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  1. 1

    Daniel

    Thank you for the article, its a topic of significant importance. The government supports for mental health care are certainly complex and important – the data on the impacts to the economy and the personal impacts on individuals are very clearly established.

    unfortunately it is not a system that is susceptible to simple analysis as Dr Rosenberg points out. I am not aware of NDIS plans coming out with more than 50 psychological sessions outlined – and it would be very uncommon very a plan to specify hours allocated to particular disciplines. More commonly it is an overall allocation to be spent through the persons choice on the therapy types that are most important to them including Speech Therapy (inc. swallowing issues), Physiotherapy, Occupational Therapy, Psychology and others under the Allied Health umbrella. Generally speaking larger allocations that are relevant to Psychologists involve the development of behavioural assessments and management plans which require intensive work to establish (frequent average of 30 hours) with ongoing monitoring of restricted practice to prevent abuses. In contrast to this severe disorders seen by Psychiatrists under Medicare have a cap of 160 sessions per year (Item 319) which is a systemic blanket approval by diagnosis as opposed to individual planning. Perhaps a more suitable alternative given the wide variety of needs within people who experience mental health issues is to shift to a full NDIS model, genuinely accept people with psychosocial disabilities rather than have a very challenging battle to get on to the program and then be denied significant funding under the instruction of: Medicare should fund that. If Mental Health items were removed entirely from Medicare and reallocated to NDIS and the program expanded to include Psychiatric expertise (unfortunately it currently excludes it) it would create a platform of individual planning which could encompass multidisciplinary teams as required and as directed by the individual.

    As pointed out, the NDIS rates are substantially higher than the Medicare rates for Psychologists. The NDIS rate for example is 72% of the recommended rate by the APS where as the Medicare rate is 34% of the recommended rate. Comparatively, this Medicare rate is 45% of the Psychiatric rate under #319 or 24% of rebate under #352. The advantage of the NDIS system in this respect is that it also prohibits ‘gap fees’ – under the Medicare system the gap fee’s are usually more than the rebate itself in order to make a practice viable. Whilst NDIS has a higher rate this exclusion creates a fairer system that provides universal remuneration for the same service provided and acts as a substantial protection to the participant.

    Unfortunately, the Medicare rate is not very useful as a benchmark as it doesn’t reflect the cost of practice. Current practice recommendations are to work at 66% productivity – in practice this means for every hour a client is seen, 30 minutes of correspondence, report writing, care collaboration and other non-remunerated tasks are required. For an average work week, that means a maximum of 25 billable hours per week. If bulk-billing is done for this service, that is a maximum of 25 hours at 34% of the recommended rate or $2120 per week. In many areas this would not be sufficient to pay rent for the premises and utilities let alone a wage as well.

    One of the recommendations to come out of the review process was the establishment of outcome measures to be completed as a required part of treatment under Medicare. The development of a national minimum data set in this areana will hopefully provide some of the efficacy information that is so vital to ensuring that programs assisting people continue.

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  2. 2

    Dano

    You are focusing quite heavily on Psychologists and characterising the normal operation of market forces in Psychology as a negative thing – it actually means there is demand, and the community is accessing service. The fact of repeat clients is easily explained by the nonsense of applying the medical model in psychology – psychology is effective, evidence is in. But it’s not medicine. It’s barely a science and almost as mystical as psychiatry! Let’s be transparent here and not blinded by assumption or misinformation. Anyway, on psychology in MBAS, Government commissioned an outcome study and it is published on the health website [http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-ba-eval-sum].
    It showed that Psychologists regardless of training pathway/title saw internationally comparable improvements in clients across mild, moderate and severe categories.

    You have implied that there is a terrible situation in MBAS because outcome data for psychological services is not collated by Government on an ongoing basis, thus raising the question is there value for money (singling Psychology out for special criticism here despite ongoing measures not existing for any other primary, specialist, or allied health!

    Aside from missing the fact there is value for money as evidenced in the Pirkis study, what you have also failed to provide in your essay is an exploration of the cost and benefit of all other aspects of mental health care provision in Australia for a comparative analysis. For example, the cost of GP and psychiatry involvement in mental health – an incredibly expensive field, with vast access to Medicare funding, almost wholly based on a fee for service model, with treatment in isolation, and with outcomes not measured at all. They wrote a staggering 35.7m mental health drug scripts 2016/17 for 4m patients (GPs wrote 87.4 of them; Psychiatrists 7.9% ). 70 percent of these were for anti-depressants.

    How about some balance. Some sophistication in analysis. And some critical thinking – from the ground up. The model is wrong – I agree. But not for the reasons you have articulated.

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  3. 3

    Professor Emeritus Henry Jackson

    This is an important, very carefully written and considered article. As Dr Rosenberg states Better Access (BA) was poorly set up. It was, and continues to be, riddled with problems. No doubt the intention to provide treatment for diagnosed common mental disorders was a good one but from its inception it was beset by issues pertaining to the fee for service model, which psychologists were best trained to provide this service, the number of sessions available, who made the diagnosis, issues around the mental health plan,and a problem pertaining to geographic maldistribution of psychologists (which to be fair also affects medicine). The so-called evaluation in 2011 was in my opinion inadequate. An important point that I have made elsewhere previously is this: BA was intended to provide care for those unable to access treatment for those common disorders. Instead there are at least some instances I am directly aware of, where psychologists increased their fees following the implementation of BA, thus rendering their service unaffordable for those most in need.

    The MBS Medical Benefits Mental Health Reference Group (MHRG) has now recommended treatment ‘at risk’ for common mental disorders. On the surface this might seem appealing but my reading of the MHRG Recommendation is that it a very poorly conceptualised and structured item. Perhaps I am being too suspicious of the intentions of the MHRG but I suspect this Item (if accepted), will be open to abuse by some practitioners.

    In the Interests of transparency I should state that I am a clinical psychologist and have trained many clinical psychologists over the years. Given my misgivings about the scheme, I have never registered to practice under the BA scheme.

    Reply

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