GPs say systemic Medicare issues impact provision of mental health care

Matt Woodley

20/07/2022 4:04:30 PM

The MBS structure suggests that GP time spent on mental health is worth less than other areas of medicine, a comprehensive new survey indicates.

GP conducting mental health consultation
The high prevalence of mental illness, along with the burden of disease associated with it, is likely to get worse.

The rebate gap between mental health and other consultations must be removed to help GPs deliver quality mental health care, new research has found.
Commissioned by the General Practice Mental Health Standards Collaboration (GPMHSC), the report’s conclusions are drawn from a survey that was distributed to a randomly selected list of GPs with Level 1 mental health skills training and all GPs with Level 2 Focussed Psychological Strategies (FPS) skills training.
Overall, 846 GPs completed the survey, revealing what GPMHSC Chair Dr Morton Rawlin says are ‘critical issues’ associated with the broader system and environment in which GPs deliver mental health services.
In particular, Dr Rawlin told newsGP the report shows there is a pressing need for a more equitable Medicare Benefits Schedule (MBS) structure that is conducive to the general practice model of patient-centric care.
‘The high prevalence of mental illness, along with the burden of disease associated with it, is likely to get much worse,’ he said.
‘Structural barriers of access, time and cost of undertaking further training, as well as the emotional, economic and practical viability of delivering mental health services are closely intertwined and need to be addressed concurrently.
‘There is also an urgent need to address the number and distribution of psychologists, psychiatrists and peer-support workers through government initiatives and support programs.
‘Training, standards and nationally consistent referral opportunities for patients moving from area to area are going to be important in this process.’
A key finding from the survey is that GPs would be motivated to do further training if the economic return for treating mental health improved significantly.
Only 9% of GPs reported being able to receive a ‘suitable financial return on their time’ dedicated to treating mental health conditions, as these issues are often more complex and many respondents (45%) feared triggering an audit by billing too many long consultations.
The rebate for MBS mental health item number 2713 is also marginally lower than a standard consultation (36) of the same length.
Dr Rawlin believes major reform and changes to the MBS are needed to encourage more GPs to upskill, including appropriately remunerating GPs for the additional time required to coordinate care and follow-up patients with mental health conditions.
‘Removing this disparity will give GPs a clear signal that their time spent on mental health is valued,’ he said.
‘Likewise, removing the disparity between mental health and other consultations, such as de-coupling the number of MBS-rebated sessions available for a patient to see a psychologist from the number of rebated sessions available for a patient to receive FPS from their GP will motivate more GPs to actually use FPS in their practice.’ 
This position is supported by the research, which found that 79% of FPS-trained GPs who are outsourcing FPS treatment say that they would do more if it did not take away from the number of MBS billable sessions available for a psychologist.
But while the economic issues form a major barrier to providing mental health care, they are not the only burden GPs face. A lack of access to mental health services in general, especially in rural in remote areas, is highlighted as a particular challenge.
‘The system in which GPs operate is not optimised to encourage the delivery of mental health services,’ the report states.
‘While the paucity of resources motivates many GPs to do further training to support their community better, it also contributes to the difficulty of delivering mental health support to patients and detracts from the motivation to make this a greater focus in their practice.
‘Only 13% agree that there is sufficient access to other mental health services in their area … [and] 55% agree that the administrative requirements for mental health consultations are onerous.’
The combined impact of a system that does not properly reflect or reward the work required to provide comprehensive, holistic mental health care also appears to be taking a toll on the GPs themselves.
Many GPs reported mental health to be a ‘challenging area’ of their practice, with nearly three quarters (72%) agreeing that they find the work ‘tiring and emotionally draining’.
The same percentage of respondents said that the longer consultations required for mental health care create other problems in their practice, while 67% agree that dealing with mental health puts pressure on their ability to meet the needs of other patients.
An even greater number (83%) reported that there is a great deal of unpaid time coordinating care and follow-up for patients with mental health conditions.
‘While many GPs find it rewarding work and recognise the need for it in their community, it places a high degree of pressure on the GP and their practice environment,’ the report states.
‘[This results] in little appetite to grow this area of their practice or to be known as a “go to” GP for mental health by colleagues and patients, unless this is an area of health they have a particular interest in.’
And while the RACGP’s Health of the Nation reports have consistently shown that mental health is the most common reason for patients to visit their GP, the ‘quantum of mental health addressed by GPs’ is ‘substantially underestimated’ by MBS billing data.
‘Attending to mental health forms a significant portion of GPs’ caseloads, with an estimated 38% of consultations in a typical week attending to an element of mental health,’ the report states.
‘Thirteen per cent of consultations attend to mental health alone and 25% attend to mental health and other items in combination.
‘Estimates … [suggest that] for every one consultation billed as a mental health consult, another 1.8 are not.
‘A key contributing factor is that the MBS item numbers are not structured to accommodate co-billing and in practice GPs are attending to mental health alongside other items in 25% of consults.
‘Even where consults attend to mental health alone, approximately 45% are not being billed using the MBS mental health item numbers.’
With the system unlikely to undergo drastic change in the short-term, Dr Rawlin encourages all GPs to seek support for any mental health and wellbeing issues that results from their attending to mental health presentations.
‘GPs should be encouraged to seek help without the fear of being identified or reported,’ he said.
The RACGP has a GP wellbeing program members can access, while DRS4DRS provides specific support for doctors and medical students, including a confidential telehealth service.
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Dr Robert William Micallef   21/07/2022 6:50:28 AM

GP’s should keep in mind plumbers and solicitors are charging $450 an hour for labour a New York trade commissioner is worth $500,000 a year and politicians pay has gone up very generously over time. Every aspect of GP remuneration under Medicare is undervalued. The only solution is to abandon bulk billing and set a fee that reflects the value of the work. A level B should be worth $100 based on wage relativity.

Dr John William Addis   21/07/2022 11:03:09 AM

In a nutshell, underfunding mental health care compared to other parts of health system is discrimination by proxy and should be banned by law. This reminds me of the significant inequities in Medicare funding overall: the worst case I can remember is the rebate for a plastic surgeon pinning back one bat ear is twice that for a general surgeon removing a pussey appendix.