Since the May budget, when the Federal Government announced that $1.5 billion in mental health investments over the next five years would be partly funded by a redirection of $580.5 million from the Better Access program, the cries of outrage have been growing.

Any number of professional groups have been crying foul, including those representing doctors and psychologists, and many community voices have also joined the chorus of concern.

There are now 141 submissions on the website of the Senate Community Affairs Committee’s inquiry into Commonwealth Funding and Administration of Mental Health Services, and no doubt more in the mail (the full terms of reference for the inquiry are at the bottom of this post).

However, the issues involved are more complex than the “government cutbacks” mantra being waved by many of the protesters, and go to fundamental questions about equity, and the fairness and sustainability of fee-for-service models of care. They also highlight the challenges of meeting the needs of those who often miss out on services, and whose needs therefore are not always at the forefront.

In the article below, Dr Tim Woodruff, Vice President of the Doctors Reform Society, provides some of the background to the issues involved, and suggests that if we really care about equity, we should be having a much more wide-ranging look at how health services are funded.

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It’s time to focus the debate on the systemic issues which contribute to inequity

Tim Woodruff writes:

In the May Budget there was a major mental health funding initiative. There were some small cuts to current programs, and significant expansion of others.

Two of the programs affected are aimed at providing short-term psychological treatment. What do the changes tell us about the direction of Government policy?

The Better Access initiative was introduced in 2006 and finally recognised the importance of psychologists in the treatment of mental health disorders.

Funding is through a fee for service Medicare rebate for each visit to the psychologist at the bequest of a GP who receives a rebate for collating a Mental Health Plan.

Whilst each visit to the psychologist generates a Medicare rebate, it is different from the fee for service arrangement for seeing GPs, or specialists, or having surgery, in that the number of visits with the psychologist is capped. Ten sessions and it’s over. It is very popular and the number of patients involved has been increasing about 20% per year.

Another initiative introduced in 2003 also recognised the importance of psychologists and funded access for short-term psychological treatment. This program (ATAPS) is tiny, less than $50 million per year compared to Better Access, which costs about $550 million per year.

Funding for ATAPS is completely different. The money is distributed to Divisions of General Practice (now Medicare Locals) to administer in ways which suit that Division. The amount is largely determined by population. The aim however, has been to provide services to groups which had been identified as not accessing much care at all, ie rural dwellers, young people, and indigenous Australians.

There are significant differences in the programs, which in part reflect the funding mechanism. ATAPS delivers 45% of its services to people in rural and remote Australia. Better Access delivers 25%, similar to the delivery of other Medicare rebate services.

Patient copayments are zero for over 75% of patients in ATAPS and where they do exist, they are between $5 and $20. For Better Access however, only 35% of psychology consultations have no copayment and the average copayment is $35.

Given these figures it is not surprising that use of Better Access is 10% lower for the poorest fifth of the population compared to the richest. That should be of concern as it is well recognised that health status and outcomes are inversely related to socioeconomic status.

One might however, regard the programs as complementary. That is the Federal Government view. Better Access provides the majority access to psychologists and ATAPS picks up the pieces. ATAPS is the safety net for the fundamentally flawed funding mechanism of Better Access.

Fee for service with copayments almost guarantees some patients will not be able to afford the treatment. The capacity to charge fee for service plus copayment contributes to providers staying in areas where they can get copayments, rather than working in poor and rural areas. With continued financial and geographical barriers to access guaranteed, the safety net of ATAPS is crucial.

It all sounds very familiar. General GP and specialist services in the community have been funded that way since Medicare was introduced. Safety nets and targeted programs abound but financial and geographical barriers to access persist. The ABS Patient Survey 2009 showed that 6.4% of average Australians delayed or didn’t see their GP because of cost. The Commonwealth Fund Survey of sick Australians showed that 23% didn’t see the doctor or get follow up because of cost.

Apart from problems with access, there are other concerns with Better Access and with fee for service funding generally. The first is the issue of flexibility to meet local needs in innovative ways. It is identified by the report on ATAPS by the Department of Health and Aging

The current ATAPS initiative enables Divisions to utilise a model of service delivery that meets local needs.

Better Access, as with all Medicare subsidised services, offers a universal model (that is the same model for the entire Australian population) and does not have the flexibility to be modified to meet the needs of sub‐populations. It is recognised that Better Access mental health services are not always accessible to all consumers’

The second is the issue of over-servicing. This is a potential problem with any professional trained to manage a problem. There is the possibility that such a professional can have more faith in his/her knowledge and skills than the evidence suggests is justified. This can be exacerbated by patient expectations that something should be done. It is compounded by the often-siloed nature of medical practice.

Thus in the United States it has been found that one in every eight non-urgent but quite dangerous and invasive heart procedures for patients at risk of heart attack were not really justified by the evidence. In Australia it’s been shown that following a heart attack one is much more likely to get an operation in a private (fee for service) hospital than in a public hospital next door.

The same concerns exist for both the Better Access and ATAPS. The uncapped and siloed nature of the Better Access program combined with the fee for service remuneration for providers makes that even more of a concern when compared to ATAPS.

The May Budget cut Better Access funding in two ways. Firstly it reduced the rebate for the GP assessment, partly because the evidence indicated that the assessment was generally taking much less time than anticipated. Secondly it reduced the number of psychology consultations from 12 to 10, partly because the evidence was that the average need was for only 6 sessions. Clearly these cuts were also about saving money.

In addition, the funding for ATAPS was doubled (still very small). This was recognition that a better safety net was needed. Overall, the changes are minor.

They do move more in the direction of equity and efficiency but there is no underlying aim to achieve equity. The cut to the rebate for the GP assessment ignores the fact that many GPs working in the most difficult areas use this large rebate to cross subsidise the psychologist eg through reduced rental fees for the psychologist. But that is of no concern to a bureaucracy intent on saving money. It also is a further reflection of the flaws in the funding model.

Safety nets are only needed when the basic structure is flawed. Better Access has delivered some great care to many people. Almost every new health funding program will help some people. Even the PHI rebate and the Extended Medicare Safety Net have helped some people access services they would not otherwise have accessed.

But do we want an efficient use of health funds? Or do we want to keep on chasing the gaps in service left by a flawed funding structure?

ATAPS, a fundholding arrangement rather than a fee for service system, delivers to the most needy. It could be expanded slowly to be a major component of our health system.

The allocation of funds could be on the basis of need rather than just population. The resistance to such an expansion will continue from the AMA because it is seen as a potential threat to the independence of doctors. This is despite the fact that health care is increasingly complex and requires the cooperative approach that is facilitated by fundholding and frustrated by siloed practitioners.

The resistance by Government to such an expansion reflects a belief that safety nets and programs are the way to address problems, that targeting the worst is the way to reduce inequity.

It probably also reflects a belief that private provision of services under fee for service, rather than the much more obviously public provision under fundholding, is the right way to go, despite the evidence of the demonstrated failure to achieve equity after over 20 years fiddling trying to address the problems of such total reliance on fee for service funding.

The alternative is to aim for equity. Equity is not equality. It is addressing the preventable causes of inequality. It is not about targeting the most disadvantaged. It is about removing any disadvantage that is due to systemic factors over which we have control.

That is possible, and we can do it by looking at major structural changes to how we fund our health system.

Gradually increasing our use of fundholding and decreasing our dependence on fee for service warrants much more serious consideration than it has been given to date.

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PS from Croakey

The Terms of reference for the Senate inquiry are:

The Government’s funding and administration of mental health services in Australia, with particular reference to:

(a) the Government’s 2011-12 Budget changes relating to mental health;
(b) changes to the Better Access Initiative, including:
(i) the rationalisation of general practitioner (GP) mental health services,
(ii) the rationalisation of allied health treatment sessions,
(iii) the impact of changes to the Medicare rebates and the two-tiered rebate structure for clinical assessment and preparation of a care plan by GPs, and
(iv) the impact of changes to the number of allied mental health treatment services for patients with mild or moderate mental illness under the Medicare Benefits Schedule;
(c) the impact and adequacy of services provided to people with mental illness through the Access to Allied Psychological Services program;
(d) services available for people with severe mental illness and the coordination of those services;
(e) mental health workforce issues, including:
(i) the two-tiered Medicare rebate system for psychologists,
(ii) workforce qualifications and training of psychologists, and
(iii) workforce shortages;
(f) the adequacy of mental health funding and services for disadvantaged groups, including:
(i) culturally and linguistically diverse communities,
(ii) Indigenous communities, and
(iii) people with disabilities;
(g) the delivery of a national mental health commission; and
(h) the impact of online services for people with a mental illness, with particular regard to those living in rural and remote locations and other hard to reach groups; and
(j) any other related matter.

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