APS Green paper – clear as mud 2

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Anyone expecting a rigorous Green Paper from the APS’ hand picked expert committee will be bitterly disappointed. They are proposing to roll out mental health services to millions more Australians at unknown cost, yet give no evidence that this intervention might help them. Instead of citing Pirkis et al. (2011), which clearly demonstrates that mental health treatment is effective, they squib the issue with weasel words like “..has the potential…”. This omission is vitally important given the paper’s stress on ‘cost-effectiveness’. If you want to talk about that, you have to measure the effect.

So what does the APS and its expert committee actually know about the effects of mental health treatment after 13 years of Better Access? Well, they know that a lot of psychologists collect before-and-after measurements and they believe that it’s “imperative” for the Australian Government to analyse these. Why? Shouldn’t the APS take some responsibility here?

The rest of the paper shows how out of touch the Society is with its members. They received submissions from about 2% of the membership and completed surveys from 14%. Why so low? This is a very important issue which will affect psychologists’ incomes and practices for decades. Have members given up on the idea that the APS will take any notice?

This is not to say that they haven’t come up with some sensible and reasonable suggestions which include:

– payment for psychological assessments
– payment for collaborations about payment care
– improved access to telehealth for patients who cannot attend a practice (e.g., agoraphobia)
– improvements to the administration of group therapy, and
– better systems to promote continuity of care.

But what you’re all waiting to hear is “Will there be a two-tier or a one-tier system?”

Neither. That’s right. It’s going to be a three-tier system.

The model follows the governmental approach to stepped care delivery in which patients are divided into mild (40%), moderate (40%) and severe (20%).

The ‘mild’ category of patients would attract an item number which would be open to all psychologists. This means consumers in this category who are now receiving treatment from a clinical psychologist would attract a reduced rebate (p.40).

In the ‘moderate’ category there would be two possible approaches – treatment from any registered psychologist at a lower rebate, OR treatment from psychologists with a relevant Area of Practice Endorsement (AoPE) or a practice certificate which would make them ‘Registered Psychologists Plus’ who would then receive a higher rebate. The word ‘relevant’ is undefined and may not include YOUR area of endorsement.

In the ‘severe’ category, treatment would be ONLY be available from psychologists with a relevant Area of Practice Endorsement (AoPE) or a practice certificate designed for non urban areas which would make them ‘RRR Registered Psychologists Plus’. These two categories of practitioner would attract a rebate which would be 70% higher than the lower level rebate. The word ‘relevant’ is undefined and may not include YOUR area of endorsement.

The term AoPE can apply to a wide range of psychologists e.g., Health, Educational, Counselling and so on. It is not limited to people with clinical qualifications. As the authors of the paper rightly point out – opening up these certificates to psychologists with a wide range of qualifications will improve access and increase the patients’ chances of finding a suitable practitioner. The only drawback here really is how many psychologists are there left with AoPEs other than clinical?

So this leaves us with two questions:

– What is involved in these practice certificates?
– Who decides the patient’s level of severity?

Turning first to the practice certificate question.

There are supposedly going to be two – an Advanced Mental Health Certificate and a Regional, Rural and Remote Practice Certificate. Detail on content is scarce because it all remains to be negotiated with Medicare, but it is “.. anticipated that these certificates will consist of approximately 40 hours of online/face to face training (or recognition of prior learning), assessments and supervised practice” (p.40). Given that only people who hold the one for Regional etc Practice will be allowed to treat patients rated as ‘severe’, it’s possible that there will be some difference in content, but that’s not explained. Would people who practised in Sydney or Perth be allowed to hold a Regional, Rural and Remote Practice Certificate so that they could treat severely ill patients? We don’t know.

While this certificate system looks suspiciously like the bridging courses that many members have been requesting for years, it’s not at all clear what’s involved or how much it will cost. Would members be expected to pay for a certificate? If so, how much? The workload involved in setting up and running these courses, especially in the first few years, would be formidable. If there are 35,000 registered psychologists and 70% of them are interested in getting a certificate that means 24,500 people being put through courses presumably not yet written. Probably training providers would need to be sourced and accredited (and paid) right across the country given that face to face learning is an option.

Moving to the next issue – the patient’s level of severity.

Level of patient severity is the key to the proposed system with rebates (and qualifications of approved providers) varying according to degree of severity. Unless you want to have a marked increase in the severity of mental health conditions, and a big cost blow-out, the system must include a method of rating patients which is independent of the treatment provider. If you are going to be paid 70% more for treating someone with a moderate or severe condition, this creates a strong temptation to rate them upwards. You might not boost the severity level, dear reader, but there are always unscrupulous practitioners who would do just that. So this unfortunate fact of public administration means that some kind of agency or rating body needs to be set up to handle this part of the proposal.

Another problem is the stability of the rating. As all practitioners know, the patient’s level of severity can fluctuate markedly in either direction. Someone can come in as a ‘worried well’, only to suffer a psychotic break and become very seriously ill. Does the practitioner then seek a reassessment and possibly a referral to another practitioner who can treat people at the severe level? Similarly one would hope that people with severe problems would benefit from the treatment to the point where their condition was mild towards the end of treatment – how will the last few treatment sessions be paid?

Summary
While some attempt has been made to deal with the problems of the current two-tier system, the proposed replacement is cumbersome, bureaucratic and unworkable.

Reference:

Pirkis, J. et al. (2011). Australia’s Better Access initiative: an evaluation. ANZJ
Psychiat., 45, 726-739.