Download Counselling and psychological care Medicare bulk payment option

Counselling and psychological care
Medicare bulk payment option
As part of its work on redress, the Royal Commission has identified that survivors of child sexual
abuse may require access to life-long counselling and psychological care that recognises the episodic
nature of their needs, as well as flexibility and choice in terms of both the nature of therapeutic
interventions provided and the mode of service delivery. There are a range of existing government
and non-government generalist and specialised organisations which provide services that are of
benefit to survivors of child sexual abuse. However, these services are not available in all locations
(especially regional and remote areas), often have long waiting lists for access, and may not meet
the needs of survivors who prefer to access services in the private market. The Royal Commission is
of the view that these services should continue to be supported as primary providers. However,
there is a need for better universal access to evidence-based psychological interventions for
survivors of child sexual abuse. Using existing service delivery channels provided through Medicare
but funded by the institutions responsible for abuse could be administratively simpler and more cost
effective then setting up a new service delivery channel, and would give survivors a level of certainty
as to the availability of ongoing services.
Currently, Medicare benefits are available for psychological treatment by registered psychologists
and other approved providers under a range of Australian Government initiatives for people in
certain situations, such as those with an assessed mental health disorder; children up to 15 years of
age with autism spectrum disorders; children up to 15 years of age with a range of other disorders
such as sight or hearing impairment and cerebral palsy; women concerned about pregnancy and
people with chronic health conditions.
Of these, the initiative most relevant to adult survivors of child sexual abuse is the Better Access to
Mental Health Care initiative for people with an assessed mental health disorder. To be eligible,
patients must be referred by their GP, or sometimes by a psychiatrist or paediatrician. The GP needs
to complete a detailed mental health assessment and prepare a Mental Health Treatment Plan
before referring the person to an approved provider. Up to 10 individual (with a review by the GP
after six sessions) and 10 group sessions (where services are available and appropriate) are available
per calendar year. The sessions are free if the provider bulk bills, otherwise the patient is required to
pay the gap between the scheduled Medicare fee and the fee charged by the provider.
Survivors of child sexual abuse often have complex needs and require access to psychological
services on an episodic basis throughout their life. While individual needs will vary, some survivors
will need intense support. It can also take a long time for survivors of child sexual assault to build
trust and rapport with a therapist. As such, the current Medicare entitlement to 10 sessions under
the Better Access initiative is unlikely to be adequate to meet the needs of survivors of child sexual
abuse. In addition, the need for a clinical diagnosis for referral is likely to be a significant barrier to
access. Apart from the emotional difficulty of telling their story to a GP, many survivors will not be
able to articulate the impact the abuse may be having on their lives in a 15 minute session with a GP.
While many survivors will present with a range of symptoms consistent with a mental health
disorder such as anxiety, depression or PTSD, they may not necessarily meet the clinical criteria for
diagnosis and eligibility for referral under the current Better Access Initiative. In addition, not all
registered psychologists, mental health trained social workers and occupational therapists
accredited to provide services under Medicare will have the required competencies for working with
survivors of child sexual abuse. This may mean the therapy is not effective, or at worst, might cause
further harm.
The Royal Commission proposes to explore a new initiative to access ‘evidence-based psychological
interventions’1 through the Medicare system which better meets the needs of survivors of child
sexual abuse as follows:
Services: Life-long access to uncapped sessions (subject to assessment and review as discussed
below) with approved providers (who currently may be registered psychologists and some mental
health trained social workers and occupational therapists) on the Australian Psychological Society
(APS) list of clinicians who have undertaken a capability assessment to work with survivors of child
sexual abuse (see service providers below). Services provided would be based on the best available
evidence (see for example the ASCA Practice Guidelines for Treatment of Complex Trauma and
Trauma Informed Care and Service Delivery).
Eligibility: Any person whose claim is accepted by the redress scheme recommended by the Royal
Commission would be eligible for counselling under the scheme. There would be no requirement for
a mental health plan or referral from a GP or anyone else. The need for evidence-based counselling
and psychological care for this group is clear. While this group may present with a range of
psychological symptoms such as depression or anxiety, they do not always clearly fit the diagnostic
criteria for a psychological disorder under DSM-V. They may also have trouble articulating their
needs and issues in the relatively short time available for consultations with a GP.
Assessment and review: While the services should not be capped at a particular number per year,
for each ‘episode’ in a survivor’s life where counselling is required, there should be an initial and
ongoing assessment of need to ensure services are appropriately targeted. This process will need to
be sensitive of the unique needs of survivors (for example, the Better Access model of assessment
by a GP would not be appropriate as GPs do not necessarily have the competencies to undertake
this task). The Royal Commission is yet to develop a view on the mechanism to enable this
assessment and review, but envisions a process of initial assessment and development of a
treatment/care plan which indicates an estimate number of sessions that would be required for a
particular episode, and a built in review process to assess progress. Justification would need to be
made for further sessions, and if the therapy is not successful, alternative treatment/support
options should be considered.
Fees: A separate MBS item number would be allocated for evidence-based psychological
interventions provided to survivors whose applications are accepted by the redress scheme, with
higher rebates than general psychological services to account for the requirement that no gap fee be
charged on the item number.
The item number would be required to be “bulk-billed” by the service provider, that is, the Medicare
rebate should be accepted as the full fee and there should be no out of pocket expenses for the
individual.
Service providers: Treatment for survivors of child sexual assault requires particular capabilities
which are not part of standard training for all providers under the current Better Access Scheme. As
such, not all clinicians would have the framework to provide appropriate treatment for this group.
Services by untrained clinicians may cause further harm. To ensure services are provided by
appropriately skilled practitioners with expertise in dealing with adult survivors of child sexual abuse,
1
The Royal Commission has adopted this terminology as it currently applies to the Better Access initiative.
Discussions would need to occur to determine, in practice, what services this would include.
Medicare-funded services would be provided only by Better Access providers who have undergone a
capability assessment through the APS.
The assessment provided by the APS would need to consider the capabilities of psychologists to
deliver evidence-based psychological interventions to:
 Adult and child survivors of child sexual abuse, both female and male;
 Indigenous adult and child survivors of child sexual abuse;
 Adult and child survivors with disabilities, and
 Adult and child survivors of child sexual abuse who are from culturally and linguistically
diverse communities.
The APS currently provides capability assessments for psychologists under the child ATAPS scheme,
and the Children with Autism and other Pervasive Developmental Disorder (PDD) initiative, as well as
for eligibility to provide the pregnancy support counselling items. The APS also assessed eligibility for
delivery of the psychological therapy Medicare items from 2006 to 2010 until the commencement of
National Registration. The APS has indicated it would be willing to also undertake this role for a
counselling scheme put in place for survivors of child sexual abuse, in consultation with relevant
stakeholders and peak bodies such as specialist sexual assault service providers. The APS would
maintain a publicly available list of appropriately skilled clinicians (as it does now for approved
providers for the Autism and PDD initiative).
To enable flexibility and choice for survivors, exemptions should be provided under s19(2) of the
Health Insurance Act 1973 to enable specialist sexual assault services who may also receive funding
from Governments to claim Medicare rebates for providing psychological care to survivors of child
sexual abuse. This would be similar to arrangements put in place for Aboriginal Community
Controlled Health Services and some remote State/Territory Government health clinics such that the
Better Access Medicare items can be claimed for evidence-based services provided by eligible allied
health professionals salaried by, or contracted to, the service as long as other requirements like
accreditation with Medicare and capability assessments through the APS are met.
Funding: There are two options for how this model could be funded. Given the unique needs of
survivors, and the various precedents for providing special access to counselling through Medicare
for special groups (e.g. children with autism, people with chronic health conditions, women
concerned about pregnancy etc.) a policy case can be made that this should be publicly funded
through Medicare. The Royal Commission is of the view that a policy case for special consideration
of the needs of survivors of child sexual abuse in institutions has already been acknowledged with
the establishment of the Royal Commission. This would also be the most administratively simple
option.
The second option is for funding to be provided by the institutions participating in the redress
scheme. A bulk payment arrangement would be negotiated such that the redress scheme pays
Medicare an agreed rate per survivor who is accepted by the redress scheme for future services to
be provided by Medicare (the Royal Commission acknowledges this would require legislative
amendments). Similar arrangements are currently in place for services provided in the past under
the Health and Other Services (Compensation) Act 1995. Actuarial analysis would be undertaken to
ensure an appropriate level of payment per survivor to enable a sustainable funding source for
Medicare to provide ongoing services.