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10 Jul 2017

What is the role that Commonwealth and State governments envision for our private practice specialty? The federal AMA and a number of the individuals in the AMAPG have attempted to discuss the issue of the role of private psychiatry in current mental health reforms. Unfortunately, we have had very little traction in doing so. This seems to mirror the difficulty that our own College of psychiatrists appears to be having in finding traction in mental health policy development generally.

The recent budget announcement saw an end to the Medicare rebate freeze. This does not apply to psychiatry for another two years. The consequence of that, given that many of our patients are not well-off financially, will be that many more people will be excluded from accessing psychiatrist services, there will be a greater load on the public sector, and patients may well limit how often they see a psychiatrist in order that they can manage their own financial budgets. This can lead to inadequate care for their conditions. Whilst it was a win for the AMA in negotiating a schedule for the ending of the freeze, no allowance appears to have been made for level of disadvantage for different specialty patient groups.

Although the Minister, Mr Greg Hunt, announced when he took over the role from Minister Ley, that he would set mental health as a high priority, this did not seem to play out in the last federal budget. A number of new initiatives and elements of spending were announced, but when one looks at the actual amount of funds committed, the total is very small indeed. The Minister's heart may well be in the area of mental health, but his financing of our sector seems quite limited still.

Primary Healthcare Networks

The Minister has emphasised the delivery of mental health care in the community through the Primary Healthcare Networks. Many of us in the AMAPG, and a number of colleagues in the College of psychiatrists, have been trying to determine how the PHNs will interact with both public and private psychiatry. So far, we do not have any clear idea about how this will occur. The Federal Government steering committee which is developing the policy for mental health in PHNs does not contain a specific representative from private psychiatry, even though the private psychiatrist sector treats just as many people as are treated by the specialist public sector mental health services. It is therefore difficult to imagine that PHNs will seamlessly interact with our sector.

A number of us have had discussions with individual PHNs, and such discussions indicate that the type of mental health services and interactions with different specialist sector groups can vary hugely between different PHN localities. We feel that there is a high likelihood of extreme further fragmentation of the mental health sector, and a decrease in access to services overall as a result. One has to wonder whether the extra money being provided to PHNs may in fact be an almost complete waste of money.

Access Problems for GPs

At the last AMA Federal Council meeting and National Conference I met with a number of general practitioners who I have known for many years, and who have very high referral standards, and a good capacity for dealing with mental health patients. They complained to me quite bitterly that they were not able to obtain referrals to psychiatrists for many of their mental health patients, either for services in the public or the private sector. This is a very serious state of affairs, and appears to be an escalation of the difficulties that general practitioners have faced in obtaining access to services in the past. I have been trying to work out why this has occurred, and why it should be coming to a head right now.

There are many different players in the mental health sector, and now there is quite a strong component of community-based services alleging to provide treatment services to mental health patients. I suspect that one element in the pressure for obtaining psychiatric services is that much of the resourcing and change in mental health care delivery in recent years has been focused on the primary sector. There has therefore been a huge increase in case identification, and therefore many more of the “unmet need” mental health group have been identified. If resources and assistance is not provided to psychiatrists in public or private for delivery of adequate treatment for such cases, then access problems and mounting frustration is likely to escalate. I suggested to my GP colleagues that they lobby for more assistance for private and public psychiatrists in carrying out our treatment work with increasingly complex patients.

Psychiatrists in private practice cannot by themselves fill the gaps left by community-based mental health services and the public sector. There is a need for private psychiatrists to be facilitated and adequately remunerated for providing services to complex mental health care cases, with, and without Private Hospital Insurance. It is very difficult to find other Allied Healthcare practitioners in the community who are appropriate partners for us to work with, to help us leverage our expertise to a wider group of patients. The mental health space has become so fragmented, that it is very difficult to see who amongst the allied health practitioners we are able to adequately and safely collaborate with. That would seem to be a major area needing to be addressed in the National Mental Health Plan. 

Medicare Item Number Review

The College has been told that the Medicare item number review will now be postponed to later this year, or possibly even early next year. Many people have said to me that we should not expect really helpful changes in the Medicare item review of mental health items. We should not expect either that there will be great disadvantage from the review. The fact that private psychiatrists’ remuneration is based on allocated time face-to-face with patients means that there is little room for gaming of the system, and accountability through the patient is easy. We therefore are unlikely to be a target for difficult reforms, but nevertheless we are being cautious in our approach. 

Adverse “Hidden Rules” in Private Hospital Insurance

A number of private psychiatrists have been concerned about the so-called hidden rules of private health insurance. These have largely amounted to rules which are applied through hospital contracts about length of stay and readmission. One fund has introduced a 28 day rule where people admitted before the end of 28 days after their last admission will enter whatever step down phase they are in from the previous admission. Similar rules are being introduced by other funds which may last 14 days. These rules our replacing the previously accepted seven-day rule, where patients admitted before the end of seven days post their last admission are rebated at the step-down phase that they ended that admission with.

These hidden rules and are not made apparent to the patient and are meant to be kept secret by the hospital. The hospital is meant to accept the terms of the contract, even if they have very little choice in the matter because members from that health fund provide a large part of the admissions to that hospital. Private psychiatrists often notice the difficulty when it is problematic obtaining admission for patients to private hospital, even though there is a perception that beds should be available. A number of AMAPG members have actually approached the Federal Health Minister's office concerning this problem. We are not convinced that the difficulties created by these rules that have no association with any clinical meaning have been heard adequately by the Minister. We will continue to advocate for our patients in this area. We would also appreciate psychiatrists experiencing similar difficulties in different parts of Australia in terms of private health insurance to get in touch with the IMA secretariat or members of the AMAPG known to them.

Published: 10 Jul 2017