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GPs are the least likely to have large gap payments, but the most likely to be under-remunerated by Medicare for their work. We need to take a long, hard look at why a GP spending 40+ minutes on assessing and designing a management plan for a patient under a Mental Health Care Plan has a scheduled fee of $141.00, ($3.33 per minute for 45 minutes, or 35 minutes, just $96.25) and a psychiatrist undertaking an item 291 assessment and management plan of over 45 minutes has a scheduled fee of $485.70 ($10.79 per minute), almost 3.5 times the GP fee
IS there a doctor, nurse or allied health professional anywhere in Australia who thinks that our current mental health system is doing fine? The recent InSight+ article by Rosenberg and Hickie has been marred by their misunderstanding of how GPs work, how we bill, and how we actually engage with our patients, but has usefully caused me to reflect on the state of the system as a whole.
The mental health care system comprises primary healthcare (GPs and allied health professionals), secondary healthcare – outpatient services (psychiatry, nursing and allied health, both private and public), and hospital care, (again, both private and public). The system is completed by myriad programs operated by non-government organisations, not-for-profits, and charities. Some of them operate under commissioning by primary health networks (PHNs), some by commissioning from state health departments, and some operate quite independently, funded through donations, direct government grants and/or bequests.
The “system” is a Jackson Pollock painting, with coverage dripped and splashed, reaching most of the canvas, but not visibly planned and definitely not orderly. (Disclaimer – I quite like Jackson Pollock art, but don’t recommend it as a method of strategic planning).
In reality, we have a non-system, cobbled together by sticky tape and paper clips. The complexity and disconnectedness of it makes it difficult to get a picture of the overall state of the system. If I find this non-system bewildering, what hope is there for a patient with severe depression or ADHD, whose executive functioning and motivation are compromised?
The day-to-day work of general practice brings me into contact with the entire spectrum of mental health need; from the high functioning but depressed executive to the chronically psychotic and undertreated; from those who have never had any contact with the mental health care system, to those who have endured involuntary admissions and long term morbidity.
It doesn’t seem to work optimally for any of them, and among all the discussion about funding and who should be working in the mental health space, it’s important that we continue to be focused on what works for the people who need services.
Our system does have some strengths. We have an enormous amount of good intent, and we have high levels of community engagement and interest. We have made huge inroads in addressing stigma and denial, acknowledging that much remains to be done. We have a government that is interested to improve things (here and here), and we do have (and I can say this with more authority than most) some of the best trained mental health providers in the world. So, what is going wrong?
The weaknesses of our system include the fragmentation, a fee-for-service model (that is inadequate even for physical health, let alone mental health) the reliance through this fee-for-service model on private business to deliver, and the unaddressed mismatch between access and need (here, and here). We also have a lack of consensus on the roles and responsibilities of the different health professionals, which can play out as an unedifying turf war, to the dismay of observing mental health consumers.
Fragmentation occurs both through service and professional silos, but also through service models. We have multiple entities and programs, and there can be completely different service providers depending on the intensity of need. Not just different teams in the same organisation, but completely different organisations. Fragmentation inevitably leads to gaps, as each program stakes out its territory, unfortunately excluding those outside its remit.
The fee-for-service model creates disincentives for engagement with patients whose needs are complex, because above all, the Medicare system rewards throughput. It punishes longer, intensive work, incidentally, contributing significantly to the gender pay gap. Forty-five minutes on one mental health care plan remunerates $3.33 per minute for a GP. Four 10- to 12-minute consultations in 45 minutes generates $4.86 per minute, and significantly more in a mixed-billing practice, or even if bulk billing incentives are included. The model rewards the practice of superficial medicine and reactive care.
Doctors and allied health practitioners in private practice understand that they are small business owner-operators. They must make a profit if they are to survive, if they are to make payroll, keep the lights on and pay the rent. Everyone else seems to forget this.
Quite bluntly, the entire Better Access to Mental Health Care Program relies on autonomous for-profit businesses – general practice, allied health and psychiatrists. While underpinned by Medicare, our pricing structures are not constrained by it, so the program is operating in an environment that is, to all intents and purposes, a free market that relies on individual acts of altruism to rescue the system when that free market fails. Demand and workforce shortages have driven prices up, but supply has not increased.
As a result, it has become normal for the private mental health sector to decline referrals, or price themselves out of common access. The current intake approach of private mental health facilities in my area is that the GP must send a letter and they circulate it to their panel of specialists and see if there was anyone who was “willing” to take the patient on. This is not just one facility, it seems to be almost universal, in my experience. Some don’t bother to answer at all, some revert and say “no sorry, nobody will take that patient”, and some are actually helpful, responsive and give a timeline for when they will contact the patient.
When I prepare a GP Mental Health Care Plan, if I refer to private providers for psychological therapies, the waiting time is usually in the order of 3 to 6 months, and the block-funded (free to consumer) programs are booked out to the extent that they often decline referrals. The financially neediest or patients at high risk of suicide may be able to access support through PHN commissioned services, but this leaves a lot of people not really covered.
But when all avenues fail, no private practitioner or facility will accept the referral, and the public system assesses them as not “severe” enough, there is nowhere to go. This is in a metropolitan area – I cannot begin to imagine how things go for colleagues in rural and regional Australia.
There can be very large financial barriers. Accessing private psychology services under a mental health care plan has an out-of-pocket per session of approximately $100 or more. For many people this is exclusionary, but they don’t meet the criteria of financial hardship to access any of the free programs.
GP remuneration is not the core issue here, but it is an important part of the system failure and if GPs were to join psychiatrists and psychologists with large gap fees, those most in need would be left in desperate circumstances.
GPs are the least likely to have large gap payments, but the most likely to be under-remunerated by Medicare for their work. We need to take a long, hard look at why a GP spending 40 + minutes on assessing and designing a management plan for a patient under a Mental Health Care Plan has a scheduled fee of $141.00, ($3.33 per minute for 45 minutes, or 35 minutes, just $96.25) and a psychiatrist undertaking an item 291 assessment and management plan of over 45 minutes has a scheduled fee of $485.70 ($10.79 per minute), almost 3.5 times the GP fee.
The nuances of minutes aside, this difference entrenches the government (and the public) view that GP work is low value, and that other specialists deserve far better remuneration than general practice specialists.
That’s just the private system.
The public system (at least in Queensland) is very clear that their scope is “severe and complex mental health morbidity”. Note the and. I can’t think of many other conditions where the public system denies care for moderately severe disease.
I have patients who are financially compromised because their condition has cost them their job. The public health system will do acute assessments, but if the person is not a risk to themselves or others, they are invariably handed back to me.
One of the hallmarks of general practice is recognising that while you may not be the best doctor for the job, you may indeed be the only doctor available for the job.
With that mindset, in this current operating reality, I have expanded my scope of practice in mental health significantly and somewhat uncomfortably. I enjoy mental health work, and I can see that I make a difference. But I am uncomfortable, because unlike every other part of my practice, I cannot count on my other specialist colleagues to help me when I am faced with a problem I cannot manage. The inability to get psychiatry review is without question contributing to the GP discomfort in stepping up in mental health.
I have completed online training (even looped back and did it a second time to work out what I missed), read countless online resources, studiously avoided drug company marketing materials and initiate medication in a shared decision-making model with my patients and sometimes involving (if they have one) their psychologist in that decision, using only authoritative clinical guidelines. I refer to psychiatry colleagues when it is indicated, but this is often a thankless endeavour, with wait times of many, many months, and often, closed books.
We need some urgent reflection by the Royal Australian and New Zealand College of Psychiatrists on the models of care being promulgated by the available psychiatry workforce, to see if there is any way additional appointments can be opened up. GPs need our patients to be able to access specialists to help us maintain safe scope of practice. We need much better access to item 291 and 293 psychiatric reviews.
The data presented by Rosenberg and Hickie shows the widening gap between GP plans, psychology reviews and specialist psychiatry under the Better Access Program. There is a clear financial incentive to do these, as the Medicare fee is higher for the 291 than 296 (the standard initial consultation fee), so something is not working, and any review needs to understand what the barriers are and how they can be overcome.
If the private sector cannot meet this demand, then we need the public system to step up and help us manage those patients who might have historically been outside their remit.
So, what do we need from a review of the Better Access Program, but more importantly, from reform of the entire mental health care system?
The Productivity Commission report of 2021 was released by the former federal government, along with a “national mental health plan”, but it is concerning that only one of the recommendations of the Productivity Commission has been fully supported – the rest have been either “support in part” or “support in principle”.
Table 1- summary of Morris Government Response to Productivity Commission Report.
| Rec Description | Morris Government Response. |
| Create a person-centred mental health system | Support in part |
| Focus on children’s wellbeing across the education and health systems | Support in principle |
| Support the mental health of tertiary students | Support in part |
| Equip workplaces to be mentally healthy | Support in part |
| Support the social inclusion of people living
with mental illness |
Support i part |
| Take action to prevent suicide | Support in part |
| Increase informed access to mental
healthcare services |
Support in part |
| Expand supported online treatment | Support |
| Address the healthcare gaps: community mental healthcare | Support in part |
| Improve the experience of mental healthcare for people in crisis | Support in principle |
| Improve outcomes for people with comorbidities | Support in principle |
| Link consumers with the services they need | Support in part |
| Increase the efficacy of Australia’s mental health workforce | Support in part |
| Improve the availability of psychosocial supports | Support in principle |
| Support for families and carers | Support in part |
| Tailor income and employment supports | Support in part |
| Supportive housing and homelessness services | Support in principle |
| Improve mental health outcomes for people in the justice system | Support in principle |
| Best practice governance to guide a whole-of-government approach | Support in part |
| Funding arrangements to support efficient and equitable service provision | Support in part |
| Drive continuous improvement and promote accountability | Support in part |
The same applies to the Final Advice of the National Suicide Prevention Advisor – only two recommendations were supported, the rest meeting the same fate of “Support in part” : or “Support in Principle”. I have worked in bureaucracy enough to know that the pile of “support in principle” is where good work goes to die. It’s the place where you put things you have no intention of implementing, but lack the courage or support to say so.
Table 2: Summary of Morrison Government Responses to Suicide Prevention Advisor’s Final Advice
| Rec Description | Morris Government Response. |
| Leadership and governance to drive a whole of government approach | Support in principle |
| Lived experience knowledge and leadership | Support |
| Data and evidence to drive outcomes | Support in principle |
| Workforce and community capability | Support in principle |
| Responding earlier to distress | Support in part |
| Connecting people to compassionate services and supports | Support in part |
| Targeting groups that are disproportionately impacted by suicide | Support |
| Policy responses to improve security and safety | Support in principle |
My challenge to federal Health Minister Mark Butler and his team is to prepare a new government response to the Productivity Commission report and the National Suicide Prevention Advisor’s final recommendations. They were urgent enough for him to put out a press release about them in March 2021, so they should now be important enough to warrant a clear statement from government of what we are going to do.
It does not matter if the report was commissioned by a previous government – its findings and recommendations are non-partisan and are clearly aiming for a system that better meets the needs of mental health consumers. At the end of the day, that is what should underpin all the discussions, not turf discussions, not rebates, and not the federal-state divide. Every decision should be interrogated to the standard of “how is this good for the consumer”. Plans need implementation targets and KPIs, so that we can actually implement reform.
The piecemeal solutions of splashing more funds, like Jackson Pollock’s paint, are not going to fix a system that is fundamentally broken. A clear roadmap and a staged, transparent implementation plan are needed. It is possible that we will have a Labor government for at least two terms, and an unprecedented situation of mostly Labor state governments. If ever there was a time to take a national approach, it is now.
Dr Jillann Farmer is a Brisbane-based GP and former Medical Director of the United Nations.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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If you would like to submit an article for consideration, send a Word version to mjainsight-editor@ampco.com.au.
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I am commenting belatedly, but wanted to add my perspective as a private psychiatrist in a metropolitan setting. I have been in the same practice for over 20 years, diligently taking on “new patients” throughout. I have never done item 291, which is highly rewarded by Medicare, as I saw it as unsafe: I have to have a firm diagnosis and treatment plan for the GP to enact, while knowing that it is often not achievable at the initial assessment and leaves me exposed on several levels: what if the diagnosis is incorrect (eg. due to undisclosed substance abuse issue), what if my proposed treatment fails/causes side effects/cannot be implemented etc? Too many variables to consider, too much responsibility to take on, without the possibility (for the next six months) to review and reconsider. These 291 assessment are requested so the patient can be bulk billed (as the rebate is generous), but they are inherently too risky and burdensome for me to take on (but I totally see the value of 291 in a rural or remote setting).
Regarding the practice of screening referrals: I have only started doing so during the pandemic, when all consults were Telehealth. Again, due to safety concerns I felt it too risky to take on a patient with ? dementia, ?mania,? paranoid psychosis as assessment often relies on creating trust and rapport, which can be difficult to achieve over a screen or a telephone, and MMSE is frankly impossible. As the pandemic progressed, ADHD emerged as the main reason for a referral; by 2021 these were the vast majority of my new referrals: 67% compared with 5% for the 20 years prior. The rise in ADHD referrals was mostly driven by social media, with patients self diagnosing and then demanding prescription stimulants they believed were panacea for their lockdown-induced apathy and lack of focus. (A reminder: stimulants are cognitive and performance enhancers, so they can appear to be beneficial whether one suffers from ADHD or not. Can you see the potential for misuse here? Are you concerned about iatrogenic stimulant abuse epidemic coming our way? I am). As I derive most satisfaction from helping the sickest patients, I have continued to screen referrals to give other patients a chance to have an assessment for their mental health complaints. Also, as I am reaching the latter part of my career (as a lot of us are) I am simply running out of puff to see everyone who presents (eg a recent referral for a commercial drivers licence) or to offer bulk billing, like I used to, for what is often a long haul of “hand holding” for a range of psycho-social issues, rather than actual psychiatric treatment.
The idea that there is a mental health system is itself contradictory.
Harold A Maio
Thank you for a really important article. Its observations are all the more poignant after a week of social media blitzing by a prominent psychiatrist who has been criticising GPs for allegedly limiting access, and, not just questioned the gate-keeping role of GPs, but their very role in the system.
The paradox is this: GPs (and, importantly, EDs) are not gate-keepers to the specialist psychiatrist, they are the gaffer tape that holds needy patients together while struggling to find specialist care.
The very concept of rejected referrals smacks of poor ethics, unless an alternative service or pathway is offered.
Psychiatry could do so much beyond on-line apps to improve access to specialist psychiatric medicine. Telehealth with a specialist psychiatrist could be delivered to community health centres. Telephone “triaging” discussions could be organised between a GP and a psychiatrist.
Finally, it would take a whole other thread to explore, but the final common pathway for unsolved problems continues to be ED. So-called “mainstreaming” meant that psychiatry services decided to divest themselves of their acute assessment and intake role, forcing patients at the end of their choices to line up with the febrile children, the patients with chest pain and potential strokes, the fractures and the sepsis. This is not a therapeutic environment for people in acute mental distress and yet, even if they are assessed by inpatient psychiatry as needing admission, they can languish in ED for days because the inpatient Mental Health Unit has closed doors – both literally and metaphorically.
In the middle of all this – people whose needs for mental health assessment and management depend on their location and means.
Dear Reader,
I would like to know others thoughts in regard to the concept of funding GPs to help case manage those with severe and acute Mental Health conditions? I am thinking along the line of the Practice Nurse Incentive Payment but an appropriuate professional (mental health nurse, social worker, psychologist perhaps) who could receive some funding for a few hours per week to do this. And for what it’s worth something similar for the Aged Care sector?
Would love to hear others thoughts re this.
Thanks
Thanks for this excellent description and analysis of the current situation, which concurs strongly with my experience as a currently practising GP.
Thanks for this article Jillann. Agree with nearly everything! But a terrific summation of the recent ‘debate’. I am struck by two things. The first, and this was really the major point of our original article here in Insight, is that accountability for mental health is really shot. And while GPs are doing lots of mental health work, from a systemic point of view, it is simply not possible to tell if their role in the Better Access Program is helping consumers or not, and how it could be improved. This was a point raised by the Prod Commission – that one size does not fit all. Without this accountability, systemic quality improvement in mental health is not possible. The lack of accountability applies to all services and professionals.
My second key point is even this Jack the Dripper mess, as you so accurately describe it, really only pertains to the people that ARE seen. We know that 53% of people in the last 12 months had symptoms that indicated a potential mental disorder but did not receive ANY care from a health professional for their problems. Some may say they did
not need any help. This could be true. But I don’t think this would be tolerated in any other area of health care, to leave such a large percentage of people potentially needing assistance alone.
So, as your article points out, massive challenges in relation still to both access and quality in mental health. Just putting more money into such a broken system, like more oil into a leaky engine, seems like an inadequate response.
Congratulations Jillann for your superb article and to InSight in highlighting, at long last, the shambles that is mental health “care”. I retired last year at the age of 74, having spent the last 25 years as a special interest GP with a practice exclusively devoted to counselling and psychotherapy for men, teenage boys and their families, the last 16 years in a deprived regional area. All that time, I operated alone, without a receptionist or any other support. No one was turned away (within my designated remit). I had 75-minute appointment slots, bulk-billed all card holders (about 50% of patients) and never had a gap of more than $40 for privately billed patients. I very rarely prescribed medication. I didn’t make a lot of money but had a very rich and rewarding career.
Not only is the evidence for the efficacy of “antidepressants” highly contentious but so is the construct that “depression” is an illness. What is the evidence? I contend that uncomfortable emotions are part of a homeostatic mechanism designed by nature to restore emotional wellbeing. The more that we pathologise emotional discomfort, the more that we teach people to avoid and fear discomfort reducing their emotional resilience. THE CURRENT PATHOLOGISING PSYCHIATRIC PARADIGM IS RESPONSIBLE FOR THE EVER-GROWING CRISIS. Once a “diagnosis” is decided, we effectively stop listening to the patient and just (ineffectively) treat the diagnosis.
My model is presented in a blog in Critical and Ethical Mental Health for anyone interested and in a longer article accessed via my website. One problem is that those of us at the coal-face, with no status or access to publication, are never consulted or listened to by the system (if not denied). Let everyone be heard without fear or favour.
Thank you for the article. I am a retired specialist (no gap) – for 30 years I was able to practice with the assistance of my primary care doctor (ieGP), the public and private hospital systems, psychology, psychiatry, workplaces, the NSW Medical Board, the PBS and family:friends. Over past 5 years my GP has continued care – management of mental illness can be extremely effective in many ways if accessible in a timely fashion- I am waiting after the round table acceptance of a referral for a review by a psychiatrist happily my GP is overseeing my management and I can afford the deposit and gap and I am not acutely ill or in crisis and I have a place to live. General Practice has been the key to my life really- the difficulties faced have been increasing for years as you ve described- and need extensive work and likely quite some time- thankyou for your efforts.
But Jackson Pollock was cheap compared to mental Health – also one can see the result
– whereas mental health is merely a piece of modern art consisting of a white wall with a hole in the centre where the politicians pour money into the hole –
Everyone is bemused because it is neither a piece of art nor is it functional.
It is Australia’s art form of cryptocurrency combined with cryptomedicine. Instead of bitcoin we have Bitmed.
Thanks Jillian, for your in-depth & Accurate Analysis of our Mental Health System Inadequacies.
Whilst you & us GPs at the Coal-face are stating the Realities, this is what Prof. Ian Hickie is stating :
“ In the primary care mental health space and many other spaces, we need people not to have to go to the GP as gatekeeper to the system, ” Professor Hickie told The Medical Republic.
“ They need to be able to get much of the care without going anywhere near a GP. ”
I find that Prof. Ian Hickie’s Statements & Claims are very Derogatory to us GPs.
I would like to know your Views on Ian Prof. Hickie’s Statement & Claims.
with a lot of Respect for you,
DR. AHAD KHAN
Thank you Jillann for an outstanding piece of writing (not that I’m surprised). I think the elephant in the room is gatekeeping. It is clear that we are no longer able to afford best practice for everyone. We may not be willing to admit it, but we can’t. If we could there would be no circumstances like ambulance ramping, or waiting months for an outpatient appointment for an acute issue, or 8 hour waits in accident and emergency, or a 9 month wait for a private bed for someone with anorexia.
My concern is who gets to decide who gets what. If we can’t afford, or don’t want to afford, best practice care to everyone, I think we have two choices.
The first is to provide best practice care to some and not others. We might do this by investing heavily in some services (eg cancer care) because of strong community support and lobby power, and less in services that are not as popular (eg incontinence care, or arthritis management). Or we can invest in certain treatments (eg buying a PET scanner) but not others (eg community social work, dental care). Or we can treat certain communities with best practice care (eg some urban centres) and not others (eg some rural and remote centres). We can do that honestly, openly and transparently, or we can do that via “nudges”. Make the services hard to navigate and complex. Have an online form you have to find, read and complete prior to access. Make the services geographically clustered in urban. Do not measure or address systemic bias, so it’s just accidental that patients who get in are more white and privileged that those who don’t.
Or we can make the politically difficult to decision to ration care for all, and gatekeep somehow. The “Karens” of the world will not be happy (sorry Karen Price). At the moment, the privileged are able to negotiate their way around the Jackson Pollock painting to have multiple services for the same thing, all covered by government investment. While many of my patients quietly give up.
Gatekeeping is currently done by the market: those who have the capacity to navigate the complexity get the services. I personally think if there is a clinical question, it should be a clinician who makes the call as to who gets what. Generalist power to gatekeep is long gone. No matter how hard I plead, grovel, clinically justify, call in favours etc etc, all of which is quite soul destroying, many of my patients are rejected by secondary and tertiary public care. They decide, essentially, that I am the right person to manage them even when I say I can’t
As a community, we have to move to “good enough care for all” or we have to invest more heavily in the sector. Saying we should “work smarter” is not helpful. We are smart people. We are working as smart as we can. Karen may not like that she doesn’t get best practice care via the public purse, but are we as a community prepared to wear her angst if it means our most vulnerable at least get affordable basics? I think we should
Having relied on my GP for MH support over the years I realize they are a front line but one which the govt doesn’t seem to fully understand from several points of view. First the benefits of their accessibility compared to other parts of the MH system. Second their ability to respond to interactions between any MI and other morbidities. Third their early intervention minimizing population entry into the ER systems. Forth the relative speed with which a patient can re-enter their form of productivity – be it employment, volunteering or domestic needs. The reimbursement by Medicare item is silly when the true effectiveness of GPs sits in clusters of items, many nuanced and not classified as a Medicare item. I would like to see a review of payment items and the better recognition of what is needed and what actually happens in the interactions between a GP and person in or cusping on an MI. PS – i am not a medico.
Jillann, what an impressive article regarding the chaotic mental health service model in Australia! I am a fan of Pro Hart and Howard Steer’s work myself, as I am partial to local art! Other than that minor difference I share with you the pain of practicing as a GP trying to provide adequate mental health services to our needy community, with significantly worse service access to my regional community’s needs. It was a pleasure to serve with you in Student Union days and I look forward to the ‘sit up and listen’ that I hope your comments will bring to the needy mentally ill in this country in all walks of life including our colleagues in the medical profession. Keep up the good work and thank you for your timely reminder to this ‘naive art’ approach to the serious issue of mental illness in our part of the world.