the highest rates of offering
                                                          chronic disease management.
to bulk bill (respectively). Although the base
of respondents in the study was smaller, the              • Proposed Solution: Improve access to
Australian Capital Territory (ACT) and Tasmania             allied health services for people with chronic
(Tas) have very low levels of offering to bulk bill.        and complex conditions through the MBS by
The study showed very little difference between             recognising the current limitations by increasing
urban and rural clinics and between with sole               the number of available consultations and
traders and group practices.                                reducing the out of pocket cost to consumers.

                                                                                    2020-2021 Pre-budget Submission • 17
Goal: Enable access to funded prevention strategies where there
is evidence supporting both immediate need and cost-effectiveness

PROPOSED SOLUTION: Enhance access to early intervention pain physiotherapy services

One in five Australians under the age of 65 is          A significant amount of the burden of chronic
affected daily by chronic pain, this rises to one in    pain arises from musculoskeletal disorders. For
three in over 65 years of age.14 Chronic pain costs     example, the direct costs of low back pain are
the Australian economy about $34 billion per            estimated at $4.8 billion per year in Australia. The
year. This is the third most costly health burden in    indirect costs are estimated at more than $8 billion
Australia and the leading cause of early retirement     in Australia.17
and absenteeism in the workplace.15
                                                        There are well-defined predictors of pain
The Productivity Commission has recommended             chronicity in the literature. These include high
the health sector shifts its focus to integrated        levels of pain, poor self-efficacy, poor pain-related
and patient centred care. It is estimated this shift    beliefs and fear avoidance.18 Early intervention
could save the economy $140 billion over 20             to address these predictors has been shown to
years.16                                                reduce the risk of developing chronic pain and
                                                        may help address the burden of disease and
There is strong evidence that early interventions       prevent chronicity.19
can result in health system savings and, more
importantly, reduce the negative impact of pain         Physiotherapy has been shown to be effective in
on quality of life. We believe there is a missed        the early intervention setting and lead to outcomes
opportunity to address the gap in service               such as fewer sick days, shorter injury duration and
delivery that exists in identifying people at risk of   decreased utilisation of the healthcare system.20
developing persistent pain.                             Physiotherapists are well placed to employ a

                                                                                  2020-2021 Pre-budget Submission • 18
biopsychosocial approach to educate and promote
best-practice approaches to pain including pain
education and promotion of healthy movement,
as well as being well placed to screen for co-
morbid predictors of chronicity. Physiotherapy can
help address the domains that are predictors of

As a result, it is important for health funding to
include services that provide early intervention
physiotherapy services for people at risk of
persistent pain. The presence of these services
provides a routine, accessible option for patients
and GPs when the risk of persistent pain is
identified.                                                                                  priority health problems. A broad range of
                                                                                             interdisciplinary methods including face-to-
Rural communities, service and provider deficits,                                            face, group meetings and telehealth will ensure
and distance, also factor strongly. Targeted                                                 stronger coverage and support accessibility aims.
strategies are needed to address access
constraints so patients can receive treatment                                                A proposed service is described in Appendix 2.
close to home.                                                                               • Proposed Solution: Develop a service
MBS pain-related items should be expanded                                                      delivery model that utilises existing
to enable high value care via multidisciplinary,                                               physiotherapy infrastructure to improve access
patient-centred approaches to pain management.                                                 to early intervention pain services.
This expansion could provide an effective                                                      Cost estimate: $200,000
and lasting solution to one of the nation’s

14 Pain Australia 2018-2019 Pre-Budget Submission. December 2017.
15 Productivity Commission 2017, Shifting the Dial: 5 Year Productivity Review, Inquiry Report.
16 & 17 Productivity Commission 2017. op cit.
18 Picavet HSJ, Vlaeyen JW, Schouten JS: Pain catastrophizing and kinesiophobia: predictors of chronic low back pain. American journal of epidemiology 2002,
19 Raymond A, Bouton C, Richard I, Roquelaure Y, Baufreton C, Legrand E, Huez J-F: Psychosocial risk factors for chronic low back pain in primary care—a systematic
    review. Family practice 2011, 28(1):12-21.
20 Hallegraeff JM, Krijnen WP, van der Schans CP, de Greef MHG (2012) Expectations about recovery from acute non-specific low back pain predict absence from usual work
    due to chronic low back pain: a systematic review. Journal of Physiotherapy 58: 165–172.
21 Guzman, J., Esmail, R., Karjalainen, K., Malmivaara, A., Irvin, E. & Bombardier, C. (2001). Multidisciplinary rehabilitation for chronic low back pain: a systematic review.
    British Medical Journal, 322(7301), 1511-1516.

                                                                                                                                         2020-2021 Pre-budget Submission • 19
Goal: To bring equity of access to high quality physiotherapy for people
in rural and remote locations and areas of workforce shortage

PROPOSED SOLUTION: Recognise the higher costs associated with rural living and service
provision by providing support to existing services and to attract a new workforce

We know that the costs of running a business in        “If GP clinics are able to claim up to $120,000
regional, rural and remote areas is already higher       per year (depending on location and SWEPI of
than metropolitan areas. We also know that these         the clinic) simply to employ a physiotherapist at
practices are committed to keeping the out-of-           their clinic, it is very clear that GPs will happily
pocket costs to their community to a minimum.            accept this grant and then refer all their usual
                                                         cases to the “in house” physio. Long term
Rural physiotherapy practices are the backbone           community based physios will no longer have
of the community, and support provided to                a source of GP referrals that we rely on for our
those practices will help them thrive and extend         livelihood. The GP clinics will not only receive
their reach. Our members believe that existing           the WIP grant but the income the in-house
practices already have infrastructure and                physio generates so they are likely to be very
business models in place to expand into a more           happy about this! However, the scenario I can
comprehensive, multidisciplinary practice model.         perceive is a new graduate physio could be
                                                         attracted to take up this position, will have no
We have raised our concerns about the Workforce
                                                         one to mentor them and consequently have
Incentive Program with the Minister for Health,
                                                         a negative working experience and everyone
However; we are yet to be reassured that the
                                                         misses out!”
viability of existing services is being protected,
despite the program being scheduled to begin in
January 2020.

                                                     “Support of existing practices
                                                     is the only way to keep experienced
                                                     practitioners in these areas......
                                                     the same experienced practices
                                                     who can mentor and nurture
                                                     prospective practitioners”

                                                     Rural physio practitioner

                                                                                  2020-2021 Pre-budget Submission • 20
We understand that the majority of local practices       by the Department of Human Services and to
would welcome the opportunity to employ and              community pharmacies through the 6th Community
be able to retain more allied health practitioners,      Pharmacy agreement. Physiotherapy and allied
and to provide the professional support that is          health services receive no support.
best provided by peers. A thriving rural practice
that can invest in more staff, infrastructure and        We believe it is time all health providers were
technology can more easily attract new graduates         recognised for their essential contribution.
for training. The capacity to pay competitive rates      Department-funded incentive payments must be
to attract urban based practitioners is also key.        shared equitably and not just provided exclusively
                                                         to general practice. There is already significant
We also believe, that in an area where there is          investment in the allied health infrastructure that
sufficient workload to support a general practice        does support the “all under the GPs roof” model,
that is large enough to employ an allied health          yet this is often not mentioned.
professional, there is also a viable option to
support a new independent allied health practice.        Disrupting the delicate ecosystem of local
This practice, like a general practice is, should be     services will result in a reliance on higher levels of
allied health practitioner led.                          ongoing government funding and there are many
                                                         examples of where this has occurred already.
We believe there are inequities of access in             The impact on these communities can be far
the system for consumers and health care                 reaching, with new models exposed to a high risk
professionals. Government-funded services                of failure, and an increasing chance that existing
providing lower cost options is anti-competitive. The    services will relocate to urban areas where costs
higher cost of delivering rural services is recognised   are reduced and the competition is more equal.
for general practices through funding provided

                                                              “The most likely people to stay
                                                              rural and do good things for
                                                              their communities are those
                                                              who are already there.
                                                              These practices should
                                                              be supported. They are also
                                                              the best people to train early
                                                              career therapists.”

                                                              APA member

                                                                                    2020-2021 Pre-budget Submission • 21
There needs to be better collaboration between            These are examples of rural and remote
PHNs and the physiotherapy profession to                  support that is currently provided to other health
facilitate a deeper understanding of local service        professionals that should be open to all health
needs, and to be able to provide viable solutions.        professionals, including allied health:
We believe it is imperative that the government
work closely with individual exiting allied health        • HECS Reimbursement Scheme
practices to determine a model to support future          • Workforce Incentive Program –
viability.                                                  Practice Stream
 “In the first four months of this year, I lost out 18   • Workforce Incentive Program – Practitioner
   hours’ worth of contracts to nearby aged care            Stream
   and public hospitals to two different large health
   corporations. Our practice had been providing          • Medicare funded Telehealth consultations
   physio services to these sites for many years
   and now they are being serviced by a rolling           • Rural Pharmacy maintenance allowance
   series of mostly limited registration physios who
                                                          • Rural start-up allowances
   have no interest in the local community and are
   only working out their contract until they pass        • Outreach support
   their exams. This is largely due to the ACFI pain
   management 4A and 4B funding models that               • Better Access to funding such as the MBS
   make it very attractive for agencies to employ           and private health insurance to reduce out of
   these corporates in exchange for increased               pocket costs to consumers
   funding but, unfortunately, decreased services
   and consistency. So I am left in a position of         • The PIP-QI
   trying to keep my staff still employed with not        • EHealth incentives
   enough to do and again at great cost to myself.
   So this may seem slightly contrary to what is          • Relocation costs subsidies
   perceived as gaps in treatment in rural physio
   areas. We are actually trying to source more           • Rural practitioner loadings
   work to keep us all afloat! I am facing the very
                                                          • Proposed Solution: Recognise the higher
   real prospect of having to downsize my services
                                                            costs associated with rural living and service
   and staff, which means local physios who are
                                                            provision by providing financial support to
   prepared to work in this area are losing jobs to
                                                            existing services and support to attract and
   health corporates who have a fiscal bottom line
                                                            retain the physiotherapy workforce
                                                          • Proposed Solution: Promote viable rural
We believe that rural practice is often not
                                                            markets by redirecting government programs
recognised for its agility and progressive
                                                            towards enhancing utilisation of existing
culture. The lack of administrative red tape that
                                                            infrastructure, expertise and relationships.
inhibits innovation in metropolitan locations is
                                                            Stop the preferential incentivising of certain
an opportunity in rural practice. We believe that
                                                            sectors, which creates an uneven playing
investments in the development of rural practice
                                                            field, such as the General Practice Workforce
will pay dividends at a national and international
                                                            Incentive Program. Cost estimate: neutral
level. The opportunity to access the support
needed to harness this is limited for rural allied
health practitioners.

                                                                                    2020-2021 Pre-budget Submission • 22
PROPOSED SOLUTION: Provide ready access to high quality, affordable education
and training for both public and private practice

We support initiatives to increase access to          Choosing to become a healthcare professional
professional development activities for rural         needs to be a practical option for rural students.
practitioners, particularly programs which            When students are forced to relocate to meet
recognise the diversity of the skill set, the         these needs, the connection is disrupted. Given
increased workload, the breadth and depth of          the current connectivity of the world, and the
practice scope, along with the inevitable decrease    rate of technology advancement, distance is
in access to highly skilled mentors. We see this      no longer an argument for variations of either
as an iterative process that must continue to         standard or opportunity. We need to keep pace
evolve to keep pace with opportunities that are       with other industries and ensure that health uses
available in metropolitan locations. The issues       data informed distribution of funding to ensure
are well documented, and we know that if we           equivalent standards for the provision of training
don’t support our rural practitioners, then we will   and education in rural and metropolitan Australia.
continue to lose them. The pipeline in terms of
students, university placements, new graduate         • Proposed Solution: Provide ready access to
positions and clinical supervisor capacity building     high quality, affordable education and training
is a key priority to ensure future workforce            for both public and private practice to attract
distribution matches population need.                   and retain the rural workforce.
                                                        Cost estimate $200,000

                                                                               2020-2021 Pre-budget Submission • 23
Goal: To reduce the current underutilisation of physiotherapy services
by Aboriginal and Torres Strait Islander people

PROPOSED SOLUTION: Trial the impact of embedding appropriately trained
physiotherapists into ACCHs

The APA supports the core premise that there           we think that inside that safe space should be a
is not currently the access to culturally safe and     team that can service the needs of each person.
affordable physiotherapy and other allied health
services that there should be.                         Physiotherapy plays an essential role in improving
                                                       health outcomes for Aboriginal and Torres Strait
For physiotherapists, there remains significant        Islander people, including in managing chronic
financial and structural impediments to                diseases such as cardiorespiratory disease and
providing care. A broader population health            chronic pain. However we are concerned that in
policy framework is required that recognises           addition to the well-recognised financial barriers,
the role of primary care, prioritising allied          there is a lack of understanding of the role of
health in addressing health disparities. The           allied health providers and difficulty in identifying
recommendations outlined here move us closer           culturally safe providers. And therefore, people
to addressing key access constraints enabling          choose to not use physiotherapy as a way to
physiotherapists to provide the best possible care     reduce their burden of disease and instead suffer
for Aboriginal and Torres Strait Islander people.      for longer, and put themselves more at risk of
                                                       poorer outcomes.
In recognising the importance of culturally
appropriate healthcare, the APA is heavily             Strengthening the cultural competency of
invested in delivering a Reconciliation Action         the allied health professions and building the
Plan (RAP), working alongside Aboriginal and           indigenous allied health workforce are key shifts
Torres Strait Islander people. Our RAP delivers        required in making health services work for
on culturally appropriate physiotherapy services       Aboriginal and Torres Strait Islander people. In
to all people. But while we know that all allied       the meantime we need to understand if we can
health services must be culturally safe, and we        impact outcomes by placing the person at the
are committed to achieving this, we also know,         centre of how they choose to receive their care,
through experience, that this is a process that        and ensure that all ACCHS have access to at
will not occur overnight, and that physiotherapy       least one culturally safe physiotherapist.
utilisation by Aboriginal and Torres Strait Islander
people remains starkly below non-indigenous            • Proposed Solution: Provide funding to trial
rates.                                                   the impact of embedding appropriately trained,
                                                         culturally safe physiotherapists into Aboriginal
We believe that community-controlled health              Community Controlled Health services.
service provision plays a critical role in helping       Cost estimate: $2.75 million
Aboriginal and Torres Strait Islander people
identify a recognised culturally safe service. And

                                                                                 2020-2021 Pre-budget Submission • 24
PROPOSED SOLUTION: Increase access to CDM items by providing a no-gap service
for physiotherapy

We believe that the bulk-billing incentive is a step    Strait Islander people who already carry a higher
toward addressing the issue of out-of-pocket            burden of care will go some way toward closing
costs for some Aboriginal and Torres Strait             the gap. We acknowledge that further research
Islander people. However, the scheduled fee             needs to be done to determine the appropriate
would also need to be increased to adequately           number of allied health sessions.
reflect the true costs to service providers to
ensure that all Aboriginal and Torres Strait Islander   In the interim, we recommend that all limitations
people have access.                                     be removed and access to allied health services
                                                        for Aboriginal and Torres Strait Islander people
We call on the government to adopt the same             is uncapped and based on clinical need. We
model applied to other Closing the Gap initiatives,     recommend the determination of clinical need is
such as access to pharmaceuticals, where                made by the treating allied health provider.
there should be a no-gap model for all services.
Increasing the scheduled fee to an appropriate          • Proposed Solution: Enhance utilisation of
level to enable all practices to utilise the bulk-        existing Chronic Disease Management items
billing incentive, which may then enable this to          in the Medicare Benefit Scheme, by providing
occur without incurring a loss.                           a no-gap physiotherapy consultation policy,
                                                          similar to other Closing the Gap initiatives for
Five appointments across all allied health services       Aboriginal and Torres Strait Islander people
is insufficient for people with a chronic disease
or at risk of chronic disease. Increasing the
number of appointments for Aboriginal and Torres

                                                                                  2020-2021 Pre-budget Submission • 25
PROPOSED SOLUTION: Research into underutilisation

It is clear there is a correlation between cost       We call on the government to further investigate
impacts and the utilisation of allied health          the reasons for the low utilisation to ensure a
services for those most in need, however there        comprehensive solution to fully address these
are multiple determinants, beyond cost, driving       barriers and improve access to vital allied health
the inequity and gap.                                 services. We recommend further economic
                                                      modelling be undertaken to enable a fee
We believe that high out-of-pocket fees               schedule that truly represent the costs of
associated with MBS allied health items,              high-quality service delivery.
combined with low access to culturally safe
service, underpins low utilisation. However, this     • Proposed Solution: Provide funding for
area warrants further research to ensure future         research into an evaluation of the barriers
changes achieve the desired impact.                     and enablers to appropriate utilisation of
                                                        physiotherapy by Aboriginal and Torres Strait
While there is a strong understanding of the            Islander people. Cost estimate $150,000
barriers to accessing mainstream services such
as general practice, it is less well understood for
physiotherapy and other allied health services.
Investments in further research are required to
enable fully informed solutions to be developed
and implemented.

                                                                                2020-2021 Pre-budget Submission • 26
Goal: To re-orient aged care services to evidence-based early
interventions, such as physiotherapy, to improve the quality and safety
of care provided

PROPOSED SOLUTION: Development of a ‘train the trainer’ model for Residential
Aged Care providers

The Australian Pain Society report (2018) talks         The goal is to upskill Aged Care workers to
to the increasing burden of pain among elderly          recognise and properly assess the signs of
people in Australian residential aged care facilities   pain, provide safe manual handling, posture and
(RACF), that pain is under-diagnosed and                positioning and supervision of exercise programs.
inadequately managed in RACF’s and that pain            In addition, training would be provided to family
is unnecessary and leads to serious decline in          and carers of residents to empower them to
quality of life.                                        support and facilitate effective pain management
                                                        techniques and to recognise pain and advocate
The National Pain Management Strategic Action           for the resident in relation to their need for pain
Plan includes the following action item, under          management.
Goal 3: To Develop a ‘train the trainer’ model for
Residential Aged Care providers and distribution        It is anticipated that training is offered via face-to-
and dissemination of the existing guidance and          face or video-link across all states and territories.
management strategy documents.                          There is also an option of videoconference training
                                                        for physiotherapists in rural and remote services.
With appropriate funding the APA can develop
a ‘train the trainer’ program for physiotherapists
working in RACF’s to upskill staff and carers
in the complexity of chronic pain and effective
prevention, diagnosis and management of pain.

                                                                                   2020-2021 Pre-budget Submission • 27
Proposed Solution: The Australian National Aged Care Classification (AN-ACC) system
includes a new funding layer for consumer directed wellness and reablement care to be
delivered by allied health

A number of systematic failures in the current          and restorative care in the AN-ACC, this vital
aged care system are contributing to poor               component of quality care will not occur.
quality and safety for older people. These failures
include, but are not limited to, inadequate funding     We believe the proposed AN-ACC funding model
for high quality care, including restorative and        does not include adequate direct incentive to
reablement care.                                        work with the older person to improve their ability
                                                        and quality of life.
There is opportunity to improve the quality of
care provided to older people by embedding              Reablement and restorative care should not
restorative and reablement care as a key support        be considered a ‘nice to have’ addition in the
service. The very nature of aged care support           variable or fixed component of the funding model.
is that they must be considered in the broader          Rather, it should be considered as an integral part
social, economic, environmental and physical            of the proposal.
attributes of the individual’s life – a key pillar of
physiotherapy care.

We believe that an aged care model focussed
on reablement, preventive and restorative care
reflects safe, high quality and best practice care.

Reablement care focuses on strategies
that maintain or improve functional ability
and independence, through maximising an
individual’s intrinsic capacity and the use
of environmental modifiers. Currently lacking in
the Australian policy context is a true reablement      Physiotherapists working to the full scope of
focus and supporting best practice and quality          their practice, which includes restorative and
outcomes for older Australians.                         reablement care, provide not only financial value,
                                                        but also high quality care and improved life
Physiotherapists consistently tell us that the          outcomes for the consumer.
current Aged Care Funding Instrument (ACFI)
precludes physiotherapists from using funding           In a consumer directed care model, where quality
for activities that will provide the best long term     of life and wellbeing of an older person are at the
outcome (best value) for an older person.               centre, funding for restorative and reablement
                                                        care is vital to ensure the best outcomes for each
We acknowledge that the proposed AN-ACC                 older person.
model is an improvement on the ACFI, which
contains a perverse incentive for people to             • Proposed solution: In the Australian National
experience greater pain, disability and frailty to        Aged Care Classification (AN-ACC) system
gain additional funding.                                  include a new funding layer for consumer
                                                          directed wellness and reablement care to be
However, we are concerned that without a carved           delivered by allied health.
out financial incentive for preventive, reablement

                                                                                  2020-2021 Pre-budget Submission • 28
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