Diagnostic practices have clearly shifted in response to the NDIS. Medicare-subsidised paediatricians and psychiatrists are doing fewer autism diagnoses than in the past. This pattern emerges very clearly in regions that were first exposed to the NDIS. Instead, NDIS service providers are also providing diagnoses of autism that are then funded by the NDIS. This is not an ideal set of incentives. Having those who benefit from providing a service also decide whether the service is necessary seems less than ideal.
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The increase in autism diagnoses has not been driven by diagnosing children at younger ages, despite some claims to the contrary.
There is no strong correlation between NDIS diagnoses and household income. New diagnoses are slightly more likely to happen in wealthier households, but the effects are quite small. The distribution of diagnoses is spread fairly evenly across the income distribution. Again, anecdotal stories of wealthy people exploiting the system do not appear to be confirmed in the data.
Are these “real” cases of autism? Are people “taking advantage of the system”? We would suggest that these are not useful questions, nor are they the right way to think about what is happening.
First, we don’t have any good way to differentiate between “real” and “false” diagnoses of autism. Even if we had a machine that we could put up to people’s heads, it wouldn’t tell us whether someone had autism or not.
Second, it is important to recognise that neurodiversity reflects a spectrum of neurological and developmental conditions. There may be a fine line between “autism” and other neurodiversity diagnoses.
Third, incentives matter. The July 1, 2004, baby bonus resulted in 1005 births on that exact date! This was more than any number in the 30 years prior, and more than any other day after 2004 until Australia stopped publishing daily birth data. People shift all kinds of behaviours in response to government programs.
A Level 2 autism diagnosis entitles a participant to tens of thousands of dollars in support each year. A Level 1 diagnosis provides no access to the NDIS. This puts tremendous pressure on medical professionals to diagnose in the immediate best interests of patients without considering their long-term needs or the long-term financial implications of the accumulation of these diagnoses on the sustainability of the NDIS. Strong incentives indeed!
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The key to improving outcomes for children with autism and developmental delay is quality early intervention in everyday settings. The NDIS struggles to deliver in this regard, specifically because it is using a “medical” model of disability.
The NDIS is unsustainable, as many have pointed out. Individualised funding is too expensive a model for the whole population with disability. Letting the system expand outward at the current rate towards inevitable collapse will harm people with disability. Instead, we need to find cost-effective ways to deliver services to those with needs.
The government has been slow to act on advice from researchers and its own review. The new Thriving Kids program is a good start. Dispensing with the medical model of disability for high-functioning autism diagnoses and developmental delay is a first step. Replacing lifetime entitlements with quality community interventions is key.
NDIS funding for these children is already a sunk cost for the government – redirect these funds towards pathways within existing systems. Provide disability training for professions that interact with children and their families during early development, including early childhood educators and teachers.
Finally, transform the market for service providers into one that assesses function, measures outcomes and acts as a conduit between families and community-based support.
This can stop unsustainable growth in government spending while also achieving better outcomes for children. Breaking the deadlock in negotiations between the state and federal governments is a prerequisite for this to work.
These steps will shift the focus from ensuring lifetime access to money to the long-term wellbeing of children and their capacity to independently engage with society.
Professor Robert Breunig is the director of the Tax and Transfer Policy Institute at the Crawford School of Public Policy.
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