GPs rebut criticism of mental health care plan oversight

Nine GPs, including RACGP President Adj Prof Karen Price, have co-written a response to a recent article that accused GPs of leaving patients’ mental health care plans ‘largely unmonitored’.
 
The responding opinion piece, published in the most recent edition of the MJA Insight+ journal, describes that suggestion as ‘deeply misleading’.
 
In the original article, which appeared in the same publication, Professors Ian Hickie and Sebastian Rosenberg of the Brain and Mind Centre at the University of Sydney said that of more than 1.2 million mental health care plans written by GPs in 2020–21, only 36.8% of them were reviewed.
 
They based their calculation on official MBS mental health item number statistics.

‘Without monitoring, it is not possible to discern if a person’s mental health is improving or worsening and plan next steps appropriately,’ they wrote in their article, which looked at the priorities of mental health care reform. ‘It also removes an important element of systemic accountability.’
 
In their reply, the GPs say the figure is not an accurate gauge.
 
‘Counting mental health item numbers has always been a poor proxy for quantifying the mental health care that GPs do,’ they write in a response entitled Myth-busting: role of the GP in primary mental health care.  
 
They point out that GPs must use mental health plan item numbers – including 2700, 2701, 2715 or 2717 – if patients need to see psychologists, social workers or occupational therapists under the Better Access program.
 
However, the GPs write that the mental health item consultation and review item numbers are optional – with the mental health review item attracting a lower rebate than a consultation item (a rebate of $75.80 compared to $76.95 for a consultation lasting the same amount of time).
 
‘If patients and GPs are financially penalised when mental health item numbers are used, why would we choose to utilise them?’ they ask.
 
Other factors are also cited, including threats of compliance action by the Professional Services Review, a reluctance by parents to label their children with a mental health disorder, and concerns that evidence of mental illness in a medical record could impact access to insurance.
 
Authors also reference the fact that almost two-thirds of GP consultations (65%) involved a psychological issue in 2020–21, as summarised in the RACGP’s most recent Health of the Nation report. However, at the same time only 8.8% of patients receive treatment subsidised by a Medicare mental health item number, according to the Australian Institute of Health and Welfare.
 
‘MBS mental health item numbers suggest that only 36% of mental health consults are billed as such,’ they write. ‘Using mental health item numbers as a proxy for clinical activity is deeply misleading.’
 
The results of a survey commissioned by the General Practice Mental Health Standards Collaboration (GPMHSC), Delivering mental health care in general practice: Implications for practice and policy, reinforce the contention that many GPs do not bill all longer mental health consultations.
 
‘While the qualitative interviews suggested that the problems leading from the long consult are widespread, a recurring theme was that billing many long consults creates risk for the GP as it may make them a statistical outlier and trigger a Medicare audit,’ the researchers of that work concluded.
 
‘A substantial proportion of GPs (45%) agree that when doing mental health consults, they will sometimes claim a shorter consult to avoid billing too many long item numbers.’
 
Any implication that GPs do not work effectively with other health professionals when treating mental health was also rejected, with the authors stressing their readiness to ‘collaborate with a variety of individuals, institutions and teams to provide care’. 
 
‘Good GPs integrate their understanding of context, relationships, meaning, life story, and bodily health alongside what the psychiatric model separates out as “mental health”,’ the response reads.
 
‘This fundamental difference in how we see people means that strategies developed for psychiatry and psychology led segments cannot be generalised into our context.
 
‘Using evidence justified in one context to drive policy in another is poor science and poor practice.’
 
The importance of long-standing relationships is also highlighted, along with the warning that ‘complex systems can harm patients with complex needs.’
 
‘We also know that a long-standing therapeutic alliance improves outcomes in therapy,’ the GPs write.
 
‘This is particularly important in vulnerable patients with a history of trauma. We also know that long-term therapeutic relationships reduce healthcare cost.
 
‘Outsourcing and modularising this relationship may have unintended consequences that should be carefully considered to ensure the benefit of such an approach exceeds potential harm.’

The GPs also warn about increasing the use of technologies such as artificial intelligence in mental health care without careful examination of the likely impacts, including on privacy and transparency.
 
‘We are the best value mental health care in the country, using less than 3% of the total mental health budget to see the majority of the patients needing community care,’ the GPs conclude.
 
Although the authors of the two articles diverge on many matters, both underline the urgency of primary mental health care reform.

A review of the Better Access scheme, which is in place to ensure Medicare rebates go to eligible people ‘so they can access the right mental health services’, has been underway since last year.
 
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