Professor Lyn Littlefield OAM FAPS

Millions of Australians with mental health disorders have accessed Medicare-funded psychological treatment under the Better Access initiative since its introduction. Proposals for changes to Better Access in the recently released report of the National Review of Mental Health Programmes and Services, as well as a measure in the 2015 Federal Budget, have seen APS advocacy efforts strongly focused on protecting Australians’ access to accessible and effective mental health treatment under Medicare.

Why Better Access has been such a success

Now in its ninth year, Better Access was introduced under the Howard Government and the then Health Minister, Tony Abbott, with the primary purpose of increasing treatment rates for people with commonly occurring mental health disorders that frequently were otherwise left untreated. It is estimated that 45 per cent of Australians will experience a commonly occurring mental health disorder in their lifetime (AIHW, 2013), including depression, anxiety, stress-related and substance use disorders for adults, and behavioural and anxiety disorders for children. Each year, it is estimated that 1 in 5 adults (aged 16-85 years) and 1 in 7 children and adolescents (aged 4-17 years) will experience a common mental health disorder.

Better Access was designed to provide improved access to evidence-based psychological treatment for people with these common mental health disorders supported by Medicare and a destigmatised pathway to services through the primary care system. It was designed to encourage people to seek help in the early stages of their mental health conditions, and to prevent the deterioration of symptoms and subsequent increased demand on more acute and expensive services.

Better Access effectively meets a vital community need

Since its introduction, Better Access has filled a significant gap in treatment services for people with common mental health disorders, demonstrated by the initially rapid rate of growth in the uptake of Medicare-funded psychological treatment. The growth in uptake of Better Access psychological services has stabilised in recent years, suggesting the program is effectively and sustainably keeping pace with demand in the community. A recent health policy study (Whiteford et al., 2014) found significantly increased treatment rates for people with mental disorders in Australia (from 37% in 2006-07 to 46% in 2009-10) and attributed this solely to the introduction of Better Access.

Nearly four million sessions of evidence-based psychological treatment are delivered to mental health consumers under Better Access each year by psychologists. A 2011 Government evaluation of Better Access demonstrated the initiative’s effectiveness, finding that consumers’ symptoms decreased from moderate or severe levels to normal or mild levels following psychological treatment (Pirkis et al., 2011).

Better Access has contributed to destigmatisation of help-seeking for mental health problems, by increasing the availability of affordable, funded psychological services in private primary care settings via GP referral. A shift from antidepressants as the primary treatment to psychological treatments, associated with a steady decline in the use of antidepressants and anti-anxiety medications, has also been attributed to the introduction of Better Access (Berk, 2012).

Better Access and the cost argument

The overwhelming success of the Better Access initiative in increasing access to effective psychological treatment of people with mental health disorders was unanticipated by the Government, and has necessarily entailed an increase in funding. The initiative’s very success has made it the target for cost‑cutting by subsequent Governments. But just how much does Better Access really cost?

Better Access is low cost and cost-efficient

Since Better Access was introduced, 22.3 million psychological treatment sessions have been provided to Australians with mental health disorders by psychologists operating in private settings, with all administrative overheads borne by these small businesses. Rebates for psychology services under Better Access cost $388 million in 2012-13, representing just four per cent of the total Commonwealth expenditure on mental health of $9.5 billion. This compares to $300 million in rebates for 2.1 million psychiatrist sessions. In contrast, mental health expenditure through the Pharmaceutical Benefits Scheme in 2012-13 totalled around $770 million, representing eight per cent of the total Commonwealth mental health expenditure.

The investment in Better Access compares favourably to the cost of mental illness in the community, which includes an estimated cost of $10.9 billion for Australian workplaces (PricewaterhouseCoopers, 2014) and $28.6 billion in direct service expenditure (Medibank Private/Nous Group, 2013).

Mental Health Review proposals concerning Better Access

Better Access came under significant scrutiny in the recent National Review of Mental Health Programmes and Services, given that it is a large mental health program funded by the Federal Government. The Review made two very concerning suggested changes for service arrangements under Better Access that would, in effect, lead to reduced expenditure under Better Access and therefore reduced community access to this highly effective program.

Rural and remote service provider restrictions

The first of these proposals is a suggestion to restrict new psychologists to providing Better Access services in rural and remote areas as a means of redistributing the psychology workforce to rural areas of Australia. It is acknowledged that psychology services, like other health services including those from GPs and psychiatrists, are not well distributed in rural and remote areas of Australia, and Australians with mental health problems in these areas do not have equitable access to treatment services.

However, the APS believes that this proposal would not meet its desired objective of increasing the availability of psychological treatment services in rural and remote areas, and the many significant and systemic disincentives that affect all health workforces in rural and remote areas would remain unaddressed. This proposal is presented as a rural redistribution initiative but also appears to represent a means of severely restricting service provision under Better Access. This change is predicted to have a major impact on the psychology training pipeline as it significantly undermines the attractiveness of entering the psychology profession. It would therefore result in severely reduced access to psychological treatment services for people with mental health disorders in all areas of Australia over time.

The APS has presented the consequences of this proposal to the Government, and has proposed alternative and more effective approaches to address the important issue of increasing access to effective psychological services in rural and remote areas, such as those currently used as incentives to increase medical services in these areas. Such policy initiatives could include loadings on Medicare items, discounted HECS/HELP loans, scholarships and rural student placements, and rebates for telehealth services.

‘Cashing out’ Better Access to Primary Health Networks

The other highly concerning proposal in the Review is to ‘cash out’ the funding provided for services delivered by psychologists under Better Access, and redistribute it instead through regional commissioning agencies, such as Primary Health Networks, for psychological services on a contracted basis. This proposal would in effect redistribute Better Access funds for an expanded roll-out of the Access to Allied Psychological Services (ATAPS) model. The proposal would result in a more expensive service and risks Australians with mental health disorders missing out on vital psychological treatment services if funding runs out, as it has in the past. The proposal unnecessarily increases complexity and administrative costs, given that existing administration of Better Access is lean, efficient and borne by the private sector (there is evidence that Better Access is demonstrably more [2–10 times] cost-efficient than ATAPS).

This proposal appears to represent a Better Access funds-capping exercise that will have a major impact on community access to effective and cost-efficient psychological services. The APS has strongly argued this case to the Government and has offered a number of alternative policy initiatives to improve the integration of psychological services as part of a stepped-care approach in the primary health care system. These alternatives include integration and co-location of services, and funding for servicing people with complex conditions referred from Primary Health Networks.

The APS has also questioned the legality of the Review's proposal to restrict Medicare provider numbers to specific geographical areas. We have brought the Government’s attention to similar proposals for the medical profession some years ago to address workforce distribution, which were successfully challenged as unconstitutional and therefore did not proceed.

2015 Federal Budget measure affecting Better Access

The 2015 Federal Budget contained a measure to continue the freeze on the indexation of the Medicare Benefits Schedule (MBS) fees and rebates, including those for Better Access psychology items, until 1 July 2020. A freeze on the annual CPI indexation of fees and rebates for services provided by psychologists under Better Access was first brought in from 1 November 2012, initially for two years. This freeze was extended in subsequent Federal Budgets, and in the most recent Budget was extended until 2020. In effect, this represents a situation where psychologists providing services under Better Access will not have had a ‘pay rise’ in eight years to keep pace with the rising cost of living. Many psychologists will have to address this issue by raising their fees, possibly meaning greater and growing out-of-pocket costs for Australians with mental health disorders receiving psychologists’ services under Better Access.

Again, this represents a way of the Government reducing Better Access expenditure that ultimately impacts on Australians with mental health disorders by reducing their access to affordable and effective psychological treatment services. The freeze on indexation of MBS fees and rebates also applies to GP Medicare items, and the Australian Medical Association has voiced the GPs’ concerns. The consequences of the indexation freeze on psychologists’ rebates for Better Access consumers has been brought to the Government’s attention by the APS, and we are watching closely how the similar GP indexation freeze is resolved.

APS advocacy

It is important to note that the two very concerning suggested changes for Better Access service arrangements that were contained in the National Review of Mental Health Programmes and Services are just that – suggested changes only. The proposals are not the Government’s position, which is yet to be finalised following a consultation period and input from an Expert Reference Group. The APS is working hard to inform the Government’s responses through meetings with Ministers, their advisors and senior bureaucrats, using the arguments outlined above to present compelling reasons why the very concerning proposals should not be accepted. APS advocacy also includes strongly reinforcing the important and hard-won achievements of the cost-efficient Better Access initiative in increasing access to skilled and effective psychological treatment of mental health disorders for millions of Australians.

References

InPsych June 2015