The Systemic Shortcomings of the NDIS Care Model

Part 2A: The Systemic Shortcomings of the NDIS Care Model

This is part two of a five part series discussing the National Disability and Insurance Scheme.

We suggest starting with the original article on Introducing Absolute Power within the NDIS as a precursor to this piece.

The Misdirection of Therapy Budgets

The current structure of the National Disability Insurance Scheme (NDIS) incentivises inefficiencies that not only fail participants but also undermine professional integrity. As a former physiotherapist who has both run a profitable practice and worked directly with NDIS clients, I’ve witnessed this dynamic firsthand.

A typical scenario unfolds when practitioners inherit a patient with a $20,000 capacity building support budget. Instead of tailoring care based on clinical needs, they craft plans that exhaust the available funds, often through unnecessary or excessive services.

This isn’t malice; it’s a systemic flaw. Participants are encouraged to utilise their full budget or risk losing it. Consequently, practitioners find themselves defaulting to pre-allocated spending, often resulting in therapy plans that prioritise volume over value.

The system’s structure inadvertently encourages dependency rather than empowering participants to self-manage and build sustainable health outcomes.

Dependency vs. Self-Efficacy

The twice-weekly physiotherapy or exercise physiology model typifies this inefficiency. Regular sessions that remain unchanged week after week make little sense in facilitating long-term self-efficacy for participants.

While check-ins and bursts of intensive care around specific incidents (e.g., hospitalisation or falls) are clinically sound, rigid twice-weekly sessions can create dependency, stalling progress and inflating costs.

Let’s put it in perspective:

At $387.98 per week, a year’s worth of twice-weekly therapy costs $20,175.

Who else pays this for a service they can largely self-manage with guidance? No one. Yet the system supports it, it’s sub-optimal, but it’s also the path of least resistance.

Non-Clinical Oversight and the Cost of Inefficiency

Adding another layer of complexity is the approval process. Therapy plans are vetted by plan managers and support coordinators with little or no clinical background. This creates a cycle of nonsensical decision-making, where care models are moderated by those unqualified to assess their efficacy. Participants, clinicians, and taxpayers all bear the cost of this misalignment.

Problem 2: The oversight of these programs has been designated to support coordinators and plan managers without clinical expertise.

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“It’s New, The Shape of Your Body It’s Blue, The Feeling I’ve Got…” (Swift, 2019)

Part 2B: Why Expertise Should Anchor NDIS Care Delivery

The Role of Expertise in Complex Care

To address these inefficiencies, we need to involve sub-specialty experts who understand the intricacies of participant needs. As it stands, the capped rates and bureaucratic processes undervalue clinicians’ expertise. Highly skilled practitioners, such as titled physiotherapy specialists or those with decades of experience, are increasingly opting out of the NDIS sector.

The reasons are clear:

• Bureaucracy: Administrative burdens detract from their ability to deliver care.
• Undervaluation: Rates fail to reflect the expertise needed for complex cases.
• Non-Clinical Gatekeeping: Clinical decisions are often subject to approval by non-clinical staff, creating friction and inefficiencies.

This structural failure is not just a waste of talent; it’s a disservice to participants.

Reforming Funding and Valuation in Physiotherapy

The Australian Physiotherapy Association’s (APA) National Physiotherapy Service Descriptors (2018) offer a potential roadmap for reform in physiotherapy. The document underscores the importance of aligning remuneration with outcomes, recognising the variance in expertise, and valuing the complexity of services provided.

"Remuneration for services should take account of the degree to which the service achieved health outcomes – the goal is to optimise health outcomes achieved per dollar spent."  National Physiotherapy Service Descriptors (2018)

Instead of capping rates and spreading funds indiscriminately, we need a relativity-based approach:

• Higher rates for specialist care where complex needs demand advanced expertise.
• Streamlined administrative processes to enable clinicians to focus on care delivery.
• Incentives for self-management and autonomy to reduce dependency and costs.

A System in Need of Structural Reform

The current state of NDIS care delivery exemplifies systemic inefficiency, driven by misaligned incentives and a lack of focus on outcomes. Without fundamental changes to how funding is allocated, care plans are designed, and expertise is valued, the system risks further inefficiencies and diminishing returns. By prioritising expertise, reforming oversight, and embracing efficiency, the NDIS can realise its potential as a world-leading disability support system.

Problem 3:  We have excluded our best clinicians by putting a cap on pricing that undervalues their expertise.

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In Part 3, the Barbell Strategy for NDIS Physiotherapy, we discuss how we can structure this style of therapy, using a Barbell approach.

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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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