The White Paper – Bitter Tiers

White Paper Recommendation 17

Scheduled Fees: Extend the higher rebate to all endorsed psychologists.

Since at least 2003, past and present industry power brokers have hawked their perspective of the psychology profession to Government. Uniformly, they have denigrated psychologists who do not hold endorsement in clinical psychology as being unfit to provide services in the public healthcare system. The introduction of the two-tier structure to psychological services under the Medicare Better Access Scheme in 2006 was the first proof of this; the industry power brokers at that time having recommended (as presaged in earlier discussions with Government) that only clinical psychologists should be Medicare approved. The argument? Only clinical psychologists could be considered competent to provide a quality service. The evidence? None. Lack of supply saw the Government include registered psychologists at a lower rebate to reflect the advice they were given.

Now supply continues to present a barrier to restricting Medicare to clinical psychologists. Clinical psychologists number roughly 9,000. Of course, they cannot meet the demand of the entire nation’s mental health needs. Even if the other 28,000 members of the profession were as inept as suggested, apparently they are still required. For now…supply will not always be a barrier.

When the APS submission to the Mental Health Reference Group was rejected as non-consultative and non-representative last year, the APS MBS Expert Panel was convened to develop a better proposal. They built bias into their terms of reference:

  • Differentiation based on endorsed areas of practice as defined by the Psychology Board of Australia

In the white paper released last Thursday, The Future of Psychology in Australia, we find Recommendation Seventeen, to extend the higher rebate to all psychologists with an area of practice endorsement.  Here we see an almost complete undermining of prior arguments for Area of Practice Endorsement, because the recommendation for the higher rebate is not tied to the higher intensity service provision pathway. After years of positioning clinical psychologists as the holders of the keys to publicly funded mental health within the medical model of Medicare, now we see a push for other endorsements to get a slice of the higher medicare rebate – for the provision of “Psychological Therapy”. Literally the same restricted “Psychological Therapy” assigned to registered psychologists on the lower intensity pathway.

Now, we know that most psychologists are providing clinical services to a high standard, and we’re all about inclusion. But, we’re wanting to examine the shift in position. For 13 years we have hammered the fact that psychologists working in clinical practice are competent if they are compliant with National Law and their ethical obligations to self-limit their practice to their areas of expertise. Since 2010 we have hammered the fact that endorsement is no guarantee of competence. The APS has dismissed our claims and at no point advocated for inclusion. But this recommendation turns the APS’s historical position on its head, as it goes against the argument of specificity of endorsement and against the argument of assurance of competence it supposedly confers. We’re seeing a backflip on a position that has seen 13 years of economic and practice restriction in our field.

Either qualitative differences exist between the skills of psychologists with area of practice endorsement, or they don’t.  Either we have assurance of clinical competency on the basis of clinical AOPE or we don’t.  If AOPE does signal qualitative difference in area of practice competence, what health economist would support a non-clinical psychologist offering the public a higher Medicare rebate (for argument’s sake, an organisational psychologist treating a child with ASD)? Should the taxpayer pay more for the same service simply on the basis that the psychologist holds an AOPE in an unrelated area?  We don’t think so – not on the basis of logic or outcome evidence, anyway.

We believe that ALL psychologists, with clinical competence, should be able to offer the same sustainable rebate for the same effective service. Structural economic and rank inequity is political, not empirical.

If AOPE doesn’t signal specific and qualitative difference in area of practice competence, why would Medicare wish to distinguish between psychologists on the basis of an AOPE at all? All registered psychologists must be clinically trained in order to obtain registration. National registration places no restriction on practice, only on use of titles (and this is only to prop up the marketing of AOPE as “better.”)

So to the authors of the White Paper, we see an inconsistency. We recognise this is a long game strategically, but here and now this doesn’t make a lot of sense, and it supports a more inclusive approach. We want to see more inclusion of our registered colleagues.

We wonder if what we’re actually seeing here is an attempt to reverse the homogenisation of skills in the profession (90 percent of us work clinically) and the death of all non-clinical masters programs. We wonder if we’re seeing a sly push for Medicare to pick up the tab by structuring yet more elitist (zero evidence for AOPE in terms of public benefit) and divisive economic drivers into the public mental health system. Our industry body hasn’t appeared to value non-clinical AOPE economically, strategically, or academically, and now we’re asking the public to foot the bill for the professional ramifications of 13 years of devaluing diversity?

We wonder if the white paper proposal to extend the higher tier rebate to all AOPE is going to sneak past the taskforce terms of reference to create a medicare structure that is cost-effective, evidence based, and medical. Frankly, we think it’s fantastic to see a more inclusive proposal for our colleagues who, no doubt, work as hard as we do for our clients. What we also need to see is our non-aope colleagues included as well. The same rebate for the same service.

What remains to be seen are whether we will ever regain the values that our profession has lost. We are scientist-practitioners. We must follow the best available evidence and that suggests there is no empirical basis for the division that has so harmed our profession. We continue to advocate for one tier of psychological service provision until good data suggests otherwise.

Please comment below. We recognise the recommendations in the white paper that colleagues with AOPE should be working in their area of practice to obtain specific referrals (e.g., neuro, ed & dev, forensic, clinical, etc) and to work within the high intensity pathway. We believe Recommendation 17 takes this further to recommend that all colleagues with an AOPE regardless of pathway, should be able to offer the higher rebate.