This is a hot topic right now considering the Australian Government just cut 10 sessions from the already very limited 20 Medicare rebates for psychology. I am a critic of the Medicare Better Access Initiative and I have wanted to write something about it for some time. I participated in writing an APS submission regarding the rebate amount a number of years ago. A debate that went no where. There is still a huge chasm between the way psychological services are deciphered and funded and a lack of serious advocacy, decisive action and recognition from our representative bodies as well as our politicians. Psychology services are still lacking a coherent and consistent offering in terms of fair and equal access to treatment services for people in Australia.
The Medicare initiative offers rebates for 6 rebated sessions of psychological therapy. You can visit your GP to qualify for another 4 rebates to see your psychologist again totaling to 10 rebates in any calendar year. Many people don’t use these rebates because it is painfully cumbersome. People do not enjoy repeating their sensitive and sometimes difficult or traumatic mental health concerns several times to different practitioners (i.e., sometimes a GP is on leave and the second or third referral has to be written by another practice). We handle these therapeutic aspects with a lot of care. The best qualified person to see psychology patients are psychologists and any barriers or hurdles to this process has to be eliminated by the government as a matter of priority.
Many high functioning patients may want to see a psychologist and wish to work directly with their psychologist, which may be sufficient to manage their treatment and care. In my clinical practice it is uncommon that I would need to speak or discuss a matter with someone’s doctor. I usually do this directly with the patient. I am skilled to assess and involve other services when people require it. All of these issues get managed and handled on a case by case basis. Each patient has a different level of care, and my approach is very nuanced. So it is baffling to me that our politicians cannot see the effects and impacts of their one size fits all decisions on individuals who are in need of treatment. Ignorance is bliss for bureaucrats with miserable and detrimental consequences for users of dysfunctional systems which are structured in a way to not hear those users.
Recently I heard in the news that a politician indicated that Medicare funded sessions for psychological therapies was reduced as a measure to assist more people to get an appointment with a psychologist. This rationale was apparently based on the premise that if more rebates were available to people they would continue to see the therapist and therefore not free up the time-slot for someone else. Let’s pause and ponder over the absurdity of this statement for a moment. Only a politician or a bureaucrat could come up with such absurdities and fantasies. I have never met a patient who continued their treatment with me because of rebates. The rebates are there to ease the pressure so people are more encouraged to take up treatment, and some people really do not have the financial means to fund any therapy. So rebates must help not add extra barriers and stress. People want to see us because they are suffering and they are in pain. Psychologists assess and treat, we aren’t bureaucrats, administrators, stock brokers or real estate agents. Our object isn’t money, it is care and to help cure or address human distress. This is the reason that we entered the profession in the first place. There is also free will. People engage us based on their autonomy, freedoms and their perceived level of psychological suffering at any point in their life times. Our focus is on providing treatment and care, so we need a system that realigns their focus on this aim that we have always shared with our patients.
People don’t come to see us because we give them free stuff, rebates, money or fashionable things they can wear and show off to their friends and families. Most people who see us keep us private because there is still a lot of stigma associated with seeing a psychologist in Australia. Although it is improving, our politicians also must exercise sensitivity and care in providing support to people. There was no transition period, there was a hard cut off date resulting in many patients fearing a continuation of their treatments. Many people felt discouraged by the government introduced change. We have to remember that change specially sudden ones can be anxiety provoking for people. So we don’t need the government to increase the burden, the suffering and worries of the patients.
It is appalling when governments get involved at these sorts of levels where clinical knowledge and expertise is absent. Moreover there are politicians who are doctors. I do not think it is possible to mix politics with care. I do not think it is possible for a politician to apply their clinical thinking, because the clinical decision making is bound to be impacted and biased by the parties political interests and messaging. It is not an independent model that critically reviews its workings. I do not think people can wear two hats. It’s one head for one hat. A politician is always a politician. Luckily in Australia there are ombudsman to investigate, but these processes are very time consuming and as a psychologist I just want to be able to care for my patients’ treatments and not the politics and cuts to medicare. Unfortunately in recent years this is becoming increasingly difficult. I am having to think about medicare and what will be cut, reduced or changed next. All sorts of psychological therapies in private practice clinical, non-clinical, counseling, psychoanalytic, psycho educational, motivational and whatever else that is considered scientific and research based that people want to access as a therapy that helps them to stay alive must be supported by the Australian Government funding initiative.
I am baffled as to how politicians make clinical decisions when I have undergone many years of intensive work to get to where I am in order to think about a patient’s treatment which includes of course the frequency and other therapeutic aspects that their treatment requires. Politicians must not authorize themselves to comment on people’s experiences in therapy and their needs. They need to leave it up to people and their psychologists. We continue to receive babysitting on matters by our government. I feel we aren’t given the respect we each deserve to make our own decisions regarding needs and well-being. Even during the lock downs there were people who needed to attend in person sessions for whatever clinical reason, and there was so much pressure by the government to see people over tele-health, that was paradoxical to providing good care. It deterred some people from getting the care that they needed. Many of us carefully continued to work through these clinical decisions on a one by one basis while adhering to the government policies despite the challenges. Other than managing all the matters associated with managing covid requirements, there was additional anxiety and fear generated by every message or update that was delivered by the Australian government calling people who needed to leave the house irresponsible. The messaging was confusing, some patients thought they could not leave the house if they needed urgent care to see a psychologist in person and so on.
As citizens we should ask ourselves, what is it about our culture that enables our governments continue to scare us under preconceived ideas of safety, such that we no longer ask questions about their decisions over things concerning our well-being. In clinical practices, ethical decision-making is rigorous, when in doubt we run it in supervision with other colleagues and ponder over it for days. This is reflective practice, but politicians in this country regularly do a botched job of things that has detrimental effects on people’s lives without any responsibility, reflection and evidence of ethical decision making process having taken place. What about the ethics of cutting someone’s rebates midway treatment? Why is that left up to me to figure out when it was never a decision that I made in the first place? Why am I constantly left to clean up after the Australian Government’s mess over medicare rebates and its funding policies?
The APS recommended psychologist fee is $280. I don’t know any colleague who charges this recommended fee. Why should money and funding even be a consideration in Australia, this is a wealthy country with high tax brackets. We can afford to cover people who are in need of psychology. Sometimes I feel that the psychology profession does not receive the respect, recognition and the meaningful place in society that it deserves in our country. A country gives respect to the people and its profession by giving it the adequate funding that it deserves so we can look after people, specially those who are most vulnerable. As a registered psychologist who also speaks Persian, I am left to provide services to asylum seekers and people on work visas who don’t have jobs or medicare yet. These people always fall through the gaps, and we have to figure out the funding situation on our own with our patients. These patients often get no advocacy because they are in the minority, and margins of Australian society. I want to remind us of the meaning of humanity with this poem from the Medieval Persian poet Saadi, “human beings are body parts of one another, when one body part is in pain, other parts of the body are also impacted”. It is a poem about having empathy for one another. This means paying for those who cannot pay. People pay taxes and those taxes must be used for covering everyone’s psychological treatment expenses.
It is impossible to provide the care and attention each patient requires and bulk-bill on these rebates. I have capped the number of patients I see in a day to make sure that I am present and I can listen to every patient. Politicians should reduce our administrative and bureaucratic work load so we can see more patients. I would like to know if people actually take the time to read my reports. It feels as though the reporting tasks are dictated by the Medicare regime. Why can’t I be trusted to decide when I need to communicate with another health practitioner or a patient’s GP. Why does Medicare dictate to psychologists that we have to write to the GP after 6 rebates. There is not a one size fits all and the Medicare regime renders my psychological training redundant really, because what I have been taught is that each patient moves at a different pace in their treatment. However Medicare dictates this process. Sometimes I have nothing to communicate after 6 sessions with a patient, and sometimes I need to speak to a GP after one session.
Australia is a democratic country, but as clinicians we operate within the dictatorship of Medicare. Everything is pushed and forced. We have to toe the Medicare party line, otherwise acting in the best interest of our patients might result in fines from Medicare (i.e., a patient must have a fresh referral after 6 rebates, if we issue a receipt for a 7th rebate, then we could get fined during a Medicare Audit). There is plenty of evidence of these harsh behaviours and punishments from Medicare. There is plenty of evidence over these Medicare controversies with the doctors even recently undermining the work of our medical profession.
I want to offer treatment to my patient and I don’t want to apologise for Medicare anymore. “Sorry, rebates have finished; sorry it’s six; sorry it’s 4 now; sorry it’s 10; sorry it was 20 now it’s not; sorry it’s that and it’s not this; sorry your referral letter is missing blah; yes there is out of pocket, sorry medicare stuffed up…” The process is so confusing that international patients just cannot navigate our systems. People think that if they have a Medicare card they can be eligible for rebates, which is not the case. I have to spend the session time to explain, or ring in my personal unpaid time to sort out Medicare mistakes and mess to help patients. If politicians care about psychologist time and patient treatment they could make a start by simplifying the convoluted referral process and get rid of it. We don’t need any referral to see a patient, we are qualified to make that assessment ourselves.
Why have we reduced our precious doctors and their skills to referral writers, sometimes forced to come up with diagnoses in brief consultations to satisfy Medicare requirements, when all of this has to get done by a psychologist who treats anyway. These diagnoses stay on someone’s medical record forever. It can take several sessions to get an accurate diagnosis sometimes. There is so much double handling and inefficiencies. Everyone knows you cannot give things to people (i.e., the extra 10 rebates for the past two years) and then take it back. It doesn’t work like that. It seems arbitrary and a misuse of political power where the disadvantaged individuals always suffer the most in these instances of the arbitrary applications of power. Giving rebates and taking it back is unsettling for people.
Everyone knows that money is power in a capitalist world. If you have money you can have health and we are there already. However people’s psychological wellbeing must not be treated like a commodity or an “extra” as noted on many private health insurances. It has become an acceptable notion that psychology is mostly available in the privileged suburbs of Melbourne, and not as widely available in outer areas of Melbourne and areas where people are likely to suffer from lower incomes with more psychological barriers to accepting psychological interventions.
Seeing a psychologist is daunting and anxiety provoking for many people. No patient volunteers to see a psychologist unless they absolutely need it. So this idea that the government has proposed, that they are assisting more people this way to access psychological sessions by capping the sessions at 10 rebates is nothing but baseless political commentary. It is an oxymoron. This cut to rebates and sessions is one of the not so thought through “initiatives” of the Australian government. The Australian public are polite and they don’t protest, but politeness and patience should not be mistaken for satisfaction of mental health services funding. Just because we live in a capitalist society, it doesn’t mean we have to operate our psychology with capitalist ideology and treat it like a commodity. People’s mental well-being is not a material object. We can maximize the potentials of capitalism to the benefit of the citizens of this country. It is time we all wake up and talk to the awful changes and cuts introduced by our governments. It is time the Australian Government listens to its people and treat the public with the respect that is deserves regarding the appropriate and limitless funding of its psychology and therapeutic services for any one who needs it without discrimination or question.
Bita Riazati Psychoanalyst 