helping people find their way

Third Party Payments, Psychological Services, Medicine, and Evidence-based Practice

Medicare Rebates for Psychologists

Since the introduction of Medicare rebates for psychologists in 2006 there has been an explosion in Medicare funded, privately operated psychological services in the community.  Whilst there has been a corresponding increase in community awareness of the availability of government subsidies for these services this has not been matched by similar community awareness about the nature of what these privately provided services are intended to target. Increasingly, the general community has come to regard them as subsidies for any issue one might want to seek a psychological service for. Whilst in the past the government looked after its mentally and emotionally impaired constituents primarily through a government provided infrastructure in the form of health and mental health services based in publicly funded hospitals and community health centres, the government of the day shifted the funding model from one of a primarily publicly provided infrastructure to a significantly privately operated one. Essentially, this was a way to try to save money for the public purse, similar to the introduction of private health fund incentives by the same government in 2000.

What this means is that third party interests have been introduced into what used to be a privately negotiated professional contract between two parties. Many privately operated psychological services now have at least 4 interested parties: Apart from the practitioner and client, there is now also the referring medical practitioner and the government in the form of Medicare. Further indirect stakeholders that have become more prominent through the involvement of medical practitioners and the government are the pharmaceutical industry and university based or pharmaceutically sponsored researchers. Along with professional associations these researchers work on and determine the ‘evidence base’ for these services. This ‘evidence-base’ is used by the government as the basis for deciding which models of practice providers should utilise for the services, which are funded or subsidised by the taxpayer. This has some significant background implications, which potentially affects the relationship between the practitioner and client. Whilst in Australia we are only at the beginning of these developments there is significant experience with such ‘Managed Care’ in the US

Restrictions to Services

Third party reimbursement schemes for health services usually have one main issue to contend with: They tend to be bottomless pits. Hence the need arises to restrict access to them. The way this has been achieved with the Better Access to Mental Health Care scheme is by restricting 4 aspects of such services:

  1. The target group to people with a medically diagnosed mental illness.
  2. The number of eligible sessions available for any one recipient during a specified time frame.
  3. The type of eligible practitioner.
  4. The model of practice provided to the client.

The community does generally not have much awareness of the nature of these restrictions or their implications for the services provided as the emphasis tends to lie on the reimbursement of costs.
This article is written in an attempt to explain these implications and why some practitioners are not comfortable with them.

Practical Implications

What third party reimbursements mean in a practical way for recipients of psychological services is that:
1.    The gatekeeper for such services is usually the medical profession in the form of required medical diagnoses. This means that you are required to have a medically certified mental illness, which remains on your health record and can have consequences for your life, especially with regard to insurance issues.
Your confidentiality may be compromised due to reporting requirements, primarily to GP’s. As national electronic medical records, which can be accessed from multiple points, have recently been introduced in Australia, this has increasing implications for recipients of health services.
Health records may be requested from third parties, such as insurance companies. Whilst such requests require your consent, the fact remains that psychological services for a mental illness cannot be erased from such records and this may have implications that many people receiving Medicare funded psychological services are not aware of.
As a result of the gatekeeping function by the medical profession you are more likely to receive drug treatments, which you may or may not need or feel comfortable with. The significant vested interests of pharmaceutical companies and the research conducted and funded by them, either directly or indirectly, to support such medically oriented views, has been widely documented (on this link see particularly Daniel Carlat Blog, Psychology Today, and CriticalThinkRx;  and also Wampold, Duncan & Miller 2010).
2.    There is a strong emphasis on and bias towards time-limited, short-term models and services in order to contain costs. This may not be what you need or want.
3.    There is less choice in the therapist you are able to see as currently only psychiatrists, psychologists, GP’s , and appropriately trained social workers, and occupational therapists are able to provide psychological services under Medicare. This excludes a range of other competent professionals with experience and expertise in the field, such as counsellors and psychotherapists. Incidentally, this situation has also started a divisive inter-professional turf war in the fight for a piece of the government funded pie.
4.    You may not be able to access the model of practice you are interested in, feel most comfortable with, or that is suited to your personality, history, circumstances, or expectations. This is due to stipulations and restrictions, which are biased towards short-term, low cost treatments, which are selectively chosen out of a range of models with documented evidence. It reflects a significant bias towards financial considerations, either in the form of cost savings or profits for the stakeholders involved. Furthermore, the focus on ‘therapeutic modalities’ reflects a medical bias which emphasises the provision of specific ‘treatments’ for defined ‘disorders’ analogous to the provision of drug treatments for physical conditions. This is an approach that is being questioned with regard to its appropriateness in relation to psychological services as other ways of conceptualising this work have become more prominent and supported by evidence, eg. the important role of the individudal practitioner [Wampold, Duncan & Miller 2010; Wampold 2001].

There are psychological implications of having someone else pay for this work, especially given that third party payers don’t necessarily have your interests at heart, and, as a result of their focus on financial considerations, in fact frequently have interests diametrically opposed to our own. Being in control of the process is a significant issue to be considered here as there are potential implications of starting a process, which may not be able to be brought to a satisfactory close due to the restrictions in the number of subsidised sessions. Determining how many sessions are required can be hard to identify at the outset. Another issue impacting on your sense of control over the process is to do with the possibility of the third party payer suddenly changing the rules. This has happened recently (November 2011) when the government decided to cut back on the number of eligible sessions, which had significant implications for consumers and practitioners alike.

My Approach

I don’t regard the services that I provide as medical ones, or even as primarily therapeutically oriented. My work concentrates on issues of living and helping people find their way by collaboratively addressing the questions and issues that really matter to them. Essentially, this is an inquiry into the nature of lived experience. There is a strong emphasis on gaining greater awareness of the internal and interpersonal processes, which drive and motivate our behaviours, actions, and interactions with others, which in turn create our emotional life experiences.  Having said this, we often get pushed into considering these issues more seriously and urgently when difficulties arise in our lives. However, many of these difficulties in living have become appropriated by a medical discourse, which has turned them into ‘diseases’ that can be treated with specific expert medical interventions analogous to medical treatments for physical conditions. Many mental health practitioners are unhappy with the appropriation and association of the medical model with psychological services, primarily because there are a number of important differences between them [Wampold 2001].
True to the meaning of ‘psycho-therapist’ I regard the work that I do as ‘attending to souls’. This tends to focus on developing a deeper relationship with ourselves, others, and life itself through the cultivation of awareness and in particular self-awareness as this is the crucial factor that enables us to change unhelpful, and sometimes destructive behavioural and relational patterns, which are often operating outside of our conscious awareness. This is not something that most third party payers value or prioritise, and consequently would want to support financially.
For these reasons I prefer to work outside of third party payment structures.

References:
Wampold B., Duncan B., Miller S. (2010, 2nd ed.). The heart and soul of change. Delivering what works in therapy. Washington: American Psychological Association

Wampold B (2001). The great psychotherapy debate. Models, methods, and findings. Mahwah, NJ: Laurence Erlbaum Associates, Inc.