ESSA vs SIRA NSW c.2020-2022
Here we go, again.
The Workers Compensation (Accredited Exercise Physiology Fees) Order 2022 has now been published by SIRA NSW. My initial thought was this, I will be changing my job title from “accredited exercise physiologist” to “remedial medical gymnast” because according to SIRA these two titles are now interchangeable. As I understand it (and I’m very open to comments and correction) the accredited exercise physiology fees order was reviewed to bring it into parity with other allied health providers working in the SIRA NSW system. There was also an intention to reduce the cost to the system as services were seen as being “more costly” than other allied health services. I will not contend the merits of an exercise rehabilitation program to support recovery for both physical injuries, and psychological conditions – I’ll leave this to some of my colleagues, and to the, you know, science.
The thing is, all allied health disciplines are different. Treatment modalities and clinical goals are highly variable across these disciplines so bringing any fees order into parity is nonsensical.
Accredited Exercise Physiologists (AEPs) have long argued that their treatment modalities require time to implement because modalities are active and not passive. Patients need time to work through motor control patterns, cognition and learning, and then into the exercise program itself. All this takes time, time and more time. Speaking of time, let’s jump back in time for context. The previous fees order outlined fees based on a maximum consultation of one-hour, pro-rata time-based fees in five-minute increments. Someone correct me if needed - I believe the pro-rata fee was introduced in the 2018 or 2019 fees order. This meant if a consultation was at least 60 minutes in duration, AEPs could charge at the maximum fee. If the consultation duration was less than 60 minutes they should charge at the pro-rata rate. Undoubtedly, some businesses would’ve charged at the maximum rate even if sessions durations were less than 60 minutes. It’s a fairly safe assumption. That fee structure, however, allowed for flexibility. It allowed for AEPs to make sound, ethical decisions based on the needs of their patients, as patients required more consultation time, whilst others did not. There are many variables to consider when determining not only the duration of consultation, but also the frequency of sessions, and modalities used. I have a wonderful discussion with Nikki Lodge and Matt Hicks on episode 7 of The Intelligent Rebellion Podcast around this topic (click here to have a listen).
In short, when crunching the data, SIRA discovered there was a disproportionate number of maximum hour charges to pro-rata charges. The cost of AEPs services within the overall cost of medical intervention across the entire scheme was unsustainable. This data could be interpreted as AEPs services failing to promote self-management strategies and failing to engage in a graded reduction in consultations inferring the focus was not towards independence. (Again, I’m very open to comments and correction). In late 2021, ESSA received the following data from SIRA on utilisation of item code Subsequent Consultation (EPA002):
“For claims that received exercise physiology services in the NSW workers compensation scheme in the 12 months to June 2021, 38% have been assessed as low complexity, 45% ️as medium complexity, and 17% as complex.
For the 12 months to June 2021, 92% of subsequent exercise physiology consultations were invoiced at a pro-rata rate from the NSW workers compensation Fees Order equivalent to a one-hour consultation.”
This brings us back to the now. The 2022 fees order outlines different types of treatment consultations, removed the confusing reduced and group consultation types, and introduced a “Consultation C” for complex treatments - which actually, has caused some confusion. And whilst some have been celebrating the new fees order. Me? I’m not yet sure.
Are AEPs being incentivised to take more patients per day?
After my initial thought of changing my job title to “remedial medical gymnast,” my second thought was about service delivery and how businesses would navigate the 2022 fees order. The 2022 fees order does not reference a minimum or maximum time for a consultation. It does, however, require certain consultations to be on a one-on-one basis. (Phew!) Doing the math, the subsequent consultation fee is equivalent to 32 minutes of the previous maximum one hour consultation fee. AEPs have long argued and continue to claim that consultations require more time, for the reasons I have previously discussed, and also because active treatment modalities do require more consultation time than passive modalities. This has been the long-standing rationale AEPs used to justify the higher consultation fee. Additionally, AEPs have argued it is difficult to provide adequate service in 20-30 minutes. “How do I get through a session in just 30 minutes? It’s not enough time for the patient to warm up, go through their motor control movements, stretches, exercises, and then prescribe a home program.” If you’re an AEP you’ve said this aloud more than a few times. Be honest.
I’m curious…
With AEPs average consultation times currently at 45-60 minutes, could this new fee structure compromise service delivery?
With no minimum time required, could businesses be compelled to reduce the duration of their consultations, thus increasing their total number of appointments per day?
If so, what is the implication on their staff who would unavoidably have increased caseloads, increased patient numbers, and more appointments?
What is the implication on the patients who deserve treatments under the scheme?
For those AEPs who have long stood on their moral high ground about providing the best service to patients, achieving positive outcomes, and taking the necessary time to work with their patients – What would you do if a patient needs more than a 32-minute consultation?
How do you plan on balancing the margin of business with the mission of healthcare?
I suspect three things will happen:
Businesses will adjust and reduce their appointment times to 20-30 minutes.
There will be an increase in the frequency of consultations per patient.
The majority of treatments will be invoiced under the newly introduced “Consultation C.”
My overall prediction is: The scheme will see a reduction in outcomes, and a marginal difference in the total cost of accredited exercise physiology services in the scheme.
And having a scientific mind, I’m open to being proved wrong (or right).
Hey ESSA! Remember me?
My most viewed article since launching Ruminating with Rhea is “ESSA, We Have a Problem.” So, I’m going to give the people what they want. At the time of writing this over a three day period, I had read all (yes, all) of the comments on the ESSA NSW Facebook page on this topic which was just shy of 250 comments on a few main threads. One was Mark Hills’ post on 30 May 2022, another is Mark Goswell’s post on 1 June 2022, and the other was ESSA’s announcement via Elodie Anderson on 27 May 2022. I’m sure plenty more have popped up as I have been preparing to publish this article. Digesting and writing all this stuff takes time, a lot of time and it’s not possible to be across everything. Personally, where did I land on everything?
It looks like SIRA NSW pulled a fast one on ESSA.
ESSA dropped the ball back in 2020, and SIRA kicked it under the couch.
In 2020, SIRA proposed the 2021 fees order which was so utterly ridiculous and so far below par with other allied health professionals that it actually peaked ESSA’s attention. Yes, ESSA was (very) late to the party, though, was anyone really surprised given ESSA has set the bar so low when it comes to advocacy within the compensation and personal injury schemes. The members were told about meetings between ESSA and SIRA throughout 2020 and early 2021. In May 2021, SIRA announced there would be no immediate change to the fees order whilst they continued consultations. After meetings with SIRA, ESSA national staffers updated members using the ESSA NSW Chapter Facebook page and via email. Aside from this, the membership have yet to see other evidence of advocacy. Members are now demanding minutes from meetings only to be told by the ESSA CEO, Anita Hobson-Powell that personal meeting minutes are private. Okay, okay, let’s give Anita and the ESSA team a break. I can sympathise with this, my hand writing is so terrible I’ve been accused of being a GP, some of my internal dialogue carelessly makes it onto the page, and admittedly, when I don’t actually understand what is happening in a meeting, I tend to doodle. Would I want someone peeking at my personal meeting notes? Probably not. That’s why I then type them up, fancy-like, with bullet points and complete sentences. I’m also assuming that it would be difficult to write notes for a meeting which one didn’t attend. But, I wouldn’t know, I’ve never tried.
For goodness sake ESSA, just show us something, anything. Please? Pretty please? I’ll pay you $700.
May the odds be ever in your favour.
I digress. Let’s return to the 2022 fees order. On the face of it, it seems like a win, right? ESSA says in their announcement, “This is the first time AEPs have achieved parity with other allied health professions.” Parity! Parity! Parity! Seriously though, I’m not celebrating because it does seem more like the difference between shit and shittier. In 2020, SIRA proposed a 2021 fees order which was shitter than the shit 2022 fee order. And, as some members like to remind other members, “It could’ve been worse” and “You should just be grateful”, “Why are you complaining?” “What? You haven’t joined the advocacy group?” As is ESSA’s default, if you are unhappy, make sure to approach ESSA with a solution as they don’t like to hear about problems. Or you could write to SIRA and tell them what you think, and there’s always the creative option of buying an ad spot on your favourite regional television network to advocate for your profession.
Have you heard about the MTV Approach? This explains perfectly what has happened. Allow me to enlighten you. When MTV first started to air music videos, bands would make two versions of their music video to pitch to MTV. The first one they pitched was so obscene, offensive, and inappropriate that by the time they pitched the second version, which was the “real” video, it looked like a cat playing with a fluffy ball of string (nawww, isn’t it cute!). Let’s say you’re Marty Callner pitching Cher’s “If I Could Turn Back Time” music video to the MTV executives, in your first pitch Cher is wearing only the leather G-string and sheer stockings to reveal the tattoos on her buttocks. When you pitch the second video, Cher puts on a leather jacket and suddenly the music video is as innocent as a cat playing with a fluffy ball of string (nawww, isn’t it cute). Option two is more digestible because option one is so incomprehensible. For the record, I’m not throwing shade on Cher. That music video is fucking legendary and Marty Callner should be a household name.
Simply, the 2021 fees order is the G-string and sheer stockings, and the 2022 fees order is the leather jacket.
The thing is though, ESSA members are a clever bunch and have called this situation out for what it is – Bullshit. For those who did read my article titled, “ESSA, We Have A Problem” you already have an idea as to my position regarding ESSA’s competency to support its members. If we speak to parity, ESSA’s ability to understand and support members who raise concerns is about on par with their ability to move beyond tokenism when addressing diversity and inclusion within the organisation and within the membership. I cannot find my can opener, so the worms will remain inside…for now. What we are seeing on the ESSA NSW Chapter Facebook page was inevitable. This is the combination of a few very powerful forces - irresponsible leadership, organisational distrust, indifference towards member inclusion, and an organisation devoid of insight. This has collided with years of frustration by members who are weary and angry at ESSA’s failure to support them, even as they screamed and shouted for help. This is exactly what I have been warning ESSA about for years.
As I wrote this opinion piece and the day turned into night, the ESSA NSW Chapter Facebook page descended into a version of the Hunger Games. Members turned on each other in what could be described as a “digital tsunami.” A cascade of comments complete with assumptions, accusations, retorts, justifications and speculation. A deluge of intuitive, impulsive and spontaneous thoughts whilst the members of the Capitol sat in their corporate box. Excuse me whilst I take my popcorn out of the microwave.
I don’t know how to fix this. I do know that it will take lots of years and lots of ears. It will require inclusion, intuition, innovation and insight. There are just so many issues which need resolving. Let’s give ESSA the benefit of the doubt, it’s been 31 years and look where we are now. The one thing I think most AEPs could agree on is that ESSA is lacking leadership. So, maybe, it’s time for a change.
Cheers for now, -Rhea (Remedial Medical Gymnast)
“Strong opinions, loosely held”