My two beautiful grandchildren 

Thursday is grandchildren day. I love Thursdays because I get to chill out with a four year old and sometimes a six year old (and my husband Bob), watch my grandsons play, look at the birds, the plants and nature in general and relax from the hectic pace of our clinic. But today there was a ‘snotty nose alert’ from my daughter and after the last ‘snotty nose’ episode (3 weeks of coughing and spluttering and 2 COVID tests later), she let us off the hook.

Now that made me feel sad, but it allowed me time to do some Admin and the first thing that needed addressing was a note from my secretaries who had reported that 3 patients in the space of 2 weeks had reported that BUPA Health Fund had told these 3 separate patients that “Sue Croft Physiotherapy was not a recommended practice “(!?!?!) and that they would do better to go to ‘XYZ Practice’ as they would get the whole charge back as a rebate.

One of these patients had actually asked me to ring her about this Health Fund conversation, as she was perplexed by the words and she wanted to chat about our charges. It was a day before I got the opportunity to ring her back and by the time I did ring her, she had already contacted the Health Fund and heard for herself why her rebate was so low.  She herself angrily defended the integrity of my practice saying – ‘Sue’s treatment was extremely thorough, comprehensive and she  (the patient) couldn’t understand why this health fund would say such a thing as ‘not a recommended practice’.

This patient was irate about the fact that she pays the same yearly amount to the Health Fund as the next person and why should she get rebated so substantially less than that person who goes to a physio who signs a contract with the health fund to only charge what the health fund dictates? The patient and I both discussed the inequity of the situation and also realised that because of the very private nature of the problems that women (men and children) come to us about, there will be very little ranting from the rooftops by the patients about this injustice.

The Silence of pelvic floor dysfunction is pervasive.

So with this unexpected spare time today, I attempted to get onto BUPA to find out about the this other scheme and ask them why they were directing patients in that way. 3 hours…..and by this time I was fuming – three phone calls on hold for 30 to 50 mins and one disconnection later – I finally reached a human being who listened, understood my frustration and had some positive suggestions for me. He also actually apologised for the words ‘Not a recommended practice’  (after all this is quite defamatory) and promised re-education of the people in the call centres throughout Australia so these words would not be used in the future about any physiotherapist not a part of BUPA’s scheme.

While I had his attention, I also alerted him to the fact that patients with prolapse and/or incontinence are fitted with a pessary – a silicone device  or splint  (for which they are not rebated) and which is absolutely life-changing for a woman with a bulge, drag or heaviness or urinary leakage. So if you sprain your ankle, you will get rebated for a moon boot, which you will wear for 6 weeks (unless you chuck it in the bin at 4 weeks because it drives you crazy), but not a pessary, which you can wear for years and resume exercise and perhaps not have surgery, which would cost the health funds thousands and thousands of dollars.

Silicone pessaries – a life-changing intervetion for women with prolapse or urinary incontinence

But I also grabbed the opportunity to discuss the lack of fairness about the rebates for different Allied Health Professions. I told him some stories. My husband went to the dentist recently and had his six monthly check up. It took 30 minutes (longer because he had a filling). He had an examination (it has a separate code), a clean (it has a separate code), a filling (it has a separate code) and the total of the bill was $298 and the rebate on that total was $259 therefore around $38 out of pocket (and the dentist very kindly accepted the rebate only for that). The cleaning of teeth and check up (and healthy rebate) with the dentist usually takes 15 minutes and can happen twice a year. Pretty great for the dentist and the patients!

Another story. In 2017, I went to the podiatrist for a orthotic for my plantar fasciitis. The whole consultation took 20 minutes. I had an assessment (it had a separate code), a walking assessment on the treadmill (it had a separate code), I had a cast made of each foot (pressed each foot into a foam box- it had a separate code) and then there was the making of the orthotic themselves (separate code again). My total bill for this appointment was $715 and the rebate from the health fund was $400. Staggering amount of money for the pair of orthotics and 20 minutes consultation, but a very healthy rebate. This one consultation used up my complete podiatry allowance for the year.

Many people, including some GPs and specialists, actually still think that all that pelvic health physiotherapists do is teach pelvic floor exercises. But pelvic health physiotherapists are much more than just pelvic floor exercises.

We are more than pelvic floor exercises

When a patient comes to see a physiotherapist at our practice with pelvic floor dysfunction, we comprehensively assess the patient which most often includes, amongst many other facets of an assessment, an internal examination because the pelvic floor muscles are situated on the inside of the pelvis (there is no separate code), there are measurements taken with a digital biofeedback device (no separate code), we comprehensively educate the patient about (for example) what is the normal bladder and bowel function or what is persistent pain science (no separate code), and we comprehensively educate about how to treat what has gone wrong (no separate code). We regularly do a pre and post-void residual measure with a real time ultrasound (no separate code). We regularly fit pessaries, a life-changing internal device for helping women with prolapse (again no separate code!)

Peritron Biofeedback device to objectively measure vaginal resting pressure and squeeze pressure and a POPSTIX to measure the GH+PB on valsalva to assess the risk of prolapse, risk of levator avulsion and OASIS injury antenatally  plus an ultrasound prior to voiding to check for residual urine.

The codes available to us at the rooms: Initial consultation 500, subsequent consultation 593 (or 505 depending on your health fund). Nothing else.

When we see a new patient, especially if the patient has a pain condition, it takes a minimum of 1.25 hrs (and more often is 1.5 even 2 hours if it is a pain condition) to help that patient. The charge for an initial consultation to see my physios is $195. The patient receives a rebate of around $35 – $42 unless they are in a fund that gives a percentage of the charge. They can be substantially out-of-pocket.

This is grossly unfair for the patient. Should I charge less? The overheads at our practice are huge. As I said, we fit pessaries (we have many different types of fitting kits for patients to try to a large stock of pessaries so patients can leave with their pessary) and we have a steriliser for these pessaries. We always have two secretaries on. We give a 15 page handout to the patient to assist them with remembering all the information they have learnt; a copy of my book; a specipan to allow the patient to do an accurate bladder diary; plus if they have a pain condition they will get a specific pain handout and perhaps depending on the severity of their pain/anxiety also maybe get a 50 page booklet on managing pain and anxiety.

To keep up-to-date with the constant stream of emerging evidence with pelvic floor dysfunction, my staff and I have to undertake a considerable amount of continuing education each year. For example in one year I undertook a Norman Doidge 2 day workshop $760; an Explain Pain course (my 4th one- I do one every 3 years because they are excellent and the research is updating all the time) $1250 – it was in Melbourne, so there were airfares, accommodation; the CFA National Conference in Hobart – it was $700 plus airfares and accommodation; in 2016 I went to Florence for the International Continence Society 4 day conference. Was it amazing? Absolutely. Did it change and enhance my practise with patients? Absolutely. There are many, many others but I want to get to the point.

The point is that my belief (from years of having the same low rebate given to my patients – I have been in Private Practice for over 30 years) is that the Health Funds do not recognize the complexity of pelvic floor dysfunction and the time involved in seeing these patients.

The point is that the health funds do not value treatment of pelvic floor dysfunction the way they obviously value good healthy teeth or getting an orthotic for your foot.

What I can’t understand is why they don’t see the health burden of pelvic floor dysfunction for the patient and the community.

They don’t recognise the tremendous value in investing in preventative health measures like we offer patients.

If women can’t have sex with their partners because they have vaginal pain, then their relationship is put under strain. The mental health of each partner may suffer. The relationship breaks down and then the children suffer. It becomes a much bigger health issue. Who is going to take the time to assess and treat this condition to potentially help salvage this relationship?

If men leak urine, have pelvic pain, have erectile dysfunction with subsequent sexual dysfunction, it severely affects their mental and physical health. Who is going to be confident to explain what is going on for this man in a matter-of-fact, un-embarrassing way?

If women can’t run or exercise properly because they leak urine or faeces or they have prolapse, then their cardiovascular health, their mental health, their bone density and their general body strength will be compromised. Who is well equipped to educate, apply electrical stimulation (if necessary to rehab the muscles) and fit a pessary to allow this woman to return to exercise and all it’s benefits?

The answer to all these questions is of course the pelvic health physiotherapist.

Pelvic Floor Dysfunction (PFD) is a much bigger health issue than people realise. It is widespread, common, but silent, because of the shame and embarrassment factor. And importantly, it not only affects the Health Funds’ financial bottom line, it severely affects Australia’s productivity and therefore Australia’s financial bottom line.

The burden of pelvic floor dysfunction is huge. It is time it got recognised for what it is and the Private Health Funds should be thanking us for what we do, not punishing our patients with poor rebates or suggesting to the pelvic health physiotherapists that if you do not comply with the charges that the Private Health Funds dictate by becoming a provider in their special scheme, they may defame you by saying: ‘She is not a recommended provider.’

I believe the Health Funds should be encouraging the patients to seek treatment earlier, rather than later, to try and minimse the future cost of surgery, psychological counselling or other more expensive interventions (such as a Sacral Nerve Stimulator for OAB or faecal incontinence which costs upwards of $30,000).

The very kind, empathetic, listening representative who I finally got onto had some excellent suggestions to try and address this problem.

He promised he would:

• Forward my complaint to someone in authority
• Counsel the call centre staff about not defaming pelvic health physiotherapists (and any other physiotherapists) by saying in BUPA’s opinion they are ‘not recommended physiotherapists’.
• Ensure the offending words of ‘preferred provider’ would be removed from all BUPA’s website
• Forward my email to the relevant Senior Benefits Advisor about the need to address a rebate and therefore Item Number for any pessary fitted for a woman for incontinence and/or prolapse

I have decided that, instead of writing an email with all this information in it to him, I would write it in a blog and attach the blog to the email, as it is worthy of all physiotherapists and patients to read and perhaps ask more of their health funds. I am asking for our patients’ pelvic floor dysfunction to be respected as a very serious problem and for us as pelvic health physios to be respected for what we do to help patients with pelvic floor dysfunction.

I was offended by the words they used about my practice in the call centre hence my action in writing this blog.

Let’s hope Change will Happen.