Sharon October 24, 2018 at 12:02 pm

MEDICARE REVIEW ON BETTER ACCESS TO MENTAL HEALTH PROFESSIONALS

The Australian Psychological Society (APS) Submissions—Whose interests are being served?

The welfare of all clients is of paramount importance to psychologists. The Australian Psychologists are a large group of psychologists who feel very strongly that the public needs to be informed of their concerns which have arisen as the result of a recent submission by the Australian Psychological Society (APS). The APS has proposed significant changes to the Medicare rebate system for psychology services, which are currently available to clients via the Better Access to Mental Health Care scheme. The APS proposal to the review of Medicare Benefits Scheme (MBS) will directly impact the public. The proposal would effectively reduce access to timely and appropriate mental health care. It would significantly increase the financial cost to Medicare, the Government and overtaxed.

Australia already has a crisis, inadequately servicing the mental health needs of our communities who are experiencing increasing rates of suicide and other mental health-related issues. The government, psychologists and other mental health professionals are endeavoring to provide people with timely and adequate access to mental health services.

Currently, the public can claim Medicare rebates for 10 sessions per calendar year for psychological services provided by a registered psychologist. The different rate of rebates range from $99.75-$146.45 (for a clinical psychologist) and $70.65-$99.75 (for a non-clinical psychologist). This equate to a bulk-billing rebate of $124.50 (for clinical psychologists) and $84.80 (for non-clinical psychologists)

In their recent submission to the Medicare Review, the APS proposed a number of recommendations, including increased sessions for complex cases. This recommendation is commendable. However, APS has also proposed a new item (“new item”)—“Mental Health Assessment, Opinion and Report or Ongoing Management: Create an MBS item for the referring practitioner to refer for assessment, opinion and report, or ongoing management to a clinical psychologist, i.e. similar to MBS item #291 referral to a psychiatrist.”(https://www.psychology.org.au/getmedia/5ee546ee-7a78-4807-a404-45d0d12adca7/2018- APS-submission-Better-Access-following-presentation-aug.pdf)

All Australian registered psychologists are regulated by the Psychology Board of Australia and the government organisation, The Australian Health Practitioners Registration Agency (AHPRA). AHPRA is also responsible for the registration of medical practitioners, nurses and a number of other health professionals. Registration has strict rules, including meeting requirements for competence to practice, continuing professional development, ongoing and regular clinical supervision, and adherence to a strict Code of Conduct.

The new item proposed by APS if put into place would have significant implications for the Australian public needing psychological services, and has the potential to:

Significantly Increase the financial cost to Medicare and the Government and heavily burden the Health and Hospital System—members of the public who are unable to afford or access a clinical psychologist are likely to be admitted to hospitals for ongoing management. Hospitals’ resources will be severely stretched and the quality of service may be compromised.

This will result in major financial costs to the government and Medicare. In the current environment, where suicide and serious mental health cases are increasing, the new item could put clients and the community at greater risk.

Exacerbate the artificial distinction amongst registered psychologists—The proposed new item requires clients to only be referred to clinical psychologists for mental health assessment, opinion, report and ongoing management. The Australian population is multi-cultural and multi-ethnic. They present with a varied and diverse range of issues, which requires help from a range of psychologists. Restricting consumer choice will reduce access for many Australians. It has the potential to discriminate against the most vulnerable population who are unable to access psychological help due to costs. Over 95% of clinical psychologists live and work within 30 minutes of the major cities in Australia. Australians in rural and remote areas with difficulties in accessing mental health services, either face-to-face or online, will have another additional burden to shoulder.

Discriminate and restrict consumer choice—All Australian taxpayers should be entitled to the same rebate when they see a registered psychologist of their choosing. Studies in the USA have shown that it is the qualities and characteristics of the therapist, i.e., “therapist effects” that account for most of the variance in treatment outcomes, and is the most critical factor in the success of the therapy. Adherence to treatment protocols and the type of treatment offered by the practitioner do not significantly account for the variance (Wampold, 2015).

While therapists tended to focus on the technical component, such as their skills and techniques, clients placed high value on the experiential aspect of the relationship, such as being listened to and understood (Wampold, 2015).

When research demonstrates that there is no difference in outcomes for clients from seeing different kinds of psychologists, how is it justifiable for clients seeing non-clinical psychologists to be rebated approximately only two-thirds of their costs?

Create uncertainty around responsibility for clients—If a client is unable to gain timely access to a clinical psychologist (due to increased demands for their services), will the responsibility fall on the referring practitioner to hunt around for an available clinical psychologist? Does it fall on the non- clinical psychologist to remain looking after the client in the meantime? Does it fall on the family of the patient?

A colleague described the uncertainty and challenge that the new item would create:

Recently I had to admit a client experiencing a psychotic episode to hospital urgently. I had been looking after the client for a long time. If the new item proposed by APS is put in place, it would mean that as a counselling psychologist (and a longstanding member and fellow of the College of Counselling psychologists), my client would probably be referred by her GP to a clinical psychologist (who would not even know, or have the experience to look after my client) for assessment, opinion and management. My client had been assessed to be at “risk to herself and others”, and is still in hospital. If my client had to wait to be referred to a clinical psychologist, any delay may have serious consequences.

In proposing the new item, is APS prepared to take responsibility if something untoward happens to the client or others?

Create increased demand for clinical psychologists—As the demand for clinical psychologists increase and the demand for non-clinical psychologists decrease in future, there will be a smaller number of non-clinical psychologists available to look after clients, resulting in greater reliance on clinical psychologists.

As the Medicare rebate for clients of clinical psychologists are significantly higher than that for other psychologists, there will be a blowout to the costs to Medicare, and a greater financial burden on the government. Such a situation will make effective mental health care unsustainable both for the government and the public who needs it.

Add pressure on Referring Practitioners—Referrals are usually made by a general practitioner (GP). The new item is essentially asking the GP to make a definitive diagnosis of an often-complex mental health client, within the parameters of the GP’s practice. Why is APS recommending that GPs refer clients only to clinical psychologists under the new item? This recommendation runs the real risk of undermining the public’s confidence in other registered psychologists.

The creation of a new item that requires referring practitioners to refer clients to clinical psychologists only for mental health assessment, opinion, report and ongoing management have the potential to create a new hierarchy in the health-care system, analogous to that of the legal system that requires clients to engage a solicitor and a barrister to represent them in court.

The solicitor-barrister system is an expensive process, and justice may often depend on financial ability, rather than on merits. Similarly, if it is recommended that referring practitioners refer clients to clinical psychologists only, clients would have to pay for the services of a clinical psychologist alongside their own psychologists (if they are not clinical psychologists).

This recommendation has significant implications for the public, government and the health system.

THE REALITY IN PRACTICE IS NOT THAT BLACK AND WHITE.

Mental health services are nuanced, and tailored to each client’s individual needs and situation, culture and beliefs. A good outcome for a client depends on what their psychologist understands about their individual situation, usually acquired over many sessions, and from developing a good therapeutic relationship.

EVIDENCE SHOWS that good outcomes are not correlated to a referral to a clinical psychologist. Any delay in clients gaining appropriate professional help may result in dire consequences.

The new item proposed by APS has not taken into account the practical implications and serious consequences for mental health professionals and the Australian community.

It is time that the Australian public question whose interests are being served in the APS submissions. We urge the Government and Medicare to seriously consider the implications and consequences of the APS recommendations for all Australians.

REFERENCES

Wampold, B.E. (2015) The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work (2nd edition), Routledge.

These concerns have recently been highlighted in the media: Australian Psychological Society Medicare review submission betrays members and clients (https://theaimn.com/australian-psychological-society- medicare-review-submission-betrays-members-and-clients/)