Barbell Strategy for NDIS Physiotherapy: Aligning Expertise with Efficiency

Part 3: A Healthcare System in Crisis

The NDIS is a system built on promise but mired in inefficiencies. At its core lies a failure to align funding with patient complexity and practitioner expertise. Instead, it opts for a flat, one-size-fits-all pricing model that undervalues high-level skills and overspends on low-complexity tasks.

It’s not only a waste of talent but a gross misallocation of resources. But there’s a way to fix this: a barbell strategy.

This is part 3 of a 5 part series, if you're just catching up, I'd suggest beginning with our first article, Introducing Absolute Power within the NDIS.

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Aligning Expertise with Efficiency

Nassim Taleb’s barbell strategy is about balancing opposites to build resilience: investing heavily in extremes—one side focused on safety and stability (e.g., low-risk, scalable tasks) and the other on high-reward ventures (e.g., expert interventions)—while avoiding the middle ground, which is typically fragile and inefficient (ie. the NDIS).

In healthcare, this means distributing resources between highly skilled practitioners for critical moments and low-cost implementers for routine tasks, bypassing the inefficiencies of one-size-fits-all models.

The Barbell Physiotherapy Strategy:

This approach strikes a balance between quality care and cost efficiency, ensuring that every dollar achieves maximum impact.

Here’s how it works:

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Expert Physiotherapist:

• These are your architects of care—seasoned professionals who deliver comprehensive assessments, design care plans, and step in during critical moments. Their expertise is used sparingly but precisely, making them the cornerstone of high-value interventions.
• Example: A Titled Neurological Physiotherapist performs a detailed two-hour assessment, creates a year-long care plan, and provides oversight during acute episodes (e.g., post hospitalisation).

Intermediary Physiotherapist:

• Acting as project managers, they bridge the gap between expert planning and ground-level implementation. Their role involves ensuring continuity, identifying escalating needs, and providing moderate oversight.
• Example: A physiotherapist ensures the care plan is followed, adjusts programming as required, and intervenes when participants' needs change (eg. Post a fall at home)

Allied Health Assistant (AHA):

• The boots-on-the-ground implementers. AHAs handle frequent interactions with participants, such as facilitating exercise sessions, tracking progress, and building rapport. While their scope is narrower, they make care both accessible and personable.
• Example: An AHA supports participants in executing their therapy programs, often in group settings, where they can provide both individual and communal benefits.

This trifecta of care is a barbell strategy in action: expertise and efficiency at opposite ends of the spectrum, creating a system that thrives on their synergy.

Value Over Cost: A Practical Illustration

The barbell strategy doesn’t just make philosophical sense—it’s financially sound. Let’s break it down:

• Initial Specialist Assessment: <$1,500

Expert physiotherapist spends 2 hours creating a care blueprint.

• (Optional) Expert Therapy Package: $3,000

Four additional hours of targeted intervention designed for intensive phases.

• Ongoing Needs Management: <$5,500

Split between intermediary physiotherapists and allied health assistants.

• Total Participant Cost: <$10,000 per year

Compared to current NDIS inefficiencies, this model potentially saves up to 50% of funds through shear efficiency of service.

These numbers aren’t hypothetical—they demonstrate how aligning expertise with outcomes can revolutionise funding efficiency.

Every dollar is spent where it matters most.

Revisiting and Redefining Roles

Currently, the system misallocates resources in ways that defy logic:

• Highly skilled physiotherapists are often absent from the system due to capped rates.
• Regular physiotherapists often spend their time doing mundane, repetitive interventions.
• Participants pay $193.99 per hour for tasks that could be delegated to an allied health assistant at $86.79/hour, with proper oversight.

This isn’t a case of blaming practitioners but rather the systemic inefficiency that forces them into these roles.

By redefining roles within a barbell framework, we can address these inefficiencies:

• Experts lead the planning, manage complexity, and step in during critical moments.
• Intermediary professionals maintain continuity and adapt plans.
• Assistants deliver day-to-day care and create personable connections.

This approach works because it ensures every practitioner operates at the top of their scope while participants receive high-quality, efficient care.

Problem 4: Why is a Physio OR an Exercise Physiologist being paid $193.99 to effectively stand next to someone on a treadmill for an hour?

Group Models: A Forgotten Gem

Before the privatisation of community health services, group models thrived. Here’s an example:

• 1 Practitioner. 4 Participants. 1 Assistant. $280/hour (based on current costs).
  • The practitioner oversees group therapy while the assistant supports participants individually.
  • Participants benefit from social interaction and high-value care.
  • Businesses increase efficiency without sacrificing quality.

This wasn’t just theory—it was reality in community health settings until “efficiency-driven” privatisation dismantled the model.

By revisiting such approaches, we can reintegrate collaborative, cost-effective solutions into the NDIS.

Technology as an Enabler

Incorporating technology further strengthens the barbell strategy:

• Telehealth consultations allow titled specialists to manage cases in rural areas, reducing travel costs while ensuring high-quality oversight.
• AI-generated reporting can streamline assessments, freeing up specialists for more meaningful tasks.
• Data sharing platforms can enhance communication among multidisciplinary teams, creating a web of accountability and shared responsibility.
• And this can be integrated into a team based approach, again where local providers are front line beneficiaries of the technical expertise that may not otherwise be available in their areas.

Efficiency Meets Expertise

The barbell strategy doesn’t aim to cut costs, however this is no doubt a side effect of it’s efficiency—it aims primarily to allocate resources where they’re most effective. By using expertise strategically and delegating implementation to scalable resources, we create a system that is both antifragile and compassionate.

The result? Participants receive better care, providers work at their highest scope, and taxpayers see real value for their investment.

It’s time for the NDIS to embrace this model—not as a radical shift but as a return to common sense. The system can be better, leaner, and more effective. All it takes is the courage to rethink the roles we play and the resources we allocate.

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In tomorrow's article we will delve further into The NDIS Bureaucracy, Big Business, and Moneypots.

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Addendum 04/01/2025

Since publishing this article, I’ve received feedback and criticism from colleagues and professionals within the physiotherapy and NDIS sectors. I want to take this opportunity to address some of the key points raised, clarify misunderstandings, and reiterate the purpose of this piece.

1. A Framework, Not a One-Size-Fits-All Solution
This article was never intended as a prescriptive, one-size-fits-all solution to the challenges facing the NDIS. Instead, it aimed to outline a framework for discussion—a starting point to explore how clinical expertise can be aligned with case complexity while appropriately valuing high-level skills.

I fully acknowledge that some cases require one-on-one attention from highly skilled clinicians. The tiered approach suggested here is not a rigid solution but a tool to raise the floor of the system, ensuring participants receive care that is both high-quality and resource-efficient.

2. Clarifying the ‘Treadmill Supervision’ Example
The reference to “treadmill supervision” was intended as a hyperbolic example to illustrate inefficiencies in service delivery—not to diminish the complexity of work undertaken by physiotherapists in the NDIS space.

I deeply respect the nuanced work done by clinicians, from assistive technologies and manual handling to addressing unique participant needs. This article advocates for recognising and valuing that complexity, and I apologise if the example detracted from that message.

3. The Role of APA Service Descriptors
A core goal of this article was to begin defining scope for high-value care. To that end, I used the APA’s service descriptors as a foundation for the proposed framework. These descriptors reflect professional standards and serve as a bridge between clinical expertise and service delivery.

For additional context, I encourage readers to view The Systemic Shortcomings of the NDIS Care Model, where these ideas were initially framed. While this article cannot fully encapsulate the nuances of the NDIS, I welcome further dialogue to refine this starting point.

4. Outsider Perspectives and the Value of Dialogue
Some feedback suggested that only those deeply entrenched in the NDIS system are qualified to propose solutions. While I respect the expertise of those working within the system, outsider perspectives bring a unique value. Stepping back from daily challenges allows for a broader view of inefficiencies and opportunities for reform.

This article was not about claiming ultimate expertise but about contributing to a collaborative conversation that includes diverse perspectives. The NDIS, as a public system, impacts many stakeholders, and discussions about its future should reflect that diversity.

My experience as a practice owner (2018–2023), generating 25% of revenue through NDIS, and as part of the largest physiotherapy provider in Australia during the NDIS rollout, gives me firsthand insights into this system. I continue to work with businesses operating within the NDIS, and this informs my perspectives.

5. Revisiting Tiered Pricing
Tiered pricing, initially proposed by McKinsey during their 2018 review, faced opposition due to concerns about complexity and equity. However, the issues we face today—stagnation, commoditisation, and a lack of differentiation—suggest this topic warrants a fresh look.

An imperfect solution in 2018 may have prevented some of the challenges we face now. Revisiting tiered pricing through robust debate could help the profession align expertise with case complexity and ensure fair valuation for high-level skills.

6. A Conversation, Not the Final Word
This article was written to spark a conversation, not to provide the final word on these complex issues. While the solutions proposed may not be perfect, they aim to provoke thought, raise questions, and encourage collaboration toward a better system.

I encourage readers to engage with this material as an opportunity to challenge entrenched beliefs and perspectives—not as an attack on physiotherapy or its ethical practices.

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Why This Matters:

‍Despite numerous government reports and think tank publications exploring the NDIS, truly actionable solutions have remained elusive. Recent policy changes, such as the removal of Music and Art therapists, have inadvertently harmed participant wellbeing while failing to tackle the system's fundamental inefficiencies. Often, these decisions, although presented as evidence-based, tend to reflect political convenience rather than genuine reform. The strategy of targeting smaller providers to cut costs sidesteps the larger, structural issues at the core of the program.

Over the past decade, the NDIS has evolved into a $40 Billion+ initiative. Yet, it has become synonymous with inefficiency, unethical practices, and fraud. This state of vulnerability demands immediate attention. Meaningful reform is urgently required to protect participant outcomes and safeguard taxpayer investments.

At Culture of One, we hold accountability, transparency, and ethical leadership as paramount for governments, providers, and all stakeholders involved. This series provides a comprehensive exploration of the sector’s challenges and opportunities. It’s not a quick read, but it is a necessary one for anyone committed to understanding and improving the landscape of disability care in Australia.

To receive a copy of the full report when it is published in January, please sign up below.

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