The 'rise and rise' of new professional groups: mental health professions under Medicare.

• Author: Doessel, Darrel P.
• Position: Contributed Article - Author abstract - Report

Abstract

From November 2006, three paramedical professions that provide mental health services--eligible or approved psychologists, social workers and occupational therapists--came within the scope of Medicare. The purpose of this article is to place that historic decision in context, first by examining several key secular trends in psychiatry as a profession, and then by presenting some data on the professional groups newly subsidised under Medicare. The trends in psychiatry give the context of that decision and point to the structural forces that are likely to be associated with the provision of mental health services in Australia.

1. Introduction

   The purpose of this paper is to document some recent changes in the workforce relevant to the provision of mental health services in Australia. In particular we document the relative decline of services provided by psychiatrists, and the expansion of mental health services provided by allied health professionals since 2006 when specific services produced by psychologists, social workers and occupational therapists came under Medicare.

   The paper has two specific objectives. First, we provide an explanation for the Australian government's decision to bring a specified group of mental health services provided by three paramedical professions (psychologists, social workers and occupational therapists who are eligible (i)) into the web of Australia's universal and compulsory health-funding arrangements, commonly called Medicare. This important change took effect on 1 November 2006. At Medicare's inception in February 1984 (and for its precursor, the 1975 Medibank system), the only professions included in the general Medicare system have been registered medical practitioners (general practitioners and all medical specialists) and registered optometrists (Scotton and Macdonald 1993). In November 2006, most allied health professions attained eligibility status for Medicare funding. These professions are chiropractors, diabetes educators, exercise physiologists, Indigenous health workers, osteopaths, physiotherapists, podiatrists and speech pathologists (see endnote i). Excluded in 1974 and 1985, and still largely excluded, are dentists. In April 2010, the extension of Medicare funding to nurse practitioners was expected to be implemented in November 2010. Thus, the 2006 decision may be regarded as historic.

   Our second objective is to describe the effect of bringing a new type of labour (the three paramedical professional groups) into the Medicare system to provide mental health services. We determine the extent to which this decision has reversed the relative decline of government subsidies for mental health services.

   It is relevant initially to recognise that mental health issues were on the public agenda in the lead up to the Australian government's decision to place some other professionals within Medicare's scope. A community-based epidemiological sample survey of mental disorders in Australia in 1997 (ABS 1998), and a repeat of it in 2007 (ABS 2008a), are representative samples of the Australian population and provide various indications of the prevalence of mental disorders. There also have been the various Burden of Disease studies, which indicated that the impact of mental illness is considerable (Mathers, Vos and Stevenson 1999; Mathers et al. 2000; Vos and Mathers 2000). The Australian Institute of Health and Welfare's (AIHW) reports on relative health expenditures by disease groups indicate that mental illness is an expensive disease category in Australia (AIHW 2004a; AIHW 2004b).

   Also relating to the context of this study is the issue of people with mental disorders who are not receiving mental health treatment, or not receiving it as required. The extent of this problem is known now not to be trivial. In the mental health literature, this issue is referred to as unmet need (Andrews 2000; Whiteford 2000) and it is a problem that exists in other countries such as the United States (Regier et al. 1993; Kessler et al. 1994) and Canada (Lin et al. 1996). In a recent paper, using Australian data from the 1997 epidemiological study, it was determined that 1,477,500 adult Australians with mental disorders were not receiving mental health services. These data represented 61 per cent of all adults with mental disorders (Doessel, Williams and Nolan, 2008). A policy issue implied by this--assuming that the measurement of unmet need is approximately correct--is whether the existing supply of mental health workers can cope with this problem. While this paper does not answer that question, it does provide some context to the need for more attention to be directed to workforce issues.

   On the agenda at the time were two prominent stories of mental illness that were constantly on the front pages of the nation's newspapers, namely those of Cornelia Rau (in 2004-05) and Vivian Solon (in 2001 ). Some details of how these tragic occurrences happened are now available (Palmer 2005; Commonwealth Ombudsman 2005). In addition, Not for Service was a major report from the Mental Health Council of Australia (2005) which provided evidence of how mental health services throughout the country were still inadequate, despite the years of reform under the National Mental Health Strategy (see also Hickie et al. 2005; Whiteford and Buckingham 2005; Singh and Castle 2007). In addition to Not for Service, a Senate Report (Senate Select Committee on Mental Health 2006) also contributed to the growing body of concern that serious issues existed in the mental health sector. A message which emerges from the numerous and varied reports is that the problems of the mental health sector are of long standing. While scandals in the mental health sector motivate political action to some extent, several problems remain unaddressed, which suggests that more quantification work is needed. That task is the impetus underlying this study.

   On 5 April 2006 the Australian government announced details of its intention to allocate an additional $1.8 billion for the treatment of mental disorders in Australia as part of a five-year action plan. One important component of the action plan was a 'new teamwork approach ... with psychologists ... able to work alongside GPs and psychiatrists' (Howard 2006). The funding mechanism for this approach was to have those new services provided by psychologists, social workers and occupational therapists (operating on a fee-for-service basis) subsidised by the Australian government under Medicare. While announcing the Australian government's component of the funding, Prime Minister Howard said that it was his 'hope that the States will be in a position to match what the Commonwealth is proposing', by allocating additional funds to 'supported accommodation, improvements in emergency and crisis services and hospital and prison care'. Some three months later (14 July 2006) the Council of Australian Governments (COAG) announced both the Australian government's and State governments' programs in a joint document entitled National Action Plan on Mental Health (COAG 2006). In all, there were 14 components to that plan, including New Funding for Mental Health Nurses; Improving the Capacity of Workers in Indigenous Communities; Mental Health Services in Rural and Remote Areas. This paper is only concerned with the incorporation of specified mental health services by the three professional groups under Medicare--the new teamwork approach.

   The article proceeds by a series of snapshots of the mental health sector. These depict time-series data on various measures, thus shedding some light on the structural forces at play in the sector. In particular, Section 2 presents some time-series data on the size of the psychiatry workforce. Particular attention is directed to private practice psychiatry operating on a fee-for-service basis under Medicare. Although there has been growth in the absolute number of psychiatrists since 1984-85, this growth has been dominated by part-time workforce participation, and, on average, hours worked have fallen. Section 3 presents data on the number of psychiatry services produced (per hundred thousand of the population) from 1984-85 and shows that this measure of the profession's output reached a maximum in 1995-96; since then it has consistently fallen. Section 4 indicates government subsidies (via Medicare) for those services. These also reached a maximum and have subsequently declined (relatively) since 1995-96. It is argued in Section 5 that under any health insurance system, there are two important concepts of price--gross prices and net prices--which ought to be measured and analysed. The difference between them is explained by the subsidy paid under Medicare. It is shown that gross prices have risen slightly on average, and that the average Medicare subsidy for these services has fallen through time, both in absolute terms and as a proportion of average gross prices. It is therefore not surprising that regression analysis shows that net out-of-pocket prices have risen over time. Section 6 shows the rise in the services of approved psychologists, social workers and occupational therapists under the government subsidies via Medicare, thus providing an answer to the second question addressed in this paper. Section 7 presents a conclusion, which is a story of the relative decline of the psychiatry profession in Australia's mental health workforce.

2. The Psychiatry Workforce

   The first snapshot of the structural forces operating in the mental health sector is now provided. We examine the number of workers in the psychiatry workforce. Psychiatry is a small but important component of the medical workforce; in 2006, there were 3,258 psychiatrists (and psychiatrists in training, including overseas psychiatrists in training) which represented 10.8 per cent of all medical specialists, and 5.2 per cent of all employed medical practitioners in Australia (AIHW...