The decision by health minister Mark Butler to end the temporary increase in Medicare rebates for psychological counselling, halving sessions from 20 to 10 a year, has led some to ask how committed the Albanese government is to mental health and suicide prevention. As Butler was the previous Labor cabinet minister for mental health and ageing, he is well aware of the size of the unmet need for better mental health services.
As with his concerns about the sustainability of general practice, Butler is also well aware of the reality that Medicare is now overly reliant on fee-for-service and substantive out-of-pocket payments. Major medical and psychological advocacy groups still strongly promote these arrangements, despite the fact they overwhelmingly disadvantage lower socio-economic groups, young people, elderly people and those who live in outer urban, regional or rural Australia.
These inequities are most profound in mental health, as emphasised by a series of recent reports. While those living in the lowest socio-economic groups report the highest levels of mental distress, they receive the lowest proportion of Medicare-rebated services. Within the mental health world, there is a general consensus that we have failed not only to build a system that responds to the acute care needs of those with the most severe forms of illness, but we have also largely neglected the many Australians who have other ongoing or complex needs.
So, it’s time we moved well beyond tinkering or operating at the margins of reform. Simply arguing for more cash for selected programs, or increasing Medicare rebates for private practitioners, deflects attention from the more serious questions about what system-level reforms would actually improve the mental health and productivity of all Australians.
We do have new tools for this exercise, such as dynamic health system modelling, simulation and monitoring. These are the same tools that are often used in other complex finance, engineering and planning exercises. Their importance to mental health was recognised internationally during the pandemic. At that time, the need to provide substantive and prolonged employment (jobkeeper) and financial (jobseeker) support, and not more glossy mental health awareness or self-care campaigns, was clear.
For Australia, there is no one-size-fits-all approach. We need to deliver public health and health services initiatives in each of the 52 major regions in which we live and work. Having looked systematically at these approaches, we have been able to estimate the relative advantage of prioritising system-level reforms (for example, distributed early and affordable access to specialised services, and smart IT-based coordination of care) over simple cash injections into the existing dysfunctional (Medicare and state) arrangements.
Currently we spend just over $11b on mental health services annually. Before we simply spend more, however, we have a choice. If we spent $15b intelligently, we could achieve substantively better outcomes for most Australians. By contrast, if we stick with the current arrangements, we would need to spend $23b annually (or almost 60% more) to achieve the same results.
In each region of this vast country, we need to make specific adjustments to national initiatives to respond to the different demographic, geographic and socio-economic challenges. We need to deliver affordable care to those in disadvantaged groups.
During his time in opposition, Butler took time to look at system-level options. The same material was presented to the Coalition government, but it had little impact on decision-making before or during the pandemic. So, if the minister is to make substantive changes, there are modern tools to guide and monitor the implementation of a system-level and long-term approach. More regional healthcare organisations have already headed down this path.
Within these serious policy options, changes to the existing Medicare rebate schedules are the least important. Along with more community awareness campaigns, they are the most likely to result in unintended and adverse consequences such as reduced access to care, greater disengagement by the most disadvantaged and greater pressure on current emergency care responses. (Research shows community awareness campaigns can backfire by simply driving up demand and leading to greater disengagement for those who are frustrated and can’t get access).
Much work has been done by consensus policy and community groups to develop priorities for action. These include: support for community-based prevention; enhanced and affordable access to early intervention for those with emerging major anxiety, mood or psychotic disorders; rapid access to more specialised services for those with more complex and disabling disorders (such as eating disorders, bipolar disorder, psychotic disorders, severe personality disorders); IT-enhanced rapid access to care and triage of need, allocation and coordination of ongoing care; easy access to digitally supported and professionally assisted self-care programs for common forms of distress; and significant growth in the training of skilled mental health professionals, most notably clinical psychologists.
We need to stop focusing on minor adjustments to funding models and shift the conversation to funding the right care models. We need to be clear about what problems benefit from which specific treatments; who is being paid give to these specific treatments; and do they, individually or as a team, have the capability to deliver the most effective forms of care. The outcomes of care need to be closely monitored, and reported openly, so that we can be confident that our goal of “right care, first time, where you live” can actually become a reality for most Australians. That would be the style of reform that would be genuinely consistent with prime minister Albanese’s aspiration that “no Australian is left behind”.
Prof Ian Hickie is a co-director at the University of Sydney’s Brain and Mind Centre. He is a shareholder in Innowell, a joint venture between the University of Sydney and PwC Australia
