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?