Better Access to Telepsychology

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Accessing mental health care during a pandemic has presented some challenges. Medicare restrictions are making it much harder than it needs to be when delivering psychological care. In this short post, I’ll try to summarise the main problem areas and offer a few constructive solutions.

Background context

Australians are gradually coming around to the idea of social distancing. For health practitioners, that means changing the way we deliver services. In the main, the plan for Medicare is that telehealth consultations can help minimise contact and transmission of the virus. Psychotherapy is well-suited to telehealth. There’s generally no need for direct physical contact and our main forms of intervention focus on the way we relate, through words, sentiments, and other forms of expression. The big problem is policy. Significant barriers have been put in place by Government, which make it very difficult to deliver telepsychology services to those who really need them.

On the surface, Australia’s policies on telepsychology might sound fine, but when it comes time for you to access those services, you’ll encounter a whole lot of fine print. Medicare support for telepsychology is restricted by a complicated maze of exclusion criteria, which shuts most people out. There’s a confusing array of inconsistencies across the various telepsychology items in Medicare too. My summary below might clear up some of the confusion, but I really do hope it shows why we need to urgently streamline the process of accessing psychological care.

Obstructive policies create barriers to care

First, we have telepsychology items for people living in regional and remote areas. To be eligible for these services, you’ll need a GP referral, with a diagnosis, and you must live in a region coded as being remote enough. Try putting in your address here to see if you would qualify (scroll down to the ‘start now’ button). In my own work as a psychologist, I’ve encountered some really hair-splitting distinctions, where a person living on one side of a street is eligible, while those living on the other are ineligible. Obviously that’s not helpful for anybody living in suburbia right now during this pandemic.

Second, we have telepsychology items for people affected by the recent bushfires. With these items you don’t need a diagnosis or a GP referral. You don’t even need to live in a bushfire-affected region. The only eligibility criteria is that you self-identify as being affected by the bushfires. Apparently that’s it. And those eligible can access an additional ten sessions of therapy to the usual maximum quota of ten sessions per year.

Third and finally, we have the telepsychology items for COVID-19. Now I don’t want to cop any flak for pointing this out, however, it has to be said that the eligibility criteria for these items are in stark contrast to the bushfire items. To be eligible you need to either have a confirmed diagnosis of COVID-19, be in quarantine, or otherwise belong to a susceptible group (aged over 70 or 50 with ATSI background, pregnant or with a child under 12 months, or living with a chronic health issue). For health practitioner eligibility, you must have a diagnosis of COVID-19 or be placed under quarantine. It’s incomprehensible to me why those other risk factors don’t apply to health practitioners. That’s just the way it is.

EDIT: Yesterday the Federal Minister for Health announced that practitioner eligibility would be corrected to allow those with known vulnerabilities to COVID-19 to have the same protections as members of the public.

There’s SO MUCH I could say about these COVID-19 items, but I will try to keep it really short. I promise…

Diagnostic eligibility for telepsychology

Right now we are rationing test kits for COVID-19. Australia doesn’t have enough supplies of protective gear, reagents, and swabs, to do widespread community testing as they are doing in Singapore. Testing has been limited to people who have travelled overseas with symptoms and those in contact with a confirmed case. Many stories are emerging of people with COVID-19 symptoms, who report to their GP, only to be told that they will not be tested. It’s not the fault of GP’s but it does reflect the fact that Australia was completely unprepared for a pandemic of this magnitude. The implication is that we cannot possibly know what the rate of community transmission is. Coming back to those criteria for telepsychology services, community transmission is completely invisible to those criteria. The healthiest approach for Australia would be to remove the diagnostic criteria so that people can self-isolate.

Removing diagnostic requirements should not be limited to COVID-19. If it was right in principle to allow bushfire affected Australians to access psychological care without a diagnosis, then surely the same approach is justified by this pandemic. Allowing direct access to mental health care services would also reduce pressure on GP waiting lists. With increased pressure on our health system, we are hearing reports that people are having difficulty getting in to see their GP for ongoing renewal of their Mental Health Care Plan.

We should bear in mind that people don’t stop needing mental health care when there’s a pandemic. Quite the opposite. Those with existing anxiety or trauma are likely to be triggered by situations like this one. Depression is bad enough without adding the impact of self-isolation. For some, this pandemic will trigger their first experience of a serious mental health issue. The very best thing we can do is encourage help seeking early and offer timely and consistent support. I make the obvious point that one of the best things we can do to reduce public panic during this pandemic is to provide basic psychological care for those who need it.

My recommendations

We need urgent reforms to adequately manage the psychological response to this pandemic. Given that many Australians are opting to self-isolate we should optimise the capacity of our Medicare workforce to deliver services using telehealth. In the case of psychological support, all administrative barriers to care should be removed for the time being.

Removal of the GP referral requirement across all items for psychological care should be a priority. This will free up waiting lists and reduce pressure on our health care system. Similarly, the requirement for GP review after 6 sessions of therapy should be removed for now. Mental health care providers must be trusted to refer people to their GP or psychiatrist if or when that’s needed. There is no reason to doubt that will occur naturally, as it does under usual circumstances where a therapist is concerned about the health status of their client.

Eligibility for telepsychology should be assessed by the mental health care provider. Providers of psychological care in the system are quite capable of assessing whether someone needs help or not. It’s part of the work we already do in the Medicare system.

On a similar note to the above, mental health care providers are also in a good position to work with people directly to assess when it is time to bring therapy to a close. There is a significant body of research examining issues around the termination of therapy which indicates that when people improve over time, they bring therapy to a close on their own. Now is the perfect moment in time to de-restrict session limits and evaluate this process in action. Just as more Medicare-supported sessions are allowed for the treatment of eating disorders and for people affected by the bushfires, one would think something similar should apply right now in a pandemic.

Finally, this situation should give us pause for thought about the issue of bulk billing. A large number of commentators on social media have talked about the negative impact of the requirement that all telepsychology services must be bulk billed. For those unfamiliar with what that means, essentially it requires the mental health care practitioner to accept the Medicare refund as payment for their services. For those practitioners who attract a higher rebate (i.e., clinical psychologists), bulk billing is slightly less problematic. Conversely, those who attract a lower rebate (OTs, SWs, and other psychologists) face a financially crippling situation. It is not just their livelihoods which are being put on the line here, but also their ethical integrity. Should they run their practice at a financial loss, knowing that they will inevitably end up not being able to support anyone? Are they to offer services only to full-fee paying clients, further compounding disadvantage for those who can’t afford therapy? Or do they risk community transmission of the virus by insisting on face-to-face therapy, to ensure that their work remains viable? There’s no easy answer to these ethical conundrums, but I do make the point that if Australia did set a consistent fee for psychological services which spans across practitioner groups, then we would not be facing this problem right now.

Practical Limitations

There will of course be some clients for whom face-to-face therapy is the only option. We need to think about a range of factors to take in this problem. First, at the national level we have to consider the impact of Australia’s botched and delayed National Broadband Network (sorry that has to be stated plainly). We also need to consider the fact that many people living in disadvantaged circumstances may not have access to the technology required to receive telepsychology services – particularly those who are displaced or in a state of transition right now, such as people who are homeless and those fleeing from domestic violence. If we don’t look after them right now in this crisis then it will cost society much more in the long run. Whatever solution we come to here in Australia, it needs to be relatively straightforward, easy to access, and both fair and consistent for everyone who needs help. There are certainly some limitations with telepsychology, however if it is well implemented, then it could significantly reduce the pressure on standard face-to-face care across the entire health system.

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, then please identify yourself by name to maintain ethical standards and professional respect. Comments from health practitioners who cannot be identified will not be published. In general terms, I would like to keep the discussion positive and focused on how we can improve the Medicare system to benefit the community. You may be asked to support your view. However, elitism and disrespect has no place here. Thanks in advance.

I’d also like to thank everyone from the Alliance for Better Access group on Facebook who shared their ideas about this topic. Without you, I would not have been able to bring together all of the relevant information about this topic at short notice. Good work everyone!