4.8 Informing the summative evaluation

This section presents the key findings relating to:

• characteristics of consumers receiving Medicare rebateable Better Access mental health services;
• service provider, consumer and carer awareness of the Better Access initiative;
• impact of the Better Access initiative on the use of medications; and
• other unintended consequences for stakeholders.

4.8.1 Summary of summative findings
4.8.2 Characteristics of individuals accessing the Better Access initiative
4.8.3 Awareness of the Better Access initiative
4.8.4 Impact on use of medications
4.8.5 Other consequences
4.8.6 Differential rebates for allied health providers
4.8.7 Impact on non approved counsellors
4.8.8 Impact on private health insurance
4.8.9 Operational issues in relation to the Better Access initiative MBS items

4.8.1 Summary of summative findings

Although AHPs noted a broad range of clients using services, generally clients tended to have a diagnosis of moderate to severe anxiety or depression, largely reflective of the prevalence of these conditions in the general population. Most services were provided in metropolitan areas, reflective of the geographic dispersion of the population and location of AHPs. Services were mainly provided to adults, with some children, fewer older people and few, if any, individuals in nursing homes receiving services. Access by Aboriginal and Torres Strait Islander people and individuals from culturally and linguistically diverse communities was described as low. Importantly, it was noted by AHPs that they rarely 'turned away' referrals and that the characteristics of individuals receiving services was determined by the referring GPs.

It was generally reported that the Better Access initiative was well established and that psychiatrists, GPs, AHPS and other mental health services in the community were well aware of services available and how the referral process operated. It was noted by GPs and AHPs that referral processes and pathways are continuing to improve as the Better Access initiative matures. There was also a perception by GPs, AHPs, consumers and carers that general awareness in the community as to availability of services through the Better Access initiative was increasing.

Despite the generally positive consumer outcomes reported by AHPs and GPs, the Better Access initiative was perceived by psychiatrists, GPs and AHPs as having minimal, if any, impact on the level of medications prescribed for mental disorders. Generally, it would appear from the consultations that the Better Access initiative operated as a complementary treatment option to pharmacological interventions:

• a small number of GPs noted that referral to an AHP sometimes allowed trialling non medical interventions or a treatment option for patients reluctant to accept medication;
• AHPs noted that some individuals initiating referrals to an AHP did so as they wanted an alternative to medication; and
• a small number of GPs and AHPs also noted that, on occasions, AHPs would refer back to the GP for a medication review to maximise the impact of the psychological therapies.

Top of pageGPs, consumers and carers identified the 'gap' payment required for services provided by AHPs as an issue. The fee charged by AHPs and subsequent gap payment varied across providers, though many had an informal discounting process for clients in necessitous circumstances. A contentious issue between clinical psychologists, psychologists and social workers was the differential Medicare rebate paid for services provided by clinical psychologists. This was seen to contribute to the 'gap' differential and had the effect of allowing clinical psychologists who received a rebate of $37 to $46 per session more than a psychologist or social worker, to charge a lower gap. The lower 'out of pocket' cost to patients in turn encouraged GPs to refer patients to, and patients to seek referrals to, clinical psychologists. Though a saving to patients, this created a perverse incentive for patients to utilise services that were at a higher cost to Medicare. The issue of whether clinical psychologists offered a materially different service and achieved better outcomes for patients than did psychologists, social workers or occupational therapists was also questioned by many psychologists and social workers, although this issues was outside of the scope of Component D of the evaluation.

Prior to the Better Access initiative there were a range of counsellors, psychotherapists and therapists providing fee-for-service counselling and therapy services in the community. Representatives of counsellors, psychotherapists and therapists not eligible to be approved providers under the Better Access initiative perceived the MBS rebate available through the initiative as providing an unfair competitive advantage to approved providers and having a detrimental effect on the financial viability of their members. These representative bodies also expressed concern that the Better Access initiative does not provide scope for psychoanalysis and long-term psychotherapy for more severe psychological disorders⁷² and that an expansion of eligibility to include their members would expand the availability of services and improve access to services.

The Better Access initiative appears to have had some impact on private health insurers. Insurers consulted supported the Better Access initiative as it was seen as providing better outcomes for their members in the long term and prevented unnecessary hospitalisation. Subsequent to the introduction of the Better Access initiative, where members may have previously accessed psychologists and occupational therapists through their ancillary insurance cover, they can now do so only after they have accessed all services available through Medicare. As per MBS guidelines, ancillary cover is not available to pay the gap between the fee charged and MBS rebate paid.

4.8.2 Characteristics of individuals accessing the Better Access initiative

Overall, the Better Access initiative was seen as complementing the public mental health system and providing services to a cross section of clients. During the consultation process, stakeholders and interviewees identified a number of characteristics of consumers receiving mental health services under the Better Access initiative.

Table 11 highlights the more general client characteristics reported.

A more detailed discussion of those receiving mental health services within the Better Access initiative are reported in the preceding sections of this report examining access and appropriateness of services.

As noted in the discussion on access, many respondents reported perceived inequalities in access with individuals from rural and remote communities, poorer communities, children and young people, older persons, Aboriginal and Torres Strait Islander people, and people from culturally and linguistically diverse backgrounds being under represented in the profile of clients using the service.

In discussions of appropriateness, stakeholders and interviewees indicated that the profile of clients accessing the Better Access initiative services was largely reflective of the client group defined in the Medicare guidelines. Better Access providers reported providing services appropriate to the needs of individuals referred or suggesting an alternative referral. Although most AHPs interviewed reported an informal arrangement of cross subsidisation of poorer clients by 'bulk billing' or charging reduced fees for these clients, this was not formalised and generally not advertised. Often it was restricted to existing clients whose circumstances changed during the course of treatment. AHPs did not report a proactive approach to targeting services to high need populations and indicated that they did not think it would be financially viable to do so.

The focus on 'who comes through the door', without a prioritisation based on clinical need or capacity to pay, was seen by state and territory government health departments and public mental health providers as a key limitation of the Better Access initiative. Conversely, when questioned, AHPs indicated that referrals were generated by GPs and it was the GP who determined the profile of referrals.

Both AHPs and public mental health providers perceived the primary differentiator in clients receiving public mental health services and services through the Better Access initiative to be that public mental health clients tended to have a higher level of chronicity, be more complex with more co-morbidities, less able to manage their own day-to-day affairs and more likely to require case management. In areas where there were no public mental health services or available public mental health services were unable to meet demand, the Better Access initiative provided therapy to this more chronic, more complex, poorer functioning client group, including clients with long standing mental health conditions including bipolar disorder and chronic psychoses. In this situation, AHPs treated these more complex clients with the support of GPs and psychiatrists.
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Discussion with local AHPs indicated that the profile of clients is changing over time and a much more diverse client group is emerging.

AHPs reported that initial referrals comprised a high proportion of women and clients with more simple anxieties and mood disorders. A number of them reported that the general client group was now expanding to include:

• more men, particularly men in their 50s and 60s, and accessing services for the first time;
• more children being referred by paediatricians;
• older people; and
• more complex clients who are referred as an alternative or adjunct to GP medication management of more complex disorders.

There was also a perception among most AHPs that the complexity of clients was increasing and that they are managing a number of clients who would otherwise be managed by the public mental health service, because public mental health services are not available. Many of these clients have a long history of involvement with the public mental health system and include clients with bipolar disorders or chronic psychoses, and clients requiring case management, with the case management provided by parents and family supports. The increasing complexity of referrals is requiring more intensive and longer interventions, and treatment periods of 12-18 sessions are now becoming more common. It also appeared that in areas with poor access to public mental health services, AHPs and GPs were managing caseloads with a greater proportion of clients with multiple comorbidities and lower prevalence disorders.⁷³

The change in client profile is primarily perceived to be a result of a maturing of the practices of the Better Access initiative and:

• very little capacity in the public mental health system to provide therapy;
• developing of trust and relationships and referral pathways between GPs and AHPs;
• very few psychiatrists, with those who are available having limited capacity to provide therapy, resulting in GPs referring to AHPs;
• increased awareness that services are available and word of mouth referrals leading to client initiated referrals;
• accessing mental health services is now being seen as more normal and there is reduced stigma associated with seeking mental health care;
• receiving treatment from a AHP carries less stigma than treatment by a psychiatrist; and
• increased penetration and awareness of service availability in the local community and sub groups in the community.

Table 11: Better Access client characteristics reported by AHPs

Table 11 is presented as a list in this HTML version for accessibility reasons. It is presented as a table in the PDF version.
Typical Better Access consumer, by characteristic:

• Diagnosis - Anxiety and/or depression
• Severity of illness - Moderate to severe
• Geographic location - Metropolitan more than rural
• Age - Primarily adults, some children, fewer older people and few, if any, in nursing homes
• Cultural background - Few from Aboriginal and Torres Strait Islander people and few from culturally and linguistically diverse communities

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4.8.3 Awareness of the Better Access initiative

Generally, it was reported by all stakeholders that the Better Access initiative was now well established, awareness amongst GPs was high and that this would continue to improve as the Better Access initiative matured.

Psychiatrists and RANZCP representatives reported that the Better Access initiative was largely well established.

GPs and GP representative bodies were of the opinion that the Better Access initiative was now well established and referral pathways were continuing to evolve. The degree of progress and implementation varied across Divisions as did the reported level of engagement and commitment of resources to building relationships and referral pathways with AHPs. Overall, GP representatives were pleased with the degree of progress achieved in implementing the Better Access initiative.

All AHP provider bodies were very interested in participating in the evaluation and supportive of their members moving into private practice. The APS appeared the most proactive in developing resources and supporting members engaged in private practice: less so were the OT Australia and AASW. APS resourcing of members included the development of directories of members for GPs, proactively lobbying on behalf of members and initiating research showing the efficacy of psychological interventions provided through the Better Access initiative.

Public mental health providers were also aware of the Better Access initiative and, although most were proactive in building partnerships with GPs, they had varying levels of interactions with AHPs.

Private psychiatric hospitals were aware of the Better Access initiative, but had no direct contact with the Better Access initiative. This was due to engagement with primary mental health care services being via the admitting psychiatrist and, through the psychiatrist, with the patient's GP. An exception is Belmont Private Hospital in Brisbane who has developed in partnership with the Brisbane South Division coordinated access to psychiatrists under Better Access through the GLAS program. This innovative program recently won the 2009 Australian Private Hospital Association Award for Ambulatory Care for its General Practice Liaison and Assessment Service (GLAS).

Peak state mental health NGOs were aware of the Better Access initiative and reported a number of organisations exploring the possibility of, or currently accessing services through the Better Access initiative to improve access to services for their clients.

There was also a perception by GPs, AHPs, NGOs and consumer groups that general awareness in the community of service availability through the Better Access initiative was increasing. Both GPs and AHPs reported increasing numbers of individuals directly requesting services from, or referral to, an AHP for treatment of their mental health problems.

Despite the overall positive comments in relation to awareness of the Better Access initiative by GPs, there were some reported instances evidencing poor GP awareness. These included:

• A small number of consumer groups, NGO groups and individual consumers reported instances of clients presenting to GPs and not being advised of the availability of the Better Access initiative, but only being offered medication;
  
  
• one rural GP receiving the background information on the evaluation through the RACGP and then contacting the evaluation team to request information on how the Better Access initiative worked, reported they were the sole GP across a number of rural communities and had never heard of Better Access;
  
  
• All AHPs reporting that a number of referrals they receive from GPs contains minimal documentation, noting this is in a minority of cases and the general level of documentation is improving;
  
  
• Most AHPs reporting that in a small number of instances they have received inappropriate referrals from GPs, noting that generally the quality of information is good and that the numbers of inappropriate referrals were perceived as decreasing; and
  
  
• All GPs reporting instances of receiving minimal information in documentation and reports from AHPs, again noting that the quality of reporting in improving

Stakeholders and interviewees who expressed concern in relation to awareness of the Better Access initiative in the community and how the Better Access initiative works did so while also reporting that these instances were in the minority of cases, and awareness of and operation of the Better Access initiative was improving.
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4.8.4 Impact on use of medications

Overall, psychiatrists, GPs and AHPs perceived that the Better Access initiative had had minimal, if any, impact on the level of medications prescribed for the treatment of mental disorders, in particular anti-depressants. A number of AHPs and GPs did however highlight that the Better Access initiative had facilitated access to another treatment option for patients presenting with mental disorders or as an alternative to medication in the first instance.

A small number of AHPs and GPs reported incidences of patients being referred back to GPs by the AHP for prescriptions, with the view of maximising the effectiveness of the psychological therapies. One group practice of psychologists provided the results of a survey involving 130 of their recent clients. Of this sample, 48 per cent of clients did not take medication at the time of referral. These psychologists reported that GPs often refrained from prescribing medication until psychological therapy had been trialled. A number of GPs noted that the push to try non pharmaceutical interventions also came from patients and that well established relationships with AHPs allowed this to be trialled while closely monitoring the patients' condition.

Five or six senior GPs and GP representatives reported that, given the relatively 'low level' of mental health training within general practice, the impact of the Better Access initiative on GP prescribing practices would be minimal. These interviewees identified the role of pharmaceutical company representatives as the most significant driver of prescribing practices and were of the opinion that, until enhanced mental health training and strategies to counter the promotional activities of pharmaceutical representatives were enacted, prescribing practices were unlikely to change significantly.

Offsetting these concerns is evidence that 25 per cent of GPs underwent mental health training as part of Better Outcomes, that GPs under Better Outcomes were required to undertake ongoing professional development and that younger GPs are being exposed to higher levels of mental health training during their postgraduate studies.

The online survey of consumers provided an indication of which services were provided by the GP, Table 12. Of the 125 consumers who reported that they had seen a GP for their mental health disorder in the past 12 months 27 per cent received a treatment plan, 30 per cent received medication and 16 per cent were referred to a AHP (some consumers received a combination of the above). Of the 34 receiving a treatment plan, 19 (56 per cent) were referred to a AHP. Of the 20 consumers referred to a AHP, 13 (65 per cent) also received medication.

Table 12: GP services reported as being received by consumers

Services received from GP	Number	Percent
Seen GP in last 12 months	125
Received medication	38	30
Received a Treatment Plan	34	27
Referral to a psychiatrist	7	6
Referral to a AHP	20	16
Received a Treatment Plan and referred to AHP	19	15
Received medication and referred to AHP	13	10

4.8.5 Other consequences

During the course of consultations, a range of unintended consequences and issues were identified. Key among these were:

• the impact of the Better Access initiative on non-approved therapists and counsellors;
• strongly differing opinions as to the rationale for differential payments levels for clinical psychologists, general psychologists, occupational therapists and social workers;
• operational issues in relation to the Better Access initiative MBS items; and
• the impact on private health insurance.

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4.8.6 Differential rebates for allied health providers

The differential rebates for clinical psychologists, general psychologists and occupational therapists and social workers were a highly contentious issue and the subject of considerable debate, particularly within the psychology profession. Table 13 provides examples of the range of rebates paid for the provision of focussed psychological strategies lasting more than 50 minutes for professional attendance in consulting rooms and at a place other than consulting rooms.⁷⁴

General psychologists, occupational therapists and social workers argued that the differential failed to reflect experience or specialist skills developed by AHPs across professional groups and did not necessarily reflect a variation in service provided to clients. Occupational therapists and social workers perceived the lower level of rebate as unfair, arguing that the services provided were of a comparable quality and, in many cases, providers utilised the same range of interventions. Social workers reported that the differential in payment is not reflected in payments to allied health providers approved to provide services through the Family Law Court, Department of Veterans' Affairs or Commonwealth Rehabilitation Service. (The evaluation has not examined payment schedules for allied health providers under other Commonwealth contracting arrangements.) Only the APS and clinical psychologists perceived the difference in rebate as a valid reflection of the additional training and skills of clinical psychologists.

Most GPs and psychiatrists acknowledged that the variation in payment failed to capture the expertise of individual providers. However, GPs generally reported feeling more confident referring a patient to a clinical psychologist. It was suggested by some psychiatrists and social workers that GPs have not had the professional exposure to clinical occupational therapists and social workers in their training and professional practice to understand the services offered by these professions.

Table 13: Example of differential rebate - Provision of FPS greater than 50 minutes

Allied health provider	In consulting rooms Item number	In consulting rooms Rebate paid	Other places Item number	Other places Rebate paid
Clinical psychologist	80010	$115.05	80015	$134.60
General Psychologist	80110	$78.40	80115	$98.40
Occupational therapist	80135	$69.10	80140	$89.00
Social worker	80160	$69.10	80165	$89.00

4.8.7 Impact on non approved counsellors

A range of counsellors and therapists who are not eligible to be approved Better Access initiative providers have well established practices. Consultations were undertaken with the national and some state branches of organisations that represented these groups.

Although having in-principle support of the Better Access initiative and the improved access to services offered by the Better Access initiative, non-approved counsellors had three primary concerns:

• the Better Access initiative does not provide scope for psychoanalysis and long-term psychotherapy for more severe psychological disorders;
  
  
• that their professional members who are not clinical psychologists, general psychologists, occupational therapists or social workers are not eligible to provide the Better Access initiative services; and
  
  
• the introduction of the Better Access initiative has had a detrimental effect on the professional practices of their members by introducing an element of subsidised competition into the market.

They also noted that expansion of the Better Access initiative to include their professional members would expand the available workforce and improve access to services.
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4.8.8 Impact on private health insurance

In the course of the evaluation, the evaluation contacted three major health insurers: MBF (BUPA), HCF and Medibank.

Health Insurers reported a limited stake in the Better Access initiative but, in general, supported improved access to focussed psychological strategies in the community as they deliver better outcomes for patients in the long term and prevent unnecessary hospitalisation. Health Insurers have experienced some difficulty with members who wished to claim against both the Medicare rebate and Health Insurer rebate (double dipping), which required Insurers to adjust their policies accordingly.

Prior to the introduction of the Better Access initiative, all three providers offered rebates for services provided by occupational therapists and psychologists, but not social workers. Since the introduction of the Better Access initiative, there has been no change made to business rules in relation to these services. For members to receive a rebate provided by occupational therapists and psychologists, the service providers need to be recognised by the fund and customers must be on a level of cover offering benefits for these services.

Members are able to access rebates from Medicare and their policy, but not both for the same claim. As per the MBS guidelines, they are not able to use their private health insurance ancillary cover to cover the gap between the charge and the Medicare rebate for these services.

Members can only claim services through their private health insurance once they have accessed all available services under the Better Access initiative. One fund reported that subsequent to the introduction of the Better Access initiative there has been an apparent decrease psychology treatments claimed and members claiming rebates for psychology treatments.

4.8.9 Operational issues in relation to the Better Access initiative MBS items

Several operational issues relating to the Better Access initiative were reported during the course of consultations. These were perceived as impeding the efficient operation of the Better Access initiative and included the following:

• A small number of Divisions of General Practice and individual GPs reported ongoing confusion as to the Better Access initiative MBS item numbers, more so than other areas of the MBS, and identified the need for greater clarity within the MBS itself and/or more training and information from Medicare.
  
  
• In small area consultations GPs and AHPs reported that when they contacted Medicare they often received contradictory advice. They identifies a need for clarification and simpler explanations of mental health items within the MBS.
  
  
• Several GPs reported that if they code an item 23 (professional attendance – MBS rebate $33.55) and later in the same day (they may have asked the patient to come back for a longer consultation as per the intention of the Better Access initiative) they code an item 2710 for the preparation of a GP Mental Health Treatment Plan (MBS rebate $156.85), the MBS computer system only approves the Item 23. This means that the patient takes the completed Treatment Plan to the AHP who initiates treatment and bills the patient. The patient then presents to Medicare seeking their rebate and is advised that there is no approved Treatment Plan and therefore they are not eligible for a rebate. Additional to the stress and anxiety this causes the patient, it adds another administrative process for the GP and/or AHP who then need to work out what has gone wrong. Several AHPs also reported instances of the client reporting that the payment of the rebate had not been approved though the patient had a Treatment Plan. One consumer also reported a similar instance on non payment when it appeared the paperwork was OK, but that this was 'fixed up' when they talked to the AHP ⁷⁵

Similarly, the evaluation was advised that if, after 12 sessions within a calendar year, a GP approves a further six sessions due to exceptional circumstances, the MBS system defaults to not approving the referral. KPMG understands that the MBS computer system should flag the refusal and the referral should then be reviewed by an MBS officer, who notes the coded exceptional circumstances and then manually approves the referral. In practice, the evaluation was advised that this does not occur and it is the GP or AHP who has to rectify the situation after the client has been refused the rebate.

Footnotes

⁷² Nor was it the intent of the Better Access initiative to do so, see note 12 in section 4.2.2.
⁷³ The treatment of more complex and chronic patients is not the intent of the Better Access initiative (see note 12 in section 4.2.2) and the 12-18 sessions being more common does not appear to be supported by the average number of sessions provided through the Better Access initiative being five session (see note 58 in section 4.5.3).
⁷⁴ MBS online data, "Medicare Benefits Schedule - Item 80160" accessed 7 July 2009. Link. Available on the Department of Health and Ageing website (www.health.gov.au).
⁷⁵ Though only identified by a few GPs, AHPs and consumers this may be a technical issue warranting further investigation and clarification.