The APS Survey Finally Opened and another Submission Template

The APS survey for members on Medicare funding is finally open. RAPS encourages all APS members to complete the survey here

In addition, RAPS encourages all APS members to raise their voices by writing a submission of less than 2000 words to the APS MBS Expert Committee. Written submissions from members will be accept until February 1, 2019.
Send to: mbsconsult@psychology.org.au
We also suggest you send a copy of your submission to the Health Minister Greg Hunt and the shadow Minister of Health! Catherine.King.MP@aph.gov.au; Minister.Hunt@health.gov.au

Below is a suggested template only. Everybody needs to write and express their own opinions.
APS MBS Expert Committee Submission Template

Name:
APS member number:
I am an APS member who would like to express my concerns regarding the two-tiered rebate of the Medicare Better Access Program and the Stepped Care Program.

Executive summary

Summary your of points and recommendations

Medicare Better Access

One tier system
– all the other allied professions are on a one tier
– privileging one group of psychologists over the others implies that their qualifications, skills and experience are inferior
– privileging one group of psychologists over the others is discriminatory
– I propose removing the two-tier rebate system in favour of equality and a single Medicare rebate for psychological services.

A single-tier Medicare rebate for psychological services will:
1. Decrease the cost of psychological services to the public eg gap payment.
2. Significantly increase the number of Australians able to access psychological support. A higher single tier will allow more psychologists to either fully bulk-bill or lower the amount of out-of-pocket costs for patients.
3. One tier Medicare system is vitally important to people in rural and remote areas where clinical psychologists are difficult to find.
4. Redress the partisan bias that favours one group of psychologists over others – unprecedented in Western countries ¬and unsupported by any evidence of superior outcomes.
5. Allow patients to choose psychologists on a therapeutic needs-basis rather than choosing a psychologist based on a higher rebate.
6. Utilise and uphold the extensive depth and breadth of clinical practice expertise found within the broad scientific community of psychologists registered to practise in this country.
7. Ensure an increased availability of affordable, effective psychological assistance and reduce numbers in the public health system.

Evidence based
– there is NO evidence that clinical qualifications produce better outcomes for patients.

Bridging courses
– A ‘bridging program’ is implicit admission that ‘clinical’ psychologists have higher skills and abilities
– In fact, general registration in psychology is a licence to practice the full scope of psychology, thus it confers the title ‘clinical’ on all registered practitioners. These develop further their skills as they practice – through experience, CPD, peer consultation etc. Thus, all should be upgraded to the higher rebate.
– Research conducted on the Medicare statistics to calculate how much more it would cost to lift all psychologists to the highest rebate indicates that it would cost approximately $100M/p.a. (peanuts in the larger scheme of things).
– Once a sector of psychology is paid more, people interpret that as meaning that they are better.
– Higher rebate for all psychologists would mean that more clients would benefit from psychological treatment instead of seeking the smaller number of the ones perceived currently as more skilled.
– Psychologists would welcome a possibility of studying to develop further their field of competency, which may have been chosen or that has emerged out of their practice. Some might seek competency in a new field if an appropriate course was available. However, that should be a choice and remain independent of the issue of higher rebate for all.
Impact on the profession
– the impact of the two-tiered system has been devastating to the psychology profession as it discourages diversity, creates disunity and has resulted in restricted avenues for study.

Impact on the general public
The two-tier system limits access to experienced practitioners who are unable to practise in areas where they have specific expertise. Clients are also restricted in their choice of practitioner due to arbitrary and discriminatory distinctions.

Stepped Care Model

• The stepped care model needs to be more carefully considered as it has been trialled internationally with mixed results. For example, UK research by Richards, Bower and Vasilakis suggests that attrition rates from services are no better with stepped care and referrals of people up to more severe treatment levels are low.
• The Stepped Care model does not favour client choice.
• The Australian version of the Model does not have adequate evidence to support it
• It would be irresponsible for the APS to support a model that has been inadequately researched, has limited evidence to support its efficacy and has not been thoroughly investigated as best practice in psychological care. Such an approach is reactive and unlikely to result in improved access to mental health services.
• The Stepped Care model also promotes an elitist approach within the psychology profession. This encourages discriminatory practices within the profession and will promote further disunity within the profession. It is questioned why the peak body for all psychologists would support such an approach when its mandate is to act in the best interests of all its members.

Conclusion

– Provide a conclusion eg a single Medicare rebate for all psychologists providing the same services.

 

Yours sincerely,

Some more information for you to consider:

What is a ‘generalist’ or ‘registered’ psychologist?
All registered psychologists are trained in diagnose, assess and treat, regardless of whether they are clinically endorsed or not. Some psychologists choose to apply for endorsement in a particular area. Many of these endorsement areas are relevant to servicing a wide range of mental health consumers under the Medicare Better Access program. In Australia, we have nine areas of endorsement but only clinical endorsement attracts the higher rebate. Registered psychologists represent by far the majority of the Australian psychology workforce. In September 2016 there were 27,791 (79%) registered psychologists (incl. 3,725 other endorsed) compared to 7,620 (21%) clinical psychologists (AHPRA: 2016).

Relevantly, the Psychology Board of Australia (PsyBA) via its parent body the Australian Health Practitioner Regulation Agency (AHPRA) presently offers endorsements in areas of practice and other equally valid and effective pathways to registration. All psychologists experience advanced training with supervised practice. Further, all registered psychologists are required to undertake Continuous Professional Development (CPD) that is relevant to the scope of their practice.

Beyond the notion of Area of Practice Endorsement obtained via a more pedagogical educational process involving university masters courses, there is currently a supervised practice pathway to registration in Australia. This captures and effectively utilises more of the diversity available among students and thereby increases the overall validity of the training process. One reason for this is that some students are more aware of and more specifically targeted in their learning needs than others. Such students are more appreciative of training systems where they can experience far more situated practice combined with a genuine reflective action research oriented approach in which they can begin to develop their own practice.

There are three key reasons why all psychologists have equivalence in practice expertise:
1. All psychology pathways to registration and practice are subjected to rigorous development and stringent monitoring to ensure the same baseline competencies are upheld;

2. Expert clinical practice involves a complex mix of practice experience, supervision and professional development as key variables in treatment outcomes – beyond academic qualifications; and

3. Yearly registration ensures all psychologists have extensive formal requirements across practice experience, supervision and professional development to ensure practice expertise continues to build post-graduation.
Unlike specialities in medicine, the notion of clinical practice in psychology is not unique to clinical psychologists. Psychologists who have gained registration from many different training pathways are engaged in clinical practice every day in Australia, treating people across a very broad range of conditions and levels of severity. The skills to diagnose, treat mental illness therapeutically, and produce effective outcomes are not unique to one area of psychology. Once again, this is highlighted by the scientific evidence. Importantly, there are a number of different pathways to registration to practice as a psychologist in Australia. Psychologists, participating in and completing these pathways, all experience advanced levels of training and supervised practice. All psychologists are required to complete Continuous Professional Development that is relevant to the scope of their practice and interests.

A notable research project commissioned by the Australian Government (Pirkis et al, 2011) incidentally provided evidence of equivalency among psychologists. Psychologists treating mental illness across both tiers of Medicare Better Access produced equivalently strong treatment outcomes (as measured by the K10 and DASS pre-post treatment) for mild, moderate and severe cases of mental illness.

There was no observed difference in treatment outcomes when comparing clinical psychologists treating under tier one of Medicare Better Access with the treatment outcomes of all other registered psychologists treating under tier two of Medicare Better Access.

Do clinical psychologists see clients with higher complexity or severity of mental illness?
Myself and many psychologist colleagues have worked in mixed practices and found that clinical and non-clinically endorsed psychologists see very similar clients. Psychologists generally see clients based on their areas of interest and training, such as working with children or clients experiencing specific mental health conditions, clients with intellectual/developmental disability or certain health conditions.

Far from focusing on those high-intensity patients, the caseload of endorsed clinical psychologists in private practice closely resembles that of their lower paid colleagues in clinical practice who are, according to all available evidence, achieving the same or better outcomes.

Should there be two categories for psychological therapy?
There are two different categories for therapy under the Better Access program: Focussed Psychological Strategies (which covers what non-clinical psychologists can use with their clients, however OTs, GPs and Social Workers can also use these strategies); and Psychological therapy services (clinical psychologists only).

Fully-registered and qualified psychologists should not be restricted to deliver the same services as other allied-health professionals who are not specifically trained in psychology. Every psychology degree includes a number of units of counselling and therapy and all psychologists are required to deliver interventions under supervision during their 4+2 / 5+1 internships or masters/doctoral programs. All psychologists completing their internships via these pathways must demonstrate competency in eight core areas of clinical practice, including ethical, legal and professional matters, psychological assessment and measurement and intervention strategies.

Focussed Psychological Strategies dictates a restrictive set of psychological techniques (See Appendix A). All psychologists are educated and trained in the main therapeutic approaches of psychology and psychotherapy. However, many of us have completed further non-university based study in areas such as Acceptance and Commitment Therapy, Schema Therapy, Trauma-Focussed Therapies, Narrative Therapy etc. If psychologists have completed further training in these areas and feel competent in their delivery, shouldn’t they be able to use the evidence-based approach that is most suited to the client? For example, Eye Movement Desensitization and Reprocessing (EMDR) requires therapists to be certified by the international EMDR Institute and is now considered an evidence-based practice. This certified training is not part of any clinical masters program and psychologists outlay thousands of dollar to be certified. Similarly, many non-clinically endorsed psychologists are advanced trained in ACT or Schema Therapy. However, due to the restrictions placed on the FPS, these therapies cannot be used with Medicare clients.
Inversely, there are no restrictions placed on clinical psychologists under the ‘psychological therapy services’ category. If these arbitrary restrictions must continue, the FPS strategies needs to be updated in light of new research on evidence-based practices.

Does a higher rebate equal increased access to psychological services?
The justification for the two-tier system – that it would allow patients cheaper access to “specialist” psychologists with improved treatment outcomes has not happened, despite over ten years of operation. Nor has it led to endorsed clinical psychologists treating more serious mental health conditions than non-endorsed psychologists in clinical practice – a major point made by the original advocates for the two-tier system. Likewise, Harrison and colleagues found that uptake for Better Access services was highest in advantaged urban areas rather than being spread fairly across the country. This is likely due to concentrations of clinical psychologists in urban locations. Accessing clinical psychologists has recently been shown to be unfairly distributed. The richest segment of society has over double the use rate for clinical psychology services.

“The Better Access initiative is not providing universality or consistent equity of delivery in mental health care” (Meadows et al., 2015, p194). The lower rebate for psychologists of $84.80 means that very few non-clinically endorsed psychologists can afford to fully bulk-bill clients, when taking into account office/room rental, reception costs and resources this brings the wage per hour of a psychologist down to approximately $40/hour. After the rebate, the average out-of-pocket co-payment per session for both clinical and non-clinical psychologists is between $31 and $37 Interestingly, even with the co-payment at $37, non-clinical psychologists are still charging less than the clinical psychologist Medicare rebate alone. If there was a slightly higher single-tiered payment, more psychologists could run viable bulk-billing private practices and fully bulk-bill low-income clients. Referring GPs and patients would be guaranteed no out-of-pocket costs and thereby removing any financial disincentive to seek mental health care.

Consequences of the two-tiered system
1. Reduced rebate for clients: Members of the public are accessing different rebates according to the type of psychologist they see, rather than by need. All registered psychologists are competent to assess, diagnose and treat mental illness and both clinical and other psychologists see complex, comorbid and demanding presentations. Generalist psychologists all have accredited training in professional psychology, including assessment, diagnosis, formulation and treatment of mental health disorders. Members of the public are entitled to fair rebates for services, this is not the current policy.

2. Financial consequences and sustainability: From July 2015 to December 2016, the cost to government of psychological rebates was almost $485 million dollars. More than half of this was spent on clinical psychologists, who represented only a fifth of the workforce (Dept. Human Services, Medicare data). With their growth increasing at 10% per year, in the next 5 years, rebates for clinical psychology services will absorb almost the entire current Better Access funding for mental health.

3. Negative impact on psychology as a discipline: Among the direct, destructive consequences of the two-tier Medicare rebate system is the immediate, overwhelming bias it conferred towards clinical psychology degrees. It has inflated the demand from future graduates for a clinical degree, triggering an all-but-complete bias in Australian universities to offer clinical psychology programs. Students contemplating their financial future were naturally attracted to clinical psychology programs because of the higher Medicare rebate. Student (not client) demand for other degrees plummeted. The subsequent decline in teaching other specialist areas has profoundly impoverished mental health treatment in this country. As a result, Australia is heading towards a monoculture in the practice of psychology which threatens its international standing within the profession. No such monoculture exists in the UK, US or European jurisdictions and Australia’s bias to a single approach (medicated CBT) threatens the reputation of Australian psychology internationally.

The two-tier system has led to the unseemly public denigration of psychologists by some clinical psychologists, and consequent marginalisation of the majority of psychologists registered to practice in Australia, even though most psychologists have many years of experience and in many cases equal or even higher academic qualifications than their clinical counterparts. This is institutionalised discrimination and unfair work practice with no empirical justification. Many psychologists with advanced training in specific techniques and those who hold non-clinical post-graduate qualifications, have clients who are being substantially financially disadvantaged by this process.

Employment opportunities for non-clinically endorsed psychologists across the government and non-government sector are diminishing as agencies prefer to employ clinical psychologists to attract higher rebates for Medicare and DVA etc. Therefore, psychologists are graduating from university to find limited employment opportunities unless they hold clinical endorsement. Entry into clinical masters programs is very competitive and there is the chance that students will be deterred from studying psychology in favour of other allied health professions. This may have consequences in the future if there is a shortage of qualified psychologists in the workforce to support the mental health of Australia’s growing population.

All AHPRA Registered Psychologists, regardless of endorsement, have attained the competency to provide psychological treatment under Medicare and there is no evidence to date of any difference in patient outcomes for endorsed clinical psychologists compared to other registered psychologists in clinical practice. Psychologists cannot be considered better trained than each other merely by virtue of holding the title clinical psychologist or any other endorsed area. The quality, skills and knowledge of a psychologist cannot be deemed by endorsement status alone.

Research demonstrates no difference in treatment outcomes when comparing clinical psychologists with all other registered psychologists.
It is a waste of taxpayers’ money to pay a higher Medicare rate to endorsed clinical psychologists than for other registered psychologists in clinical practice. No subsequent research has shown evidence to the contrary.
As Australian taxpayers and psychologists who work in the frontline of delivery of services, please consider our recommendations.

References:

Harrison, Britt & Charles. (2012). Better Outcomes or Better Access — which was better for mental health care? Med J Aust,197(3), p170-172. doi: 10.5694/mja12.105554

Meadows, Enticott, Inder, Russell & Gurr. (2015). Better access to mental health care and the failure of the Medicare principle of universality. Med J Aust, 202(4), p190-194. doi: 10.5694/mja14.003305

Pirkis, et al., (2011). Australia’s Better Access initiative: an evaluation. Aust N Z J Psychiatry, 45(9), p726-39. doi: 10.3109/00048674.2011.594948
https://industry.gov.au/…/Docu…/2015Submissions/ACPA.pdf

Okiishi, J., Lambert, M. J., Nielsen, S. L., & Ogles, B. M. (2003). Waiting for supershrink: An empirical analysis of therapists effects. Clinical Psychology and Psychotherapy, 10, 361-373.
“The initial analysis of therapist data were aimed at
seeing if therapists differed from one another on
outcomes based on four therapist variables: type of
training, amount of training, theoretical orientation
and gender. An HLM was performed using these
four variables as predictors. This analysis indicated
that none of these therapist variables differentially
contributed to the outcomes of patients”. P. 365
Clinicians were 16 clinical psychology graduates, 38 counselling psychology graduates and 2 M Soc Work graduates.