November 2016 marked the 10th anniversary of the introduction of the Better Access initiative, which saw psychological treatment services for people with mental health disorders included under Australia’s Medicare system for the first time. This was a momentous decision by the Government which provided access to psychological services to people who would not otherwise have been able to afford treatment.
The APS first commenced advocating for consumers to be able to access government funded psychological services in the community more than 30 years ago, so there was a great feeling of achievement when this landmark mental health reform was implemented.
The success of Better Access
In the past decade, Better Access has been shown to be enormously successful in providing accessible, effective, and relatively low cost services to meet public need, particularly for people with high-prevalence disorders such as depression and anxiety (Whiteford et al. 2014). When Better Access was established in 2006 the demand for mental health services far exceeded what could be offered through State and Territory mental health and Federal Government initiatives such as the Access to Allied Psychological Services (ATAPS). The Better Access initiative through Medicare provides universal access to services for consumers, and an uncapped funding source. This has allowed people who could not previously afford to access mental health services, to seek assistance. Earlier Federal Government initiatives such as Better Outcomes in Mental Health Care differentially targeted particular population groups (e.g., people in rural and remote areas, those at risk of suicide) with available funding capped annually.
The need and the demand for Better Access services was high from the beginning and continued to grow across the years with increasing numbers of individuals accessing psychological services. Figure 1 shows the continual increase in the number of individuals accessing Better Access from 2009.
Evaluations of the Better Access initiative, including an independent evaluation commissioned by the Australian Government (Pirkis, Harris, Hall, & Ftanou, 2011), report that most people using Better Access have moderate to high levels of psychological distress and that Better Access has demonstrated positive client outcomes with a reduction in symptoms for many people.
Data collected from a range of sources confirmed the huge demand for psychological services and the effectiveness of the initiative (APS, 2008; 2011; Pirkis et al., 2011; Whiteford et al., 2014) demonstrating that:
- Better Access improved treatment rates for people with mental health disorders – an increase from 35 to 46 per cent by 2010 – and appeared to be the sole driver of increased treatment rates.
- Medicare-funded items were being used by new consumers (~50 per cent), which demonstrated the increased accessibility and affordability of the initiative.
- Better Access is used by people with high or very high levels of psychological distress, as measured by the Kessler Distress Scale (K10).
- Interventions from psychologists resulted in levels of anxiety and depression going from moderate or severe to normal or mild levels after treatment, thus indicating effectiveness.
- Better Access provides cost-effective treatment that was cheaper than expected at an average of $753.00 per person.
Figure 1. Number of individuals accessing the Better Access initiative between 2009 and 2015.
(Note: Data for individuals not available prior to 2009 and data for individuals accessing a GP Mental Health Treatment Plan and GP FPS not available prior to 2011.)
As well as surveying psychologists, the APS undertook a client satisfaction survey of more than 2,000 clients. Client reports indicated that for 91 per cent of clients, psychological treatment resulted in significant or very significant improvement, and that 96 per cent of clients who received services could not afford psychological treatment without a Medicare rebate. APS surveys found that 72 per cent of clients presenting under Better Access received a diagnosis of depression, 68 per cent anxiety, and 46 per cent comorbid anxiety and depression. Fourteen per cent of clients had received a diagnosis of post-traumatic stress disorder (PTSD), nine per cent adjustment disorder, and five per cent drug and alcohol use disorder (APS, 2008; 2011).
In 2010, at the time of the Better Access evaluation, the Budget spend for Better Access was nearly $500 million and growing. Of this, $142 million went to GPs for the Mental Health Treatment Plans, and just under $360 million went to allied health (primarily psychologists) for evidence-based services. At the time, most GPs, approximately 3,200 clinical psychologists, 12,700 ‘registered’ psychologists, 1,200 social workers and 330 occupational therapists were providing Better Access services, with psychologists being by far the largest profession providing services.
By 2013 more than three million people had accessed psychological services through Better Access and more than 20 million services had been provided at a cost of nearly $3 billion dollars and service demand continued to grow. Figure 2 shows the increasing number of Better Access services provided annually.
It became clear that the demand for psychological services was not slowing down and had by far exceeded Government budget expectations. The Government talk was of a blow-out of the budget allocation and a need to curtail the ongoing overspend in Better Access. This was a time of angst within the profession, and the Society was again involved in lobbying the Government with the now substantial evidence of the effectiveness and the cost efficiencies gained from the provision of psychological services under Better Access (e.g., in addressing productivity losses as a result of mental illness, as well as the clear benefits provided to clients and the community).
Government changes to Better Access
In spite of the positive outcomes demonstrated in the Government commissioned evaluation of Better Access, by 2010 the Federal Government was seriously looking to reduce the costs of Better Access. It became increasingly clear to the APS that the Focussed Psychological Strategies (FPS) items were at risk, and the APS met with Government to convince them of the importance of retaining these items and ‘generalist’ psychologists in Better Access to ensure community access to psychology services. In the 2010 Federal Budget the Government announced that social workers and occupational therapists would be removed from the Better Access initiative, with no mention of cuts to psychology. The Australian Association of Social Workers and Occupational Therapy Australia began a campaign which saw the Government decision overturned in November 2010. However, it was clear that there were likely to be cuts to the Better Access initiative as the Government argued that the current spend and continued growth of Better Access was not sustainable.
Despite ongoing lobbying by the APS to retain the full allowance of treatment sessions, the 2011-2012 Federal Budget announced a reduction in the number of Medicare sessions available under Better Access. When Better Access was first introduced, clients were eligible for up to 12 individual sessions per calendar year, with an additional six sessions available under exceptional circumstances. The changes reduced the number of available sessions from 12 (or up to 18 in exceptional circumstances) to a maximum of 10 sessions for individuals per calendar year, with no exceptional circumstances. The APS again lobbied the Government about the impact that these cuts would have on the Australian community and while the six sessions based on exceptional circumstances were reinstated briefly in March 2012, this ended in December 2012.
Figure 2. Number of Better Access services provided between 2006 and 2016
As a result of the cuts to the services previously allowed under exceptional circumstances, it was determined that 87,000 Better Access consumers per annum would be adversely affected. The cuts meant that many thousands of Australians with moderate to severe mental health problems, those most likely to require more than 10 sessions, were denied access to a sufficient number of affordable services to meet their treatment needs. Alternative services are not often available for these consumers – very few private psychiatrists’ offer bulk billing, and State and Territory mental health services have huge waiting lists or turn away people because they were not deemed to meet the threshold for admission.
In 2012 the APS conducted a survey to determine the impact of the reduction in sessions from 18 to 10 for those clients who required more than 10 sessions (APS, 2014). Data were collected from psychologists for approximately 900 clients. Ninety per cent of clients reported moderate to severe mental health problems, mainly anxiety, depression and PTSD and were not eligible for State and Territory health services. It therefore fell to the psychologist to determine whether any pathways of care existed for the client. Many psychologists reported providing services pro bono or at a reduced cost, although they reported that this was not sustainable in the longer term. Very few psychologists were able to redirect clients to community services (10 per cent) or to other health professionals such as psychiatrists (six per cent).
Even with the Government cuts to Better Access, uptake of services has not slowed. In the last decade nearly 5 million Australians have accessed over 33 million psychological treatment services under Better Access and this increasing Better Access expenditure continues to be on the Government’s radar.
National Review of Mental Health Programmes and Services
In 2014 the National Mental Health Commission undertook a review of mental health services in Australia. The report of the review was released in April 2015 and identified nine strategic directions incorporating 25 recommendations, some positive for psychology, and some that were very concerning. The recommendations most pertinent to psychology included:
- The “cashing out” of the funding provided for the Focussed Psychological Strategies (FPS; non-Clinical Psychology) Medicare items to services provided through the Primary Health Networks (PHNs).
- This recommendation was particularly concerning as basically the entire non-clinical Medicare services would be moved over to the PHNs so again the ‘generalist’ psychology services had been targeted. This would put a large component of Better Access at risk as access to these services would be controlled by the PHNs and potentially could be limited to specific population groups as well as enable the funding to be shifted to a capitated model.
- That new psychologists entering the workforce can only provide Medicare-rebated services to consumers residing in rural areas with populations of less than 50,000. Psychologists who subsequently gain area of practice endorsement can provide services to consumers living in any area of Australia.
- This was a concerning recommendation as it would result in all new psychologists who want to provide the general psychology items only ever being able to provide services in a rural area if they want to work under Medicare. This would be a terrible outcome for psychology as the majority of psychology graduates provide the general psychology Medicare items and so it would impact on the number of students choosing to study to become a psychologist.
- That the number of available sessions under Better Access be increased to 16 in a calendar year but that those consumers identified as likely to require the additional sessions be referred to clinical psychologists.
- This was counter to the APS position which was that the treatment sessions should not be limited to clinical psychologist providers, as there is a much broader range of psychologists who can provide effective services to consumers with complex mental health needs.
The APS decided to take action to again to protect the FPS services and the inclusion of ‘generalist’ psychology items in Medicare by not only lobbying the Government but also giving media interviews and issuing media releases explaining the consequences of a capitated funding model through the transfer of services to the PHNs. There was also a strong focus on the inappropriateness of limiting a professional group to providing services under Medicare based on a geographical location.
The APS continued to advocate for a Government commitment to provide mental health services through Medicare as the universal healthcare scheme for all Australians as it provides healthcare on the basis of need and not ability to pay, and the services are not capped at a particular level of expenditure. The basis of APS advocacy was that the Better Access initiative demonstrated beneficial outcomes and was meeting a huge need in the community that could not be met as cost-efficiently through other services, and the high demand reflected consumer needs which should be met. The APS, along with the broader Australian community, was then waiting for a Government response to the mental health review.
Australian Government response to the National Review of Mental Health Programmes and Services
In November 2015 the Government’s response to the National Review of Mental Health Programmes and Services was released. In their response the Government acknowledged the importance of the Better Access initiative and affirmed that psychological services would continue to be provided through Better Access. However, the Government proposed a three-year plan for system change which places the 31 PHNs as being central to the future provision of mental health services.
As part of the transition to establish the PHNs as overseeing the provision of mental health services, funding attached to many Government programs that were previously provided under the Access to Psychological Therapies (ATAPS), as well as the youth and child mental health initiatives (e.g., headspace) would be moved to the PHNs.
In addition, the Government announced that there would be changes to the way services are provided to particular client groups currently treated under Better Access; specifically those at the two ends of the severity continuum – those presenting with mild mental health problems and those with severe and complex mental illness. The Government signalled a move towards a ‘stepped care’ service approach in which people presenting with mild to moderate mental health problems will be encouraged to take part in a low intensity treatment (e.g., e-therapy, coaching for mental health issues) and only ‘stepping up’ to more intensive treatment if clinically required. As part of this stepped-care approach the Government announced the development of a digital mental health gateway providing both online and telephone information, crisis support, assessment and treatment that could be obtained directly by consumers. This raises threats to the professional provision of psychological services, and potentially to the community through the redirection of services previously provided by psychologists to other professionals who are certainly not as well trained in treating mental health disorders (and in some cases have questionable training to deal with psychological distress).
At the other end of the severity continuum, those people presenting with complex and severe mental illness would receive services under a new funding model providing ‘tailored packages of care’. These packages of care are to be administered by select PHNs (lead sites) and will require voluntary enrolment with a GP practice that will provide access to a range of services under the packages of care.
Hence, the Better Access initiative has been cut at both ends of the spectrum – Better Access is now focused on people with moderate mental health disorders. The Government also announced the establishment of Health Care Homes which would have a coordinating role in providing packages of care to people with chronic and complex physical health conditions and associated mental health disorders.
In making these changes, a major driver for the Government is to reduce mental health care expenditure which has continued to rise with no indication of a slowdown. By shifting mental health funding to these different models of service provision the Government is able to reallocate the funding to a capitated funding model. Some of these proposed changes have now been put in place, including the redirection of many funded mental health programs to the PHNs, with other aspects of the proposed changes still being trialed (e.g., Health Care Homes) and others in development (e.g., the Digital Mental Health Gateway). This is likely to be a sign of the times as the Government trend is to contain expenditure by moving to capitated funding.
While many of these changes are transforming the way services have been provided in the past few years, there are opportunities for members to engage in many of these new models of service provision. It is important that psychologists are central to many of these new initiatives and contribute their high level of expertise in the planning and provision of psychological services. Services such as those provided to individuals with complex and severe mental illness will be dependent on psychologists, psychiatrists, and mental health nurses. Similarly, psychologists have been at the forefront in the development of many online therapy programs and many others have integrated these into their practice to benefit their clients. There are opportunities for psychology in the changes that the Government has implemented and these opportunities can complement and expand on psychology services provided through Better Access.
However, there are also high risks – both for mental health consumers and for psychologists – including in the shift to low intensity services delivered by a poorly trained workforce, and a lack of information on how the packages of care will be funded and whether there will be sufficient funds to meet the high needs of consumers with severe and complex mental health conditions.
What does the future hold for Better Access?
While the Government has indicated that Better Access will be retained there are a number of activities that the APS is closely following that may have an impact on Better Access – either positively or negatively. These include the Government’s review of the Medicare Benefits Schedule (MBS) which involves scrutiny of over 5000 MBS items, including the MBS items associated with Better Access. The focus of the review is on best practice in health care to improve patient outcomes rather than an emphasis on cost savings, and we know from the outcome data to date, that Better Access has provided effective and efficient mental health care services. There is also no focus on adding additional items but rather, the focus is on screening for items that, through developments in healthcare, are now obsolete or provide little value.
The recent media campaign to allow Government-funded residents of aged-care facilities, a population group experiencing a higher incidence of mental health problems than the wider community, and currently excluded from Medicare-funded psychological treatment, to access services through Better Access has been welcomed by the APS. There has been broad support across the health sector calling for changes to Better Access to allow access to residents of aged-care facilities.
As we move into the changing landscape of mental health services in Australia it is important to acknowledge the enormous benefit that Better Access has had for the Australian community and what has been achieved for the profession through actively promoting and lobbying for all psychologists. The APS has at all times maintained a strong voice for all members, in particular in protecting the continued inclusion of generalist psychologists, as well as advocating for the Australian community. While there are likely to be more challenges ahead, it is important that all members are united in advocating for the continuation of Better Access services at a time when there is great uncertainty about the Government’s agenda for curbing health expenditure.
The establishment of the two-tiered structure
There is considerable misinformation circulating in relation to the APS position on the two-tiered structure and the extent to which the APS influenced the eventual structure implemented by the Government.
The Government determined that access to providing Medicare rebates under the initiative would be limited to psychologists who were members of the APS College of Clinical Psychologists on the advice from its mental health advisors. Indeed, this position was put forward in a media release by Tony Abbott dated 9 May 2006 (see media release on page 6).
The APS lobbied the Government on this issue and argued that all registered psychologists should be funded to provide effective psychological treatments for mental health consumers, on the basis that Government-funded psychological services were already being successfully provided by these psychologists under the existing Better Outcomes in Mental Health Care scheme which had been operating through the Divisions of General Practice since 2001. As a result, the Government then decided that psychologists and appropriately qualified social workers, occupational therapists and GPs would be included to provide Focussed Psychological Strategies (FPS) under the Better Access initiative, but at a lower rate than clinical psychologists, to boost community access to affordable psychological care, with the FPS services provided by psychologists attracting a higher rebate than other health providers. This was in line with the Medicare framework which differentiates between general and specialist medical training. Hence, the two-tiered Medicare rebate system was established for psychologists. It was a huge turnaround that the APS was able to achieve for mental health consumers and the profession and it was the Federal Government that was adamant that the two-tier system would be put in place.
It is frequently incorrectly claimed that the APS originally proposed the two-tier Medicare system, but this is not the case. In the lead up to the introduction of the Better Access initiative in early 2006, the APS originally proposed a position to the Government (which was APS Board-approved) regarding psychologists considered to have the necessary skills to be considered to be competent in providing treatment for high-prevalence mental health disorders i.e., predominantly depression and anxiety disorders. After it was announced that only clinical psychologists were to be funded under Medicare, the APS tried to expand this category by proposing:
- Medicare rebates should be available for services provided by psychologists defined by specified competencies in terms of level of mental health knowledge and skills in psychopathology (assessment, diagnosis and case formulation), counselling skills and psychotherapy/psychological interventions, plus supervised post-registration experience in mental health settings.
- Eligible psychologists would include those with postgraduate professional Masters/Doctorate degrees who possessed the specified training and supervised experience, as well as those with four-year undergraduate degrees who met the specified mental health training and supervised experience criteria.
- The Government should expand the number and categories of psychologists funded under Medicare.
The Federal Government did not adopt the APS recommendations and the two-tier system remained. Nevertheless, when the announcement about the expansion of Medicare items to include psychologists was made, psychologists were ecstatic about what this would mean for their ability to provide psychological services to the community. Many members, including those who did not hold College membership, contacted the APS to offer their congratulations and to share in the excitement of the success. It was an incredible achievement.