Sustainability: The Foundation for NDIS Reform

Part 5:  Systemic Failures in the NDIS

This is the final stanza in our 5 part series on the National Disability and Insurance Scheme.

If you're just catching up, I'd suggest beginning with our first article, Introducing Absolute Power within the NDIS.

Physiotherapy Valuation in the NDIS Space

The NDIS, while transformational in its ambition, has inadvertently created systemic inefficiencies in the valuation of physiotherapy. At the heart of this issue are several key failures:

1.        Undervaluation of Expertise
Physiotherapists—especially those operating at the top of their scope—have been grossly undervalued. The capped rates under the NDIS fail to reflect the skill, expertise, and time required to deliver high-quality care for complex participants.

2.        Over-Servicing to Compensate
This undervaluation has driven a culture of over-servicing. Providers are incentivised to compensate for low rates by maximising billable hours, often at the expense of genuine care outcomes. The result is significant cost blowouts and a funding model that prioritises volume over value.

3.        A Need for Specialisation
The current system operates as a volume-based market in a niche field that desperately requires specialisation. Participants with complex needs are often serviced by practitioners operating outside their scope, leading to suboptimal outcomes.

4.        The Barbell Strategy as a Solution
A barbell approach, where practitioners work at the top of their scope while lower tier therapists handle routine tasks, offers a sustainable path forward. This model ensures that participants retain autonomy while the system operates more efficiently.

The Misalignment of Market Forces

Participants seeking quality care often equate the capped rate of $193.99/hour with high-value service. In reality, this rate is insufficient to sustain even a new graduate in a health field, let alone experienced specialists.

This misalignment forces businesses to adopt unsustainable practices:

• Volume-Based Operations: Providers rely on high throughput, often at the expense of care quality.
• SEO-Driven Business Models: Many businesses optimise for online visibility rather than clinical excellence, offering little more than government-funded handouts under flashy brand names.

The lack of oversight compounds these issues, enabling a distorted market that fails both participants and taxpayers.

Recommendations for Reform

Rather than commissioning another 338-page think-tank report, the system needs actionable change. Drawing from the Working Together in the NDIS report, here’s what’s required:

1.        Re-Evaluate Practitioner Valuation
Align funding with practitioner expertise and participant complexity. High-value practitioners should be adequately compensated for their specialised skills.

2.        Adopt a Barbell Framework
Deploy expertise where it’s most impactful—specialists for planning and acute care, intermediaries for oversight, and allied health assistants for day-to-day implementation.

3.        Enable Ethical Business Models
Support ethical SMEs that prioritise patient outcomes over profit margins. These businesses should be the cornerstone of the NDIS, not an afterthought.

4.        Conduct a Comprehensive Review
A full-scale independent review of the system’s financial and clinical inefficiencies is overdue. A leader like Ken Henry could bring the necessary depth and independence to this process.

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The Reckoning Ahead

The NDIS faces a critical inflection point. What was designed to improve access and choice has, in many ways, constrained both.

• Access: Capped rates have driven many quality practitioners out of the system, leaving participants with fewer options.
• Choice: Participants are often left with providers focused on volume rather than quality, undermining the scheme’s intent.

As we face a $40 billion program—nearly half of national hospital expenditure—the stakes couldn’t be higher. Ethical business owners have a unique opportunity to rise above these challenges, attracting top-tier therapists and positioning themselves for a sector-wide restructure.

Meanwhile, unscrupulous providers are shifting to adjacent markets, where undoubtedly the rorting of participants in these schemes will continue. This exodus will also create further instability in both sectors, as oversupply in alternative markets (such as Home Care Packages) drives prices down and creates challenges for those genuinely engaged in the process.

Sustainability As The Foundation

The NDIS can no longer afford inefficiency and mismanagement. Reforming physiotherapy valuation and service delivery is not just a financial imperative—it’s a moral one. By adopting a barbell strategy, incentivising quality care, and supporting ethical providers, the NDIS can fulfill its promise to Australia’s most vulnerable.

The reckoning is here.

For the genuinely ethical business owners, it’s an amazing opportunity.

For the unscrupulous...

it's ooh, woah. It’s a Cruel Summer.

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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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