Since writing our last piece about the reach of Medicare to disadvantaged people, we have received information that the Federal Government is questioning how we came up with our figures. Those of you who read the last article would know that we explained in detail where all of the figures came from and how we calculated the estimate. The Government is claiming they didn’t provide any details about the number of people who have accessed the ATAPS scheme, yet, they are not replying to requests for that information when it is readily available to them. So we decided to take an even more comprehensive look at the figures to demonstrate that, any way you look at it, the estimates come up roughly the same. In short, the ATAPS program simply does not have anywhere near the capacity needed to replace Medicare services in mental health care.
An Overall Comparison
To begin with, let’s take a look at both of these programs in the broadest terms possible. The most up to date information we have about ATAPS comes from the 19th Interim Evaluation Report which provides us with figures about the number of referrals and the number of sessions of care used between 1 July 2003 and 31 December 2011. It also provides figures from between 1 July 2011 – 30 March 2012, which can be added to the total. This leaves an area of overlap between July 2011 and December 2011, which means that any calculations we make will over-estimate the number of people seen. That’s fine because our aim is to be as generous as possible with our estimates about the program.
Combining the figures from both of those periods, there were less than 224,017 referrals to ATAPS in the July 2003 to March 2012 period that resulted in psychological services being provided. It must be noted that in some cases the same person receives multiple referrals across a single year via the ATAPS system, so the number of real people who received services under ATAPS will be less than the number of referrals. The 16th Interim Evaluation Report provides us with figures that allow us to calculate the average rate of referrals to individual patients, going by data gathered between 2006 and 2010, showing that approximately 75% of referrals represent unique persons. Factoring that proportion in against the number of referrals, there have been approximately 168,013 individual patients who have received psychological services via ATAPS all up.
There are other ways to calculate that figure though, and in the absence of the Federal Government providing the details they have about the number of people using these programs, the most sensible approach is to consider this from various angles. The other way to calculate the number of real people who have accessed ATAPS is to begin with the number of sessions delivered and divide that across the average number of sessions (appointments) used by each person. Over the period in question we know that 1,173,132 sessions were delivered by ATAPS, and at an average rate of 5.2 sessions per person, the estimate comes to 225,602 people. We can now use both of these estimates to compare the ATAPS program to Medicare (i.e., the Better Access initiative).
Using the most up to date figures available on the Medicare website, we calculate that there have been 2,214,457 referrals to the Better Access initiative and 16,936,619 sessions provided, spanning from November 2006 to October 2012. We arrive at those figures by generating reports over the online MBS Item query system for both all GP referral items, and all Allied Health service items for the Better Access initiative. The Better Access evaluation identified that the average number of sessions used by people is 5, therefore using the same calculations we used for ATAPS, there are an estimated 3,387,324 people who have used Medicare for psychological treatment. Comparing these figures directly, it becomes clear that ATAPS provides only around 5-6% of the overall capacity of Medicare when it comes to psychological services.
It could be argued that because the ATAPS program and the Better Access initiative have operated over different time periods, they should be scaled to the same time-scale, and that is certainly a valid argument. The first Interim Evaluation Report indicates that ATAPS data stretches back to July 2002, which means that the available data spans 117 months (9.75 years). By comparison, the available data for the Better Access initiative spans 71 months (5.92 years). This allows us to calculate an average yearly rate for both programs. When scaled in this way, the ATAPS program reaches an estimated figure of providing psychological services to between 17,232 people and 23,139 people each year. By comparison, the adjusted yearly rate for Medicare is an estimated 572,183 people. By these figures, the ATAPS program is operating at just 3-4% of the capacity of the Better Access initiative.
Reaching the Disadvantaged
The massive reach of Medicare across Australian society cannot be overlooked. On the one hand, the ATAPS program sees a higher percentage of people identified as being on a ‘low income’, but on the other hand we need to factor in how many people that actually represents. It is vital for us to consider what these figures mean in terms of real people who are reached.
We know from various ATAPS reports that there has been a fairly consistent finding that the program reaches an average of 62% of people identified by the GP as being on a ‘low income’. Using the estimates we calculated earlier, this proportion represents between 104,168 and 139,873 people in total since the ATAPS program began. Using the yearly adjusted estimate, this represents somewhere between 10,684 and 14,346 people living in disadvantaged circumstances each year.
By comparison, the Better Access evaluation used the Index of Relative Socioeconomic Disadvantage (IRSD) as a rough estimate of the level of disadvantage of a patient in terms of their post-code. As we mentioned before, there are some obvious problems associated with labelling someone as being disadvantaged on the basis of what postcode they live in. However, the chief criticism levelled at the Better Access initiative is that the data shows that people living in postcodes labelled as being the ‘most disadvantaged’ represented 13% of all patients seen by the program (equal representation would have been 20%). Using the estimates above, 13% comes to an estimated 440,352 disadvantaged people who have received psychological services since the Better Access initiative began. The yearly adjusted estimate represents 74,384 disadvantaged people.
Comparing the two programs demonstrates once again that ATAPS is simply not up to capacity, even when we restrict our focus to disadvantaged populations. Even going by the most generous estimate for ATAPS, the program has reached less than a third of the number of disadvantaged people as has been reached by Medicare, despite having been established a decade ago. Using the yearly adjusted rate to put both programs on a level playing field, the ATAPS program provides services to 19.3% of the number of disadvantaged people reached by Medicare each year. In other words, Medicare provides psychological treatment to 5 times the amount of people in real terms when it comes to disadvantaged groups.
The Latest Figures
No doubt the Minister for Mental Health will protest that the estimates shown above don’t factor in the growth of the ATAPS program since the May 2011 budget announcement. But has the situation changed much? Not really. In fact in some ways, the issue has become even worse. I will go over the latest figures to show why this is the case.
The most recent ATAPS report provides us with figures from 1 July 2011 to 30 March 2012 (i.e., the majority of the last financial year). The report shows that there were 10,972 referrals to ATAPS resulting in services. At a rate of approximately 75% of these representing unique persons, there are an estimated 14,629 actual people who accessed ATAPS in that period. Using the amount of sessions delivered in this period to estimate the number of real people who used ATAPS, we arrive at an estimated 13,586 people (i.e., 70,647/5.2). So this puts the figure somewhere between 13,586 and 14,629 real people who used ATAPS over the period in question.
In terms of the proportion of disadvantaged people seen via ATAPS, the latest report shows that the percentage has dropped significantly, from an average rate of 62% down to 57.3% (it seems to vary widely across the various ATAPS programs). In any case, what that means is that the estimates above represent between 7,785 and 8,382 people identified as being on a low income.
Using the online MBS item query system to check the corresponding data for Better Access we identified that there were 546,144 referrals via Medicare across the same period and a total of 2,698,065 appointments of psychological treatment. With an average rate of 5 appointments, there are an estimated 539,613 people who accessed Medicare for psychological treatment between 1 July 2011 and 30 March 2012. With a rate of 13% living in the ‘most disadvantaged’ quintile, we estimate that Medicare reached approximately 70,150 disadvantaged people in that period.
Now when we compare these programs over that period in the last financial year, it is plain to see that ATAPS does not have anywhere near the reach of Medicare. These figures demonstrate that ATAPS provided psychological treatment to just 2.7% the number of people that Medicare did. That means that Medicare reaches 35 times the number of people with a mental health condition. In terms of disadvantaged people the ATAPS program reached only 12% the number of people in real terms. That means that Medicare provided over 8 times the amount of disadvantaged people access to psychological treatment in the last recorded period.
Can ATAPS meet the Public need for Psychological Treatment?
No matter which way we tried to calculate it, the figures came up roughly the same. Overall, Medicare has reached 20 times the number of people with a mental health condition. For disadvantaged groups, Medicare reaches 3 to 5 times as many people in real terms. As we have shown, the most recently reported figures are measurably worse for ATAPS, despite a substantial funding boost supplied from the cuts to Medicare in the May 2011 budget. Our estimates show that in the last financial year Medicare reached around 35 times the number of people with a mental health condition as ATAPS, reaching 8 times the number of people identified as being disadvantaged.
Now of course one could argue that there are far more people who are disadvantaged than those we have identified. Indeed, we would argue that disadvantage goes far beyond which postcode you happen to live in or whether your GP identifies you as being on a ‘low income’. Our point is that critics of the Better Access initiative, such as Professor Ian Hickie, have singled out these statistics from both of these programs, without factoring in any consideration for the real people that those figures represent. As we have shown, even when we take their claims seriously, the Better Access initiative reaches far more people with a mental health condition who are identified as being disadvantaged than any other program in Australia. In fact, we would even go one step further and point out that having a mental health condition is disadvantaging in itself. When we consider the repeated finding from numerous studies showing that over 80% of people using Medicare to access psychological treatment have serious levels of symptom severity, often with co-morbid factors, then it should become quite clear how disadvantaging that can be for any person.
The ATAPS program is not ready to meet the need for mental health care services, neither generally, nor for the disadvantaged. It comes nowhere close to meeting the need for psychological treatment across Australian society and there are no other programs that do. We need all of these programs, including fair and reasonable access to treatment in Medicare. To the figureheads and politicians in the mental health circuit, we ask you to face this problem directly and consider the real people who are going to have their psychological treatment cut short by this foolish decision to scale back Medicare support.
Please leave your thoughts below. If you would like to re-calculate our estimates, or can supply some better information, please share!