The Medicare Manifesto

As our once beloved Australian Psychological Society releases its Medicare manifesto, its self-interest and callous disregard for the needs of our communities validates our decade of distress and anger. It also strengthens our determination to awaken the community and the profession to the malignant values it now openly embraces.

Don’t get me wrong, it’s a nicely designed document. Nice cover. Great font. Front picture could have been less ambiguous. We personally think folks standing on a precipice can be interpreted a few ways when you work in mental health. That’s probably fuel for our opinion that our representative organisation perhaps doesn’t work in mental health so much as make mental health work for it. It is a corporate enterprise with a business model to doggedly pursue.  There is some good stuff in there…but you can’t polish a poop, my friends. Mythbusters confirmed it. And overall, this is a stinker.

You don’t have to read far to start to grasp the shift in ideology The Future of Psychology in Australia represents. Its aim is to extend and embed further its fallacious division of the psychology profession, tied to inequitable rebates for services based on titles. Full marks for really poor creativity too, the new made up name they seek to base their rebate difference upon is a corker!  Raise a glass to the mythical “Advanced Psychological Therapies,” only for use by advanced super experts in psychology!  All other psychologists, use Psychological Therapies (apparently we’re highly trained and after 13 years of arbitrary restriction can now use the therapy we’ve all been using. All along, just with a different made up name).

But don’t integrate approaches to suit your client’s needs. No way. That’s the new no-no. It’s an advanced skill and only endorsed psychologists can do it. Never mind the fact it’s a bread and butter skill to the entire profession and every practicing psychologist knows that. If this wasn’t so linked to the death of our livelihoods, it might be humorous.

By the way, the rebate inequity is not going anywhere if APS have anything to do with it.

There is an overt focus in this document not on the mental health of communities, but on the structuring of rank and status into a major public health program. That requires division. It’s not a particularly helpful focus, given the dire needs of the community, our profession’s equivalent and effective skills, and the obvious expertise of our colleagues in other allied health.

The proposal suggests more sessions, but watch out for the 10 session review – if the GP would like to refer to a different psychologist, they might just do that. The model apparently does not rate the client’s choice as being of material interest to client participation or outcomes…

Let’s set to one side the cynical use of the Medicare Review Taskforce to covertly ‘launch’ this new world domination paradigm and take a look beneath the shiny formatting, and falsely comforting headings.

The first recommendation: Amend the Better Access Framework

This initially reads as nice and inclusive – psychologists can provide the full scope of Medicare services for the benefit of the client.  Until you realise the content describes precisely the opposite and bizarrely tries to justify elevating an endorsed psychologist over another psychologist on the false assumption that endorsement is equivalent to competence or client outcomes. Half of endorsed psychologists were grandfathered, and countless endorsed psychologists don’t work within their endorsement. It’s plain silly on so many levels.

The APS draws out 17 MBAS recommendations. We’ve jotted down some thoughts on a few of them in the slightly mixed up and badly executed table below (we’ll look at it again tomorrow and fix it up).

We’d love to hear your thoughts too. Leave a comment below.

 

Recommendation 1False assumptionsRecommendation goes against empirical evidence and frontline knowledge
Other allied mental health provide “basic” services (and something really strange about relationships with clients and relatives…)Other allied health have less competence than psychologists, and their client outcomes are not as strongIt’s as settled as climate change, guys. Treatment modality is just branding. Have a modality and know how to convince your client of its utility, but that’s as far as it goes.
Advanced Psychological Therapy is different to Psychological TherapyEndorsement guarantees advanced competency in the area of practiceTherapeutic alliance is the key to outcomes. It’s not associated with academic training, titles, or nature of supervision. Only feedback and deliberate practice is associated with development of this skill – and that process is based on a brief check in with the client on outcomes and relationship, and then working on that. There is literally nothing complex about this.
Endorsement in the relevant area is a pre-requisite for delivering Advanced Psychological TherapyRegistered psychologists are not competently providing services to complex clients every single day.Clinical endorsement vs other psychologists – no difference in clientele or client outcomes. Sorry guys! The Health Department evaluated that directly, remember?
Complex clients are happy to sit on waitlists for months for access to a clinically endorsed psychologist rather than see their local community down in the trenches psychologist who works with complex clients day in and day out. All psychologists offer services within their competence. That is, the registered psychologist working alongside the clinically endorsed psychologist in a mental health unit in a hospital are doing the same work because they’re competent (if they weren’t, endorsed or not, they wouldn’t be there – remember ethics anyone?).
Check the national law. Endorsement is not competence. It’s a legal instrument that is being misrepresented by the APS (but not the Psychology Board) as a speciality (as in a cardiothoracic surgeon vs an anaesthetist). Psychology is not medicine.
Endorsed psychologists are not confined to their endorsed area of practice – they, along with any psychologist, will offer services within their competence.
Integrated approaches to intervention are ubiquitous in the profession. There is literally no psychologist who is not flexibly adapting and combining approaches (and by the way, this is okay, because the modality is actually irrelevant). Psychologists are experts in helping clients achieve outcomes.
Just for a laugh, well, also because it’s published fact, I’ll add that more academic training is associated with greater adherence to manualised treatments, not more flexibility integrating approaches.
Recommendation 2False assumptionsRecommendation goes against empirical evidence and frontline knowledge
Multi-clinician stepped careIntensity of service delivery means not only increased time to effect change, but a different academic title, and a whole lot more money.The outcomes of the clients of endorsed psychologists are equivalent to those of non-endorsed psychologists. We know. You know.
Increased sessionsThe complex clients of psychologists with clinical endorsements achieve better outcomes than the complex clients of non-endorsed psychologists in clinical practice.In addition to mandatory referral to a titled psychologist conferring absolutely no guarantee of benefit to the client, the 30 percent of clients who are lost to the health system with each onward referral suggests this is a really, really, bad idea.
The Psychology Board of Australia is involved in frontline delivery of services and recognises the need ofAssuming they were working within their competence, any scheme which requires a psychologist to abandon a high risk client to a waiting list because they’ve determined that they’re complex, wold require working in a stigmatising, rejecting system – as callous as Centrelink or Child Safety. Is this what we’re aiming for in mental health? Endorsement is not competence. Rupture of alliance is harmful. APS what are you thinking?
Increased sessions will be determined by the GP, and based on “expertise of the psychologist,” pre-post outcome measures (of some kind) and the GP may determine that they will refer to endorsed psychologist – regardless of therapeutic alliance.Impact: GPs will refer all MHCP to clinically endorsed psychologists to protect them from this. Psychologists may choose not to work in Medicare to avoid unethical demands being placed on them.
The client’s preference is not important. Nowhere in the criteria is the clients choice of provider considered.“Expertise of psychologist” has no objective measure unless a database of pre-post outcome measures is to be established which will eventually be used to assess the workforce. Let’s hope the measures are validated.
Recommendation 6False assumptionsRecommendation goes against empirical evidence and frontline knowledge
Developmental neurocognitive assessments by psychologists with endorsement in clinical neuropsychology or ed and dev.Endorsement is equivalent to competence.There is no evidence that endorsement is equivalent to expertise. We will all be very happy to see outcome measures published so we can put this one to bed.
There is enough supply to meet demandThere are 1300 endorsed clinical neuropsychologists and ed and dev psychologists working in Australia. Do the math.
Registered psychologists working within their area of competence should be restricted from practice.National law prescribes that registered psychologists are competent to practice psychology. Restriction of trade is unlawful.
Recommendation 8False assumptionsRecommendation goes against empirical evidence and frontline knowledge
Neuropsychological assessment to distinguish dementia from mental health disorders.Endorsement is equivalent to competence.There is no evidence that endorsement is equivalent to expertise. We will all be very happy to see outcome measures published so we can put this one to bed.
There is enough supply to meet demandThere are 600 endorsed clinical neuropsychologists psychologists working in Australia. Another maths quiz for you.
Registered psychologists working within their area of competence should be restricted from practice.National law prescribes that registered psychologists are competent to practice psychology. Restriction of trade is unlawful.
Recommendation 16False assumptionsRecommendation goes against empirical evidence and frontline knowledge
Independent mental health assessment, opinion and report.Endorsement is equivalent to competence.National law prescribes that registered psychologists are competent to practice psychology. Psychology is the assessment, diagnosis, and treatment of mental disorders. Restriction of trade is unlawful.
Clinical or counselling endorsed psychologists only.There is enough supply to meet demand
Registered psychologists working within their area of competence should be restricted from practice.
Recommendation 17False assumptionsRecommendation goes against empirical evidence and frontline knowledge
FeesThere is a difference between psychological therapy and advanced psychological therapyThese terms are arbitrary.
Clients should not receive the same rebates for the same services.Ask yourself – how would you operationalise the ‘advanced skill’ required to engage a traumatised child into a safe and therapeutic relationship, within a multidisciplinary team, to create the stability required for treatment of anxiety and depression?
Psychologists who were grandfathered into endorsement, or who took the most expensive route to registration should be remunerated.How would you compare this to engaging a client with a psychotic illness into multidisciplinary care?
A registered psychologist is deemed by APS perfectly fit to care for the former, but not the latter. The arbitrary nature of these distinctions is very clear.