‘More care’ isn’t the mental health answer

Medicare needs to move beyond fee-for-service to drive real change

Sebastian Rosenberg

Government and governance, Social policy, Health, Arts, culture & society | Australia

17 April 2019

Despite high associated costs, Australia’s Better Access Program is unable to provide adequate support to those struggling with mental health issues, especially in the long-run, Sebastian Rosenberg writes.

The recent Medicare review into the provision of psychology services recommended a radical expansion of the Better Access Program, with some clients eligible for up to 40 sessions of psychological care.

This program, which began on 1 November 2006, currently provides publicly funded access for up to ten sessions with a psychologist every year under Medicare. It is worth noting that generally this does not mean that treatment is free, with out-of-pocket costs per session averaging around $30 but often costing more.

It should also be noted that, like most Medicare-provided services, there are very significant differences in the rate of access to care depending on whether you live in an urban, regional, or remote area of Australia and also depending on your socio-economic status.

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The program has been evaluated once, with around 800 people – all selected by their own health professionals – reporting their treatment had a positive effect.

The program is costing Australia $22 million every week – the cost of psychology services and requisite referrals from general practitioners (GP), plus out-of-pocket costs paid by consumers after each visit.

Analysis of Medicare data suggests that average annual growth in expenditure for the program has been 6.7 per cent. While numbers of clinical psychologists and GPs are currently limited, there is an endless stream of registered psychologists being produced in our universities and being added to the labour force, opening up the prospect of continued program growth.

Already, some 46,000 Australians receive care under the program every week, and I’m sure many of these people are being helped. However, even as a taxpayer, let alone as an advocate for mental health, Australia’s approach to funding the program seems extravagant. Particularly when so little is known about the issues people face when they seek care, what is done to them, and the extent to which they’re experiencing long-term positive benefits.

The number of ‘repeat’ customers into the Better Access Program has increased markedly. New clients into Better Access were 68 per cent in 2008, 57 per cent in 2009, and just 32.6 per cent in 2016–17. If people are having to return to the program for care, it again raises questions about whether the current model is the most appropriate.

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It may well be that many current clients of the program struggle with a level of complexity that requires more than can be addressed by a single provider. Team-based, multi-disciplinary care is probably the answer here. Fee-for-service Medicare-funded programs like Better Access do not foster this type of care.

This is a difficult argument to run. Mental health receives 7.7 per cent of the total health budget while accounting for 12 per cent of the burden of disease. More resources in mental health are clearly required.

I also appreciate how concerned people might be about ‘losing’ access to rare mental health care. However, simply saying we need more of the same type of care is not enough. There are yawning gaps in the mental health service landscape for those with more complex and impairing conditions, as well as the fundamental inequities in current patterns of service delivery.

Addressing these matters needs new models of service, supported by new models of funding. How can we introduce the necessary incentives to, for example, provide a person with an eating disorder not only access to a GP and a psychologist, but also to a nutritionist, a community nurse, a psychiatrist, peer support, specialist medical care, and psycho-social and vocational support?

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This kind of integrated, team-based approach was promised under the concept of ‘stepped care’ introduced by the government in response to the 2014 review into mental health conducted by the National Mental Health Commission.

In reality, though, many people find it hard to even identify the ‘steps’ in their mental health care. Where they do, often what they prioritise isn’t what works best or what they actually need, but whether their service is funded by the Federal Government, the State Government, or the National Disability Insurance Scheme.

The Better Access Program is emblematic of Australia’s willingness to invest in mental health care. The program is a large fragment in our very fractured national response to mental illness. It is imperative we now look to balance our concern about access with a new focus on quality and integration.

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