Inequality

'Better access to mental health care and the failure of the Medicare principle of universality' by Graham N Meadows, Joanne C Enticott, Brett Inder, Grant M Russell and Roger Gurr in (2014) 202(4) MJA 191-195 comments

Australia’s national health insurance scheme, Medicare (introduced in 1975 as Medibank), was envisioned to deliver the “most equitable and efficient means of providing health insurance coverage for all Australians”. Questions have been raised as to whether, 40 years after its introduction, Medicare is equitable, particularly in terms of access to mental health services. Investigations over more than 70 years in various parts of the world, including Australia, have consistently found greater levels of psychiatric disorder in areas with greater socioeconomic disadvantage.

In November 2006, the Australian Government introduced the Better Access to Mental Health Care initiative (Better Access), consisting of new Medicare Benefits Schedule (MBS) items to improve access to psychiatrists, psychologists and general practitioners. Evaluation of the program, supported by Commonwealth government funding, highlighted the success of Better Access in increasing psychological service use. For example, the number of allied mental health services accessed almost doubled in the first year, and most users were new (68% in 2008 and 57% in 2009). The report by Harris and colleagues also commented: “Uptake rates for Psychological Therapy Services items … decreased as levels of socio-economic disadvantage increased”. Findings from Bettering the Evaluation and Care of Health data also suggested possible inequity, with less service provision going to more disadvantaged areas.

Another concern is whether Better Access is reaching rural and remote communities as well as the metropolitan areas. Here, a primary driver may be provider availability, as the problem of securing specialist health care and other service delivery to non-metropolitan areas of Australia is well recognised.

We obtained Medicare data on the Better Access program and related mental health care items, following a freedom of information request by one of the authors (R G) on behalf of Transforming Australia’s Mental Health Service Systems.

We aimed to determine whether adult use of mental health services subsidised by Medicare varies by measures of socioeconomic and geographic disadvantage. We hypothesised that services would be particularly inequitable where delivered by mental health professionals with higher gap payments.

We conjectured that services provided by GPs, general psychologists and allied health practitioners would be relatively equitable, while services generally provided by psychiatrists and clinical psychologists would be less equitably delivered. We focused separately on item 291 (GP mental health care plan preparation by a psychiatrist), hypothesising that this item might differ in pattern from other psychiatry items.

The authors conclude -

Our findings confirm previous findings of inequity in services provided by psychiatrists. Better Access activity rates are typically greater in more advantaged areas. There is variability between provider disciplines and items; within Better Access, this association is most strongly observed with high-volume clinical psychology services. Activity rates for Better Access and related mental health care MBS items decline with increasing remoteness across all types, reinforcing findings from previous work.

Examination of the latest national survey did not suggest that areas of higher socioeconomic status were characterised by high use rates of Better Access items among people without disorders, but this may not be how inequity manifests. Rather, among people with comparable levels of diagnosable mental health problems, it may be easier for the socioeconomically advantaged to pass through the filters to specialist care. In other words, the criteria for stepping up a level of care may be different, and the disadvantaged may need higher levels of distress or disturbance to secure entry to care.

These results are consistent with a multitier system, where people living in more disadvantaged and more rural areas will typically receive a service model in response to mental health needs that is characterised by lower volumes of services, provided possibly by less highly trained providers. Item 291 is something of an exception among Better Access items but at a very low absolute rate.

Medicare provision through Better Access does not then conform to the kind of equitable delivery that would merit characterisation as universality. While we are not offering specific solutions to such a complex issue, we note that our key hypotheses were formulated with consideration of the likely influence of copayments as a disincentive and structural deterrence to accessing care. These findings would be compatible with a situation in which higher-paid professionals practise in areas closer to home, and where this spatial distribution aligns with direct considerations of affordability, it reduces access by people from more disadvantaged areas.

Our study has some limitations. The Medicare data do not take into account the Access to Allied Psychological Services initiative or the public mental health services provided by states and territories. Including these would require further data sources and analyses.

Regarding funding models to public mental health services in Australia’s most populated states, Victorian public mental health services adopted transparent resource distribution processes in the late 1990s, including a correction to state funding based on level of private activity. In New South Wales, a special commission of enquiry recommended introducing a resource distribution formula to take into account socioeconomic factors and substitutable private services; however, this has not yet happened.

Our data span financial years 2007–08 to 2010–11; changes to the scheme from late 201125 may have led to some changes in usage.

Without controlling for area-based need disparities, it seems most likely that our analyses may have underestimated rather than overestimated inequity.

Our findings, confirming previously demonstrated inequity in private psychiatric service activity, show that the Better Access initiative is not providing universality or consistent equity of delivery in mental health care. We hope that the findings may contribute to debate and discussion around policy incentives and strategies that work towards universal and equitable delivery of mental health care for all Australians.