Antony

Good afternoon. My name is Anthony Hirst. I'm chair of the National Business Group.

I'm in Cairns for the APA FOCUS26 conference. And I'm here with Jim Zouch. Jim, welcome to the program. Welcome to Cairns.

Jim

Thank you very much. Great to be here.

Ant

Tell our listeners, what have you been studying?

Jim

Okay, so for the last six years, part-time, I've been studying the entry point into the health care system for patients with musculoskeletal problems. So we're looking at the interaction of healthcare providers, patient preferences and then seeing how that influences downstream outcomes. And obviously that wraps in really nicely with, I suppose, the push over the last few years to see if publicly funded physio is a viable option in Australia.  

Ant

So what, from your perspective, the research that you're doing, what are the key drivers that influence someone, whether they go to a physiotherapist or to a GP for care, if they've got a musculoskeletal, you know, pathology or injury?

Jim

So our latest study was trying to answer that exact question to see what drove patient preferences. And unsurprisingly, cost. Cost was the biggest factor that drove patients’ preference for the type of healthcare service they wanted for their musculoskeletal pain. But interestingly, following up from that was waiting time. So patients really valued being seen the same day. They would pay more money to be seen the same day as opposed to waiting a week or two weeks. They valued travelling short distances as opposed to travelling 60 minutes or more. And consultation length didn't seem to be something that really influenced choice. So 20 minutes versus 40 minutes versus 60 minutes wasn't strongly influential of who patients chose for their provider. And then another layer, in terms of the healthcare provider, a negative preference towards seeing a GP, positive preference towards seeing physios, but no real separation when we look at averages between seeing a physio and a specialist physiotherapist.  

Ant

So do you think the average consumer out there understands the difference between a non-titled to a titled to a specialised physio?

Jim

I don't think so. That's a really good question. I think that's an area that we need to work on, so that specialist care might reflect a lack of understanding from the patients, but there are some further analysis we did that would separate specialists out and I'm sure we can get into those.  

Ant

But then in the context of actually setting fees…

Jim

Yes.

Ant

for the average, of course, if there’s such a thing as the average private sector organisation, what has your research told you? Is there a tipping point? Clearly convenience is a factor. You're talking before about, you know, location. And can I get in an appointment when I want one tomorrow, not waiting till next week because I'm in pain or it's a new injury.

Jim

Yep.

Ant

But is there a bit of a tipping point in terms of the setting of fees?

Jim

There is. And there's probably two ways to look at this. 

So I think if we look whole healthcare system, what we did was simulate a current, funded landscape. And we used the Nous Group a little bit to guide our pricing. But essentially we wanted to set prices that wouldn't strongly turn people away from physio either. So we set GPs at $0 out-of-pocket cost. We set them as having 20-minute consultations and a long wait to reflect what we think is representative of GP care. We set physios somewhere in between that, so at $120 for a 40-minute consultation and we set the waiting time as one week. What we found in the current scenario, on average, 62% of the population that we sampled would choose the GP, even though they didn't like GPs as a provider. Cost was a big driver of that. And what was really interesting when we flipped, well, sorry, when we publicly or simulated a publicly funded scenario, so same service attributes that I just described, but physio was set at zero, GP set at $0, that flipped completely. So now the majority of patients would opt to choose a physiotherapist. So 62% would choose a physio, around 20-30% would choose a GP, and the rest would opt out. 

The tipping point where it was equivalent and this is probably not overly supportive of a lot of things, was $35 where this tipping point, where GP and physio services were assumed to be equivalent. So patients were willing to pay $35 more to see a physio, to make that an equivalent choice of between a GP and a physio for their first care, for their MSK care. But there's nuance.

Ant

Yeah, so was that across different socioeconomic sectors and different suburbs and regions of Australia etc?

Jim

To add some, I suppose, some detail to that. We took, we surveyed panellists. So these are people that are paid to fill in panel surveys. But we knew that there is some weakness to taking panel data. So what we did was make sure we benchmarked the demographics against ABS, sorry, the Bureau of Statistics sample data, and they were quite reflective. We were probably underrepresented in people from the lowest socioeconomic areas or, sorry, the lowest earners. And we're underrepresented in people who spoke a language other than English at home. Other than that was pretty comparable to the national demographics. 

But I think what's interesting, and this is maybe where you're getting to is that was averages. So when we looked at averages, yes, there was a preference at the moment that's driven by price to see GP. But when we split the, or we looked at statistically to see if there were distinct groups that would pay different, that have different preferences for their provider, there absolutely was. So as you'd expect, there’s some patients out there that will go for the cheapest option of care. But there were definitely patient groups, in fact, our biggest patient group, were willing to pay a lot more money to get the provider they wanted, so they would pay more money to see a specialist physio over and above a “standard” standard physio and a lot more than they would to see a GP. 

There are groups of patients who would pay a lot more money to be seen the same day. There were groups of patients who, it didn't matter what you kind of threw at them, they were less likely or were reluctant to engage in care. There’s some information about the types of people that might be in those groups. So for example, we labelled it the “big spender class”. They were 30% of the sample. These were the ones that would pay more to see a specialist. They tended to be, unsurprisingly, young, in the highest income brackets, have private health insurance and they've seen a physio in the past. And then now people that were reluctant to engage in care, typically had or relied on Medicare funding, were in the older population groups and perhaps have seen a GP as their last MSK provider. Some of these results are probably unsurprising to the practice owner.

Ant

Correct.

Jim

But it's nice to see the numbers on paper.

Ant

It's nice to have the data to back it up.

Jim

Absolutely.

Ant

We'll sort of come back to that in a minute, but I am interested whether you think, does this sort of back up the research that you've done, back up the APA's advocacy work in relation to trying to get physiotherapy services covered by Medicare more than what it currently is?

Jim

Yes, I would say there's some really good data to support that lever, to pull that lever, that publicly funded physio will shift the majority of patients who currently have a preference for a GP as their MSK provider, which is largely driven by cost, over towards physiotherapists, because we know when we look at averages, patients prefer the physio as their provider. But when you add all the service things together, the waiting time and largely cost, they're going to the GP.  

Ant

But that tipping point of $35 above a GP, correct? And for the research that you were doing, what was the average GP consult?

Jim

So we set the average GP consult in this scenario analysis at $0. So simulating bulk billed, which I appreciate, not all appointments are bulk billed but we set it at $0 and I'm talking out of pocket cost here as well. So not what the government is paying.

We're talking out of pocket cost to the patient.

Ant

Okay. So you've obviously read the Nous report because you used it as part of your research to some extent.

Jim

Yes.

Ant

One of the questions we always get asked, you know, I always get asked is, is there any research to back up whether or not our consumers of our services would actually be comfortable paying what the Nous report says should be charged, whether it's a, I’ll call it a standard physio, for lack of a better term, to a titled, to a specialised.

Jim

Yes. We did that comparison.

Ant

Right. And?

Jim

I’ll add some nuance. So essentially what we did is we had a, again, that simulated scenario, we set physio, as I said before, 30-minute travel distance, waiting time of an appointment within one week. Cost of $120, 40-minute consultation. Just so everyone's aware of the service, we hypothetically created. The specialist, we made it a 60-minute drive to reflect there's probably less specialists out there. We made the appointment 60 minutes to represent they generally take longer. We made the cost $240, which I know is not perfect, but getting towards where that now is report set prices. And I think we made the waiting time two weeks, again to reflect that it's probably going to be more waiting time for a specialist. And these settings are debateable. But that's what we thought was appropriate. And then we compared the two to see what happened on average in terms of choice. At no price point, unfortunately, did patients in our sample choose the specialist over the, again, “standard” physio. So even at the 240 price point, those other attributes, the waiting time, the distance, were influential enough that they were still choosing the standard physio. 

Might be a multitude of reasons for that, including patients’ understanding, because effectively in our survey that they're getting, you have the options of seeing a GP, this is what a GP is. One line. This is what a standard physio is. One line. Our definition of specialist physio was “someone who has specialist training in treating your musculoskeletal pain above and beyond a standard physio”. So this was something we debated over how we would articulate that, but it had to be something that was understandable enough that ran through health literacy software. So patients at a reading level of nine and above could understand it, but it could reflect that, you know, in the general population, people may not know what a specialist is.

Ant

Correct.

Jim

So that's on average.

Ant

You know, look, it's often discussed, you know, the public's perception and awareness about what is a specialist physiotherapist versus a titled versus someone who's not titled or specialised.

Jim

Yep.

Ant

Clearly we need to try and improve the awareness of what is the difference between each ones, and if we do over time, then maybe that would change. But where do you think your research will lead to? What's your hope or your dream that the conclusion, not the conclusion, the findings? Where are you hoping they will lead to?

Jim

I think it gives us a really good stepping stone when we're talking about the healthcare system as a whole to advocate for this publicly funded physio. So I think in my reading and through my PhD, I think we sort of want to position ourselves as an industry that can offload GP workload for MSK pain and the reason being that we know that we have a shortfall of GPs. It's predicted to worsen as our population ages.

Ant

Correct. Yes.

Jim

It’s a problem facing many westernised healthcare systems and probably something that the policymakers are going to listen to. So all we really need to do, I think, as an industry, is demonstrate that we can offload that MSK workload.

Ant

Correct.

Jim

And be no worse. I know that sounds terrible, but be no worse in terms of clinical outcomes. That's all we have to demonstrate. And all of a sudden we free up GP access for complex conditions, we have positive downstream effects in terms of rural access to GPs, as well as any positive effects we get from physio. So if we have better cost effectiveness or timely care, fantastic. But really I think they're secondary.

We just have to position ourselves as a way to offload GPs, and then we put ourselves on the same side of the argument as GPs. It’s not us versus them.

Ant

Yeah, we sort of elevate outside of Allied health.

Jim

Absolutely.  

Ant

Which would be a great outcome if I get to see that in my career.

Jim

Yep.

Ant

But people who are listening to this are going to go, think to themselves, ‘Great, this guy's doing his PhD, I'm happy for him. He's getting this information. I'm delighted for him. It's going to change the healthcare landscape. Great.’ But there’s going to be a cohort out there that go, ‘Well, what does this mean to me in my day to day practice in the suburbs?’ So to speak.

Jim

Yep.

Ant

How do you think the information you're getting and the research findings is going to influence the day-to-day operations of, you know, I'll call that a “traditional”, for lack of a better term, a traditional musculoskeletal clinic in the suburbs.

Jim

Yep, I think what I'd want to say to that is the information that supports publicly funded physio shouldn't be the same information that says we need to race to the bottom in terms of price points and getting patients in, because when we did our analysis to look at these distinct groups, there were groups of people, in fact, the largest group of people, 30% of our sample were patients who were, like I said, motivated to engage in care, highly educated, good income, private health insurance. They were willing to pay for the services that best suited their needs.

And so I would argue they're the patients that probably businesses are already trying to attract and you would keep wanting to attract because they’re the ones who are going to stay with you and they're going to pay for what they want and they're willing to pay for what they want. So I don't think we should race to the bottom in terms of price points. I still think we should be looking at, you know, arguing our case that we are valued healthcare professionals in the musculoskeletal space. I'm just purely, in the other sense, talking about the out-of-pocket cost for the physios in terms of publicly funded. I think that's a separate scenario. So businesses, there are patients out there that definitely are willing to pay, you know, the right price to see you.

Ant

Yeah, I think if there's value there, the consumer, if they see value and feel like they're getting value and value has to come first, I always say. If the value is there, I think the fees that are set by the Nous report will not be a problem.

Jim

Yeah, I would agree.

Ant

There will be a sector of society that will find the value and be quite happy, and they'll accept it. There will also be a sector that won't, but that will be for any services, whether that be health care or any part of the economy, so to speak.

Jim

Yeah. And our research shows that, at least, and again our experiment’s hypothetical and the responses are predicted responses. But we saw groups of patients that wouldn't choose physio. When you offered them public funded physio they still wouldn't choose physio. They're still opting out of care. And they're probably patient that we don't see in private practice a lot anyway, right? So these aren’t the patients that necessarily we are trying to attract, I would say, from a business point of view. There's other people that see value in physio. That's the patients that we should look after.

Ant

And when does your research wrap up, so to speak? When are you anticipating the final thing done, the report completed, packaged, you know, ready to rock and roll?

Jim

Well this is my final study I’m presenting tomorrow and hopefully it's published in the next few months because I've got to submit my PhD next month. And then I'm working as part of a much bigger team on Physio Direct, which is to trial publicly funded physio. That's an NHMRC sponsored trial and we'll be hopefully, if things go according to plan, recruiting our first participant in July 2027 to, yeah, test effectively how well publicly funded physio works.

Ant

I wish you were the best with your PhD. I'm very impressed that you're doing it, and I know you’re close to completing it. And I think the work, the outcome of the report and the evidence there is going to play a significant factor in how the APA advocates to not only the government but to other organisations in relation to getting physiotherapy to, not the masses, but more people than what we currently do in a cost-effective and a sustainable way for the industry. Not a race to the bottom, but a sustainable way. So congratulations and I look forward to hearing the final outcomes.

Jim

Thank you very much. Me too. Cheers.