Chapter 6

Two-tiered Medicare rebate system for psychologists

Introduction

6.1        As discussed in Chapter 2, the Better Access initiative provides Medicare rebates for mental health services provided by GPs, psychologists, occupational therapists and social workers. The rebatable amount for psychological services varies according to:

• the time spent providing services to the client;
• where such services are provided (in consulting rooms or otherwise); and
• whether such services are provided by a clinical or non-clinical psychologist.

6.2        The inquiry's term of reference (e) addresses the 'two-tiered Medicare rebate system for psychologists'. The 'two-tiered system' refers to the situation whereby services provided by clinical psychologists (tier one) attract a higher rebate than those provided by registered psychologists (tier two). The Department of Health and Ageing notes that this has been the case since the implementation of the Better Access initiative, and 'based on advice from the psychology profession'.[1] The Medicare items relevant to psychologists are:

• Items 80000, 80005, 80010 and 80015—Individual Psychological Therapy services provided by a clinical psychologist;
• Item 80020—Group Psychological Therapy services provided by a clinical psychologist;
• Items 80100, 80105, 80110 and 80115—Individual Focussed Psychological Strategies services provided by a psychologist;
• Item 80120—Group Focussed Psychological Strategies services provided by a psychologist.[2]

6.3        As seen above, Medicare differentiates the services provided by psychologists from those provide by clinical psychologists. The items that clinical psychologists may use attract a higher rebate than those provided by (general) psychologists. For example, the recommended fee and benefit rate for item 80000—a 30 to 50 minute consultation for psychological therapy provided by a clinical psychologist at consulting rooms—are $92.20 and $78.40 respectively. However, the recommended fee and benefit rate for item 80100—a 20 to 50 minute consultation for focussed psychological strategies services provided by a psychologist at consulting rooms—are $65.30 and $55.55 respectively.[3]

6.4        This chapter examines the differing requirements for registration as a general psychologist, a clinical psychologist and an endorsed psychologist (in any of the nine practice areas). It then provides a summary of the arguments presented both for and against the two-tiered system. The committee notes that no proposal to adjust the two-tiered system was made by the government in the 2011–12 Federal Budget.

Training to be undertaken by psychologists providing rebatable services under the Better Access initiative

6.5        Psychologists eligible to provide rebatable focussed psychological strategies services under the Better Access initiative are required to hold and maintain General registration with the Psychology Board of Australia (the Board), and be registered with Medicare.[4] In most cases, General registration for a psychologist is granted to applicants who have completed a total of six years of training approved by the Board; for example, six years of university training, or five or four years of university training plus an approved internship for one or two years respectively.[5] Many submitters to the inquiry cited four years' study and a two-year internship (the '4+2' pathway) as the most common pathway to General registration. However, the Board is currently liaising with the Australian Psychology Accreditation Council (APAC) and universities to transition away from the 4+2 system and towards a new 5+1 system.[6]

6.6        This registration system is part of the National Registration and Accreditation Scheme for psychologists which replaced previous state- and territory- based registration arrangements on 1 July 2010.[7] On the day of the commencement of the scheme, registration was transferred at equivalent level from state and territory boards to the Australian Psychology Board. Subsequent renewal applications (required on an annual basis) are made to the Board. The transition will be complete by 30 November 2011 at which time psychologists in all states and territories will be uniformly registered with the Board until 30 November 2012.[8]

6.7        As part of the transition arrangements, registrants were initially transferred to the equivalent registration level in the national scheme for a period of less than one year and are subsequently obliged to register under the national scheme. All psychologists in all states must have applied for General registration under the current national scheme by 30 November 2011.[9]

6.8        To maintain General registration, the Board requires psychologists to complete 30 hours of Continuing Professional Development (CPD) each year. Board guidelines stipulate details of acceptable training, record keeping, auditing and related matters.[10] This training requirement came into effect on 1 July 2010 as part of the National Registration and Accreditation Scheme.

6.9        In the 2009–10 Federal Budget, and to apply from 1 July 2011, the Government introduced further training requirements for allied health professionals, including (non-clinical) psychologists providing focussed psychological strategies services. Eligible psychologists must have completed 10 hours of focussed psychological strategies Continuing Professional Development (FPS CPD) in the period 1 July 2009–1 July 2011, and then an additional 10 hours of approved training annually to remain eligible for Medicare registration.[11]

6.10      Rebatable psychological therapy services under the Better Access initiative may only be provided by clinical psychiatrists registered as such with Medicare. In order to be eligible for registration with Medicare, clinical psychiatrists must:

• Hold and maintain General registration with the Psychology Board of Australia, and either:

  o   Hold and maintain membership of the Australian Psychological Society’s (APS) College of Clinical Psychologists; or

  o   Meet the requirements of such membership as judged by the Australian Psychological Society; or

  o   Hold and maintain endorsement as a clinical psychologist by the Psychology Board of Australia.

6.11      In order to gain eligibility for membership of the Australian Psychological Society’s (APS) College of Clinical Psychologists:

...a minimum of six years university training, including approved postgraduate clinical studies and placements in mental health settings, plus a further two years approved supervision in the clinical field is required. Members are also required to maintain a program of ongoing professional development.[12]

6.12      The Psychology Board of Australia may grant endorsement to eligible psychologists in nine areas of practice: clinical psychology, counselling psychology, forensic psychology, clinical neuropsychology, organisational psychology, sport and exercise psychology, educational and developmental psychology, health psychology and community psychology.[13] Of these nine areas, only clinical psychologists can access the higher rebate tier of the Medicare rebate.

6.13      In order to gain endorsement in any of the nine practice areas, candidates must satisfy an area-specific list of competencies and have completed further specialised study (usually an approved doctorate or master degree and one or two years' approved supervised practice respectively).[14]

6.14      As discussed above, a national registration scheme was introduced relatively recently. As part of the transition from the state- and territory- based accreditation systems to endorsement by the Board, transition arrangements and grandparent clauses apply. In the case of WA, psychologists holding specialist registration in seven practice areas (including clinical psychology), were eligible for automatic endorsement. Titles such as 'Specialist Clinical Psychologist' may not be used by any psychologist except those registered as specialist psychologists in WA on 17 October 2010, for a period of three years from 18 November 2010.[15]

Two-tiered Medicare rebate system for psychologists—debate

6.15      Submitters were divided as to whether the current scheme should remain unchanged (the argument primarily made by clinical psychologists) or should be changed to a single- or multi- tiered system (the argument primarily made by non-clinical psychologists). Aspects of this debate—alongside the rationalisation of rebatable sessions from a maximum of 18 to a maximum of 10 as discussed earlier—provided the impetus for more than a thousand psychologists to submit to the inquiry.

In favour of the two-tiered system

6.16      Most witnesses who considered that the higher rebate should be retained for clinical psychologists justified this position by referring to the higher education and training requirements for registration as a clinical psychologist as opposed to general registration as a psychologist.

6.17      As discussed above, candidates are required to have completed six years of formal education and two years of supervised practice in order to be eligible for Medicare registration as a clinical psychologist. Several submitters considered that this combination of education and experience better equips clinical psychologists to make holistic diagnoses and implement treatment plans.[16]

6.18      Some clients who had experienced positive mental health outcomes as a result of treatment by a clinical psychologist made submissions in support of the two-tiered rebate. For example, submitters 58 and 213 (both name withheld), considered that clinical psychologists provide better treatment, especially to clients with complex mental health needs:

Originally, and for nearly 20 years, [my son's] schizophrenia was controlled almost entirely with medication. Counseling from a clinical psychologist from 2006 onwards worked a miraculous improvement in the quality of his life.[17]

6.19      Given that study leading to endorsement as a clinical psychologist requires significant time and financial commitments, some submitters held the view that abolishing the higher rebate for clinical psychologists may act as a disincentive to professional development in that field:

The loss of the two tiered system will lead to the loss of the clinical skills...to the community of Australia. Simply, the loss of the two tiered system will turn back the advancements that have been achieved over 30 years. In a short period of time the skills of the clinical psychologist will be lost because there will be no incentive and no career path for psychologists to train and move to specialisation.[18]

6.20      Several submitters emphasised the considerable expense of post-graduate education in clinical psychology:

A professional clinical doctorate costs in excess of $100,000 when course fees and loss of income to attend lectures and clinical placements is taken into account. This is a significant disincentive to those early in their careers.[19]

6.21      Other clinical psychologists cited international training standards and asserted that Australia has comparatively low requirements for registered psychologists. These submitters consider that clinical psychologists should be recognised with the higher rebate because the number of years they spend training is similar to that required of registered psychologists overseas.[20]

6.22      The Australian Psychological Society (APS) College of Clinical Psychologists stated that the higher rebate for clinical psychologists is vital to the public interest—that the general population needs to be able to compare clinical and non-clinical psychologists in order to make informed choices when accessing psychological services:

In the best interests of the public, who cannot be reasonably expected en-masse to have the required knowledge-set to easily differentiate who has received accredited specialist training in the provision of evidence-based and scientifically-informed psychological interventions with psychiatric disorder across the entire lifespan and all levels of complexity and severity...[21]

6.23      While those who supported the continuation of the current two-tier rebate cited the educational qualifications of clinical psychologists, other submitters held that their own qualifications justify the opposite argument.

In favour of change to the two-tiered system

6.24      Many submitters who advocated for change to the present two-tier rebate arrangement did so on the basis that clinical psychology is only one of nine practice areas eligible for endorsement by the Psychology Board of Australia. As discussed earlier, endorsement in any given practice area has approximately equivalent requirements with respect to post-graduate study and experience. Several submissions were received from psychologists endorsed in one of the practice areas apart from clinical psychology who consider it inequitable that they are ineligible for the higher rebate. The sentiment of the following submitter, a forensic psychologist, is echoed in many other submissions from psychologists endorsed in non-clinical practice areas:

I am an experienced forensic psychologist with a Doctoral Degree and eight years experience in the field.

At present, my clients are within the criminal justice system and have drug addictions, homelessness and mental illness.

Although, I am a recognised specialist in working with these clients, the two tiered Medicare system does not recognise me. Instead, if I was a clinical psychologist with no experience working with individuals in the criminal justice system, I would receive a higher rate of pay for working with these clients.

I do not charge my clients a fee and rely solely on the Medicare rebate. This is because my clients are often homeless and suffering significant financial hardships. Equality in the rate of pay for the Medicare system would allow me to broaden my work with disadvantaged clients and provide additional services.[22]

6.25      The above example illustrates the primary arguments made in favour of change to the two-tiered system: that other endorsed psychologists are also highly trained; that the current system favours one particular qualification over experience; and that other endorsed psychologists and their clients deserve more assistance from Medicare.

6.26      Other submitters suggested that an independent assessment process should take place to recognise highly-skilled psychologists.[23] This process is envisaged to be completely separate both from the present recognition of clinical psychologists through the top tier rebate, or current PBA endorsement requirements:

Rather than maintaining a ‘two-class’ rebate system based on which degree someone completed at university, I propose to implement a national registration and accreditation body (perhaps as part of the Australian Health Practitioner Registration Agency) which assesses the knowledge and skills of all health professionals at the time they apply for their Medicare provider status. In this way if a non-clinical psychologist or allied health professional could demonstrate that they possess equal skills to those of a Clinical Psychologist they should be able to provide psychological therapy services and charge accordingly.[24]

6.27      The proposal was also made that the two-tiered system be abolished completely. Under the model proposed by some submitters, every registered psychologist would be eligible for the same Medicare rebate, regardless of any further qualification:

The solution to the dichotomy created in the profession by the two-tier Medicare rebate system is to immediately abolish this discriminatory and divisive system and replace it with a single rebate covering consultations with registered psychologist under a mental health care plan.[25]

6.28      While the committee received a very high volume of submissions from psychologists regarding the two-tiered rebate, the vast majority cited anecdotal evidence in support of their positions. There was almost no systematic, independent evidence demonstrating any difference or similarity in health outcomes achieved by clients of clinical compared with other psychologists.

Health outcomes for clients

6.29      Some submitters claimed a comparison of results achieved by clinical and non-clinical psychologists shows no difference in health outcomes. The committee is not aware of any reputable study supporting this, nor the opposing claim. In early 2009, an AAP article cited University of Canberra academic Associate Professor Tim Carey's claim that comparable treatment outcomes can be achieved by clinical and non-clinical psychologists.[26] The Australian Psychological Society responded to this assertion, stating:

[N]o study has been done comparing the two, therefore there is no evidence...

Given their differences in training, it is reasonable to expect that general and clinical psychologists will often be treating cases of different complexity. It is this and their more extensive, specialised training that justifies the higher Medicare rebates for their patients, just as similar factors justify higher rebates for medical specialists.[27]

6.30      Pirkis' evaluation of Better Access included an analysis of the outcomes achieved by clinical psychologists, general psychologists and GPs.[28] Three linear regression analyses were undertaken to demonstrate factors contributing to clients' improvements as measured by the Kessler Psychological Distress Scale (K-10). However, the purpose of the analysis was to examine factors contributing to improvements within the cohort of clients receiving treatment by each group of professionals—clinical psychologists, general psychologists and GPs—rather than comparing them. Nevertheless, the analysis demonstrated similar trends in treatment outcomes across professional groups:

...for all three groups of consumers, those with worse baseline manifestations of psychological distress demonstrated greater levels of improvement than those with lower pre-treatment scores.[29]

6.31      This trend is reflected in the mean improvement in K-10 scores of the sample groups who consulted clinical psychologists, registered psychologists and GPs: 9.53, 10.58 and 8.01 respectively.[30] While the raw data may appear to suggest slightly better results are achieved by registered psychologists, it is actually reflective of the higher distress level recorded pre-treatment by clients in the sample group who consulted registered psychologists. As quoted above, the greater the initial distress experienced by the client, the greater the improvement, regardless of which professional was engaged to provide treatment.

Senator Rachel Siewert

Chair

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