Better Access and equitable access to clinical psychology services: what do we need to know?

Critical data on the delivery, outcomes and out-of-pocket expenses of services are lacking

The Australian Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) initiative aims to improve access to evidence-based mental health care in the community.1 Providing rebates for private services appears to be improving treatment uptake,2 yet the equity of Better Access has been questioned, with a recent study showing that specialised Better Access mental health services were disproportionately concentrated in affluent areas.3 This effect was particularly visible for clinical psychology services, with more than 2.5 times the volume of these services provided in the most, versus least, affluent areas. Within Better Access, clinical psychology services are intended for “the treatment of patients with complex and/or chronic mental health disorders, quite often with comorbid drug and alcohol problems”.4 As these patients are also more likely to experience financial distress and live in socio-economically disadvantaged areas,5 there is a pressing need to identify why clinical psychology services may be particularly vulnerable to inequitable service distribution.

Cost as a factor in inequitable access to clinical psychology services

Potential causes proposed for this inequitable service distribution include higher-paid professionals choosing to live in more affluent areas and work closer to home, or patients’ out-of-pocket expenses for these services being prohibitive.3 The differential impact of out-of-pocket expenses on access to specialist health services is widely recognised.6 Such expenses include those associated with attending treatment sessions, with incidental costs (eg, lost income, childcare, travel) averaging $57 per treatment session for face-to-face psychological interventions.7

Copayments, often used as a cost-sharing mechanism to distribute health care burden and encourage more judicious use of health services,8 are another common cost. Within Better Access, copayments are the responsibility of patients and cannot be covered by private health insurance rebates or other schemes, although they may be reduced through Medicare safety net arrangements after a specific threshold of expenses has been reached.9 Although copayments may place a financial burden on patients, they are often essential for supplementing non-remunerated tasks, including administration, professional development and supervision, to ensure sustainable private practice.10,11

Why comorbidity may be more important than copayments

However, there is evidence to suggest that copayments for clinical psychology services cannot fully account for inequitable service provision. Roughly 35% of Better Access clinical psychology services are bulk-billed (no copayment), with this rate similar to that for consultant psychiatry services (36%) and lower than that for services provided by other allied health professionals (43%).12 However, average copayment amounts are lower for clinical psychology services ($32) than for other allied health professionals ($37) or consultant psychiatry services ($82).12 So, while Better Access services are associated with higher out-of-pocket expenses overall — compared with schemes such as Access to Allied Psychological Services (ATAPS), where one in 20 sessions incurs a copayment averaging $13.5913 — these costs are not unique to clinical psychology services. Instead, epidemiological and treatment outcome studies suggest that comorbidity is a more likely contributor to inequitable Better Access clinical psychology service distribution.

Currently, there is no routine data collection on the number of treatment sessions provided by health professionals once Better Access allowances (ten individual and ten group sessions per calendar year) have been exhausted. Yet, several factors suggest that, if clinical psychology services are being used for more complex and comorbid presentations as intended, these services will extend beyond ten individual sessions. Comorbidity between mental disorders can signal more severe and treatment-resistant presentations and is often the norm, rather than the exception, in those with mental illness.14 Current best-practice guidelines for managing comorbid mental and substance use disorders include providing empirically supported treatments for each disorder, either sequentially or concurrently.15 Clinical practice guidelines synthesising high-quality clinical and health economic research literature, such as the guidelines developed by the United Kingdom’s National Institute for Health and Care Excellence,16 highlight that these empirically supported treatments are likely to extend beyond ten individual sessions, even for single disorders treated in isolation (Box). Although there is some debate about whether comparable treatment outcomes can be achieved in fewer sessions,17 it is unlikely that combinations of empirically supported treatments for multiple disorders (even in reduced formats) can be contained to ten individual sessions.

The financial impact of mismatched policy and practice

It is important to consider the financial impact of this mismatch between Better Access allowances and empirically supported treatment guidelines. Any sessions beyond Better Access allowances are not supported by alternative initiatives, such as ATAPS, or the Medicare safety net. Private health insurance rebates may also be less available to this population, as increased mental disorder has been linked to both limited financial resources5 and reduced private health insurance coverage.18 Currently, there is little guidance about how to adapt therapy for people with complex presentations who cannot afford treatment beyond ten individual sessions. The Australian Psychological Society recommends adjusting usual intervention techniques to “ensure an outcome is achieved” within available sessions,19 but it is unclear how this is to be achieved or what impact these modifications will have on the effectiveness of treatment.20 There is also little guidance about how to use combinations of Better Access individual and group sessions to best support people with comorbid disorders.

After exhausting Better Access allowances, people who cannot afford ongoing care may be referred to other services, such as consultant psychiatrists (up to 50 individual consultations subsidised by Medicare per year1) or community mental health services. Yet, limited availability of these services may result in long waiting periods, reflecting the “missing middle” of the mental health system.21 It is also unclear whether referral to consultant psychiatrists or community mental health teams for delivery of psychological interventions reflects the most cost-effective or efficient use of scarce health resources. Extending Better Access clinical psychology allowances from ten to 16 sessions, as has been proposed,21 may help bring health policy more in line with empirical evidence.

However, the reduced provision of Better Access clinical psychology services in less affluent areas may not necessarily reflect poor treatment coverage in these areas. Better Access is only one component of federal mental health investment, representing 9.5% ($907.9 million) of federal government spending on mental health in 2012–13.21 It is complemented by a range of programs (eg, ATAPS) targeting hard-to-reach and disadvantaged populations. Lower Better Access coverage in some areas may not be inequitable if general practitioners are instead referring a comparable proportion of people to alternative schemes. This highlights how complex networks of funding arrangements make it hard to assess the overall equity of services.

Implications for mental health policy

Exploring discrepancies between clinical practice guidelines and reimbursement structures highlights the importance of empirical evidence in the design of health care financing. Although finite resources are a constraint in any health care system, without thoughtful consideration of empirically supported treatments, short-term cost-saving measures may have longer-term financial consequences. For example, capping Better Access sessions may contain costs in the short term but may also result in ineffective treatment, increasing rates of drop-out, relapse or reluctance to engage in treatment.22 This may then result in increased costs such as welfare payments, lost productivity and increased use of other health care services. The most recent estimate of the costs of mental disorders in Australia reaches up to $40 billion each year,21 highlighting the importance of identifying cost-effective methods for reducing this burden.

Rather than capping the number of sessions, more creative approaches to achieving efficiencies in the mental health system, while also potentially enhancing the quality of clinical care, could be explored. An example of this could include replacing the review of GP Mental Health Treatment Plans after six sessions with innovative technologies for tracking clinical trajectories. Recent estimates show that patients seek an average of 4.8 Better Access sessions,23 but it is unclear whether these brief treatment courses reflect successful treatment outcomes or treatment drop-out. This means the six-session review may occur too late to identify people at risk of poor outcomes. Anecdotally, requiring a review after six sessions can also have the unintended effect of setting unrealistic expectations about progress that demotivate patients or create treatment delays that negatively affect momentum of change. An alternative may be replacing the six-session review with the use of standardised assessment measures to monitor trajectories of symptom change, identify at-risk patients, provide clinically useful information to practitioners and generate real-time service use data.24

The importance of measurement for management

There is a critical lack of data on the delivery of mental health services under Better Access,21,25 including limited data on how practitioners adapt therapies to fit session constraints, the impact of these modifications, relapse rates, average out-of-pocket costs (not just copayments), the influence of the Medicare safety net on copayments and how various populations may be differentially affected by all these factors. A full understanding of the effectiveness and equity of Better Access requires information about the number of sessions completed once Better Access allowances have been exhausted, the utility of separating Medicare Benefits Schedule items for individual and group psychological therapy and how people transition through services over time.

With the most recent Australian population survey of mental disorders and service use conducted almost a decade ago,26 it is essential to develop a plan to ensure the collection of timely and meaningful data to inform current mental health reforms. It is also essential to take a multidisciplinary approach to mental health policy, to ensure policies facilitate the delivery of best-practice care to those who need it most.

Box – Number of sessions for psychological interventions recommended by NICE clinical guidelines for mental disorders16

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CBT = cognitive behavioural therapy. NICE = National Institute for Health and Care Excellence. * These figures do not include initial assessment sessions, which are typically required to confirm and refine diagnosis.4 † Signifies the current cut-off of Better Access sessions. ‡ Some sessions longer than 60 minutes recommended. § Recommended in conjunction with pharmacotherapy for moderate to severe presentations.