Select Committee on Mental Health and Suicide Prevention- Final Report

Posted on 5 November 2021

Reforms to the two-tier MBS rebate system

As we well know, the MBS system for accessing psychologists is provided through two rebate tiers (the two-tier system). It maintains a higher rebate for psychologists with clinical endorsement and a lower rebate for registered psychologists and psychologists with endorsement in the remaining 8 AoPE. AAPi believes that the two-tier Medicare system is fundamentally flawed and needs to be immediately changed. 

AAPi was quoted extensively in the report on this issue: 

“...the current system, which has psychologists and clinical psychologists on two different rebate levels, is financially affecting the public, consumers, and making services unaffordable for many”. 

AAPi calculated that, given the significant costs for registration, insurance, professional development, supervision, equipment and administration required, the hourly income of a registered psychologist seeing five or six bulk-billing clients per day is approximately $23 per hour.

“AAPi also identified that having a two-tier system has led to professional discrimination across the MBS, employment opportunities, scope of practice and funding. AAPi further contended that: 

We see this played out in places like Centrelink, where you need a report from a clinical psychologist to open up a disability support application. We're restricting consumers with a disability to the 30 per cent of psychologists who have clinical endorsement. Rather than allowing them to see someone who might have been treating them for five years to try to overcome their disability and get back into the workforce, we're asking people to go and see a clinical psychologist or psychiatrist for a few sessions and get a report for Centrelink. We see this is as inappropriate, and the best evidence would come from someone who's actively been trying to support them to overcome their issues.” 

The Committee questioned the Department of Health on the evidence that was relied upon to establish the two-tier system. The Department of Health explained:  

“the two-tier rebate system for clinical psychologists and registered psychologists under the MBS was initially implemented on advice from the psychology profession, as referenced in the 2011 final report of the Commonwealth Parliament’s Senate Community Affairs Reference Committee's Inquiry into Commonwealth Funding and Administration of Mental Health Services.”

In response to question from the committee the APS identified that at present there are not any Australian studies available that compare the outcomes between psychologists with clinical endorsement and other psychologists. 

Committee Recommendations:

We are very proud to report that the Committee has recommended that the Australian Government’s evaluation of Better Access, and reform of the system, should focus specifically on:

• the viability of bulk-billing incentives available to general practitioners (GPs) being similarly made available to mental health practitioners
• the two-tier system impacts on treatment access, appropriateness and affordability of psychological care
• including psychologists with other areas of endorsement (non-clinical endorsement) on the higher rebate tier, noting that this will increase access to specialists, address non-clinical endorsement disincentives and support the diversity of the psychological workforce
• the Committee is also concerned by the lack of patient outcome and outcome evaluation for psychologists, psychiatrists and GPs in the delivery of mental health care, to guide policy decision-making and MBS rebate amounts. 
• the lack of any recent Australian study proving an outcome disparity, and thus justifying the rebate distinction between clinical psychologists and other psychologists, is a concern. 

Diversity of psychology

The concerns of AAPi regarding the lack of diversity of psychology as a result of the two-tier system were addressed in the report. 

“Witnesses raised concerns that a significant barrier to providing the right type and level of expertise was the ‘crisis of diversity’ in the psychology workforce and education programs available.

In addition to ‘a lack of government funding’, Dr Davis-McCabe noted that the combined impact of the introduction of the Better Access initiative in 2006 has led to ‘quite devastating consequences for postgraduate university programs’: 

We've seen in recent years many areas of practice endorsement programs close across the country. This means that the number of work-ready graduates is falling, and this is a real problem for the Australian people, who will ultimately lose access to the specialist skill set of these psychologists. This is a pressing concern at a time where the public need quick access to advanced psychology services.

Committee Recommendations:

The Committee recommends that the Australian Government support the growth and diversity of psychology specialties by: 

Simplify access and reducing reporting and admin requirements

In our submission, AAPi addressed the need to simplify the process to access a psychologist and to reduce the red tape and administrative burden on psychologists. 

The complexity of the current system means that clients often drop out of treatment when they are required to present back to the referrer for review for a number of reasons. 

Additionally, making a living wage under the current system is increasingly difficult for psychologists, considering the many hours of unpaid admin work coupled with the low rebates and the inequitable lower rebate for registered psychologists. 

Matching AAPi’s view, the Committee has recommended that the Australian Government review available digital technologies to identify and promote best practice options for mental health and suicide prevention professionals to, amongst other things, coordinate with other service providers to reduce administrative pressures on professionals and improve the user experience. 

“In terms of service access rigidities, the Australian Association of Psychologists Inc called for improvements to make accessing a psychologist easier: 

At the moment there's a lot of red tape. There are appointments with GPs you need to access. There are review appointments. There are letters going back and forth to unlock access to more sessions. This impacts on the consumer, especially at the moment, when it's really hard to get appointments with GPs. A lot of people are also not wanting to go out, or might not have access to telehealth services in order to access their GP.”

Committee Recommendation:

Limit of two GP review sessions – an initial Better Access assessment/ referral and another after session 10 (to assess if another 10 sessions with the current provider is appropriate). 

The committee also discussed further initiatives for simplifying the system.

Permanent universal access to telehealth

As noted in the report, the call to make the COVID-19 MBS telehealth item numbers permanent was widely supported by stakeholders, including AAPi. 

AAPi Vice-President Karen Donnelly, spoke about the increase in telehealth referrals beyond their regular client base. It was noted that this was largely driven by those in areas with service gaps – rural or remote areas or specialist services.

AAPi was also quoted in the report as recommending that the Australian Government retain all MBS telehealth items, ensuring access to both videoconferencing and telephone items:

“... because we know that in rural and remote areas internet access is often problematic and that it excludes consumers that might have disabilities or financial constraints that would see them unable to have access to internet or smartphone technology”. 

In line with these concerns, the Committee has recommended that the Australian Government leverage the existing Australian Rural Health Education Network by providing funding for clinical placements in regional, rural and remote university clinics, and using these clinics to trial multidisciplinary, hybrid mental health hubs that integrate digital services and face-to-face services.

AAPi was quoted further in the report on this topic:

“We would also like to see telehealth remain a permanent feature of the MBS. It has many, many benefits that improve access to psychologists. We've seen throughout the COVID pandemic that it has been essential in keeping services going to those that need services. Especially for our rural and remote communities, it is essential”

AAPi was also quoted in the report that while telehealth is an important tool, funding for face-to-face services also remained a priority:

“This was observed by AAPi who experienced difficulties with telehealth for certain consumers: 

A lot of people who were elderly or had intellectual impairments or were homeless had difficulty accessing telehealth because of the multiple steps that were required to connect to a service.”

Supporting provisional psychologists and rural and remote psychologists

The report also acknowledges AAPi’s call for further support for provisional psychologists and well as those working in rural and remote areas.

The report references AAPi’s calls to enable provisional psychologists “to provide an agreed level of Medicare-subsidised services, including a loading for psychologists providing services in rural and remote areas”.

AAPi will continue to advocate for these changes.

The report was favourable on the recommendation for financial incentives and support for rural and remote practitioners. 

Culturally appropriate services

AAPi is dedicated improving mental health care for Aboriginal and Torres Strait Islander people. This was another area that was covered in depth in our submission. We thank the AAPi Aboriginal and Torres Strait Islander Expert Reference Group for their input.

The Committee has recommended that the Australian Government ensure the principle of accessibility is at the forefront of all policy and funding programs for the mental health and suicide prevention sector, with a focus on Indigenous-led and culturally appropriate models improving Aboriginal and Torres Strait Islander experiences with mental health and suicide prevention services.

The Committee also recommended that the Department of Health and the National Mental Health Commission develop, define and promote a common mental health language that can be shared across the community, and especially vulnerable groups including Aboriginal and Torres Strait Islander peoples, other culturally and linguistically diverse communities, elderly, youth, and LGBTIQ+ people. 

Fund a dedicated preventative/early intervention psychology workforce

Another of AAPi’s recommendations to the committee included the need for further funding dedicated to preventative and early intervention initiatives, especially in the key settings of schools and workplaces. Organisational psychologists and psychologists supporting improved mental health in workplace settings are also fundamental. 

“Recognising the ‘fluid factors’ in suicide prevention and the fact a significant number of people may not see a psychologist or other mental health professional, the Australian Association of Psychologists Inc (AAPi) spoke in support of a community focus on suicide prevention, including education in the workforce and in areas where rates of suicide may be higher.”

AAPi’s recommendation for broadening MBS sessions with psychologists to include prevention and early intervention was mentioned in the report.

More psychologists in schools

School psychologists are a vital component of our mental health care system. From the report:

“AAPi stated psychologists in schools have the capacity to provide early intervention and counselling support to reduce the need for students to be removed from schools to receive care. Bringing psychological care into schools, AAPi argued, would result in ‘a big improvement in the mental health of our young people.”

The Committee recommended that the Australian Government work with state and territory governments to:

• conduct an independent evaluation on the effectiveness of existing programs that support wellbeing in schools, including the National School Chaplaincy Program, with a focus on the outcomes of children participating
• implement an agreement to increase the ratio of school psychologists to a minimum of one full time equivalent on-site for every 500 students across all levels of school.
• The Committee also supports school psychologists being empowered to assume a leadership role in schools. 

Increased MBS rebated sessions

AAPi has staunchly advocated for more sessions for clients. In our submission we recommendation for up to 40 MBS rebated sessions.

“In response to the increased rates of mental health problems as a result of COVID-19, the Australian Government doubled the number of MBS-rebated psychological therapy sessions from 10 to 20 for eligible patients. Many stakeholders recommended this increase be permanently available under the MBS.”

AAPi: “It's also our position that more sessions need to be allowed under the MBS. We've seen that recommended across so many different inquiries. The review of the MBS, the Productivity Commission—they have all recommended that session numbers be increased. If we actually treat people with the amount of treatment they need then they won't be presenting back year after year, needing more access to the system and remaining unwell.”

Committee comment 

• There are significant concerns about the trend outlined within various reports that the lowest access to MBS item numbers also correlates with the lowest socio-economic demographics. The Committee recognises that this is at odds with the purpose of the MBS system in supporting broad access to health services. 
• The current annual cap on MBS-funded sessions with a psychologist does not support the effective delivery of evidence-based care for complex presentations. This can prevent individuals from receiving sufficient treatment and instead see them exit the system. This increases long-term costs for the individual, for the sector and for governments. 
• The current cap also results in drop-outs by requiring excessive GP review of patients, impacting the delivery of treatment by psychologists, and reducing the quality of treatment for complex mental illnesses. Reform should ensure treatment is patient-oriented, with the number of sessions to be determined by a mental health professional, such as a GP, psychologist or psychiatrist in the interests of the patient’s health.
• The Committee calls for a change to the GP referral system for psychological services to match that of other health professionals, with a 12 month referral. This should be supported by digital services to track patient outcomes and reduce the need for patient/ GP review sessions. This will improve patient outcomes, communication between referrer and referee, and efficiency and reduce administrative burden. This will also prevent interruptions to treatment, and reduce the risk of the patients dropping out. 

Conclusion

AAPi welcomes the recommendations from the Committee and thanks all members who also made submissions. AAPi will continue our tireless and ongoing advocacy for changes to the current system. We are stronger together.