3.1.1 Opportunities
Potential for proactive care
There was broad agreement among participants around some key opportunities of embedded provider models, in comparison to fee-for-service models. Participants noted the potential for these models to be more proactive in nature, with a greater focus on preventive care. The potential for financial benefits of prevention was also discussed, with several participants providing examples of instances where they believed the provision of primary prevention activities had contributed to reduced service use at a later stage. There was acknowledgement that individual disciplines were at different stages in terms of implementing preventive approaches, with mental health and nutrition seen as leading the way.
When athletes have easy access to services, they will be proactive… rather than sit on issues, wait for a formalised appointment and then catch the issue too late, then there’s a lot of training missed and big implications.
Health provider
Inter-disciplinary collaboration
The potential for embedded provider models to enhance inter-disciplinary collaboration was a dominant theme to emerge across all focus group discussions. It was noted that health problems in this setting, particularly as they relate to performance, are typically complex and cross multiple disciplines, meaning that collaboration is often necessary to resolve issues optimally. The importance of the distinction between multi-disciplinary and inter-disciplinary collaboration was highlighted:
Instead of going around a medical room: update, update, update; its, let’s look at this athlete and how are we going to get them 3% faster, stronger, whatever the performance challenge is. Put the [performance] problem in the middle and we all come together collectively to solve the problem. When I’ve worked in organisations who transition to truly doing that, you get huge performance gain.
Lead health provider
The ability for inter-disciplinary collaboration to assist with breaking down barriers between disciplines was also highlighted. Participants described the benefits of this collaboration as not only relating to the level of expertise being contributed by those in specific fields, but the nature of the process in getting people to be comfortable in hearing other views that they may not have considered, or that may be in opposition to their own view but shared in a way that works towards finding an optimum outcome, with all relevant information being considered.
To break down some of those barriers you need people to trust each other and be face-to-face, and that takes time out of consulting hours, but it’s incredibly valuable and you can really gain some enormous performance benefits over time with that approach.
Sports manager
Some participants described the flow-on effects of inter-disciplinary collaboration on athlete engagement. Specifically, athletes who observed the process of this collaboration within the context of an inter-disciplinary consultation or assessment, were observed to have a greater appreciation for the complexity of treatment decisions, and the level of time, expertise and organisational resources that were behind these decisions.
You get greater adherence, it increases an athlete’s role and ownership of it, and confidence in the process when they understand the context.
Health provider
The importance of collaboration across both clinical and non-clinical staff was described. Participants perceived a shift away from the belief that the role of health providers was solely to influence health, while the role of performance coaches was to focus solely on performance. There was a general recognition of the significant influence of performance coaches on health outcomes, as well as clinician impacts on performance outcomes. The ability for embedded models of service delivery to promote relationship development between clinical and performance staff was suggested to be a key factor in facilitating this type of collaboration.
My experience with high performance coaches is for the most part they are very relational people, and are often reluctant to engage in support without a sense of the person they’re working with, their motivations, their commitment to the program.
Health manager
Understanding context
The ability of embedded models to allow providers to achieve a greater sense of context was noted as being a key opportunity, relative to fee-for-service arrangements. This includes a deeper understanding of what an individual provider’s role was and where that was situated within the broader high performance strategy for the athlete and the sport. This understanding of context was perceived to increase provider buy-in by providing a sense of purpose and shared goals.
The more embedded model allows the opportunity to understand far better what’s trying to be achieved with the athletes.
Health provider
Duty of care considerations
The duty of care providers felt for athletes in high performance sport was described as being more involved than what typically exists in a private practice setting. The increased duty of care was attributed to the additional complexities in sporting environments. For example, providers are often responsible managing an athletes’ health while they are travelling, as well as having responsibility for whole teams of individuals, where issues affecting one individual may also impact on the broader team. By achieving cohesion and integration across all relevant aspects of healthcare, particularly for mental health issues, athlete outcomes are more likely to be optimised.
If we don’t have all the relevant information, we’re taking really big risks and practitioners can make naive decisions.
Health provider
Creating incentives for proactive care
While it was generally recognised that embedded models had greater implicit incentives for activities such as proactive care and inter-disciplinary collaboration, some participants reported on their experiences in creating explicit incentives to further encourage these activities within both fee-for-service and embedded provider models. This included the provision of ‘billable’ fee-for-service time for non-consultation activities such as attending meetings, gym sessions or performing administrative tasks (e.g. shared care plans), as well as a formal directive for embedded providers to allocate a certain proportion of their time to non-consultation activities.
I’d rather there’s less consulting time, but the consulting that’s done is good quality because there’s a communication with other practitioners, coaches and sports and conditioning staff.
Health manager
It was noted that good integration can be achieved with external fee-for-service providers, but this continuity needs to be prioritised and resourced. An example was provided of a long-term fee-for-service provider who regularly attended competitions, travelled in camps and participated in other activities beyond the traditional clinic-based model. As such, the provider was able to gain a better understanding of the demands of the sport and what coaches needed, as well as allowing the athletes to view the provider as a core member of the team.
3.1.2 Challenges
Capacity of providers to deliver proactive models of care
A perceived challenge to the successful implementation of embedded provider models was a lack of provider capacity. When providers were required to deliver services across a relatively large number of athletes on a limited full time equivalent (FTE) allocation, their ability to deliver high quality and proactive or preventive types of care was likely to be diminished.
It’s more about being able to get access. Access to that expertise, being able to get a management plan continued throughout each athlete’s progression. They can’t be done if we have only 0.1 FTE across more than 40 athletes.
Sports manager
Attracting high calibre providers
The challenges of attracting and retaining highly experienced providers was highlighted as a key barrier to the successful implementation of embedded models. This arises from the disparity in provider remuneration levels available within the government funded sport system, in comparison to professional sports or private practice where providers can receive substantially greater remuneration. It was suggested that it may not be economically viable for experienced providers to be engaged on a full-time basis within government funded sport settings, with most opting to supplement their income through private practice.
There’s only so much you can do… I have to keep enough private work so I can support working in high performance sport
Health provider
We’ve found that 0.4 [FTE] seems to be the sweet spot... you’re embedded enough to have a meaningful impact and do some proactive service delivery, maybe up to 0.6 [FTE]. Anything beyond 0.6 [FTE] you then lower the calibre of the provider, is what we’re finding.
Lead health provider
Lack of specialist expertise
Issues around generalisation versus specialisation as they relate to provider reimbursement models were discussed. It was acknowledged that embedded models are not able to achieve the level of specialist expertise available from external referrals to fee-for-service providers. Decisions, therefore, need to be made about which services to embed and which need to sit outside of that model and can be accessed on a needs basis.
It’s not one size fits all… we need to have the flexibility within the service to enable us to bring in the experts and specialists when required.
Lead health provider
While the lack of specialisation was a commonly perceived limitation of embedded models, the trade-off that comes with this was also acknowledged, with interdisciplinary collaboration and coordination being prioritised over higher-end expertise on an acute basis.
Other types of reimbursement models
In addition to fee-for-service and embedded models, there was some discussion around the potential merits and drawbacks of other types of arrangements. While none of the participants had direct experience with pay-for-performance models, some commented that these types of arrangements were unlikely to be effective in the context of high performance sport. One participant noted the more common use of these arrangements within professional sport, where there was a perceived higher rate of ‘low value care’ provision. Another participant suggested that pay-for-performance arrangements had the potential to be influenced by personal relationships and a provider’s networking ability, rather than outcomes. The potential for cultural issues to arise was also mentioned.
Culturally that would be difficult within the organisation. The organisation may struggle if different providers were engaged on entirely different arrangements.
Sports manager
Some providers discussed being engaged on a ‘daily rate’ or ‘retainer’ type arrangement, defined by the provision of a certain number of hours or level of access to the provider. There were mixed experiences under these arrangements. One provider indicated that the level of services they provided far exceeded the agreed number of days they were being reimbursed for, while another provider felt comfortable that they could provide an adequate service within the agreed terms.
I’m engaged for one and a half days a week, but I’ve tracked my time and it’s way more… it sits more around two and half days’ worth of hours
Health provider
I’m willing to take the risk… they can sign up for unlimited access to me, and I take the risk that I’m good enough at my job that they don’t ring me 10 times a day.
Lead health provider