The costs of disunity
Divisions within the psychology profession over the two-tier Medicare rebate structure are once again threatening to derail advocacy for the maintenance of current funding for the highly successful Better Access initiative. Over the last few months, APS advocacy efforts have been focused on opposing the reduction in the yearly maximum allowance of sessions of psychological treatment a client can receive under Better Access (cut from 18 to 10 sessions), which was announced by the Government in the Federal Budget and is due to take effect from 1 November this year. A Senate Inquiry was established in June to investigate these Budget funding cuts, according to the APS understanding, and the scope of this Inquiry was subsequently broadened to include other aspects of the Better Access initiative. This development has brought a broader focus of attention and inflamed the divisions within the profession over the two-tier Medicare rebate structure. Although there are understandable grievances, the often very public debate about the two-tier Medicare system reflects poorly on the psychology profession and gives the appearance of self-interest. This plays into the hands of those Better Access critics who believe the initiative should be dismantled and detracts from the campaign to maintain current levels of funding for the initiative.
Ever since the introduction of the Better Access initiative there have been strong and very public critics who have maintained their opposition to the Government-funded program, and there have been persistent rumours that funding cuts are imminent. The general APS strategy in relation to advocacy has therefore been to publicly highlight the success of the initiative for mental health consumers rather than the two-tier debate within the profession. The current APS strategy has been consistent with this approach and we are advocating strongly for the maintenance of existing Better Access funding arrangements and opposing the Federal Budget cuts to the number of sessions of psychological treatment available to Better Access consumers.
APS advocacy has focused on highlighting the needs of these consumers who are too often a silent voice in this debate. Firstly, the APS conducted an audit survey of clients seen for more than 10 sessions by psychologists under Better Access to ascertain the nature and severity of their disorders and therefore the potential impact of a reduction in the number of psychological treatment sessions. The compelling survey results have provided evidence to strengthen the APS campaign with politicians and senior health bureaucrats for the funding cuts to be reversed (see article on the following spread for more information on the survey results). The APS has also been working with consumer and carer groups to highlight the impact of the funding cuts on Better Access consumers in advocacy with politicians.
The APS has submitted a response to the Senate Inquiry and highlighted the impact of the Better Access funding cuts on consumers through the evidence obtained from Medicare data, the APS audit survey, and consumer and carer groups. As the Senate Inquiry Terms of Reference also included an examination of the two-tier Medicare rebate system for psychologists, the APS also responded to this in its submission.
The APS Board extensively discussed the strategic implications of the inclusion of the two-tier matter in the Senate Inquiry to inform the APS response. The Board is very aware of the highly divisive nature of the two-tiered Medicare rebate, the wide variety of views of APS members, and the sensitivities associated with issues of status, valuing of psychological work and reimbursement for this. The APS submission to the Inquiry is available from the APS website (www.psychology.org.au/news/news_updates/) and the position in relation to the two-tier Medicare system is consistent with that originally proposed by the APS in 2006 when Better Access was being established. The Board is aware that this position may not please all members but believes it is the most rational stance. This position is presented below for members' information. It is important to clearly present this information to members as there have been so many inaccurate claims made about the APS position in this debate. For this reason, it is important to reiterate some of the facts.
Some facts in the debate
1. The APS Board’s responsibility to all APS members The APS Board has a responsibility to recognise and promote the skills and interests of all APS members, including those with specialist training across the various sub-specialties of psychology and those with general training, and its policies reflect this responsibility. In keeping with its mission, the APS also must promote and maintain high standards of psychology education and practice, and its advocacy must be in the context of improving community wellbeing. The Board must strive to fulfil this responsibility regardless of the particular interests and views of individual Board members, however, as the Board is comprised of members elected by the APS membership, the Board is usually broadly representative of the APS membership. Relevant to the two-tier debate, half of the current APS Board of Directors provide services as private practitioners, with a representation of different College memberships and some in the so-called 'general psychologist' category.
2. History of the APS position on the two-tiered structure In the lead-up to the introduction of the Better Access initiative in early 2006, the APS originally proposed a Board-approved position to the Government regarding psychologists considered to have the necessary skills to be considered a specialist in providing treatment for high prevalence mental health disorders (i.e., predominantly depression and anxiety disorders). The APS proposed that Medicare rebates should be available for services provided by these psychologists – termed "clinical and mental health specialist psychologists" in the original APS submission and defined by specified competencies in terms of level of mental health knowledge and skills training (in psychopathology [assessment, diagnosis and case formulation], counselling skills and psychotherapy/psychological interventions) plus supervised post-registration experience in mental health settings. The APS proposed that these psychologists would include those with postgraduate professional Masters/Doctorate degrees who possessed the specified training and experience, as well as those with four-year undergraduate degrees who met the specified mental health training and experience criteria. At that stage in early 2006 the Government had only proposed one level of Medicare rebate.
Informed by its own mental health advisors, the Government subsequently determined that access to providing services under the initiative would be limited to psychologists who were members of the APS College of Clinical Psychologists or the equivalent. The APS argued that there were many other psychologists who could be funded to provide effective psychological treatments for mental health consumers, on the basis that Government-funded ‘Focused Psychological Strategy (FPS)’ services were already being successfully provided by psychologists under the existing Better Outcomes program. The Government then decided that psychologists and appropriately qualified social workers, occupational therapists and GPs would be funded to provide FPS services under the Better Access initiative to boost community access to affordable psychological care, with the FPS services provided by psychologists attracting a higher rebate. Hence the two-tiered Medicare rebate system for psychologists was established.
It is frequently erroneously claimed that the APS originally proposed the two-tier Medicare system, and some individuals have even gone to the extent of accessing APS-submitted documents through Freedom of Information requests to the Government in order to 'prove' this. Documents obtained under FOI have been perused out of context and many erroneous claims have been made about the APS position to create division and unrest. However, most of the APS negotiations about the Better Access initiative were undertaken in direct face-to-face meetings for which there was no documentation, and the original APS position on this, as outlined above, is available in hard copy for anyone to peruse by arrangement at the National Office.
3. The medical model of the Medicare Benefits Scheme The Medicare Benefits Scheme is a medical model of service provision which broadly recognises through a differential Medicare rebate those services provided by general medical practitioners and those provided by medical practitioners with additional specialist training. As the Better Access initiative is implemented through the Medicare Benefits Scheme this medical model of general and specialist levels of Medicare rebates has been adopted. The APS views the current two-tiered Medicare rebate system for psychologists providing services under Better Access as consistent with the broad MBS model in its recognition of additional specialist training attracting a higher rebate.
The APS position on the two-tiered Medicare rebate
Under the current two-tiered rebate structure, the APS Board believes that there should be a broadening of the upper tier to include services provided by psychologists who possess specialist skills in the treatment of high prevalence mental health disorders. The APS Board stands by the original proposal submitted to the Government in early 2006 in terms of a broader definition of psychologists who are considered to have the necessary skills to be considered a specialist in providing treatment for high prevalence mental health disorders, and hence to deliver services at the higher fee level under the current structure. The eligibility criteria to provide services under the upper tier is therefore recommended to include psychologists with:
- Specified training to enable specialist competence in:
- Psychopathology (including assessment, diagnosis and case formulation)
- Counselling skills
- Treatment planning and psychological interventions
- Specified supervised experience post-registration in a mental health setting
The APS Board believes that a two-tier Medicare structure (with a revised format) should be maintained for two reasons – (1) it recognises and values formal postgraduate professional degree education as the primary means of gaining specialist knowledge and skills; and (2) it is never acceptable to advocate for a reduction in fee for service for psychologists, which is what would surely ensue under a single tier structure. The Board is currently reviewing the originally proposed criteria to define specialist mental health skills training and experience, and how this would be assessed, as well as the title for these specialist psychologists.
The APS position on the Medicare rebate structure outlined above is consistent with:
- The original APS Board-approved negotiating position in early 2006 in the lead-up to the introduction of the Better Access initiative on how to define a psychologist with specialist mental health skills
- One of the options endorsed by the APS Member Concerns Working Group in 2009, which was established to assist the Board in relation to the divisions within the Society over the two-tier Medicare system and whose work incorporated wide feedback from the APS membership.
Ongoing APS advocacy in relation to Better Access
The APS strategy is to continue to strongly advocate against the funding cuts to the Better Access initiative in the period leading up to the reduced session arrangement on 1 November this year. If this advocacy does not achieve a result by then, the APS will aim to influence next year's Budget to have the funding cuts reversed by continuing to provide information on the impact of the cuts on mental health consumers.
As these negotiations are often very delicate, a judgement will be made about the timing of when and how strongly to advocate for changes in relation to a broadening of the upper Medicare rebate tier. Although the APS Board remains extremely aware of the ongoing sensitivities in relation to the Medicare rebate matter, it believes that the protection of the overall Better Access initiative and access to Medicare rebates for psychologists and their clients needs to be a high priority of APS Better Access advocacy. In the meantime, even though the Medicare rebate structure has caused such angst, it is important for all to be mindful of the costs of disunity and the dangers of the appearance of self-interest. Our voice is always stronger if it is united and focused on the needs of those who our profession has been established to serve – the clients we treat.