Abstract
Objective:
To explore the impact of proposed expansion of Australia’s Better Access Program and alternatives.
Method:
Australia’s Better Access Program, which costs taxpayers AUD28 million every week, is once again the focus of national political and professional scrutiny. The current Medicare Review calls for a massive expansion. This article reviews its history and context. It challenges the recommendations made by the Review. It also provides three scenarios which model the proposed expansion, with significant implications for consumers, the workforce and taxpayers.
Results:
The capacity for continued growth of the Program is demonstrated. At the same time.
Conclusion:
There has been recent evidence suggesting the impact of the programme on key mental health indicators in Australia has been negligible, while also perpetuating social, economic and geographic inequities. While advocacy for increased mental health expenditure is easy, active reform of existing patterns of service is hard. Nonetheless, this article suggests that it is timely to reconsider the structure and scale of this AUD1.5 billion annual investment, which has the potential to grow to up to AUD10 billion per year over the next decade. In our view, it is possible to make the programme fit for purpose in the 21st century. Specifically, the principal focus could be shifted to better support the interdisciplinary, team-based care that responds to the needs of people with more complex mental health problems. An increased role for incorporation of digital technologies alongside clinical services is part of the mix. The combination of changes suggested would suggest that the programme could be rebranded as ‘Better Access and Quality’. This shift in the primary focus of the clinical programme away from brief interventions for those with lower needs to more sustained interventions with those with greater impairment requires new service models, as well as new regionally based health care systems. In addition, we propose specific outcomes that can be measured regionally, and collated nationally, to properly evaluate the impact of the programme and drive systemic quality improvement.
Introduction
The Better Access Program, which costs taxpayers AUD28 million every week, is once again the focus of national political and professional scrutiny. The unbridled growth of the programme, from AUD50 million a year in 2005, which was the last year of the previous ‘Better Outcomes’ Program, to AUD1.5 billion in 2018, bears testimony to the demand for mental health care in Australia.
As highlighted by Jorm (2018) in this journal, we have repeatedly suggested that the programme be the subject of serious evaluation in terms of its effectiveness on personal outcomes but also other nationally relevant measures (Crosbie and Rosenberg, 2007; Hickie et al., 2011; Rosenberg and Hickie, 2010, 2019). At this point, however, it is important to recognise both the historical context for the programme and the need to now reformulate its policy intentions.
By contrast, the draft report by the Medicare Review team (Australian Government 2018) now recommends a further massive expansion to the scope of the programme. We present modelling so as to better understand the financial implications and opportunity costs associated with the Review’s recommendations.
This viewpoint presents alternatives to the expansion suggested by the Medicare Review, based on consideration of the current state of mental health services development in Australia, our likely needs over the next decade, the urgent need to support team-based alternative care pathways (particularly for those experiencing more complex and impairing conditions) and the potential to make much greater use of digital technologies.
The story so far
Prior to 2001, Medicare did not provide support for access to psychological interventions that had established efficacy for common anxiety or depressive disorders. State-based mental health services also provided very little access to these treatments.
By contrast, the rate of prescribing of selective serotonin reuptake inhibitors (SSRIs) and other new antidepressant agents had surged throughout the 1990s (Hickie et al., 2001; Mant et al., 2004). A patient-based survey of more than 46,000 persons attending General Practices across Australia had indicated not only the high prevalence of common anxiety and depressive disorders but also the lack of access to skilled psychological interventions. As public awareness of the adverse impacts of anxiety and depression grew, the public and professional pressure to provide Medicare-based support for a more reasonable mix of medical and psychological services grew rapidly.
The outcome of this advocacy, initially, was the Better Outcomes Program (2001–2005). Its initial focus, when administered via Divisions of General Practice, was to provide access to psychological interventions to those who were most disadvantaged – socio-economically and geographically. It also emphasised the fact that brief psychological interventions were best provided by those professionals with skills to deliver such services. The target population was clearly those individuals with common anxiety or depressive disorders that are highly prevalent in primary care settings but who are also less impaired and not likely to require more specialised, multidisciplinary or prolonged interventions (Whiteford 2019).
In 2005–2006, there were both Senate and Human Rights Commission inquiries into mental health. As the centrepiece of the Federal Government’s response and as part of the Council of Australian Government’s National Action Plan on Mental Health (2006–2011), in November 2006, the Better Outcomes Program was replaced with the Better Access Program. Con-sequently, this key political decision not only massively expanded the Common-wealth’s investment in these services but also dismantled specific payments for episodes of care, distribution of services to disadvantaged populations and reliance on highly skilled practitioners.
Ever since, the lack of a large scale evaluation of the impact of the programme or systematic data collection alongside the provision of clinical services has made it almost impossible to test the merit of spending AUD22 million in Medicare rebates plus about AUD6 million in out of pocket costs (on average AUD27 for per visit to a registered psychologist and AUD32 for a clinical psychologist) each week on these brief intervention services. 1
The only substantive published claim around impact is from Whiteford et al. (2013; based on unpublished data from the Department of Health), suggesting that the programme has contributed to the estimated increase in access to mental health care in the Australian population from 37% to 46%.
Whether this modest increase is likely to have had any other benefit (as highlighted by the recent discourse in this journal) remains entirely unclear. Jorm (2018) notes the lack of evidence of decline in rates of national distress (as measured by the k-10), while national suicide rates have increased from 10.9 deaths per 100,000 persons in 2008 to 12.7 in 2017.
Where are we now?
Australia is a rich country. Former Prime Ministers John Howard, Julia Gillard and Malcolm Turnbull have all understood the level of community concern and made substantive investments in new programmes in mental health and suicide prevention. For sheer scale, however, none compare to Better Access: AUD1.5 billion annual spending meaning that each week 46,000 Australians receive 212,500 services.
Productivity Commission (Report on Government Services) data show that the number of repeat clients into the Better Access Program increased markedly. New clients into Better Access were 68% in 2008, 57% in 2009 and just 32.6% in 2016–2017. The average number of sessions per patient has been steadily declining over the past 5 years. Byles et al. (2011) found the programme did not provide care to key demographic groups. Meadows et al. (2015) found the programme was inequitable, with far more services available in richer and urban areas than in poorer and non-urban. In its 2014 Review, the National Mental Health Commission (NMHC) recommended new eligibility and payment arrangements to ensure that psychological services were available those in greatest need.
Mental health receives 7.7% of the total health budget while accounting for 12% of the burden of disease (Australian Institute of Health and Welfare, 2019). More resources in mental health are clearly required. However, unless new investments and repurposing of existing programmes like Better Access address the yawning gaps in services for those with more complex and impairing conditions, as well as the fundamental inequities in current patterns of service delivery, we are unlikely to see substantive changes in national mental health outcomes.
What are the implications of expanding Better Access?
Clearly, the Medicare Benefits Sched-ule (MBS) review panel which considered the Better Access Program was of the view that the demand for psychological services is so great, and the need to support earlier (if only very brief and non-focused) early intervention was so self-evident that massive expansion of the programme should be immediately supported. While formal research into the pro-gramme might be rare, there is no shortage of administrative data from Medicare demonstrating its unbridled growth, as shown in Table 1. 2 It includes all the items designated under Better Access. Some figures for 2017–2018 yet to be made available.
Better Access 2011–2012 to 2017–2018.
Due to data availability, the 2017–2018 fees charged is an estimate only, modelling the same rate of out of pocket costs as were paid in 2016–2017. ? indicates data not yet available.
Over the 7 years reported in Table 1, the average annual rate of growth for the programme has been 6.7%. While all the professions providing services under the Better Access Program have grown, rates of growth have differed. Between 2011–2012 and 2016–2017, psychiatry experienced an annual average growth rate of 5.7%, clinical psychology 11%, registered psychology 7.8% and general practice 7.9%.
Psychiatric services were already included in Medicare before Better Access. The real interest is how the programme affected the services provided by other health practitioners, with the largest volumes being those provided by psychologists and general practitioners (GPs). These data are shown in Figure 1.
Growth in psychology and GP services November 2006 to June 2018 (by most frequent Medicare Items claimed).
The top two lines indicate the dominant role of psychologists and the trajectories in growth for these services. The third line down shows an increasing tendency for GPs to provide psychological treatments as part of Better Access. This does not include preparation of the mental health plan itself (here there are two items, 2715 and 2717, which can be added together). The GP review of the mental health plans only occurs for about half of all the plans written.
The MBS review and estimated growth
The MBS review now suggests significant expansion of psychology services in addition to this existing growth, through making eligible for supports:
People without any mental health diagnosis;
People with moderate to severe mental health conditions, requiring up to 40 sessions of psychology care in any year;
The family and carers of people with a mental illness who might benefit from psychological care.
On this basis, we have developed three scenarios to estimate the financial impact of these changes. The MBS review paper provided no similar estimates.
Scenario 1: existing rates of growth by profession persist
This scenario simply charts the estimated change of the programme based on the rates of expenditure growth of each profession under the Better Access Program (see earlier). By 2028–2029, the Better Access Program will cost just under AUD3 billion annually. This is presented in Table 2.
Existing growth only.
Scenario 2: growth doubles for psychology
There are significant limitations on the psychiatry workforce, restricting room for expansion. GP-based services are also limited by workforce and time constraints. By contrast, psychology is taught in most universities across Australia, representing a growing supply of new service providers. This is strongest in relation to registered psychologists.
Scenario 2 responds to these workforce realities, as well as the expansion proposed by the MBS review. It assumes a doubling of the rate of growth for both clinical and registered psychology. This scenario is presented in Table 3 with a 22% rate of growth applied to clinical psychology and 15.6% to registered psychology. The only change applied to psychiatry and GPs is average growth (5.7% and 7.9% respectively). Under this scenario 2, by 2028–2029 the Better Access Program will be costing AUD5.4 billion annually.
Psychology growth doubles.
Scenario 3: psychology growth at 25% combined with a 2% annual fee increase for GPs and psychiatry
While a significant increase in numbers for GP and psychiatry consultations under Better Access is not likely given workforce constraints, the professions have argued strongly for increases in the Medicare fee payable for these services. Hence, scenario 3 models a 2% annual Medicare fee increase for both GPs and psychiatry. This also factors in a 25% growth in both clinical and registered psychology (Table 4).
Twenty-five percent psychology increase plus 2% Medicare fee increase for psychiatry and general practitioners (GPs).
While this is significant, the MBS review basically suggests removing most if not all constraints on Australians seeking psychology care. This estimate is provided to demonstrate the likely financial impact of this recommendation. Consequently, under scenario 3, the Better Access Program would cost AUD8.5 billion annually in 2028–2029.
Out of pocket costs
It is of course worth noting that the modelling provided only considers the impact of the changes on the cost to Medicare, not the actual costs to users of services. Since 2011–2012, out-of-pocket costs have been growing at an average of 7.8% annually and add around 24% to the Medicare fee. A true and full reflection of the additional impact of the MBS panel’s proposed expansion of the Better Access Program should refer to this cost, as shown for each modelled scenario in Table 5.
Growth scenarios including out of pocket costs.
What options do we have in the future?
Consistent with population-based estimates of need, and in response to community demand, there will be increases in both government and private expenditure on mental health services. As emphasised by the report of NMHC (2014), if we simply continue our current practices, we will see increases in state-based expenditure that focus on hospital beds and acute services for a very small proportion of the population, an increased supply of private hospital beds and an increased utilisation of Medicare and Pharmaceutical Benefits Scheme services that respond poorly to population-based needs.
Within that context, our support for publicly subsidised access to skilled psychological interventions is unchanged. However, more than 15 years after first attracting Medicare-based support, and with the cost of the programme likely to increase rapidly (possibly as high as over AUD10 billion annually), it is timely and prudent to review in what ways appropriate psychological interventions can be delivered at scale. This is particularly important to arrange multidisciplinary teams working with more complex clients, and to assist in overcoming socio-economic and geographical inequities. While team-based and other highly collaborative care models have long been recognised as best practice (National Institutes of Medicine, 2006), they fail to flourish under the current provider-centric fee-for-service system (Hickie and McGorry, 2007). While geographical-based funding models were part of the original design of ‘Better Outcomes’, are such models (presumably administered by the Primary Health Networks [PHNs]) still preferable to the provider-determined service location models supported by ‘Better Access’?
Given the size and scale of this programme, it is now urgent to ask:
Do we really expect that this scheme, which based on the most optimistic estimates still fails to reach about half the population in need, is likely to ever have substantive impacts on national rates of psychological disorder or suicidal behaviour?
Do much more targeted or multi-dimensional outcomes need to be defined for the programme, and then assessed both regionally and nationally. These could include the following: Reductions in suicidal thoughts or behaviours; Reductions in presentations to Emergency Departments or other acute care services; Secondary prevention of illness progression or development of comorbid alcohol or other substance misuse; Reductions in concurrent medical comorbidity or service use; Increased stability in housing/accommodation; Increased productivity (in terms of increased participation in education or employment)?
Do we need much clearer identification of the populations that are most in need of these services – as a consequence of financial circumstances, geography, membership of a high-risk population and illness impacts?
Would we see much more impact on productivity from directing clinical service provision away from very brief interventions with middle-aged adults with anxiety and depression but little additional impairment, towards more substantive, multidisciplinary, team-based and prolonged interventions with younger cohorts (Knapp et al., 2011)?
Can new digital technologies (with or without additional clinical supervision) provide many of the brief or early interventions that were within the original scope of both the Better Outcomes and Better Access Programs?
Most importantly, we also need to ask how the impacts of such changes can be modelled prior to implementation and then tracked, both regionally (in light of the more recent development of PHNs) and nationally (through collation of regional data or by other independent means). This type of prior regional modelling, and then sustained outcome measurement, is now feasible (Page et al., 2017) and fits with the much broader goal of developing more robust accountability for mental health (Rosenberg and Salvador-Carulla, 2017). This is a goal that could apply to other Medicare services, beyond mental health.
Recommendations for changes to the programme
Following the 2019 Federal election, and the outcomes of the 2019 Productivity Commission Review, it is highly likely that the Commonwealth will need to make active choices about where to next for the 2006-designed ‘Better Access’ Program.
In our view, the next round of programme changes should take the opportunity to:
Actively curtail further rapid growth of brief intervention services for those with psychological distress but minimal functional impairment. While this may be strongly opposed by the relevant professional associations, inevitably, it must confront the ways in which current MBS fee-for-service systems deliver inequitable access to high quality care for those with the greatest need;
Support practice-based and PHN-based incentive models to develop team-based and other relevant practice models that respond to the needs of those groups poorly served by the current systems: These include the following: (a) Lower socio-economic status; (b) Outer urban, regional rural and remote locations; (c) Those individuals with complex, persisting and impairing disorders; (d) Young people with emerging major disorders and impairment, notably under age 25 years, who have limited access to quality services; (e) Older people, whose mental health needs are often ignored.
Incentivize the adoption of digitally supported psychological services through appropriate use of evidence-base practice models (e.g. Mindspot) and use such tools to meet the genuine health care needs of those with less severe, persisting or impairing disorders.
Add pooled and other non-fee-for-service-based funding arrangements to the way Australia pays for mental health care, to provide the funding environment necessary to support these policy and service reforms.
Conclusion
While advocacy for increased mental health expenditure is easy, active reform of existing patterns of service is hard – and often most resisted by those who provide those services. The Better Access Program, based largely on providing brief psychological interventions for those with common anxiety and depressive disorders, under a fee-for-service model, has been the most significant new investment by the Commonwealth. If the MBS review recommendations are adopted, not only will the costs of the programme grow exponentially but also will its socio-economic, demographic and geographical inequities. Furthermore, the needs of those with more complex, impairing and persisting disorders will be further marginalised. In our view, any serious approach to national mental health reform cannot proceed without considering serious restructuring of this programme to make it fit for purpose in the 21st century.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
