Chapter 1: Background

1.1 Setting the context
1.2 Overview of the Better Access initiative
1.3 Evaluation of the Better Access initiative
1.4 The current report

1.1 Setting the context

The last decade has witnessed substantial reforms to Australia's mental health care system. These follow the publication of influential findings from the first National Survey of Mental Health and Wellbeing (NSMHWB) in 1998¹ and the Australian Burden of Disease and Injury Study in 1999.² These studies revealed the widespread nature of mental illness in the general population, unexpectedly low treatment rates for these conditions, and the considerable impact of disorders such as depression on individuals' lives and Australia's health burden. The 1997 NSMHWB revealed that one fifth of the population had experienced a mental disorder in the past 12 months, but only one–third of these people had consulted a health professional in the past 12 months for this reason.^{1, 3} This is half the treatment rate of physical disorders causing comparable disability.⁴ The survey also confirmed that general practitioners (GPs) were the most common providers of mental health care. Seventy–six percent of those receiving any mental health care reported using this type of service, often in conjunction with another health service.⁵ The Australian Burden of Disease and Injury study found that mental disorders were the leading cause of years of life lost due to disability (YLD), and depression was the leading cause of nonfatal disease burden.² Together, these findings indicated a need for effective treatments for mental disorders, including high–prevalence disorders such as depression and anxiety that are available to a greater proportion of the Australian population.³ The policy response to these findings was to expand the population health scope of the National Mental Health Strategy and to develop a focus on primary mental health care with the aim of increasing the treatment rates for common mental disorders.

Recently, several wide–scoping reviews into the provision of mental health services in Australia^6–9 have highlighted the still–pressing need for people with mental illness to have greater access to – that is, an opportunity to utilise – mental health services, particularly evidence–based treatments by specialist providers such as psychiatrists and psychologists. 'Out of hospital, out of mind', an inquiry conducted by the Mental Health Council of Australia (MHCA) in 2002,⁷ recommended "incentives for psychiatrists and other specialists to increase their consultancy to primary care" (p. 40), and that "increased access to therapies ... in both the public and private sectors ... could be enhanced by the inclusion of psychological therapies under the Medicare Benefits Schedule" (p. 26). This latter recommendation was repeated in a subsequent review by the MHCA,⁶ a Senate inquiry,⁸ and is consistent with expert opinion.¹⁰
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'Out of hospital, out of mind'⁷ identified the cost of specialised mental health services, such as psychiatry and psychology, as a significant barrier to meeting the treatment needs of people with mental illness. In 2006, Hickie and colleagues¹⁰ reported that the affordability of these services has also been worsening in recent years, with the average out–of–pocket cost (i.e., difference between fees charged and Medicare rebate paid) to consult a psychiatrist increasing by 39% between 1995/96 and 2001/02. In the same year, a Senate inquiry⁸ attributed these rising costs to a progressive decline in the number of psychiatrists working in the public sector, and a dearth of Medicate–rebated psychological services.

Two programs have been pivotal components of the reforms addressing gaps in the provision of accessible and evidence–based treatments for common mental disorders. In July 2001 the Better Outcomes in Mental Health Care (BOiMHC) program (www.health.gov.au/internet/main/publishing.nsf/Content/mental–boimhc)¹¹ was introduced, which enabled psychological services to be provided through the use of locally negotiated service contracts between Divisions of General Practice and allied health professionals. BOiMHC is a two–component program designed to improve access to high quality mental health care for Australians. One of the key components is the Access to Allied Psychological Services (ATAPS) component, which enables GPs to refer consumers with high prevalence mental health disorders to allied health professionals (mainly psychologists, but also social workers, mental health nurses, occupational therapists and Aboriginal and Torres Strait Islander health workers) for affordable, evidence–based mental health care. Consumers can receive up to 12 (or 18 in exceptional circumstances) individual and/or group sessions of government–subsidised, focused psychological strategies per calendar year. The extent of service delivery determined by the capped funding granted to Divisions of General Practice, who act as fund–holders for this program. The program continues today, and is supported by evidence that it is meeting demand for psychological services among its intended target group¹² and is achieving positive outcomes for its consumers.¹³

More recently, the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) initiative (www.health.gov.au/internet/main/publishing.nsf/Content/coag–mental–q&a.htm)¹⁴ was introduced as pivotal component of the Council of Australian Governments (COAG) National Action Plan on Mental Health 2006–2011.¹⁵ It complements the BOiMHC program, by offering a range of mental health services for consumers which are either partially or fully funded by Medicare. The initiative is described in more detail below.

1.2 Overview of the Better Access initiative

1.2.1 Aims and objectives

The highest level aim of Better Access is to improve outcomes for people with mental disorders by providing new and increased rebates for Medicare–subsidised services and encouraging a multi–disciplinary approach to mental health care. A number of lower level objectives support this aim. These include: encouraging GPs to undertake early intervention, assessment and management of patients; supporting GPs and primary care service providers with education and training to better diagnose and treat mental illness; encouraging private psychiatrists to see more new patients; streamlining access to appropriate psychological interventions in primary care; and providing referral pathways for appropriate treatment of patients with mental disorders, including by psychiatrists, GPs, clinical psychologists and other appropriately trained allied mental health professionals.¹⁴

1.2.2 MBS item numbers

Under Better Access a series of item numbers were added to the Medicare Benefits Schedule (MBS). The specific MBS items numbers include:

• GP Mental Health Treatment item numbers: These reimburse GPs for preparing (2710 and 2702) and reviewing (2712) mental health treatment plans, and providing mental health treatment consultations (2713);
  
  
• Consultant Psychiatry item numbers: These reimburse psychiatrists for conducting an initial consultation with a new patient in their consulting rooms, in a hospital or at the patient's home (296, 297 and 299, respectively), for providing and reviewing a patient assessment and management plan (291^a and 293^a, respectively); and
  
  
• Allied health professional item numbers: These reimburse clinical psychologists for delivering Psychological Therapy Services (80000, 80005, 80010, 80015 and 80020), registered psychologists for providing Focussed Psychological Strategies (80100, 80105, 80110, 80115 and 80120), selected occupational therapists for providing Focussed Psychological Strategies (80125, 80130, 80135, 80140 and 80145) and selected social workers for providing Focussed Psychological Strategies (80150, 80155, 80160, 80165 and 80170).

Focussed Psychological Strategies are defined as specific mental health treatment strategies derived from evidence based psychological therapies; these include cognitive behavioural therapy, interpersonal therapy, psychotherapy and motivational interviewing. Psychological Therapy Services include psycho–education and cognitive behavioural therapy, with other evidence–based therapies, such as interpersonal therapy, used if clinically indicated.

The costs of services provided under the Better Access MBS items are reimbursed in part or wholly by Medicare Australia. The relevant provider can either bulk–bill the consumer (by charging the schedule fee and directly billing Medicare Australia), or can bill the consumer an amount above the schedule fee and the consumer can then obtain a rebate up to the level of the schedule fee from Medicare Australia. A complete list of the Better Access MBS items, including schedule fee and rebate information, is shown in table 1.1.
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Table 1.1 Better Access MBS items, as at 31 March 2010

Table 1.1 is separated into 4 smaller tables in this HTML version for accessibility reasons. It is presented as one table in the PDF version.

Consultant psychiatry items

MBS Item	Provider	Item description	Detail	Schedule fee	MBS rebate
291a	Consultant Psychiatrists	Referred Patient Assessment and Management	45+ minute consultation	$427.80	$363.65
293a	Consultant Psychiatrists	Review of Referred Patient Assessment and Management	30-45 minute consultation	$267.40	$227.30
296	Consultant Psychiatrists	Initial consultation on a New Patient - in rooms	45+ minute consultation	$246.00	$209.10
297	Consultant Psychiatrists	Initial consultation on a New Patient - in hospital	45+ minute consultation	$246.00	$209.10
299	Consultant Psychiatrists	Initial consultation on a New Patient - home visit	45+ minute consultation	$294.20	$250.10

GP mental health treatment items

MBS Item	Provider	Item description	Detail	Schedule fee	MBS rebate
2710	General Practitioners	GP Mental Health Treatment Plan	GP has undertaken mental health skills training	$160.45	$160.45
2702b	General Practitioners	GP Mental Health Treatment Plan	GP has not undertaken mental health skills training	$125.95	$125.95
2712	General Practitioners	Review of a Mental Health Treatment Plan		$106.95	$106.95
2713	General Practitioners	GP Mental Health Consultation	20+ minute consultation	$70.60	$70.60

Psychological therapy services items

MBS Item	Provider	Item description	Detail	Schedule fee	MBS rebate
80000	Clinical Psychologists	Psychological Therapy Services - in rooms	30-50 minute consultation	$94.30	$80.20
80005	Clinical Psychologists	Psychological Therapy Services - out of rooms	30-50 minute consultation	$117.85	$100.20
80010	Clinical Psychologists	Psychological Therapy Services - in rooms	50+ minute consultation	$138.40	$117.65
80015	Clinical Psychologists	Psychological Therapy Services - out of rooms	50+ minute consultation	$161.95	$137.70
80020	Clinical Psychologists	Psychological Therapy Services Group Session - 6 to 10 patients	60+ minute consultation	$35.15 (per patient)	$29.90 (per patient)

Focussed psychological strategies allied mental health items

MBS Item	Provider	Item description	Detail	Schedule fee	MBS rebate
80100	General Psychologists	FPS Service - in rooms	20-50 minute consultation	$66.80	$56.80
80105	General Psychologists	FPS Service - out of rooms	20-50 minute consultation	$90.85	$77.25
80110	General Psychologists	FPS Service - in rooms	50+ minute consultation	$94.30	$80.20
80115	General Psychologists	FPS Service - out of rooms	50+ minute consultation	$118.40	$100.65
80120	General Psychologists	FPS Service Group Session - 6 to 10 patients	60+ minute consultation	$24.05 (per patient)	$20.45 (per patient)
80125	Occupational Therapists	FPS Service - in rooms	20-50 minute consultation	$58.85	$50.05
80130	Occupational Therapists	FPS Service - out of rooms	20-50 minute consultation	$82.85	$70.45
80135	Occupational Therapists	FPS Service - in rooms	50+ minute consultation	$83.10	$70.65
80140	Occupational Therapists	FPS Service - out of rooms	50+ minute consultation	$107.10	$91.05
80145	Occupational Therapists	FPS Service Group Session - 6 to 10 patients	60+ minute consultation	$21.10 (per patient)	$17.95 (per patient)
80150	Social Workers	FPS Service - in rooms	20-50 minute consultation	$58.85	$50.05
80155	Social Workers	FPS Service - out of rooms	20-50 minute consultation	$82.85	$70.45
80160	Social Workers	FPS Service - in rooms	50+ minute consultation	$83.10	$70.65
80165	Social Workers	FPS Service - out of rooms	50+ minute consultation	$107.10	$91.05
80170	Social Workers	FPS Service Group Session - 6 to 10 patients	60+ minute consultation	$21.10 (per patient)	$17.95 (per patient)

Table 1.1 footnotes

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Sources: (a) Department of Health and Ageing (2008);¹⁶ (b) Department of Health and Ageing (2008)¹⁷
Items and fees are as effective at 31 March 2010, the latest date of Better Access MBS items considered in this report.
^aThese items existed prior to 1 November 2006, but the fees and rebates attached to them were increased as part of the Better Access initiative.
^bItem 2702 commenced 1 January 2010. Previously services captured under 2702 were captured under 2710, which did not distinguish between GPs on the basis of mental health skills training.

1.2.3 Referral pathways and protocols

To be eligible for Psychological Therapy Services and Focussed Psychological Strategies services the consumer must meet diagnostic criteria for a mental disorder, and be referred from an appropriate medical practitioner – a GP, psychiatrist or paediatrician. The GP is required to prepare a Mental Health Treatment Plan (including a relevant history, mental state examination, diagnostic formulation and management) under item 2710. The Plan is expected to identify the clinical rationale for the referral. Referrals can be made for up to 12 individual (18 in exceptional circumstances) and 12 group treatment sessions in a calendar year. After the initial course of treatment (a maximum of 6 services but may be less depending on the referral) the allied health professional is required to write a report to the referring practitioner, who then conducts a review and, if appropriate, approves the next six sessions. It is intended that GPs use the GP Mental Health Treatment Review item (2712) for this purpose.

1.3 Evaluation of the Better Access initiative

A comprehensive evaluation of the Better Access initiative was commissioned by the Department of Health and Ageing (DoHA), to be conducted within an overarching evaluation framework that describes the program logic of the initiative. The evaluation explores a range of questions related to the broad areas of service access, appropriateness, effectiveness and impacts (on the mental health care system and its workforce). Four evaluation components were funded, namely: a study of consumers and their outcomes (Component A); an analysis of MBS and Pharmaceutical Benefits Scheme (PBS) administrative data (Component B); an analysis of allied mental health workforce supply and distribution (Component C); and consultation with stakeholders (Component D).

A consortium led by the Centre for Health Policy, Programs and Economics (School of Population Health, The University of Melbourne) was commissioned to conduct Component B. Component B involves an analysis of Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data to profile the uptake of the item numbers and examine the impact of Better Access on patterns of MBS, PBS and other service usage over the two years prior to the introduction of Better Access and the two to three years following.

1.4 The current report

The current report presents the findings of Component B. Chapter 2 describes the data sources used and the methods of analysis. Chapters 3 to 9 outline the key findings from a series of analyses addressing the seven core evaluation questions relating to access, affordability of care, equity, protocol–based care, interdisciplinary care, impact on medication prescribing and impact on other mental health programs. Chapter 10 summarises the findings, and interprets these in the context of the existing literature on Better Access and future research directions. A glossary and list of abbreviations are provided in Appendices 1 and 2, respectively.

Footnotes

^aThese two item numbers existed prior to the introduction of the Better Access initiative, but became part of the cohesive core of Medicare–subsidised services provided through Better Access and became associated with a higher rebate under Better Access.