Anecdotes can be powerful. At their best, they can galvanise public opinion in ways that numbers and graphs can’t. At their worst, they can obscure the facts and lead us to emotional conclusions. I started looking into the data on Australian Medicare’s Better Access scheme for mental health after noticing this anecdote in the Sydney Morning Herald:
THE mental health activist, Neil Cole, says he knows a couple with a $14 million mansion and two Mercedes cars who still claim from Medicare for counselling from a psychologist they don’t really need.
”It is the worst form of middle-class welfare I have ever seen,” Associate Professor Cole said of the Better Access mental health scheme for consultations.
I’m not sure how Associate Professor Cole knows the couple don’t really need counselling. That’s probably a question best left to the couple and their psychologist. But I’m interested in what the data says about the Better Access scheme’s outcomes and reach. Is it really paying for the rich and the not-very-ill to contemplate their navels? Or is the story more complex than that?
The Better Access program (or, if you prefer tortuous Health Department-speak, the “Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule initiative”) was launched 2006. It pays for people with diagnosed mental illnesses to have limited sessions with psychiatrists and psychologists. It also gives extra rebates to GPs when they make mental health care plans for their patients. Like most Medicare programs, Better Access isn’t means-tested. In 2009, one in every 19 Australians made a claim.
The cost of the program has blown out to $1.4 billion over four years – more than twice what the government planned to spend. In this year’s budget, sessions with a psychologist were cut from 12 to 10 per year and the rebate for GP visits was halved. But debate has continued over whether Better Access is the best use of limited mental health dollars. Professor Ian Hickie of the Brain and Mind Research Institute has called it a “travesty”, saying it excludes those most in need of care.
I’ve been digging into the recent evaluation of the program commissioned by the Health Department. It’s hundreds of pages long, but I’ve put together a bubble chart based on one of its more interesting tables. It shows the number of patients who claimed from Better Access for sessions with psychologists, psychiatrists or GPs in 2009. The bubbles represent the average cost to Medicare per patient, and the axis at the bottom is the Index of Relative Socieconomic Disadvantage (IRSD) — more on that in a moment.
The chart shows that highly disadvantaged people are less likely to use Better Access, and Medicare spends less on their treatment when they do. But it’s not quite as simple as ‘better care for the rich’. Despite news reports to the contrary, the IRSD doesn’t measure patients’ incomes. It measures the relative disadvantage of people in the postcodes where they live. Disadvantage does include income, but it also includes things like the number of Indigenous residents, the number of households without a car, and the number of people who are separated or divorced. My own postcode, for example, puts me in quintile 3 — and my neighbours include both public housing tenants and the owners of million-dollar terraces.
Still, since most of us don’t care to be quizzed on our income before seeing a doctor, the IRSD is the best measure we have. So, why is Better Access providing fewer services to people in the most disadvantaged postcodes?
Well, according to the evaluation, there are a few reasons. Decades of user-pays mental health care has concentrated the mental health workforce in the affluent suburbs of major cities. So it can be hard for people from poorer places to find a psychologist or psychiatrist near them. And although health providers who serve disadvantaged communities are more likely to bulk-bill, there aren’t enough of them to meet demand. Finally, some of the groups who receive less care under Better Access may be receiving it elsewhere – for example at headspace centres or community mental health clinics. The data shows that access to mental health care in Australia is not evenly distributed – but there’s no evidence that the Better Access program has made the situation worse.
So what about Neil Cole’s other assertion – that the people receiving care under Better Access are not particularly ill? No, the data doesn’t support that claim:
From October 2009 to October 2010, 82 per cent of patients referred to clinical psychologists were suffering high or very high levels of psychological distress. The proportion who had low levels of distress? Just 4 per cent. The Mercedes-driving, mansion-owning couple who don’t really need their psychologist might make for a compelling anecdote, but the evidence suggests they’re in the minority.
What’s your take on the Better Access scheme? What would you change to make it fairer?
Hi, just a clarification. The reduction is from 18 to 10, not 12 to 10. This is important as the misinformation campaign run by the government has sought to keep this fact from the public. People are going to lose almost HALF of their medicare rebate-able services.
An excellent post Jacinta. The very same article caught my attention and I blogged about it also: http://exclusivelyalison.blogspot.com/2011/07/im-still-seething.html My response was much more of an emotional one though, so I’m very glad there are people like you willing to analyse the data and present the facts. Thank you
yup … the government is flogging spin on this one – the cuts are from 6+6+6 to 6+4 … too bad for the 1 woman in 3 that is being beaten and/or abused by her intimate partner, and is 85% likely to end up with PTSD, 75% likely to end up with depression and 18% likely to want to or try to commit suicide … when you compare these figures with those for the general population (PTSD 6%, depression 35%, suicidality 3.5%), it is quite shocking that the government is cutting the access to psychological services by a wopping 44% (18 to 10 sessions) … so “Australia says NO! to violence against women” but if it does happen to you, suck it up Princess, cos you aint gonna get straightened by seeing a psychologist !
i don’t see chemotherapy being means tested – let’s say we decide to cut the access for “rich” people to get chemo … can you imagine the public backlash on that one ??? no one is refused treatment for physical health conditions, and no one is stopped from accessing as much treatment as is needed for physical health issues … so the big question is why is mental health treatment capped at 18 sessions per year ???? does anyone have the right to tell someone how much treatment they need? does anyone have the right to limit how much treatment someone gets for a condition?
and having “advocates” for mental health issues who have somewhat dodgy qualifications (exactly how many years of study and research has he done for his associate professorship anyway?? and which uni did he graduate from – cos i havent been able to find any record of his qualifications in psychology other than the honourary a/prof) and are quite obviously “in bed” with the other so called advocates who just happened to get a healthy chunk of the MH budget thrown their way at the expense of the every day person is a little suspicious … let’s talk conflict of interest shall we ????
If it saves a life ,its money well spent imo
This is a great post! I’ve been following the issue from the get-go, and particularly like some of the graphic representations you have used, especially to counteract the argument that these services are used by people who don’t need them. I hope you will consider submitting something like this to the senate inquiry into the issue: http://www.aph.gov.au/Senate/committee/clac_ctte/comm_fund_men_hlth/index.htm
I am also curious, is there an easy way to find out the IRSD for my postcode? I live on a Disability Support Pension, but wonder if because I live across the road from people with big houses and fancy sports cars (although also 5 mins away from commission flats) I’m “officially” considered to be in a higher income group than my actual income would suggest. This could explain a lot and I’d like to find out more.
And, yes, beware of the info that says the cutbacks are from 12-10. It’s definitely 18-10. I have written a blog post on this issue if you’re interested: http://betteraccesscampaign.blogspot.com/2011/07/better-access-in-media-dont-believe.html
Thanks to those who clarified that the reduction is from 18 to 10. The Medicare website suggests that the original scheme provided 12 sessions, with an extra six available if required. It doesn’t clarify whether the extra six sessions will be available under the revised scheme. I understand that some of you are users of Better Access – have you been told that you will no longer be eligible for the extra six sessions?
Thembi, you don’t need to worry that your suburb’s IRSD is affecting the services you receive. The IRSD isn’t used to make decisions about individuals. It’s a population-level measure that helps governments and institutions figure out whether they’re delivering services fairly to all sectors of the population. It’s actually a really good tool, because it recognises that low income is not the only barrier to fully participating in society. Being Indigenous or not having a car can also make life difficult.
The IRSD was used appropriately in this research; the problem is that some commentators have misinterpreted it as a direct measure of income, and that lets them argue that the program is only serving the rich. This is inaccurate, partly because the IRSD is a population measure, and partly because it only measures *dis*advantage – there are other indexes which count the number of rich, advantaged people, but this one doesn’t. That’s not to say there aren’t equity problems with Better Access – in particular, the rich are much more likely to be able to afford a co-pay – but the situation is complex. I’m actually not advocating one way or the other, just pointing out inaccuracies where I see them.
If you want to argue against the cuts to Better Access, the IRSD probably isn’t the place to start. I see no methodological problems with its use in this research. But if you’re just interested in how it works, you can read about the index here: http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/2033.0.55.001Main+Features12006?OpenDocument. If you’re in the mood for a thoroughly boring afternoon, there are spreadsheets on the downloads page which will show your postcode’s IRSD. (They give IRSD deciles, so you need to halve them and round up to get a quintile like I’ve used above).
Thanks for your reply. I have found it really interesting to find out about the IRSD. I’m actually really pleased to hear that being disadvantaged is measured on more than just income, because I do think that despite my low-income, I have certain advantages that others don’t. However reports in the media (such as the one you pointed to) seem to always just refer to it being judged on income, which doesn’t fit with the picture of the people I know who use Better Access. I am glad this post has explained (in simple to understand terms) how this is not providing the full picture.
I was mainly just interested to find out where my own postcode sits on the scale because of the vast difference in circumstances I see for people living in my area. It does seem odd to me that they would all be lumped into the same category of advantage because they clearly are not. However I’m more than willing to admit I don’t understand the way statistics work!
As for session numbers, the extra six sessions will definitely no longer be available. It’s my personal opinion that this fact has been made particularly difficult to find because there is a big difference between a cutback of two sessions and a cutback of eight. If they were only reducing sessions by two I probably wouldn’t be nearly as concerned, but as someone who has used all 18. loosing eight sessions is a big deal. Anyway, here’s a government fact sheet that refers to the cut of the extra six sessions so you don’t just have to take my word for it! http://www.qldalliance.org.au/sites/www.qldalliance.org.au/files/110527%20-%20Fact%20Sheet%20-%20Changed%20cap%20on%20allied%20mental%20health%20services.pdf