In recent weeks, Croakey has run several articles examining the potential pros and cons of the Medicare Select concept floated by the National Health and Hospitals Reform Commission in its final report.
Now a senior mental health advocate, Sebastian Rosenberg, is weighing into the debate, asking what such a model might mean for those with mental health problems. He is a Senior Lecturer at the Brain and Mind Research Institute and Deputy CEO of the Mental Health Council of Australia.
““Plus ca change” the French say – the more things change, the more they stay the same. That is the justifiable concern among many in the mental health sector as the Federal and State Governments contemplate the recommendations of the National Health and Hospital Reform Commission.
In mental health, the status quo just isn’t an option.
Ten years of so-called mental health reform has seen Australia fail to lift the rate of access to care for people with a mental illness – 38% of people with a mental illness were in care in 1997 and 35% in 2007.
So debates about concepts like Medicare Select take on particular significance. For areas of health that are well serviced, the old axiom not to fix something that ain’t broke may well apply. Rates of access to care in other chronic illness are more like 70-80%, with the majority of people getting the care they need.
This is clearly not the case in mental health and has spurred calls for fundamental reform. It is no surprise that some of the leading proponents (occupying a telephone booth near you) of Medicare Select highlight mental health as a key potential beneficiary of a new approach.
But the motivations underpinning their support vary. For some, Medicare Select represents a chance to promulgate an individualised approach to health care, taking funding decisions out of the hands of health professionals or the nanny-state, and giving choice instead to each consumer.
These supporters talk of ‘cashing out entitlements’ and giving each consumer ‘leverage’ to buy tailored packages of care. This is certainly a model which exists in the construct of packages of care for the support of profoundly disabled children, though the extent to which these packages are really based on understanding the costs of care is debatable.
What is clear is that in such situations, governments work with families to develop packages of care that can be worth hundreds of thousands of dollars in order to enable health, community and other services to be available. These packages are regular features of disability support but, of course, there aren’t lots of them.
So what are the entitlements of a person with a mental illness? While there is plenty of evidence about what treatments, services and programs work, what is the right package of care for a young person showing early signs of psychosis? How much does it cost? How will a person with a mental illness know what to buy? And who will ensure they get what they pay for?
Other mental health supporters of Medicare Select seem to come from a more secular school. They would simply point out that we need more money and more services provided in new ways to new clients. Attracting some of the missing 65% into care will almost certainly cost more than the mental health system currently spends. And much of this spending will not be in the ‘health’ system but more broadly, in a range of community services, some clinical, some psycho-social.
Medicare Select is seen through this lens as being a vehicle by which to drive a general argument that business as usual won’t wash and this is completely understandable.
But would establishing Medicare Mental Health Select, by pooling funds (however calculated) really drive the establishment of new models of service provision? If we build it, will they come?
This question really requires more analysis. It is a business question as much as a health question. The New England Journal of Medicine again published evidence of the benefits of collaborative care and the drawbacks of fee-for-service medicine.
Would a Medicare Select approach to funding drive new models of employment and payment for health professionals to work collaboratively? Would it end the cycle of fruitless incentives which have failed to entice mental health professionals out of metro areas and into the bush? Which organisations or new collaborations can we identify who might be willing to take on the business of meeting the holistic needs of people with a mental illness? What happened in Holland – did new mental health service providers emerge?
Despite the recent prominence of mental health as an issue, its consideration by CoAG, the Reform Commission and repeated investigations by the Senate and others, it is still reasonable to suggest that Australia remains in crisis.
Unless the Federal Government decides to pursue fundamental reform arising from the Commission’s recommendations, then some tinkering of responsibilities between the Federal and State Governments is the likely minimalist outcome of current deliberations. It is ironic that is the precisely the community-based mental health services that are most critically needed that fall right into the grey area of responsibilities now. There is some evidence that some state governments may be withdrawing from this field in anticipation of a Federal takeover.
Perhaps the real allure of a concept like Medicare Select is that it could end the often tragically disconnected series of services that passes for our mental health ‘system’. The programs which work in health offer integrated care. Financial planning services offered to parents in children’s hospitals, employment officers working in psychiatric wards of a Melbourne hospital. These are exceptional glimpses into a system of care that attempts to manage a whole person, rather than just a limb or a symptom.
I am quite sure that mental health consumers and carers don’t care a jot for who holds the money or which level of government runs which type of service. The current debate about health reform needs to be about more than this. In mental health it needs to be about establishing evidence-based sustainable models of community care in which health, employment, education and other services each play a role.
For mental health in Australia, ‘plus ca change’ just isn’t an option. And if Medicare Select can drive reform then it deserves support.”