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Relying on the system keeps you sick

Medicare Better Access Psychology

Everyone is thankful that Medicare allows rebates for psychological services for up to 10 times per calendar year. This means easier access to psychological services hence more people can be helped. However, not all is wonderful. The 2018 budget does not sound promising that things will change for the better. We all know by now that mental health needs strong advocacy and resources to help the 20% of Australians that are effected by a mental heath condition every year, including many children.

This is why I want to share my understanding which has been shaped by scientific training and having worked in private practice for 7+ years in Germany and 8+ years in Australia. I feel significant changes are needed to meet tomorrow’s challenges.

Referral system:

For people to take advantage of the rebates they need to see their doctor, who creates a Mental Health Care plan for them. Does not sound very difficult, but in real everyday life terms the price tag attached to the MHCP is high. Also, Medicare requires patients to go back to the doctor to be reviewed after only six sessions.

Regularly patients report about feeling uncomfortable with the process. Some have feelings of shame, some feel put into a “mental” box, often people resent that suggestions about medication were made quickly (and take a script but not the medication). When due for a review, trying to see the doctor can lead to interruptions the treatment, for practical but also for the psychological reason that “they have to go to the doctor before they get the rebate” creates an artificial gap between session six and seven. This is never a good place when clients are concerned with the external mechanics of the therapy instead of focusing on the internal therapy process, right?

By definition a GP is not a mental health expert, however, is required to make a diagnosis. This does not make sense to me.

Looking back at 8 years I need to say that most of the diagnosis made out in the referral letter are unspecific and therefore are of limited value: the vast majority of all Mental Health Care Plans (MHCP) have either depression or anxiety or mixed anxiety and depression as a diagnosis. Do you see where I am heading?

Further, what is labeled undifferentiately as “depression” turns in reality out as a comparatively simple adjustment disorder. The same label “depression” can mean a recurrent depressive disorder, which in terms of treatment approach, treatment length and treatment steps is a complete different cattle of fish than an adjustment disorder.

There might be a total misconception about the validity of a diagnosis. It is not as straight forward as it seems. It is not just matching up diagnositic criteria with symptoms presented by the client. Symptoms cannot be taken at face value.

For instance, what might at first look like a mild adjustment disorder turns out to have co-morbid trauma problematic or emotionally unstable personality features that keeps the person stuck in problematic patterns. These people require and benefit from ongoing support and a stable therapeutic relationship. A shotgun approach is contra-indicated.

Expecting the unexpected would be a wiser stance, thinking that every diagnosis is provisional. Guidelines should calculate that in.

Another point is, that As a treating practitioner I will do my own assessment. I cannot see any value why GPs should be required to make a diagnosis. A constant observation in my practice has been, that patients referred by GPs, have a higher drop out rate than self-referred patients: they seem to be less motivated to do the work, some only attend 2-3 sessions, drop out. This is the result of inappropriate referrals of clients who are not ready to do the therapeutic work. Inappropriate referral, from my point of view, are the result of a lack of knowledge and understanding by the referring GP. Just because someone presents with a diagnosable condition does not make him a customer for therapy. A lot of monetary resources are wasted by inappropriate referrals.

I come to the conclusion that the requirement of the MHCP cost the tax payer more than an arm and a leg. Referring and reviewing cost a whopping 50% of the Better Access budget, i.e. half of the budget just for the referrals and only 50%  of the allocated budget for treatment. The defeats the intention of the Better Access initiative.

It will be interesting for you to hear, that not all countries require a referral from a doctor to access publicly funded psychological services. Since 1999, when Germany introduced the psychotherapy act, the public has direct access to licensed psychologists, who look after their clients entirely independent of doctors (apart from a check-up to assess physical factors). With that in mind I do believe well trained Australian psychologists would be truely able to case manage our patients fully autonomously.

That would immensely ease the access to psychologist and would free up financial resources that could be used for fund the services. Doctors, of course, can still refer as they would to other specialists. I strongly feel, that a mindshift set has to happen in doctors, that is to refer freely … More to that below.

Demands from doctors to bulk bill

The gate keeper role of GP and the subsequent power differential has created a challenging market condition for us, in terms of how we can set our fees. Doctors have expectations that psychologists do not charge a gap fee and may raise expectations in patients too. Let me explain. In dozens of meet and greets with local GPs the very first question was “do you bulk-bill?”, which means, that GPs have a high priority to communicate their expectation that we see their patients free of charge.

At first sight it might be in the best interest of the patient to save money. The “bulk-billing” mindset however has a hefty price tag to it. First, let’s talk about dollars.

“We’re not in it for the money”: Most would agree that psychologists are not known for being money hungry. But we need to feed families, pay ourselves super, cater for seasonal fluctuation, sickness and holiday leave, pay staff etc.

As some readers know, the fee that is recommended for a 50-60minute consult is $246 (Australian Psychological Society) which is a cost-covering fee. Medicare however, only pays a fraction of that. How much? Only $84.50 for a registered psychologist, $124.50 for a clinical psychologist. Compared to a reasonable charge-out rate I would give the client a whopping $80-100 discount for each session. I hope it is easy to see, that you cannot run a profitable business merely on discounted fees without cutting corners … as they say “something’s gotta give”. Cost have been rising every year, but the Medicare rebates have not been adjusted in 4 years. Not surprising that doctors too regularly moan about the Medicare fees. However, unlike doctors, we cannot compensate. Psychologists are bound to deliver 50 minute sessions, cannot increase the hourly rate by doing “faster” sessions. Hence, I stopped bulk-billing altogether by the end of 2015.

You might be interested to hear what the consequence is if we do not bulk-bill?

Very simple: GPs are not going to refer. How often have I heard “don’t worry, we’ll send you plenty of business”. Zero response. Another example: a doctor who was #1 referrer by far for a very long time, stopped referring altogether after introducing a gap fee.

You may object that people cannot afford a gap fee (as many doctors would put that reason forward). However, this is not the case, by far, based on my observation of hundreds of bulk-billing treatments over 5 years. Your mileage may vary, depending on your demographics, however, I have found that people spend a lot elsewhere and often do not want to pay, or are promised by the referring doctor to be able to see us for “free”.

Some doctors feel entitled to exercise control and to use scare tactics. Recently, when I objected to see a patient who was in a high income bracket under a program for people in need (formerly ATAPS), the doctor still demanded that the patient should be seen for free and lectured me that I should see everyone for free like he did for 30 years and bragged about the million dollar he would charge to Medicare under bulk-billing every year.

This is one example highlighting that doctors can feel safe to cross professional lines. The system has their back. As shown, the power differential between doctors and psychologists is unjustified in terms of expertise and creates lots of costly results without adding value that would balance those costs.

Another point to think about, how are treatment outcomes different for patients who do not pay for their sessions?  It is really motivational 101 that people have an intrinsic drive to get the most of the counselling process when they invest their hard earned. This is also backed up by research.

When I worked in Germany where no gap fee whatsoever is charged, I often wished that people would pay a certain amount, because it increases commitment. People sometimes get complacent if they do not contribute financially. Paying clients invest more in the relationship between therapist and patient. Relationships are about giving and taking. Third party payments, irrespective of clients or therapist’s engagement and skills, weaken this balance of giving and taking.

The artificial 10 session limit

Only a few years back clients had access to 18 sessions per calendar year (in “exceptional circumstances”). Then, from 2014, the government cut the number of sessions to only 10 was justified with a rising costs. Most non-psychologists understand that this number of sessions is not enough. In fact, this number of sessions is entirely inconsistent with any serious research that has been published in the past 3 decades. Treatment that follows arbitrary number of sessions only allows for mutilated for those with the most prevalent disorders (anxiety and depression). Sessions are stretched out beyond what would be indicated.

Just this week, a client told me about a depressive episode she experienced 2 weeks ago. She had called lifeline a few times and felt she was not able to see me, being fearful that she would be running out of sessions. This is nothing out of the ordinary, many clients would benefit from weekly or fortnightly sessions for a while. This is typical clientele in private practice, which should be able to receive the support they need.

It goes without saying that this ultra short-term framework also puts pressure on practitioners and sets unrealistic expectations in patients and referrers. Pressure is detrimental to outcome and is responsible for treatment interruptions.

If the public health is unable to cater for the needs of the community, the result is known as the revolving door phenomenon: people get temporarily better and return the next year, in two years etc. Or they do not get better and get frustrated with the system (or themselves or the practitioner). False economy.

Even an uncomplicated major depressive disorders require some ongoing support, around the 25 session mark.

Some people suspect that the system would be abused by people having sessions that are not required, or that the wrong people (“the worried well”) use up resources. I believe this is entirely far fetched and contradicts my experience and my own simple stats.

When I practiced in Germany with virtually unlimited session (patients have access to up to 80 (eighty) sessions free of charge) the results were as follows:

50% attended 25 or less sessions, the other half attended 45 sessions, with a typical private practice population. Patients are not longer in therapy than needed, and the reason for this is that therapy is work! Therapy is actually asking the client to contribute and to make an effort. In other words, the risk to abuse the system is – from my point of view – absolute negligible.

One question I asked myself was, how German bureaucrats manage to finance up to 80 sessions, at no gap fee for the patient? The answer is that the German health system is funded a little differently, ie. by a certain percentage taken from the salary, and both employer and employee contribute. Yet, psychotherapy is inexpensive and is only about 1% of the health budget.

I think it is a very good idea to learn from those who have already solved the same problem. The challenges we are facing now in Australia will even cost us more in the future, if we do not find ways to use existing resources more efficiently and reform the underfunded mental health services.

 Over-emphasise on medical treatment

I discussed before, that by default, GPs are not mental health experts. When I saw the following statistic, I had to read twice because I could not believe it. According to a RACGP (The Royal Australian College of General Practitioners) statistic, GPs manage a whopping 90% of all their patients with a mental health problem. They only refer 7% of their mental health patients to psychologists, and only 2% to psychiatrists. I would dare to say that could mean that 90% do not get the treatment they need!

(For the time being, remember that it costs the tax payer 50% of the money that is budgeted for Medicare psychology services, only for referring those 7% of the mental health patients)

I am then wondering what kind of help are patients receiving from a GP? There might be some benefit to having a supportive conversation, however that is not specific help.

Clients often report that they feel prematurely suggested to commence medication. This is inline with Australia being second in world in anti-depressant prescriptions. The prescription rates of anti-depressants in Australia appear to have doubled between 2000 and 2011. The topic of over-prescribing is discussed elsewhere. Based on my observation that diagnosis made by GPs are not necessarily accurate, I have concerns that medications are too often given for the wrong purposes (e.g. adjustment disorder, mild forms of depression etc).

It is a fact, that medicating depression as the sole treatment is not at all backed up by research. As if that was not enough, anti-depressant medication is yet to prove that is superior to a placebo (a pill without a effective agent)! Ethical treatment is much than taking pills, I’m afraid.  “Drugs may treat symptoms but they do nothing to help people navigate depression, appraise and manage stressors, or critique the validity of their negative thoughts. A prescription for antidepressants might fulfil a physician’s clinical duty of care on current guidelines, but drugs alone fall short in the moral domain”, Paul Biegler says (MBBS and researcher at Monash University).

Why in all the world is the practice of drug treatment so widespread and publicly funded, despite not being at all supported by research? Is it that people just want to pop a pill, like in the pro-verbal fat burning pill, that never existed and never will?

Former Australian of the Year Professor Patrick McGorry said in 2013 “One factor that might be relevant is that Better Access was reduced in scope a couple of years ago, so the number of sessions funded under Better Access was reduced from a maximum of 18 down to 10” and “My impression is that they really feel they need to be doing something but there is that pressure. We know that for many GPs they can only spend eight to 12 minutes with a patient and it’s simpler to write a script for that time,” he said.

What I take from McGorry comment, is that time poor GPs help their patients best by referring them on to psychologists as early as possible.

Some clients need psychiatric care as well. Unfortunately, psychiatrists in private practice are hard to come by and often quite pricey. An hourly rate of $400 is not unusual, leaving a tangible gap for the patient. However, patients have access to 50 (five zero) rebates with a psychiatrist per year, which does not make sense to me, considering that seeing a psychologist with a much broader scope of help is limited to 10 visits.

The taxpayer would save a lot if we could see people more often and we could do much more effective work than we are now doing (by reducing the revolving door effect) I dare to say, psychologists would deliver a very good return on investment.

 Summary

The option to receive Medicare rebates for psychology services is an important part of public health. However, I hope it is easy to see that the current medical dominance as outlined here is an outdated model of help. The conditions under which psychologists and private practice owners operate, limit the effectiveness of our services unduly and unnecessarily. Bulk-billing at the current rates is not a sustainable practice. The powerful gatekeeper role of GPs is costly and false economy.

If we do not know how to take the next step, it can be wise to find someone who has already overcome similar struggles. It can be wise to look for support. I have worked for over 7 years under German psychotherapy guidelines, which have been effective since 2000. Psychologists can provide the treatment that patient need, and the patient can trust to be able to receive sufficient treatment. At no cost. Let’s be clear: Psychotherapy is cheap in the bigger scheme of things. It cost the German taxpayer approximately only 1% of the health budget, not too much, hey?

My hope is that we allow ourselves to be inspired and to think big. My vision would include:

•  Psychologists to be the first point of contact for diagnosis and treatment planning.

•  Make short visits possible for those in crisis or those who need ongoing but low intensity support. Allow for 24 visits of 25 minutes each would also reach out to clients who need less support or have motivational barriers.

•  Allow for short and long term psychological therapy/psychotherapy, e.g. 60 sessions over a two year period (perhaps subject to approval by independent assessor).

There is plenty of room to utilise our excellent resources that we already have. We have highly skilled and motivated psychologists that are able to help a wide range of people effectively. The close knit interaction between body and mind suggests strongly that mental health should have the same standing in public health system as physical health. We can all help getting there.

Frank Breuer, Clinical Psychologist

Newpaths Psychology