Reactions to the APS Medicare MBS Submission

RAPS has received a lot of responses to our call for people to write to politicians and the APS regarding the recent APS MBS Submission – here are some of them.

Thank you for your email Frances. As a long term member of the psychology profession, and of the APS, I’m frankly angry at the actions/inaction taken by the APS board over the past 12 years. The recent APS Submission to the MBS review panel is a case in point. My concerns are as follows:

1. While you have stated that proposals by other interest groups are not evidence-based, I would put to you that the 3 Tier proposal by the APS has no basis in evidence either. There is no evidence to suggest that non-endorsed psychologists do not have skills in working with complex cases or produce poorer outcomes than do endorsed psychologists. Neither is there evidence that Australian psychologists produce poorer outcomes than psychologists in other countries. This ongoing denigration of the skills of non-endorsed psychologists is causing a huge rift in the profession of psychology, is negatively impacting on the public’s perceptions of psychologists, and reducing employment options for non-endorsed psychologists who have been approved by AHPRA to practise within, and recognise their own, competencies. If we are to be recognised as an evidence-based profession, any submissions that the APS makes must show evidence to support their recommendations.

2. The APS submission contains blatant factual errors. ” A psychologist with AoPE therefore has at least eight years of training” is incorrect. Due to the grandfathering process some years ago, more than 40% of endorsed clinical psychologists do not have a Masters or Doctorate. Many have no more than 4, and some as little as 3 years of university training and some graduated prior to the requirement to complete a 2 year supervision program on graduation. Those who completed supervision via the clinical college for grandfathering may therefore have as little as 5 years of formal training.

3. The 3 Tier model will impact on client access to timely and affordable care, particularly in rural and remote areas of Australia. The majority of psychologists in Australia are non-endorsed (around 60% according to AHPRA), yet according to this model, they will be able to work only with referrals categorised as mild. This constitutes about 10% of total referrals under Medicare (Littlefield, 2017). The other 90% of referrals will somehow need to be managed by 40% of psychologists, most of whom are centralised in urban areas. How will this work given that over 50% of episodes of service (under Medicare) are currently provided by non-endorsed psychologists?

To illustrate: I live and work in a community of approximately 20 000 people, and I receive additional referrals from surrounding towns. We have 4 part-time non-endorsed psychologists and 1 full-time clinical psychologist, who specialises in chronic pain management. My waiting list varies anywhere between 1 and 3 months at any time. Likewise, the waiting list of the clinical psychologist varies between 1 to 3 months. Under the APS 3 Tier model, and according to the data cited above my caseload will be reduced by 90%. Those clients will need to be referred on to the clinical psychologist who, as already pointed out, has a wait-list of 1-3 months now, or to our already stretched community mental health service. There are 3 other non-endorsed psychologists who will have to refer their clients on as well. The most likely scenario is that, with our caseloads reduced by 90%, the non-endorsed psychologists in this community will be forced to close our businesses, further reducing access to services. Clients in need of intervention will be forced to wait for extended periods of time, travel at least 100km to see another psychologist for timely care (at their own expense), or utilise Telehealth. Telehealth is an excellent facility, but it does not solve the problem of access, given that 90% of referrals will still need to be serviced by only 40% of psychologists.

4. The APS have not been transparent in their dealings with members. The submission to Medicare was not made available to members until after membership renewals were due, and 1 day after public consultations for MBS Reviews closed. As a result, members were uninformed prior to making a decision to renew their membership and denied the right of reply to the MBS Review Panel. The APS claims to represent all psychologists but it is clear to me, as a non-endorsed psychologist, that my interests are not being represented. If the APS submission to Medicare were applied, the likely outcome would be the loss of my business and my livelihood. I have worked in the profession for more than 20 years, the majority of it working in various community mental health settings managing patients diagnosed with moderate to severe mental illness. I have invested my money, time and effort training in ICD & DSM diagnosis, EMDR, CBT, Mindfulness based therapies, Psychometric assessment and report writing. Nearly 2 decades ago I was assessed as competent and considered qualified to practise in these areas, yet I can no longer offer specific types of intervention (in which I have accredited training) to clients who see me under Medicare, nor can I provide a report or diagnosis for a client for Centrelink or the NDIS. Now, according to the APS, I am not even competent to manage patients with moderate to severe mental illness, although I did exactly that for most of my career.

I made a reluctant decision to renew my APS membership this year, not because I hold any belief that the APS is currently representing me fairly, but because I believe that I need to belong in order to encourage necessary change. Given the above factors, I remain convinced that the APS needs to make drastic change, and lacking in faith that change will occur. It is unlikely that I will renew my membership next year unless I see evidence of that change. What disturbs me the most is the call for unity in our profession from an organisation whose actions are complicit in creating the divide that currently exists. If your aim is to make psychology a united profession, then the APS needs to ensure that they are treating members with the respect they deserve and with recognition for their competencies as approved by AHPRA. As a member, I am asking you for equitable and fair representation. I will not make a show of unity with an organisation whose actions and words undermine my skills and threaten my livelihood.

Yours faithfully
Lareina Cahill
Psychologist
APS Membership Number: 031948

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Dear Frances Mirabelli,

I am a psychologist who works as a school counsellor within the Department of Education and I also provide psychological services under Medicare through my private practice. I am writing you regarding my concerns stemming from the APS submission to the MBS review.

Firstly, I wish to note that I have been a member of the APS for several years. Throughout my time as a member of the APS I have consistently received notification of APS proposals and submissions on a variety of subjects involving the profession and have been invited as a member to take part in consultation via survey on APS proposals. 
However, for this submission I, along with many of my other registered colleagues, was not consulted by the APS regarding the current submission to the MBS review. I, along with the vast majority of my registered colleagues, had no idea of this proposal to restrict our practice unethically and unlawfully until after close of business on Friday 17 August 2018.

From the time I first got my psychologist registration I have worked within the Occupational Rehabilitation sector treating patients with complex presentations including chronic pain, anxiety, generalised anxiety difficulties, and severe and persistent depression. Whilst working in this industry, the company I was in at that time made me the primary contact to work with the Defence Force assisting army and airforce personnel who were experiencing PTSD and trauma.
I then worked in private schools completing academic and psychological testing of children presenting with developmental difficulties such as autism, ADHD, and learning difficulties. 
Following this I worked in a developmental testing centre alongside paediatricians, again completing psychometric assessments for children with developmental difficulties including autism difficulties, ADHD, conduct disorders, oppositional defiant disorders, and global developmental delay.
After this I established my private practice where I’ve provided services to patients under Medicare who presented with persistent anxiety, depression, bipolar, borderline personality disorder, chronic pain, autism spectrum difficulties, obsessive compulsive disorders, PTSD, trauma including abuse, substance use difficulties, eating disorders, complex grief, and interpersonal difficulties. Many clients I see in my private practice also experience financial hardships and often I am the only clinician available in their area who they are financially able to access for treatment and support.

In order to work as a school counsellor in the Department of Education I had to complete further university training aligned with working with developmental and learning difficulties within the education system inclusive of testing. The work I am currently doing with students in my schools involves supporting students experiencing persistent anxiety, complex grief, persistent depression, autism, obsessive compulsive disorders, PTSD, trauma, physical and emotional abuse, eating disorders, interpersonal difficulties, and complex learning needs. In order to assist students and their families access supports within the education system I frequently complete cognitive and academic assessments which point to developmental difficulties. As you can see, the proposal of the APS for a three tiered model which relegates generally registered psychologists to Level 1 services, essentially the “walking well”, whilst endorsed psychologists test and treat the majority of difficulties most commonly presented by clients, is unrealistic in light of the work generalist psychologists complete with clients daily.

The APS proposal is seeking to stratifying services in terms of endorsement and university specialist qualifications. By doing this, the expertise and skillsets of generally registered psychologists is completely disregarded. Such stratification is ludicrous as both generalist and endorsed psychologists have to complete the same level of supervision and professional development annually to maintain and further their knowledge and skills as outlined by AHPRA. Also, both generalist and endorsed psychologists are only ethically able to practice within their competence (ie a generalist or clinical psychologist with nil to limited experience treating eating disorder is ethically and lawfully unable to treat such as client).

Moreover, disallowing generalist psychologists to provide service to clients presenting with moderate, severe, chronic, and unremitting mental health difficulties is unethical and unlawful. Restricting service would negatively impact vulnerable clients by;

• reducing the number of clinicians available to meet client needs or who can work with specific populations (ie indigenous, low SES, rural),

• causing GPs to refer clients to less experienced psychologists who hold an endorsement due to the clients presenting problem,

• causing potential financial hardship by forcing clients to unnecessarily pay more to access service (ie attend a clinical psychologist, be unable to access a rebate for their preferred psychologist)

• risk to treatment for clients already partway through an intervention

• overall restriction of access and choice for clients to psychologists or other skilled mental health professionals.

My private clients seek me out, and even the most difficult students and complex families in my schools actively engage with treatment with me, not because of what I learnt in a university course leading to endorsement, but because of the skills I have actively honed through practice and enhanced through consult with experienced colleagues and professional learning selected to increase skills in my areas of deficit so that I can practice within my competence, as per AHPRA guidelines and ethical standards.

The APS proposal of a three tiered system is unethical and unlawful as it completely disregards the skills of the practitioner and the rights of the clients to choice and equitable access to service. The three tiered system is not consistent with the requirements of AHPRA or the ethics of practice. It is merely equating experience against the hallmark of a university testamur.

I feel completely disrespected, belittled and betrayed by the APS. The APS on it’s website defines a psychologist with general registration as:

“Psychologists with general registration have a minimum of six years of university training and supervised experience, and build on that every year with ongoing education to keep their skills and knowledge up to date. They are often experts with supplementary skills, experience and training in other areas applying their skills in psychology within a broad range of professional settings. Psychologists with general registration can work in any number of settings and assess, diagnose and treat a wide range of clients and areas of concern. They use evidence-based psychological approaches customised to suit each individual, setting, issue or challenge. They are often called upon to conduct psychological assessments and write reports for individuals, education and forensic settings, health and government departments.” – https://www.psychology.org.au/for-the-public/about-psychology/types-of-psychologists/General-psychologist

Yet, according to the APS submission all my experience and competence as a psychologist means nothing against the hallmark of an embossed university testamur! I am disgusted!

Yours sincerely,

Rebecca Martin
School Counsellor, Registered Psychologist (PSY0001634431), AssocMAPS

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To the Board of Directors of the Australian Psychological Society, and Frances Mirabelli, Chief Executive Officer,
I am writing as a Registered Psychologist and Member of the Australian Psychological Society (APS) for over 20 years to express my overwhelming concern at the impact of the recent APS submission to the Medicare Benefits Scheme (MBS) Review.

Firstly, I am shocked that the group responsible to represent my profession has submitted a proposal which clearly discriminates against the majority of the membership, with no clear evidence or rationale for doing so. I am not aware of any research evidence showing increased effectiveness of treatment provided by endorsed Psychologists when compared to their non-endorsed colleagues. If such evidence exists I urge the APS to make this available to the membership.

It seems clear that further segregation of our profession risks significant harm to our reputation in the health service sector, sending confusing messages to the public and referrers about access to treatment, risking significant disruption to the current treatment system, and leaving many thousands of clients unable to continue therapy with their current Psychologist.

The Mental Health Service Framework proposed by the APS in the MBS submission recommends extending funding for people with complex and severe disorders, which would provide welcome assistance for those who could benefit from more intensive and longer term therapy. However, differentiating which Psychologists are able to provide these services is extremely problematic as:- It impacts on the clients ability to choose their treatment provider

– It ignores challenges in accessing service provision for those with more significant needs
– It assumes academic training alone is an indicator of proficiency working with people with complex mental health needs

Also, the real life experience of Psychologists in the field seems to have been ignored by the APS in this submission. I am the Director and Principal Psychologist of a group practice in Melbourne providing therapy for people with Eating Disorders. Our team of five highly qualified and experienced Psychologists see more than 80 clients every week, the majority of whom have a diagnosis of an Eating Disorder, often with comorbid conditions. Of our Psychologist team one has Clinical Endorsement, one has Health Psychology Endorsement, and three are General Registered Psychologists. All of our Psychologists have significant training in Eating Disorders additional to their academic qualification through professional development, supervision, and clinical experience. If this proposal is accepted by the MBS Review team, I am extremely concerned about the impact on our client group – this change would most likely force many of them to seek therapy elsewhere, from a treatment system in which there are very few providers experienced in providing treatment for people with Eating Disorders.
Lastly I wish to express my dissatisfaction with the APS for this submission, and the lack of representation provided for the majority of the Membership. Unless there is an urgent and significant change in this representation, I will be withdrawing my membership.

Regards,

Name Redacted