PHI natural therapies reform
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Further to our earlier communications about private health insurance reform relating to Pilates, the Department of Health has appointed an expert panel of advisors for its 2019-2020 review of the rebate for natural therapies.
The role of the advisory panel is to provide advice to the Chief Medical Officer, Professor Brendan Murphy, about the 16 excluded natural therapies and any additional evidence of their clinical effectiveness published since the original 2014-15 review.
Two physiotherapists have been appointed to the panel, neither of whom is an APA member. We are disappointed that the APA’s recommendation was not taken up and will address this at a meeting with Minister for Health, the Honourable Greg Hunt, this week.
Further details about the advisory panel members and its terms of reference can be found here.
We are very aware that this issue remains contentious and confusing for many of our members, and we wish to assure you that we are actively pursuing clear and consistent guidelines for the continued use of Pilates-informed physiotherapy for individuals, groups and classes.
We urge members to use the APA as their credible source of information and thank you for the trust you have placed in us to do this work. We know this issue affects a significant proportion of our membership and we are looking to reach a satisfactory outcome for you.
The issue
In 2017, the Federal Government announced its plans to make certain natural therapies ineligible for private health insurance rebates. Among these was Pilates. The Government’s original position was that Pilates would not be rebatable, regardless of who delivers it or how it is delivered.
Department of Health Private Health Insurance Circular
The steps we are taking
We have negotiated with the Department of Health and Private Health Insurers for a more reasonable and tenable position on Pilates for physiotherapists. Through our advocacy, we have reached this position:
The Department considers that an insurer may lawfully pay benefits if a physiotherapist, providing services to a patient within the accepted scope of clinical practice, uses exercises or techniques drawn from Pilates as part of that patient’s treatment as long as the exercises or techniques are within the accepted scope of clinical practice.
However, if a physiotherapist (or any other health professional) conducts a Pilates session – either advertised or promoted as such, or a session where the only service provided is Pilates exercises – then benefits cannot lawfully be paid.
How this helps
As long as your practice is performed within the scope of physiotherapy, it does not need to change. It should be underpinned by individualised assessment, treatment and follow-up, and backed by thorough notes. The Department and private health insurers agree that physiotherapy is physiotherapy, and therefore fundable through private health insurance. Be mindful of our guidance on note-taking and the way you promote your treatments, sessions and classes.
Tools and resources
Changes to private health insurance – consumer flyer
APA member case studies
Holly Brasher, APAM
Sydney-based sports physiotherapist and Square One Director Holly Brasher says the PHI natural therapy reform will improve Pilates-informed physiotherapy through a renewed focus on assessment, monitoring and outcome measures. While she won’t be changing how her classes are run, she has reviewed her practice processes. And it’s all for the better, she says. Read about the steps she has taken to be prepared for the natural therapy reforms that take effect on 1 April.
Jennifer Guest, APAM
South Australian-based physiotherapist and former president of the Pilates Alliance of Australasia, Jennifer Guest, APAM, says she is fighting for the physio brand. The APA SA branch council member says she is well prepared for the changes to PHI rules – after 18 years’ involvement in Pilates. Read about how Jennifer is preparing for the natural therapy reforms.
Rachel Combe, APAM
Physio Pilates Proactive Director Rachel Combe, APAM, says rebates will not be available for preventative Pilates sessions including 50-60 weekly mat classes and reformer classes at her three practices from 1 April. 'The majority of the clients have been supportive of us as a small business. They say: "We will keep coming".' Read about how Rachel is preparing for the natural therapy reforms.
Craig Phillips, APAM
APA Sports and Exercise Physiotherapist and Pilates expert Craig Phillips says PHI natural therapy reforms will have little impact of practices treating patients with chronic long-term conditions. Find out how Craig is preparing for the changes here.
John Contreras, APAM
Melbourne-based APA Sports and Exercise Physiotherapist John Contreras believes PHI Pilates reform will help differentiate the profession’s expertise from other health and fitness professionals. Read John's interview here.
Frequently Asked Questions
It’s important to understand that the Department of Health – not private health insurers – introduced the review of natural therapies in its campaign to remove rebates for low-value care. Private Healthcare Australia has been very supportive of physiotherapy.
Physiotherapy is recognised by all parties as high-value, evidence-based care. Therapeutic exercises delivered by physiotherapists are still eligible for rebates.
The Department of Health chose to include Pilates in an effort to reduce the cost of private health insurance. The National Health and Medical Research Council (NHMRC) conducted the Natural Therapy Report on behalf of the Department of Health.
The NHMRC assisted in the assessment of submissions and supervising the evidence review. Submissions and evidence reviews were considered in the context of the NHMRC’s Additional Levels of Evidence and Grades for Recommendations for Developers of Guidelines.
Service descriptors have not been impacted by the PHI reforms. You can continue to claim item code 560 and 561 where the private health insurance company allows it. You can continue to claim on 593, 595, 596 for pelvic, post and ante natal sessions if you are providing clinically justified treatment reflected in your notes and not called Pilates.
All parties have agreed that physiotherapy is physiotherapy. This presents a great opportunity to market our profession and its evidence-based effectiveness even further.
It is up to individual practices to decide on what to call their sessions. You might consider using the term 'group physio'.
The APA will highlight approaches being taken within the profession in the coming months.
The Department of Health does not differentiate between Pilates and clinical Pilates and has removed rebates for sessions that are solely Pilates. Therefore rebates will not be paid for clinical Pilates and clinical Pilates should not be referenced in your clinical notes. All parties have agreed that physiotherapy is physiotherapy, and your physio exercises classes can include exercises drawn from Pilates but must not consist solely of Pilates.
You might tell clients that your Physio sessions are a mixture of clinically appropriate exercises, which may include exercises delivered on Pilates equipment or exercises drawn from Pilates that target their particular needs.
Physios deliver these exercises within an evidenced-based and therapeutic framework, rather than purely for fitness.
The reform does not impact the basis of good physio practice, which includes regular assessments and adjustments to treatment plans based on clinical reasoning and justification. You should continue to assess your patients on a case-by-case basis. Some private health insurers require at least yearly reviews.
Receipting, like all advertising and promotion of sessions, should reflect that they are physio exercise classes and not Pilates. This presents a great opportunity to market our profession and its evidence-based effectiveness even further. All billing and receipting should reflect the correct item codes.
Your clinical notes must reflect the treatment provided. Under the Rules, sessions that are solely Pilates are not eligible for rebates. Therefore, notes should not reference Pilates. Your notes should reflect your physio exercise sessions and the individual exercises prescribed to your patients.
Yes, but you cannot claim for them.
Yes, but you can only claim for Physio sessions, not Pilates.
There is no urgency to consider rebranding your business. The most important steps to compliance with the new PHI rules from 1 April are:
- conducting assessments, monitoring patients and catering for their individual needs in all settings
- ensuring sessions do not consist solely of Pilates-informed exercises
- not scheduling Pilates sessions in your systems, social media, website or printed material
- taking clinical notes that reflect Physio exercises, not Pilates.
The reforms take effect on 1 April 2019 and you have until then to adjust your advertised timetables and advise your patients.
Physios who are already meeting their obligations as clinicians - such as suitable screening, assessment and record keeping - will continue to be compliant with PHI rules as long their sessions do not solely consist of Pilates exercises and are not scheduled as Pilates.
While the APA does not believe the methodology used in the review to be the best approach, there is little other evidence that we are aware of to support Pilates at this stage. As in many areas of physiotherapy, more data and research is required. The APA continues to support all research into physiotherapy that strengthens our evidence-based profession.
The reform acknowledges that while Pilates-informed exercises have a role in physiotherapy, physiotherapy is physiotherapy. This strengthens our profession, gives us a point of difference and an opportunity to market physiotherapy.
The APA has had lengthy discussion with the Department of Health and Private Healthcare Australia. We successfully reversed an initial decision to rule out rebates for Pilates-informed exercises delivered by physiotherapists.
With political focus on reducing the cost of private health insurance and removing rebates for non-evidence based practices, there is no indication that reforms will be reconsidered in the near future.
The APA successfully negotiated that physiotherapists can continue to claim rebates for Pilates-informed exercises within their scope of practice on the basis that physiotherapy is physiotherapy. Our understanding is that other professions do not have the certainty about the new rules that our profession does and they are interpreting the rules as they see fit.
Yoga is not eligible for PHI rebates at all. Physiotherapy practices can continue to offer yoga without claiming PHI rebates.
The APA will provide you with information about preparing for the reforms in the lead up to 1 April, including:
- physios on Pilates Reform case studies highlighting what individual physios are doing to comply
- regularly updated FAQs on our website addressing key questions as they arise
- a consumer-focused pamphlet explaining the reform to patients that will be in the April issue of InMotion and on our website
- a member-focused brochure that will be mailed out in March and inserted in InMotion magazine in March
- an information webinar by physios on how they are adjusting to the change
- interviews with physios will be published in our In Motion magazine in March and April.
The APA will continue talking to members to understand your views. We are also actively continuing to engage with the government and the PHI industry to assist with reforms and protect the role of the physiotherapist in our community.