The most disadvantaged Australians have long experienced higher rates of mental illness^[1] than the broader population. But they also access fewer mental health services^[2].

Increasing everyone’s access to mental health care led to the creation of the Better Access^[3] initiative, which subsidised psychology sessions under Medicare. Officially called Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule^[4], the Howard government launched the initiative in November 2006.

During COVID, the former Morrison Coalition government temporarily expanded the yearly cap^[5] on the number of psychology sessions, from ten to 20. The Labor Albanese government reverted to ten sessions^[6] at the end of 2022.

Now the Coalition says if elected at this year’s polls, it will take the number of sessions back to 20^[7].

But did capping sessions at 20 increase access to mental health care, especially for disadvantaged Australians? Or are there more effective ways to achieve this?

How does it work?

Australians can access^[8] up to ten rebated psychology sessions annually. Patients need to have a mental health treatment or management plan from their GP or psychiatrist.

The Australian Psychological Society^[9] recommends consultation fees of around $311 for a standard 46- to 60-minute consultation. The typical Medicare rebate is $141.85 per session with a clinical psychologist and $96.65 with other registered psychologists. (All psychologists are university qualified^[10] mental health professionals, but clinical psychologists have more qualifications^[11].) Psychologists can choose their own fees. They can bulk bill (no out of pocket cost for patients) or charge consultation fees, leaving some patients hundreds of dollars out of pocket for each session. How did access change during COVID? To assess the changes during COVID, we need to consider three components: number of people accessing services, service use rates (number of sessions per population) and the average number of sessions per patient. 1. Number of people accessing services In 2020-21, all states saw a 5% jump^[12] in the number of people accessing Medicare mental health services, coinciding with the first year of the COVID pandemic. In the three years prior to this, there was an average yearly increase of about 3% more people^[13]. However, a 2022 independent evaluation of the Better Access initiative showed^[14] that between 2018 and 2021, new users declined from 56% to 50%^[15], with the steepest drop between 2020 and 2021. This reduction in new users coincided with the temporary increased cap to 20 sessions. Australians from disadvantaged backgrounds continued to have poorer access^[16] to psychologists than those from wealthier population groups, despite an increase in the number of sessions. 2. Service use rates (number of sessions per population) Service use rates tell us how much a particular service is being used each year. To compare service use rates between different years, and because the Australian population is growing yearly, we report service use rates per 1,000 people in the population. In 2020-21, service use rates for clinical psychologists and other psychologists^[17] increased by 18%. This was a large increase compared to the typical 5% increases in previous years. This persisted in the next two years. When the cap on number of sessions was reduced to ten sessions, there was a small drop in service use rates, but it didn’t return to the pre-pandemic levels.

3. Average number of sessions people used

The increase in services occurring in the first two years of the COVID pandemic (and around the time as the cap temporarily increased from ten to 20 sessions), resulted in a small increase in the average number of sessions per patient.

In the ten years between 2013-14 and 2022-23^[19], average number of sessions with a clinical psychologist increased from five to six sessions whereas the average number of sessions with other psychologists increased from four to five sessions.

Importantly, more than 80% of people received fewer than ten sessions^[20].

What does this tell us?

Overall, most people used ten or fewer sessions, even when up to 20 sessions were available.

Some extra services were provided to existing clients during COVID and this may have actually prevented new people from receiving services.

So the evidence suggests simply increasing the number of rebated psychology sessions from ten to 20 for everybody isn’t the most effective approach.

What should Labor and the Coalition do instead?

We don’t limit the number of chemotherapy sessions for cancer patients, so why do we cap evidence-based psychological treatments for mental illness?

Instead of capping access to Medicare rebates for mental health care, access should be based on a person’s needs and treatment outcomes. The number of sessions should be determined collaboratively between the person and the provider, ensuring people receive the appropriate level of evidence-based care for their condition.

Measure outcomes

Currently in Australia for Medicare-funded mental health services, we only measure service activity. Patient outcomes are not collected^[21], which hinders the development of value-based mental health care.

Without collecting outcomes, current initiatives to address inequities are only partially informed and may not work as intended^[22].

We urgently need to establish a set of outcomes (patient-reported outcome measures and experience measures) through consensus with the community, providers, professional organisations and governments.

Address affordability

We should also address inequities, such as gap fees^[23] that act as barriers to accessing services.

Greater rebates and bulk billing incentives for vulnerable people can assist those with less money^[24].

Offer other evidence-based support

Evidence also suggests people with mild to moderate mental health problems can benefit from psychological and social supports provided by people who are non-health-care professionals^[25], such as the Friendship Bench^[26] and digital mental health programs^[27].

We need to develop and invest in a range of services that cater to differing levels of need. This would ensure more specialised services are available for those with higher complexity or severity.

References

1. ^{^} higher rates of mental illness (theconversation.com)
2. ^{^} mental health services (www.cambridge.org)
3. ^{^} Better Access (www.cambridge.org)
4. ^{^} Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (www.health.gov.au)
5. ^{^} expanded the yearly cap (www.health.gov.au)
6. ^{^} reverted to ten sessions (www.mbsonline.gov.au)
7. ^{^} take the number of sessions back to 20 (x.com)
8. ^{^} access (www.health.gov.au)
9. ^{^} Australian Psychological Society (psychology.org.au)
10. ^{^} university qualified (psychology.org.au)
11. ^{^} more qualifications (www.mindbodypractice.com.au)
12. ^{^} 5% jump (www.aihw.gov.au)
13. ^{^} average yearly increase of about 3% more people (www.aihw.gov.au)
14. ^{^} showed (www.health.gov.au)
15. ^{^} 56% to 50% (www.health.gov.au)
16. ^{^} poorer access (www.health.gov.au)
17. ^{^} service use rates for clinical psychologists and other psychologists (www.aihw.gov.au)
18. ^{^} Ben Bryant/Shutterstock (www.shutterstock.com)
19. ^{^} ten years between 2013-14 and 2022-23 (www.aihw.gov.au)
20. ^{^} fewer than ten sessions (www.health.gov.au)
21. ^{^} Patient outcomes are not collected (www.pc.gov.au)
22. ^{^} may not work as intended (todayspaper.theaustralian.com.au)
23. ^{^} gap fees (theconversation.com)
24. ^{^} less money (theconversation.com)
25. ^{^} provided by people who are non-health-care professionals (www.thelancet.com)
26. ^{^} Friendship Bench (www.centreforglobalmentalhealth.org)
27. ^{^} digital mental health programs (theconversation.com)