We influence decision making on the structure and funding of physiotherapy services in Australia
Our advocacy centres on reforms to strengthen the primary care system and improve equity of access to essential care for all Australians through affordable high-value physiotherapy.
We call for action at national, state, and local levels to deliver improvements in population health through value-creating solutions encompassing physiotherapy. To guide our policy decision making, we have curated two evidence-based pieces:
- Economic Value of Physiotherapy in Australia – the landmark analysis of physiotherapy interventions in the Nous Group-led report is a key advocacy tool. It provides a robust analysis of the high-level impact and economic benefit that physiotherapy services can provide to the health care sector.
- Future of Physiotherapy in Australia – our white paper that lays out a transformative reform path.
We recommend solutions with a focus on key reform areas — from easily realised fixes to more complex reform components. In tackling the major system issues, the key pathway to reform lies in lifting the current barriers to enable service integration and collaborative models of care.
Below outlines our targeted advocacy.
National Healthcare Reform
The APA provides governments with recommendations to improve the value of health care and drive better health outcomes.
Our reform recommendations to Strengthen Medicare call for (click the title for more information):
- Improvements to the patient pathway – Removing structural barriers that make it harder to access necessary care.
- Utilisation of the full value of physiotherapy in primary care – Investing in new publicly funded physiotherapy treatment pathways to meet patient needs.
- Urgent care reform at the primary and acute interface – Improve access to care through reform at the primary and acute care interface that sees publicly funded First Contact Physiotherapy as part of the Urgent Care Clinic trial.
- Establishment of new models for preventative health treatments – remove inequities in access for in-need populations and reduce the long-term cost to the health system through early invention.
- Reform of MBS for chronic disease and pain-related items – New funding to drive new models of care for chronic pain prevention and management.
- Long Covid – Prioritise access to physiotherapy through a long COVID rehabilitation pathway.
- Payment model reform – moving to a value-based healthcare system that improves patient outcomes.
Strengthening Medicare Taskforce report
The Strengthening Medicare Taskforce report was handed to the government on 3 February 2023. The Taskforce was established to provide a vision for the primary care system and recommend top priority improvements to address the problems within it. The APA has developed a position statement in response to the report outlining the successfully addressed elements and missed opportunities to outline implementation requirements for the 2023-24 Federal Budget in the report.
1. Improvements to the patient pathway
The referral system to specialist care must be better aligned to patient needs. Physiotherapists are experts in the diagnosis of musculoskeletal conditions. Their existing scope includes ordering tests and making referrals, but restrictive Medicare Benefits Schedule (MBS) rules limit this in practice. For the patient, this results in increased costs, time delays, and potentially delayed access to essential care. We want these barriers removed to improve the patient journey and ensure value-based care at a lower cost to the health system.
Actions we are calling for:
- Allow physiotherapists to directly refer patients to orthopaedic surgeons within their scope of practice.
- Expand medical imaging rights for physiotherapists across a range of modalities.
How this helps
Removes a key obstacle to patient care of structural inefficiencies by shifting to specialist referrals and expanding medical imaging rights for physiotherapists.
Relevant documents
- APA Federal Pre-Budget Submission 2023-24
- Dec 2022 Media Release – Physiotherapists identified as key lever to improving outdated healthcare system
2. Full value of physiotherapy in primary care
Faster treatment, better outcomes and lower costs are required to meet Australia’s current and future health care needs.
New measures are needed to improve access to essential care, reduce out-of-pocket costs and, most importantly, reduce costly and inefficient treatments. A more cost-effective system and better health outcomes will happen if patients are treated by physiotherapists in primary care settings.
The absence of publicly funded access to physiotherapy primary care means patients are missing out on better and faster access to diagnosis and treatment of musculoskeletal (MSK) pain and conditions. This is particularly critical for the seven million Australians who live with a MSK condition.
Actions we are calling for:
We want more investment in publicly funded physiotherapy to enable patient access as part of a multidisciplinary team. Having physiotherapists in primary care, it creates a needed integration of prevention into the management and delivery of care.
- A defined role for physiotherapy in primary and community care by investing in the publicly funded First Contact Physiotherapy model.
- Funded physiotherapy to be prioritised in Urgent Care Clinics.
- Funding to drive new models of care for chronic disease, chronic and persistent pain, and injury prevention and management.
- Investment at the interface of primary and acute care to relieve pressure on the health care system.
- Prioritised access to physiotherapy through a long COVID rehabilitation pathway.
How this helps
These measures will improve access to essential care, reduce out-of-pocket costs, relieve demand on our emergency departments and, most importantly, reduce costly and inefficient treatments.
Relevant documents
- APA Federal Pre-Budget Submission 2023-24
- March 2023 Fact Sheet – Publicly Funded First Contact Physiotherapy
- December 2022 Media Release – Physiotherapists identified as key lever to improving outdated healthcare system
- July 2022 Position Statement – Long Covid
3. Urgent care reform at the primary and acute interface
Urgent Care Clinics (UCCs) are part of a $2.9 billion package announced in the Albanese Government’s 2022-23 Budget to rebuild Australia’s primary health care system, take pressure off hospitals, and increase affordability and access to care for all Australians.
UCCs are a significant and necessary step in reforming the health care system. The provision of bulk-billed urgent medical care will ensure that families can see a doctor without needing to visit overburdened hospital emergency departments. However, to meet community demand and reduce unnecessary ED presentations UCCs must incorporate physiotherapists.
Actions we are calling for:
We want more investment in publicly funded physiotherapy to enable patient access as part of a multidisciplinary team. Having physiotherapists in primary care, it creates a needed integration of prevention into the management and delivery of care.
- A defined role for physiotherapy in the UCC rollout.
- Incorporate a trial of funded First Contact Physiotherapy within UCCs.
- Develop a new pathway to activate multidisciplinary rapid response teams to support older people in the community with emergency help.
- Prioritise funding for post-acute and transition care in the home or community setting and where physiotherapy has a leading role in recovery.
How this helps
Physiotherapy treatment is key to ensuring the continuity of care across the primary and acute care interface. The investment of UCCs nationally will alleviate GP workload and divert non-life threatening emergencies to the ED.
Incorporating publicly funded First Contact Physiotherapy, as part of the UCC trials, will have key benefits for patients and the health system in the form of cost savings and better utilisation of resources, including the health workforce.
Relevant documents
- APA Federal Pre-Budget Submission 2023-24
- January 2023 Position Statement – Physiotherapy in Urgent Care Clinics
4. Preventive health
Health reform must focus on prevention, which requires fundamental changes in the way health care is delivered.
The prevalence of chronic disease has increased, with the majority of the disease burden caused by dementia, cancer, cardiovascular diseases, musculoskeletal conditions, and mental and substance disorders. It is estimated that about one third of this disease burden could be prevented by reducing modifiable risk factors, such as obesity and physical inactivity.
We need to shift towards new preventive health models by focusing on health promotion. This could include the social and cultural determinants of health, physical activity, diet and exercise, injury prevention, health literacy, and secondary prevention in chronic disease and disability management.
We call for the accelerated establishment of new preventive health models across priority populations to reduce disparities in health and its determinants. Priority populations stand to benefit the most from physiotherapy-led prevention. The first step involves gaining access to affordable health care.
Actions we are calling for:
We want more investment in publicly funded physiotherapy to enable patient access as part of a multidisciplinary team. By having physiotherapists in primary care, it creates a needed integration of prevention into the management and delivery of care.
- Increased funding for preventive health to five per cent of the total health budget as outlined in the National Preventive Health Strategy 2021-2030.
- Investment in new physiotherapy-led preventive health models across priority populations. This includes priority funding for:
– Falls prevention: Fund physiotherapy-led falls prevention at home and/or in the residential aged care facility. Falls are the leading cause of preventable deaths in older people.
– Dementia care: Fund preventive physiotherapy-led physical therapy to delay symptom onset and maintain physical and emotional health for as long as possible.
– Mental health: Fund referral pathway to physiotherapy for mental health patients experiencing physical pain, a low mobility issue, or any physical impairment. - Expand access to funded physiotherapy for people at risk of developing chronic disease and pain through relevant MBS items to encompass physiotherapy as a preventive health service.
How this helps
More money is spent on musculoskeletal disorders, such as osteoarthritis and back pain, than any other disease, condition or injury in Australia – representing the highest health spend at $14 billion.
The National Preventive Health Strategy emphasises the importance of physiotherapy in prevention over the lifecycle, and points to physical inactivity as a key determinant of developing cardiovascular disease, diabetes, breast and colon cancer, mental health conditions, experiencing falls and musculoskeletal conditions. Physiotherapy plays a key role in preventing or reducing the length of hospitalisation through prescribing tailored physical activity to prevent and/or manage these conditions.
Relevant documents
- December 2021 Media Release – Physical activity prioritised as part of new preventive health strategy
- September 2020 Submission – Department of Health National Preventive Health Strategy consultation
5. Chronic disease and pain
Chronic disease and injury dominate the total burden of disease in Australia. Along with the rise in chronic conditions, we are seeing an increase in the number of people experiencing a disability, either temporary or permanent, which has an impact on their physical capacity and/or mobility. Pain underpins much of the chronic disease and injury burden, with up to 80 per cent of Australians missing out on treatment that could improve their health and quality of life.
Actions we are calling for:
We are working with the government to ensure patients have access to the care they need and to bring savings and efficiencies in primary care.
The five consultations currently available under Chronic Disease Management (CDM) Plans have never been enough to provide comprehensive care. We want the number of sessions available to patients increased to expand access to physiotherapy. The Medicare Benefits Schedule Taskforce Review was an opportunity to modernise the health system and address inequitable access to CDM and quality pain care. The review’s recommendations provide evidence-based savings and efficiencies in primary care, and it’s time to implement them.
- Funding to drive new models of care for chronic pain prevention and management.
- Expand MBS chronic disease and pain-related items encompassing physiotherapy.
- Physiotherapy services to be prioritised in the new First Nations health clinics to strengthen chronic disease treatment and rehabilitation.
- A funded trial to embed appropriately trained, culturally safe physiotherapists into Aboriginal Community Controlled Health Services.
- Comprehensive clinical assessment and targeted funding for physiotherapy across settings to prolong independence and manage the physical and cognitive symptoms of chronic disease.
- Provide patients experiencing Long COVID with funded access to physiotherapists as part of a multidisciplinary care team.
- Fund integrated care clinics to include qualified physiotherapists, who play a vital role in treating patients with conditions affecting the heart and lungs and who specialise in chronic respiratory and other long-term conditions.
How this helps
Physiotherapists are at the cutting edge of developing better treatments for chronic health conditions and chronic pain, including back pain and osteoarthritis, and for patients with movement disorders and neurological conditions. For the more than 11 million Australians who live with one or more chronic health conditions, receiving team-based primary health care, including access to physiotherapy, is vital for the management and prevention of future health problems.
Relevant information
- October 2022 Media Release – Chronic low back pain is common and often complex – physio can help
- July 2022 Media Release – Preventative health reform key to reducing Australia’s disease burden
- June 2019 Media Release – National Strategic Action Plan for Pain Management calls on coordinated team approach and MBS funding to tackle chronic pain
6. Long COVID
The coronavirus pandemic disrupted health care by reducing supply and increasing demand. This plunged our health care system into crisis, intensified by the pandemic-fuelled burnout of our health workforce, and drained our system of vital skills and expertise.
We now need to adapt our health system for the decade ahead and this begins with recognising that COVID-19 has not left us, and that we have a growing issue of long COVID in the community.
Actions we are calling for:
The role of physiotherapists during and after this pandemic is vital. Greater integration and increased investment in physiotherapy are required to manage the ongoing impact of long COVID, and we need to advance pathways to COVID recovery, including ensuring access to publicly funded physiotherapy.
Physiotherapy must be funded to support patients throughout the patient journey, from admission through to rehabilitation, and across a range of settings — in hospitals and acute settings, in the home and in the community. We want MBS and PBS benefits, which adequately support patients living with long COVID and other safety net measures, to reduce out-of-pocket costs. And we also want to see Primary Health Networks properly funded to support integrated care models beyond general practice.
How this helps
Across the world, physiotherapists are working within multidisciplinary teams, supporting patients to recover their mobility and assisting them to pace through their fatigue. Cardiorespiratory physiotherapists, who treat patients with conditions affecting the heart and lungs, are working on rehabilitation and recovery programs. Australia is yet to adopt best practice for long COVID.
Multidisciplinary collaboration will be essential to provide integrated care for patients presenting with post recovery symptoms and comorbidities following COVID infection. A fully funded multidisciplinary integrated care pathway response, similar to the approach to other chronic conditions, will be required.
Relevant documents
7. Payment model reform
In January 2023 Health and Aged Care Minister, Mark Butler, indicated the Government will reform Australia’s Medicare system and decrease the reliance on the fee-for-service patient rebate system.
The current fee-for-service model encourages throughput and separate billing for healthcare services. There is, in many ways, a perverse incentive that rewards volume over value and therefore increases inequities and barriers to access appropriate health treatments. Fee-for-service also directs patients to general practice to obtain referrals for rebated musculoskeletal problems, a system which is ineffective, inefficient and can delay patients’ pathways to the most appropriate health practitioner.
Australia’s Medicare system has reached its use-by date, and we support new models of funding healthcare that incorporates physiotherapists working to their scope of practice.
Actions we are calling for:
- Reform that redesigns the health system around patient need, experience, and effective outcomes measurement.
- New models that support collaborative commissioning to deliver integrated, value‐based health care in hospitals and the community.
- More local engagement in the design of models of care that address specific needs including in rural health.
- Digital health systems that connect patients to vital care and strengthen preventive healthcare, improve quality of care, and reduce costs.
There are a range of mechanisms and approaches to funding healthcare and reforming Australia’s primary care system. We acknowledge that every funding model presents defined benefits but also disadvantages and disincentives. This is why we support a mix of models and approaches in Australia’s distinctive context: an enormous landmass and highly urbanised population that makes the provision of universal health care uniquely challenging.
However, all systems must be designed around patients, not clinicians. Moving to value-based healthcare models will be an expensive and lengthy process, but we cannot continue funding the existing Medicare system and expect it to meet the needs of the current and future population.
The APA supports the ‘Quadruple Aim’ as a framework for reform and this should serve as a framework to optimise healthcare system performance:
- Improved patient experience.
- Better health outcomes.
- Lower cost of care.
- Improved clinician experience.
How this helps
The fee-for-service model acts, in many respects, as a barrier to value-based care. It also silos health providers for most people – this can and does make diagnosis and treatment inefficient, overly lengthy, and costly to the patient. The model disincentivises preventive health and impedes team-based, connected care between practitioners. The concept of patient-centred holistic healthcare is often unachievable in a funding model that rewards single-visit payment for consultations.
Private health insurance
The Government invests $11 billion in private health insurance (PHI) each year. More than half of the population has private insurance — about 13.6 million people. Australian Prudential Regulation Authority (APRA) figures show that in the year to June 2020, 56,000 Australians aged between 20 and 49 abandoned their cover.
The industry continues to face the challenge of falling membership among younger people and growing membership in older age groups. The key reforms needed are incentives for health insurers to provide better models of insurance cover that minimise out-of-pocket expenses, and allow patients to access preventive and early intervention physiotherapy treatments when required.
Actions we are calling for:
1. More choice:
- Ensure patients have the right to choose, where, when and how they see a physiotherapist of their choice.
- More physiotherapy services to be included in the product offering.
2. More afforable care:
- Create funding models that minimise out-of-pocket expenses across both preventive care and early intervention treatments.
- Provide strong incentives through regulation if necessary to ensure that rural Australians have an equivalent access to care.
3. More prevention:
- Facilitate a stronger focus on maintenance of health, by funding prevention programs that work.
- This includes broadening focus to reduce hospitalisations by expanding chronic and complex disease management.
4. More service options:
- Facilitate more access to home-based care and out-of-hospital health services.
- Expand access to mental health services encompassing physiotherapy to provide the team-based care needed to keep people healthy.
- Allow the adoption of new digital health modalities that are safe, cost-effective and promote continuity of care.
5. More out-of-hospital care:
- Lift current restrictions to replace inpatient care with lower-cost out-of-hospital services, where the same or better care is available.
- Expand models to include pre-operative care to prepare patients for procedures such as knee surgery or after-hospital rehabilitation care.
How this helps
Achieving reform in PHI is reliant on a recognition of the benefits that physiotherapy-led interventions deliver to patients and health providers. Physiotherapy can help make PHI simpler and more affordable. Improving efficiency of health care through a shift to more preventive interventions is a solution to the premium pricing pressures. It will also produce significant savings by reducing hospital admissions and unnecessary procedures.
Patient pathways direct referrals
Our current system leaves people waiting too long for referrals and the care they need—a key reform fix lies in addressing the structural barriers to patient care by shifting to specialist referrals to orthopaedic surgeons and expanding medical imaging rights for physiotherapists.
Fixing the patient journey means removing the obstacles that hinder access to the right care. We must remove health system barriers that lead to inefficient care—and this means addressing structural governance and funding inefficiencies. The restrictions on MBS subsidies impact the patient pathway and lead to significant opportunity costs. For the patient, this means increased costs, time delays and potentially delayed access to essential care. These barriers can be easily removed to ensure value-based care and a better patient journey, at a lower cost to the health system. Models facilitating direct access to physiotherapy have proven effective, with lower rates of referral to imaging due to the high level of expertise in clinical examination of people with MSK conditions.1 Advanced musculoskeletal physiotherapists are less likely to order imaging2 and have high accuracy in clinical assessment.3
Towards a new and more efficient patient journey
Reform is needed to:
- Allow physiotherapists to directly refer to orthopaedic surgeons within their scope of practice.
- Expand medical imaging rights for physiotherapists across a range of modalities.
- Modernise My Health Record to enable full participation by physiotherapists and accelerate interoperability with practice management systems.
The APA is calling for:
- An amendment to Medicare Benefits Schedule—Note GN.6.16 on Referral of Patients to Specialists or Consultant Physicians to allow physiotherapists to directly refer patients with musculoskeletal conditions to orthopaedic surgeons.
- Medicare physiotherapy referral rights across a range of MSK imaging items
Report
The Nous Group has conducted a cost–benefit analysis of physiotherapist direct referral to specialists and imaging that shows the positive impact of the policy change on the patient journey, with efficiencies for the health system that would generate $160 million in savings.
Read the report, see: Direct patient pathways for physiotherapy (PDF)
References
1 Babatunde, O., Bishop, A., Cottrell, E., Jordan, J., Corp, N., Humphries, K., et al. (2020). A systematic review and evidence synthesis of non-medical triage, self-referral and direct access services for patients with musculoskeletal pain. PLoS One, 15(7).
2 Peter Schulz, P., Prescott, J., Shifman, J., Fiore, J., Holland, A., Harding, P. (2016). Comparing patient outcomes for care delivered by advanced musculoskeletal physiotherapists with other health professionals in the emergency department—A pilot study. Australasian Emergency Nursing Journal, 19(4), 198–202.
3 Jibuike, O.O., Paul-Taylor, G., Maulvi, S., et al. (2003). Management of soft tissue knee injuries in an accident and emergency department: the effect of the introduction of a physiotherapy practitioner. Emergency Medicine Journal, 20, 37–39.