‘Hugely detrimental’: Mental health item changes raise concern

Changes to MBS mental health items due to kick in on 1 November are likely to have a detrimental impact on patient wellbeing and the sustainability of clinics with a focus on mental health, GPs have warned.
 
From that date, under reforms to Better Access, key MBS mental health items will be scrapped, including item 2712 to review a mental health plan, and item 2713 for a mental health consultation longer than 20 minutes.
 
Generic time-based items will be used for this care instead.
 
Equivalent mental health telehealth items are also due to stop, as will the current exemption to the 12-month relationship rule for GP Mental Health Treatment Plan (MHTP) items.
 
Dr Owen Harris, a GP working in inner-city Melbourne, has real concerns about the potential repercussions of losing items he has used to reduce the patient out-of-pocket costs often attached to complex mental health care.
 
Offering standard appointments of 20 minutes, Dr Harris says his patients – who include people requiring treatment for problematic use of alcohol and other drugs, and gender-affirming care – often need longer.
 
While he would love to bulk bill everyone, he says that is ‘simply not possible given the structure of Medicare item numbers and rebates’.
 
Under the existing system, Dr Harris reduces the cost to patients by co-billing, which is allowed under certain circumstances by Medicare guidelines. 
 
One example is co-billing a patient with hypertension and depression, with the ‘standard’ MBS item 23 privately billed, and MBS item 2713 bulk billed if the appointment lasts 26 minutes or more.
 
According to Services Australia, MBS item 2712 was used 521,485 times in the past financial year, with 1,082,666 MBS 2713 items billed – although the data does not specify when items have been co-billed.
 
For Dr Harris, the key is being able to thoroughly treat each patient in front of him.

‘This allows me the time to explore the patients’ needs and actually develop a trusting relationship with them, create a treatment plan and also practice some preventive medicine,’ he told newsGP.
 
‘Longer appointments with me mean less attendances overall, less trips to hospital, fewer referrals to specialists.’
 
Dr Harris calculates patient costs could increase by ‘30% or more’ under the changes unless he absorbs them himself – and fears a system already geared towards ‘six-minute medicine’ is about to get worse.  
 
‘Under the new system, the financial incentive is to see as many people as possible in order to make use of the new bulk-billing incentives, ie six patients an hour rather than two or three,’ he said.
 
‘This is clearly not good for the patient, not good for the community, and is likely to result in a huge wave of burnout amongst GPs and the closure of even more clinics.’
 
An analysis of the Better Access reforms published by Cubiko describes the removal of co-billing as ‘the biggest financial impact’ of the changes, and predicts ‘a noticeable drop in billings’ related to those consultations.
 
Its dataset suggests an average of 14 MHTP reviews at clinics every month, a level Cubiko says it would not expect to have a significant impact on long-term sustainability – but the company says this depends on the emphasis placed on mental health services.
 
‘Many clinics may need to consider charging private or mixed fees for these longer, complex mental health consultations to maintain financial viability,’ the blog states.
 
Encouraging practices to adopt a proactive, transparent approach to the changes, the blog observes that item numbers used for preparing MHTPs will remain in place – and also finds potential ‘silver linings’.
 
‘Ultimately whether you will better or worse off under the new framework comes down to how mental health reviews have been billed historically, and what bulk-billing incentives may apply within your MMM region,’ the author writes.
 
Close observers of the MBS have already pointed out difficulties in knowing when co-billing can and cannot happen when using the outgoing item numbers, which are by no means universally liked.
 
Associate Professor Caroline Johnson sits on the RACGP Expert Committee – Quality Care and its Mental Health Working Group and is the RACGP representative on the Better Access Industry Liaison Group. 
 
Commenting in a personal capacity as a GP who wants to help colleagues navigate the mental health system, she does not oppose the removal of items 2712 and 2713 per se.
 
She notes that MBS item 2712 was introduced more than 20 years ago due to emerging evidence that proactive follow-up of patients with depression led to better outcomes. 
 
‘Whether an item number is the best way to achieve that “proactive follow up” remains unclear, and I suspect continuity of care and the quality of the GP–patient relationship are more important factors than the financial incentive,’ she told newsGP.  
 
However, she acknowledges the item numbers’ removal as ‘a pain-point’ for GPs who use them legitimately to co-bill alongside standard consultation items. 
 
‘Item 2712 and 2713 have provided an opportunity to slightly reduce the significant financial penalty GPs experience when they offer longer consultations with their patients,’ she said.  
 
‘So the real problem with the removal of item 2712 and 2713 is that it removes one of the few mechanisms GPs have to maintain their income and still offer longer consultations. 
 
‘The upcoming expansion of bulk-billing incentives will add to this disadvantage for GPs who work with patients who need more time, and unfortunately these are often exactly the patients we would like to bulk bill.’
 
Like Dr Harris, Associate Professor Johnson would like to see the changes paused until there is ‘a more equitable redistribution of MBS funding to reduce the financial disadvantage for those who appropriately offer longer consultations’.
 
The impact on telehealth
For Dr Tim Kirchler, a GP working in headspace clinics in rural NSW, it is the telehealth changes that have the most significant ramifications to his practice and his patients.
 
Telehealth mental health item numbers 92114 and 92115 (video) and 92126 and 92127 (phone) will no longer be available from 1 November, leaving only MBS telephone items for Focussed Psychological Strategies (FPS) available.
 
The exemption to the ‘established clinical relationship’ requirement for remaining telehealth items will also be removed – again apart from FPS items – making many patients ineligible for MBS rebates if they have not been seen in person in the past year, or have not signed up to MyMedicare.
 
‘Our headspace centre covers a wide geographical rural area and many of our patients are unable to attend in person due to the distances involved,’ Dr Kirchler told newsGP.
 
‘Most of our patients are unable to afford private fees so this would mean that we either turn them away or accept a large decrease in Medicare billings.
 
‘In our case the proportion of remote mental health services we provide means that this cut could affect the viability of our headspace centre’s GP service.
 
‘Overall this change is hugely detrimental to the provision of GP mental health services in rural areas.’
 
He wants the change delayed until an alternative can be worked out.
 
‘Ideally there should be a set of MBS items similar to the blood-borne virus, reproductive and sexual health items where timed items can be used for GP mental health telehealth visits without requiring the patient to have attended in person in any particular time frame,’ he said.
 
Response from DoHDA
In response to these concerns, the Department of Health, Disability and Ageing (DoHDA) said ‘GPs will be able to use general consultation items for mental health services, including consultation and review of treatment plans’.
 
‘This means a patient can receive a benefit based on the time a GP spends with them, and they are able to get advice on both their physical and mental health needs in the one appointment,’ a spokesperson told newsGP.
 
They also said GPs can bill for longer level D and level E consultations ‘which recognises that GPs often spend longer with their patients to provide quality mental health care’.
 
While they pointed out that items 2712 and 2713 have a benefit of $83.65, less than the level C, level D and level E consultations of $84.90, $125.10 and $202.65 respectively, they did not directly address a newsGP question about co-billing.
 
‘In addition, should a GP choose to bulk bill their patient they may also qualify for the triple bulk billing incentive instead of just a single, making these services more affordable for people in need of mental health support,’ they said.  
 
The RACGP has previously written to the Government to request a delay so the changes do not coincide with the start of the Bulk Billing Practice Incentive Program, and so the findings of a review of MBS time-tiered items can be taken into account.
 
RACGP President Dr Michael Wright continues to stress that complex mental health care cannot be provided in six minutes – and noted the recent Health of the Nation report which found more than seven in 10 GPs have mental health as one of their top reasons for patient presentations.
 
‘The RACGP is urging the Government, alongside their valuable investments in Medicare and GP training, to increase patient Medicare rebates for longer consultations by 40% and rebates for mental health items by 25%,’ he said.
 
‘For some, general practice can be the only point of care when seeking out mental health services, particularly in rural and remote areas.
 
‘Increasing patient rebates to keep pace with the rate of inflation will help ensure everyone, no matter where they live, can access a trusted GP for their mental health issues without facing high out-of-pocket costs.’
 
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