The number of people needing care is growing, but there is still no real incentive for GPs to upskill in the topic.
Almost everything we know about mental health consults in Australia could be wrong.
How many patients there are, how many GPs are skilled in managing it and whether those skills are appropriate for the patient base – all are on relatively shaky ground.
Unsurprisingly, it all comes down to money.
According to an independent report commissioned by the General Practice Mental Health Standards Collaboration (GPMHSC), GPs only bill a mental health-specific MBS item number for a mental health consult one-third of the time.
Meanwhile, official figures claim 80% of MBS-subsidised mental health care is delivered by GPs.
If accurate, the data from the GPMHSC report would mean GPs deliver far more mental health care, and far more patients are seeking it, than is reflected in MBS statistics.
Given that an MBS mental health item number 2713 pays slightly less than a Level C consult of approximately the same length, many GPs choose to bill a time-based general consult item instead.
Only 9% of the 846 GPs interviewed for the research reported being able to earn a suitable financial return from treating people with mental health issues.
“I earn three times as much per minute if I do flu vaccines than if I see a complicated mental health patient,” Clinical Associate Professor Louise Stone, a GP with special interest in mental health, told The Medical Republic.
The GPMHSC, which is led by a committee of representatives from the RACGP, ACRRM, RANZCP, the Australian Psychological Society and Mental Health Australia, manages standards for GP training in mental health.
Under the Better Access initiative, GPs with the base level of GPMHSC accreditation can claim a higher MBS fee for preparing a mental health care plan than a GP with no training.
While nine in 10 Australian GPs have completed the basic level 1 mental health training with GPMHSC, just 3.5% have undertaken the level 2 focused psychological strategies skills training and registered as a focused psychological strategies provider.
Professor Stone, who is involved in training other doctors in both level 1 and 2 GPMHSC standards, says that sometimes the additional training can have the unintended consequence of depriving patients of the opportunity to see a psychologist at a subsidised rate.
“One of the biggest problems is that if you use the item numbers that are open to you in Level 2, you remove options to see a psychologist,” she said.
“If I bill for focused psychological strategies three times, and there’s a total of 10 available to the patient, they can only get seven from the psychologist.
“The more work I do, the less the psychologist can do.”
Given that the patient rebate for these item numbers is already relatively low and actually using them can negatively affect the patient’s access to care, Professor Stone believes that many eligible doctors simply forgo the additional training.
“There’s a gross underestimate of the number of people doing that level of work, because a level 2 qualification does not pick up a lot of doctors who are already doing it,” she said.
When you have a master’s in psychotherapy, family therapy, psychotherapy or psychiatry already, Dr Stone pointed out, why would you do a 20-hour course?
Issues with the way mental health care translates to the MBS don’t stop there.
University of Sydney mental health policy researcher Dr Sebastian Rosenberg told TMR that the Better Access program – which is what mental health care plans and the like fall under – was not necessarily set up for the type of patients which now access it.
“When I read about the way this program is supposed to work … it’s meant to be for people with mild to moderate mental health problems that would benefit from the short-term interventions of cognitive behavioural therapy – which is, I understand, where the evidence for cognitive behavioural therapy is strongest,” he said.
“What instead you’re finding, particularly with repeat customers coming back to the Better Access program, is it may well be that people are using Better Access who were never intended to be the original customers.”
These are people who need prolonged assistance, have more complex problems or comorbidities and are really in need of multidisciplinary care.
“For a young person with an eating disorder, just going to see a psychologist over and over again might be helpful, but probably what they will need is additional support from a dietician, a nurse, a GP, potentially a psychiatrist, or psychologist, maybe allied health, in terms of keeping them in contact with their schooling, or their employment, and so on,” Dr Rosenberg said.
“You’re really talking about the need to respond to complexity with a multidisciplinary team rather than just permitting the same client to see the same health professional 10, 20 times ad infinitum.”
Both Dr Rosenberg and Professor Stone are calling for major reform to the way data on mental health care is recorded, as well as greater collaboration within the industry.
The GPMHSC report recommended “urgent and serious” action on mental health, including righting the economic inequality between mental health and other presentations so that there is no financial disadvantage for GPs to do mental health consults.
