Health funding cuts are always controversial, and the Federal Government’s decision to restrict the number of Medicare-funded psychology sessions for patients with a mental health care plan was no different.
The Minister for Health and Aged Care argued he was saving the system from itself because the extra sessions introduced in response to COVID-19 had left psychologists overwhelmed.
But even before Mark Butler wielded the scalpel, there were questions over the system’s fairness given the average gap fee under Better Access had risen to $78.
Catriona Davis-McCabe is president of the Australian Psychological Society.
Here, she responds to Mr Butler’s claim that extra sessions made the system worse, as well as broader concerns over potentially prohibitive out-of-pocket costs.
Australian Doctor: Mr Butler says allowing patients to claim more treatment sessions clogs the system and stops some people getting care at all. What is your response to that?
Catriona Davis-McCabe: Research shows that, when we are working with people with moderate-to-severe mental health issues — things like chronic depression and anxiety — you need about 18-20 sessions to adequately treat those issues.
With only half the treatment, many patients will continue their negative pre-treatment trajectory.
In fact, a significant number of patients will have their worsening symptoms accelerated should treatment plans be suddenly halted or significantly reduced.
That is what we are seeing across the country.
My response is you would not do this with physical health issues.
You would never ration chemotherapy or insulin to people; sessions to see your GP are not rationed either.
So why ration mental health sessions?
Most psychological issues can be treated in fewer than 10 sessions; a minority of patients who need the extra sessions. But with mental illness rates expected to rise for years, we need systems in place to deal with this coming increase.
Cutting the extra sessions goes not only against the advice of the government’s own independent review but also against the advice of psychologists, patient groups, nurses, paramedics and other allied health workers.
One million additional sessions were claimed in the past financial year. This shows people were using them and needed them.
AD: Even before the changes, there were concerns about long wait lists for psychologists. Didn’t the extra sessions exacerbate the problem?
Catriona Davis-McCabe: There had been pressure on the system with the extra sessions.
What we know is that, before the pandemic and before the 20 sessions were introduced, one in 100 psychologists had their books closed.
During the pandemic, this has increased to one in three.
So we need the 20 sessions, but we also need investment in psychology.
But that is the next part of our response.
There is a core issue that needs to be addressed.
Governments are not spending enough on the psychology workforce.
Australia only has 35,600 psychologists: 35% of the number that is needed under the Federal Government’s own workforce target.
Thousands of students are being turned away from completing postgraduate psychology programs every year because there are not enough spots for them.
Psychology is not funded like medicine and dentistry, which means universities are losing money with every student they train.
AD: Isn’t that a slow fix when there are major issues now?
Catriona Davis-McCabe: More funding for training could turn around the workforce issue very quickly because students in their fifth or sixth year already go on placements as provisional psychologists.
With more psychologists in training, we could deploy more of them to the areas that most need psychological support.
AD: The other issue is out-of-pocket cost. The government says about half of patients are paying a gap fee — $78 per session, on average. Is the system working when costs are prohibitive for some patients?
Catriona Davis-McCabe: Currently, gap fees are the norm, and we need to work with the government on affordability.
The government has got to come to the table and invest more money, particularly for those from lower socioeconomic backgrounds.
It is only February, and our clients are already telling us they will need to ration their sessions because of costs.
They are anxious about how they are going to pay for their full treatment.
We have put forward to government a range of options to increase accessibility and affordability for those who need it most.
As their independent review makes clear, there is a problem with workforce density and location.
Resolving that through increased funding for university places will see thousands of additional psychologists deployed to areas of need.
The government is 65,000 psychologists short of its target, and nothing can be adequately implemented without this workforce shortage being addressed.
Adding provisional psychologists to the MBS will make services more affordable.
We would also like to see the rural GP incentives replicated for psychologists to help improve access for those in rural and remote communities.
There should also be a greater focus on prevention and early intervention.
Having psychologists in schools, particularly in low socioeconomic areas, would be a great tool in preventing serious mental illness and disorders from developing.
We know that 50% of mental illness is identified before age 14, so addressing these issues early can have a dramatic effect over a lifetime.
AD: The review backed GPs’ role in writing mental health care plans — the so-called ‘glorified referrer’ job. But even some GPs disagree with their role in Better Access. Do you think GP referrals should be scrapped?
Catriona Davis-McCabe: We think it is important that patients continue to see their GP because there can be a lot of comorbidities, and there might be underlying health issues.
But the initial referral can act as a barrier to access.
People who are vulnerable — for example, those from lower socioeconomic areas and those experiencing domestic violence or perinatal depression — when they decide they want mental health treatment, they need to be able to access it quickly and safely.
We recommend allowing people to attend three psychology sessions before needing to get that mental health referral from their GP.
That would mean more people would attend, but it would also ensure safety.
Our proposed referral changes seek to remove a barrier of care for vulnerable groups and relieve GP clinics of some of the current pressures they are facing.
Psychologists would still refer patients to GPs or other primary health or allied health providers commensurate with their level of risk — as is current practice.
Effective communication with a patient’s GP following their third and final referral-free session would also reflect a multidisciplinary approach, which is often what is needed for best-practice care.