Letter to my Member of Parliament
Elaine Hosie on Medicare
30th March, 2008
The Right Hon. Nicola Roxon, MHR
Minister of Health
Dear Ms Roxon,
I have been a service provider for Medicare since November 2006. From the start, I was struck by the inefficiency of the system, and the way its duplications and inconsistencies must make it far more expensive to run than is necessary. Since it has been announced that you are reviewing Medicare, I would like to contribute suggestions based on my limited contact with it.
Currently, a service provider needs to have a unique provider number for each location. A Registrar training for admission to the College of General Practitioners needs 6-monthly placements in different practices. This means that a new number needs to be issued for each change. Similarly, a service provider working at different addresses needs several numbers.
This means that there are many more provider numbers than needed, which has costs. Costs to the taxpayer include:
There are also costs and annoyances for the service providers.
Currently, there are three ways of claiming a Medicare rebate. All three have their disadvantages. A single system, combining the best features of the existing ones, would save significant costs of administration. The three systems are:
a) Payment to patient
The service provider charges a fee that may be any amount, receives payment from the patient, and issues a suitably detailed receipt. The patient presents the receipt to Medicare and receives the rebate.
The main disadvantage of this system is that the patient needs to pay up front. Even if the fee were no more than the rebate, this would cause hardship for some people. Before I obtained bulk billing forms, some clients were unable to access my services for financial reasons, although they desperately wanted help.
Further, in the event of a refusal to pay by Medicare, something that is quite frequent, the patient is left with the cost of the service. Many people are ignorant regarding the workings of the bureaucracy, and do not know how to proceed in such a situation. The refusal may be because of some mistake made by the service provider, and yet the patient is left without the rebate. Often, the refusal to pay is because of a minor administrative matter, or the error of the clerk handling the claim, and can easily be sorted out -- if approached according to the rules. So, this becomes easy for a service provider, but likely to be overwhelming for a typical patient.
b) Cheque to service provider
Current procedure is that the cheque is sent to the patient, who then needs to forward it to the service provider. The reason for this is understandable, in that it is a safety measure to minimise fraud.
However, the procedure is very vulnerable to error. Patients often live in disorganised and stressful circumstances. Some may be dishonest, or merely forgetful. They may even change addresses immediately after treatment. Therefore, a proportion of these payments is never handed over to the service provider. Since delay is likely because of the multiple handling, the service provider may not be able to follow up a nonpayment in a timely fashion.
c) Bulk billing
In this system, the patient pays nothing. The service provider sends proof of the service to Medicare, and receives a payment.
This is the most reliable of the three options. However, because no excess fee can be charged, it may simply be financially unviable for many service providers, except when dealing with cases of hardship.
My suggestion therefore is that the bulk billing methodology be retained, and the other two discontinued. However, the prohibition against charging an additional fee should be removed. That is, the patient signs a Medicare form, and pays whatever additional fee is charged (from $0 up). Medicare then pays the rebate directly to the service provider.
This simplification will benefit everyone: cheaper and easier administration for Medicare, fewer problems for the service provider, and a simple, automatic process for the patient.
There are a number of other minor but annoying features of the system that could use improvement, and this would result in small savings per item that will cumulate over time. For example, the header form for bulk billing requires the service provider's signature to be witnessed. This provides no security from anything, it is just another impediment for the service provider, and either it is ignored at the other end, or uses up some administrative time.
My particular experience is as a provider of psychological services, and my further suggestions are limited to this area.
There is considerable research evidence (list can be supplied) that psychological therapy, particularly if used as an early intervention, will save money for the community in many ways, for example:
Thus, money spent on facilitating access to psychological therapy is an investment that will pay high returns. However, there is an inevitable time lag. When you gained your office, you made a firm statement that prevention of health problems would be your preferred action. This is highly commendable. Continuing to fund psychological interventions is a necessary part of such a strategy, and this goes beyond Medicare rebates for psychological therapy. Generally, psychologists of all specialties have a lot to offer in changing society into one that is kinder, more cooperative, less inherently stressful -- and therefore needing less investment in health services.
Some GPs may have attended a six-hour course on diagnosing depression. Basic medical training has a very small component on psychological medicine. In contrast, the freshest graduate psychologist with full registration will have had a minimum of 6 years of training in psychology, and 2 years of supervised practice.
Therefore it seems to be odd that in the current system, GPs are expected to diagnose according to DSM IV (Diagnostic and Statistical Manual of the American Psychiatric Association). Most psychologists receive a semester of training on how to use this classificatory system, so six hours of training in identifying one disorder is quite inadequate. And yet, the GP is placed in a supervisory role to the psychologist. The psychologist is expected to write reports to the GP (without remuneration) while the GP is paid $150 for the initial Medicare item (Mental Health Care Plan) and $100 for a Mental Health Care Revision if more than 6 sessions are required. In "exceptional circumstances," the GP can earn another $100 with a second Revision. The psychologist only gets paid for doing the actual work.
Does the GP have the same role when referring to a psychiatrist, dermatologist or rheumatologist? I suggest that it makes sense for referrals to psychologists to follow the same procedure, and carry the same financial rewards, as referral to any other specialist.
This will result in major financial savings, money that can then be spent to benefit the patient directly.
Currently, this is registration with a State Psychologists' Registration Board. This is entirely inadequate, and is based on a misunderstanding of the profession of psychology. It is a costly mistake, in that funding may go for misguided therapy that can do harm rather than good.
Not all fully qualified, registered psychologists are skilled and experienced at providing therapy. There are many other fields of interest for psychologists.
For this reason, other funders of psychological services require proof of relevant experience. For example, when the Victims of Crime Assistance Service was set up in Victoria, it accepted only those psychologists who could demonstrate experience working with trauma sufferers. A psychologist without such experience needed to undergo supervised practice.
Senior psychologists have informed me of instances where other psychologists, including Members of the College of Clinical Psychology, had decided to take advantage of Medicare by setting up a private practice for the first time, without relevant experience.
The current system does nothing beyond State registration to ensure that service providers have the necessary skills. Rather than a procedure for examining if a person would qualify for membership of the College of Clinical Psychologists, it is necessary to ensure past experience, and to mandate supervised practice for those who lack it before they qualify under Medicare.
Currently, the system is set up under the assumption that Clinical Psychologists provide a higher, more effective service than other psychologists. This is not true, and the extra they are paid is a waste of taxpayers' money.
Psychological expertise does exist at two levels. There are 9 Colleges of the Australian Psychological Society. A person with the training and experience to qualify for any of these Colleges has a higher level of expertise than a person who does not qualify. However, as an examination of course content and membership requirements will readily show, there is a huge overlap between all the Masters courses. Differences are according to the likely needs of target populations. For example, Developmental and Educational Psychologists learn more about working with children -- but all the Masters courses contain some relevant information. Clinical courses have considerable focus on serious psychiatric diagnoses such as schizophrenia, but, although not to the same extent, all specialist psychologists need to know about this disorder, and their courses teach them this.
This is very different from medical specialisations. A dermatologist and a gynaecologist need very different training. It is more like the situation in law. All lawyers receive very similar training, and then specialise according to their interests. A Family Court solicitor can be admitted to the bar, but thereafter will not be a barrister in criminal cases or in workers' compensation.
In particular, Clinical Psychologists focus their training and supervised practice on working with people who need to be hospitalised: severely psychotic, traumatised or otherwise disturbed individuals. Naturally, they can also work outside the hospital system.
However, the target audience for the current Medicare system is people who live in the community. They suffer, so see their GP, who then sends them to a psychologist. This is the target audience of Counselling Psychologists, what their training specifically focuses on. So, if there is to be a two-tier system, it should specify Counselling rather than Clinical psychologists as being the special experts.
At the moment, services by Clinical Psychologists are accorded a higher rebate than other psychological service providers. My suggestion is that this be eliminated, and instead there be just a single level. However, to qualify for this, the psychologist should have two qualifications:
1. Qualification for membership to any of the 9 Colleges of the Australian Psychological Society. This ensures training and supervised practice at the same level as a medical specialisation.
2. Demonstrated expertise with therapy for the kinds of issues that experience since November 2006 has shown to arise. This may mean the need for further supervised practice for some applicants.
The rebate for this service should be less than that currently paid for Clinical Psychologists' services, but higher than that paid to Registered Psychologists. This is to acknowledge the special expertise of those who satisfy the above two criteria.
Sincerely,
Bob Rich
Counselling Psychologist.
index page Letter to my Member of Parliament Elaine Hosie on Medicare