Making markets work for disability services: The question of price setting

We have recently been doing some work writing papers from a data set we gained through working with National Disability Services in a national survey they do with providers of disability services.  We have recently published a paper from this data that explores issues relevant to price setting.  This paper was written just before the price increase that was announced at the end of March.

The abstract is below and the full article can be found here.

Personalisation schemes and associated markets for social care have been a growing trend in industrialised countries over recent decades. While there is no single approach to marketisation of social care and personalisation, often funds are devolved to clients of care services to be used to purchase services directly from market. Such arrangements are vulnerable to market failures and ‘thin’ markets, causing the need for stewardship of the social care markets. We present findings from a 2018 survey of 626 care service providers in the Australian National Disability Insurance Scheme market on their experience of market conditions. Over 46% of respondents listed ‘addressing pricing’ as their top action for addressing market problems. Qualitative findings show that central price setting is detached from service delivery realities, affecting service quality and capability building potential. We argue that devolution of price setting to, or at least flexibility and discretion at, the local level is likely to be a key to solving pricing dilemmas in personalisation schemes.

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Here’s what needs to happen to get the NDIS back on track

The Conversation


More than 277,000 people have already benefited from the NDIS, but there’s room to improve. From shutterstock.com

Helen Dickinson, UNSW

In one of his first official public remarks since being re-elected, Prime Minister Scott Morrison pledged that addressing failures in the national disability insurance scheme (NDIS) would be a priority for the new government.

Stuart Robert has assumed the role of minister for the NDIS and will be charged with delivering on this important agenda.

So what does the new minister need to do to get the NDIS back on track?

There is much that the NDIS has done well. Just over 277,000 people have already accessed the scheme and this is set to rise to 460,000 at full roll-out in 2020.

Some scheme participants report greater choice over support workers, access to new services and technologies,and generally strong satisfaction rates.


Read more: Explainer: how much does the NDIS cost and where does this money come from?


Alongside these positives are a number of concerns about the scheme and areas that need improvement.

The development of the NDIS is a massive undertaking; such schemes take time to get right and inevitably face a number of teething issues. But in recent months, the number of challenges has grown and the calls for change have become louder.

Every Australian Counts, the grassroots disability advocacy group that campaigned for the introduction of the NDIS recently released a statement arguing:

The problems with the NDIS must be fixed so people can finally get the support they desperately need. Too many people are falling through the cracks and not getting essential help. The scheme is not working the way it was intended to.

Long waits for services

Many of the problems with the scheme relate to the time people have to wait – either to receive a plan, to activate it, or to have it reviewed.

In 2018, the Commonwealth Ombudsman investigated the NDIS’s handling of reviews on the basis that around one-third of all complaints it received about the scheme related to this issue.

This system was judged “unapproachable” and “lacking in fairness and transparency” and leading to delays of up to nine months to receive an outcome.


Read more: The NDIS is delivering ‘reasonable and necessary’ supports for some, but others are missing out


The Coalition addressed some of these issues in its election promises around the NDIS.

It committed to introducing an NDIS Participant Service Guarantee. This would set timeframes for participants to receive an access decision, and have their plan approved or reviewed.

This, the Coalition promised, should reduce the time taken for people with disability to access the NDIS and have their plan approved and implemented.

There is also a commitment to introduce a single point of contact for the NDIS and to allow those with a “stable” disability to opt into a three-year plan, rather than being reviewed every 12 months.

These developments have been welcomed by those who have experienced significant delays in having plans approved, executed or reviewed – delays that often lead to significant personal and family costs.

Yet the minister will face a challenge in terms of how to deliver on these promises.

Staff shortages

The National Disability Insurance Agency (NDIA) is the independent statutory agency charged with implementing the NDIS. One of the challenges it has faced is limited staff to drive these changes.

In 2014, a staffing cap was placed on the NDIA, restricting the numbers employed to 3,000. Although the government has committed to increasing the cap gradually to 3,400 in 2020-21, it will be a challenge to deliver on this bold agenda with a limited workforce.


Read more: Why more investment in the NDIS may not boost employment


The Productivity Commission has previously criticised the pace of the roll-out of the scheme, arguing it is taking place too quickly for the volume of resources available to the NDIA.

The NDIA received significant criticism for spending over A$600 million in 2017-18 on consultants, contractors and outsourced staff.

Continuing to spend significant amounts of money on consultants may put pressure on future NDIS budgets.

But it will be challenging for the minister to avoid using consultants and outsourced staff to help fill this workforce gap.

The ableism elephant in the academy

A new paper I am involved in has just been published by Disability and Society and written with a bunch of amazing scholars at the University of Sydney. In this paper we explore issues of ableism within universities. We argue that little attention has been paid to how we can support people with disability to develop their careers as researchers. I have written previously about issues relating to gender in academia and I think that this is an area that is even more neglected.

When we reviewed the literature we found that there is little attention paid to this issue in terms of research.  So in plotting a way forward we draw on personal testimonies of four of the authors who are researchers and who have experienced career challenges in part at least because of their disability.  In the paper we develop a series of recommendations in terms of how universities might better support individuals with disability within the academy.

The abstract for the paper is below and the full version can be found here.

The academy should be a welcoming environment for people with disability. Across Australia, however, there is a current shortage of programmes supporting people with disability to develop their careers as researchers. This article critically investigates current practice and experiences concerning universities and the employment and career development of people with disability as advised by the literature, and how this practice aligns with the lived experiences of several of our authors. Our review of the literature utilising Scopus, PsycINFO and ProQuest databases found a deficiency of research attention on this topic, with only 16 relevant articles identified. This paucity of literary evidence has been augmented in the article by personal stories shared by four of its authors. By focusing on evidence-based measures with potential to support disability employment and career pathways throughout universities in Australia and elsewhere, this article challenges leaders to address ableism and to advance a more inclusive academy.

Implementing the Australian National Disability Insurance Scheme: implications for policy and practice

Although our project ‘Choice, control and the NDIS‘ completed some time ago, we are now starting to see some of the academic outputs follow.  Just published is a paper by based on this data and other review data.  In the paper we focus on the implementation of the scheme, some of the challenges that have emerged so far and implications for policy and practice.  Below is the abstract and the paper can be accessed without a pay wall here.

Australia is immersed in its largest reform of disability services in a generation – the staged rollout of the National Disability Insurance Scheme (NDIS). Enacted swiftly to capitalize on rare bipartisan political and public support, the $AU22billion scheme promises to design and deliver disability services differently, with emphasis on service user choice and control. However, the scheme’s rollout is outpacing the readiness of service users, service providers and the agency charged with implementing it to achieve its stated aims, threatening to derail it. Research suggests issues arising in the implementation of the scheme can be attributed in part to the design of the policy and, in part, to how it is translated into practice, both making scant reference to lessons from comparable reforms. Reflecting on the implications of these findings for policy and practice, we explore a range of challenges that arise when embarking on large scale reform in an environment of tight timelines, high expectations, extant policy silences, competing priorities, and jurisdictional ambiguities. This paper adds to the growing body of literature on the NDIS by bringing in the views of participants, and elaborating on implementation challenges posed by its governance structure, system architecture, and administrative structures.

The NDIS and its impact on service providers

A few years back I was lucky enough to be part of  team who were funded to do some work exploring the impact that the NDIS is having on service providers.  The work was funded by the Australia and New Zealand School of Government and reported a little bit ago, but now the journal articles from this project are starting to emerge.

The first is in Health and Social Care in the Community and the abstract appears below:

As governments worldwide turn to personalised budgets and market‐based solutions for the distribution of care services, the care sector is challenged to adapt to new ways of working. The Australian National Disability Insurance Scheme (NDIS) is an example of a personalised funding scheme that began full implementation in July 2016. It is presented as providing greater choice and control for people with lifelong disability in Australia. It is argued that the changes to the disability care sector that result from the NDIS will have profound impacts for the care sector and also the quality of care and well‐being of individuals with a disability. Once established, the NDIS will join similar schemes in the UK and Europe as one of the most extensive public service markets in the world in terms of numbers of clients, geographical spread, and potential for service innovation. This paper reports on a network analysis of service provider adaptation in two locations—providing early insight into the implementation challenges facing the NDIS and the reconstruction of the disability service market. It demonstrates that organisations are facing challenges in adapting to the new market context and seek advice about adaptation from a stratified set of sources.

You can find the full article here.

Competition and collaboration between service providers in the NDIS

In recent decades governments in industrialised nations worldwide have been embracing marketbased models for health and social care provision including the use of personalised budgets. The Australian National Disability Insurance Scheme (NDIS) which commenced full implementation in 2016 is an example of a personalised funding scheme which has involved substantial expansion of public funding in disability services. The scheme involves the creation of a competitive quasi market of publicly funded disability service providers who had previously been block funded and had historical practices of communication and collaborative working.

Research has shown that introducing or increasing competition can impact collaborative efforts between service providers.  I am part of a team who have recently released a report based on qualitative interview data from disability service providers during the roll out of the NDIS to examine the effects of the introduction of a more competitive environment on collaborative working between providers who had historical relationships of working together. The data shows that while collaborative efforts were largely perceived to be continuing, there are signs of organisations shifting to more competitive relationships in the new quasi market. This shift has implications for care integration and care co-ordination, providing insight into how increasing competition between providers may affect care integration.

You can find the full report through the Centre for Social Impact here.

Research – nothing about us without us

The Consumers Health Forum of Australia (CHF) is the national peak body representing the interests of Australian healthcare consumers. CHF works to achieve safe, quality, timely healthcare for all Australians, supported by accessible health information and systems.  One of the things they do in meeting these aims is produce a journal called ‘Health Voices‘ which is published two times a year to promote debate on health care issues affecting all Australians and of interest to health consumers, government and industry.

The latest issue focuses on how consumers can influence research.  I have the privilege to have a piece in this issue alongside a number of leading research and consumer engagement voices, which I have written about a the co-produced project on the NDIS which I have previously written about in this blog.  In this I reflect on what we learned about doing consumer-engaging research and where next for this field.  The full article is open access and can be found here.

Explainer: how much does the NDIS cost and where does this money come from?

File 20180507 166877 1boj64.jpg?ixlib=rb 1.1
More Australians are joining the NDIS than predicted, so cost predictions have had to be updated.
Shutterstock

Helen Dickinson, UNSW

Although the National Disability Insurance Scheme (NDIS) is relatively young, there has been much debate over how it will be funded.

Treasurer Scott Morrison recently said Labor had left a A$57 billion shortfall in funding for the NDIS. So many were left scratching their heads at the announcement that next year’s proposed increase in the Medicare levy – which was supposed to cover some of this shortfall – would be scrapped.




Read more:
Turnbull government abandons $8.2 billion Medicare levy increase


So how much does, and will, the scheme actually cost? Who is supposed to pay for it and why is there debate over the funding?

Calculating the costs

These are difficult questions to answer because we lack high-quality data about the extent and nature of disability in Australia. The information we do have is based on predictions, and work is underway to check these are accurate.

The case for creating an NDIS was made by the Productivity Commission in its 2011 inquiry on Disability Care and Support. The commission recommended Australia’s system of inequitable, fragmented and inefficient disability services be replaced by a new national scheme that would provide insurance cover to all Australians in the event of significant disability.

The one thing all sides of politics agree on is the NDIS represents a significant increase in disability spending, which stood at around A$8 billion per year at the time of the initial Productivity Commission report.

Original estimates suggested the NDIS would cover 411,000 participants and cost A$13.6 billion at maturity. However the Productivity Commission now estimates that around 475,000 people with disability will receive individualised support at a cost of around A$22 billion per year.

The A$8.9 billion difference between the Productivity Commission’s original estimates and the current estimate is a substantial gap. But A$6.4 billion of this difference is due to pay rises awarded to social and community services employees.

The remainder is due to the growth in the population and also the inclusion of participants over 65 years who were not included in original estimates. Once we account for these, estimates are fairly close to those originally predicted.

Last year’s Productivity Commission review of costs found the NDIS was broadly coming in on budget. Greater-than-expected numbers of children with autism and intellectual disability were accessing the scheme, but not all those with an individualised plans were able to spend their budgets.

So, for now, the NDIS seems to be tracking as intended. The NDIS budget is estimated to gradually increase over time to 1.3% of GDP by 2044-45 as participants age. Estimates also suggest the scheme will produce benefits adding around 1% to the GDP.

Where the money comes from

The original Productivity Commission report suggested the federal government be the single funder of the NDIS and that revenue to support the NDIS be paid into a separate fund (the National Disability Insurance Premium Fund) to provide stable funding for the scheme.

The Productivity Commission suggested this approach because disability services have long been subject to debate about who should bear the costs of these services: the Commonwealth or the states and territories. Indeed, part of the reason for the NDIS was to guarantee funding for disability services and stop these debates and blame-shifting.

But this isn’t what happened.




Read more:
The NDIS costs are on track, but that doesn’t mean all participants are getting the support they need


The way the NDIS is funded is complex, with revenue coming from a number of sources. The NDIS is funded via a pooled approach from Commonwealth and state and territory governments. The Commonwealth provides just over half of the funding for the NDIS and the rest comes from state and territories. This arrangement is governed by a number of bilateral agreements that are revisited every five years.

At the creation of the scheme, all existing money spent by various governments was directed into the NDIS to cover costs. Then, in July 2014 we saw a first increase in the Medicare levy: from 1.5% to 2% of taxable income.

However, the increased Medicare levy doesn’t meet the full costs of the scheme – just as the levy doesn’t cover all the annual costs of Medicare. This revenue was directed into a special fund for the NDIS, DisabilityCare Australia, which is designed to reimburse governments for NDIS expenditure.

Any additional funding the NDIS needs has to come from general budget revenue or borrowings.

The NDIS Savings Fund Special Account was established to collect the Commonwealth’s contribution to the scheme. This fund pools underspends or savings from across government, protecting these as a forward contribution to the scheme as it grows over future budgets.

Behind the funding debate

Warnings have been sounded about the NDIS’s reliance on multiple sources, fearing it creates a risk of future instability of financing.

When the Labor government originally introduced the NDIS, it said it would fund the scheme through an increase in the Medicare levy, reforms to private health insurance and retirement incomes, and a range of “selected long-term savings” including an increase in tobacco excise and changes to fringe benefits tax rules.

Labor said the combination of these revenue streams would ensure the NDIS was fully funded to 2023. But many of the savings Labor promised were intentional, rather than set in stone, and were not dedicated to the NDIS as the Medicare levy was.

It’s estimated the Commonwealth will contribute around A$11.2 billion to the NDIS in 2019. Of this, around A$6.8 billion will come from the redirection of existing disability funds and the Commonwealth’s share of the DisabilityCare Australia Fund.

This leaves an annual funding gap of around A$4 billion once the scheme becomes fully operational, accumulating to around A$56 billion by 2028.

The Commonwealth announced it would increase the Medicare levy from 2% to 2.5% of taxable income from July 2019 as a way of filling the funding gap. Estimates predicted this would raise an additional A$8 billion in revenue over its first two years.

The bill needed to do this had stalled in the Senate, with Labor and the Greens opposed. They suggested the increase should only be applied to those in higher income tax brackets.

Last week the Treasurer announced tax receipts were running A$4.8 billon higher than was estimated in December, meaning the levy was no longer needed.

For now it looks like funding for the NDIS is assured, but many within the disability community have expressed concern this does not assure funding for the long term and uncertainty may continue to prevail.




Read more:
Disability workers are facing longer days with less pay


Helen Dickinson, Associate Professor, Public Service Research Group, UNSW

This article was originally published on The Conversation. Read the original article.

 

Information requirements when choosing and using disability services

One of the great things about my role is having the opportunity to work with some fantastic PhD students.  One of my current students – Aviva Kelk – is doing a PhD exploring the types of information that people with disabilities need to make decisions about care services in the context of individualised systems such as the National Disability Insurance Scheme.  In all the spare time Aviva has outside of her PhD (!) she runs the organisation Clickability, an online service directory of disability services that features reviews written by people with disability.

Aviva is currently doing a survey of the kinds of information people who use and/or choose disability services need to make good decisions.  If you have any insight into these issues and are willing to fill in a short survey then please see the message below.  I hope to be able to follow up and in the coming months and tell you what Aviva finds.

 

Hi there, 

I’m researching what information people want to help them choose disability or mental health services under the NDIS. It’s for my PhD at the University of Melbourne. 

I’d love your help with a survey. It’s 11 questions. It takes about 10 minutes. Here’s the link: 

https://www.surveymonkey.com/r/ndis-info

People with disability, family members, carers, support workers, LACs, and anyone else who’s involved in choosing services are invited to respond. 

Feel free to shoot through any questions. 

Thanks!

Aviva Beecher Kelk

avivabk@student.unimelb.edu.au

Taking the pulse of the NDIS

I recently recorded a Podcast for the Policy Shop, which is hosted by the University of Melbourne’s Vice Chancellor – Glyn Davis on the topic of the NDIS.  The other guest in this conversation (apart from my terrible cold) is Bruce Bonyhady, the former Chair of the NDIA.  In this episode we discuss how this policy came to be, the scheme’s rollout, and whether the NDIS will in fact improve the livelihood of people living with disabilities in Australia.  The episode can be found here.