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Changes in Australia Psychiatry: For better or worse?
DR GIL. M . ANAF
National Association of Practising Psychiatrists,
PO Box 12,
Arncliffe, NSW 2205, Australia.
Tel: 61+ 8+ 8 364 5357
Fax: 61+8+ 8 364 1621
© Psychiatry On-Line, 1997
Version 1.0, Published April 1997
This article aims to familiarise the reader with the enormous changes currently occurring in the delivery of psychiatric services in Australia, and the apparent reasons which lie behind them. I believe this has implications for the future of health care in Australia as we know it . The changes described below are aimed, I feel, at setting a precedent which will be difficult to reverse if not vigorously opposed and protested against - a precedent which can then be gradually applied to the entire medical system.
The Federal Government, in delivering its first Budget in August, let it be known that as of November 1st, medical rebates for those patients receiving intensive psychiatric treatment would be cut by 50% after a prescribed limit. There was no discussion beforehand with any of the relevant organisations such as the AMA or the College of Psychiatrists. Further, these measures were described as being related to the need for all sectors of the community to bear the cost of reducing the black holes, and were aimed at bringing about structural reform into the practice of psychiatry by providing price signals to doctors and their patients.
In attempting to understand the agenda behind this political jargon, the impact on patients can all too easily be overlooked. The effect of these changes will be that financially disadvantaged patients will be unable to have intensive psychotherapy, thus introducing a problem of equity of access to health care. Patients already having this treatment will have to drastically curtail it, as most cannot afford the fees involved without subsidy. By effectively saying patients can't have, or continue, a prescribed treatment (and here we are talking about a specific treatment, not counselling), the Government has shown itself willing to interfere in standards of care. In short, the proposals discriminate against a vulnerable group of patients in an unprecedented way.
We should be clear as to the nature of the illnesses this group of patients live with. Here we are referring to a group of patients who have often failed with other less arduous treatment regimes. These people suffer from eating disorders, major depressive disorders, panic attacks or severe personality disturbances - and often suffer from a combination of these. These are patients like Liz, a woman in her late 30ís who suffered an assault at work which then unleashed memories of emotional and sexual abuse as a child, leading to severe depression and suicidal feelings. Or Julie, in her 40ís, who every day has to struggle to clear her mind from the confusion that reigns within her mind, a confusion so severe that she is never sure that anyone can be trusted, or that her own perceptions can ..
It is these reports that seem to me to be influencing policy making, and it is these reports that contain the ideas that will transform medical practice and patient care in the future - transform it from a system that admittedly has funding problems but has reasonably high standards and expertise to a system of managed care whereby we imitate a failing American model where cost is everything and patient welfare comes second. A system where privatisation allows insurers to dictate the amount of treatment a patient can have, not the doctor and their patient, yet which paradoxically costs the US 14% of its GDP as compared to our system which costs 8%.
In defence of his policy Dr Wooldridge, the Federal Minister of Health in Australia, cited the US where only six sessions are rebated. He further goes on to admit that this is not primarily a cost-cutting exercise - apparently this is about increasing access to psychiatrists for severely ill patients. This policy would imply that the patients I described above are not seriously ill. They can have half a treatment so someone else can have half a treatment too - but no one gets a full treatment. Further, the Minister claims that if these patients are seriously ill, then they are likely to be in-patients: it seems now that people will only be deemed to be really sick if they are seen to be sick, an odd view when we are talking about mental illness.
This curious kind of thinking is seen more starkly when the Minister sent a reply to a local MP in June 96, prior to the Budget. A patient had written to her MP asking if rumours of changes to rebates for psychotherapy were true. The MP forwarded the letter to Dr Wooldridge, who duly sent his response. He stated categorically that the Government's commitment to maintaining Medicare in its entirety was quite clear. The MP then reassured the patient, who has understandably been bewildered since. The assertion that Medicare has been entirely maintained has been restated openly in parliament (Sept. 96) - an assertion which goes completely unchallenged. 50 sessions per year is not the same for this patient as the treatment she lost - Medicare has not been retained in its entirety.
And lastly to the reports mentioned above. At the outset it should be noted that both reports were available to professional bodies some considerable time after the health bureaucrats had them, presumably to reduce the chances of criticism. The SBE report was severely criticised by the Research Committee of the College of Psychiatrists for using such flawed statistics as to make its conclusions unreliable. Conclusions such as 'only 45%-54% of Australians with serious mental illness are receiving treatment by private psychiatrists' and 'there is ... considerable need for private psychiatrists to spend more time treating [these] people'.
The bulk of this report is built again on two apparently flawed concepts: (a) the concept of a large unmet need, and (b) the concept of serious mental illness. The latter is unfortunately a term which is now in regular use among bureaucrats, but was originally a term lifted directly from US discussion about US health policy and which we would be interested in US based doctors commenting on.
In 1994, the Victorian Branch of Psychiatrists Newsletter issued a detailed response severely criticising the SBE report. Critical articles were published in the Australasian Psychiatry magazine. In fact they found, inter alia, that private psychiatry dealt with roughly double the number of patients claimed by the SBE report. That there was a large unmet need was now openly questioned given the discrepancy in the figures. Even the notion of putting a limit on available sessions was foreshadowed as a possible option in the SBE report, and argued against in these articles.
The McKay report, just recently released, builds on the same themes by leaning heavily on the SBE report and its figures - as if the objections to the latter never happened. It even cites consumer dissatisfaction as justification - but it's only when you read Vol. I of this that you find the former is based on an arguably biased structured interview of 100 patients who are to represent the entire country. Not that all of their complaints should be dismissed. Access to services is a real problem, but not one which will be solved by disenfranchising particular patient groups. Rather it's the use made of these complaints by the report that is at issue, as it seeks to use this as justification for radically altering our health system.
These recommendations include reducing the incentive for psychiatrists to treat patients directly and encouraging them to be more consultancy oriented; in short, they ought to tell others how to treat patients so that it becomes cost-effective (note the lack of mention of concern for patients). Further, the report envisages the formation of associations of psychiatry i.e.: psychiatrists will be asked to form groups with allied health staff - and from there it is easy to imagine that it's but a short step to dictating funding measures and overall reductions prior to allowing private insurers to take over the Government's role.
And yet, as I understand it, in America the shift to managed care (that's what it's really about) was brought about first by attacking psychoanalysis, then extending this to private psychiatry, and then to the entire medical system. This has left Americans with an appalling system where the expectation of treatment cannot be relied upon (an insurance company decides if its OK for you to be treated, and in which way), and a large underclass get little if any treatment - a system they are trying to be rid of.
To say that health costs are rising and therefore some people should just do without (an opinion I heard this week) misses the point. Real people are really suffering and the bureaucrats don't understand that the way we are heading will increase people's suffering. Fundamentally it raises issues about the kind of society we want to live in - if there is a shortage of money how can we redistribute it to maintain our system rather than destroy it? Do we really want to ape another country's mistakes as if we have no identity of our own?
Equally one could wonder why Dr Wooldridge makes so much of American funding strategies while ignoring other international strategies. Germany and Canada both provide universal access to psychoanalysis and intensive psychotherapy - and there the research demonstrates enormous long term economic advantages because it actually reduces health costs by reducing the need for medication, hospital visits and absenteeism. Perhaps these facts don't suit Dr Wooldridge's policy aims ?
As a recent editorial comment in the Melbourne Age , a Melbourne Newspaper, (14/10/96) put it: it. Every member of society is entitled to fair access to the health system for the treatment regime that for them is most therapeutically appropriate. Is it too much to ask that a supposedly universal health insurance system not exclude those whose situation warrants more intensive therapies? To which one might add, is it not naive and short sighted to think that a society which is ageing and increasingly stressful will not require increased medical input ? Psychiatry in this respect is no different to general medicine.
These are the wider questions that surround the introduction of managed care into our country, a concept which is being insidiously introduced by creating such chaos in our current system that the Government will eventually be obliged to introduce ìreformsî. It is a concept which I feel lies behind the current trial of coordinated care in South Australia: co-ordinated care is managed care by another name, as Sen Graham Richardson pointed out. A US health insurance organisation is assisting with this trial.
It is a concept which lies behind the Health Funds push to ask for the introduction of a managed care system, and which lies behind their push to be absolved from having to provide private cover for psychiatric inpatient treatment. It also seemingly lies behind their request to be able to have access to patient's private records, ostensibly to check that their claims are legitimate - but one could argue that this could easily lead to vetting and the refusal to insure expensive treatments.
It is a concept we should vigorously oppose before it is too late.
DR GIL. M . ANAF
President, National Association of Practising Psychiatrists,
PO Box 12
Arncliffe NSW 2205
Tel: 61+ 8+ 8 364 5357
Fax: 61+8+ 8 364 1621