Wednesday, 9 November 2011
Matters of Public Interest
We are fortunate in this country that health care is, by and large, free and available to all. From last week, however, a needy section of our community does not have that facility and is not resting so easily. On 1 November changes made to the Medicare Benefits Schedule announced in the May budget took effect. Under this budget cut, changes have been made to the allied mental health services available under the Better Access initiative. The Better Access program was first announced as part the COAG's National Action Plan on Mental Health. It began in November 2006 and established Medicare rebates for general practitioners so that they could provide early intervention, assessment and management of patients with mental disorders as part of a GP mental health treatment plan.
Most people with mental illnesses do not have major disorders such as schizophrenia or manic depressive disorder. Much more common are reactive depression and other less serious problems, where treatment and counselling by a GP is more appropriate and a less costly treatment option than referral to a psychiatrist. Previously Medicare rebates were available for up to 12 individual consultations and/or up to 12 group allied mental health services in a calendar year for patients with an assessed mental disorder who were referred by a health professional to a doctor, such as a medical practitioner managing the patient under a GP mental health treatment plan or under a psychiatrist for assessment and management for the problem, or a psychiatrist or paediatrician.
In exceptional circumstances, patients could access an additional six individual services. The Medicare Benefits Schedule defined exceptional circumstances as a significant change in the patient's clinical condition or care circumstances which made it appropriate and necessary to increase the number of services or consultations. It was up to the referring practitioner to determine that the patient met the requirements for exceptional circumstances. Under this initiative, allied mental health services included psychological assessment and therapy provided by eligible clinical psychologists, and the focus was on psychological strategy provided by such people and appropriately trained social workers and occupational therapists. That was then. That was the initiative introduced under the Howard government.
But last week some of society's most vulnerable citizens, those with mental illness, were prescribed a bitter pill. Now Medicare rebates for those with a diagnosed mental disorder under the Better Access initiative will be capped at just 10 individual mental health services per calendar year from the previous maximum of 18. That is one consultation every five weeks. Medicare benefits for medical practitioners have also been slashed. Bulk-billing GPs will now receive a rebate of $126.46 if a care plan consultation lasts more than 40 minutes. A second rebate of $85.92 will now be offered for care plans taking 20 to 40 minutes. Both rebates are a significant reduction on the $163.35 GPs previously received from Medicare prior to 1 November.
Additionally, for the first time, GP mental health care plans will attract lower rebates than care plans for physical diseases. In all, $405 million has been amputated from the Better Access program. Of course, the fact is that dealing with a mental health problem takes more time than dealing with a physical illness in many cases. More time is needed in dealing with a mental health problem at each consultation, as the essence of mental health therapy is just that: time—time for the patient to talk through their symptoms and time for the doctor to give advice. This is because psychiatric illness is very much like an iceberg: what you see painted on the outside is just a small capture of the canvas on the inside, and it does take time to reveal the whole picture.
A three-year review conducted by the Department of Health and Ageing in 2009 found the Better Access initiative had been just the prescription for the mental health community as, firstly, there had been a significant increase in the number of new patients receiving GP mental health plans and the number of providers using the items. Secondly, in general, stakeholder feedback suggested that the significant uptake of the Better Access MBS items indicated a positive response to a previously unmet need. An independent review was then conducted at the end of 2010. It too found that the Better Access program was having a positive influence on a section of the community often neglected. It found that the use of services under Better Access had been high and had increased over time.
In 2007 more than 700,000 Australians—that is, one in every 30—received at least one Medicare rebatable mental health service under the initiative. In 2008 this figure was more than 950,000, or one in every 23 members of the Australian community, rising to more than 1.1 million, or one in every 19 members of the Australian population, in 2009. Australians received a total of 2.7 million Better Access services in 2007, 3.8 million in 2008 and more than 4.6 million in 2009. After accounting for some people who received several services in one year, this equates to over two million individuals, who received more than 11.1 million services over the three-year period from 2007 to 2009.
Importantly, the 2010 review found that around half of all Better Access consumers may well have been new not only to Better Access but to mental health care more generally. Additionally, the evaluation indicated that consumers experienced clinically significant reductions in levels of psychological distress and symptom severity upon completing treatment. Clearly the Better Access initiative was meeting the demands of the mentally ill, bringing more into the doctors' rooms and helping them cope with what for many are often terribly debilitating conditions which impact not only on their personal lives but also on their work performance.
While just 13 per cent of patients go beyond the 10 sessions, the benefits to those clients in alleviating symptoms and in some cases avoiding hospitalisation should not be underestimated. The Australian Psychology Society said in its submission to the Senate inquiry that a survey of almost 10,000 psychology patients who had undergone between 11 and 18 sessions found that 84 per cent had a moderate to severe or a severe disorder at the start of the treatment. In its submission to the inquiry conducted by the Senate community affairs committee, the Royal Australian College of General Practitioners said the changes to the Better Access scheme will be damaging. The college believes that reducing the number of sessions from a maximum of 18 to 10 will likely 'result in the failure of many treatments', adding that 'such a change ignores the research evidence' on the management of mental illness. I add for the record that I am a Fellow of the Royal Australian College of General Practitioners and do strongly believe that GPs have a major role to play in identifying and treating psychiatric illness in the community. The Australian Medical Association commented that in slashing the Better Access funding the government had taken yet another clumsy approach and this was typical of the health policy of the Gillard government.
Better Access, in fact, has become limited access. According to an Access Economics report, mental health is the key health issue faced by young people. According to its report The economic impact of youth mental illness and the cost effectiveness of early intervention, mental health disorders account for over 50 per cent of the total disease burden in Australian youth, led by depression, anxiety and substance use disorders. Each year nearly a quarter of Australians aged between 12 and 25 years—over a million young people—experience a mental disorder. Cuts to the Better Access program are going to affect these people particularly.
The coalition is critical of the government for the way it has undertaken changes to Better Access. There has been scant consultation with key stakeholders to assess the impact of the changes—most especially on the patients it will stand to impact. Instead the government has relied heavily on the Better Access evaluation, which has been criticised for having deficiencies in methodology and datasets. The government has, as it has with many other issues in health and ageing, taken piecemeal action that fails to adequately assess the impact on key stakeholders and, most importantly, on patients themselves. Sadly, this lack of consultation with stakeholders should come as no surprise. Funding for medical services like joint injections and cataract surgery was also recently slashed in a similar non-consultative manner by the Gillard government. Consultation on health policy is clearly not the government's way. Even the recommendations of the independent Pharmaceutical Benefits Advisory Committee on the listing of PBS medicines have been ignored by this government.
The coalition will continue to listen to the community's concerns and will ask questions at Senate estimates in February to gauge the impact of changes to this Better Access program. The coalition has a strong commitment to reforming mental health and will take the concerns of patients, their families and health professionals into account while reviewing policies before the next federal election. Clearly, while the government would have people believe it consults, the reality is that people are left sitting in the waiting room and the doctor is certainly not in for people with mental health problems under the programs of the Gillard government.