Patient enrolment has a part to play in rebalancing expenditure where it's most needed.
Mental health services are poorly targeted, outcomes are getting worse, and out-of-pocket payments are increasing. The new government faces a tough challenge in improving mental health.
This year marks 30 years since the first national mental health policy. The latest national mental health and suicide prevention plan is the sixth of its kind. But services are increasingly fragmented and chaotic and the number of people reporting very high psychological distress was rising even before COVID.
Medicare spending and out-of-pocket mental health-care costs are increasing but those most needing care aren’t getting it: mental health services use goes up in better-off areas where mental health-care needs are lower. A new government needs to address this mental health triple-whammy of spending, costs and areas of need.
Middle-aged women on low incomes are struggling
Very high psychological distress is rising most steeply in the middle-aged; more than doubling for women aged 55–64 (3.5% to 7.2%) from 2001–2018.
Earning less is associated with much worse mental health. When we combine gender and income, we see that of men in the highest 20% income bracket, just 0.4% have very high psychological distress. The rate of this high level of distress is 28 times greater (11.9%) for women in the lowest 20% income bracket.
So, mental health services should be targeted to people with low incomes, particularly middle-aged women. But Medicare for mental health fails any reasonable test of universality that would mean equitable delivery of mental health care for all Australians.
Rather, it follows an “inverse care law” that sees those needing the most getting the least. Often, poorer individuals in mid-life and in poorer communities – who really need psychological, allied health and psychiatric services – only get a minimal level of GP treatment, sometimes so restricted in range that it makes mental health worse.
Help is out of reach for many
This mismatch between need and services follows from a market-driven service model.
Most Commonwealth government mental health-care support is through Medicare rebates – supporting services by GPs, psychiatrists and psychologists.
Medicare rebates are for services provided by individual clinicians, rather than oriented toward team-based care. A GP can unlock additional mental health support through a “mental health treatment plan”, or a psychiatrist referral, allowing Medicare rebates for visits to psychologists or other professionals.
But here’s the rub. These visits often require out-of-pocket payments of more than A$200 per year, with only about 40% of people having all their Medicare-subsidised psychologist services bulk-billed. And these plans are only [reviewed by their GP about half the time.
So Medicare support for psychiatrists and psychologists is inequitable and poorly targeted. Essentially, both psychologists and psychiatrists are out of reach for people on low incomes.
Agree on where we’re heading
Taxpayers get better value for money when there is a closer alignment between spending and need. The first step in service redesign is agreeing on a destination.
The current expression of what the mental health system should look like, in operational terms rather than policy waffle, is the national mental health strategic planning framework. But this does not consistently guide planning and it needs revision. It should incorporate how social drivers of health, including relative disadvantage, affect community mental health-care needs.
The government also needs to decide whether it will direct more money into mental health; there was no pre-election commitment to this. Mental health needs – especially for people on low incomes – are not being met. Without extra money, redistribution of funding will be required. The current “haves” will argue vociferously against redistribution to the “have-nots”, causing political pain.
A fresh frame
Commonwealth responses to addressing mental health needs have been siloed and poorly integrated into broader health care. Labor’s pre-election Strengthening Medicare policy provides new context and the potential for a more integrated response to mental health needs.
In the next five to ten years, block payments to GPs for patients enrolled with their practice will supplement fee-for-service and performance payments. But where will mental health fit in? And what opportunities might enrolment present for improving access to integrated primary mental health care for everyone?
Enrolment-based funding will need to be risk-adjusted, with higher payments for patients with greater needs. Mental health status should be calculated as a health factor in the new formula. Then, general practices caring and supporting more people living with mental illness would attract higher funding.
Risk-adjustment also should be higher for people with social or economic drivers of poor mental health, such as unemployment. Then we need to figure out what services and support GPs would provide for the new enrolment payments.
A low payment, implying few extra services, would not drive the significant transformations needed in mental health-care provision. A higher payment, perhaps phased in, could help reshape mental health care. Existing funding for mental health-care plans could be collapsed into the enrolment payment. So could the cost of a psychologist and other services which these plans unlock.
A new funding model
Funding should allow allied health professional such as social workers and occupational therapists to use their discipline-specific skills. GPs would be able to employ psychologists and other providers directly or subcontract them. Primary health networks might also have a role here in accrediting services or developing service networks with GPs.
A new funding model, involving funding weighted for those in greatest need, and more closely integrated into general practice, could transform access to mental health services. It would be more equitable and seamless, leading to higher quality care for the same cost.
Stephen Duckett, Honorary Enterprise Professor, School of Population and Global Health, and Department of General Practice, University of Melbourne
Graham Meadows, Professor of Adult Psychiatry, Monash University