Who should provide psychological care? (The NMHC Report: Part 2)

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Since the release of the review of all mental health services in Australia, I have been carefully going through the document to understand the implications for policy change in the Better Access to Mental Health Care program. Under this program people with a mental health condition are eligible to receive psychological care supported through the Medicare system. A few days ago we looked at the recommendations in the report about the number of appointments people can access. Today I am covering a rather more difficult question: which mental health professions should be eligible to provide psychological care?

Before I begin, I would like to remind everybody that the wording of the NMHC Report is confusing and in some parts contradictory. My sense is that sections of the report were cobbled together by different authors who perhaps did not fully understand what they were talking about. Parts of the report suggest that critical information was either lost or misunderstood from one section to another. In the summary below I will attempt to bring all of that information together from different sections of the report so that the central issues can be discussed and debated properly. As before, I will offer my own suggestions for change at the end.

But first a little background…

Provider eligibility has always been a contentious issue in the mental health field since Medicare began providing support for psychological care. These issues originated a few years earlier under a predecessor scheme called ‘Better Outcomes’ (not ‘Better Access’) which saw GPs accessing Medicare Benefits Schedule (MBS) items for what were called ‘focused psychological strategies’ (FPS). At the time psychologists raised concerns about the limited training of medical practitioners in psychological therapies. The Department of Health responded to the psychology profession that ‘focused psychological strategies’ were not intended as ‘psychological therapy’ and that GP’s would refer the more complex and severe cases on for proper psychological therapy if needed. Their response wasn’t particularly reassuring. It raised serious questions about the level of care people deserve when a mental health condition is recognised. At the same time though, it did send a message that psychologists were valued by the medical profession for their role in providing bona fide psychological therapy.

A few short years later in 2006 the Better Access to Mental Health Care program launched. For the first time a patient could see their GP and get a referral to a psychologist, social worker, or an occupational therapist so they could receive psychological care with support from Medicare. All of a sudden the term ‘focused psychological strategies’ was switched around and applied to the work of psychologists and other dedicated mental health professionals. A separate MBS item was added using the term ‘psychological therapy’ to exclusively refer to the work of clinical psychologists.  That move resulted in the formation of a two-tiered mental health care system which has caused a lot of heartache ever since.

Who provides psychological care?

The NMHC Report seems to be conflicted on this issue, diverging in two completely different directions. On the one hand the Commission recommends the examination of whether the provider eligibility should be extended to include speech pathologists and nurses in cases where the practitioner has undertaken appropriate additional training at the post-graduate level (Volume 1, page 96). Other sections of the report also make specific mention of adding neuropsychologists and counselling psychologists as Medicare providers (Volume 2, page 150).

Professional entitlements: for no clear reason, some allied health professions are excluded from the MBS subsidy entitlement under Better Access. Professional groups which can usefully form part of a multi-disciplinary mental health team include neuropsychologists, counselling psychologists and speech pathologists.

However in both of these latter cases, Neuropsychologists and Counselling Psychologists are already eligible Medicare providers under the ‘Generalist’ category (i.e., they are seen by the system to provide ‘focused psychological strategies’). One possible way to read this recommendation is that the Commission intended to expand eligibility of the ‘psychological therapy’ MBS items to both of those groups, as they have equivalent levels of post-graduate training and supervision to clinical psychologists. That interpretation would be consistent with the views expressed in Volume 3 of the report (page 14):

Psychologists who have a specialist registration equivalent to that of a clinical psychologist believe they are treated inequitably in terms of Medicare subsidies.

At this stage it remains unclear what the Commission meant. What is clear however is that the Commission envisions that an expansion of eligibility criteria will benefit the public. In my opinion there are some clear advantages to expanding the range of therapists people can see. Professional title is very rarely a useful indicator about the effectiveness of a therapist. What is far more important is whether a therapist undergoes advanced training in mental health care and has an extended period of supervised practice behind them. A strong background in ethical training, ongoing professional development, and continuous reflective practice, all help to improve the way a therapist works. If we can keep these factors in mind, our mental health system will benefit from multidisciplinary diversity as we expand eligibility criteria.

How much support should Medicare provide?

Under the current system Medicare offers significantly less support when a patient receives care from a therapist who is not a clinical psychologist. Put simply, the Medicare refund that a patient receives is much less if their therapist is a social worker, occupational therapist, or a psychologist tagged with the ‘generalist’ label. It is worth pointing out that among those providers are a great many who possess Masters, Doctorate, and PhD qualifications directly relevant to mental health care, however the system does not recognise their training or experience. This quirk of the system is a relic which dates back to the original negotiations between Medicare and the APS College of Clinical Psychologists back in 2006.  We must remember that such exclusive relationships of support put vulnerable patients at a significant disadvantage if they prefer to seek psychological care from any therapist who is not a clinical psychologist.

This issue has been debated within the psychology profession, however it seems that Medicare has not changed in any way to reflect the outcome of those discussions. Some have defended the higher Medicare rebate for clinical psychologists by arguing that ‘psychological therapy’ MBS items are different to ‘focused psychological strategies’. However, as Dr Tim Carey pointed out in the July 2010 issue of Clinical Psychologist, these Medicare items are in fact functionally equivalent to one another:

O’Kearney and Wilmoth maintain that these items are different types of services, with the psychological therapies requiring ‘‘more independent clinical decision making’’ (p. 81) and ‘‘more expertise’’ (p. 81). If this is the case, it is not expressed in the MBS. For psychological therapies, ‘‘In addition to psychoeducation, it is recommended that cognitive behaviour therapy be provided. However, other evidence-based therapies – such as interpersonal therapy – may be used if considered clinically relevant’’ (p. 722). For focused psychological strategies, ‘‘A range of acceptable strategies has been approved’’ (p. 726). Five strategies are listed: psychoeducation; cognitive behavioural therapy; relaxation strategies; skills training; and interpersonal therapy (p. 726). Thus, there seems little to justify describing these items as different types of therapy and it is unclear where the ‘‘independent’’ versus ‘‘prescribed’’ distinction emphasised by O’Kearney and Wilmoth is operationalised. The most defensible conclusion is that the two different items are, in fact, the same type of therapy.

Later in the article Carey reinforces the point made earlier about the diversity of training which leads to expertise in psychological therapy, as follows: “To suggest that a psychologist with a masters or doctorate in health psychology, forensic psychology, or counselling psychology (for example) does not have the necessary expertise to provide evidence-based psychological therapies is clearly fallacious.” (p. 70). To a lot of us within the profession of psychology it doesn’t make any sense that we provide the same services for strikingly different Medicare fees. Given these points many of us were curious what the report of the Commission might say.

Volume 1 of the Commission’s report makes a recommendation that MBS benefit levels for allied health professionals should be more equitable (page 96):

Realign MBS benefits levels between allied health professionals: on the next indexation of MBS items weight the first component of the increase to align MBS benefits for social workers and occupational therapists with those for registered psychologists, with any remaining elements of indexation then being distributed equitably across Better Access items (current differential is about 12 per cent or $8: parity would take up the first 0.9 per cent of any future indexation increase and cost $1.8 million).

There was no mention of the MBS item for clinical psychologists. To my eye, the wording of the recommendation shown above is unclear. It begins by referring to the realignment of allied health professionals, which would naturally include clinical psychologists. However, the recommendation goes on to list only those providers who deliver MBS items for ‘focused psychological strategies’. Once again, it does not make sense to provide differential Medicare benefits to patients who receive the same treatment: namely, psychological care.

My recommendations

It seems to me that the Australian public need a consistent, fair, and equitable level of support when they receive psychological care. Ideally the emphasis should be on helping people find the right mental health care practitioner to match their needs, rather than distractions associated with how much they will get back from Medicare. Given that the function of these Medicare items are identical, my suggestion is that there should be just one MBS item for ‘psychological therapy’ with the same level of support available for every patient.

The expansion of provider eligibility is an excellent idea, however the question is how to implement such a change. The easiest way to do that is to add new criteria to expand provider eligibility for the ‘psychological therapy’ MBS item. This could be achieved by making new pathways for each different mental health profession which is presently excluded from providing that MBS item. Each practitioner discipline can establish profession-specific criteria that recognise advanced competencies in delivering psychological care. I would suggest that the system needs to be reset within the psychology profession to make provider eligibility criteria neutral and without bias for factions or professional titles. That is, all psychologists providing therapy under Medicare should meet the same eligibility criteria rather than being forced to identify as a clinical psychologist. Provided the new criteria we set are rigorous and show respect for diversity, the system can be made fairer and easier for distressed people to navigate when they are looking for help.

PLEASE NOTE: This is at times a highly charged topic and comments on this thread are moderated. If you are speaking as a mental health care professional please identify yourself to maintain ethical standards and professional respect for one another. I would like to keep the discussion positive and focused on improving the system to benefit people accessing care. Thank you in advance.