Last week, Minister for Health, Greg Hunt, announced a $48.1 million Mental Health and Wellbeing Pandemic Response Plan. A significant component of this funding is for mental telehealth care services.
In launching the Plan, Minister Hunt said that the package would help deliver a ‘seamless mental health system’ where everyone could get the care they need ‘regardless of where they turn to for help.’
Can this package live up to this goal? Who is likely to access the services funded under this plan and who will miss out? What is the difference between simply transferring a Medicare-funded professional service to online and delivering mental health care via a truly digital platform?
Dr Sebastian Rosenberg, from the Brain and Mind Centre, University of Sydney, answers these questions and more, below.
Sebastian Rosenberg writes:
As Croakey readers would know, I have been preparing short summaries of international webinars on the impact of COVID-19 on mental health.
These meetings, co-hosted by our Centre for Mental Health Research at the Australian National University (Prof Luis Salvador-Carulla) and ConNetica Consulting (John Mendoza), have offered fascinating insights into the reactions of different regions and nations.
Regardless of whether the location had been massively hit by the pandemic or only relatively lightly, a key common theme has been the collective and urgent switch to telemedicine.
In some places, this meant entirely new skills and resources, focusing on health professionals substituting face to face care with virtual appointments. In more sophisticated places, these virtual sessions hooked into existing online medical and pharmaceutical records, creating a new and powerful service system, including mental health.
At the same time as these webinars were occurring, Prof Ian Hickie was also hosting international meetings focusing more specifically on how COVID-19 spurs an opportunity for more integrated, personalised, digital mental health services.
Under the moniker #fliptheclinic, Hickie posed the question why 80% of mental health services could not be digital and 20% face to face, rather than the other way around, after all, after COVID-19, if not now, then when?
Telehealth and mental health
Minister Hunt proudly announced the inclusion of telehealth services for mental health care, suggesting that “changes that would otherwise have taken 10 years [were] done in 10 days”. In this respect the Federal government has pulled the main health lever available to it – Medicare funding.
It has been reported that $35m has been spent on mental telehealth services in the six weeks between mid-March and end April. This decision is not to be diminished.
But as psychologists, psychiatrists and allied health workers scramble to customise their Zoom meeting background images, we should consider what this change really means.
This is particularly significant given concerns about a post-COVID-19 surge in people seeking professional mental health support, increased anxiety and suicidality.
Comparing March 2020 to the same month in 2019 reveals the impact of COVID-19 on traditional help-seeking, with a decrease this year of more than 110,000 services and around $9m in Medicare spending.
|
Service Type |
March 2019 |
March 2020 |
||
|
|
No. of Services |
Medicare Benefit Paid $M |
No. of Services |
Medicare Benefit Paid $M |
|
Clinical Psychologist |
223,388 |
28 |
205,406 |
26.2 |
|
Other Psychologist (and allied health) |
312,863 |
26.7 |
276,893 |
23.9 |
|
GP Mental Health Care Plan and Treatment |
333,726 |
27.7 |
273,585 |
23 |
|
Total |
869,977 |
82.4m |
755,884 |
73.1m |
Enough of a difference?
While it is possible to suggest this decrease is offset by the new telehealth services, does this really constitute major reform or simply create a new way for existing clients to access existing services? Is that enough?
One key issue was illustrated in a report published by the Commonwealth Fund in 2019 entitled Primary Care Physicians’ Role In Coordinating Medical And Health-Related Social Needs In Eleven Countries.
This survey considered the level of preparedness of general practitioners (primary care physicians) across 11 countries to use health information technology for coordinating care with patients (all patients, not just mental health). It suggested that providers needed to be able to offer their patients access to four key online functions:
- Making appointments
- Requesting prescription repeats
- Viewing test results
- Viewing summaries of visits/attendances
Here are the survey results, showing the extent to which GPs in different countries could offer their patients these four functions.
Australia ranks low. The survey provides a bit more granular detail, suggesting our use of technology for booking appointments is actually higher than in other countries but the other three functions are practically never available to patients.
So, while Medicare now pay providers for telehealth services for mental health, the overall environment for these services to work is rudimentary and focuses on the provider experience not the patient. And Australia still faces a significant ‘digital divide’.
People living in poorer socio-economic areas, regional Australia, multicultural communities and others still struggle to access telehealth.
It should also be noted that there are currently no agreed guidelines or standards against which these telehealth services should operate.
While we have already spent $35m on mental telehealth, it is unclear who got these services, why they accessed them, who provided the care and what service they actually received.
And it goes without saying in mental health, we of course know nothing about whether the service they received helped or not.
And finally, it seems to me there is an emerging gap between simply putting Medicare-funded professional services online versus truly digital mental health platforms.
Australia has seen the emergence of some truly world-leading digital mental health systems, like Mindspot, This Way Up and Innowell.
These services provide integrated platforms, empowering individuals to design, monitor and measure their own mental health plan with the support of their health professionals.
I have no doubt virtual Medicare is popular and convenient, both for providers and service users.
More pieces in the jigsaw
But we cannot permit mental telehealth services to simply be the next odd piece added thoughtlessly to our already jumbled mental health system jigsaw.
And speaking of jigsaws, the next set of pieces has been released by the Federal Government, through a specific mental health response to COVID-19 and looks like this:
|
Item |
Amount $ (m) |
|
Funding for suicide data improvements |
2.6 |
|
Funding to Suicide Prevention Australia for research |
4.7 |
|
Funding for Older Person’s Mental Health Services (through Primary Health Networks) |
19 |
|
Funding for Culturally and Linguistically Diverse Communities |
3.5 |
|
Funding for mental health carers |
3.5 |
|
Mental Health Services for Indigenous Australians (through Primary Health Networks) |
3.5 |
|
Funding for mental health service integration (through the Federal Department of Health) |
0.9 |
|
A Federal Department of Health Communications Campaign encouraging people needing help to seek it |
10.4 |
|
Total |
$48.1m |
It is easy to take potshots at lists like this and the Federal Government should be acknowledged for the focus they have placed on mental health as part of the overall pandemic response.
But this funding equates to less than $2 per Australian and the plan itself is a bewildering bureaucratic buzzword bingo of objectives, principles, key phases, priorities, actions, nouns and verbs – all unfunded (apart from the list above) and relying on state and federal cooperation, just like the 5th National Mental Health Plan.
On this basis, would you really want a communications campaign to be successful, risking encouraging people to look for services they are very unlikely to find?
Learn from elsewhere
COVID-19 has demonstrated the futility of relying on hospitals to provide the bulk of mental health care as is the case now in Australia. Experience overseas has demonstrated how systems with a more robust array of community mental health services are better positioned to cope and be flexible at times of crisis.
Australia lacks this array. The pandemic has encouraged us to consider practical but radical community-based reforms. Intersections between online and face to face services need to be obvious and smooth.
Services need to be intelligently allocated to where they are needed most, drawing on new systems of predictive and dynamic modelling of the mental health ‘eco-system’. Digital services and telehealth services need to be carefully considered and mapped into this larger reform process.
Another 10 years work next week please.
As a clinical psychologist of over 25 years experience, I used online video calls with some of my clients during April. Those who used it didnt like it at all. Problems finding a confidential space at home, not being able to do some of the therapy properly and feeling disconnected from the session. I found it much harder to observe the client, and shared their sense of disconnect. Research shows a vital ingredient in effective therapy is the therapeutic relationship with another human being. Can online platforms provide this? We will end up spending a lot of money asking people to try to have a relationship a computer screen. Surely one of things we have learnt from COVID is people need face to face connection!!
The Federal governments own review a few year ago found that Medicare funded sessions with a clinical psychologist was the most economical and cost effective way to get people to see highly qualified mental health professionals. 100% of the rebate goes to direct clinical care. Money going th Primary Health Networks and other such organisations use significant Government money on administration costs and non-direct care. Please speak to some clinical Psychologist or the APS about this. I am weary of only hearing from psychiatrists.