Public purse, private service: The perceptions of public funding models of Australian independent speech-language pathologists

Abstract

Purpose

Health funding provisions supported by governments are pivotal for families accessing independent speech-language pathology services in Australia. Little is known of the facilitators and barriers that exist for accessing public funding for speech-language pathology services through independent providers. This study aimed to investigate and describe the perceptions of speech-language pathologists in accessing public funding models (PFMs) for children and young persons with communication and swallowing needs within Australian independent practice.

Method

Semi-structured qualitative interviews were conducted with twenty independent speech-language pathologists who had experience of PFMs in Australia. Digitally recorded interviews were transcribed verbatim and subjected to thematic analysis.

Result

Data analysis revealed five superordinate and eighteen subordinate themes. The five superordinate themes were: (a) accessibility in securing funding provisions; (b) time as a commodity; (c) incongruence between funding provisions and speech-language pathology evidence; (d) trust as a multifaceted quality; and (e) consequences of PFMs.

Conclusion

This original and timely research offers perceptive descriptions of the multifaceted facilitators and barriers for families seeking to access public funding for independent speech-language pathology services in Australia. Research findings illuminate challenges for the speech-language pathology profession. Accessibility to funding was identified as a major issue. Research findings suggest that current funding provisions do not align with the dosage required for evidence-based speech-language pathology management. Further, this research has highlighted the need for funding to be equitable, acceptable to stakeholders, and for services to be delivered in an efficient and sustainable manner. Future research is recommended to understand which Australian PFMs: (a) facilitate consumer access to speech-language pathology services; (b) enrich consumer experiences; and (c) align with scientific evidence to promote optimal outcomes.

Keywords:

• qualitative research
• thematic analysis
• public funding models
• speech-language pathology
• private practice
• health-economic objectives

Introduction

Successive Australian government healthcare policies endorsing privatisation (Aulich & O’Flynn, 2007) have facilitated an increase in demand for independent (private) speech-language pathology services¹. This funding has validated the use of public provisions for access to independent speech-language pathology services through private providers within Australia for children and young persons² seeking speech-language pathology management. Knowledge of public funding options for children and young persons with communication and swallowing needs assists individuals and families in the engagement of crucial primary care services through private providers. In principle, the allocation of public funding for procuring private speech-language pathology services promotes universal access. However, little is known of the facilitators and barriers that exist for accessing public funding of primary healthcare services such as speech-language pathology through Australian independent providers.

Funding is often a key determinant of access to speech-language pathology services for individuals and families (Haines et al., 2010). Without partial or full public funding, individuals with communication and swallowing needs may delay or forego services due to cost (Callander et al., 2017). In this paper, health funding is defined as the process and system of transferring funds raised by the financing system to pay for healthcare services rendered by health providers; that is, a funding model describes the mechanisms and provisions (e.g. from fund pooling to purchasing) by which funds arrive at a service or organisation as the end-point of the health financing process (Murray & Frenk, 2000; World Health Organization, 2010) and thereby acts as “policies for distribution of benefits” (Crigger, 2004, p.107).

In Australia, funding for speech-language pathology services garners resources from both federal and state coffers. Historically, speech-language pathology services in Australia have fallen under the auspice of health and disability sectors and are delivered through the public and not-for-profit sectors (Cowden et al., 2021; Law et al., 2013). Today, Australia relies on a mixed system of funding allocations for the independent speech-language pathology sector, which incorporate elements from both welfare and market models (Fisher et al., 2020). Contemporary Australian speech-language pathology services derive funding provisions through an entanglement of federal and state public health, disability, and education sources, together with private funding arrangements. In Australia, Medicare is the federal publicly funded health insurance scheme providing rebates to eligible individuals on a range of medical and allied health services. The private health insurance system also provides an optional source of funding, however the level of coverage together with out-of-pocket expenses is determined by an individual’s private health insurance policy. Additionally, state and territory health departments allow provisions for access to medical and health services, including allied health, medical specialist services, community health services, and hospital-based care. Primary Health Networks add another layer of public funding, which support region specific programs and health initiatives. The National Disability Insurance Scheme (NDIS) is a federal publicly funded social insurance system that supports individuals with permanent and significant disability in accessing speech-language pathology care. Australia’s three tier education systems (i.e. public, Catholic, and independent schools) provide speech-language pathology services through state and federal government funding arrangements. Whilst some Australian speech-language pathology services are provided through state government-funded health and education services with no direct costs to families, funding for ongoing communication and swallowing needs is supported increasingly through federal public funding provisions (i.e. NDIS and Medicare) and delivered by independent speech-language pathologists through their private practices. Many public funding provisions, however, may only partially cover speech-language pathology service costs, thereby creating funding gaps, with families contributing the remaining out-of-pocket balances. A taxonomy of four prominent public funding models (PFMs) is currently supported within the Australian independent sector to assist individuals and families in accessing speech-language pathology services: (a) health insurance, (b) social insurance, (c) third party insurance, and (d) education (see Table I).

Table I. Examples of public funding typologies used in Australian independent speech-language pathology practices for children and young persons.

Australian funding typology	Example of public funding model accessed within independent practice	Example of primary funding formula	Example financing method	Example regulator
Health insurance	Medicare Benefits Scheme: Item 10970: Chronic Disease Management Plan (CDMP)^a Items 82005 (Assessment) & 82020 (Treatment): Helping Children with Autism (HCWA)^b & Better Start for Children with Disability (BS)^c Item 81360: Allied Health Services for Aboriginal and Torres Strait Islander Decent	Combined universal, tax financed health insurance^e. Compulsory public health insurance^e.	Federal taxation, which includes the imposition of a levy on taxable income via the Medicare Guarantee Fund^e	Federal level, Department of Human Services
Social insurance	National Disability Insurance Scheme (NDIS)^d: Early Childhood Approach (under 7 years) Ages 7–64 years	Compulsory levy, funded by increase of 0.5% to Medicare Levy ^f.	Federal Taxation which is collected via Disability Care Australia levy^f State taxation^f	Federal level, National Disability Insurance Agency
Third party insurance	Transport Accident Commission, Victoria: Speech-language pathology treatment related to accident injuries	Fee charged on annual vehicle registration, legislated by Transport Accident Act, Amendment 2018, Section 94^g. The TAC charge is calculated depending on type of vehicle, registered owner (vehicle registration concessions may apply), intended use, seating capacity, carrying capacity, and garaged location^g.	State Transport Accident Commissions charges collected through vehicle registration^g	State level, road authorities
Education	Independent Schools of Victoria, Students with Disabilities: Speech Fluency Language Voice Alternative Communication	Disability Loading via the Australian Education Act 2013^h; data collected through Nationally Consistent Collection of Data on School Students with a Disability initiative^h.	Federal taxation^h State taxation^h	State level, public education departments or independent schools

Note: ^aMedicare’s Chronic Disease Management Plan (CDMP) refers to the current health insurance funding mechanism legislated by the Howard Government in July 2004, formerly known as the Enhanced Primary Care Plan; ^bHelping Children with Autism (HCWA) is an early intervention program legislated by the federal Howard Government in July 2008. This initiative consisted of two block funding arrangements: (i) early intervention program administered by the Australian Department of Health (ended in 2019) and (ii) the current health insurance Medicare legislated funding provision administered by Medicare; ^cBetter Start for Children with Disability initiative (BS) commenced in July 2011, providing access to health insurance funding through Medicare (similar to HCWA’s Medicare items) for early diagnosis and treatment of children with an eligible disability; ^dNational Disability Insurance Scheme (NDIS) is the current Australian social insurance funding model legislated by the federal Gillard Government in July 2013; ^eHopkins & Kidd (1996); ^fMadden (2015); ^gRoads Corporation of Victoria (2022); ^hCommonwealth of Australia (2016).

Although the literature acknowledges inadequate data on the epidemiology of childhood and adolescent communication and swallowing disorders (Cronin et al., 2020; Speech Pathology Australia, 2014; The Senate Community Affairs Committee Secretariat, 2014), existing evidence around prevalence provides estimates of childhood and adolescent communication and swallowing needs within the Australian context (McLeod et al., 2014; The Senate Community Affairs Committee Secretariat, 2014). It is estimated that up to 20% of 4-year-olds present with language impairment (Reilly et al., 2010). Within educational settings, up to 19% of students present with specific learning difficulties (McLeod & McKinnon, 2007) and up to 30% present with communication impairments (McLeod et al., 2014). Furthermore, children and young persons from vulnerable socioeconomic backgrounds are identified as being at risk of communication and swallowing disorders (Just et al., 2022). Barriers impacting these vulnerable populations include limited or no access to speech-language pathology services (Just et al., 2022) and differing frequency in accessing service provisions between children from lower socioeconomic status areas compared to peers from higher socioeconomic status areas (Ruggero et al., 2012). Such evidence demonstrates negative socioeconomic gradients, mirroring inequalities expressed by inverse care law (Hart, 1971): “disadvantaged populations need more health care than advantaged populations, but receive less” (The Lancet, 2021, p. 767).

In the field of speech-language pathology, reporting of health economic concepts such as funding and cost to access services are scarce (Le et al., 2017). In keeping within the foci of children and young persons with communication and swallowing needs, a limited number of studies specific to speech-language pathology have reported cost to consumers as a significant factor in accessing speech-language pathology management for children and young persons with communication and swallowing needs. Skeat et al. (2011) reported that families accessing speech-language pathology services for preschool children received a median of 10.8 therapy hours over a 12-month period with overall costs for these services varying from AUD $34 to AUD $16 546 (Skeat et al., 2011). Studies specific to speech-language pathology have explored total healthcare cost associated with developmental language disorders (Cronin, 2017; Le et al., 2017) and the indirect cost of communication and swallowing needs associated with a young person’s reduced productivity through curtailed workforce participation (Cronin et al., 2020). Paucity in the literature specific to funding models, therefore, invites research to identify and explore the barriers and facilitators in accessing PFMs and their subsequent impact on service delivery.

In its submission to the Australian government’s inquiry into the prevalence of communication disorders and speech-language pathology services in Australia (Speech Pathology Australia, 2014), Speech Pathology Australia identified insufficient data specifically relating to funding models for speech-language pathology service provision. The profession’s landmark project, Speech Pathology 2030 – making futures happen (Speech Pathology Australia, 2016) also identified the need for speech-language pathologists to: (a) “advocate to government, funding bodies… to prioritise evidence-based universal capacity building, prevention, and early intervention” (p. 14); and (b) “advocate for the introduction of funding models recognising the value of capacity building and support for families, friends and carers” (p. 20). Thus, an increased understanding of funding models is required to enhance the profession’s ability to lobby policy decision makers. This paucity in research, therefore, points to the need for an investigation of the facilitators and barriers specific to PFMs and the influence that they have on access and delivery of independent speech-language pathology services in Australia. The aim of this study was to investigate the perceptions of speech-language pathologists in accessing public funding for children and young persons with communication and swallowing needs within Australian independent practice settings.

Method

Study design

As no previous studies were identified, a qualitative design was chosen to explicate the perceptions of speech-language pathologists who had experience of public funding provisions available to families in accessing independent speech-language pathology services in Australia. Through the use of qualitative inquiry, individual in-depth semi-structured interviews (Minichiello et al., 2008) explored the perspectives of Australian independent speech-language pathologists in relation to public funding for access to paediatric speech-language pathology services. This study was approved for conduct by The University of Melbourne, School of Health Sciences, Human Ethics Committee (ID 1954683) prior to commencement of the study. All participants provided written informed consent.

Selection criteria and sampling procedure

Maximum variation sampling (Patton, 2015) was employed to recruit participants who: (a) had at least five years’ clinical experience working with a paediatric caseload in Australia; (b) were practising in any Australian state or mainland territory within an independent practice; (c) were a financial member of Speech Pathology Australia; and (d) had the credentials of Certified Practising Speech Pathologist (CPSP)—a legislative requirement for the provision of service through many PFMs. Using this form of purposive sampling methodology, participants were selected based on their diverse characteristics of variation (Patton, 2015). The sampling strategy aimed to capture diversity according to the following variables: gender, age, geographical spread using a population remoteness methodology (the Australian Standard Geographical Classification Remoteness Areas; Australian Institute of Health and Welfare, 2004), years of clinical experience, years as a measure of time in independent practice role, fees charged to access speech-language pathology services, practice size (i.e. number of speech-language pathologists engaged within practice), position (i.e. owner, clinician), and public funding as percentage of total practice revenue.

Participants

Participants were recruited through Special Interest Groups (i.e. Victorian Independent Practitioners Network; Queensland Private Practice Network; Private Speech Pathologists Association of Western Australia etc.) aligned with Speech Pathology Australia, the peak national body representing an estimated 70% of Australian speech-language pathologists (Speech Pathology Australia, 2014). The coordinator of each Special Interest Group was contacted directly via email seeking assistance with recruitment of potential participants through their networks. The field researcher (TN, first author) provided interested participants with verbal and written information outlining the study’s objectives and expectations, and written consent was received prior to each interview. Participants were recruited and interviewed between August 2019 and February 2020. One participant who agreed and consented to an interview withdrew from the study citing time limitations.

Twenty participants (seventeen females and three males; mean age 45 years) from across all Australian states and mainland territories met the inclusion criteria, consented, and participated in a single semi-structured in-depth interview. Table II describes the diversity of participants and demographic data.

Table II. Participant characteristics.

Participant (P#)	State	ASGC^a	Career clinical experience (total years)	Independent practice experience (total years)	Hourly service rate ($AUD)	Practice size (SLP number)	Public funding (percent of total practice revenue)
P01	NSW	MC	21–30	11–15	151–200	6–10	30
P02	QLD	MC	31+	16–20	151–200	2–5	80
P03	VIC	MC	11–15	6–10	151–200	2–5	97
P04	VIC	MC	31+	0–5	151–200	2–5	90
P05	VIC	MC	21–30	16–20	151–200	1	97
P06	VIC	MC	5–10	0–5	151–200	2–5	50
P07	SA	MC, OR	21–30	11–15	151–200	11–15	70
P08	SA	IR, R	31+	0–5	101–150	2–5	97
P09	TAS	IR	31+	21+	200+	6–10	60
P10	VIC	MC	31+	21+	200+	11–15	85
P11	VIC	IR, OR	21–30	16–20	151–200	6–10	40
P12	NSW	MC	5–10	6–10	151–200	2–5	50
P13	NSW	MC	5–10	0–5	151–200	2–5	70
P14	WA	MC	16–20	6–10	151–200	11–15	75
P15	VIC	MC	11–15	0–5	200+	2–5	40
P16	NSW	MC	21–30	21+	151–200	6–10	70
P17	ACT	MC	11–15	0–5	151–200	2–5	99
P18	QLD	OR	5–10	0–5	151–200	2–5	60
P19	NT	OR	21–30	6–10	151–200	2–5	2
P20	NT	R, VR	21–30	0–5	151–200	1	50

Note. ^aAustralian Standard Geographical Classification Remoteness Areas (ASGC). MC = Major Cities of Australia; IR = Inner Regional Australia; OR = Outer Regional Australia; R = Remote Australia; VR = Very Remote Australia (Australian Institute of Health and Welfare, 2004); NSW = New South Wales; QLD = Queensland; VIC = Victoria; SA = South Australia; TAS = Tasmania; WA = Western Australia; ACT = Australian Capital Territory; NT = Northern Territory; SLP = speech-language pathologist.

Participants’ characteristics as detailed in Table II reflect the diversity of the Australian independent speech-language pathology sector. Participants represented all Australian mainland states and territories (VIC = 7; NSW = 4; QLD = 2; SA = 2; NT = 2; WA = 1; TAS = 1; ACT = 1); thirteen participants (65%) reported practising in major cities of Australia with three (15%) practising in regional Australia and four (20%) practising in dual locations. Twelve participants (60%) reported as having >20 years clinical experience with four participants (20%) reporting <11 years experience. Business practice information revealed: (a) sixteen participants (80%) were engaged in practices that set fees between AUD $151–200; (b) two participants (10%) were sole traders, while eleven participants (55%) engaged in a practice with two to five speech-language pathologists; and (c) thirteen practices (65%) generated >60 percent of their total practice revenue via public funding provisions.

Pilot interviews

Two pilot interviews were conducted by the field researcher, providing an opportunity to review the interview schedule including a review of timings, wording of interview questions/probes to resolve ambiguity and clarify meaning, and to trial equipment. Both pilot interviews were transcribed via third party transcription (www.otter.ai; Transcription Software, 2016). They were initially analysed by the field researcher and then reviewed by an experienced qualitative researcher (BD, final author).

Data collection and procedure

In-depth semi-structured single interviews were undertaken with participants from all Australian states and mainland territories via one of three mediums: telepractice (e.g. Pro Zoom™ Video Communications platform, n = 12), in-person (n = 6), and telephone (n = 2). Development of an interview guide to structure interviews (see Supplementary Material: Interview Guide) was informed by the literature on health economic objectives of equity, efficiency, and acceptability (see Table III); participants were also encouraged to expand on topics of significance to their funding experience. The interview guide supported a structure to identify facilitators and barriers of PFMs used within independent practice settings against these health economic objectives. Participants engaged in conversational-style interviews, conducted by the field researcher, permitting participants to elaborate on their experiences. The interviews lasted between 42 and 93 minutes, with a median of 52.5 minutes. Data saturation was achieved where information redundancy or further coding was unattainable (Braun & Clarke, 2021b).

Table III. Definitions of health economic objectives: Equity, efficiency, and acceptability.

Health economic objective	Definition
Equity	“…absence of unfair, avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically or by other dimensions of inequality…”^a Healthcare can be distributed through two versions of need^b,c,d,e,f: horizonal equity implies individuals with equal need should be treated the same; and vertical equity infers individuals with greater clinical need should have more treatment than those with lesser need.
Efficiency	Delivered through three instruments^f,g: technical efficiency (improvements in production, i.e. maximum output for the minimum of inputs/costs); allocative efficiency (optimum allocation of resources to yield maximum output for minimum inputs/costs, i.e. ensuring the best allocation of resources to maximise the greatest return); and dynamic efficiency (how the system is able to change and adapt to change).
Acceptability	Delivery of health services should be underpinned by key ethical principles of autonomy, beneficence, non-maleficence, and justice^f. Acceptability of health systems is determined through the perspectives of clients, communities, and providers^f.
	Acceptability focuses on patient-centred access to healthcare, specifically objectives of availability, affordability, approachability, and appropriateness of healthcare services^h.

Note: ^aWorld Health Organization (2022, Overview section, para. 1); ^bCulyer (2001); ^cPulok et al. (2020); ^dRaine et al. (2016); ^eWagstaff (1989); ^fDuckett & Willcox (2015); ^gKerr & Hendrie (2018); ^hLevesque et al. (2013).

Data analysis

Digitally recorded interviews were transcribed verbatim (www.otter.ai; Transcription Software, 2016), deidentified, and subjected to reflexive thematic analysis (Braun & Clarke, 2019) supported by data management using NVivo™ Version 12 Plus software (QSR International, 2018). The flexibility of thematic analysis (Braun & Clarke, 2021a) was applied to the dataset and allowed examination of our broad research objectives. The field researcher familiarised himself with the data through a process of iterative review (i.e. repeated re-listening and re-reading of interview transcripts). Preparative codes emulated the smallest unit of meaning from the dataset whilst preserving descriptive nuance (Braun et al., 2019). Whilst analysing the dataset, principles of convergence and divergence were applied to central concepts and emerging themes (Braun & Clarke, 2021a). A process of assimilation allowed codes to be categorised into superordinate and subordinate themes. Inductive coding was completed by the first author (TN), with codes and development of themes scrutinised and refined through collaboration with the research team. Additionally, descriptive statistics were calculated from participants’ responses to specific issues as percentages (e.g. issues pertaining to practice revenue, hourly rate, treatment dosage).

Rigour

To ensure credibility of the research process, principles of scientific rigour were embedded into the phases of pilot testing, data collection, review, and analysis (Lyons & McAllister, 2019). The field researcher, who is a paediatric speech-language pathologist and also represented the speech-language pathology profession in establishing funding provisions within independent settings in collaboration with Australian government departments (e.g. CDMP and HCWA initiatives), ensured familiarisation of principles specific to bracketing, a method used to mitigate preconceptions that may potentially discredit the research process (Minichiello et al., 2008). This allowed for issues of potential bias to be understood and considered. Frequent debriefing between field researcher (TN) and final author (BD) became an integral part of the iterative process; providing scrutiny not only in the data collection phase, but also in the analysis of the results. Reflexive thematic analysis (Braun & Clarke, 2019) was applied, including frequent review and rumination of entries in methodological and analytical/reflexive journals. This process allowed the field researcher (TN) to detail methodology and reflections relating to emerging themes from the interview data. Member checking was included through participant validation of interview transcripts, providing participants the opportunity to validate, check for errors, add content, or remove any identifying information. Further, the use of explanatory quotations (Lyons & McAllister, 2019) and the application of the Consolidated Criteria for Reporting Qualitative research (COREQ) checklist (Tong et al., 2007) provided additional levels of rigour. Additionally, peer and participant feedback was received at Speech Pathology Australia’s 2021 National Conference during a poster presentation (Nickless et al., 2021); of significance was reporting by participants that their pre-COVID-19 responses to interview questions would differ to their PFM experiences gained during the COVID-19 pandemic (see Limitations).

Result

Themes

Five superordinate themes and eighteen subordinate themes were identified as central to the experiences of independent speech-language pathologists in relation to public funding for children and young persons with communication and swallowing needs (see Table IV). The core themes were: (a) accessibility in securing funding provisions; (b) time as a commodity; (c) incongruence between funding provisions and speech-language pathology evidence; (d) trust as a multifaceted quality; and (e) consequences of funding models. Throughout the results section, direct quotations of participants are indicated by parenthesis plus participant number (i.e. P#).

Table IV. Summary of superordinate and subordinate themes.

	Superordinate themes	Subordinate themes
Theme 1	Accessibility in securing funding provisions	Capacity of families to engage and understand funding models
		Education level and language use of parents
		Impact of socioeconomic factors
		Interplay of gatekeepers in accessing funding provisions
		Past funding experiences
Theme 2	Time as a commodity	Timely access
		Health economic considerations
		Communication of funding models
		Administration requirements
Theme 3	Incongruence with evidence	Poor relationship between funding and scientific evidence
		Limitations of existing funding provisions
Theme 4	Trust as a multifaceted quality	Professional reputation
		Listen to experts
		Client as a protagonist
Theme 5	Consequences of funding models	Inconsistencies of decision makers
		Historical context of funding models
		Navigation of funding initiatives
		Impact on workforce

Theme 1: Accessibility in securing funding provisions

“What about my families who have intellectual disabilities? What about my families who aren’t all that literate?” (P06). “So, it depends on what suburb you’re living in” (P05). “And the doctor has to make a decision about whether they believe they’re eligible or not” (P04). These participant statements highlight the critical role that accessibility has in securing funding provisions. Five subordinate themes were identified in describing how individuals and families accessed and secured speech-language pathology services through PFMs. Participants described: (a) capacity of family members to engage and understand funding models; (b) education level and language use of parents; (c) impact of socioeconomic factors; (d) interplay of gatekeepers in accessing funding provisions; and (e) past funding experiences.

Capacity of family members to engage and understand funding models

Participants described how the capacity of families (i.e. their ability to advocate, understand, and use health literacy terminology) influenced successful funding acquisition:

I think there are still inequities… the dependence on families to know a system, to advocate for a system… if you don’t know how to access the service, or you don’t have capacity to access the service, then you’re still not getting the service… (P14).

One participant commented that the ability to successfully advocate can determine the amount of funding: “that the better the family are at advocating for themselves… that if they’ve got the capacity or the background to threaten to appeal… then they tend to immediately get bigger packages” (P12). The capacity of parents to persist, advocate, and “play the system” (P06) was reported to yield the greatest return from PFMs.

Education level and language use of parents

There was general consensus that the education level of parents was a factor that influenced a family’s capacity to access funding:

The families that financially needed less, get more. Because they are the educated families… They had the capacity to do a bit of research and familiarise themselves with the terminology… Compared to our other families, who are… the more typical lower socioeconomic families who don’t have that capacity (P18).

The capacity of a family to use certain terminology when advocating for their child was perceived to make a significant difference for successful access to funding: “just because you know the right words to use, doesn’t mean you should be more entitled to NDIS funding than someone who doesn’t know the right words to use, but obviously has more need” (P01).

Impact of socioeconomic factors: “A Middle-class system”

Socioeconomic factors contributed to the success in obtaining public funding: “families who have got lots of financial resources and who have got lots of education, know how to work the system, and know how to get more money through each plan. It is not an equitable system. It really is not” (P02). An obstacle to funding accessibility was the need for families to self-fund a range of professional assessments prior to accessing funding models:

it requires parents who are very literate, who already are financially able to do all the assessments… and fund them before you get funding. So, you need to be very literate, you need to have very good language… you need to… be financially able to support all this, just to get access (P02).

In addition, location proved to be a barrier in accessing funding with one participant reporting, “definitely Aboriginal communities and country towns are very disadvantaged by the funding model, which doesn’t accommodate for travel” (P08).

The interplay of gatekeepers in accessing funding provisions

Access to public funding was influenced by gatekeepers and their knowledge of funding models. General Practitioners (GP), National Disability Insurance Agency (NDIA) planners, and Local Area Coordinators (LACs)³, who all acted as gatekeepers, played a significant role in realising access to public funding:

The gatekeepers knowing what the system is. So that’s the GP or the support coordinator or planner knowing all the ins and outs… people coming to us on CDMs [sic; Chronic Disease Management Plans] expecting to have it bulk billed and it’s free. Embarrassing both ways… (P19).

The attitudes of gatekeepers acted as a barrier in accessing funding: “because we’ve had cases of families going to the GP and the GP turning around to them and saying, ‘you’re only here to get money’" (P10). In contrast, gatekeepers can positively impact on delivering healthcare objectives and act as agents for families with limited self-advocacy skills: “Some planners are awesome and I’ve had families say… they [planner] said, ‘You know what? You haven’t asked for this! Why don’t you ask for this because I think you would get it!’” (P06). Gatekeepers, therefore, affected participants’ access to PFMs both positively and negatively.

Past funding experience

Limited access to funding in the past was reported by half of the interview participants (10/20). Participants highlighted the emotional responses (e.g. ranging from frustration, gratefulness, and a reluctance to receive assistance) experienced by funding recipients: “they’re now accessing but there’s also a lot of frustration… as to why there’s been nothing at all that they could access in the past” (P11).

Previous experiences by individuals with communication and swallowing needs in accessing PFMs influenced their behaviours and attitudes towards funding provisions; recipients were either afflicted or appreciative in how PFMs allowed access to speech-language pathology services. One participant reflected, “Why in the past have I never been eligible?” (P11).

Theme 2: Time as a commodity

Time featured as a superordinate theme with participants referring to time in diverse ways: time in communicating funding model suitability and criteria; and time required for administration, travel, and treatment. The concept of time, therefore, paralleled that of a valuable commodity. Four subordinate themes were generated: (a) timely access, (b) health economic considerations, (c) communication of funding models, and (d) administration requirements.

Timely access

Participants described how time consumed the funding process due to bureaucratic systems, which resulted in delays in accessing funding and services: “that as a highly intelligent, capable person able to engage with systems… she’d been trying to make one simple change in her child’s plan… she’d lost six months of time” (P09).

PFM system complexities and administrative demands impacted on the time it took to access funding provisions by children and young persons with communication and swallowing needs. All families, including those who were well-informed and educated, spent time navigating PFMs’ systems and processes.

Health economic considerations

The concept of efficiency dominated responses from participants. Funding models were positively reported by participants as improving practice efficiency in relation to designing appropriate intervention: “it’s an efficiency related to quality of the program… it was possible to meet with parent[s] without the child being present. And that there are times where that really matters for the quality of the intervention” (P09).

Conversely, participants identified specific funding models as being inefficient in the delivery of speech-language pathology services, of which some providers withdrew their services from certain PFMs: “the NDIA managed kids; just no efficiency. So much time wasted… the time spent, firstly, developing those reports; submitting them, following them up… we estimate now that it’s six to eight hours” (P03).

Communication of funding models

Participants commented on requirements for them to spend time in explaining details of funding provisions: “GPs refer people on care plans which can be problematic because GPs think that everybody bulk bills for care plan[s] and we don’t do that because it would be too expensive” (P07). Speech-language pathologists spent time clarifying that services were not free and that after rebates, a gap payment may exist: “‘ask about the free sessions for autism’… we find that it’s very, very misleading and we do [spend] a lot of time trying to unravel that with families… what that supposed ‘free’ means… that it’s a partial rebate” (P11). Participants also reported that they spent time addressing the requirements of funding models and that their role incorporated clarification of funding criteria: “so we spend time with the clients trying to sort through things” (P19).

The dissemination of funding information may not come from an experienced health professional, rather a gatekeeper who has limited health or disability experience in communication and swallowing.

That they’re trying to find out more about their plan. They don’t get phone numbers for NDIS people. Certainly, the NDIS case managers are not accessible, or they change… We’ve got one [planner] who’s a mechanic, one who was a hairdresser, and they don’t have a background in understanding individuals with disability. So frustrating (P11).

The communication of funding models and their criteria, therefore, impinged on the time and service delivery experience of both participants and providers.

Administration requirements

For providers of speech-language pathology services, the administrative requirements borne out of funding model requisites were described by participants as time consuming: “we take the time to explain that to them. We explain our cancellation policies… Just according to whatever the NDIS has outlined that we must do” (P13). “We spent a lot of time writing support letters and advocating and supporting parents to try and get on to plans. I had tried to access as much training as I could” (P03).

The administrative requirements of funding models significantly impacted on families as well as on speech-language pathologists. The time to prepare and organise such information limited the time family members were available to engage in employment:

she puts together every year for his plan management, a book… Would be 70 to 100 pages in detailed reports, letters, summaries… in order to maintain his level of funding… And that would not be possible if both parents worked full time… because of the need to advocate and get that information together (P03).

Due to increasing administration requirements, clinicians spent time preparing and applying for funding on behalf of their clients and families devoted time that detracted from their employment and/or other activities.

Theme 3: Incongruence with evidence

“I don’t see that there is any alignment between the NDIS funding model and evidence base” (P02); “trying to meet evidence-based research… And then you get a model that will partially rebate one session, five times a year. It just doesn’t match” (P11); “the evidence around dosage models… that the public funding doesn’t match what the evidence tells us” (P12). Seventeen participants (17/20) described incongruence between the recommended evidence base for communication and swallowing management and PFM provisions. Two subordinate themes were developed from the data: (a) poor relationship between funding and scientific evidence and (b) limitations of existing funding provisions.

Poor relationship between funding and scientific evidence

Participants reported a disparity between current PFM provisions and recommended evidence for management of a range of communication and swallowing needs (e.g. stuttering, phonological [speech], and childhood apraxia of speech disorders). Participants reported that gatekeepers provided consumers with a false sense that a block of funding (i.e. CDMP’s five sessions per calendar year across all allied health providers) is “sufficient” (P10, P12, P16) in meeting evidence-based healthcare: “Chronic Disease Management… It’s really not matched to any kind of evidence… Because people think, ‘Right, my GP's recommended I have five sessions with a speech pathologist.’ They don’t know whether that’s sufficient or not sufficient” (P16).

Another participant commented:

I think five sessions on the CDMP is ridiculous. Like what could you possibly ever achieve?… if you really talk about a chronic disease, a lifelong condition that needs additional supports from Medicare funded system, what is five consults [per year] really going to do? (P14).

Examples of two treatment pathways were discussed by participants (P10, P14, P18): (a) fluency and (b) phonological/speech sound disorders.

Fluency is apparently a major consideration… However, Medicare is a massive failure… So, when the research says average is 20 sessions, and Medicare gives five and we have to explain to families, ‘Look, the evidence is probably going to take this long. You get this many. Our chances of success is this, but we’re going to give it a go.’ How are we going to make it work? (P18).

There was a sense of positivity that PFMs could potentially support the evidence base: “we’ve talked about different avenues of public funding and some, like the NDIS, potentially can meet the evidence base” (P10); “I think the NDIS is probably getting the closest government model to that” (P14); and, “It’s doing the best it’s ever done, in terms of matching evidence base for the bulk of my caseload” (P18).

Limitations of existing funding provisions

In accessing existing funding provisions, participants identified limitations in the speech-language pathology management of fluency, childhood apraxia of speech, autism spectrum disorder, developmental language disorder, phonology (speech), and feeding. Furthermore, participants were mindful of their ethical obligations under Speech Pathology Australia’s Code of Ethics (Speech Pathology Australia, 2020): “we’re at risk of breaching it, breaching our ethics if we’re providing services that are not going to have beneficial outcomes. And they might actually do harm if we can’t finish a treatment program” (P16).

Not meeting the scientific evidence and compromising ethical principles of non-maleficence and beneficence was of particular concern for participants:

So we are caught… particularly around stuttering and CAS [Childhood Apraxia of Speech] saying to the families, if they have this model of funding, it’s better for us to not do anything, than to half arse it… to do it and not do it properly (P11).

The absence of evidence was also acknowledged by participants as a limitation together with a “one-size-fits-all” (P14) approach to service delivery: “It’s a tricky one because even in speech pathology, our evidence base is not strong for you knowing how many sessions you need to provide… Particularly in feeding, like feeding therapy is really only like a 40-year-old field” (P15). Moreover, participants reported that certain PFMs may support unethical practice, thereby doing more harm than good.

Theme 4: Trust as a multifaceted quality

“So, I figured if I was going to put it simply, they need to start to trust us as a profession” (P02); “what I need from this preschool is buy-in… I need to get them to trust me to become part of their community” (P13); “And I think that we just have to trust ourselves a little bit better” (P12). Trust, reported by half of the participants (10/20) as a multifactorial concept, emerged from the dataset as a predominant theme, with three subordinate themes: (a) professional reputation, (b) listen to experts, and (c) client as a protagonist.

Professional reputation: “Trust us as a profession”

When providing examples of trust, participants frequently conveyed feelings of suspicion by gatekeepers around their management of public funding arrangements:

no problems at all with the necessary processes of accountability, but we are often left feeling that our intention is sure to be criminal… that our intention… [is]to take advantage of the system and take advantage of the clients… that’s not our intention… and that’s uncomfortable for us (P09).

As professionals making healthcare decisions, participants described how trust was vital in their management and clinical decision-making. In addition, one participant (P02) reported that the speech-language pathology profession had a reputation of “underservicing” and “trying to save” parents money, thereby maximising funding provisions:

trust the professionals… to make decisions that are based on the needs of the child… Speech pathologists are not the sort of people who… are going to over service… I’ve seen the exact opposite, underservicing, trying to save their parents money. So, trust us as a profession (P02).

Listen to experts

Participants wanted funding gatekeepers to confer with the current, robust scientific evidence. Recognition and endorsement by participants that the peak body representing speech-language pathologists in Australia, Speech Pathology Australia, is fundamental in advocating for public funding provisions to align with scientific evidence: “I think that the NDIS does need to listen to Speech Pathology Australia and experts who have an understanding of evidence-base” (P12). Speech-language pathologists uphold professional autonomy and maintain service delivery competencies:

And I think we need more autonomy, autonomy around… what our professional background and knowledge and our ethics tells us about how services are best delivered… I don’t feel like we have a good ability to follow what we know as best practice under the current models (P11).

Client as a protagonist

“They just had to trust the provider was doing it right” (P14). Gaining trust from individuals with communication and swallowing needs was central to a client’s decision-making and healthcare management; however, one participant reported gaining trust as an additional requirement to successful service delivery and client engagement: “But I have to sort of gain their trust and then… sort of explain what it is that I want, then that’s the thing that’s sort of like, an extra step” (P13). Ensuring that individuals with communication and swallowing needs were party to the decision-making process and were able to connect with and trust their speech-language pathologists was reported by participants as being core to optimal outcomes: “But if they connect with you and trust you, you’ll get a better outcome” (P14). Trust was, therefore, vital in achieving optimal patient-centered care.

Theme 5: Consequences of funding models

“I think there’s huge discrepancies in what people are getting” (P01); “Oh, we’re booming! Absolutely booming!” (P07); “The waiting lists kept growing… we weren’t getting therapists” (P05). The superordinate theme of consequences of funding models reflects the varied facilitators and barriers that participants identified with the provisions of PFMs available to individuals to engage independent speech-language pathology providers. Four subordinate themes materialised through the process of reflexive thematic analysis: (a) inconsistencies of decision makers, (b) historical context of funding models, (c) navigation of funding initiatives, and (d) impact on workforce.

Inconsistencies of decision makers: “It was just shifting sands”

“The process is complicated. And you know, you can ring NDIS six times, speak to six different people, and you will get six different responses on how to proceed with something” (P17). Almost three quarters of participants (14/20) reported varying degrees of inconsistencies made by gatekeepers of PFMs: “And we do find that there’s an inconsistency in results… from an impairment perspective, less severe problems accessing a lot of funding” (P12). Such decisions presented as obstacles for individuals seeking support through public funding arrangements:

It will work better when there’s consistency amongst planners; I'd like to say the planners are the weakest link because you can have two people with identical needs and end up with… totally different levels of funding… it’s still very inconsistent (P07).

Participants reported decision makers “not really knowing what speech pathology can do” (P16). One participant reported variability amongst decision makers’ knowledge of life-long communication challenges, which subsequently impacted on funding arrangements:

some people lose funding, and other people unexpectedly get funding. Sometimes quite significant funding even beyond the recommendations in the report… some of the NDIA officers… seem to struggle with the idea of lifelong communication challenges and are still very much, ‘When will it be fixed? When will they no longer need funding?’ (P12).

Inconsistencies were best summarised by the same participant: “The rules often don’t match the planner’s understanding of the rules and the NDIA office’s understanding of rules” (P12).

Historical context of funding models: “A knight in shining armour”

PFMs have evolved over the past four decades since the inception of Medicare, with participants witnessing the emergence of various public funding arrangements. Funding models supporting multidisciplinary service delivery that provided regular communication between professionals were also acknowledged as an enabler: “Olden days’ support centres. The speechie sitting with a psychologist, sitting with the OT [occupational therapist]” (P05).

Medicare’s CDMP was reported as the predominant PFM that failed to meet the healthcare and service delivery requirements of individuals with communication and swallowing needs (8/20): “It’s just providing a bit of financial relief for families” (P16). Participants described the CDMP as insufficient for individuals and families who would benefit from funding and access to services:

Medicare we find really unsuccessful because families are coming in with the expectation that they only need five [sessions]. They also expected it to be free. And they also expect a report on top of that and the GP wants a report and then our LAC [Local Area Coordinator] contacts us to fill out another form for a NDIS application all for $53 (P18).

Conversely, more than half of the participants (12/20) declared that NDIS provided adequate provisions to access speech-language pathology services: “NDIS is a knight in shining armour compared to the others!” (P18). “Well, I think the NDIS is… an ideal model. [If] the whole range of communication disorders… were recognised as… a lifelong impairment… then I could see that would be much fairer” (P10).

Moreover, participants preferred contemporary PFMs where “they’re not having to pay gaps… that people can actually make a decent plan… and access consistent therapy” (P17).

Navigation of funding initiatives

With the rise of contemporary PFMs, participants described the complexities to navigate and understand funding criteria and arrangements have become onerous, particularly across populations with communication impairments (i.e. generational comprehension/cognitive difficulties):

the negative impact… is that they can’t necessarily navigate what to do and how to do and how to do it well, because they get ill advice, don’t necessarily have the cognitive capacity sometimes to be able to make decisions that are going to be in their interest (P07).

Navigating funding models including an understanding of funding criteria and their arrangements proved challenging for stakeholders of communication and swallowing needs.

Impact on Workforce: We’re Booming! Absolutely Booming!!

An increase in funding provisions has triggered a range of workforce implications as described by participants (i.e. demand for speech-language pathology services and implications of waitlists; the associated challenges of employing suitably trained professionals; occupational health and safety considerations of speech-language pathologists; and the changing nature of speech-language pathology services including mobile service delivery and information counselling):

One thing that we are careful with when we’re allocating staff to clients, so therapist to clients, is we’ve got to make sure that their skill level is the right level for the child and the family that they’re seeing (P17).

Participants also described the accompanying pressures associated with increased demand in service provision (i.e. impact on quality of service, employee burnout leading to workforce attrition, and an expectation of overtime):

we have to say no to people, because people are so desperate for services… I’m not going to run my staff into the ground or reduce their quality… because we’ve got more demand… And there’s a lot of turnover… related to burnout (P07).

Changes in the delivery of speech-language pathology services (i.e. informational counselling, travel requirements for clinical services) and in those who attend sessions (i.e. attendance by fathers and grandparents) were also reported by participants: “my staff here have had ongoing training in counselling, because we do spend a lot more time counselling our families; we do have access to fathers more often than we would in a clinic-based session… also grandparents” (P02).

Moreover, the emergence of contemporary PFMs has brought with it human resourcing issues that impact both positively and negatively on the workforce.

Discussion

This novel research explored the perceptions and experiences of speech-language pathologists in relation to public funding for children and young persons with communication and swallowing needs within Australian independent practice. The results highlight how health economic objectives of equity, efficiency, and acceptability implicate access to PFMs for speech-language pathology services for children and adolescents in Australian independent practices.

Rising to the challenge

Findings from this research present challenges for the speech-language pathology profession. The following challenges are offered to provide opportunities for stakeholders to champion and lead positive change in how PFMs are accessed by children and young persons with communication and swallowing needs.

Challenge 1: Impact on equity for speech-language pathology

This study validated how independent speech-language pathologists identified accessibility as a major factor for successful procurement of public funding provisions for their services. Consistent with previous research highlighting accessibility, factors such as capacity for families to engage and understand language (Russo et al., 2021), education level of parents (Barr et al., 2021), and impact of socioeconomic disadvantage (Cortese et al., 2021) all play a significant role in the ability of families to secure funding provisions for speech-language pathology healthcare needs.

Adding to the conversation around equity, our study identified how families applying for funding through PFMs require skills in the use of specific terminology (i.e. participant, capacity building, rehabilitation, reasonable, and necessary). Knowledge and use of such technical terminology by families highlighted the inequities of universal access to funding provisions for speech-language pathology services. In addition, our inquiry illustrated the necessity for families to acquire knowledge of differences in the jargon exclusive to particular funding model criteria (i.e. NDIS: functional impact, functional capacity, and functional impairment [Larwill et al., 2018]; Medicare’s CDMP: chronicity, complexity, and multidisciplinary [Skeat et al., 2009]; Education: National Consistent Collection of Data Severe Language Disorder with Critical Educational Needs and reasonable adjustments [Department of Education & Training, 2021]). Consistent with previous research surrounding factors affecting accessibility (Barr et al., 2021; Russo et al., 2021), our study reinforced that success in securing funding provisions was closely aligned with parents’ education levels and their understanding and use of specific terminology when advocating for their children. Subsequently, speech-language pathologists’ views on factors affecting accessibility to public funding for independent speech-language pathology services matched those raised by parents.

Impacting on horizontal and vertical equity was the scarcity of speech-language pathology services in communities where there is most need, including rural and remote regions (Ruggero et al., 2012), together with the burgeoning demand of speech-language pathology services and the impact of waitlists (McGill et al., 2021; The Senate Community Affairs Committee Secretariat, 2014). Timely access of speech-language pathology management is critical for children and young persons’ social, academic, and employment outcomes (McGill et al., 2021; Ruggero et al., 2012; The Senate Community Affairs Committee Secretariat, 2014). This study highlighted a range of barriers (i.e. capacity of family members to engage and understand PFMs; gatekeepers’ attitudes towards PFMs and their knowledge of speech-language pathologists’ scope of practice; self-funding of assessments prior to successful attainment of public funding), which prevented universal and timely access to crucial speech-language pathology services.

It may prove prohibitive for many families to access independent speech-language pathology services without the support of public funding provisions. The variability of cost and continuing expense on a family’s budget in accessing such important services through independent providers, therefore, requires support from the public purse via government funding. Table II identified that 80% of participants (16/20) reported an hourly rate for individuals with communication and swallowing needs to access speech-language pathology services of between AUD $151 to $200; an additional 15% (3/20) confirmed an hourly rate of more than AUD $200 for speech-language pathology management. Given the Australian median weekly employee earnings is AUD $1150 (Australian Bureau of Statistics, 2020), one hour of speech-language pathology management at the NDIS price guide of AUD $193.99 (National Disability Insurance Agency, 2020) would consume approximately 17% of median weekly employee earnings for families without funding. McAllister et al. (2011) identified cost as a significant barrier for families in accessing private speech-language pathology services. Although providing some financial support to families, Medicare’s co-payment model amplifies the current financial barrier that families face in accessing crucial healthcare services; this questions whether such co-payment models truly provide universal access. Not all PFMs, therefore, act as agents for equitable access; due to inequities, vulnerable populations are ostracised from accessing such essential and timely healthcare services.

In summary, a number of challenges were identified by participants in relation to accessing public funding for independent speech-language pathology services. Firstly, participants reported inconsistencies with information provided by gatekeepers together with inconsistencies of their understanding of PFMs’ criteria. Additionally, participants reported disparities in knowledge by gatekeepers of the scope and practice of speech-language pathologists. Such inconsistencies transpired into horizontal and vertical healthcare inequities, manifesting in different funding allocations for similar presentations. This concept is not novel and has been extensively reported in the literature (Pulok et al., 2020). However, inequity of healthcare delivery is concerning when the least vulnerable can readily access healthcare services (Pulok et al., 2020), a phenomenon highlighted in this study relating to inverse care law (Hart, 1971). Secondly, historical context of funding models were considered inequitable and unfair; traditionally they followed a rehabilitative framework (Law et al., 2013) and were considered safe and apolitical (Mitton & Donaldson, 2003). Historical arrangements for public funding allocations are considered poor in maximising health benefits (Mitton & Donaldson, 2003) and discriminate against those families from disadvantaged backgrounds (Woolfenden et al., 2019). In Australia, equity has partially been addressed through Medicare’s CDMP initiative as it embodies horizontal equity access (i.e. five rebated sessions for all citizens, regardless of income) in contrast to Medicare’s HCWA and NDIS, which epitomises vertical inequity (i.e. access to funding provisions only if specific criteria are met). Thirdly, the complexities of PFMs and their presenting barriers appeared inaccessible for families to navigate due to dense and confusing terminology together with exhaustive requirements to access and maintain funding provisions. Such challenges need to be addressed in order to uphold the ulterior motive of universal health coverage.

Challenge 2: Impact on efficiency for speech-language pathology

Performance measures specific to the efficiency of speech-language pathology interventions supported by public funding provisions presented as an emerging phenomenon. The science surrounding differential treatment intensity (i.e. dosage, frequency, and intensity; Baker, 2012) of speech-language pathology intervention continues to evolve as a vital instrument to measure efficiency within treatment areas. The emergent findings from our research suggest that current funding provisions do not align with the evidence base for differential treatment intensity in speech-language pathology management. Of significance, 85% of participants (17/20) reported incongruence between the recommended differential treatment intensity and funding models prescribed. Of particular concern was Medicare’s CDMP initiative, where five rebated sessions per calendar year engendered not only limitations in efficacy of treatment but also ethical dilemmas surrounding non-maleficence and beneficence (Speech Pathology Australia, 2020; i.e. knowing that funding limitations may provide little or no benefit; Cant, 2010). Participants specifically described how the CDMP could not meet the treatment efficacy for chronic and complex communication disorders such as childhood apraxia of speech (Murray et al., 2015), phonological disorder (Williams, 2012), and stuttering (Packman et al., 2015).

Challenge 3: Impact on acceptability for speech-language pathology

Acceptability of funding provisions featured as an emerging performance measure of PFMs for access to independent speech-language pathology services in Australia. With respect to funding arrangements, participants discussed the concept of trust as key to professional reputation, expert opinion, and professional autonomy. The literature defines trust as a relational phenomenon (Dinç & Gastmans, 2013); however, an erosion of trust of gatekeepers in the professional judgements of speech-language pathologists may significantly impact on an individual’s ability to succeed in their pursuit of funding success. With respect to professional autonomy, speech-language pathologists provide comprehensive evidence (i.e. written reports) to gatekeepers of service provisions (i.e. NDIS planners and GPs) to substantiate diagnoses and address funding criteria; diagnostic reports detail the minutia of deficits to meet PFM criterion. However, evidence presented to the Commonwealth of Australia (2020) highlighted procedural failures of gatekeepers to appropriately allocate NDIS funding provisions due to their neglect of professional opinion and autonomy (i.e. disregard of expert reports and altering of professional recommendations without consent by funding gatekeepers; Commonwealth of Australia, 2020). Such behaviours promote a culture of mistrust. Nevertheless, the concept of epistemic trust (Clarke et al., 2018), an individual’s capacity to trust the knowledge provided by others, is beneficial not only for speech-language pathologists and their ongoing relationship with clients, but also between funding gatekeepers and healthcare professionals. Relational trustworthiness between stakeholders, therefore, is paramount in securing appropriate funding provisions for individuals with communication and swallowing needs. Additionally, professional recognition of speech-language pathologists together with improved consultation between the speech-language pathology profession (e.g. Speech Pathology Australia and academics) and funding policy makers is essential.

As reported in the literature (Skeat et al., 2009), funding gatekeepers are crucial actors in facilitating access to funding provisions. However, their limited understanding and acceptability of speech-language pathology per se (Skeat et al., 2009) may prove restrictive for families requiring access to funding. Further education of gatekeepers in the role and scope of practice of speech-language pathologists is required to enhance access to PFMs.

Challenge 4: Impact of PFMs, public policy, and risks for speech-language pathology

Participant demographic data provided insight into public funding as a percentage of their practices’ total revenue (see Table II). Eighty percent (16/20) of participants reported that their practice revenue was derived from over 50% public funding, with 65% (13/20) of participants generating >60% of total practice revenue from public funding provisions. Independent speech-language pathology practices, therefore, risk potential financial hardship as reported in other health disciplines (McInnes et al., 2017) should there be a change in public policy and/or funding arrangements due to over-reliance of public funding provisions as a means of revenue generation. Such risks would significantly impact the structure of the speech-language pathology workforce, thereby affecting access to speech-language pathology services and mitigating public health policies that support equitable access to universal health coverage (Fisher et al., 2020). Merging such public policies into private practice and ensuring their sustainability is, therefore, a delicate balancing act.

Limitations and future direction

Firstly, only the experiences of speech-language pathology service providers were investigated in this study. The results, therefore, have perspectives only from the service delivery side and not consumers’ lived experiences of PFM arrangements. Secondly, sample bias may have arisen given that seven out of the 20 participants were Victorian independent speech-language pathologists. Whilst an overall sample size of 20 participants was adequate to achieve data saturation, our maximum variation sampling approach (Patton, 2015) may have been limited as our results may not be typical of smaller states and mainland territories. In addition, all participants except two (18/20) identified themselves as directors/owners; two of the participants reported being clinicians/managers. As per our inclusion criteria, which purposively selected speech-language pathologists with more than five years’ clinical experience, this limitation is confounded as participants practising for greater than ten years tend to progress into management/ownership roles. Future research is indicated to include the perspectives of speech-language pathologists with less than five years’ clinical experience. Findings could be influenced by the fact that directors/owners directly benefitted financially from public funding accessed by their clients. Thirdly, NDIS participants have the option to manage their public funding via three pathways that provide choice and control: self-managed, plan managed, and agency managed. Our study did not distinguish between these abovementioned funding streams, rather, data was collected under one public funding umbrella (i.e. NDIS). Although all public funding typologies have been included in the results section, the majority of our participant quotations refer to social and health insurance PFMs as these funding models currently dominate the Australian public funding landscape. Finally, data collection occurred before the COVID-19 pandemic. After providing participants with a summary of results, some participants commented that their responses would differ if the interviews were conducted post-pandemic as public policy on funding provisions changed during this timeframe (e.g. approval for telepractice consultations through Medicare’s CDMP/HCWA services and extension of funding packages for NDIS clients beyond 12 months).

This study has identified areas for future research relating to funding provisions and speech-language pathology management. In discussing the findings, our research invites future investigation into the appraisal of performance measures of PFMs. Additionally, research to support improved alignment between current funding provisions and the emerging scientific evidence of differential treatment intensity in managing communication and swallowing needs is highly recommended, such as consolidating Medicare CDMP to allow intensive approaches to intervention (i.e. instead of offering five sessions per calendar year over many years, condensing the number of sessions into an intensive timeframe to allow implementation of evidence-based care). Further translational research reporting the issues surrounding accessibility to funding is required to inform advocacy for vulnerable populations, for example, the provision of education programs regarding the scope of speech-language pathology practice and suitability of client presentation versus PFM would be beneficial for gatekeepers of public funding (such as GPs, Planners, and LACs). These gatekeepers may often be the first point of contact by individuals and families with communication and swallowing needs. Additionally, research investigating risks associated with the structural implications of workforce demand together with the reliance of independent speech-language pathology practices on public funding is warranted. It would also be feasible to investigate whether these findings can be generalised to the funding experiences encountered by provision of services to the adult population (i.e. 18- to 64-year-olds and greater than 65-year-olds). Finally, education of gatekeepers about quality of life outcomes and risks associated with lack of timely, early intervention for individuals with communication and swallowing needs is paramount. Without the active support of gatekeepers in facilitating access to funding, individuals with communication and swallowing needs within our community will be denied optimal, accessible, evidence-based, and timely intervention.

Conclusion

Funding provisions continue to be a topic of significance for stakeholders involved in speech-language pathology services. This original study is the first to have reported the perceptions and experiences of Australian speech-language pathology professionals in relation to PFMs for children and young persons with communication and swallowing needs within independent practice. Our findings highlighted the multifaceted facilitators and barriers that significantly impact access to PFMs by children, young persons, and their families to Australian independent practice service providers. Furthermore, significant investment by stakeholders is required to ensure contemporary PFM design facilitates universal access and equity for all individuals seeking speech-language pathology management. This study provides a starting point for further research into the role public funding plays for individuals, families, and communities accessing independent speech-language pathology services for children and young persons with communication and swallowing needs. Future research is recommended to understand which Australian PFMs: (a) facilitate equitable consumer access to speech-language pathology services, (b) enrich consumer experiences, and (c) align with scientific evidence to promote optimal outcomes. Furthermore, findings from this study hold relevance for clinicians and researchers evaluating the role that PFMs play in the delivery of critical healthcare services. This research provides evidence of the experiences and perceptions of speech-language pathologists in accessing public funding for children and young persons with communication and swallowing needs within Australian independent speech-language pathology practice. It has also highlighted the need for public funding provisions to be accessible, equitable, accepted, and delivered in an efficient manner.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Acknowledgements

The authors thank all participants who shared their experiences and time for this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

Tristan Nickless was funded by the Australian Government Research Training Program Scholarship.

Notes

1 Independent (private) speech-language pathology services refer to services offered by tertiary trained healthcare professionals who provide speech-language pathology management to clients within private practice settings. These practitioners are not employed by government organisations, but rather operate independently in partnership with other healthcare professionals.

2 Definition of parent, child, and young persons: (a) a parent refers to a legal guardian of children and young persons under the age of 18 years; (b) a child is legally defined as a person under the age of 16 years; and (c) a young person is characterised as a person who is aged 16 years or above but who is under the age of 18 years (Children and Young Persons [Care and Protection] Act, 1998).

3 Definitions: (a) General Practitioners (GPs) are registered medical practitioners who are vocationally recognised by Medicare Australia to provide access to rebates through the Australian government’s federally funded health insurance scheme, Medicare; (b) a National Disability Insurance Agency (NDIA) Planner is usually employed by the NDIA and refers to an administrator that works with individuals with disabilities and their families to determine suitable services and resources in achieving their goals; (c) NDIA refers to National Disability Insurance Agency, the independent statutory authority chartered to administer and implement the NDIS; and (d) Local Area Coordinators (LACs) refers to a facilitator role of the NDIA that coordinates the collection of information from participants and planning partners to identify participant goals and aspirations. Normally, LACs are employed by third party organisations. LACs act as decision makers in accessing public funding and identify options by utilising legislation, policy, and practice guidance to ensure participants achieve plan outcomes.