centre for health policy, programs andcontent/3e9bdf... · bridget bassilios2, justine fletcher2,...

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Evaluation of the Better Access to Psychiatrists, Psychologists and GPs through the Medicare Benefits Schedule initiative

Component B: An analysis of Medicare Benefits Schedule

(MBS) and Pharmaceutical Benefits Scheme (PBS) administrative data

FINAL REPORT

Meredith Harris1, Jane Pirkis2, Philip Burgess1, Sarah Olesen3, Bridget Bassilios2, Justine Fletcher2, Grant Blashki4, Anthony Scott5

August 2010

1 School of Population Health, The University of Queensland.

2 Centre for Health Policy, Programs and Economics, Melbourne School of Population Health, The University of Melbourne.

3 Centre for Mental Health Research, The Australian National University.

4 Melbourne Institute of Applied Economic and Social Research, Faculty of Business and Economics, The University of Melbourne.

5 Nossal Institute for Global Health, The University of Melbourne.

C E N T R E f o r H E A L T H P O L I C Y , P R O G R A M S a n d E C O N O M I C S

ACKNOWLEDGMENTS

This evaluation was funded by the Australian Government Department of Health and Ageing. The authors are grateful for the assistance of Ross Saunders, Chris Wall and Peter Woodley (Medicare Financing and Analysis Branch, Department of Health and Ageing) and Rosemary Smith, Marian Wolski and Andrew Kopras (Pharmaceutical Benefits Division, Department of Health and Ageing) in providing the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme data used in this evaluation. The authors are also grateful to the Better Access Project Steering Committee for their comments on previous versions of this report.

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TABLE OF CONTENTS

EXECUTIVE SUMMARY ..................................................................................................................... 1

1 BACKGROUND ................................................................................................................................. 1

2 METHOD ........................................................................................................................................ 1

3 KEY FINDINGS ................................................................................................................................. 2

4 CONCLUSIONS ................................................................................................................................. 5

CHAPTER 1: BACKGROUND .............................................................................................................. 6

1.1 SETTING THE CONTEXT ...................................................................................................................... 6

1.2 OVERVIEW OF THE BETTER ACCESS INITIATIVE ....................................................................................... 7

1.3 EVALUATION OF THE BETTER ACCESS INITIATIVE ................................................................................... 10

1.4 THE CURRENT REPORT .................................................................................................................... 10

CHAPTER 2: METHOD .................................................................................................................... 11

2.1 EVALUATION QUESTIONS ................................................................................................................ 11

2.2 DATA SOURCES ............................................................................................................................. 11

2.3 STATISTICAL METHODS.................................................................................................................... 18

2.4 ETHICS APPROVAL .......................................................................................................................... 23

CHAPTER 3: ACCESS ....................................................................................................................... 24

3.1 OVERVIEW ................................................................................................................................... 24

3.2 WHAT HAS BEEN THE RATE OF UPTAKE OF BETTER ACCESS SERVICES OVERALL? .......................................... 25

3.3 WHAT HAS BEEN THE RATE OF UPTAKE OF BETTER ACCESS SERVICES BY ITEM GROUP? ................................. 26

3.4 WHAT HAS BEEN THE RATE OF UPTAKE OF BETTER ACCESS SERVICES BY PROVIDER TYPE? .............................. 29

3.5 WHAT HAS BEEN THE RELATIVE UPTAKE OF ITEMS WITHIN ITEM GROUPS? ................................................. 31

3.6 WHAT ARE THE SOCIO‐DEMOGRAPHIC CHARACTERISTICS OF CONSUMERS WHO HAVE RECEIVED BETTER ACCESS

SERVICES? ............................................................................................................................................. 38

3.7 HAVE THERE BEEN CHANGES OVER TIME IN THE SOCIO‐DEMOGRAPHIC PROFILE OF CONSUMERS WHO HAVE

RECEIVED BETTER ACCESS SERVICES? .......................................................................................................... 48

3.8 TO WHAT EXTENT IS BETTER ACCESS PROVIDING SERVICES TO ‘NEW’ CONSUMERS? ..................................... 54

3.9 KEY FINDINGS ................................................................................................................................ 56

CHAPTER 4: AFFORDABILITY .......................................................................................................... 59

4.1 OVERVIEW ................................................................................................................................... 59

4.2 WHAT HAS BEEN THE RATE OF SERVICES PROVIDED AND COSTS OF BETTER ACCESS SERVICES OVERALL? ........... 59

4.3 DO RATES OF CO‐PAYMENT FOR BETTER ACCESS SERVICES VARY ACROSS POPULATION SUBGROUPS? .............. 65

4.4 SUMMARY OF FINDINGS .................................................................................................................. 94

CHAPTER 5: EQUITY ....................................................................................................................... 96

5.1 OVERVIEW ................................................................................................................................... 96

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5.2 WHAT IS THE DISTRIBUTION OF MENTAL HEALTH NEED AT THE INDIVIDUAL LEVEL? ...................................... 96

5.3 WHAT IS THE RELATIVE DISTRIBUTION OF MENTAL HEALTH NEED ACROSS DIVISIONS OF GENERAL PRACTICE? .... 97

5.4 WHAT IS THE RELATIVE DISTRIBUTION OF BETTER ACCESS AND ALLIED HEALTH BETTER ACCESS SERVICES USED

ACROSS DIVISIONS OF GENERAL PRACTICE? .................................................................................................. 98

5.5 WHAT ARE THE RATES OF BETTER ACCESS AND ALLIED HEALTH BETTER ACCESS SERVICES ACCORDING TO KEY

DIVISION‐LEVEL FACTORS? ...................................................................................................................... 101

5.6 WHAT IS THE RELATIONSHIP BETWEEN MENTAL HEALTH NEED AND BETTER ACCESS UPTAKE, SERVICE USE AND

BENEFITS PAID AT THE DIVISION LEVEL? ..................................................................................................... 104

5.7 KEY FINDINGS ............................................................................................................................. 106

CHAPTER 6: PROTOCOL‐BASED CARE ........................................................................................... 107

6.1 OVERVIEW ................................................................................................................................. 107

6.2 PATTERNS OF CARE FOLLOWING A GP MENTAL HEALTH TREATMENT PLAN ............................................. 108

6.3 VOLUME OF SERVICES DELIVERED BY ALLIED HEALTH PROFESSIONALS ...................................................... 115

6.4 SUMMARY OF FINDINGS ................................................................................................................ 117

CHAPTER 7: INTERDISCIPLINARY CARE ......................................................................................... 119

7.1 OVERVIEW ................................................................................................................................. 119

7.2 WHAT IS THE DISTRIBUTION OF UPTAKE AND SERVICE USE ACROSS DIFFERENT COMBINATIONS OF MBS BETTER

ACCESS ITEMS? ..................................................................................................................................... 119

7.3 DO PATTERNS OF INTERDISCIPLINARY CARE VARY ACCORDING TO SOCIO‐DEMOGRAPHIC CHARATERISTICS? ..... 124


CHAPTER 8: IMPACT ON PRESCRIBING ......................................................................................... 128

8.1 OVERVIEW ................................................................................................................................. 128

8.2 HAS THERE BEEN A CHANGE IN DEMAND FOR ANTIDEPRESSANT AND ANXIOLYTIC MEDICATIONS SINCE THE

INTRODUCTION OF BETTER ACCESS? ......................................................................................................... 128

8.3 HAS THERE BEEN A CHANGE IN DEMAND FOR ANTIDEPRESSANT AND ANXIOLYTIC MEDICATIONS SINCE THE

INTRODUCTION OF BETTER ACCESS AMONG PEOPLE ELIGIBLE TO RECEIVE MEDICATIONS AT A CONCESSION PRICE? .... 133

8.4 WHAT IS THE RELATIONSHIP BETWEEN BETTER ACCESS UPTAKE AND DEMAND FOR ANTIDEPRESSANT AND

ANXIOLYTIC MEDICATIONS AT A DIVISION LEVEL? ......................................................................................... 134


CHAPTER 9: IMPACT ON RELATED PROGRAMS ............................................................................. 138

9.1 OVERVIEW ................................................................................................................................. 138

9.2 HAS THERE BEEN A REDUCTION IN DEMAND FOR NON‐BETTER ACCESS MENTAL HEALTH MBS SERVICES SINCE THE

INTRODUCTION OF BETTER ACCESS? ......................................................................................................... 139

9.3 DO PATTERNS OF DEMAND FOR NON‐BETTER ACCESS MENTAL HEALTH MBS SERVICES DIFFER BETWEEN

METROPOLITAN AND RURAL OR REMOTE REGIONS?...................................................................................... 140

9.4 WHAT IS THE RELATIONSHIP BETWEEN BETTER ACCESS UPTAKE AND DEMAND FOR NON‐BETTER ACCESS MENTAL

HEALTH MBS SERVICES AT A DIVISION LEVEL? ............................................................................................ 144

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9.5 DOES THE RELATIONSHIP BETWEEN BETTER ACCESS UPTAKE AND DEMAND FOR NON‐BETTER ACCESS MENTAL

HEALTH MBS SERVICES AT A DIVISION LEVEL DIFFER BETWEEN METROPOLITAN AND RURAL OR REMOTE REGIONS? ... 146

9.6 HAS THERE BEEN A REDUCTION IN DEMAND FOR ATAPS PSYCHOLOGICAL SERVICES SINCE THE INTRODUCTION OF

BETTER ACCESS? .................................................................................................................................. 150

9.7 DO PATTERNS OF DEMAND FOR ATAPS PSYCHOLOGICAL SERVICES DIFFER BETWEEN METROPOLITAN AND RURAL

OR REMOTE REGIONS? ........................................................................................................................... 152

9.8 WHAT IS THE RELATIONSHIP BETWEEN BETTER ACCESS UPTAKE AND DEMAND FOR ATAPS PSYCHOLOGICAL

SERVICES AT A DIVISION LEVEL? ............................................................................................................... 155

9.9 DOES THE RELATIONSHIP BETWEEN BETTER ACCESS UPTAKE AND DEMAND FOR ATAPS PSYCHOLOGICAL SERVICES

AT A DIVISION LEVEL DIFFER BETWEEN METROPOLITAN AND RURAL OR REMOTE REGIONS? .................................. 157


CHAPTER 10: DISCUSSION ............................................................................................................ 160

10.1 OVERVIEW ................................................................................................................................. 160

10.2 INTERPRETATION OF FINDINGS ........................................................................................................ 160

10.3 ASPECTS OF THE EVALUATION QUESTIONS BEYOND THE SCOPE OF THIS REPORT ........................................ 169

10.4 KEY METHODOLOGICAL ISSUES ........................................................................................................ 170

10.5 CONCLUSIONS ............................................................................................................................. 171

REFERENCES ................................................................................................................................ 172

APPENDIX 1. GLOSSARY ............................................................................................................... 177

APPENDIX 2. LIST OF ABBREVIATIONS .......................................................................................... 180

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EXECUTIVE SUMMARY

1 BACKGROUND

The last decade has witnessed substantial reforms to Australia’s mental health care system. These follow the publication of epidemiological evidence of the widespread nature of mental illness in the general population, unexpectedly low treatment rates for these conditions, and the considerable impact of disorders such as depression on individuals’ lives and Australia’s health burden. Several wide‐scoping reviews into the provision of mental health services in Australia have also highlighted the still‐pressing need for people with mental illness to have greater access to mental health services, particularly evidence‐based treatments by specialist providers such as psychiatrists and psychologists.

In response to these concerns, there have been major reforms to the primary mental health care sector since 2001. A cornerstone of this reform has been the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) initiative which commenced on 1 November 2006. Better Access was designed to improve access for people with clinically‐diagnosed mental disorders (primarily depression and anxiety) to evidence‐based treatment from various providers, via a series of new and increased rebates under the Medicare Benefits Schedule (MBS). These modifications to the MBS included the addition of a set of item numbers that enable rebates to be claimed for psychological services delivered by clinical psychologists (these services are known as Psychological Therapy Services), and by general psychologists, and selected social workers and occupational therapists in the community (these services are known as Focussed Psychological Strategies). Referral is required from a general practitioner (GP), psychiatrist or paediatrician. Referrals can be made for up to 12 individual (18 in exceptional circumstances) and 12 group treatment sessions in a calendar year. Better Access also provides for a set of item numbers that reimburse GPs for preparing and reviewing mental health treatment plans and providing mental health consultations, and a set of item numbers that reimburse psychiatrists for conducting an initial consultation with a new patient and for providing and reviewing a patient assessment and management plan.

This current report presents findings from an analysis of MBS administrative data, conducted as part of a multi‐component evaluation of the Better Access initiative commissioned by the Department of Health and Ageing (DoHA).

2 METHOD

The current evaluation was designed to address seven evaluation questions. It uses data obtained from multiple sources. The evaluation questions, and the contribution of each source to addressing each of the questions, are shown in Table i.

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Table i Relationship between the evaluation questions and data sources used in the current evaluation

Evaluation questions M

edicare Be

nefits Sche

dule

data

Pharmaceu

tical Ben

efits

Sche

me da

ta

Australian Bu

reau

of

Statistics C

ensus da

ta

Access to

Allied

Psycho

logical Services

projects’ m

inim

um dataset

2007

Nationa

l Survey of

Men

tal H

ealth

and

Wellbeing

Question 1: To what extent has the Better Access initiative provided access to mental health care for people with mental disorders? Across all of Australia? Across all age groups?

Question 2: To what extent has the Better Access initiative provided access to affordable care?

Question 3: To what extent has the Better Access initiative provided equitable access to populations in need? (in particular people living in rural and remote areas, children and young people, older persons, Indigenous Australians, people from culturally and linguistically diverse backgrounds.

Question 4: To what extent has the Better Access initiative provided evidence‐based mental health care to people with mental disorders?

Question 5: To what extent has the Better Access initiative provided interdisciplinary primary mental health care for people with mental disorders?

Question 6: To what extent has the Better Access initiative impacted on the use of medications commonly prescribed for treatment of mental disorders, in particular antidepressant medications?

Question 7: To what extent has the Better Access initiative impacted on related MBS (and other) services?

3 KEY FINDINGS

The key findings from the analyses presented in this report are summarised below, organised under each of the evaluation questions addressed. Within each evaluation question, a series of research questions was addressed via targeted analyses.

The extent to which Better Access has provided access to mental health care for people with mental disorders was examined by profiling the rates of uptake of MBS‐subsidised Better Access items for the total Australian population, and for key population subgroups. The uptake of the initiative has been substantial, with one in every 19 Australians (5.3% of the population, or 1,130,384 people) receiving at least one Better Access service in 2009. The rate of growth of the program accelerated rapidly its first year (increasing by 13.3% per quarter in 2007) but slowed significantly thereafter to 4.6% per quarter (until the March quarter 2010). The initiative appears to be attracting ‘new’ consumers, i.e. people who have not previously used Better Access services. The majority of people who received Better Access services in 2008 (68.0%) and 2009 (57.0%) had not previously received these services. When analysed according to provider type, the percentage of new consumers was highest for the Consultant psychiatrist services (92.1% in

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2008; 86.9% in 2009), followed by the allied health services (ranging between 73.7% to 79.5% in 2008, and 66.9%‐74.5% in 2009), followed by GP services (73.1% in 2008; 62.2% in 2009). In each of 2008 and 2009, the majority of Better Access services are used by people who are receiving services for the first time in that year. These findings suggest that Better Access is meeting a previously unmet need.

Relatively lower rates of access were observed among young people, however this not unique to Better Access; young people access all mental health services less often than other members of the population. Patterns of access according to geographic location and socio‐economic disadvantage were complex. For the GP and Focussed Psychological Strategies items, the level of access was the same in rural centres as it was in capital cities, but it was lower in other rural areas and remote areas. For Consultant Psychiatry and Psychological Therapy Services items, uptake decreased across each category of geographical region from capital cities to remote areas. Uptake rates for Psychological Therapy Services items and, to a lesser extent, Consultant Psychiatry items, decreased as levels of socio‐economic disadvantage increased. By contrast, uptake rates for GP Mental Health Treatment and Focussed Psychological Strategies items were markedly lower only for persons residing in the most disadvantaged areas. The growth in uptake between 2007 and 2009 has been greatest for young people aged 0‐14 years, compared to all other age groups. Growth in uptake has also tended to be greater for people in remote locations, and for people in more socio‐economic disadvantaged areas.

With respect to whether Better Access has provided access to affordable care, analyses revealed that more than half of Better Access services delivered were bulk‐billed (54% in 2007, 57% in 2008 and 59% in 2009), and the average co‐payment was around $35. There was considerable variation in co‐payment rates and average co‐payments according to the type of provider who delivered the services. In 2009, only 7% of services delivered under the GP items involved a co‐payment by the consumer, whereas up to two thirds of the services delivered under the Consultant Psychiatrist (64%), Psychological Therapy Services (65%) and Focussed Psychological Strategies (57%) items did so. The average co‐payment was lowest for GP items ($20), close to the overall average for Psychological Therapy Services items ($32) and Focussed Psychological Strategies items ($37), and highest for Consultant psychiatrist items ($82). The proportion of services that were bulk‐billed increased as the level of remoteness and level of relative socio‐economic disadvantage increased. The average co‐payment was highest among people in remote areas ($38) and people in capital cities ($37) than those in other regions ($31‐$33). The average co‐payment decreased as level of relative socio‐economic disadvantage increased (from $38 to $33).

The extent to which Better Access has provided equitable access to populations in need was examined using a modeling exercise that estimated levels of mental health treatment need in areas defined by the boundaries of Divisions of General Practice. It then investigated whether Better Access services are being distributed across Divisions according to need. Analyses showed that, at the Division level, rates of total and allied health Better Access services used were positively associated with levels of mental health need. However other factors were also found to play a part. Higher rates of total and allied health Better Access services used were found in Divisions that had relatively higher rates of GP supply, and Divisions located in Victoria. Lower rates of Better Access services used were found in Divisions with relatively more people living in socioeconomically disadvantaged areas and Divisions with relatively more people living in remote locations. More than half the variation in total Better Access services used (54.7%) and allied health Better Access services used (51.0%) could be explained by these factors. Variables

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relating to potential to access services (GP supply, remoteness, state/territory) collectively contributed a slightly larger proportion (approximately 6.5% more) of the variance in total Better Access services used than allied health Better Access services used. Socioeconomic disadvantage contributed a similar proportion of additional variance in total (8.19%) and allied health (8.17%) Better Access services used, after all other variables were taken into account.

Two aspects of whether Better Access has provided ‘protocol‐based’ care were examined. The first of these related to the patterns of care delivered following a GP Mental Health Treatment Plan. Analyses estimated that less than approximately one fifth of consumers received both a GP Mental Health Treatment Plan and a GP Mental Health Treatment Review, which is perhaps less than ideal. It should be noted, however, that the fact that the GP Mental Health Treatment Review item was not used does not necessarily mean that a review has not occurred. It is possible that other items are being used to capture the content of the session in which the review occurs. In addition, 58% of Better Access consumers who received a GP Mental Health Treatment Plan went on to use Better Access allied health services; conversely 42% did not. Non‐receipt of Better Access allied health services following a Treatment Plan was more common among older people aged 65 years or more and among males. Non‐receipt of allied health services increased as level of geographical remoteness increased, and as level of socio‐economic disadvantage increased. It should be noted, however, that consumers who did not receive Better Access allied health services may have received psychological services from other sources, for example: from allied health professionals under the ATAPS program (which is not recorded in the MBS); from their GP, which may be recorded using the Better Access GP Mental Health Consultation item (2713) or under another MBS item; or via privately funded services.

The second aspect of ‘protocol‐based’ care was the number of psychological services delivered by allied health professionals per person per calendar year (which should not exceed 30 per person in a calendar year). Around 75% of consumers received between one and six allied health professional services, 20% received between 7 and 12, and 5% received between 13 and 18. This suggests that the protocol is being interpreted appropriately by providers.

The extent to which Better Access users received interdisciplinary care was examined by profiling the use of various grouping of Better Access MBS items. Overall, 55% of Better Access users received some combination of interdisciplinary care, most commonly from combinations of GPs and allied health professionals. The remainder received GP care alone. Rates of interdisciplinary care were the same other metropolitan areas as they were in capital cities, and only slightly lower in rural centres, but they were 15% lower in other rural areas and 33% lower in remote areas (as compared to the average across all Better Access consumers). Rates of interdisciplinary care also decreased as level of socio‐economic disadvantage increased. Specifically, in metropolitan areas rates of interdisciplinary care were 13% lower among people from the most disadvantaged areas, compared to the average across all Better Access consumers.

Analyses of the impact of Better Access on the use of medications commonly prescribed for the treatment of mental disorders found that the rate of persons using PBS‐subsidised antidepressant medications increased significantly (0.9% per quarter, on average) in the three years after the introduction of Better Access. The rate of PBS‐subsidised scripts supplied for antidepressant medications also increased significantly (1.5% per quarter, on average) post‐Better Access. In contrast, rates of PBS‐subsidised anxiolytic use were stable over the pre‐ and post‐Better Access periods. A positive association was also found between Better Access uptake

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and medication use at a Division level. That is, the rate of persons within a Division using PBS‐subsidised antidepressant medications, and the rate of scripts supplied, increased as the rate of persons using Better Access increased. This was also true for anxiolytic medications. Taken together, these findings would tend to suggest that Better Access has had the effect of increasing consumers’ access not only to the non‐pharmacological treatments that underpin it, but to pharmacological therapies which have also been shown to have good evidence of effectiveness.

Finally, the impact of Better Access on existing related programs was considered. Analyses revealed that the rate of uptake of non‐Better Access MBS mental health items at a Division level was the same in the two years after the introduction of Better Access as it was in the two years prior to Better Access. In addition, a positive association was found between the uptake of Better Access MBS items and non‐Better Access MBS mental health items at a Division level. The picture with the uptake of psychological services provided under the Access to Allied Psychological Services (ATAPS) projects was more complex. ATAPS had experienced substantial growth prior to the introduction of Better Access. This growth has continued, but has slowed since the introduction of Better Access. ATAPS has proportionally greater penetration into rural and remote regions than metropolitan regions (whereas the reverse is true for Better Access). This pattern was not affected by the introduction of Better Access. In metropolitan Divisions, higher population uptake of Better Access was associated with higher uptake of ATAPS, but in rural/remote Divisions higher uptake of Better Access was associated with lower uptake of ATAPS. These findings suggest that Better Access is filling a gap in the mental health service delivery system that was not previously being met by other related services. However, the introduction of Better Access does not appear to have negated the need for these other services, particularly in rural/remote areas.

4 CONCLUSIONS

The current analysis of MBS and related data has shown that Better Access has improved access to evidence‐based, multi‐disciplinary mental health care for Australians. These improvements have occurred for people irrespective of their age and socio‐economic status, and regardless of where they live. However, young people, people in the lowest socio‐economic stratum, and people in small rural and remote areas have not been as well served as their older, more affluent, urban counterparts. Over half of the sessions of care provided through Better Access are bulk‐billed, although – like other Medicare‐funded services – the proportion of bulk‐billed services is higher for GPs and lower for specialists (e.g., psychiatrists and psychologists). Those with greatest levels of financial need are the biggest beneficiaries of bulk‐billed services. High levels of uptake of Better Access services have not led to commensurate reductions in the use of other relevant mental health services or prescribing of antidepressant or anxiolytic medications. In fact, the opposite is true, which suggests that Better Access is a crucial piece in the web of Australian primary mental health care reforms, and is helping to meet previously‐unmet need. Before this conclusion can be definitively drawn, however, further work is required to profile the mental health status of people using Better Access services, and the outcomes of Better Access care. The study of consumers and their outcomes, which is being conducted as part of the current evaluation, will be helpful in this regard.

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CHAPTER 1: BACKGROUND

1.1 SETTING THE CONTEXT

The last decade has witnessed substantial reforms to Australia’s mental health care system. These follow the publication of influential findings from the first National Survey of Mental Health and Wellbeing (NSMHWB) in 19981 and the Australian Burden of Disease and Injury Study in 1999.2 These studies revealed the widespread nature of mental illness in the general population, unexpectedly low treatment rates for these conditions, and the considerable impact of disorders such as depression on individuals’ lives and Australia’s health burden. The 1997 NSMHWB revealed that one fifth of the population had experienced a mental disorder in the past 12 months, but only one‐third of these people had consulted a health professional in the past 12 months for this reason.1, 3 This is half the treatment rate of physical disorders causing comparable disability.4 The survey also confirmed that general practitioners (GPs) were the most common providers of mental health care. Seventy‐six percent of those receiving any mental health care reported using this type of service, often in conjunction with another health service.5 The Australian Burden of Disease and Injury study found that mental disorders were the leading cause of years of life lost due to disability (YLD), and depression was the leading cause of non‐fatal disease burden.2 Together, these findings indicated a need for effective treatments for mental disorders, including high‐prevalence disorders such as depression and anxiety that are available to a greater proportion of the Australian population.3 The policy response to these findings was to expand the population health scope of the National Mental Health Strategy and to develop a focus on primary mental health care with the aim of increasing the treatment rates for common mental disorders.

Recently, several wide‐scoping reviews into the provision of mental health services in Australia6‐9 have highlighted the still‐pressing need for people with mental illness to have greater access to ‐ that is, an opportunity to utilise ‐ mental health services, particularly evidence‐based treatments by specialist providers such as psychiatrists and psychologists. ‘Out of hospital, out of mind’, an inquiry conducted by the Mental Health Council of Australia (MHCA) in 2002,7 recommended “incentives for psychiatrists and other specialists to increase their consultancy to primary care” (p. 40), and that “increased access to therapies … in both the public and private sectors … could be enhanced by the inclusion of psychological therapies under the Medicare Benefits Schedule” (p. 26). This latter recommendation was repeated in a subsequent review by the MHCA,6 a Senate inquiry,8 and is consistent with expert opinion.10

’Out of hospital, out of mind’7 identified the cost of specialised mental health services, such as psychiatry and psychology, as a significant barrier to meeting the treatment needs of people with mental illness. In 2006, Hickie and colleagues10 reported that the affordability of these services has also been worsening in recent years, with the average out‐of‐pocket cost (i.e., difference between fees charged and Medicare rebate paid) to consult a psychiatrist increasing by 39% between 1995/96 and 2001/02. In the same year, a Senate inquiry8 attributed these rising costs to a progressive decline in the number of psychiatrists working in the public sector, and a dearth of Medicate‐rebated psychological services.

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Two programs have been pivotal components of the reforms addressing gaps in the provision of accessible and evidence‐based treatments for common mental disorders. In July 2001 the Better Outcomes in Mental Health Care (BOiMHC) program (http://www.health.gov.au/internet/main/publishing.nsf/Content/mental‐boimhc)11 was introduced, which enabled psychological services to be provided through the use of locally negotiated service contracts between Divisions of General Practice and allied health professionals. BOiMHC is a two‐component program designed to improve access to high quality mental health care for Australians. One of the key components is the Access to Allied Psychological Services (ATAPS) component, which enables GPs to refer consumers with high prevalence mental health disorders to allied health professionals (mainly psychologists, but also social workers, mental health nurses, occupational therapists and Aboriginal and Torres Strait Islander health workers) for affordable, evidence‐based mental health care. Consumers can receive up to 12 (or 18 in exceptional circumstances) individual and/or group sessions of government‐subsidised, focused psychological strategies per calendar year. The extent of service delivery determined by the capped funding granted to Divisions of General Practice, who act as fund‐holders for this program. The program continues today, and is supported by evidence that it is meeting demand for psychological services among its intended target group12 and is achieving positive outcomes for its consumers.13

More recently, the Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule (Better Access) initiative (http://www.health.gov.au/internet/main/publishing.nsf/Content/coag‐mental‐q&a.htm)14 was introduced as pivotal component of the Council of Australian Governments (COAG) National Action Plan on Mental Health 2006‐2011.15 It complements the BOiMHC program, by offering a range of mental health services for consumers which are either partially or fully funded by Medicare. The initiative is described in more detail below.

1.2 OVERVIEW OF THE BETTER ACCESS INITIATIVE

1.2.1 AIMS AND OBJECTIVES

The highest level aim of Better Access is to improve outcomes for people with mental disorders by providing new and increased rebates for Medicare‐subsidised services and encouraging a multi‐disciplinary approach to mental health care. A number of lower level objectives support this aim. These include: encouraging GPs to undertake early intervention, assessment and management of patients; supporting GPs and primary care service providers with education and training to better diagnose and treat mental illness; encouraging private psychiatrists to see more new patients; streamlining access to appropriate psychological interventions in primary care; and providing referral pathways for appropriate treatment of patients with mental disorders, including by psychiatrists, GPs, clinical psychologists and other appropriately trained allied mental health professionals.14

1.2.2 MBS ITEM NUMBERS

Under Better Access a series of item numbers were added to the Medicare Benefits Schedule (MBS). The specific MBS items numbers include:

http://www.health.gov.au/internet/main/publishing.nsf/Content/mental-boimhc�

http://www.health.gov.au/internet/main/publishing.nsf/Content/coag-mental-q&a.htm�

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• GP Mental Health Treatment item numbers: These reimburse GPs for preparing (2710 and 2702) and reviewing (2712) mental health treatment plans, and providing mental health treatment consultations (2713);

• Consultant Psychiatry item numbers: These reimburse psychiatrists for conducting an initial consultation with a new patient in their consulting rooms, in a hospital or at the patient’s home (296, 297 and 299, respectively), for providing and reviewing a patient assessment and management plan (291a and 293a, respectively); and

• Allied health professional item numbers: These reimburse clinical psychologists for delivering Psychological Therapy Services (80000, 80005, 80010, 80015 and 80020), registered psychologists for providing Focussed Psychological Strategies (80100, 80105, 80110, 80115 and 80120), selected occupational therapists for providing Focussed Psychological Strategies (80125, 80130, 80135, 80140 and 80145) and selected social workers for providing Focussed Psychological Strategies (80150, 80155, 80160, 80165 and 80170).

Focussed Psychological Strategies are defined as specific mental health treatment strategies derived from evidence based psychological therapies; these include cognitive behavioural therapy, interpersonal therapy, psychotherapy and motivational interviewing. Psychological Therapy Services include psycho‐education and cognitive behavioural therapy, with other evidence‐based therapies, such as interpersonal therapy, used if clinically indicated.

The costs of services provided under the Better Access MBS items are reimbursed in part or wholly by Medicare Australia. The relevant provider can either bulk‐bill the consumer (by charging the schedule fee and directly billing Medicare Australia), or can bill the consumer an amount above the schedule fee and the consumer can then obtain a rebate up to the level of the schedule fee from Medicare Australia. A complete list of the Better Access MBS items, including schedule fee and rebate information, is shown in Table 1.1.

a These two item numbers existed prior to the introduction of the Better Access initiative, but became part of the cohesive core of Medicare‐subsidised services provided through Better Access and became associated with a higher rebate under Better Access.

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Table 1.1 Better Access MBS items, as at 31 March 2010

MBS ITEM PROVIDER ITEM DESCRIPTION DETAIL SCHEDULE

FEE MBS

REBATE

Consultant Psychiatry Items 291a Consultant Psychiatrists Referred Patient Assessment and

Management 45+ minute consultation $427.80 $363.65 293 a Consultant Psychiatrists Review of Referred Patient

Assessment and Management 30‐45 min consultation $267.40 $227.30 296 Consultant Psychiatrists Initial Consultation on a New

Patient ─ in rooms 45+ minute consultation $246.00 $209.10 297 Consultant Psychiatrists Initial Consultation on a New

Patient ─ in hospital 45+ minute consultation $246.00 $209.10 299 Consultant Psychiatrists Initial Consultation on a New

Patient ─ home visit 45+ minute consultation $294.20 $250.10 GP Mental Health Treatment Items 2710 General Practitioners

GP Mental Health Treatment Plan GP has undertaken mental health skills training $160.45 $160.45

2702b General Practitioners GP Mental Health Treatment Plan

GP has not undertaken mental health skills training $125.95 $125.95

2712 General Practitioners Review of a GP Mental Health Treatment Plan $106.95 $106.95

2713 General Practitioners GP Mental Health Consultation 20+ minute consultation $70.60 $70.60 Psychological Therapy Services Items 80000 Clinical Psychologists Psychological Therapy Services ─

in rooms 30‐50 minute consultation $94.30 $80.20 80005 Clinical Psychologists Psychological Therapy Services ─

out of rooms 30‐50 minute consultation $117.85 $100.20 80010 Clinical Psychologists Psychological Therapy Services ─

in rooms 50+ minute consultation $138.40 $117.65 80015 Clinical Psychologists Psychological Therapy Services ─

out of rooms 50+ minute consultation $161.95 $137.70 80020 Clinical Psychologists Psychological Therapy Services

Group Session ─ 6 to 10 patients 60+ minute consultation $35.15 (per patient)

$29.90 (per patient)

Focussed Psychological Strategies ‐ Allied Mental Health Items 80100 General Psychologists FPS Service ─ in rooms 20‐50 minute consultation $66.80 $56.80 80105 General Psychologists FPS Service ─ out of rooms 20‐50 minute consultation $90.85 $77.25 80110 General Psychologists FPS Service ─ in rooms 50+ minute consultation $94.30 $80.20 80115 General Psychologists FPS Service ─ out of rooms 50+ minute consultation $118.40 $100.65 80120 General Psychologists FPS Service Group Session ─ 6 to

10 patients 60+ minute consultation $24.05 (per patient)


80125 Occupational Therapists FPS Service ─ in rooms 20‐50 minute consultation $58.85 $50.05 80130 Occupational Therapists FPS Service ─ out of rooms 20‐50 minute consultation $82.85 $70.45 80135 Occupational Therapists FPS Service ─ in rooms 50+ minute consultation $83.10 $70.65 80140 Occupational Therapists FPS Service ─ out of rooms 50+ minute consultation $107.10 $91.05 80145 Occupational Therapists FPS Service Group Session ─ 6 to



80150 Social Workers FPS Service ─ in rooms 20‐50 minute consultation $58.85 $50.05 80155 Social Workers FPS Service ─ out of rooms 20‐50 minute consultation $82.85 $70.45 80160 Social Workers FPS Service ─ in rooms 50+ minute consultation $83.10 $70.65 80165 Social Workers FPS Service ─ out of rooms 50+ minute consultation $107.10 $91.05 80170 Social Workers FPS Service Group Session ─ 6 to



Sources: (a) Department of Health and Ageing (2008);16 (b) Department of Health and Ageing (2008)17 Items and fees are as effective at 31 March 2010, the latest date of Better Access MBS items considered in this report. a These items existed prior to 1 November 2006, but the fees and rebates attached to them were increased as part of the Better Access initiative. b Item 2702 commenced 1 January 2010. Previously services captured under 2702 were captured under 2710, which did not distinguish between GPs on the basis of mental health skills training.

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1.2.3 REFERRAL PATHWAYS AND PROTOCOLS

To be eligible for Psychological Therapy Services and Focussed Psychological Strategies services the consumer must meet diagnostic criteria for a mental disorder, and be referred from an appropriate medical practitioner ‐ a GP, psychiatrist or paediatrician. The GP is required to prepare a Mental Health Treatment Plan (including a relevant history, mental state examination, diagnostic formulation and management) under item 2710. The Plan is expected to identify the clinical rationale for the referral. Referrals can be made for up to 12 individual (18 in exceptional circumstances) and 12 group treatment sessions in a calendar year. After the initial course of treatment (a maximum of 6 services but may be less depending on the referral) the allied health professional is required to write a report to the referring practitioner, who then conducts a review and, if appropriate, approves the next six sessions. It is intended that GPs use the GP Mental Health Treatment Review item (2712) for this purpose.

1.3 EVALUATION OF THE BETTER ACCESS INITIATIVE

A comprehensive evaluation of the Better Access initiative was commissioned by the Department of Health and Ageing (DoHA), to be conducted within an overarching evaluation framework that describes the program logic of the initiative. The evaluation explores a range of questions related to the broad areas of service access, appropriateness, effectiveness and impacts (on the mental health care system and its workforce). Four evaluation components were funded, namely: a study of consumers and their outcomes (Component A); an analysis of MBS and Pharmaceutical Benefits Scheme (PBS) administrative data (Component B); an analysis of allied mental health workforce supply and distribution (Component C); and consultation with stakeholders (Component D).

A consortium led by the Centre for Health Policy, Programs and Economics (School of Population Health, The University of Melbourne) was commissioned to conduct Component B. Component B involves an analysis of Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data to profile the uptake of the item numbers and examine the impact of Better Access on patterns of MBS, PBS and other service usage over the two years prior to the introduction of Better Access and the two to three years following.

1.4 THE CURRENT REPORT

The current report presents the findings of Component B. Chapter 2 describes the data sources used and the methods of analysis. Chapters 3 to 9 outline the key findings from a series of analyses addressing the seven core evaluation questions relating to access, affordability of care, equity, protocol‐based care, interdisciplinary care, impact on medication prescribing and impact on other mental health programs. Chapter 10 summarises the findings, and interprets these in the context of the existing literature on Better Access and future research directions. A Glossary and List of Abbreviations are provided in Appendices 1 and 2, respectively.

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CHAPTER 2: METHOD

2.1 EVALUATION QUESTIONS

Component B is designed address seven evaluation questions relating to the uptake of services through the Better Access initiative:

• Question 1: To what extent has the Better Access initiative provided access to mental health care for people with mental disorders? Across all of Australia? Across all age groups?

• Question 2: To what extent has the Better Access initiative provided access to affordable care?

• Question 3: To what extent has the Better Access initiative provided equitable access to populations in need? (in particular people living in rural and remote areas, children and young people, older persons, Indigenous Australians, people from culturally and linguistically diverse backgrounds)

• Question 4: To what extent has the Better Access initiative provided evidence‐based mental health care to people with mental disorders?

• Question 5: To what extent has the Better Access initiative provided interdisciplinary primary mental health care for people with mental disorders?

• Question 6: To what extent has the Better Access initiative impacted on the use of medications commonly prescribed for treatment of mental disorders, in particular antidepressant medications?

• Question 7: To what extent has the Better Access initiative impacted on related MBS services?

Questions 1 to 5 relate to the uptake of the Better Access item numbers during the first three years of their introduction. Questions 6 and 7 consider the two years prior to introduction of Better Access and two to three years following (depending on data availability).

2.2 DATA SOURCES

The data used in the Component B evaluation has been obtained from multiple sources. The contribution of each source to addressing the seven evaluation questions is shown in Table 2.1.b

b It was originally planned that Evaluation Question 7 would also be informed by data from the Community Mental Health Care National Minimum dataset, which would be used to describe rates of use of public sector community mental health services. Unfortunately, it was not possible to obtain these data.

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Table 2.1 Relationship between the evaluation questions and key data sources

Med

icare Be

nefits

Sche

dule data

Pharmaceu

tical Ben

efits

Sche

me da

ta

Australian Bu

reau

of

Statistics C

ensus da

ta

Access to

Allied

Psycho

logical Services

projects’ m

inim

um dataset

2007

Nationa

l Survey of

Men

tal H

ealth

and

Wellbeing

Question 1: To what extent has the Better Access initiative provided access to mental health care for people with mental disorders? Across all of Australia? Across all age groups?

Question 2: To what extent has the Better Access initiative provided access to affordable care?

Question 3: To what extent has the Better Access initiative provided equitable access to populations in need? (in particular people living in rural and remote areas, children and young people, older persons, Indigenous Australians, people from culturally and linguistically diverse backgrounds.

Question 4: To what extent has the Better Access initiative provided evidence‐based mental health care to people with mental disorders?

Question 5: To what extent has the Better Access initiative provided interdisciplinary primary mental health care for people with mental disorders?

Question 6: To what extent has the Better Access initiative impacted on the use of medications commonly prescribed for treatment of mental disorders, in particular antidepressant medications?

Question 7: To what extent has the Better Access initiative impacted on related MBS (and other) services?

The remainder of this chapter gives a brief description of the data sources used and the statistical methods employed in their analysis.

2.2.1 MEDICARE BENEFITS SCHEDULE DATA

SCOPE OF DATA

Data on the activity of all providers making claims through the Medicare Benefits Schedule (MBS) is collected by Medicare Australia. The MBS items used in this report included the 29 Better Access MBS items plus 66 ‘other mental health’ MBS items. The Data Analysis & Program Evaluation, Workforce Development Branch, Mental Health & Workforce Division of the Department of Health and Ageing provided a spreadsheet identifying all mental health MBS items as at 4 August 2008. One additional Better Access item was subsequently added – item 2702 (GP Mental Health Treatment Plan by a general practitioner who has not undertaken mental health skills training), which was introduced in January 2010. A summary of the mental health MBS items is provided in Table 2.2.

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Table 2.2 Mental health MBS items used in this report

Program Item group MBS item numbers Better Outcomes in Mental Health Care

GP 3‐Step Mental Health Care Plan (General Practice attendance)a

2574, 2575, 2577, 2578

GP 3‐Step Mental Health Care Plan (other non‐referred attendance)a

2704, 2705, 2707, 2708

GP Focussed Psychological Strategies 2721, 2723, 2725, 2727 Better Access Psychiatrist

‐‐Initial consultationb ‐‐Assessment and Management Planb ‐‐Review of Management Planb

296, 297, 299 291 293

GP Mental Health Treatment ‐‐Planb ‐‐Reviewb ‐‐Consultationb

2710, 2702e 2712 2713

Psychological Therapy Services ‐‐Clinical Psychologistb

80000, 80005, 80010, 80015, 80020

Focussed Psychological Strategies (Allied Mental Health) ‐‐Psychologistb

80100, 80105, 80110, 80115, 80120

‐‐Occupational Therapistb 80125, 80130, 80135, 80140, 80145 ‐‐Social Workerb 80150, 80155, 80160, 80165, 80170

Chronic Disease Management

Community Case Conference – Psychiatrist 855, 857, 858, 861, 864, 866

Enhanced Primary Care

Enhanced Primary Care Plan ‐‐Mental Health Worker ‐‐Psychology Health Service

10956 10968

Psychiatrist Items Management Plan ‐‐Assessmentc ‐‐Reviewc

291 293

Consultation ‐‐Consulting room ‐‐Hospital ‐‐Other locations ‐‐Mixed

300, 302, 304, 306, 308, 310, 312, 314, 316, 318, 319 320, 322, 324, 326, 328, 330, 332, 334, 336, 338 289d

Group Therapy 342, 344, 346 Consultation with non‐patient 348, 350, 352 Telepsychiatry 353, 355, 356, 357, 358, 359f, 361f

Consultation post‐telepsychiatry 364, 366, 367, 369, 370 Electroconvulsive Therapy 14224

Psychologist Items Psychologist Consultationd 82000, 82015 Other Family Therapy 170, 171, 172

Source: Department of Health and Ageing spreadsheet (personal communication); Adapted from AIHW (2009).18 a Item groups discontinued April 2007; b Commenced November 2006; c Commenced May 2005 and discontinued October 2006; d Commenced August 2008; e Commenced January 2010; f Commenced November 2007.

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The MBS data used in this report were provided by the Medicare Financing and Analysis Branch of the Department of Health and Ageing. The data were extracted from a national dataset of all services rendered on a ‘fee‐for‐service’ basis for which Medicare benefits were paid. This dataset does not capture services provided to public patients in hospitals (where these are funded by state and territory governments), services provided through other publicly funded programs, or private services that are not subsidised by Medicare.

Data were extracted on two occasions during the course of this project. The first extraction included data for the period 1 October 2004 to 31 March 2009 and has regard to all claims processed up until April 2009. The second extraction included data for the period 1 January 2009 to 31 March 2010 and has regard to all claims processed up until April 2010. Footnotes to relevant tables have been used to denote the extraction to which data belong. Note that data provided in the first extraction were not revised in the second extraction to capture adjustments for late claims. The exception was data regarding the first quarter of calendar year 2009 which was included in both extractions, therefore the second extraction was used.

The data included counts of persons, services or benefits paid for MBS‐subsidised mental health services received between 1 October 2004 and 31 March 2010. Most Better Access items were introduced on November 1 2006 (except 291 and 293 which were introduced on May 1 2005, and 2702 which was introduced on 1 January 2010), whereas the other mental health items included items existing prior to that date.

The data were provided in de‐identified, aggregated format according to a set of specifications developed by the consultants based on the data required to address each evaluation question. Datafiles provided the relevant counts for various combinations of MBS items across various reference periods (usually quarterly or annual) in either of two formats: (1) Stratified by reference period, region, relative socio‐economic disadvantage, gender and age group (0‐14, 15, 16‐17, 18‐24, 25‐34, 44‐54, 55‐64, 65‐74, 75‐74, and 85+ years); or (2) Stratified by reference period, Division of General Practice, gender and age group. Items were assigned to reference periods according to the date on which the service was provided, rather than the date on which the service claim was processed.

As most Better Access items were introduced on November 1 2006, counts provided for the December 2006 quarter will not contain data for most Better Access data items during October. The first quarter that provides complete coverage of Better Access uptake is the March 2007 quarter. A caveat to this effect has been included in tables that report quarterly data.

Data on services received includes: total services; total bulk‐billed services; sum of fees charged; sum of benefits paid; total services for which a co‐payment was paid; and sum of co‐payments. For bulk‐billed services the fee charged was set equal to the benefit paid.

METHODS USED TO DETERMINE AGE, GENDER, REGION, RELATIVE SOCIO-ECONOMIC DISADVANTAGE AND DIVISION OF GENERAL PRACTICE

Since consumers’ demographic characteristics (namely, age group and address) can change during a reference period and thus result in an over‐count of consumers, an ‘updating’ rule was applied. Date of birth, gender and patient postcode were obtained for each consumer from the last date of service record for the consumer (having regard to all mental health items) in the reference period. Age was derived as the age of the patient on the last mental health service the patient received in the reference period.

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Regional data was based on the consumers’ enrolment postcode and classified according to the Rural, Remote and Metropolitan Areas (RRMA) classification system.19, 20 The RRMA allocates geographical areas into seven classes: Capital cities (RRMA category 1); Other metropolitan centres (2); Large rural centres (3); Small rural centres (4); Other rural centres (5); Remote centres (6); Other remote areas (7). To facilitate analysis and interpretation, RRMA categories were aggregated into five regions by combining classes 3 and 4 into ‘Rural centres’ and classes 6 and 7 into ‘Remote areas’.

The Index of Relative Socioeconomic Disadvantage (IRSD)21 was used as an area‐based measure of relative socio‐economic disadvantage. The IRSD is one of four Socio‐Economic Indexes for Areas (SEIFA) produced by the ABS using census data. The IRSD score is calculated from socioeconomic characteristics of the residents of a locality relating to low income, low educational attainment, high unemployment, jobs in unskilled occupations, and other indicators of disadvantage such as Indigenous origin, public rental housing, and separated/divorced or single parent households. A concordance file obtained from the ABS website22 was used to map consumer enrolment postcodes to IRSD quintiles, where quintile 1 = most disadvantaged localities and quintile 5 = least disadvantaged localities. Data for postcodes not represented in the ABS concordance file (e.g., PO Box postcodes) were classified as ‘unknown’. In the Northern Territory, a significant number of Medicare claims are through PO Box postcodes (around 25 per cent).

Division of General Practice was based on the consumers’ postcode, rather than the Division in which the provider practices. Since some enrolment postcodes overlap Division of General Practice boundaries, a concordance file23 was used to allocate records to Divisions.

2.2.2 PHARMACEUTICAL BENEFITS SCHEME AND REPATRIATION PHARMACEUTICAL BENEFITS SCHEME DATA

SCOPE OF DATA

Medicare Australia collects data on prescriptions funded through the Pharmaceutical Benefits Scheme (PBS) and Repatriation Pharmaceutical Benefits Schemec (RPBS). Drugs captured by these Schemes are classified according to the Anatomical Therapeutic Classification (ATC) system developed by the World Health Organization.24,d The PBS and RPBS items used in this report included those relating to drugs in the following ATC Level 3 categories: (1) N05B Anxiolytics; and (2) N06A Antidepressants. The anxiolytic medications were Alprazolam, Bromazepam, Buspirone hydrochloride, Diazepam, Flunitrazepam, and Oxazepam. The antidepressant medications were Amitriptyline hydrochloride, Citalopram hydrobromide, Clomipramine hydrochloride, Desvenlafaxine succinate, Dothiepin hydrochloride, Doxepin hydrochloride, Duloxetine hydrochloride, Escitalopram oxalate, Fluoxetine hydrochloride, Fluvoxamine maleate, Imipramine hydrochloride, Lithium carbonate, Mianserin hydrochloride, Mirtazapine, Moclobemide, Nortriptyline hydrochloride, Paroxetine hydrochloride, Phenelzine sulfate,

c Claims under the Repatriation Pharmaceutical Benefits Scheme (RPBS) have been included as they amount to approximately 5% of claims for mental health drugs. d The current report uses the Schedule of Pharmaceutical Benefits version of the ATC classification system, which is slightly different from the WHO version. Notably, Lithium carbonate is classified as an Antidepressant in the PBS Schedule (rather than an Antipsychotic, as in the WHO version).

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Reboxetine mesilate, Sertraline hydrochloride, Tranylcypromine sulfate, and Venlafaxine hydrochloride.

The PBS and RPBS data used in this report were provided by the Pharmaceutical Benefits Division of the Department of Health and Ageing. Data were extracted on two occasions during the course of this project. The first extraction included data for the period 1 October 2004 to 31 March 2009 and was undertaken in August 2009. The second extraction included data for the period 1 January 2009 to 31 December 2009 and was undertaken in June 2010. Footnotes to relevant tables have been used to denote the extraction to which data belong. Note that data provided in the first extraction were not revised in the second extraction to capture adjustments for late claims.

The data included counts of consumers making claims for mental health drugs subsidised by the PBS and RPBS, and the total number of prescriptions claimed, between 1 October 2004 and 31 December 2010.

The data were provided in de‐identified, aggregated format according to specifications developed by the consultants based on the data required to address the relevant evaluation question. Datafiles provided the relevant counts for various combinations of mental health drug items across various reference periods (usually quarterly or annual) in the following format: stratified by reference period, Division of General Practice, contribution type (general or concessional)e, gender and age group (0‐14, 15, 16‐17, 18‐24, 25‐34, 44‐54, 55‐64, 65‐74, 75‐74, and 85+ years).

Items were aggregated into time periods according to the date on which the prescription was supplied, rather than the date of prescribing or that date on which the claim was processed. Records without a unique patient code were excluded from consumer‐based analyses, but were included in prescription‐based analyses.


Methods were the same as those described for the MBS data.

2.2.3 ATAPS MINIMUM DATASET

SCOPE OF DATA

The ATAPS minimum dataset captures routinely collected de‐identified consumer‐level and session‐level information from the ATAPS projects that are currently being run by Divisions of General Practice under the BOiMHC program (see section 1.1 of this report for a description of BOiMHC). The dataset is managed by Strategic Data Ltd, data management subcontractors of the

e There are 2 levels of co‐payments: general ($32.90) and concession ($5.30) (as at January 1, 2009; http://www.health.gov.au/internet/main/publishing.nsf/Content/health‐pbs‐general‐pbs‐co‐payment.htm). People who receive social security benefits because they hold a Pensioner card, a Health Care card or a Commonwealth Seniors Health card are eligible for the concession co‐payment. Most are aged 65 and over. Military veterans covered by the RPBS pay the concession price. The PBS data do not include prescriptions where the average dispensed price is below the patient copayment.

17

Centre for Health Programs, Policy and Economics at the University of Melbourne as part of an ongoing evaluation exercise.

Counts of persons who had received psychological treatments under the ATAPS projectsf were extracted from a consolidated datafile that captured session‐level information including patient demographics (year of birth and gender) and referral characteristics (patient postcode at time of referral, GP postcode, Division of the referring GP) and date of psychological treatment session. Aggregated person counts were derived for each Division, stratified by reference period (quarterly or annual), gender and age group.


Age was calculated as the difference between session year and year of birth.

Geographical area classification for Divisions was sourced from the Division Benchmarking Tool developed by the Primary Health Care Research and Information Service.25 The classification uses five categories based on the Rural, Remote and Metropolitan Areas (RRMA) classification. As a number of Statistical Local Areas (SLAs) contribute to each Division, allocation to the five RRMA categories takes this into account. The five categories were: (1) Metro (>95% of population in RRMA 1,2); (2) Metro/Rural (<95% of population in RRMA 1,2 & <95% in RRMA 3,4,5); (3) Rural (>95% of population in RRMA 3,4,5); (4) Rural/Remote (<95% of population in RRMA 3,4,5 & < 95% in RRMA 6,7); and (5) Remote (>95% of population in RRMA 6,7).

In the ATAPS datasets, Division of General Practice is assigned to each record according to the Division in which the referring GP practices. For consistency with other datasets in the current project a patient‐based Division variable was derived from the patients’ postcode, using a concordance file for mapping postcode to Division.23 In instances where patient postcode was not available (approx. 9% of session records), Division was derived from the GPs postcode or Division.

2.2.4 2007 NATIONAL SURVEY OF MENTAL HEALTH AND WELLBEING

The 2007 National Survey of Mental Health and Wellbeing (2007 NSMHWB) was conducted by the Australian Bureau of Statistics (ABS) between August and December 2007.26, 27 The 2007 NSMHWB is a nationally representative household survey of 8,841 Australians aged 16 to 85 years. Chapter 5 of this report uses a number of measures from the 2007 NSMHWB. These are described below.

The survey instrument was based on a modified version of the World Mental Health Survey Initiative version of the Composite International Diagnostic Interview (WMH‐CIDI 3.0). Lifetime diagnoses of mental disorders were assessed by the WMH‐CIDI 3.0 according to International Classification of Diseases (ICD‐10)28 criteria. Symptoms experienced during the 12 months prior

f For the purpose of analysis the sample was restricted to consumers who received psychological services under the General, Telephone‐CBT, and Postnatal depression ATAPS projects, as the diagnostic eligibility criteria are the same for these three programs. Consumers who received services under the Bushfires and Suicide early intervention ATAPS projects were excluded, due to the broader inclusion criteria of these projects. These latter projects accounted for only 2.7% of ATAPS sessions during the time period of interest.

18

to interview were also assessed, and combined with lifetime diagnosis information to determine 12‐month disorder. The mental disorders assessed were: affective disorders (depression, dysthymia, and bipolar affective disorder); anxiety disorders (panic disorder, agoraphobia, social phobia, generalised anxiety disorder, obsessive‐compulsive disorder and post‐traumatic stress disorder); and substance use disorders (harmful use or dependence of alcohol or drugs).

The functioning module included a measure of ‘Days out of role’, defined as the number of days in the past 30 the respondent was unable to perform, or had to cut down on, their normal activities because of health problems. Psychological distress in the past 30 days was assessed with the Kessler Psychological Distress Scale (K10).29, 30

Suicidality in the past 12 months was assessed by presenting respondents with descriptions of three experiences – ‘seriously thought about suicide’ (suicidal ideation), ‘made a plan for committing suicide’ (suicide plan), and ‘attempted suicide’ (suicide attempt) – and asked if any of these experiences had happened to them in the past 12 months. Respondents were only asked about suicide plans and attempts if they reported suicidal ideation.

The service use module of the 2007 NSMHWB gathered information about respondents’ 12‐month and lifetime use of services for mental health problems. As part of this module, respondents were also asked whether they had been hospitalised for a mental health problem in the past 12 months.

2.2.5 POPULATION DENOMINATORS

Population estimates as at 30 June of each year of interest were provided by the Medicare Financing and Analysis Branch of the Department of Health and Ageing. The estimates were compiled from Australian Bureau of Statistics (ABS) estimated resident population (ERP) by gender, age (single year) and postal area data. Postal area data were used to map postal area data to Division of General Practice, and to IRSD and RRMA classification, using concordance files held by the Medical Benefits Division.

Aggregated population counts were provided in two formats, corresponding to the formats in which MBS and PBS data were requested: (1) stratified by Division of General Practice, gender and age range (0‐14, 15, 16‐17, 18‐24, 25‐34, 44‐54, 55‐64, 65‐74, 75‐74, and 85+ years); and (2) stratified by RRMA, IRSD, gender and age rangeg.

2.3 STATISTICAL METHODS

2.3.1 POPULATION RATES

Crude, age‐standardised and age‐specific rates are presented, as indicated, in this report. Rates are adjusted for age to facilitate comparisons between geographic regions and across time, because the age structures of populations may vary across time or between areas. Standardised rates were calculated using the direct standardisation method with the Australian estimated resident population (persons) as at 30 June 2001 as the standard population (as per ABS and

g At the time of writing, these stratified population estimates were available for 2004 through 2008. 2008 data have been used as the population denominator for 2009 and the March 2010 quarter.

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Australian Institute of Health and Welfare (AIHW) convention). For ease of interpretation, rates of Better Access uptake and other services are expressed per 1,000 population, unless noted otherwise.

2.3.2 DEFLATORS

Expenditure (benefits charged, fees charged and co‐payments) on Medicare services was converted to 2009 dollars to adjust for inflation, using the ratio of Consumer Price Index values in each year to 2009.31

2.3.3 STATISTICAL ANALYSES

All analyses were undertaken using PASW Statistics version 17.0 (SPSS Inc., Chicago IL, 2009) and Stata version 11.0 (StataCorp LP, College Station TX, 2009).

PREDICTORS OF UPTAKE OF BETTER ACCESS AND OTHER SERVICES

Negative binomial rate regression models were used to examine predictors of uptake of Better Access and other services, using a range of aggregated datasets depending on the question being addressed. Negative binomial regression was selected because it is an efficient approach to analysis that allows for the overdispersion (i.e. where the variance is greater than the mean) that commonly characterises count data such as health service utilisation data. It also accommodates non‐normal distributions that are also common in health service utilisation data, and thus avoids the need to transform non‐normally distributed data in order to satisfy the assumptions of general linear model analyses.32 In cases where overdispersion is not present, Poisson regression techniques are preferred. Hence for each of the models evaluated, the Pearson chi‐square statistic (χ2) was calculated. In all relevant cases the value of χ2 divided by the number of observations (n) was greater than 1, which indicates overdispersion, hence the negative binomial model was considered more appropriate. The dependent variable is specified as the count of the health service measure of interest (e.g., number of persons using Better Access services or number of Better Access services used). The negative binomial rate regression model adjusts for the size of the population in each stratum of the dataset (e.g., a Division of General Practice) by incorporating the logarithm of the population size as an offset term. Thus, taking the exponent of each β regression coefficient provides the rate ratio (RR) for a one unit change in the corresponding independent variable.

TIME TRENDS IN UPTAKE RATES OF BETTER ACCESS AND OTHER SERVICES

Negative binomial regression models were also used to assess the magnitude and statistical significance of trends in uptake rates for Better Access and other services over time. In Chapters 3 and 4 these analyses examined trends in uptake of Better Access services (in total, and by various groupings) since the introduction of the initiative, and whether there has been a change in trend as the initiative has become more established. The period of interest for these analyses was from the March 2006 quarter (the first full quarter of Better Access operation) to the end of the March 2010 quarter (the most recent data available to us). The period of establishment of Better Access was defined as the first calendar year of operation (i.e., 2007) and the period post‐establishment as being from 2008 onwards.

20

Three models were used (based on the procedure outlined by Chapman and colleagues33) reflecting the research questions outlined above: Model (a) estimates the trend (measured as the average quarterly change in rate) in uptake in the first calendar year of Better Access; Model (b) estimates the trend (measured as the average quarterly change in rate) in uptake after the first calendar year of Better Access; and Model (c) estimates the effect on trends in uptake pre‐ and post‐ the establishment period. In Model (c) the relative trends in pre/post rates are estimated by the interaction term in a model including terms for pre/post group, time and pre/post group by time.

In Chapters 8 and 9 negative binomial regression was used to examine trends in uptake of other services (i.e., use of antidepressant and anxiolytic medications as recorded on the PBS, non‐Better Access MBS services, and ATAPS psychological services) before and after the introduction of Better Access, and whether there has been a change in trends in uptake of these services associated with the introduction of Better Access. The period of interest for these analyses was from the March 2004 quarter (two years prior to the first full quarter of Better Access operation) to the March 2009 quarter (for non‐Better Access MBS services, and ATAPS psychological services) and the December 2009 quarter for PBS data. Because Better Access services were introduced part‐way into the December 2006 quarter, models of trends pre/post Better Access exclude the December 2006 quarter.

Three models were used, reflecting the three research questions outlined above: Model (a) estimates the trend (measured as the average quarterly change) in uptake of relevant services before the introduction of Better Access; Model (b) estimates the trend in uptake of relevant services (measured as the average quarterly change in rate) in uptake after the introduction of Better Access; and Model (c) estimates the effect on trends in uptake of relevant services associated with the introduction of Better Access. In Model (c) the relative trends in pre/post rates are estimated by the interaction term in a model including terms for pre/post group, time and pre/post group by time.

SYNTHETIC MODELLING OF POPULATION NEED (CHAPTER 5)

Chapter 5 uses a synthetic estimation and modeling approach to investigate whether Better Access services and expenditure are being distributed among Australian adults according to need. The procedure is based on previous studies34, 35 and involves 5 steps:

Step 1: Defining geographic units.

Divisions of General Practice were chosen as the geographic unit for analysis. Divisions are funded by the Australian Government Department of Health and Ageing to co‐ordinate local primary care services, and to improve the quality of general practice care and health outcomes for local communities.36 As already described, the Medicare Financing and Analysis Branch of the Department of Health and Ageing provided population structure estimates for each of the 113 Divisions of General Practice in Australia. For the current analyses, the relevant population structures within each Division involved gender (male, female), age group (16‐19, 20‐24, 25‐29, 30‐34, 35‐39, 40‐44, 45‐49, 50‐54, 55‐59, 60‐64, 65‐69, 70‐74, 75‐79, 80‐84 years)h and section of

h The age range was restricted to individuals aged 16 to 84 years because this is the group for which the full range of data required for analysis was available. The 2007 NSMHWB provided individual level information on adults aged 16 to 85 years. MBS Better Access service use data and population

21

state (capital cities, other metropolitan regions, remainder). This yielded 84 strata (2 gender x 14 age group x 3 section of state categories) within each Division.

Step 2: Deriving a measure of mental health need.

Level of adult population‐based mental health need was modelled using data from the 2007 NSMHWB (see section 2.2.4 for an overview of the survey and explanation of the measures used in the current evaluation). For the current study, mental health need was defined as having at least one of the following: (1) an ICD‐10 12‐month affective, anxiety or substance use disorder; (2) 12‐month symptoms (but no ICD‐10 lifetime disorder); (3) any psychiatric hospitalisation in the past 12 months; (4) high or very high level of psychological distress on the K10 measure; (5) 7 or more days out of role; or (6) any suicidality in the past 12 months.

The approach to modelling mental health need was inclusive. That is, it took into consideration the groups to whom Better Access services are principally targeted (namely the common mental disorders including affective, anxiety and substance use disorders), as well as other factors that may prompt individuals to seek treatment. This decision was guided by a previous study which, using data from the 2007 NSMHWB, estimated that 81.7% of users of Better Access services provided by allied health professionals had a 12‐month ICD‐10 affective, anxiety or substance use disorder, and a further 11.5% of users had at least one other indicator of potential need (which included lifetime disorder, 12‐month symptoms or lifetime hospitalisation for a mental disorder).37 Definitions of mental health need based on diagnostic criteria alone were also considered, but were thought to be too restrictive in scope and to not fully represent the range of reasons for which people may use Better Access services.

Using age , gender, and section of state information collected by the 2007 NSMHWB, the rates of mental health need for each of the 84 population strata were calculated. By taking this population category data from the 2007 NSMHWB, and weighting each Division of General Practice according to its population structure, it was then possible to model the percentage of each Division with mental health need.

Step 3: Other explanatory variables.

A range of other Division‐level variables were also obtained for consideration as independent variables in the analyses. These included:

• A measure of GP workforce supply. The supply measure was the count of full‐time workload equivalence (FWE) of GPs in each Division in 2008‐09. The GP FWE is a measure of workload that takes into account the differing working patterns of GPs. FWE is calculated by dividing each doctor’s Medicare billing by the average billing of full‐time doctors for the year. The FWE are allocated to the Division in which the GPs’ services are claimed, thus accounting for instances where a GP has worked in more than one Division of General Practice. The GP FWE estimates were obtained from the Primary Health Care Research and Information Service website25, and are based on data from the Department of Health and Ageing.

• Indicators of potential to access services. These included: (1) eight State/Territory indicators (yes, no) specifying the state or territory in which each Division of General

structure were available by single year of age up to 84 years, but were aggregated for all ages 85 years and above.

22

Practice is located; and (2) the percentage of the population in each Division living in a remote locality (as judged by RRMA categories 6 and 7). This measure was selected because, as shown in Chapter 3 of this report, the most marked differences in Better Access uptake rates are between people in remote locations as compared to all other locations.

• Measures of other Divisional characteristics. These included: (1) the percentage of Division population (aged 15 years and over) participating in the labour force; (2) the percentage of Division population unemployed; (3) the percentage of Division population living in localities of greater relative socioeconomic disadvantage (as defined by IRSED deciles 1 to 2). The latter measure was selected because it takes into account that the distribution of IRSD deciles in each Divisions varies. As shown in Chapter 3 of this report, the most marked differences in Better Access uptake rates tend to be between people in areas of greater socioeconomic disadvantage compared to all other locations. Information about the distribution of IRSD deciles by Division of General Practice was provided by the Medicare Financing and Analysis Branch of the Department of Health and Ageing.25 All other measures of Division characteristics were obtained from the Public Health Information Development Unit website.38

Step 4: Defining the outcome measures.

Two outcome variables were derived: (1) total MBS‐subsidised Better Access services received in 2009 (crude rate per 1,000 population); and (2) total MBS‐subsidised allied health Better Access services received in 2009 (crude rate per 1,000 population). The Medicare Financing and Analysis Branch of the Department of Health and Ageing provided the Better Access service use and population data required to calculate these outcome variables for each of the 113 Divisions. Analyses were conducted using 2009 data, as these are assumed to better represent established Better Access utilisation patterns than earlier years.

Step 5: Data analysis.

A series of multivariate regression equations was developed (using Ordinary Least Squares regression) in which total Better Access services used and total allied health Better Access services used were predicted by mental health need and the other explanatory factors. The distributions of the two outcome measures were examined to assess whether they satisfied the assumption of normality for linear regression. The ratio of the skewness and kurtosis statistics to their standard errors indicated no significant departure from normality for either measure.

The best fitting models for the data were obtained using an hierarchical model‐building process comprising 5 steps. Step 1 included the GP supply factor variable: GP FWE. Step 2 included the measures of potential to access services: remoteness, and state/territory. Step 3 included the measure of mental health need. Step 4 included other Division characteristics: labour force participation, unemployment, and relative socioeconomic disadvantage. The successive contribution of the variables in each step to the explanatory power of the model was examined using the R2 statistic. Variables that were associated with the outcome variables in univariate analyses at or below the 0.15 probability level were considered for inclusion in the models. In addition, each predictor was retained only if it contributed at least an additional 1% to the variance explained by the model. All candidate variables for analysis were screened for multicollinearity using standard regression diagnostics, including tolerance, variance inflation

23

factors, and variance decomposition proportions. With respect to outliers, extreme cases (standardised residuals > 3) were excluded from the final models.

Divisions of General Practice were weighted to reflect their population size. In an unweighted analysis, each Division of General Practice would have had equal bearing, regardless of its population size. However, as some Divisions are many times larger than others, it was considered that analyses should take this into account.

Data from the 2007 NSMHWB Basic Confidentialised Unit Record File, April 2009 version39 were weighted to account for the differential probability of survey selection and to ensure conformity to known population distributions. Standard errors and 95% confidence intervals (CIs) were calculated using jackknife repeated replication to take account of the complex survey design.

2.4 ETHICS APPROVAL

The study received approval from The University of Melbourne’s Health Sciences Human Ethics Sub‐Committee (Ethics ID: 0930991) and The University of Queensland’s Behavioural & Social Sciences Ethical Review Committee (#2009001396).

24

CHAPTER 3: ACCESS

3.1 OVERVIEW

This chapter considers Evaluation Question 1: To what extent has the Better Access initiative provided access to mental health care for people with mental disorders? Across all of Australia? Across all age groups? Specifically, the chapter examines the rate of uptake of MBS‐subsidised Better Access items for the total Australian population and for key population sub‐groups. Analyses are conducted using data on Medicare‐subsidised Better Access services received since the inception of the program on 1 November 2006. The focus is on the number of persons using these services, rather than the number of services they used.

To examine the broad question of access, descriptive statistics were generated describing the number and demographic profile (age group, sex, geographical location, and socio‐economic disadvantage group) of consumers who have been provided with MBS‐subsidised mental health services under the Better Access initiative. In addition to a summary profile including all relevant MBS items, profiles were generated separately by item group (Consultant Psychiatry Items [291‐299], GP Mental Health Treatment Items [2710‐2713, 2702], Psychological Therapy Services Items [80000‐80020], and Focussed Psychological Strategies [80100‐80170]) and provider type (General Practitioner, Consultant Psychiatrist, Clinical Psychologist, General Psychologist, Occupational Therapist and Social Worker). The items accounting for the greatest uptake within each item group were also profiled. Trends in uptake over time were examined in order to determine whether there have been changes in the rate of uptake as the Better Access initiative has become more established. Finally, the extent to which Better Access providing services to ‘new’ consumers, that is, consumers who have not previously used these services, was examined.

The analyses presented in this chapter address Evaluation Question 1 via the following series of research questions:

1. What has been the rate of uptake of Better Access services overall?

2. What has been the rate of uptake of Better Access by item group?

3. What has been the rate of uptake of Better Access by item provider type?

4. What has been the relative uptake of items within items groups?

5. What are the socio‐demographic characteristics of consumers who have received Better Access services?

6. Have there been changes over time in the socio‐demographic profile of consumers who have received Better Access services?

7. To what extent is Better Access providing services to ‘new’ consumers?

25

3.2 WHAT HAS BEEN THE RATE OF UPTAKE OF BETTER ACCESS SERVICES OVERALL?

The uptake of Better Access has been substantial. The age‐standardised uptake rate of any MBS‐subsidised Better Access item was 33.8 persons per 1,000 total population (3.4% of the total population or 710,840 persons) in 2007, rising to 44.5 persons per 1,000 in 2008 (4.4% of the total population or 951,454 persons), and further to 52.8 persons per 1,000 total population in 2009 (5.3% of the total population or 1,130,384 persons) (Table 3.1). Expressed another way, one in every 30 Australians received at least one Better Access service in 2007, one in every 23 did so in 2008, and one in every 19 did so in 2009.

Table 3.1 Persons receiving MBS‐subsidised Better Access services, 2007, 2008 and 2009

2007 2008 2009 N

persons % of

persons Rate (per

1,000) N

persons % of

persons Rate (per

1,000) N

persons % of

persons Rate (per

1,000)

All Better Access items 710,840 100.0 33.8 951,454 100.0 44.5 1,130,384 100.0 52.8

2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. Rate per 1,000 total population; Rates are directly age‐standardised.

Table 3.1 shows that Better Access uptake increased annually by 31.7% between 2007 and 2008, and by 18.7% between 2008 and 2009. The magnitude and statistical significance of trends in uptake rates for Better Access, were further examined via a series of negative binomial regression models (see section 2.3.4 of this report for further information). Specifically, these analyses were used to estimate the trends in uptake of Better Access services since the introduction of the initiative, and to identify whether there has been a change in trend as the initiative has become more established. The period of interest for these analyses was from the March 2007 quarter (the first full quarter of Better Access operation) to the end of the March 2010 quarter (the most recent data available to us). The period of establishment of Better Access (defined as the 2007 calendar year, the first year of operation) was compared with the period post‐establishment (defined as being from 2008 onwards).

Figure 3.1 plots the growth in rates of uptake by quarter from the December 2006 quarter to the March 2010 quarter. This shows that that the rate of uptake of any Better Access item rose from 10.4 per 1,000 total population in the March 2007 quarter to 23.0 per 1,000 in the March 2010 quarter.

26

Fig 3.1 Uptake of any Better Access item by quarter, December 2006 quarter to March 2010 quarter.

Table 3.2 presents the results of the trend analyses. During 2007, uptake showed an average quarterly increase of 13.3% (RR = 1.133, 95% CI 1.090 to 1.177, P < 0.001). Uptake was still increasing after 2007, but slowed to 4.6% per quarter (RR = 1.046, 95% CI 1.036 to 1.056, P < 0.001). This decrease in growth was statistically significant (RR = 0.924, 95% CI 0.890‐0.958, P ≤ 0.001).

Table 3.2 Estimated change in trends for uptake of MBS‐subsidised Better Access services, March 2007 quarter to March 2010 quarter

Trend in year 2007 Trend after 2007 Ratio of trendsa RR (95% CI) P RR (95% CI) P RR (95% CI) P All Better Access items 1.113 (1.090‐1.177) <0.001 1.046 (1.036‐1.056) <0.001 0.924 (0.890‐0.958) 0.001

2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. RR, rate ratio; CI, confidence interval. a The ratio of the post‐2007 trend to the 2007 trend.

3.3 WHAT HAS BEEN THE RATE OF UPTAKE OF BETTER ACCESS SERVICES BY ITEM GROUP?

Using the same procedure, patterns in uptake of Better Access items were examined separately by item group. Table 3.3 shows the number of persons who received services in each item group, as well as the percentage they represent of all Better Access users, and the rate of uptake of each item group per 1,000 population for 2007, 2008 and 2009. Annual rates of uptake increased in each successive year for all item groups. For most item groups, however, the rate of increase slowed over time. The successive increases from 2007 to 2008, and 2008 to 2009 for each item group were: General Practitioner items, 29.8% and 18.5%; Psychological Therapy Services items, 51.1% and 25.4%; and Focussed Psychological Strategies items, 36.1% and 21.1%. The exception

0

5

10

15

20

25

Rate per 1,000

pop

ulation

Quarter

27

was the Consultant Psychiatry items, for which rates increased by 4.8% between 2007 to 2008 and by 6.8% between 2008 and 2009.

Table 3.3 Persons receiving MBS‐subsidised Better Access services by item group, 2007, 2008 and 2009

2007 2008 2009 N

persons % of

persons Rate (per

1,000) N

persons % of

persons Rate (per

1,000) N

persons % of

persons Rate (per

1,000)

Item group GP items 618,867 87.1 29.5 817,738 85.9 38.3 971,836 86.0 45.4 CP items 87,947 12.4 4.2 93,736 9.9 4.4 100,434 8.9 4.7 PTS items 98,612 13.9 4.7 151,587 15.9 7.1 189,418 16.8 8.9 FPS items 226,169 31.8 10.8 312,035 32.8 14.7 379,284 33.6 17.8

All Better Access itemsa 710,840 33.8 951,454 44.5 1,130,384 52.8

2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. GP, General practitioner; CP, Consultant Psychiatry; PTS Psychological Therapy Services; FPS, Focussed Psychological Strategies; Rate per 1,000 total population; Rates are directly age‐standardised. a The sum of persons receiving services under each item group will be greater than for all Better Access items because a person may receive services from more than one item group.

Table 3.3 shows the relative percentage of Better Access users who used each of the item groups:

• In each of 2007, 2008 and 2009, the majority of Better Access service users received at least one of the GP Mental Health Treatment items, which reflects the function of the GP Mental Health Treatment Plan (2710) and Review (2712) items as ‘gateways’ to further Better Access services.

• Uptake of the Focussed Psychological Strategies items was the second greatest in magnitude, with approximately one‐third of Better Access service users receiving at least one of these services (31.8% in 2007, 32.8% in 2008, and 33.6% in 2009).

• Uptake of Psychological Therapy Services items was the third greatest in magnitude with 13.9% of Better Access users receiving at least one of these services in 2007, 15.9% in 2008, and 16.8% in 2009.

• Uptake of the Consultant Psychiatry items was the smallest in magnitude, with 12.4% of Better Access users receiving at least one of these services in 2007, 9.9% in 2008, and 8.9% in 2009.

Figure 3.2 plots the growth in rates of uptake for each item group from the December 2006 quarter to the March 2010 quarter, for each item group.

28

Fig 3.2 Uptake of Better Access item groups by quarter, December 2006 quarter to March 2010 quarter.

Comparisons of the 2007 and post‐2007 trends for each item group are shown in Table 3.4.

Table 3.4 Estimated change in trends for uptake of MBS‐subsidised Better Access services by Item group, March 2007 quarter to March 2010 quarter

Trend in year 2007 Trend after 2007 Ratio of trendsa RR (95% CI) P RR (95% CI) P RR (95% CI) P GP items 1.073 (1.051‐1.094) <0.001 1.044 (1.035‐1.053) <0.001 0.973 (0.945‐1.002) 0.067 CP items 1.008 (1.982‐1.034) 0.567 1.009 (0.995‐1.022) 0.198 1.001 (0.959‐1.045) 0.958 PTS items 1.238 (1.138‐1.348) <0.001 1.056 (1.041‐1.072) <0.001 0.853 (0.798‐0.912) <0.001 FPS items 1.204 (1.123‐1.291) <0.001 1.048 (1.034‐1.062) <0.001 0.871 (0.822‐0.922) <0.001

2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. GP, General practitioner; CP, Consultant psychiatrist; PTS Psychological Therapy Services; FPS, Focussed Psychological Strategies; RR, rate ratio; CI, confidence interval. a The ratio of the post‐2007 trend to the 2007 trend.

Together, Figure 3.2 and Table 3.4 indicate that:

• The rate of uptake of any GP Mental Health Treatment Better Access item rose significantly from 8.3 persons per 1,000 total population in the March 2007 quarter to 16.4 persons per 1,000 in the March 2010 quarter. Uptake of these items increased significantly in both the 2007 (RR = 1.073; P < 0.001) and post‐2007 (RR = 1.044; P < 0.001) periods. Although the rate of growth was somewhat lower in the post‐2007 period, the change in the rate of growth from 2007 was not statistically significant.

0

2

4

6

8

10

12

14

16

18

20

Rate per 1,000

pop

ulation

Quarter

General Practitioner Mental Health TreatmentConsultant psychiatryPsychological therapiesFocussed psychological strategies

29

• The rates of uptake of any Consultant Psychiatry Better Access item were stable between the March 2007 quarter (1.2 persons per 1,000 total population) and the March 2010 quarter (1.2 persons per 1,000 total population). The analysis of trends showed that there was no significant trend in uptake within or between the 2007 and post‐2007 periods.

• The rate of uptake of any Psychological Therapy Services Better Access item rose from 1.3 persons per 1,000 total population in the March 2007 quarter to 4.2 persons per 1,000 in the March 2010 quarter. The rate of uptake of any Focussed Psychological Strategies Better Access item rose from 3.1 per 1,000 total population in the March 2007 quarter to 7.9 per 1,000 in the March 2010 quarter. Uptake of Psychological Therapy Services and Focussed Psychological Strategies items grew significantly in both the 2007 and post‐2007 periods, but the rate of growth was significantly slower after 2007.

3.4 WHAT HAS BEEN THE RATE OF UPTAKE OF BETTER ACCESS SERVICES BY PROVIDER TYPE?

Patterns in uptake of Better Access items were then examined separately by provider type – General Practitioner, Consultant Psychiatrist, Clinical Psychologist, General Psychologist, Occupational Therapist, and Social Worker. Data for the first three provider types map exactly to the General Practitioner Mental Health Treatment, Consultant Psychiatrist and Psychological Therapy Services item groups, respectively, examined in the previous section. However the Focussed Psychological Strategies item group examined previously combines services provided by three provider types ‐ General Psychologists, Occupational Therapists and Social Workers. Hence these provider types are the focus of this section. Table 3.5 shows the number of persons who received services from each provider type, as well as the percentage they represent of all Better Access users, and the rate of uptake of each item group per 1,000 population for 2007, 2008 and 2009.

Table 3.5 Persons receiving MBS‐subsidised Better Access services by provider type, 2007, 2008 and 2009

2007 2008 2009 N

persons % of

persons Rate (per

1,000) N

persons % of

persons Rate (per

1,000) N

persons % of

persons Rate (per

1,000)

Provider type General Practitioner 618,867 87.1 29.5 817,738 85.9 38.3 971,836 86.0 45.4 Consultant psychiatrist 87,947 12.4 4.2 93,736 9.9 4.4 100,434 8.9 4.7 Clinical psychologist 98,612 13.9 4.7 151,587 15.9 7.1 189,418 16.8 8.9 General psychologist 213,963 30.1 10.2 289,785 30.5 13.6 348,417 30.8 16.4 Occupational therapist 2,011 0.3 0.1 3,701 0.4 0.2 5,103 0.5 0.2 Social worker 10,918 1.5 0.5 20,157 2.1 1.0 28,276 2.5 1.3

All Better Access itemsa 710,840 100.0 33.8 951,454 100.0 44.5 1,130,384 100.0 52.8

2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. Rate per 1,000 total population; Rates are directly age‐standardised. a The sum of persons receiving services under each item group will be greater than for all Better Access items because a person may receive services from more than one type of provider.

30

Table 3.5 shows that:

• Annual rates of uptake increased in each successive year for all provider types. For all provider types, however, the rate of increase slowed over time. The successive increases from 2007 to 2008, and 2008 to 2009 for each item group were: General Psychologist, 33.3% and 20.6%; Occupational therapist, 81.8% and 38.2%; and Social Worker, 81.6% and 40.1%.

• Of the 379,284 people using Focussed Psychological Strategies in 2009 (refer to Table 3.3 for total figures), 91.9% (348,417 people) used services provided by general psychologists, 1.3% (5,103 people) used services provided by Occupational Therapists, and 7.5% (28,276 people) used services provided by Social Workers. The corresponding figures for 2007 were 94.6%, 0.9% and 4.8%; for 2008 they were 92.9%, 1.2% and 6.5%.

Figure 3.3 plots the growth in rates of uptake for each item group from the December 2006 quarter to the March 2010 quarter, for each provider type.

Fig 3.3 Uptake of Better Access items by provider type by quarter, December 2006 quarter to March 2010 quarter [GP, General practitioner; CP, Consultant psychiatrist; PTS Psychological Therapy Services; FPS, Focussed Psychological Strategies].

Comparisons of the 2007 and post‐2007 trends for each item group are shown in Table 3.6. Together, Figure 3.3 and Table 3.6 indicate that:

• The rate of uptake of any General Psychologist Better Access item rose from 2.9 persons per 1,000 total population in the March 2007 quarter to 7.2 persons per 1,000 in the March 2010 quarter. Uptake of these items increased significantly in both the 2007 (RR = 1.193; P < 0.001) and post‐2007 (RR = 1.048; P < 0.001)

0

2

4

6

8

10

12

14

16

18

20

Rate per 1,000

pop

ulation

Quarter

General PractitionersConsultant psychiatristsClinical PsychologistsGeneral PsychologistsOccupational TherapistsSocial Workers

31

periods. Although the rate of growth was somewhat lower in the post‐2007 period, but the rate of growth was significantly slower after 2007 (RR = 0.878; P < 0.001).

• The rates of uptake of any Occupational Therapist Better Access item rose from 0.02 persons per 1,000 total population in the March 2007 quarter to 0.11 persons per 1,000 in the March 2010 quarter. The rate of uptake of any Social Worker Better Access item rose from 0.10 per 1,000 total population in the March 2007 quarter to 0.60 per 1,000 in the March 2010 quarter. Uptake of Occupational Therapist and Social Worker items grew significantly in both the 2007 and post‐2007 periods, but the rate of growth was significantly slower after 2007.

Table 3.6 Estimated change in trends for uptake of MBS‐subsidised Better Access services by Item group, March 2007 quarter to March 2010 quarter

Trend in year 2007 Trend after 2007 Ratio of trendsa RR (95% CI) P RR (95% CI) P RR (95% CI) P General Practitioner 1.073 (1.051‐1.094) <0.001 1.044 (1.035‐1.053) <0.001 0.973 (0.945‐1.002) 0.067 Consultant psychiatrist 1.008 (1.982‐1.034) 0.567 1.009 (0.995‐1.022) 0.198 1.001 (0.959‐1.045) 0.958 Clinical psychologist 1.238 (1.138‐1.348) <0.001 1.056 (1.041‐1.072) <0.001 0.853 (0.798‐0.912) <0.001 General psychologist 1.193 (1.114‐1.278) <0.001 1.048 (1.034‐1.062) <0.001 0.878 (0.830‐0.929) <0.001 Occupational therapist 1.445 (1.317‐1.585) <0.001 1.081 (1.056‐1.108) <0.001 0.749 (0.682‐0.821) <0.001 Social worker 1.400 (1.272‐1.540) <0.001 1.083 (1.064‐1.102) <0.001 0.774 (0.717‐0.836) <0.001

2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. RR, rate ratio; CI, confidence interval. a The ratio of the post‐2007 trend to the 2007 trend.

3.5 WHAT HAS BEEN THE RELATIVE UPTAKE OF ITEMS WITHIN ITEM GROUPS?

Uptake rates varied enormously across the 28 items that comprise the suite of Better Access MBS items. Figure 3.4 shows the uptake rate for each item, sorted by descending order of magnitude within each item group. Note that rates less than 0.5 per 1,000 total population are not visible on the figure.

32

Figure 3.4 Uptake of individual Better Access MBS items, in descending order of magnitude within Item group, 2007, 2008 and 2009

A complete list of the uptake rates for individual items is provided in Tables 3.7 and 3.8. The first six rows of Table 3.7 show the six items with the highest uptake rates. These items were used by at least 5% of Better Access users in each of 2007, 2008 and 2009. Tables 3.7 and 3.8 show that:

• Three of the six items with the highest uptake were the GP Mental Health Treatment items (2710, 2712 and 2713).

• The highest uptake rate was for the GP Mental Health Treatment Plan (item 2710), which is consistent with its role as the main point for initial assessment and subsequent referral, if appropriate, to other health Better Access services.

• The ratio of people receiving GP Mental Health Treatment Plans (item 2710) relative to people receiving GP Mental Health Treatment Reviews (item 2712) was 4.6:1 in 2007, decreasing to 3.3:1 in 2008 and 3.1:1 in 2009.

• More than one‐third (36.2%) of Better Access users received at least one GP Mental Health Consultation service (item 2713) in 2009 (31.5% in 2007 and 34.3% in 2008). This service is used for ongoing management of a patient with a mental disorder, including but not limited to, patients being managed under a GP Mental Health Treatment Plan (item 2710). Item 2713 can be used with or without item 2710, however item 2710 must be used

0

5

10

15

20

25

30

2710…

2713…

2712…

296…

291…

297…

293…

299…

80010…

80000…

80015…

80020…

80005…

80110…

80160…

80115…

80100…

80135…

80120…

80165…

80105…

80150…

80140…

80125…

80155…

80130…

80145…

80170…

Rate per 1,000

total p

opulation

Better Access Item and Item group

200720082009

GP CP PT FPS

33

initially to trigger patient access to allied health Medicare rebatable services.

• Of consumers who received services under the Consultant Psychiatry items, approximately 80% used item 296 (Consultant Psychiatrist – Initial Consultation), again reflecting the item’s function in assessing consumers for appropriateness to receive other Better Access services. This pattern was consistent across 2007, 2008 and 2009.

• Of consumers who received services from clinical psychologists under the Psychological Therapy Services items, virtually all (98%) used the 80010 (Service provided in rooms, 50+ minute consultation) item. Approximately 4% used the 80000 item (Service provided in rooms, 30‐50 minute consultation). Use of the Psychological Therapy Services items for out of room services (items 80005 and 80015) and for group sessions (item 80020) was negligible. This pattern was consistent across 2007, 2008 and 2009.

• Of consumers who received services from other allied health professionals under the Focussed psychological therapies items, virtually all (approximately 90%) used the 80110 (Service provided in rooms, 50+ minute consultation) item provided by general psychologists. Use of services provided by Occupational Therapists was negligible, as was use of services provided by social workers with the exception of item 80160 (Service provided in rooms, 50+ minute consultation).

• Claims for group session Psychological Therapy Services and Focussed psychological Strategies items (item numbers 80020, 80115, 80145, 80165) were negligible.

34

Table 3.7 Persons using individual MBS Better Access items in 2007, 2008 and 2009, in descending order of magnitude for 2009

Item group

Provider type

Item

number

2007 2008 2009

N persons

% of persons

Rate (per 1,000)

N persons

% of persons

Rate (per 1,000)

N persons

% of persons

Rate (per 1,000)

GP GP 2710 469,902 66.11 22.41 554,984 58.33 26.06 636,908 56.34 29.91 GP GP 2713 223,612 31.46 10.59 325,969 34.26 15.16 409,137 36.19 19.02 FPS GenPsy 80110 206,601 29.06 9.86 279,432 29.37 13.13 334,964 29.63 15.74 GP GP 2712 102,380 14.40 4.86 166,070 17.45 7.76 205,036 18.14 9.59 PT ClinPsy 80010 96,750 13.61 4.63 148,860 15.65 7.01 185,914 16.45 8.75 CP CP 296 72,859 10.25 3.46 75,347 7.92 3.52 79,437 7.03 3.71 FPS SW 80160 10,415 1.47 0.50 18,892 1.99 0.89 26,470 2.34 1.24 CP CP 291 8,836 1.24 0.42 11,280 1.19 0.53 13,451 1.19 0.63 FPS GenPsy 80115 5,350 0.75 0.26 8,773 0.92 0.41 12,902 1.14 0.61 FPS GenPsy 80100 9,794 1.38 0.47 10,343 1.09 0.49 12,511 1.11 0.59 CP CP 297 7,256 1.02 0.34 8,323 0.87 0.38 9,012 0.80 0.41 PT ClinPsy 80000 4,277 0.60 0.20 5,938 0.62 0.28 7,076 0.63 0.33 FPS OT 80135 1,797 0.25 0.09 3,178 0.33 0.15 4,380 0.39 0.21 PT ClinPsy 80015 1,236 0.17 0.06 2,197 0.23 0.10 3,119 0.28 0.15 FPS GenPsy 80120 849 0.12 0.04 1,433 0.15 0.07 2,253 0.20 0.11 FPS SW 80165 501 0.07 0.02 1,287 0.14 0.06 2,151 0.19 0.10 CP CP 293 896 0.13 0.04 1,490 0.16 0.07 2,033 0.18 0.09 FPS GenPsy 80105 890 0.13 0.04 1,117 0.12 0.05 1,479 0.13 0.07 PT ClinPsy 80020 602 0.08 0.03 1,019 0.11 0.05 1,342 0.12 0.06 CP CP 299 915 0.13 0.04 951 0.10 0.04 1,018 0.09 0.05 FPS SW 80150 342 0.05 0.02 607 0.06 0.03 760 0.07 0.04 FPS OT 80140 239 0.03 0.01 538 0.06 0.03 664 0.06 0.03 FPS OT 80125 181 0.03 0.01 374 0.04 0.02 589 0.05 0.03 FPS SW 80155 65 0.01 0.00 346 0.04 0.02 338 0.03 0.02 PT ClinPsy 80005 279 0.04 0.01 292 0.03 0.01 332 0.03 0.02 FPS OT 80130 23 0.00 0.00 63 0.01 0.00 118 0.01 0.01 FPS OT 80145 29 0.00 0.00 107 0.01 0.01 92 0.01 0.00 FPS SW 80170 30 0.00 0.00 70 0.01 0.00 90 0.01 0.00 All Better Access itemsa 710,840 33.8 951,454 44.5 1,130,384 52.8

2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. Item group: GP, General Practitioner; CP, Consultant Psychiatry; PT, Psychological Therapy Services; FPS, Focussed Psychological Strategies. Provider type: GP, General Practitioner; CP, Consultant Psychiatrist; ClinPsy, Clinical Psychologist; GenPsy, General Psychologist; OT, Occupational Therapist; SW, Social Worker. Rate per 1,000 total population; Rates are directly age‐standardised. a The sum of persons receiving services under each item group will be greater than for all Better Access items because a person may receive services from more than one type of item group.

35

Table 3.8 Persons using individual MBS Better Access items in 2007, 2008 and 2009, in descending order of magnitude within item group for 2009

Item group

Provider type

Item number

2007 2008 2009

N persons

% of persons within Item

group

Rate (per

1,000) N

persons


group

Rate (per

1,000) N

persons


group

Rate (per

1,000) GP GP 2710 469,902 75.93 22.41 554,984 67.87 26.06 636,908 65.54 29.91 GP GP 2713 223,612 36.13 10.59 325,969 39.86 15.16 409,137 42.10 19.02 GP GP 2712 102,380 16.54 4.86 166,070 20.31 7.76 205,036 21.10 9.59 All GP items 618,867 87.1 29.5 817,738 85.9 38.3 971,836 86.0 45.4 CP CP 296 72,859 82.84 3.46 75,347 80.38 3.52 79,437 79.09 3.71 CP CP 291 8,836 10.05 0.42 11,280 12.03 0.53 13,451 13.39 0.63 CP CP 297 7,256 8.25 0.34 8,323 8.88 0.38 9,012 8.97 0.41 CP CP 293 896 1.02 0.04 1,490 1.59 0.07 2,033 2.02 0.09 CP CP 299 915 1.04 0.04 951 1.01 0.04 1,018 1.01 0.05 All CP items 87,947 12.4 4.2 93,736 9.9 4.4 100,434 8.9 4.7 PT ClinPsy 80010 96,750 98.11 4.63 148,860 98.20 7.01 185,914 98.15 8.75 PT ClinPsy 80000 4,277 4.34 0.20 5,938 3.92 0.28 7,076 3.74 0.33 PT ClinPsy 80015 1,236 1.25 0.06 2,197 1.45 0.10 3,119 1.65 0.15 PT ClinPsy 80020 602 0.61 0.03 1,019 0.67 0.05 1,342 0.71 0.06 PT ClinPsy 80005 279 0.28 0.01 292 0.19 0.01 332 0.18 0.02 All PT items 98,612 13.9 4.7 151,587 15.9 7.1 189,418 16.8 8.9 FPS GenPsy 80110 206,601 91.35 9.86 279,432 89.55 13.13 334,964 88.31 15.74 FPS SW 80160 10,415 4.60 0.50 18,892 6.05 0.89 26,470 6.98 1.24 FPS GenPsy 80115 5,350 2.37 0.26 8,773 2.81 0.41 12,902 3.40 0.61 FPS GenPsy 80100 9,794 4.33 0.47 10,343 3.31 0.49 12,511 3.30 0.59 FPS OT 80135 1,797 0.79 0.09 3,178 1.02 0.15 4,380 1.15 0.21 FPS GenPsy 80120 849 0.38 0.04 1,433 0.46 0.07 2,253 0.59 0.11 FPS SW 80165 501 0.22 0.02 1,287 0.41 0.06 2,151 0.57 0.10 FPS GenPsy 80105 890 0.39 0.04 1,117 0.36 0.05 1,479 0.39 0.07 FPS SW 80150 342 0.15 0.02 607 0.19 0.03 760 0.20 0.04 FPS OT 80140 239 0.11 0.01 538 0.17 0.03 664 0.18 0.03 FPS OT 80125 181 0.08 0.01 374 0.12 0.02 589 0.16 0.03 FPS SW 80155 65 0.03 0.00 346 0.11 0.02 338 0.09 0.02 FPS OT 80130 23 0.01 0.00 63 0.02 0.00 118 0.03 0.01 FPS OT 80145 29 0.01 0.00 107 0.03 0.01 92 0.02 0.00 FPS SW 80170 30 0.01 0.00 70 0.02 0.00 90 0.02 0.00 All FPS items 226,169 31.8 10.8 312,035 32.8 14.7 379,284 33.6 17.8 All Better Access itemsa 710,840 33.8 951,454 44.5 1,130,384 52.8

2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. GP, General Practitioner; CP, Consultant Psychiatry; PT, Psychological Therapy Services; FPS, Focussed Psychological Strategies. Rate per 1,000 total population; Rates are directly age‐standardised. a The sum of persons receiving services under each item group will be greater than for all Better Access items because a person may receive services from more than one item group.

36

Figure 3.5 plots the growth in rates of uptake by quarter from the December 2006 quarter to the March 2010 quarter, for each of the six highest uptake items. It should be noted that the substantial drop in uptake for item 2710 in the March 2010 quarter is due to the introduction of item 2702 which occurred on 1 January 2010. As of this date, only GPs who have completed accredited Mental Health Skills Training were eligible to claim a GP Mental Health Treatment Plan under item 2710. GPs who have not completed accredited Mental Health Skills Training were eligible to claim a GP Mental Health Treatment Plan under item 2702, which has a lower schedule fee than item 2710.

Fig 3.5 Rates of Better Access uptake for highest uptake items by quarter, December 2006 quarter to March 2010 quarter.

Comparisons of the 2007 and post‐2007 trends for each of the highest uptake items are shown in Table 3.9. For analyses involving item 2710, the period of analysis was truncated at the end of the December 2009 quarter to allow for the downturn in claims under item 2710 associated with the introduction of item 2702 in January 2010.

0

1

2

3

4

5

6

7

8

9

Rate per 1,000

pop

ulation

Quarter

2710 2712

2713 80110

80010 296

37

Table 3.9 Estimated change in trends for uptake of MBS‐subsidised Better Access GP Mental Health Treatment items, March 2007 quarter to March 2010 quarter

Trend in year 2007 Trend after 2007 Ratio of trendsa RR (95% CI) P RR (95% CI) P RR (95% CI) P 2710b 0.981 (0.978‐0.983) <0.001 1.029 (1.016‐1.042) <0.001 1.049 (1.016‐1.083) 0.003 2712 1.388 (1.207‐1.596) <0.001 1.053 (1.043‐1.063) <0.001 0.759 (0.697‐0.827) <0.001 2713 1.129 (1.104‐1.154) <0.001 1.058 (1.044‐1.071) <0.001 0.937 (0.900‐0.976) 0.002 80110 1.194 (1.113‐1.280) <0.001 1.044 (1.031‐1.058) <0.001 0.875 (0.826‐0.926) <0.001 80010 1.239 (1.138‐1.348) <0.001 1.056 (1.041‐1.072) <0.001 0.853 (0.799‐0.911) <0.001 296 0.991 (0.961‐1.022) 0.575 1.004 (0.990‐1.019) 0.568 1.013 (0.967‐1.061) 0.583

2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. a The ratio of the post‐2007 trend to the 2007 trend. b For item 2710, the period of analysis was from the March 2007 quarter to the December 2009 quarter due to the introduction of item 2702 in January 2010.

Figure 3.5 and Table 3.9 show that:

• The rate of uptake of the GP Mental Health Treatment Plan (2710) item increased from 5.8 per 1,000 total population in the March 2007 quarter to 7.2 per 1,000 in the December 2009 quarter. For this item, the rate of growth was negative in the 2007 period (RR = 0.981; P < 0.001), reflecting that the use of this item was quickly established in the initial months of operation of Better Access, but increased significantly after 2007 (RR = 1.029; P < 0.001). This change in trend was statistically significant (RR = 1.049; P < 0.001).

• The rate of uptake of the GP Mental Health Treatment Review (2712) item increased from 0.7 per 1,000 total population in the March 2007 quarter to 3.2 per 1,000 in the March 2010 quarter. The rate of uptake of the GP Mental Health Consultation (2713) item rose from 2.8 per 1,000 total population in the March 2007 quarter to 6.9 per 1,000 in the March 2010 quarter. Uptake rates for the GP Mental Health Treatment Review and Consultation items grew over both periods, although the rate of growth for both was significantly slower in the post‐2007 period.

• The rate of uptake of the Focussed Psychological Strategies item 80110 (General Psychologist) increased from 2.8 per 1,000 total population in the March 2007 quarter to 6.8 per 1,000 in the March 2010 quarter. The rate of uptake of the Psychological Therapies item 80010 rose from 1.3 per 1,000 total population in the March 2007 quarter to 4.1 per 1,000 in the March 2010 quarter. Uptake rates for items 80110 and 80010 grew significantly over the 2007 and post‐2007 periods, although the rate of growth for both was significantly slower in the post‐2007 period.

• The rates of uptake of Consultant Psychiatry item 296 were stable between the March 2007 quarter (0.9 persons per 1,000 total population) and the March 2010 quarter (0.9 persons per 1,000 total population). The analysis of trends showed that there was no significant trend in uptake within or between the 2007 and post‐2007 periods.

38

3.6 WHAT ARE THE SOCIO-DEMOGRAPHIC CHARACTERISTICS OF CONSUMERS WHO HAVE RECEIVED BETTER ACCESS SERVICES?

Having examined annual rates of uptake of Better Access items, and changes in trends in uptake over time, the socio‐demographic characteristics of people receiving Better Access services were then profiled. Table 3.10 shows the distribution of annual Better Access uptake rates according to four key socio‐demographic factors ‐ age, gender, geographical region and socio‐economic disadvantage ‐ for 2007, 2008 and 2009.

Table 3.10 Persons receiving any MBS‐subsidised Better Access services by age, gender, geographical region and socio‐economic disadvantage for 2007, 2008 and 2009

2007 2008 2009

N persons

% of persons

Rate (per

1,000) N

persons % of

persons

Rate (per

1,000) N

persons % of

persons

Rate (per

1,000) Age group

0‐14 years 41,050 5.8 10.1 61,239 6.4 14.8 81,336 7.2 19.7 15‐24 years 106,078 14.9 35.9 141,840 14.9 47.3 171,876 15.2 57.3 25‐34 years 148,378 20.9 50.6 194,595 20.5 65.2 224,648 19.9 75.2 35‐44 years 161,854 22.8 52.3 213,303 22.4 68.5 249,183 22.0 80.0 45‐54 years 128,275 18.0 44.1 170,316 17.9 57.5 199,434 17.6 67.4 55‐64 years 77,508 10.9 33.2 105,049 11.0 43.6 124,944 11.1 51.8 65+ years 47,697 6.7 17.3 65,112 6.8 23.0 78,963 7.0 27.9

Gender Male 259,533 36.5 24.8 347,705 36.5 32.7 419,561 37.1 39.4 Female 451,307 63.5 42.7 603,749 63.5 56.3 710,823 62.9 66.2

Regiona Capital cities 477,597 67.2 35.2 632,343 66.5 45.8 740,953 65.5 53.7 Other metropolitan centres 62,255 8.8 36.7 83,489 8.8 48.3 101,922 9.0 59.0 Rural centres 92,461 13.0 35.0 127,506 13.4 47.5 155,054 13.7 57.6 Other rural areas 71,572 10.1 28.5 98,863 10.4 38.9 120,434 10.7 47.3 Remote areas 6,954 1.0 12.7 9,253 1.0 16.6 12,012 1.1 21.5

Socio‐economic disadvantageb Quintile 5 (Least) 198,825 28.2 36.1 257,720 27.4 46.1 298,207 26.7 53.4 Quintile 4 153,894 21.8 33.6 205,515 21.8 44.1 245,822 22.0 52.7 Quintile 3 142,904 20.3 33.4 192,273 20.4 44.1 228,413 20.4 52.4 Quintile 2 119,399 16.9 33.2 162,561 17.3 44.6 195,517 17.5 53.6 Quintile 1 (Most) 89,651 12.7 29.4 123,408 13.1 40.0 149,683 13.4 48.5

All Better Access items 710,840 100.0 33.8 951,454 100.0 44.5 1,130,384 100.0 52.8

2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. Region based on RRMA classification. Socio‐economic disadvantage based on IRSD classification. Rates for gender, region and socio‐economic disadvantage are age‐standardised; Rates for age group are crude. a 2007, 1 case excluded due to missing data on RRMA; b Approximately 1% of cases excluded due to missing IRSD quintile data.

Changes in uptake according to the various socio‐demographic characteristics are examined the following section, hence interpretation focuses on the 2009 data. The following patterns were observed:

39

• Uptake increased with age, peaking among adults in the 25‐34 year and 35‐44 year age groups, then decreased with age thereafter.

• Uptake among young people aged less than 15 years and older people aged 65 years or more was considerably lower than for all other age groups. It should also be noted, however, that relatively lower access by young people is not unique to Better Access: young people access all mental health services less often than other members of the population5, 27, 40 possibly because they are less likely to perceive that they have a need for mental health care.41, 42

• Overall, females used Better Access services to a greater extent than males, by a ratio of approximately 1.7:1.

• In absolute terms, more than two‐thirds of people who used Better Access services (65.5% in 2009) reside in capital cities. However, after adjusting for the population size of each category of geographical region, the age‐standardised uptake rates were found to be slightly lower for capital cities (53.7 per 1,000 population in 2009) than for other metropolitan centres and rural centres (59.0 and 57.6 persons per 1,000 population in 2009, respectively). Rates were around 12% lower for people residing in other rural areas (47.3 per 1,000 population in 2009) and around 60% lower for people in remote areas (21.5 per 1,000 population in 2009) than for people in capital cities.

• In absolute terms, the percentage of people who used Better Access services decreased steadily as level of socio‐economic disadvantage (as defined by quintiles on the IRSD) increased. However, after adjusting for the population size in each quintile of socio‐economic disadvantage, the age‐standardised rates show that uptake rates were around 10% lower for people in the most disadvantaged areas (48.5 persons per 1,000 population in 2009) than in all other areas (ranging from 52.4 to 53.6 persons per 1,000 population in 2009).

Uptake by age within gender was examined to see whether the patterns of uptake by age were similar in both males and females. Figure 3.6 to 3.8 show uptake by age group for each gender, for 2007, 2008 and 2009, respectively. The figures show that:

• The female preponderance in uptake was not evident in the youngest age groups and was relatively small in the oldest age group.

• For both males and females, uptake increased with age, peaking among adults in the 25‐34 year and 35‐44 year age groups, then decreased with age thereafter.

• Although annual rates of uptake have increased, the age‐gender patterns have not changed over the 2007 to 2009 period.

40

Figure 3.6 Uptake of Better Access MBS items by age group and sex, 2007


0

20

40

60

80

100

120

0‐14 15‐24 25‐34 35‐44 45‐54 55‐64 65+

Rate per 1,000

pop

ulation

Age group

MaleFemale

0

20

40

60

80

100

120

0‐14 15‐24 25‐34 35‐44 45‐54 55‐64 65+

Rate per 1,000

pop

ulation

Age group

MaleFemale

41


It is also helpful to consider how the age‐gender patterns correspond to the prevalence of common mental disorders – affective, anxiety and substance use disorders – in the Australian community. Figures 3.9 and 3.10 plot the prevalence rates for 12‐month mental disorders (from the 2007 NSMHWB) and rates of persons using Better Access by age group for males and females (per 1,000 population in 2009). These figures show that the relative gap between Better Access use in 2009 and 12‐month disorder prevalence was greatest for young people aged 16‐24 years. For males aged 16‐24 years, rates of persons using Better Access services were equivalent to 17.8% of the prevalence rates for this age‐gender group. The corresponding percentages for males in other age categories were: 23.4% for 25‐34 year olds; 27.7% for 35‐44 year olds; 25.8% for 45‐54 year olds; 33.7% for 55‐64 year olds; 30.9% for 65‐74 year olds; and 35.6% for 75‐84 year olds. For females the percentages were: 25.9% for 16‐24 year olds; 36.2% for 25‐34 year olds; 39.5% for 35‐44 year olds; 35.6% for 45‐54 year olds; 40.8% for 55‐64 year olds; 46.1% for 65‐74 year olds; and 42.0% for 75‐84 year olds. However caution should be exercised in interpreting these figures because it cannot be assumed that all people using better Access services had one of the mental disorders assessed by the 2007 NSMHWB.

0

20

40

60

80

100

120

0‐14 15‐24 25‐34 35‐44 45‐54 55‐64 65+

Rate per 1,000

pop

ulation

Age group

MaleFemale

42

Figure 3.9 12‐month prevalence of common mental disorders and uptake of Better Access MBS items by age group, males (per 1,000 population)

Figure 3.10 12‐month prevalence of common mental disorders and uptake of Better Access MBS items by age group, females (per 1,000 population)

Uptake rates were then examined by socio‐demographic group for the major item groups (GP Mental Health Treatment items, Consultant Psychiatry items, Psychological Therapy items, and Focussed Psychological Strategies items). Table 3.11 shows the distribution of annual Better Access uptake by age and gender for each of the item groups. Table 3.12 shows the distribution

0

50

100

150

200

250

300

350

16‐24 25‐34 35‐44 45‐54 55‐64 65‐74 75‐84

Rate per 1,000

pop

ulation

Age Group

Prevalence of affective, anxiety and substance use disorders (2007 NSMHWB)Persons using Better Access services in 2009

0

50

100

150

200

250

300

350

16‐24 25‐34 35‐44 45‐54 55‐64 65‐74 75‐84

Rate per 1,000

pop

ulation

Age Group

Prevalence of affective, anxiety and substance use disorders (2007 NSMHWB)Persons using Better Access services in 2009

43

of annual Better Access uptake by geographical region and socio‐economic disadvantage categories for each of the item groups. Focusing on the 2009 data, the tables show that:

• The pattern of uptake by age group was similar for all item groups, and mirrors the pattern for any Better Access item (Table 3.10). That is, uptake increased with age, peaking among adults in the 25‐34 year and 35‐44 year age groups, then decreased with age thereafter.

• Young people showed the lowest uptake of GP Mental Health Treatment and Consultant Psychiatry items, whereas older people showed the lowest uptake of Psychological Therapy Services and Focussed Psychological Strategies items.

• The female:male ratio of uptake rates was between 1.7:1 and 1.8:1 for the GP Mental Health Treatment, Psychological Therapy Services and Focussed Psychological Strategies item groups. The female:male ratio for Consultant Psychiatry items was considerably lower (1.2:1).

• For the GP Mental Health Treatment item group, uptake rates were highest among people living in other metropolitan centres (51.2 per 1,000 population) and rural centres (50.9 per 1,000 population), and slightly lower for people living in capital cities (45.6 per 1,000 population). Compared to people living in other metropolitan regions (the region type with the highest uptake), uptake rates were 18% lower (41.9% per 1,000 population) for people residing in other rural areas and 62% lower (19.5 per 1,000 population) for people in remote areas.

• There was a similar pattern for the Focussed Psychological Strategies item group. Uptake was highest among people living in other metropolitan centres (21.3 per 1,000 population) and rural centres (20.6 per 1,000 population), and slightly lower for people living in capital cities (17.9 per 1,000 population). Compared to people living in other metropolitan regions (the region type with the highest uptake), uptake was 27% lower (15.6% per 1,000 population) for people residing in other rural areas and 80% lower (4.2 per 1,000 population) for people in remote areas.

• For the Consultant Psychiatry item group, uptake showed a steady decrease across each category of geographical region from capital cities (5.3 per 1,000 population) to remote areas (1.4 per 1,000 population). Similarly for the Psychological Therapy Services item group, uptake rates steadily decreased from capital cities (10.3 per 1,000 population) to remote areas (1.6 per 1,000 population).

• Uptake of the GP Mental Health Treatment item group was similar across all categories of socio‐economic disadvantage, with the exception of the most disadvantaged areas. Uptake rates for people in the most disadvantaged areas were 10% lower than for those in areas of highest uptake (quintile 2). A similar pattern was found for Focussed Psychological Strategies where uptake rates for people in the most disadvantaged areas were 19% lower than for those in areas of highest uptake (quintile 4).

• In contrast, uptake of the Psychological Therapy Services and, to a lesser extent, the Consultant Psychiatry item groups, decreased as levels of socio‐economic disadvantage increased.

44

Table 3.11 Persons receiving MBS‐subsidised Better Access services within item groups, by age and gender, 2007, 2008 and 2009

2007 2008 2009

N persons

% of persons

Rate (per

1,000) N

persons % of

persons

Rate (per

1,000) N

persons % of

persons

Rate (per

1,000) GP Mental Health Treatment Items

Age group 0‐14 years 31,251 5.0 7.7 46,403 5.7 11.3 61,963 6.4 15.0 15‐24 years 92,869 15.0 31.4 123,855 15.1 41.3 150,664 15.5 50.2 25‐34 years 132,666 21.4 45.3 170,806 20.9 57.2 197,275 20.3 66.1 35‐44 years 143,485 23.2 46.4 185,370 22.7 59.5 216,295 22.3 69.5 45‐54 years 112,444 18.2 38.6 146,845 18.0 49.6 171,963 17.7 58.1 55‐64 years 66,806 10.8 28.6 89,980 11.0 37.3 107,041 11.0 44.4 65+ years 39,346 6.4 14.2 46,403 6.7 19.2 66,635 6.9 23.5


Consultant Psychiatry Items



Psychological Therapy Services Items



Focussed Psychological Strategies Items



2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. Rates for gender are age‐standardised; Rates for age group are crude.

45

Table 3.12 Persons receiving MBS‐subsidised Better Access services within item groups, by region and relative socio‐economic disadvantage, 2007, 2008 and 2009

2007 2008 2009

N persons

% of persons

Rate (per

1,000) N

persons % of

persons

Rate (per

1,000) N

persons % of

persons

Rate (per

1,000) GP Mental Health Treatment Items

Regiona Capital cities 409,726 66.2 30.1 536,955 65.7 38.9 629,356 64.8 45.6 Other metro 54,412 8.8 32.1 72,338 8.8 41.9 88,461 9.1 51.2 Rural centres 83,886 13.6 31.8 112,733 13.8 42.0 136,679 14.1 50.9 Other rural 64,583 10.4 25.8 87,387 10.7 34.5 106,479 11.0 41.9 Remote areas 6,259 1.0 11.5 8,325 1.0 15.0 10,853 1.1 19.5

SE Disadvantageb Quintile 5 (Least) 166,993 27.2 30.3 213,745 26.4 38.2 247,452 25.7 44.3 Quintile 4 133,250 21.7 29.1 176,150 21.8 37.8 211,256 22.0 45.3 Quintile 3 127,172 20.7 29.8 168,322 20.8 38.6 199,709 20.8 45.8 Quintile 2 106,734 17.4 29.8 142,999 17.7 39.3 172,162 17.9 47.2 Quintile 1 (Most) 79,550 13.0 26.1 108,181 13.4 35.1 130,682 13.6 42.4


Regiona Capital cities 65,122 74.0 4.8 68,967 73.6 5.0 72,968 72.7 5.3 Other metro 7,325 8.3 4.3 7,680 8.2 4.4 8,545 8.5 4.9 Rural centres 8,029 9.1 3.0 8,803 9.4 3.2 9,923 9.9 3.7 Other rural 6,788 7.7 2.7 7,587 8.1 3.0 8,229 8.2 3.2 Remote areas 683 0.8 1.2 699 0.7 1.3 769 0.8 1.4



Regiona Capital cities 76,808 77.9 5.7 115,363 76.1 8.4 141,792 74.9 10.3 Other metro 7,278 7.4 4.3 11,835 7.8 6.9 15,777 8.3 9.2 Rural centres 8,486 8.6 3.2 14,350 9.5 5.4 18,069 9.5 6.7 Other rural 5,605 5.7 2.2 9,377 6.2 3.7 12,860 6.8 5.1 Remote areas 435 0.4 0.8 662 0.4 1.2 916 0.5 1.6


Focussed Psychological Strategies



2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. Region based on RRMA classification. SE Disadvantage, socio‐economic disadvantage based on IRSD classification. Rates for region and socio‐economic disadvantage are age‐standardised. a 1 case excluded due to missing RRMA in 2007, 9 cases in 2009; b Approximately 1% of cases excluded due to missing IRSD.

46

Because the Focussed Psychological Strategies item group subsumes services for three provider types – General Psychologists, Occupational Therapists and Social Workers ‐ Tables 3.13 and 3.14 show the uptake rates by socio‐demographic characteristic for these provider groups separately.

Table 3.13 Persons receiving MBS‐subsidised Better Access services by Provider Type (within the Focussed Psychological Strategies item group), by age and gender, 2007, 2008 and 2009

2007 2008 2009

N persons

% of persons

Rate (per

1,000) N

persons % of

persons

Rate (per

1,000) N

persons % of

persons

Rate (per

1,000) General Psychologists



Occupational Therapists

Age group 0‐14 years 552 27.4 0.14 1,287 34.8 0.31 2,094 41.0 0.51 15‐24 years 228 11.3 0.08 465 12.6 0.15 556 10.9 0.19 25‐34 years 299 14.9 0.10 453 12.2 0.15 542 10.6 0.18 35‐44 years 367 18.2 0.12 582 15.7 0.19 737 14.4 0.24 45‐54 years 318 15.8 0.11 500 13.5 0.17 623 12.2 0.21 55‐64 years 158 7.9 0.07 278 7.5 0.12 364 7.1 0.15 65+ years 89 4.4 0.03 136 3.7 0.05 187 3.7 0.07

Gender Male 844 42.0 0.08 1,635 44.2 0.16 2,437 47.8 0.23 Female 1,167 58.0 0.11 2,066 55.8 0.19 2,666 52.2 0.25

Social Workers

Age group 0‐14 years 807 7.4 0.2 1,201 6.0 0.3 2,040 7.2 0.5 15‐24 years 1,444 13.2 0.5 2,747 13.6 0.9 3,944 13.9 1.3 25‐34 years 2,228 20.4 0.8 4,237 21.0 1.4 5,518 19.5 1.8 35‐44 years 2,791 25.6 0.9 5,126 25.4 1.7 7,144 25.3 2.3 45‐54 years 2,093 19.2 0.7 3,812 18.9 1.3 5,256 18.6 1.8 55‐64 years 1,063 9.7 0.5 2,093 10.4 0.9 3,024 10.7 1.3 65+ years 492 4.5 0.2 941 4.7 0.3 1,350 4.8 0.5


2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. Rates for gender are age‐standardised; Rates for age group are crude. Rates for items provided by Occupational Therapists are given to 2 decimal places as many of the estimates in this group are small.

47

Table 3.14 Persons receiving MBS‐subsidised Better Access services by Provider Type (within the Focussed Psychological Strategies item group), by region and relative socio‐economic disadvantage, 2007, 2008 and 2009

2007 2008 2009

N persons

% of persons

Rate (per

1,000) N

persons % of

persons

Rate (per

1,000) N

persons % of

persons

Rate (per

1,000) General Psychologists




Regiona Capital cities 1,337 66.5 0.10 2,384 64.4 0.18 3,491 68.4 0.26 Other metro 164 8.2 0.10 424 11.5 0.25 549 10.8 0.32 Rural centres 259 12.9 0.10 549 14.8 0.21 594 11.6 0.22 Other rural 236 11.7 0.10 319 8.6 0.13 438 8.6 0.17 Remote areas 15 0.7 0.03 25 0.7 0.04 31 0.6 0.05

SE Disadvantageb Quintile 5 (Least) 561 28.1 0.11 1,056 28.7 0.20 1,647 32.5 0.31 Quintile 4 414 20.8 0.09 786 21.4 0.17 1,050 20.8 0.23 Quintile 3 447 22.4 0.11 699 19.0 0.16 969 19.2 0.23 Quintile 2 367 18.4 0.10 684 18.6 0.19 799 15.8 0.22 Quintile 1 (Most) 206 10.3 0.07 451 12.3 0.14 595 11.8 0.19

Social Workers

Regiona Capital cities 6,739 61.7 0.5 12,902 64.0 0.9 17,514 61.9 1.3 Other metro 651 6.0 0.4 1,238 6.1 0.7 1,913 6.8 1.1 Rural centres 1,733 15.9 0.7 3,193 15.8 1.2 4,856 17.2 1.8 Other rural 1,747 16.0 0.7 2,750 13.6 1.1 3,820 13.5 1.5 Remote areas 48 0.4 0.1 74 0.4 0.1 173 0.6 0.3


2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. Region based on RRMA classification. SE Disadvantage, socio‐economic disadvantage based on IRSD classification. Rates for region and socio‐economic disadvantage are age‐standardised. Rates for items provided by Occupational Therapists are given to 2 decimal places as many of the estimates in this group are small. a 1 case excluded due to missing RRMA in 2007, 9 cases in 2009; b Approximately 1% of cases excluded due to missing IRSD.

Given the preponderance of services provided by General Psychologists, patterns for this group mirror the general patterns for the Focussed Psychological Strategies item group. Focussing on the 2009 data, Table 3.13 shows that persons using Better Access services provided by Occupational Therapist have a somewhat different profile than persons using Better Access

48

services provided by General Psychologists and Social Workers. Occupational Therapists see a higher rate of young people aged less than 15 years. They also see similar proportions of males and females. Table 3.14 shows that the profile of persons seen by region and socio‐economic disadvantage is similar across the three provider types, although Occupational Therapists saw a relatively higher rate of persons from the least disadvantages areas in 2009 (NB. this pattern was, however, not evident in 2007 or 2008).

3.7 HAVE THERE BEEN CHANGES OVER TIME IN THE SOCIO-DEMOGRAPHIC PROFILE OF CONSUMERS WHO HAVE RECEIVED BETTER ACCESS SERVICES?

Table 3.15 shows the percentage change in the rates of persons using any Better Access item between 2007 and 2009, by age, gender, geographical region and socio‐economic disadvantage. The table shows that growth in uptake was greater for some groups than for others.

Table 3.15 Percentage change in persons using any MBS‐subsidised Better Access services by age, gender, geographical region and socio‐economic disadvantage for 2007, 2008 and 2009

Rate (per 1,000) Percentage change 2007 2008 2009 2007‐2008 2008‐2009 2007‐2009

Age group 0‐14 years 10.1 14.8 19.7 47.7 32.8 96.1 15‐24 years 35.9 47.3 57.3 31.7 21.2 59.5 25‐34 years 50.6 65.2 75.2 28.7 15.5 48.6 35‐44 years 52.3 68.5 80.0 30.9 16.8 52.9 45‐54 years 44.1 57.5 67.4 30.6 17.1 52.9 55‐64 years 33.2 43.6 51.8 31.2 18.9 56.0 65+ years 17.3 23.0 27.9 33.3 21.3 61.6

Gender Male 24.8 32.7 39.4 31.7 20.6 58.9 Female 42.7 56.3 66.2 31.6 17.7 54.9

Regiona Capital cities 35.2 45.8 53.7 30.2 17.3 52.7 Other metropolitan centres 36.7 48.3 59.0 31.6 22.1 60.7 Rural centres 35.0 47.5 57.6 35.6 21.4 64.6 Other rural areas 28.5 38.9 47.3 36.4 21.5 65.8 Remote areas 12.7 16.6 21.5 30.6 29.5 69.2

Socio‐economic disadvantageb Quintile 5 (Least) 36.1 46.1 53.4 27.7 15.8 47.9 Quintile 4 33.6 44.1 52.7 31.0 19.7 56.8 Quintile 3 33.4 44.1 52.4 31.9 18.7 56.6 Quintile 2 33.2 44.6 53.6 34.2 20.1 61.2 Quintile 1 (Most) 29.4 40.0 48.5 36.0 21.2 64.8

All Better Access items 33.8 44.5 52.8 33.6 18.7 58.6

2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. Region based on RRMA classification. Socio‐economic disadvantage based on IRSD classification. Rates for gender, region and socio‐economic disadvantage are age‐standardised; Rates for age group are crude. a 2007, 1 case excluded due to missing data on RRMA; b Approximately 1% of cases excluded due to missing IRSD quintile data.

49

Table 3.15 shows that:

• The rate of growth in uptake was substantially higher for young people aged 0‐14 years than for all other age groups. Growth in uptake for people aged 0‐14 years (96.1%) was 60% higher than the average across all Better Access consumers (58.6%).

• Growth in uptake increased as remoteness increased. Growth among people in remote areas was 20% higher than the average across all Better Access consumers.

• Growth in uptake increased somewhat as level of socioeconomic disadvantage increased. Growth among people in areas of greatest disadvantage was 10% above the average across all Better Access consumers.

Rates of growth in uptake for the various item groups were also examined according to sociodemographic characteristics. Table 3.16 shows the percentage change between 2007 and 2009 for persons using the four main item groups, by age and gender. This shows that:

• The rate of growth in uptake was substantially higher for young people aged 0‐14 years than for all other age groups for GP Mental Health Treatment items, Psychological Therapy Services and Focussed Psychological Strategies items.

Table 3.17 shows the percentage change between 2007 and 2009 for persons using the four main item groups, by geographic region and level of socio‐economic disadvantage. This shows that:

• Patterns of growth by geographic region vary considerably between item groups. However the growth in uptake between 2007 and 2009 tended to be higher for people from non‐capital city areas.

• Growth in uptake for all item groups tended to increase as level of socioeconomic disadvantage increased.

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Table 3.16 Percentage change in persons using MBS‐subsidised Better Access services by age and gender for 2007, 2008 and 2009


GP Mental Health Treatment Items









Focussed Psychological Strategies Items



2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. Rates for gender are age‐standardised; Rates for age group are crude.

51

Table 3.17 Percentage change in persons using MBS‐subsidised Better Access services by geographical region and socio‐economic disadvantage, for 2007, 2008 and 2009


GP Mental Health Treatment Items

Regiona Capital cities 30.1 38.9 45.6 28.9 17.3 51.1 Other metro 32.1 41.9 51.2 30.4 22.3 59.5 Rural centres 31.8 42.0 50.9 32.0 21.0 59.7 Other rural 25.8 34.5 41.9 33.5 21.6 62.4 Remote areas 11.5 15.0 19.5 30.4 30.3 69.9

SE Disadvantageb Quintile 5 (Least) 30.3 38.2 44.3 26.0 15.9 46.1 Quintile 4 29.1 37.8 45.3 29.7 20.0 55.6 Quintile 3 29.8 38.6 45.8 29.7 18.5 53.8 Quintile 2 29.8 39.3 47.2 32.0 20.2 58.7 Quintile 1 (Most) 26.1 35.1 42.4 34.3 20.7 62.1







Focussed Psychological Strategies



2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. Region based on RRMA classification. SE Disadvantage, socio‐economic disadvantage based on IRSD classification. Rates for region and socio‐economic disadvantage are age‐standardised.

52

Percentage change was also examined for the three provider types subsumed by the Focussed Psychological Strategies item group (Tables 3.18 and 3.19). These show relatively higher growth in young people aged less than 15 years receiving services from General Psychologists and Occupational Therapists, compared to other age groups. Growth also tended to increase as level of socio‐economic disadvantage increased, for services provided by General Psychologists and Social Workers.

Table 3.18 Percentage change in persons using MBS‐subsidised Better Access services by Provider Type (within the Focussed Psychological Strategies item group), by age and gender for 2007, 2008 and 2009


General Psychologists






Social Workers



2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. Rates for gender are age‐standardised. Rates for items provided by Occupational Therapists are given to 2 decimal places as many of the estimates in this group are small.

53

Table 3.19 Percentage change in persons using MBS‐subsidised Better Access services by Provider Type (within the Focussed Psychological Strategies item group), by geographical region and socio‐economic disadvantage, for 2007, 2008 and 2009


General Psychologists






Social Workers



2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. Region based on RRMA classification. SE Disadvantage, socio‐economic disadvantage based on IRSD classification. Rates for region and socio‐economic disadvantage are age‐standardised. Rates for items provided by Occupational Therapists are given to 2 decimal places as many of the estimates in this group are small.

54

3.8 TO WHAT EXTENT IS BETTER ACCESS PROVIDING SERVICES TO ‘NEW’ CONSUMERS?

Given the continued and substantial growth in uptake of Better Access since its introduction, it is of interest to know the extent to which the initiative is attracting ‘new’ consumers as it proceeds or, conversely, is providing services to a consistent group of people on an ongoing basis. To examine this question, the percentage of Better Access consumers who were new to the initiative in each of 2008 and 2009 was estimated. Table 3.20 shows, for each of 2008 and 2009, the number and percentage of consumers who: (1) had received Better Access services for the first time in that year (new consumers); and (2) who had used Better Access services prior to that year. The number and percentage of new Better Access consumers was calculated for any Better Access item, and then within each of several Better Access provider groups.

The first row of Table 3.20 shows that the majority of Better Access in 2008 and 2009 were new to the initiative. Of consumers who received at least one Better Access service in 2008, more than two‐thirds (68.0%) were new Better Access consumers. In 2009, the percentage of new consumers was 57.0%. Note that the 2009 figures will always be lower than 2008 because consumers have had more opportunity to receive services prior to 2009. The percentage reduction in new consumers between 2008 and 2009 was 16.2%.

Table 3.20 Persons receiving MBS‐subsidised Better Access services for the first time in 2008 and 2009, by provider type

Received services in 2008 Received services in 2009

Provider type Total N

N received services prior to 2008(a)

N received services for the

first time in 2008

% received services for the

first time in 2008 Total N

N received services prior to 2008(b)

N received services for the

first time in 2009


first time in 2009

% change from 2008

to 2009

Any Better Access item 953,161 304,696 648,465 68.0 1,130,384 486,089 644,295 57.0 ‐16.2 Any GP item 818,434 220,438 597,996 73.1 971,713 367,394 604,319 62.2 ‐14.9 Item 2710 555,479 71,207 484,272 87.2 636,908 144,569 492,339 77.3 ‐11.3 Consultant psychiatrist item 94,398 7,421 86,977 92.1 100,390 13,102 87,288 86.9 ‐5.6 Allied Health Providers 452,600 129,615 322,985 71.4 550,354 204,246 346,108 62.9 ‐11.9 Psychologists 430,928 123,106 307,822 71.4 520,588 191,838 328,750 63.1 ‐11.6 Clinical Psychologist 152,721 39,345 113,376 74.2 189,418 62,640 126,778 66.9 ‐9.8 General Psychologist 292,129 76,870 215,259 73.7 348,417 115,170 233,247 66.9 ‐9.1 Social Workers 20,319 4,155 16,164 79.6 28,276 7,198 21,078 74.5 ‐6.3 Occupational Therapists 3,719 801 2,918 78.5 5,103 1,432 3,671 71.9 ‐8.3

Data had regard to claims processed up to and including 30 April 2010. (a) Prior to 2008 refers to the period 1 November 2006 to 31 December 2007 (b) Prior to 2009 refers to the period 1 November 2006 to 31 December 2008

Subsequent rows of Table 3.20 show the equivalent figures for various provider groupings. The highest rate of new consumers occurs among those who received Consultant Psychiatrist services (92.1% in 2008; 86.9% in 2009). Rates for allied health providers were similar, ranging between 73.7% to 79.5% in 2008, and 66.9% to 74.5% in 2009. Rates were lowest for GP services (73.1% in 2008; 62.2% in 2009). Note that the percentage of new consumers in the individual

55

provider groups will be higher than for overall Better Access services, because they only compare consumers of like‐with‐like services.

The data also show that the rate of new consumers decreased only modestly between 2008 and 2009 – 16.2% for all Better Access services, 14.9% for GP services, 5.6% for consultant psychiatrists, and between 6.3% and 11.9% for allied health provider services (depending on how these were grouped).

The proportion of services used by new versus existing consumers in each of 2008 and 2009 was also examined. Table 3.21 shows, for each of 2008 and 2009, the number and percentage of services received by consumers who: (1) had received Better Access services for the first time in that year (new consumers); and (2) who had used Better Access services prior to that year. The number and percentage of services received by new Better Access consumers was calculated for any Better Access item, and then within each of several Better Access provider groups. Broadly speaking Table 3.21 shows that, in each of 2008 and 2009, the majority of Better Access services are used by people who are receiving services for the first time in that year.

Table 3.21 Number of services used by persons receiving MBS‐subsidised Better Access services for the first time in 2008 and 2009, by provider type

Services received in 2008 by… Services received in 2009 by…

Provider type Total

persons

Persons who

services prior to 2008(a)

Persons who

received services for the

first time in 2008


first time in 2008

Total persons

Persons who

services prior to 2009(a)

Persons who

received services for the

first time in 2009


first time in 2009

% change from

2008 to 2009

Any Better Access item 3,813,121 1,583,453 2,229,668 58.5 4,663,981 2,449,235 2,214,746 47.5 ‐18.8

Any GP item 1,377,036 488,896 888,140 64.5 1,659,366 773,764 885,602 53.4 ‐17.3 Item 2710 556,585 71,414 485,171 87.2 638,756 145,158 493,598 77.3 ‐11.4 Consultant psychiatrist item 102,474 8,766 93,708 91.4 109,687 15,451 94,236 85.9 ‐6.0 Allied Health Providers 2,333,466 792,016 1,541,450 66.1 2,894,713 1,243,343 1,651,370 57.0 ‐13.6 Psychologists 2,207,836 746,949 1,460,887 66.2 2,722,219 1,160,392 1,561,827 57.4 ‐13.3 Clinical Psychologist 793,290 245,983 547,307 69.0 1,000,129 385,351 614,778 61.5 ‐10.9 General Psychologist 1,414,546 438,249 976,297 69.0 1,722,090 662,293 1,059,797 61.5 ‐10.8 Social Workers 104,174 26,118 78,056 74.9 142,478 43,487 98,991 69.5 ‐7.3 Occupational Therapists 21,456 5,959 15497 72.2 30,016 10,403 19,613 65.3 ‐9.5

Data had regard to claims processed up to and including 30 April 2010. (a) Prior to 2008 refers to the period 1 November 2006 to 31 December 2007 (b) Prior to 2009 refers to the period 1 November 2006 to 31 December 2008

The data presented here suggest that, not only is Better Access attracting substantial numbers of new consumers in each successive year, but that these new consumers are also consuming a larger proportion of services than existing consumers. Having said that, it is acknowledged that the approach taken here uses a necessarily limited definition of a ‘new’ consumer. It may have included people who, although new to Better Access, are existing consumers of other parts of the mental health system. For example, people who are existing users of other Medicare mental health services, and people who are existing consumers of other mental health services or providers.

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3.9 KEY FINDINGS

The key findings from Chapter 3 are presented for each of the research questions explored:

What has been the rate of uptake of Better Access services overall?

• The age‐standardised uptake rate of any MBS‐subsidised Better Access item was 33.8 persons per 1,000 total population (3.4% of the total population or 710,840 persons) in 2007, rising to 44.5 persons per 1,000 in 2008 (4.4% of the total population or 951,454 persons), and further to 52.8 persons per 1,000 total population in 2009 (5.3% of the total population or 1,130,384 persons). That is, one in every 30 Australians received at least one Better Access service in 2007, one in every 23 did so in 2008, and one in every 19 did so in 2009.

• Although the uptake of Better Access has continued to increase, the rate of growth has slowed. The increase in rates of overall Better Access uptake has slowed significantly from 13.3% per quarter in 2007 to 4.6% per quarter post‐2007. In annual terms, Better Access uptake showed an annual increase of 31.7% between 2007 and 2008, and an annual increase of 18.7% between 2008 and 2009.

What has been the rate of uptake of Better Access item groups?

• Most Better Access consumers (86.0%) received at least one GP Mental Health Treatment service. This amounted to 45.4 persons per 1,000 population in 2009. Uptake for the allied health Focussed Psychological Strategies items (17.8 per 1,000 in 2009) was greater than for Psychological Therapy Services items (8.9 per 1,000 in 2009) and Consultant Psychiatry items (4.7 per 1,000 in 2009).

• Within the Focussed Psychological Strategies item group, uptake was considerably greater for items provided by general psychologists (16.4 per 1,000 in 2009) than those provided by social workers (1.3 per 1,000 in 2009) or occupational therapists (0.2 per 1,000 in 2009).

• The GP Mental Health Treatment, Psychological Therapy Services and Focussed Psychological Strategies item groups have all shown significant positive growth over time since Better Access was introduced. Uptake of the Consultant Psychiatry item group has remained stable.

• The rate of growth in uptake was substantially higher for young people aged 0‐14 years than for all other age groups. Growth in uptake for people aged 0‐14 years (96.1%) was 60% higher than the average for all Better Access consumers (58.2%).

• Growth in uptake increased as remoteness increased. Growth among people in remote areas was 20% higher than the average for all Better Access consumers.

• Growth in uptake increased as level of socioeconomic disadvantage increased. Growth among people in areas of greatest disadvantage was 20% above the average for all Better Access consumers.

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What is the relative uptake of items with item groups?

• Three of the six items with the highest level of uptake were the GP Mental Health Treatment items (2710, 2712 and 2713). The high uptake rate for item 2710 (GP Mental Health Treatment Plan) is consistent with its role as the main point of referral to other Better Access services.

• The ratio of the rates for 2710 to 2712 (Review of a GP MH Treatment Plan) items was 4.6:1 in 2007, decreasing to 3.3:1 in 2008 and 3.1:1 in 2009.

• Of consumers who received services under the Consultant Psychiatry items, approximately 80% used item 296 (Consultant Psychiatrist – Initial Consultation), reflecting the item’s function in assessing consumers for appropriateness to receive other Better Access services.

• Of consumers who received services from clinical psychologists under the Psychological Therapy Services items, virtually all (90%) used the 80010 (Service provided in rooms, 50+ minute consultation) item.

• Of consumers who received services from other allied health professionals under the Focussed psychological therapies items, virtually all (approximately 90%) used the 80110 (Service provided in rooms, 50+ minute consultation) item provided by general psychologists.

What are the socio‐demographic characteristics of Better Access consumers?

• Uptake rates for any Better Access service increase with age, peaking among adults in the 25‐34 year and 35‐44 year age groups, then decrease with age thereafter.

• Females use Better Access services to a greater extent than males, by a ratio of approximately 1.7:1. Only males aged 0‐14 years use Better Access services at a higher rate than females.

• The female:male ratio of uptake rates was between 1.7:1 and 1.8:1 in 2009 for the GP Mental Health Treatment, Psychological Therapy Services and Focussed Psychological Strategies item groups. The female:male ratio for Consultant Psychiatry items was considerably lower (1.2:1).

• Young people showed the lowest uptake of GP and Consultant Psychiatry items, whereas older people showed the lowest uptake of Psychological Therapy Services and Focussed Psychological Strategies items.

• For the GP and Focussed Psychological Strategies item groups, uptake rates were lowest for people residing in remote areas. For Consultant Psychiatry and Psychological Therapy Services items, rates showed a steady decrease across each category of geographical region from capital cities to remote areas.

• Uptake rates for Psychological Therapy Services and, to a lesser extent, in the Consultant Psychiatry item groups decrease as levels of socio‐economic disadvantage increase. In contrast, uptake rates for GP Mental Health Treatment and Focussed Psychological Strategies item groups were somewhat lower for persons residing in the most disadvantaged areas.

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Have there been changes over time in the socio‐demographic characteristics of consumers who have received Better Access services?

• The rate of growth in uptake was substantially higher for young people aged 0‐14 years than for all other age groups. Growth in uptake for people aged 0‐14 years (96.1%) was 60% higher than the average across all Better Access consumers (58.6%).

• Growth in uptake increased as remoteness increased. Growth among people in remote areas was 20% higher than the average across all Better Access consumers.

• Growth in uptake increased somewhat as level of socioeconomic disadvantage increased. Growth among people in areas of greatest disadvantage was 10% above the average across all Better Access consumers.

To what extent is Better Access providing services to ‘new’ consumers?

• The majority of people who received Better Access services in 2008 (68.0%) and 2009 (57.0%) were new consumers. That is, they had not used any Better Access services in preceding years.

• When analysed according to provider type, the percentage of new consumers was highest for the Consultant Psychiatrist services (92.1% in 2008; 86.9% in 2009), followed by the allied health services (ranging between 73.7% to 79.5% in 2008, and 66.9% to 74.5% in 2009), followed by GP services (73.1% in 2008; 62.2% in 2009).

• The rate of new consumers decreased only modestly between 2008 and 2009 – 16.2% for all Better Access services, 14.9% for GP services, 5.6% for consultant psychiatrists, and between 6.3% and 9.8% for allied health provider services.

• In each of 2008 and 2009, the majority of Better Access services were used by people who received services for the first time in that year. This suggests that, not only is Better Access attracting substantial numbers of new consumers in each successive year, but that these new consumers are also consuming a larger proportion of services than existing consumers.

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CHAPTER 4: AFFORDABILITY

4.1 OVERVIEW

This chapter considers Evaluation Question 2: To what extent has the Better Access initiative provided access to affordable care? Specifically, the chapter examines variations in services provided and costs associated with MBS‐subsidised Better Access items for the total Australian population and for key population sub‐groups. Analyses are conducted using data on Medicare‐subsidised Better Access services received since the inception of the program on 1 November 2006.

To examine the question of affordability, the chapter presents descriptive profiles describing the Better Access services provided and associated costs (in terms of bulk‐billing, fees charged, benefits paid, and average co‐payments) for the total population and then for particular groups (based on age, gender, geographic location, and socio‐economic disadvantage). In addition to a summary profile including all relevant MBS items, profiles were generated separately by item group (Consultant Psychiatry Items [291‐299], GP Mental Health Treatment Items [2710‐2713, 2702], Psychological Therapy Services Items [80000‐80020], and Focussed Psychological Strategies [80100‐80170]).


1. What has been the rate of services provided and costs of Better Access services overall, and within item group and provider type?

2. Do rates of co‐payment for Better Access services vary across population subgroups?

4.2 WHAT HAS BEEN THE RATE OF SERVICES PROVIDED AND COSTS OF BETTER ACCESS SERVICES OVERALL?

As outlined in Table 1.1 of this report, Better Access takes the form of 29 items numbers on the MBS. These reimburse: GPs for preparing a reviewing mental health treatment plans and providing mental health consultations; Consultant Psychiatrists for conducting an initial consultation, and for providing and reviewing a patient assessment and management plan; Clinical Psychologists for providing Psychological Therapy Services; and General Psychologists, and selected Occupational Therapists and Social Workers for providing Focussed Psychological Strategies. The costs of services provided under the Better Access MBS items are reimbursed in part or wholly by Medicare Australia. The relevant provider can either bulk‐bill the consumer (by charging the schedule fee and directly billing Medicare Australia), or can bill the consumer an amount above the schedule fee and the consumer can then obtain a rebate up to the level of the schedule fee from Medicare Australia. Medicare pays 100% of the MBS fee for GP consultations and 85% of the MBS fee for specialist consultations out‐of‐hospital (75% for in‐hospital consultations). Where a service is bulk billed, the provider claims only the relevant percentage of the MBS fee from Medicare Australia for the service, thus making the service free to the patient.

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If the provider does not bulk‐bill, then the consumer pays the difference between what the providers’ fee and the MBS rebate. A co‐payment is the contribution made by the consumer towards medical treatment. The schedule fees and MBS rebates for Better Access items, as at 31 March 2010, are shown in Table 1.1.

The impact of Better Access has been substantial not only in terms of the proportion of the population using these services (see Chapter 3), but also in terms of the program costs. Almost than 2.7 million Better Access services were provided in 2007; this grew to more almost 3.8 million services in 2008 (an annual increase of 40.6%) and to more than 4.6 million in 2009 (an annual increase of 23.2%). The total cost of these services to government, in terms of benefits paid, increased from $288.9 million in 2007 to $389.4 million in 2008 (an annual increase of 34.8%), and to $478.1 million in 2009 (an annual increase of 22.8%).

Tables 4.1 shows the annual costs associated with all Better Access services provided in 2007, 2008 and 2009. Virtually all services are bulk‐billed or attract a non‐zero co‐payment. For a small percentage of services the patient is billed but with a zero co‐payment – these have been classified as services with co‐payments. Note that only services for which the consumer contributed a co‐payment are included in the calculation of an average co‐payment (i.e., it is not the average patient cost incurred across all services). Table 4.1 shows that:

• More than half of all Better Access services were bulk‐billed – 53.6% in 2007, increasing slightly to 56.5% in 2008 and 58.6% in 2009.

• Approximately 46.4% of services in 2007 involved a co‐payment by the consumer. This percentage decreased to 43.5% in 2008 and further to 41.4% in 2009. For services with a co‐payment, the average co‐payment increased marginally from $34.20 in 2007 to $34.64 in 2008 and $35.74 in 2009.

Table 4.1 MBS‐subsidised Better Access services received, bulk‐billing rate, fees charges, benefits paid and average co‐payments, 2007, 2008 and 2009

Total services

Bulk‐billed services

Fees charged

Benefits paid

Services with co‐payments

Total patients

Year

N

N

% $ $ N

%

Average co‐payment ($)a N

2007 2,693,449 1,443,627 53.6 331,614,292 288,870,763 1,249,822 46.4 34.20 710,840 2008 3,786,600 2,138,573 56.5 446,539,711 389,447,563 1,648,027 43.5 34.64 951,454 2009 4,663,981 2,731,146 58.6 547,217,572 478,135,712 1,932,835 41.4 35.74 1,130,384

2007 and 2008 figures have regard to all claims processed up to and including 30 April 2009; 2009 figures have regard to all claims processed up to and including 30 April 2010. Fees charged, benefits paid, and average copayments are expressed in 2009 dollars. a Only services for which the consumer contributed a co‐payment are included in the calculation of the average co‐payment.

Tables 4.2 to 4.4 profile the annual services and costs of Better Access services according to four Better Access item groups: GP Mental Health Treatment items; Consultant Psychiatry items; Psychological Therapy Services items, and Focussed Psychological Strategies items. These show marked variation between provider groups:

• The bulk‐billing rate is far higher for the GP items than for the all other item groups, however the magnitude of the difference has decreased between 2007 and 2009 as bulk‐billing rates for other providers has increased. One factor that may account for the

61

lower rates of bulk‐billing rates for allied health providers, compared to GPs, relates to the types of MBS items being claimed. As shown in section 3.5 of this report, the overwhelming majority of allied health services provided are long (i.e., 50+ minute) consultations.

• Conversely, the co‐payment rate is lower for the GP items. Roughly two‐thirds of Consultant Psychiatry, Psychological Therapy and Focussed Psychological Strategies items services involve a co‐payment.

• The average co‐payment is roughly 2‐3 times greater for the Consultant Psychiatry items than all other item groups.

Table 4.2 MBS‐subsidised Better Access services received, bulk‐billing rate, fees charges, benefits paid and average co‐payment, by Item group, 2007

Total services

Bulk‐billed services Fees charged Benefits paid


Total patients

N

N

% $ $ N

%


GP items 1,012,497 925,910 91.4 119,225,281 117,636,222 86,587 8.6 18.35 618,867 CP items 94,590 30,231 32.0 25,901,960 21,222,543 64,359 68.0 72.71 87,947 PTS items 507,367 136,073 26.8 71,707,903 60,739,728 371,294 73.2 29.54 98,612 FPS items 1,078,995 351,413 32.6 114,779,148 89,272,270 727,582 67.4 35.06 226,169

2007 figures have regard to all claims processed up to and including 30 April 2009. Fees charged, benefits paid, and average copayments are expressed in 2009 dollars. GP, General practitioner; CP, Consultant psychiatrist; PTS Psychological Therapy Services; FPS, Focussed Psychological Strategies. a Only services for which the consumer contributed a co‐payment are included in the calculation of the average co‐payment.


Total services



Total patients

N

N

% $ $ N

%


GP items 1,375,025 1,269,689 92.3 152,526,591 150,519,438 105,336 7.7 19.05 817,738 CP items 101,678 34,437 33.9 27,812,365 22,676,030 67,241 66.1 76.39 93,736 PTS items 785,174 250,397 31.9 108,649,361 92,264,952 534,777 68.1 30.64 151,587 FPS items 1,524,723 584,050 38.3 157,551,394 123,987,143 940,673 61.7 35.68 312,035

2008 figures have regard to all claims processed up to and including 30 April 2009. Fees charged, benefits paid, and average copayments are expressed in 2009 dollars. GP, General practitioner; CP, Consultant Psychiatry; PTS Psychological Therapy Services; FPS, Focussed Psychological Strategies. a Only services for which the consumer contributed a co‐payment are included in the calculation of the average co‐payment.

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Total services



Total patients

N

N

% $ $ N

%


GP items 1,659,534 1,538,270 92.7 182,427,744 179,971,434 121,264 7.3 20.26 971,836 CP items 109,734 39,846 36.3 30,529,663 24,816,904 69,888 63.7 81.74 100,434 PTS items 1,000,129 345,693 34.6 139,410,904 118,370,909 654,436 65.4 32.15 189,418 FPS items 1,894,584 807,337 42.6 194,849,261 154,976,465 1,087,247 57.4 36.67 379,284

2009 figures have regard to all claims processed up to and including 30 April 2010. Fees charged, benefits paid, and average copayments are expressed in 2009 dollars. GP, General practitioner; CP, Consultant Psychiatry; PTS Psychological Therapy Services; FPS, Focussed Psychological Strategies. a Only services for which the consumer contributed a co‐payment are included in the calculation of the average co‐payment.

Tables 4.5 to 4.7 profile the annual services and costs of Better Access services according to the various provider types, allowing inspection of co‐payment rates for the various types of allied health providers. These show that co‐payment rates for general psychologists and social workers were similar, and were lower than those of occupational therapists (57.2%, 56.6% and 73.3% respectively, in 2009). However the average co‐payment was higher for general psychologists than for social workers and occupational therapists ($37.26, $31.88 and $28.16, respectively, in 2009).

Table 4.5 MBS‐subsidised Better Access services received, bulk‐billing rate, fees charges, benefits paid and average co‐payment, by provider type, 2007

Total services



Total patients

N

N

% $ $ N

%


GP 1,012,497 925,910 91.4 119,225,281 117,636,222 86,587 8.6 18.35 618,867 CP 94,590 30,231 32.0 25,901,960 21,222,543 64,359 68.0 72.71 87,947 ClinPsy 507,367 136,073 26.8 71,707,903 60,739,728 371,294 73.2 29.54 98,612 GenPsy 1,015,656 332,107 32.7 108,657,798 84,503,304 683,549 67.3 35.34 213,963 OT 10,444 2,824 27.0 1,049,111 818,985 7,620 73.0 30.20 2,011 SW 52,895 16,482 31.2 5,072,238 3,949,981 36,413 68.8 30.82 10,918

2007 figures have regard to all claims processed up to and including 30 April 2009. Fees charged, benefits paid, and average copayments are expressed in 2009 dollars. GP, General Practitioner; CP, Consultant Psychiatrist; ClinPsy, Clinical Psychologist; GenPsy, General Psychologist; OT, Occupational Therapist; SW, Social Worker. a Only services for which the consumer contributed a co‐payment are included in the calculation of the average co‐payment.

63


Total services



Total patients

N

N

% $ $ N

%


GP 1,375,025 1,269,689 92.3 152,526,591 150,519,438 105,336 7.7 19.05 817,738 CP 101,678 34,437 33.9 27,812,365 22,676,030 67,241 66.1 76.39 93,736 ClinPsy 785,174 250,397 31.9 108,649,361 92,264,952 534,777 68.1 30.64 151,587 GenPsy 1,400,485 537,534 38.4 146,008,787 114,829,917 862,951 61.6 36.13 289,785 OT 21,193 5,995 28.3 2,099,122 1,656,685 15,198 71.7 29.11 3,701 SW 103,045 40,521 39.3 9,443,485 7,500,541 62,524 60.7 31.08 20,157

2008 figures have regard to all claims processed up to and including 30 April 2009. Fees charged, benefits paid, and average copayments are expressed in 2009 dollars. GP, General Practitioner; CP, Consultant Psychiatry; ClinPsy, Clinical Psychologist; GenPsy, General Psychologist; OT, Occupational Therapist; SW, Social Worker. a Only services for which the consumer contributed a co‐payment are included in the calculation of the average co‐payment.


Total services



Total patients

N

N

% $ $ N

%


GP 1,659,534 1,538,270 92.7 182,427,744 179,971,434 121,264 7.3 20.26 971,836 CP 109,734 39,846 36.3 30,529,663 24,816,904 69,888 63.7 81.74 100,434 ClinPsy 1,000,129 345,693 34.6 139,410,904 118,370,909 654,436 65.4 32.15 189,418 GenPsy 1,722,090 737,533 42.8 178,813,409 142,132,370 984,557 57.2 37.26 348,417 OT 30,016 8,027 26.7 2,954,048 2,334,926 21,989 73.3 28.16 5,103 SW 142,478 61,777 43.4 13,081,803 10,509,169 80,701 56.6 31.88 28,276

2009 figures have regard to all claims processed up to and including 30 April 2010. Fees charged, benefits paid, and average copayments are expressed in 2009 dollars. GP, General Practitioner; CP, Consultant Psychiatrist; ClinPsy, Clinical Psychologist; GenPsy, General Psychologist; OT, Occupational Therapist; SW, Social Worker. a Only services for which the consumer contributed a co‐payment are included in the calculation of the average co‐payment.

Changes in patterns of co‐payment from 2007 to 2009 were examined, in terms of: (1) the percentage of services requiring a co‐payment, and; (2) the average co‐payment made. Figure 4.1 shows the percentage of Better Access services attracting a co‐payment in each of 2007, 2008 and 2009, broken down by item group and provider type. Figure 4.2 shows the average co‐payment made for Better Access services in each of 2007, 2008 and 2009, broken down by item group and provider type. Figure 4.1 shows that, for most provider groupings, the percentage of services requiring a co‐payment decreased between 2007 and 2009. The average decrease was 10.8% (see Table 4.1). The largest decreases have been for services provided by clinical psychologists, general psychologists and social workers. The exception was services provided by occupational therapists, for which the percentage requiring a co‐payment has remained steady. Figure 4.2 shows that, for all provider groups except occupational therapists, the average co‐payment has increased since 2007. However the average increase was only 4.5% (see Table 4.1).

64

Figure 4.1 Percentage of Better Access services for which a co‐payment was made by item group, 2007, 2008 and 2009. [GP, General Practitioner; CP, Consultant Psychiatrist; ClinPsy, Clinical Psychologist; GenPsy, General Psychologist; OT, Occupational Therapist; SW, Social Worker.]

Figure 4.2 Average co‐payment for Better Access services by item group, 2007, 2008 and 2009. [GP, General Practitioner; CP, Consultant Psychiatrist; ClinPsy, Clinical Psychologist; GenPsy, General Psychologist; OT, Occupational Therapist; SW, Social Worker.]

0

10

20

30

40

50

60

70

80

GP items CP items Clin Psy items

FPS items Gen Psy items

OT items SW items All BA items

% of services

2007

2008

2009

0

10

20

30

40

50

60

70

80

90




Average co‐paymen

t ($)

2007

2008

2009

65

4.3 DO RATES OF CO-PAYMENT FOR BETTER ACCESS SERVICES VARY ACROSS POPULATION SUBGROUPS?

Tables 4.8 to 4.10 profile the services and costs of Better Access services according to the consumers’ age, gender, geographical region and level of relative socio‐economic disadvantage, in 2007, 2008 and 2009. As patterns are reasonably similar across time, interpretation focuses on the 2009 data. The tables show that:

• The proportion of services that were bulk‐billed increased as level of remoteness increased – in 2009, from 54.2% in capital cities to 71.9% in remote areas. Conversely, the proportion of services that attracted a co‐payment decreased – in 2009, from 45.8% in capital cities to 28.1% in remote areas. However the average co‐payment was higher among people in remote areas ($37.38) and people in capital cities ($36.90) than those in other regions ($31.17‐$33.02).

• The proportion of services that were bulk‐billed increased as level of relative socio‐economic disadvantage increased – in 2009, from 43.2% in areas of least disadvantage to 78.3% in areas of most disadvantage. Conversely, the proportion of services that attracted a co‐payment decreased as level of relative socio‐economic disadvantage increased – in 2009, from 56.8% in capital cities to 21.7% in remote areas. The average co‐payment also decreased as level of relative socio‐economic disadvantage increased (from $38.08 to $32.66).

66

Table 4.8 All MBS‐subsidised Better Access services received, bulk‐billing rate, fees charges, benefits paid and average co‐payment, by gender, age, geographical region and socio‐economic disadvantage, 2007

Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%


Age group 0‐14 years 163,579 66,565 40.7 21,365,283 18,138,940 97,014 59.3 33.26 41,050 15‐24 years 372,186 198,235 53.3 47,329,973 41,200,807 173,951 46.7 35.24 106,078 25‐34 years 573,019 296,342 51.7 71,312,092 61,354,162 276,677 48.3 35.99 148,378 35‐44 years 646,285 337,832 52.3 79,143,313 68,788,920 308,453 47.7 33.57 161,854 45‐54 years 510,087 279,729 54.8 61,541,262 53,891,391 230,358 45.2 33.21 128,275 55‐64 years 291,302 168,884 58.0 34,729,314 30,665,366 122,418 42.0 33.20 77,508 65+ years 136,991 96,040 70.1 16,193,055 14,831,178 40,951 29.9 33.26 47,697

Gender Male 919,301 514,219 55.9 114,579,594 100,200,257 405,082 44.1 35.50 259,533 Female 1,774,148 929,408 52.4 217,034,698 188,670,507 844,740 47.6 33.58 451,307

Regiona Capital cities 1,896,265 940,690 49.6 238,700,362 204,987,577 955,575 50.4 35.28 477,597 Other metro 227,686 134,437 59.0 27,164,779 24,214,801 93,249 41.0 31.64 62,255 Rural centres 320,730 202,262 63.1 36,939,757 33,410,859 118,468 36.9 29.79 92,461 Other rural areas 231,182 153,567 66.4 26,751,530 24,373,375 77,615 33.6 30.64 71,572 Remote areas 17,585 12,670 72.1 2,057,794 1,884,081 4,915 27.9 35.34 6,954

Socio‐economic disadvantageb

Quintile 5 (Least) 850,490 337,857 39.7 112,347,865 93,679,522 512,633 60.3 36.42 198,825 Quintile 4 595,471 304,634 51.2 73,335,863 63,499,292 290,837 48.8 33.82 153,894 Quintile 3 520,760 305,310 58.6 62,172,033 55,260,121 215,450 41.4 32.08 142,904 Quintile 2 407,423 266,957 65.5 47,134,815 42,707,092 140,466 34.5 31.52 119,399 Quintile 1 (Most) 295,590 217,537 73.6 33,521,394 31,087,052 78,053 26.4 31.19 89,651

2007 figures have regard to all claims processed up to and including 30 April 2009. Fees charged, benefits paid, and average copayments are expressed in 2009 dollars. a Only services for which the consumer contributed a co‐payment are included in the calculation of the average co‐payment.

67


Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%



Gender Male 1,301,652 760,375 58.4 155,457,699 135,969,716 541,277 41.6 36.00 347,705 Female 2,484,948 1,378,198 55.5 291,082,013 253,477,847 1,106,750 44.5 33.98 603,749

Regiona Capital cities 2,643,794 1,384,555 52.4 319,265,857 274,197,866 1,259,239 47.6 35.79 632,343 Other metro 322,010 200,529 62.3 36,872,751 32,974,426 121,481 37.7 32.09 83,489 Rural centres 461,935 306,468 66.3 50,696,213 46,054,519 155,467 33.7 29.86 127,506 Other rural areas 334,895 230,104 68.7 36,978,668 33,742,152 104,791 31.3 30.89 98,863 Remote areas 23,966 16,917 70.6 2,726,222 2,478,600 7,049 29.4 35.13 9,253


Quintile 5 (Least) 1,152,862 478,295 41.5 147,200,365 122,275,852 674,567 58.5 36.95 257,720 Quintile 4 835,608 452,327 54.1 98,724,140 85,560,473 383,281 45.9 34.34 205,515 Quintile 3 738,265 457,252 61.9 84,008,317 74,928,084 281,013 38.1 32.31 192,273 Quintile 2 585,158 400,171 68.4 64,672,744 58,773,226 184,987 31.6 31.89 162,561 Quintile 1 (Most) 433,501 329,983 76.1 46,752,856 43,511,889 103,518 23.9 31.31 123,408


68


Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%


Age group 0‐14 years 355,901 164,877 46.3 44,834,383 38,091,086 191,024 53.7 35.30 81,336 15‐24 years 655,158 389,660 59.5 79,077,952 69,325,461 265,498 40.5 36.73 171,876 25‐34 years 936,374 523,683 55.9 111,830,884 96,094,075 412,691 44.1 38.13 224,648 35‐44 years 1,085,370 615,694 56.7 127,170,126 110,739,412 469,676 43.3 34.98 249,183 45‐54 years 862,464 518,922 60.2 98,623,205 86,768,281 343,542 39.8 34.51 199,434 55‐64 years 518,294 330,161 63.7 58,285,606 51,790,992 188,133 36.3 34.52 124,944 65+ years 250,420 188,149 75.1 27,395,417 25,326,405 62,271 24.9 33.23 78,963

Gender Male 1,643,579 992,585 60.4 195,046,140 170,876,697 650,994 39.6 37.13 419,561 Female 3,020,402 1,738,561 57.6 352,171,432 307,259,015 1,281,841 42.4 35.04 710,823

Regiona Capital cities 3,220,794 1,746,665 54.2 387,705,576 333,310,309 1,474,129 45.8 36.90 740,953 Other metro 406,611 268,669 66.1 45,903,547 41,348,924 137,942 33.9 33.02 101,922 Rural centres 577,181 392,727 68.0 63,045,538 57,295,844 184,454 32.0 31.17 155,054 Other rural areas 427,534 300,178 70.2 46,983,183 42,935,883 127,356 29.8 31.78 120,434 Remote areas 31,828 22,891 71.9 3,575,450 3,241,381 8,937 28.1 37.38 12,012


Quintile 5 (Least) 1,385,364 598,025 43.2 176,843,753 146,864,097 787,339 56.8 38.08 298,207 Quintile 4 1,040,198 586,625 56.4 122,380,008 106,271,473 453,573 43.6 35.51 245,822 Quintile 3 905,743 578,173 63.8 102,605,607 91,598,973 327,570 36.2 33.60 228,413 Quintile 2 732,988 512,346 69.9 80,322,694 73,198,042 220,642 30.1 32.29 195,517 Quintile 1 (Most) 547,063 428,338 78.3 58,516,903 54,639,090 118,725 21.7 32.66 149,683


The following series of figures (Figures 4.3 to 4.10) profile the rates of co‐payment and average co‐payments according to socio‐demographic characteristics, for each of the item groups and provider types in 2009. Tables 4.11 to 4.31 provide detailed figures regarding the services and costs of Better Access services according to the consumers’ age, gender, geographical region and level of relative socio‐economic disadvantage, for each item group in 2007, 2008 and 2009.

Co‐payment rates and average co‐payments were firstly examined according to age group. Figures 4.3 and 4.4 show the percentage of Better Access services requiring a co‐payment, and the average co‐payment, according to age group. These show that, for GP services, the percentage of services requiring a co‐payment increased with age until the 35‐44 year age group, and decreased thereafter. For all other provider groups, the percentage of services requiring a co‐payment tend to be higher for young people aged <15 years and to decrease with age, being lowest for older people aged 65 years and over. Average co‐payments for most provider types, however, were reasonably similar across most age groups, but somewhat lower for the older (65

69

years plus) age group. In particular, in 2009 the average co‐payment for people aged 65 years and over was lower for GP (17.1% lower), Psychological Therapy Services (16.7% lower) and Focussed Psychological Strategies items (18.3% lower) than the average co‐payment for all age groups combined. However for Consultant Psychiatrist and Occupational Therapist services, the average co‐payment was lowest for people aged < 15 years.

Figure 4.3 Percentage of Better Access services for which a co‐payment was made by age and item group, 2009. [GP, General Practitioner; CP, Consultant Psychiatrist; ClinPsy, Clinical Psychologist; GenPsy, General Psychologist; OT, Occupational Therapist; SW, Social Worker.]

Figure 4.4 Average co‐payment for Better Access services by age and item group, 2009. [GP, General Practitioner; CP, Consultant Psychiatrist; ClinPsy, Clinical Psychologist; GenPsy, General Psychologist; OT, Occupational Therapist; SW, Social Worker.]

0

10

20

30

40

50

60

70

80

90

100




% of services

0‐14 15‐24 25‐3435‐44 45‐54 55‐6465+

0

10

20

30

40

50

60

70

80

90




Average co‐paymen

t ($)

0‐14 15‐24 25‐3435‐44 45‐54 55‐6465+

70

Gender patterns were examined next. Figures 4.5 and 4.6 show the percentage of Better Access services requiring a co‐payment, and the average copayment, according to gender. These show that females have a slightly higher rate of services requiring co‐payment (the exception being services provided by occupational therapists) but marginally lower average co‐payments (again, with the exception of services provided by occupational therapists).

Figure 4.5 Percentage of Better Access services for which a co‐payment was made by gender and item group, 2009. [GP, General Practitioner; CP, Consultant Psychiatrist; ClinPsy, Clinical Psychologist; GenPsy, General Psychologist; OT, Occupational Therapist; SW, Social Worker.]

Figure 4.6 Average co‐payment for Better Access services by gender and item group, 2009. [GP, General Practitioner; CP, Consultant Psychiatrist; ClinPsy, Clinical Psychologist; GenPsy, General Psychologist; OT, Occupational Therapist; SW, Social Worker.]

0

10

20

30

40

50

60

70

80

90

100




% of services

MaleFemale

0

10

20

30

40

50

60

70

80

90

100




Average co‐paymen

t ($)

MaleFemale

71

Patterns according to geographical location were then examined. Figures 4.7 and 4.8 show the percentage of Better Access services requiring a co‐payment, and the average copayment, according to geographical location. These show that people residing in capital cities have a higher rate of services requiring co‐payment. Average co‐payments tended to be higher in remote locations for certain services. In particular, the average co‐payment for people in remote locations was between 15.3% and 27.8% higher for GP (27.8% higher), Psychological Therapy Services (25.4% higher) and Consultant Psychiatrist (15.3% higher) items than the average co‐payment for all geographical locations combined. However for other services (Focussed Psychological Strategies overall, General Psychologist and Social Worker items) average co‐payments were higher among people in capital cities.

Figure 4.7 Percentage of Better Access services for which a co‐payment was made by geographical location and item group, 2009. [GP, General Practitioner; CP, Consultant Psychiatrist; ClinPsy, Clinical Psychologist; GenPsy, General Psychologist; OT, Occupational Therapist; SW, Social Worker.]

0

10

20

30

40

50

60

70

80

90

100




% of services

Capital citiesOther metropolitanRural centresOther rural areasRemote areas

72

Figure 4.8 Average co‐payment for Better Access services by geographical location and item group, 2009. [GP, General Practitioner; CP, Consultant Psychiatrist; ClinPsy, Clinical Psychologist; GenPsy, General Psychologist; OT, Occupational Therapist; SW, Social Worker.]

Patterns according to relative socio‐economic disadvantage were then examined. Figures 4.9 and 4.10 show the percentage of Better Access services requiring a co‐payment, and the average copayment, according to level of disadvantage. These show that, for all provider types, people residing in areas of least disadvantage had the highest rate of services requiring a co‐payment. The proportion of services requiring co‐payment decreased steadily as level of disadvantage increased. Average co‐payments showed a similar, although far less pronounced pattern. For example, co‐payments for people in areas of greatest socio‐economic disadvantage (IRSD quintiles 1 and 2) were approximately 16% less for GP services than people in other areas.

0

10

20

30

40

50

60

70

80

90

100




Average co‐paymen

t ($)

Capital citiesOther metropolitanRural centresOther rural areasRemote areas

73

Figure 4.9 Percentage of Better Access services for which a co‐payment was made by level of socio‐economic disadvantage and item group, 2009. [GP, General Practitioner; CP, Consultant Psychiatrist; ClinPsy, Clinical Psychologist; GenPsy, General Psychologist; OT, Occupational Therapist; SW, Social Worker.]

Figure 4.10 Average co‐payment for Better Access services by level of socio‐economic disadvantage and item group, 2007, 2008 and 2009. [GP, General Practitioner; CP, Consultant Psychiatrist; ClinPsy, Clinical Psychologist; GenPsy, General Psychologist; OT, Occupational Therapist; SW, Social Worker.]

0

10

20

30

40

50

60

70

80

90

100




% of services

Q5 (Least)Q4Q3Q2Q1 (Most)

0

10

20

30

40

50

60

70

80

90

100




Average co‐paymen

t ($)

Q5 (Least)Q4Q3Q2Q1 (Most)

74

Table 4.11 MBS‐subsidised GP Mental Health Treatment Better Access services received, bulk‐billing rate, fees charges, benefits paid and average co‐payment, by gender, age, geographical region and socio‐economic disadvantage, 2007

Total servicesa


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%



Gender Male 354,266 327,564 92.5 41,611,833 41,115,053 26,702 7.5 18.60 217,822 Female 658,231 598,346 90.9 77,613,449 76,521,169 59,885 9.1 18.24 401,045

Regiona Capital cities 675,183 613,288 90.8 79,552,575 78,374,482 61,895 9.2 19.03 409,726 Other metropolitan 87,452 81,196 92.8 10,476,891 10,380,765 6,256 7.2 15.37 54,412 Rural centres 138,762 129,152 93.1 16,139,201 15,983,576 9,610 6.9 16.19 83,886 Other rural areas 101,344 93,294 92.1 11,959,159 11,820,058 8,050 7.9 17.28 64,583 Remote areas 9,755 8,979 92.0 1,097,385 1,077,271 776 8.0 25.92 6,259




75


Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%


Age group

0‐14 years 56,220 53,857 95.8 7,670,304 7,630,167 2,363 4.2 16.99 46,403 15‐24 years 193,005 180,409 93.5 22,303,661 22,064,837 12,596 6.5 18.96 123,855 25‐34 years 286,000 262,145 91.7 32,155,769 31,683,779 23,855 8.3 19.79 170,806 35‐44 years 322,607 293,850 91.1 35,547,359 34,997,323 28,757 8.9 19.13 185,370 45‐54 years 260,501 238,298 91.5 28,157,446 27,732,408 22,203 8.5 19.14 146,845 55‐64 years 159,750 147,634 92.4 16,987,055 16,758,530 12,116 7.6 18.86 89,980 65+ years 96,942 93,496 96.4 9,704,997 9,652,395 3,446 3.6 15.26 54,479


Regiona Capital cities 909,805 833,299 91.6 100,807,836 99,305,188 76,506 8.4 19.64 536,955 Other metropolitan 119,557 112,102 93.8 13,555,639 13,431,272 7,455 6.2 16.68 72,338 Rural centres 191,004 180,311 94.4 20,972,981 20,787,335 10,693 5.6 17.36 112,733 Other rural areas 141,915 132,217 93.2 15,798,436 15,628,171 9,698 6.8 17.56 87,387 Remote areas 12,744 11,760 92.3 1,391,699 1,367,472 984 7.7 24.62 8,325




76


Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%


Age group

0‐14 years 75,669 72,511 95.8 10,284,762 10,224,039 3,158 4.2 19.23 61,963 15‐24 years 239,772 225,227 93.9 27,426,660 27,140,360 14,545 6.1 19.68 150,664 25‐34 years 335,292 308,327 92.0 37,402,951 36,825,475 26,965 8.0 21.42 197,275 35‐44 years 382,615 350,443 91.6 41,772,475 41,114,951 32,172 8.4 20.44 216,295 45‐54 years 311,497 285,836 91.8 33,263,395 32,748,785 25,661 8.2 20.05 171,963 55‐64 years 194,617 180,030 92.5 20,411,374 20,121,801 14,587 7.5 19.85 107,041 65+ years 120,072 115,896 96.5 11,866,127 11,796,022 4,176 3.5 16.79 66,635


Regiona Capital cities 1,083,592 995,644 91.9 119,022,979 117,180,915 87,948 8.1 20.94 629,356 Other metropolitan 149,805 141,200 94.3 16,670,603 16,529,784 8,605 5.7 16.36 88,461 Rural centres 233,918 221,594 94.7 25,544,221 25,305,404 12,324 5.3 19.38 136,679 Other rural areas 175,437 164,254 93.6 19,387,835 19,184,372 11,183 6.4 18.19 106,479 Remote areas 16,766 15,563 92.8 1,800,360 1,769,230 1,203 7.2 25.88 10,853




77

Table 4.14 MBS‐subsidised Consultant Psychiatry Better Access services received, bulk‐billing rate, fees charges, benefits paid and average co‐payment, by gender, age, geographical region and socio‐economic disadvantage, 2007

Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%


Age group 0‐14 years 4,233 1,291 30.5 1,136,601 948,590 2,942 69.5 63.91 4,157 15‐24 years 16,062 4,487 27.9 4,470,447 3,606,347 11,575 72.1 74.65 14,841 25‐34 years 18,719 5,982 32.0 5,167,152 4,229,212 12,737 68.0 73.64 17,313 35‐44 years 19,717 6,267 31.8 5,408,638 4,445,209 13,450 68.2 71.63 18,273 45‐54 years 16,492 5,448 33.0 4,503,352 3,698,625 11,044 67.0 72.87 15,313 55‐64 years 10,780 3,526 32.7 2,913,083 2,385,700 7,254 67.3 72.70 10,043 65+ years 8,587 3,230 37.6 2,302,687 1,908,861 5,357 62.4 73.52 8,007


Regiona Capital cities 70,402 20,963 29.8 19,341,948 15,702,834 49,439 70.2 73.61 65,122 Other metropolitan 7,803 2,504 32.1 2,099,889 1,743,680 5,299 67.9 67.22 7,325 Rural centres 8,508 3,251 38.2 2,322,020 1,955,006 5,257 61.8 69.81 8,029 Other rural areas 7,168 3,159 44.1 1,946,738 1,662,079 4,009 55.9 71.01 6,788 Remote areas 709 354 49.9 191,364 158,945 355 50.1 91.32 683




78


Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%


Age group 0‐14 years 4,483 1,379 30.8 1,196,406 993,340 3,104 69.2 65.42 4,397 15‐24 years 17,032 5,329 31.3 4,721,485 3,809,421 11,703 68.7 77.93 15,703 25‐34 years 20,418 6,741 33.0 5,640,140 4,571,143 13,677 67.0 78.16 18,563 35‐44 years 21,195 7,085 33.4 5,810,287 4,741,262 14,110 66.6 75.76 19,422 45‐54 years 17,480 6,292 36.0 4,751,351 3,897,635 11,188 64.0 76.31 16,189 55‐64 years 11,584 3,929 33.9 3,150,952 2,557,872 7,655 66.1 77.48 10,698 65+ years 9,486 3,682 38.8 2,541,743 2,105,356 5,804 61.2 75.19 8,764






79


Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%








80

Table 4.17 MBS‐subsidised Psychological Therapy Services Better Access services received, bulk‐billing rate, fees charges, benefits paid and average co‐payment, by gender, age, geographical region and socio‐economic disadvantage, 2007

Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%




Regiona Capital cities 406,329 89,420 22.0 58,434,705 48,852,718 316,909 78.0 30.24 76,808 Other metropolitan 33,099 12,808 38.7 4,408,162 3,924,333 20,291 61.3 23.84 7,278 Rural centres 40,141 19,490 48.6 5,227,070 4,684,522 20,651 51.4 26.27 8,486 Other rural areas 25,992 13,522 52.0 3,389,930 3,063,745 12,470 48.0 26.16 5,605 Remote areas 1,806 833 46.1 248,037 214,411 973 53.9 34.56 435




81


Total services


Fees charged

Benefits paid


Total patients

N

N % $ $

N

%

Average co‐

payment ($)a

N



Regiona Capital cities 616,427 169,546 27.5 86,843,644 72,769,619 446,881 72.5 31.49 115,363 Other metropolitan 55,662 24,200 43.5 7,290,199 6,479,361 31,462 56.5 25.77 11,835 Rural centres 67,142 33,349 49.7 8,591,100 7,715,197 33,793 50.3 25.92 14,350 Other rural areas 43,244 22,125 51.2 5,557,048 4,987,384 21,119 48.8 26.97 9,377 Remote areas 2,699 1,177 43.6 367,372 313,390 1,522 56.4 35.47 662




82


Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%




Regiona Capital cities 776,139 235,723 30.4 110,135,752 92,298,251 540,416 69.6 33.01 141,792 Other metropolitan 75,074 36,441 48.5 9,864,343 8,773,344 38,633 51.5 28.24 15,777 Rural centres 85,008 40,830 48.0 11,038,690 9,859,716 44,178 52.0 26.69 18,069 Other rural areas 60,123 30,988 51.5 7,843,121 6,994,260 29,135 48.5 29.14 12,860 Remote areas 3,777 1,710 45.3 527,757 444,412 2,067 54.7 40.32 916




83

Table 4.20 MBS‐subsidised Focussed Psychological Strategies Better Access services received, bulk‐billing rate, fees charges, benefits paid and average co‐payment, by gender, age, geographical region and socio‐economic disadvantage, 2007

Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%




Regiona Capital cities 744,351 217,019 29.2 81,371,135 62,057,543 527,332 70.8 36.63 149,689 Other metropolitan 99,332 37,929 38.2 10,179,836 8,166,024 61,403 61.8 32.80 22,073 Rural centres 133,319 50,369 37.8 13,251,466 10,787,755 82,950 62.2 29.70 30,835 Other rural areas 96,678 43,592 45.1 9,455,702 7,827,494 53,086 54.9 30.67 22,196 Remote areas 5,315 2,504 47.1 521,009 433,454 2,811 52.9 31.15 1,376




84


Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%




Regiona Capital cities 1,042,406 357,626 34.3 110,990,840 85,476,736 684,780 65.7 37.26 204,302 Other metropolitan 138,513 61,655 44.5 13,803,135 11,234,454 76,858 55.5 33.42 29,667 Rural centres 194,398 89,088 45.8 18,574,390 15,400,953 105,310 54.2 30.13 44,377 Other rural areas 141,612 72,034 50.9 13,418,179 11,246,598 69,578 49.1 31.21 31,795 Remote areas 7,794 3,647 46.8 764,850 628,402 4,147 53.2 32.90 1,894




85


Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%




Regiona Capital cities 1,281,035 488,119 38.1 136,207,002 105,900,091 792,916 61.9 38.22 245,718 Other metropolitan 172,467 87,724 50.9 16,842,911 13,948,725 84,743 49.1 34.15 36,573 Rural centres 247,553 125,746 50.8 23,489,532 19,640,066 121,807 49.2 31.60 54,942 Other rural areas 183,047 100,518 54.9 17,291,186 14,649,175 82,529 45.1 32.01 39,655 Remote areas 10,473 5,230 49.9 1,017,339 837,691 5,243 50.1 34.26 2,394




86

Table 4.23 MBS‐subsidised General Psychologist Better Access services received, bulk‐billing rate, fees charges, benefits paid and average co‐payment, by gender, age, geographical region and socio‐economic disadvantage, 2007

Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%








87


Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%








88


Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%




Regiona Capital cities 1,163,631 448,150 38.5 124,797,302 97,008,871 715,481 61.5 38.84 226,362 Other metropolitan 161,048 81,466 50.6 15,860,421 13,113,257 79,582 49.4 34.52 34,289 Rural centres 223,399 112,662 50.4 21,469,513 17,916,499 110,737 49.6 32.09 49,872 Other rural areas 164,428 90,367 55.0 15,750,330 13,321,411 74,061 45.0 32.80 35,689 Remote areas 9,575 4,888 51.0 934,553 771,615 4,687 49.0 34.76 2,203




89

Table 4.26 MBS‐subsidised Occupational Therapist Better Access services received, bulk‐billing rate, fees charges, benefits paid and average co‐payment, by gender, age, geographical region and socio‐economic disadvantage, 2007

Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%


Age group 0‐14 years 3,726 340 9.1 414,704 324,432 3,386 90.9 26.66 552 15‐24 years 1,082 303 28.0 107,345 84,457 779 72.0 29.38 228 25‐34 years 1,312 456 34.8 127,272 95,851 856 65.2 36.71 299 35‐44 years 1,748 567 32.4 168,610 128,870 1,181 67.6 33.65 367 45‐54 years 1,474 563 38.2 135,372 106,453 911 61.8 31.74 318 55‐64 years 703 356 50.6 62,209 49,325 347 49.4 37.13 158 65+ years 399 239 59.9 33,599 29,598 160 40.1 25.01 89

Gender Male 4,936 999 20.2 515,369 405,957 3,937 79.8 27.79 844 Female 5,508 1,825 33.1 533,743 413,028 3,683 66.9 32.78 1,167

Regiona Capital cities 7,446 1,478 19.8 768,096 587,116 5,968 80.2 30.33 1,337 Other metropolitan 729 430 59.0 68,060 61,501 299 41.0 21.94 164 Rural centres 1,125 376 33.4 108,122 84,200 749 66.6 31.94 259 Other rural areas 1,082 519 48.0 97,797 80,852 563 52.0 30.10 236 Remote areas 62 21 33.9 7,037 5,316 41 66.1 41.97 15


Quintile 5 (Least) 3,424 96 2.8 383,285 281,994 3,328 97.2 30.44 561 Quintile 4 2,191 702 32.0 212,674 172,091 1,489 68.0 27.26 414 Quintile 3 1,922 464 24.1 196,970 149,385 1,458 75.9 32.64 447 Quintile 2 1,759 956 54.3 159,238 133,100 803 45.7 32.55 367 Quintile 1 (Most) 1,082 591 54.6 89,800 77,206 491 45.4 25.65 206


90


Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%


Age group 0‐14 years 9,886 1,127 11.4 1,058,762 826,120 8,759 88.6 26.56 1,287 15‐24 years 2,057 1,051 51.1 178,611 152,670 1,006 48.9 25.79 465 25‐34 years 2,207 757 34.3 216,223 160,956 1,450 65.7 38.12 453 35‐44 years 2,788 1,026 36.8 261,972 205,225 1,762 63.2 32.21 582 45‐54 years 2,489 1,107 44.5 229,290 183,903 1,382 55.5 32.84 500 55‐64 years 1,239 578 46.7 112,997 90,418 661 53.3 34.16 278 65+ years 527 349 66.2 41,267 37,394 178 33.8 21.75 136

Gender Male 10,769 2,156 20.0 1,107,737 871,754 8,613 80.0 27.40 1,635 Female 10,424 3,839 36.8 991,385 784,931 6,585 63.2 31.35 2,066

Regiona Capital cities 15,052 2,899 19.3 1,542,167 1,184,265 12,153 80.7 29.45 2,384 Other metropolitan 1,804 1,282 71.1 154,946 137,917 522 28.9 32.62 424 Rural centres 2,605 1,035 39.7 242,796 198,472 1,570 60.3 28.23 549 Other rural areas 1,629 744 45.7 144,892 125,047 885 54.3 22.42 319 Remote areas 103 35 34.0 14,322 10,984 68 66.0 49.08 25


Quintile 5 (Least) 7,395 464 6.3 813,242 604,452 6,931 93.7 30.12 1,056 Quintile 4 4,288 1,378 32.1 418,276 336,676 2,910 67.9 28.04 786 Quintile 3 3,457 1,093 31.6 336,818 265,377 2,364 68.4 30.22 699 Quintile 2 3,481 1,769 50.8 315,812 265,723 1,712 49.2 29.26 684 Quintile 1 (Most) 2,364 1,270 53.7 193,895 168,396 1,094 46.3 23.31 451


91


Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%


Age group 0‐14 years 16,177 1,913 11.8 1,678,965 1,322,343 14,264 88.2 25.00 2,094 15‐24 years 2,470 1,263 51.1 221,049 182,276 1,207 48.9 32.12 556 25‐34 years 2,548 905 35.5 247,783 185,196 1,643 64.5 38.09 542 35‐44 years 3,456 1,163 33.7 323,573 254,615 2,293 66.3 30.07 737 45‐54 years 2,888 1,310 45.4 267,539 211,436 1,578 54.6 35.55 623 55‐64 years 1,692 901 53.3 152,163 122,111 791 46.7 37.99 364 65+ years 785 572 72.9 62,976 56,949 213 27.1 28.30 187


Regiona Capital cities 22,603 4,230 18.7 2,287,488 1,782,136 18,373 81.3 27.51 3,491 Other metropolitan 2,329 1,782 76.5 196,797 174,935 547 23.5 39.97 549 Rural centres 2,940 1,017 34.6 275,579 217,802 1,923 65.4 30.05 594 Other rural areas 2,018 959 47.5 178,011 148,696 1,059 52.5 27.68 438 Remote areas 126 39 31.0 16,174 11,357 87 69.0 55.38 31


Quintile 5 (Least) 11,306 747 6.6 1,229,195 931,617 10,559 93.4 28.18 1,647 Quintile 4 6,162 1,945 31.6 586,369 473,610 4,217 68.4 26.74 1,050 Quintile 3 4,899 1,545 31.5 471,460 369,847 3,354 68.5 30.30 969 Quintile 2 4,230 2,056 48.6 372,718 312,108 2,174 51.4 27.88 799 Quintile 1 (Most) 3,091 1,728 55.9 258,344 222,180 1,363 44.1 26.53 595


92

Table 4.29 MBS‐subsidised Social Worker Better Access services received, bulk‐billing rate, fees charges, benefits paid and average co‐payment, by gender, age, geographical region and socio‐economic disadvantage, 2007

Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%


Age group 0‐14 years 3,527 1,039 29.5 337,894 266,606 2,488 70.5 28.65 807 15‐24 years 6,581 1,986 30.2 634,124 488,916 4,595 69.8 31.60 1,444 25‐34 years 10,889 2,850 26.2 1,066,816 799,510 8,039 73.8 33.25 2,228 35‐44 years 14,107 4,075 28.9 1,369,669 1,061,786 10,032 71.1 30.69 2,791 45‐54 years 10,402 3,383 32.5 994,495 782,402 7,019 67.5 30.22 2,093 55‐64 years 5,193 1,933 37.2 477,873 382,920 3,260 62.8 29.13 1,063 65+ years 2,196 1,216 55.4 191,367 167,841 980 44.6 24.01 492


Regiona Capital cities 35,627 8,685 24.4 3,609,224 2,697,401 26,942 75.6 33.84 6,739 Other metropolitan 3,048 1,422 46.7 272,303 230,705 1,626 53.3 25.58 651 Rural centres 6,864 3,104 45.2 578,388 494,577 3,760 54.8 22.29 1,733 Other rural areas 7,197 3,219 44.7 597,876 515,674 3,978 55.3 20.66 1,747 Remote areas 159 52 32.7 14,448 11,624 107 67.3 26.39 48


Quintile 5 (Least) 18,075 2,810 15.5 1,932,294 1,391,977 15,265 84.5 35.40 3,385 Quintile 4 11,281 3,107 27.5 1,064,490 831,743 8,174 72.5 28.47 2,297 Quintile 3 9,537 4,078 42.8 856,105 700,171 5,459 57.2 28.56 2,209 Quintile 2 8,202 3,009 36.7 726,762 597,831 5,193 63.3 24.83 1,781 Quintile 1 (Most) 5,350 3,366 62.9 446,546 393,578 1,984 37.1 26.70 1,157


93


Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%


Age group 0‐14 years 5,311 1,997 37.6 480,213 394,381 3,314 62.4 25.90 1,201 15‐24 years 12,892 5,462 42.4 1,169,664 936,693 7,430 57.6 31.36 2,747 25‐34 years 21,483 7,355 34.2 2,004,820 1,534,013 14,128 65.8 33.32 4,237 35‐44 years 27,457 9,649 35.1 2,567,118 2,014,596 17,808 64.9 31.03 5,126 45‐54 years 20,131 8,077 40.1 1,845,326 1,466,245 12,054 59.9 31.45 3,812 55‐64 years 11,080 5,051 45.6 976,906 801,010 6,029 54.4 29.18 2,093 65+ years 4,691 2,930 62.5 399,437 353,604 1,761 37.5 26.03 941


Regiona Capital cities 70,475 24,569 34.9 6,737,843 5,206,272 45,906 65.1 33.36 12,902 Other metropolitan 6,003 2,835 47.2 510,226 429,039 3,168 52.8 25.63 1,238 Rural centres 14,080 7,064 50.2 1,163,534 990,617 7,016 49.8 24.65 3,193 Other rural areas 12,236 5,969 48.8 1,008,917 856,775 6,267 51.2 24.28 2,750 Remote areas 251 84 33.5 22,965 17,838 167 66.5 30.70 74


Quintile 5 (Least) 32,254 6,722 20.8 3,308,708 2,431,491 25,532 79.2 34.36 5,675 Quintile 4 21,704 7,813 36.0 1,973,866 1,561,086 13,891 64.0 29.72 4,155 Quintile 3 20,081 10,163 50.6 1,736,744 1,437,329 9,918 49.4 30.19 4,224 Quintile 2 16,381 7,779 47.5 1,384,614 1,162,336 8,602 52.5 25.84 3,458 Quintile 1 (Most) 11,632 7,703 66.2 940,393 830,671 3,929 33.8 27.93 2,457


94


Total services


Fees charged

Benefits paid


Total patients

N

N % $ $ N

%


Age group 0‐14 years 9,208 3,490 37.9 869,417 697,012 5,718 62.1 30.15 2,040 15‐24 years 17,248 8,385 48.6 1,542,898 1,261,795 8,863 51.4 31.72 3,944 25‐34 years 28,464 10,944 38.4 2,644,022 2,056,965 17,520 61.6 33.51 5,518 35‐44 years 37,699 14,624 38.8 3,546,605 2,811,895 23,075 61.2 31.84 7,144 45‐54 years 27,562 12,144 44.1 2,534,001 2,042,277 15,418 55.9 31.89 5,256 55‐64 years 15,880 8,075 50.9 1,403,594 1,159,928 7,805 49.1 31.22 3,024 65+ years 6,417 4,115 64.1 541,265 479,297 2,302 35.9 26.92 1,350


Regiona Capital cities 94,801 35,739 37.7 9,122,212 7,109,084 59,062 62.3 34.09 17,514 Other metropolitan 9,090 4,476 49.2 785,693 660,533 4,614 50.8 27.13 1,913 Rural centres 21,214 12,067 56.9 1,744,440 1,505,765 9,147 43.1 26.09 4,856 Other rural areas 16,601 9,192 55.4 1,362,846 1,179,068 7,409 44.6 24.80 3,820 Remote areas 772 303 39.2 66,612 54,720 469 60.8 25.36 173




4.4 SUMMARY OF FINDINGS


What has been the rate of services provided and costs of Better Access services overall?

• Almost than 2.7 million Better Access services were provided in 2007; this grew to more almost 3.8 million services in 2008 (an annual increase of 40.6%) and to more than 4.6 million in 2009 (an annual increase of 23.2%). The total cost of these services to government, in terms of benefits paid, increased from $288.9 million in 2007 to $389.4 million in 2008 (an annual increase of 34.8%), and to $478.1 million in 2009 (an annual increase of 22.8%).

95

• More than half of all services were bulk‐billed – 53.6% in 2007, 56.5% in 2008 and 58.6% in 2009. Of services for which a co‐payment was made, the average co‐payment was around $35.

• There was considerable variation in co‐payment rates and average co‐payments according to the type of provider who delivered the services. In 2009, only 7.3% of services delivered under the GP items involved a co‐payment by the consumer, whereas up to two thirds of the services delivered under the Consultant Psychiatrist (63.7%), Psychological Therapy Services (65.4%) and allied health Focussed Psychological Strategies (57.4%) items did so.

• The average co‐payment varied according to provider type, being lowest for GP items ($20), close to the overall average for Psychological Therapy Services items ($32) and allied health Focussed Psychological Strategies items ($37), and highest for Consultant Psychiatrist items ($82) in 2009. The percentage of services requiring a co‐payment decreased by 10.8% between 2007 and 2009. For services requiring a co‐payment, the average co‐payment increased between 2007 and 2009 by 4.5%.

Do rates of co‐payment for Better Access services vary across population subgroups?

• The proportion of services that were bulk‐billed increased as the level of remoteness and level of relative socio‐economic disadvantage increased. In 2009, the average co‐payment was highest among people in remote areas ($38) and people in capital cities ($37) than those in other regions ($31‐$33). The average co‐payment decreased as level of relative socio‐economic disadvantage increased (from $38 to $33). Average co‐payments for most provider types were reasonably similar across most age groups, but tended to be somewhat lower for the older (65 years plus) age group.

• There were some variations in average co‐payments according to socio‐demographic characteristics and provider type. Most notably, average co‐payments were: lower among people aged 65 years and over for GP, Psychological Therapy Services and Focussed Psychological Strategies items; lower for people aged < 15 years for Consultant Psychiatrist and Occupational Therapist services; higher among people in remote locations for GP, Psychological Therapy Services and Consultant Psychiatrist items; and lower among people in areas of greatest socio‐economic disadvantage for GP services.

96

CHAPTER 5: EQUITY

5.1 OVERVIEW

This chapter considers Evaluation Question 3: To what extent has the Better Access initiative provided equitable access to populations in need? (in particular people living in rural and remote areas, children and young people, older persons, people from culturally and linguistically diverse backgrounds)? Specifically, the chapter brings together data on Better Access service utilisation with information about the prevalence of mental health problems (from the 2007 NSMHWB) and other Division‐based characteristics. Together, these data inform a modeling exercise that describes levels of mental health treatment need in areas defined by the boundaries of Divisions of General Practice and investigates whether Better Access services are being distributed according to need.

The analyses presented in Chapters 3 and 4 examined whether particular groups (e.g., children and young people, older persons, people living in rural and remote areas, people of low socio‐economic status) are proportionally represented in the Better Access uptake data, compared to their overall representation in the population. However, these analyses rely on the assumption that mental health problems are evenly distributed across population groups, which is known not to be the case. The analyses presented in this chapter attempt to overcome this problem by adjusting the population comparators to take into account the prevalence of mental health problems among certain groups, using data from the 2007 NSMHWB. The methodology is informed previous analyses.34, 35, 37


1. What is the distribution of mental health need at the individual level?

2. What is the relative distribution of mental health need across Divisions of General Practice?

3. What is the relative distribution of Better Access and allied health Better Access services used across Divisions of General Practice?

4. What are the rates of Better Access and allied health Better Access services according to key Division characteristics?

5. What is the relationship between mental health needs and Better Access services used at the Division level?

5.2 WHAT IS THE DISTRIBUTION OF MENTAL HEALTH NEED AT THE INDIVIDUAL LEVEL?

A first step in the analysis was to derive a measure of mental health need. Mental health need can be defined in many ways.43, 44 For the current study, an inclusive measure of need was developed that takes into consideration the groups to whom Better Access services are principally targeted (namely the common mental disorders including affective, anxiety and

97

substance use disorders), as well as other factors that may prompt individuals to seek treatment but that fall outside the criteria for determining disorder or that fall under the threshold for meeting criteria for disorder. Further information about the rationale and methodology underpinning the approach to defining and measuring mental health need is provided in section 2.3.4 of this report.

Mental health need was defined as:

• Individuals with any of the following indicators of need: a 12‐month affective, anxiety or substance use disorder and/or; 12‐month symptoms (but no lifetime disorder); and/or any psychiatric hospitalisation in the past 12 months and/or; high or very high level of psychological distress on the K10 measure and/or; 7 or more days out of role and/or; any suicidality in the past 12 months.

The distribution of mental health need among Australian adults at an individual level was then examined. Data from the 2007 NSMHWB were used to estimate the proportion of the adult population aged 16 to 84 years experiencing mental health need according to definition above. Table 5.1 shows that 31.9% (95% CI 30.0%‐33.9%) of the adult population aged 16 to 84 years were classified as having mental health need, comprising 20.0% (95% CI 18.9%‐21.1%) with any 12‐month affective, anxiety or substance use disorder plus an additional 12.1% (95% CI 11.1%‐13.1%)with at least one other indicator of need.

Table 5.1 Number and percentage of Australian adults aged 16 to 84 years meeting criteria for mental health need, and for the individual components of mental health need, as estimated by the 2007 National Survey of Mental Health and Wellbeing (N=8,841)

N % 95% CI Mental health need 2,913 32.1 30.8‐33.4

Any 12‐month affective, anxiety or substance use disorder 1,768 20.0 18.9‐21.1 12‐month symptoms of affective, anxiety or substance use disorder (but no lifetime disorder) 416

4.3 3.8‐4.8

Hospitalisation for a mental health condition in past 12 months 294 2.8 2.4‐3.3 7 or more days out of role 786 8.3 7.6‐9.0 High or very high psychological distress 849 9.4 8.6‐10.3 Suicidality in past 12 months 248 2.4 2.0‐2.8

Ns are unweighted; % (95% CI) are weighted. The total number of persons meeting criteria for mental health need will be less than the sum of the persons meeting individual criteria for its components because a person may meet criteria for more than one component.

5.3 WHAT IS THE RELATIVE DISTRIBUTION OF MENTAL HEALTH NEED ACROSS DIVISIONS OF GENERAL PRACTICE?

The distribution of mental health need across the 113 Divisions of General Practice was then estimated. Using age, gender and section of state information collected by the 2007 NSMHWB, it was possible to calculate rates of mental health need for each of the 84 strata defined by gender (male and female), age group (16‐19, 20‐24, 25‐29, 30‐34, 35‐39, 40‐44, 45‐49, 50‐54, 55‐59, 60‐64, 65‐69, 70‐74, 75‐79, 80‐84 years) and section of state (capital cities, other metropolitan regions, remainder). By taking this population category data from the 2007 NSMHWB, and weighting each Division according to its population structure (as defined by the

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same 84 strata), it was then possible to model the proportion of residents in each Division who would be expected to be meet the criteria for mental health need.

Table 5.2 summarises the distribution characteristics of the measure of mental health need across the 113 Divisions of General Practice in Australia. Between 29.5% and 34.5% of the adult population in each Division were categorised as meeting criteria for the definition of mental health need. The mean was 31.8%, and the coefficient of variation was 0.03, indicating relatively little variability between Divisions on this measure. The distribution is also shown in Figure 5.1.

Table 5.2 Summary statistics for mental health need among adults aged 16 to 84 years in 113 Divisions of General Practice in Australia

Summary statistics Percentile Range Mean SD CoV 10th 25th 50th 75th 90th Mental health need 29.5‐34.5% 31.8% 1.1% 0.03 30.4 31.0 31.9 32.8 33.3

SD, standard deviation; CoV, coefficient of variation. Data are weighted to offset the effects of population size.

Fig 5.1 Estimated proportion of adult population aged 16 to 84 years with any potential need for mental health care in 113 Divisions of General Practice

5.4 WHAT IS THE RELATIVE DISTRIBUTION OF BETTER ACCESS AND ALLIED HEALTH BETTER ACCESS SERVICES USED ACROSS DIVISIONS OF GENERAL PRACTICE?

The purpose of the current set of analyses was to examine the extent to which mental health need predicts two outcome variables: (1) total MBS‐subsidised Better Access services received in 2009 (crude rate per 1,000 population); and (2) total MBS‐subsidised allied health Better Access services received in 2009 (crude rate per 1,000 population). The following figures 5.2 and 5.3 show the frequency distributions of the rates of Better Access and allied health Better Access services used across the 113 Divisions.

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26

27

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1 5 9 13172125293337414549535761656973778185899397101105109113

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ivision po

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Fig 5.2 Total MBS‐subsidised Better Access services used in 2009 (rate per 1,000 population) by adults aged 16 to 84 years across 113 Divisions of General Practice

Fig 5.3 Total MBS‐subsidised allied health Better Access services used in 2009 (rate per 1,000 population) by adults aged 16 to 84 years across 113 Divisions of General Practice

Table 5.3 provides descriptive statistics for the 113 Divisions on each of the outcome measures. The distributions of the outcome measures demonstrated normality.

05

1015

20

Freq

uenc

y

0 100 200 300 400 500

Rate/1000: BA MBS items - Total services 2009

05

1015

20

Freq

uenc

y

0 100 200 300 400

Rate/1000: BA MBS items - Total allied health services 2009

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Table 5.3 Summary statistics for the 2 outcome measures relating to Better Access services used in 2009 for adults aged 16 to 84 years in 113 Divisions of General Practice

Percentile Range Mean SD CoV 10th 25th 50th 75th 90th Better Access services used (per 1,000) 43.6‐486.6 223.6 89.7 0.40 98.3 164.4 221.2 282.6 330.8 Allied health Better Access services used (per 1,000) 10.8‐336.3 131.3 65.6 0.50 41.8 85.1 133.7 172.6 211.8

2009 figures have regard to all MBS claims processed up to and including 30 April 2010. SD, standard deviation; CoV, coefficient of variation. Crude rates. Data are weighted to offset the effects of population size.

Total Better Access services used per Division were estimated to be between 43.6 and 486.6 services per 1,000 population. The mean was 223.6 services, and the coefficient of variation was 0.40. Total allied health Better Access services used per Division were estimated to be between 10.8 and 336.3 services per 1,000 population. The mean was 131.3 services, and the coefficient of variation was 0.50.

The following figures 5.4 and 5.5 show the overall distribution of the two outcome measures for each of the 113 GP Divisions, in ascending order. These charts illustrate the following:

• The rate of Better Access services received rates varies between Divisions of General Practice by a factor of 3.4 between the bottom 10% and the top 10%; and

• The rate of allied health Better Access services received rates vary by a factor of 5.1 between the bottom 10% and the top 10%.

Fig 5.4 Total MBS‐subsidised Better Access services used in 2009 (rate per 1,000 population) by adults aged 16 to 84 years within each 113 Divisions of General Practice

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600

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69 73 77 81 85 89 93 97101105109113

Rate per 1,000

pop

ulation


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Fig 5.5 Total MBS‐subsidised allied health Better Access services used in 2009 (rate per 1,000 population) by adults aged 16 to 84 years within each 113 Divisions of General Practice

5.5 WHAT ARE THE RATES OF BETTER ACCESS AND ALLIED HEALTH BETTER ACCESS SERVICES ACCORDING TO KEY DIVISION-LEVEL FACTORS?

It is also useful to inspect the profile of Better Access and allied health Better Access services used for the various Division‐level factors used in the analyses. There are state/territory‐based variations in Better Access and allied health Better Access services used for persons aged 16 to 84 years. These are summarized in Table 5.4 and the following Figures 5.6 and 5.7.

Table 5.4 Summary statistics for the Better Access and allied health Better Access services used in 2009 for adults aged 16 to 84 years, by state/territory and nationally

Total Better Access services used in 2009(per 1,000)

Total allied health Better Access services used in 2009

(per 1,000) Mean (95% CI) Mean (95% CI) New South Wales 257.3 (238.4‐276.2) 155.6 (140.5‐170.8) Victoria 303.2 (274.4‐331.9) 192.2 (169‐8‐214.7) South Australia 209.3 (180.9‐237.7) 113.9 (93.5‐134.3) Queensland 229.8 (198.2‐261.4) 134.4 (112.8‐156.0) Western Australia 214.7 (180.6‐248.7) 130.8 (105.6‐156.0) Tasmania 217.1 (141.2‐293.0) 138.6 (83.4‐193.8) Australian Capital Territory 216.9 (.) 143.1 (.) Northern Territory 60.4 (.) 28.9 (.) National 252.0 (238.3‐265.8) 153.2 (142.9‐163.6)

CI, confidence interval. Crude rates. Data are weighted by population size of Division of General Practice. ‘.’ – Value cannot be estimated because NT and ACT include only one Division of General Practice.

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Rate per 1,000

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The table and figures show that:

• Nationally, the mean number of Better Access services received is 252.0 (95% CI 238.3‐265.8) per 1,000 population rates. Rates varied by a factor of 5.0 between the jurisdictions with the lowest (Northern Territory) and highest (Victoria) rates (Figure 5.6); and

• Nationally, the mean number of allied health Better Access services used in 2009 was 153.2 (95% CI 142.9‐163.6) per 1,000 population rates. Rates varied by a factor of 6.7 between the jurisdictions with the lowest (Northern Territory) and highest (Victoria) rates (Figure 5.7).

Fig 5.6 Total MBS‐subsidised Better Access services used in 2009 by adults aged 16 to 84 years, by state/territory (rate per 1,000 population)

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NSW Vic Qld SA WA Tas NT ACT

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Fig 5.7 Total MBS‐subsidised allied health Better Access services used in 2009 by adults aged 16 to 84 years, by state/territory (rate per 1,000 population)

Table 5.5 shows the weighted correlations between the measures of services used, mental health need and the Division‐level characteristics. This shows the direction and magnitude of the relationships between measures.

Table 5.5 Weighted correlations among the measures

Total Better Access

services used (per

1,000)

Allied health Better Access

services used (per

1,000)

GP supply

rate (per 1,000)

Remote‐ness (%)

Mental health

need (%)

Labour force

particip‐ation (%)

Unemploy‐ment (%)

IRSED deciles

1 to 3(%)

Total Better Access services used (per 1,000) 1.00 Allied health Better Access services used (per 1,000) 0.97 1.00 GP supply rate (per 1,000) 0.33 0.27 1.00 Remoteness (%) ‐0.48 ‐0.44 ‐0.30 1.00 Mental health need (%) 0.26 0.33 0.18 ‐0.06 1.00 Labour force participation (%) ‐0.12 ‐0.05 ‐0.32 0.30 0.33 1.00 Unemployment (%) ‐0.03 ‐0.13 0.36 ‐0.10 ‐0.21 ‐0.62 1.00 IRSED deciles 1 to 3 (%) ‐0.37 ‐0.43 0.21 0.18 ‐0.29 ‐0.44 0.65 1.00

0

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250

NSW Vic Qld SA WA Tas NT ACT

Rate per 1,000

pop

ulation

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5.6 WHAT IS THE RELATIONSHIP BETWEEN MENTAL HEALTH NEED AND BETTER ACCESS UPTAKE, SERVICE USE AND BENEFITS PAID AT THE DIVISION LEVEL?

Having determined the ‘performance’ of each Division on the measure of mental health need and the two Better Access indicators (total Better Access and allied health Better Access services used), it was possible to develop regression models in which Better Access services used were predicted by various Division level factors (GP workforce supply, potential to access services, and other Division characteristics). The two sets of models are considered below.

The best fitting models for the data were obtained using a hierarchical model‐building process comprising 4 steps. Each step comprised one or more candidate variables. Step 1 included the GP workforce supply factor variable: the rate of full‐time weighted equivalent GPs in the Division (GP FWE) per 1,000 population. Step 2 included factors relating to potential to access services: state or territory; and remoteness (% of the Division population residing in remote localities, as defined by RRMA categories 6 and 7). Step 3 included the measure of mental health need: percentage of population meeting criteria for need. Step 4 included other Division characteristics: the percentage of Division population (aged 15 years and over) participating in the labour force; the percentage of Division population unemployed; the percentage of Division population living in localities of greatest relative socioeconomic disadvantage, as defined by IRSED deciles 1 to 2.

The successive contribution of the variables in each step to the explanatory power of the model was examined using the R2 statistic. Importantly, this analysis strategy enabled estimation of the independent contribution of each predictor once other factors had been accounted for. Variables that were associated with the outcome variables in univariate analyses at or below the 0.15 probability level were considered for inclusion in the models. In addition, each predictor was retained only if it contributed at least an additional 1% to the variance explained by the model. Variables were excluded if there was evidence of multicollinearity.

5.6.1 TOTAL BETTER ACCESS SERVICES USED

The final model predicting total Better Access services used is shown in Table 5.6. The final model explained 54.70% of the variation in Better Access services used.

Table 5.6 Final model showing adjusted associations between predictors and total Better Access services used in 111 Divisions of General Practicea in 2009

Coefficient SE t P 95% CI Step 1: GP workforce supply 12.10 2.66 4.55 <0.001 6.83 to 17.38 Step 2: Division in Victoria 64.25 11.03 5.82 <0.001 42.37 to 86.14 Division in SA or NT ‐20.80 17.30 ‐1.20 0.232 ‐55.10 to 13.51 Remoteness ‐1.72 0.46 ‐3.77 <0.001 ‐2.63 to ‐0.82 Step 3: Mental health need 10.11 4.88 2.07 0.041 0.43 to 19.78 Step 4: Relative socioeconomic disadvantage ‐1.39 0.32 ‐4.46 <0.001 ‐2.01 to ‐0.77 a Two influential outliers removed

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Each successive step contributed at least 1% additional variation explained in total persons using Better Access services in 2009. In step 1, the rate of full‐time workload equivalence (FWE) of GPs per 1,000 population in each Division was found to be positively associated with Better Access services used, explaining 11.07% of the variation (adjusted R2 0.1107). Of the step 2 candidate variables, being a Division in Victoria was positively associated with services used. Being a Division with relatively high percentage of the population residing in remote locations was negatively associated with services used. Being a Division in South Australia or the Northern Territoryi was not significantly associated with Better Access services used after the subsequent addition of other variables in the model. The step 2 variables together contributed an additional 32.19% to the variation explained (giving an adjusted R2 of 0.4326). The step 3 measure of mental health need was positively associated with services used, adding an additional 3.27% to the variation explained (giving an adjusted R2 of 0.4653). Of the step 4 variables, having a relatively higher percentage of the population living in areas of greater relative socioeconomic disadvantage was negatively associated with services used, adding an additional 8.17% to the variation explained (giving an adjusted R2 of 0.5470).

In summary, higher rates of Better Access services used were found in Divisions that had relatively higher levels of mental health need, after adjusting for all other variables in the model. However there were other factors that play a part in explaining rates of Better Access services used at a Divisional level. Higher rates of Better Access services used were also found in Divisions that had higher rates of GP supply, and Divisions located in Victoria. Lower rates of Better Access services used were found in Divisions with relatively more people living in socioeconomically disadvantaged areas and Divisions with relatively more people living in remote locations.

5.6.2 TOTAL ALLIED HEALTH BETTER ACCESS SERVICES USED

The final model predicting total allied health Better Access services used is shown in Table 5.7. The final model explained 50.99% of the variance in allied health Better Access services used.

Table 5.7 Final model showing adjusted associations between predictors and total allied health Better Access services used in 113 Divisions of General Practice in 2009

Coefficient SE t P 95% CI Step 1: GP workforce supply 7.09 2.08 3.40 0.001 2.95to 11.22 Step 2: Division in Victoria 45.86 8.64 5.30 <0.001 28.71 to 63.01 Division in SA or NT ‐22.51 13.57 ‐1.66 0.100 ‐49.41 to 4.38 Remoteness ‐1.19 0.36 ‐3.31 0.001 ‐1.90 to ‐0.48 Step 3: Mental health need 10.69 3.81 2.81 0.006 3.14 to 18.2 Step 4: Relative socioeconomic disadvantage ‐1.05 0.24 ‐4.35 <0.001 ‐1.53 to ‐0.57

In step 1, the rate per 1,000 population of full‐time workload equivalence (FWE) of GPs in each Division was found to be positively associated with allied health Better Access services used, explaining 6.68% of the variation (adjusted R2 0.0668). Of the step 2 variables, being a Division in Victoria was positively associated with allied health services used, whereas being a Division with a relatively high proportion of the population living in remote locations was negatively associated with allied health services used. Being a Division in South Australia or the Northern Territory was i The Northern Territory and South Australia were combined for analysis based on results of univariate analyses and the fact that the Northern territory comprises only one Division of General Practice.

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not significantly associated with allied health Better Access services used after the addition of subsequent variables into the model. The step 2 variables together contributed an additional 30.12% to the variation explained (adjusted R2 0.3670). The step 3 measure of mental health need was positively associated with services used, adding an additional 6.10% to the variation explained (adjusted R2 0.4280). Of the step 4 variables, percentage of population percentage of the population living in areas of greater relative socioeconomic disadvantage was negatively associated with service use, adding an additional 8.19% to the variation explained (adjusted R2 0.5099).

In summary, higher rates of allied health Better Access services used were found in Divisions that have relatively higher levels of mental health need, after adjusting for all other variables in the model. However there were other factors that played a part in explaining rates of allied health Better Access services used at a Divisional level. Higher rates of allied health Better Access services used were also found in Divisions that have higher rates of GP supply, and Divisions located in Victoria. Lower rates of Better Access services used were found in Divisions with relatively more people living in socioeconomically disadvantaged areas and Divisions with relatively more people living in remote locations.

5.7 KEY FINDINGS

The key findings from this chapter were:

• At a Division level, rates of total Better Access services used and allied health Better Access services used are positively associated with levels of mental health need.

• The simplest and most parsimonious models for explaining variation in total Better Access services used and allied health Better Access services used were based on five Division level factors: greater supply of GPs; being a Division in Victoria; lower percentage of the Division population living in remote locations; and lower percentage of the Division population living in socioeconomically disadvantaged areas.

• The percentage of variance explained was similar between the two models – 54.70% and 50.99% respectively. Variables relating to potential to access services (GP supply, remoteness, state/territory) collectively contributed a larger proportion of the variance in total Better Access services used (43.26%) than allied health (36.70%) Better Access services used. The mental health need variable contributed a larger proportion of additional variance explained in allied health (6.10%) than total (3.27%) Better Access services used, after variables relating to potential to access services were taken into account. Socioeconomic disadvantage contributed a similar proportion of additional variance in total (8.19%) and allied health (8.17%) Better Access services used, after all other variables were taken into account.

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CHAPTER 6: PROTOCOL-BASED CARE

6.1 OVERVIEW

This chapter presents findings relating to Evaluation Question 4: To what extent has the Better Access initiative provided evidence‐based mental health care to people with mental disorders?

The question of the extent to which the Better Access initiative has provided evidence‐based mental health care to people with mental disorders is difficult to answer for two almost contradictory reasons. The first is that the Better Access MBS item numbers are prescriptive about the type of care that is to be delivered, and designed that all such care should be evidence based. The second is that MBS data do not provide a detailed description of what happened at a given session, so it is difficult to assess the extent to which evidence‐based care has actually been delivered. Having said this, there will be certain patterns of service delivery that might give some indications of the extent to which evidence‐based care has been delivered. For this reason, this section has been re‐named ‘Protocol‐based care’.

Two aspects of the Better Access service delivery protocol were examined. The first relates to the patterns of care delivered following a GP Mental Health Treatment Plan service (MBS item 2710). As already noted, the Better Access MBS item numbers are prescriptive about the care that is to be delivered. In some cases, notably the allied health items, the protocol also specifies the quantity of these services permitted and the period over which they can be provided. For example, the allied health item numbers provide for up to 12 sessions of care on the basis of a review by the referring GP after the first six. The number of sessions that the patient is referred is determined by the GP. After the initial course of treatment (a maximum of 6 services but it may be less depending on the referral) the GP can then refer to patient for up to a further 6 sessions. It is intended that the GP Mental Health Treatment Review item (2712) is used for this purpose. Although there will be considerable variability in the actual number of sessions required for individuals, if a high proportion of individuals were receiving only one or two sessions, this would presumably indicate problems with the protocol.

The second relates to the number of allied health services that can be delivered following a GP Mental Health Treatment Plan service (MBS item 2710) in a calendar year. Under Better Access, a patient cannot have more than 18 individual services (and 12 group services) per calendar year. For example, if the GP Mental Health Treatment Plan is written in November 2008 and the patient has 2 individual sessions with a general psychologist in 2008, then in 2009 they can carry on using the GP Mental Health Treatment Plan and access 10 individual sessions and then 6 more in exceptional circumstances. Even if they then have a new GP Mental Health Treatment Plan written in 2009, they have already accessed 16 individual sessions for 2009 and can only access 2 more in 2009.

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A series of research questions was developed, focusing on these two aspects of the Better Access protocol:

A. Patterns of care following GP Mental Health Treatment Plan

1. To what extent are GP Mental Health Treatment Plans followed by a GP Mental Health Treatment Review?

2. What level of allied health services are being received by persons who have a GP Mental Health Treatment Plan followed by a Review?

3. What level of allied health services are being received by persons who have a GP Mental Health Treatment Plan not followed by a Review?

4. Does the number of allied services received vary according to number of GP Mental Health Treatment Plans received?

5. What are the socio‐demographic characteristics of people NOT receiving allied health services following a GP Mental Health Treatment Plan?

B. Volume of psychological services delivered by allied health professionals

6. How many Better Access psychological services are delivered by allied health professionals to each consumer within a calendar year?

6.2 PATTERNS OF CARE FOLLOWING A GP MENTAL HEALTH TREATMENT PLAN

To look at patterns of care following a GP Mental Health Treatment Plan, patterns of care over the entire period of available data (i.e., the December 2006 quarter to the March 2009 quarter) were examined. This decision was made because treatment ‘episodes’ can continue across calendar years. Applying annual cut‐offs to the data would potentially censor (i.e. truncate) an episode and thus underestimate the volume of services received.

The effect of censoring is illustrated in Figure 6.1. The figure shows 3 simple examples of Better Access care patterns for Persons A, B and C. Person A has received a GP Mental Health Treatment Plan, followed by 6 sessions of Focussed Psychological Strategies, followed by a GP Mental Health Treatment Review. All services were received in the 2007 calendar year. If the period of interest for analysis was restricted to calendar year 2007, for example, this would capture all Better Access care received by this person, and would provide an accurate count of the number of allied health services services they received following the Treatment Plan. Person B has received has received a GP Mental Health Treatment Plan in 2007, followed by 6 sessions of Focussed Psychological Strategies in 2008. If the period of interest for analysis was restricted to calendar year 2007, none of the allied health services they received would be counted. Person C has received services across three calendar years. If the period of interest for analysis was restricted to calendar year 2007, only two of the allied health services they received following their first Treatment Plan would be counted, and the Treatment Review would not be counted. It is acknowledged however, that even by including all available data, there will still be some censoring effects. That is, the number of services received may still be underestimated for people with ongoing episodes that are not complete by the end of the period covered by the data.

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Figure 6.1 Simple examples of Better Access care patterns.

The data presented describe the number of persons receiving Better Access services according to whether or not they received a GP Mental Health Treatment Plan with or without other services, over the period from the October 2006 quarter to the March 2009 quarter.

6.2.1 TO WHAT EXTENT ARE GP MENTAL HEALTH TREATMENT PLANS FOLLOWED BY A GP MENTAL HEALTH TREATMENT REVIEW?

Table 6.1 provides a summary of the total number of persons receiving any Better Access GP Mental Health Treatment Plan or Review service (MBS items 2710 or 2712) and the number of these services received.

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Table 6.1 Total number of persons receiving Better Access services under MBS items 2710 or 2712, October 2006 quarter to March 2009 quarter, and number of 2710 and 2712 services received.

Persons Services MBS Item

N Services (Range) N % N %

Services per Person (Mean)

2710 1 1,037,673 90.7 1,037,673 82.8 1.0 2 102,822 9.0 205,644 16.4 2.0 3 3,211 0.3 9,633 0.8 3.0 4 23 0.0 92 0.0 4.0 5+ 2 0.0 10 0.0 5.0 Total 1,143,731 1,253,052 1.1 2712 1 216,291 77.6 216,291 59.9 1.0 2 47,072 16.9 94,144 26.1 2.0 3 11,058 4.0 33,174 9.2 3.0 4 3,142 1.1 12,568 3.5 4.0 5+ 985 0.4 5,185 1.4 5.3 Total 278,548 361,362 1.3 2710 or 2712 1 815,062 71.2 815,062 50.5 1.0 2 233,394 20.4 466,788 28.9 2.0 3 64,624 5.6 193,872 12.0 3.0 4 20,481 1.8 81,924 5.1 4.0 5+ 10,412 0.9 56,768 3.5 5.5 Total 1,143,973 1,614,414 1.4

Data have regard to all claims processed up to and including 30 April 2009.

The vast majority (just under 91%) of people who received a GP Mental Health Treatment Plan received only one of these services. A further 9% received two. People who received a GP Mental Health Treatment Review most often received either one (78%) or two (17%) of these services.

The data suggest that around 21% of consumers who received a GP Mental Health Treatment Plan also received a GP Mental Health Treatment Review, a ratio of approximately 5:1. In terms of services provided, the ratio of GP Mental Health Treatment Plans to Reviews was approximately 3.5:1. In some cases, a Review may not have occurred because the first Plan was conducted shortly before the end of the counting period, and there was insufficient time for a Review to have occurred. Even allowing for this, the data indicate that many Plans may not be reviewed using the Review item.

6.2.2 WHAT LEVEL OF ALLIED HEALTH SERVICES ARE BEING RECEIVED BY PERSONS WHO HAVE A GP MENTAL HEALTH TREATMENT PLAN FOLLOWED BY A REVIEW?

Table 6.2 summarises the number of Better Access allied health services received by persons who received both a GP Mental Health Treatment Plan and a GP Mental Health Treatment Review. Data are presented separately for people who received only one Plan/Review “pair” of these services and people who received a greater number of these items.

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Table 6.2 Number of Better Access allied health services received (within ranges) by persons who had Better Access services under MBS items 2710 and 2712, December 2006 quarter to March 2009 quarter.

Percentage of persons receiving number of Allied health services within range:

Persons 0 1‐6 7‐12 13‐18 19+ Persons who received one 2710/2712 pair

183,550

25.3%

27.5%

35.2%

8.9%

3.1%

Persons who received more than one 2710/2712 pair 92,517 22.6% 17.4% 19.2% 20.5% 20.3%

Data have regard to all claims processed up to and including 30 April 2009. Data includes only those consumers who received Better Access services under MBS items 2710 and 2712.

Table 6.2 shows that, of persons who received one Plan/Review pair, one quarter did not receive any Better Access allied health services. A further 28% received between 1 and 6 services, 35% received between 7 and 12 services and 12% received more than 13 services. The distribution is similar among those who received at least one Plan and/or at least one Review.

In interpreting these data, it is important to acknowledge that some consumers who did not receive Better Access allied health services may have received psychological services from other sources, for example: from allied health professionals under the ATAPS program (which is not recorded in the MBS); from their GP, which may be recorded using the Better Access GP Mental Health Consultation item (2713) or under another MBS item; or via privately funded services.

6.2.3 WHAT LEVEL OF ALLIED HEALTH SERVICES ARE BEING RECEIVED BY PERSONS WHO HAVE A 2710 NOT FOLLOWED BY A 2712?

Tables 6.3 summarises the number of Better Access allied health services received by persons who received a GP Mental Health Treatment Plan (2710) but did not receive a GP Mental Health Treatment Review (2712). Data are presented separately for people who received only one GP Mental Health Treatment Plan and people who received two. The number of people who received more than two 2710 services (without a 2712) is too small to provide reliable patterns.

Table 6.3 Number of Better Access allied health services received (within ranges) by persons who had Better Access services under MBS items 2710 but did not have a follow‐up 2712, December 2006 quarter to March 2009 quarter.

Percentage of persons receiving number of Allied health services within range:

Persons 0 1‐6 7‐12 13‐18 19+ Persons who received one 2710 services but no 2712 services

814,841

47.8%

44.2%

6.4%

1.2%

0.4%

Persons who received two 2710 services but no 2712 services

49,832 28.4% 41.8% 17.8% 7.3% 4.6%


Table 6.3 shows that, of persons who received one GP Mental Health Treatment Plan but no Review, almost half (48%) had received no Better Access allied health services. A further 44% had received 1 to 6 services, 6% received 7 to 12 services, and 12% received 13 or more services. As

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noted in the previous section, the large percentage of people who received no allied health services may be, in part, be explained by receiving psychological services under other programs or MBS items. It may also capture people whose Plan occurred late in the observation period and for whom insufficient time has accrued for a service to have been received.

6.2.4 DOES THE NUMBER OF ALLIED SERVICES RECEIVED VARY ACCORDING TO NUMBER OF GP MENTAL HEALTH PLANS RECEIVED?

This question considers whether the number of Better Access allied health services varies as number of GP Mental Health Treatment Plans increases. People who had at least one GP Mental Health Treatment Plan (2710) and at least one GP Mental Health Treatment Review (2712) were considered first. For this analysis it was assumed that people who received 2 services most likely received one “episode” of care (where an episode is defined as a Plan followed by a Review, even if the Review was for the purpose of initiating a further episode). It was also assumed that people who received more than 3 services are most likely to have had two episodes (a 2710 followed by a 2712, followed by a further 2712 or a new 2710). People who received 4 services may have received two discrete episodes (2710 followed by 2712) or 3 contiguous episodes (2170 followed by a 2712, then another 2712), hence data are provided in a range to cover both scenarios, and so on.

Table 6.4 indicates that the average number of Better Access allied health services does not change, or may decrease somewhat, as number of episodes of Better Access care increases.

Table 6.4 Number of Better Access allied health services received and Number of 2710/2712 services received by persons who had Better Access services under MBS items 2710 and 2712, December 2006 quarter to March 2009 quarter.

Number of Allied health services received

Number of 2710/2712 services Persons Total Mean per episode

2: One episode 183,550 1,190,540 6.5

3: 2 episodes 63,871 638,860 5.0

4: 2‐3 episodes 20,475 276,510 4.5 ‐ 6.8

5+: 3‐4 episodes 10,410 152,178 3.7 ‐ 4.9


Table 6.5 indicates some variation in average number of Better Access allied health services according to number GP Mental Health Treatment Plans received among people who received GP Mental Health Treatment Plan services but no GP Mental Health Treatment Review services. The average number of allied health services increases between 1 and 3 GP Mental Health Treatment Plan services. The numbers of people receiving more than 3 Plans is very small hence these data have not been reported.

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Table 6.5 Number of Better Access allied health services received and Number of 2710 services received by persons who had Better Access services under MBS items 2710 but did not have a follow‐up 2712, December 2006 quarter to March 2009 quarter.

Number of Allied health services received

Number of 2710 services Persons Total Mean per episode 1 814,841 1,790,735 2.2 2 49,832 261,288 2.6 3 745 8,546 3.8


6.2.5 WHAT ARE THE SOCIO-DEMOGRAPHIC CHARACTERISTICS OF PEOPLE NOT RECEIVING ALLIED HEALTH SERVICES FOLLOWING A GP MENTAL HEALTH TREATMENT PLAN?

A subgroup of particular interest, as indicated by the previous analyses in this chapter, are those Better Access consumers who do not appear to be receiving allied health services following a GP Mental Health Treatment Plan.

As indicated by the previous analyses, there are a number of difficulties in profiling patterns of Better Access treatment to examine such issues. In particular, it is difficult to delineate ‘episodes’ of Better Access care in order to explore patterns of service use. The following analysis profiles patterns of care following the first GP Mental Health Treatment Plan (2710) items received by each consumer, up until their next Plan or GP Mental Health Treatment Review (2712). This involved identifying the first Plan item for each consumer referral occurring prior to 30 June 2008, and determining whether it was followed by one or more Psychological Therapy Services or Focussed Psychological Strategies services at any time up until the next Plan or review items, or the end of the March quarter 2009 (the latest date of data available). The cut‐off date of 30 June 2008 for the inclusion of Plans was chosen because protocol for the Review of a GP Mental Health Treatment Plan item (2712) is that:

An initial review should take place a minimum of 4 weeks and a maximum of 6 months after the completion of the Mental Health Treatment Plan (2710). If required, an additional review 3 months after the first review is allowed in a 12 month period.

This method allows for a minimum of 9 months of observation for each person following their first Plan, which should be sufficient time in which to accrue at least one allied health service.

Table 6.6 shows the percentages of Better Access consumers who received, and who did not receive, any Better Access allied health services following their first GP Mental Health Plan (item 2710), according to age group, gender, region and socio‐economic disadvantage.

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Table 6.6 Consumers receiving Better Access allied health services following their first GP Mental Health Plan (item 2710), according to age group, gender, region and socio‐economic disadvantage, December 2006 quarter to March 2009 quarter.

Consumers who received a GP Mental Health Treatment Plan

Consumers who received at least one Better Access allied

health service

Consumers who did not receive any Better

Access allied health services

N N % N % Age group

0‐14 years 56,373 40,070 71.1 16,303 28.9 15‐24 years 139,580 76,226 54.6 63,354 45.4 25‐34 years 194,150 111,267 57.3 82,883 42.7 35‐44 years 207,452 123,451 59.5 84,001 40.5 45‐54 years 159,658 94,620 59.3 65,038 40.7 55‐64 years 93,705 55,111 58.8 38,594 41.2 65+ years 49,198 22,980 46.7 26,218 53.3

Gender Male 320,645 179,560 56.0 141,085 44.0 Female 579,471 344,165 59.4 235,306 40.6

Regiona Capital cities 593,605 360,185 60.7 233,420 39.3 Other metropolitan centres 82,629 47,562 57.6 35,067 42.4 Rural centres 122,402 66,146 54.0 56,256 46.0 Other rural areas 93,452 46,764 50.0 46,688 50.0 Remote areas 8,028 3,068 38.2 4,960 61.8

Socio‐economic disadvantageb Quintile 5 (Least disadvantage) 247,452 159,183 64.3 88,269 35.7 Quintile 4 195,902 119,191 60.8 76,711 39.2 Quintile 3 184,656 103,174 55.9 81,482 44.1 Quintile 2 152,495 79,579 52.2 72,916 47.8 Quintile 1 (Most disadvantage) 110,998 57,626 51.9 53,372 48.1

Total 900,116 523,725 58.2 376,391 41.8

Data have regard to all claims processed up to and including 30 April 2009. a Region based on RRMA classification. b Socio‐economic disadvantage based on IRSD classification. Note that the data for socio‐economic disadvantage exclude people for whom this data are missing.

The key messages from this table are:

• Overall, 58.2% of Better Access consumers who received at received at least one Better Access allied health service following their first Plan. Conversely, 41.8% did not.

• Older people aged 65 years or more showed the highest percentage of non‐receipt of Better Access allied health services following a Plan (53.3%), whereas people aged 15 years or less had the lowest percentage (29.8%). The percentage for all other age groups was similar to the average for all Better Access consumers (41.8%).

• Non‐receipt of Better Access allied health services following a Plan was somewhat higher for males (44.0%) than females (40.6%).

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• Non‐receipt of Better Access allied health services following a Plan increased considerably as level of geographical remoteness increased. Rates of non‐receipt of allied health services following a first Plan were similar to the average for all Better Access consumers for people in capital cities and other metropolitan regions, but were 10% lower for people in rural centres, 19.6% lower for people in other rural areas, and 47.8% lower for people in remote areas.

• Non‐receipt of Better Access allied health services following a Plan increased as level of socio‐economic disadvantage increased. Rates of non‐receipt of allied health services following a first Plan were 14.6% higher for people in capital cities, but were 14.4% lower for people in other rural areas and 15.1% lower for people in remote areas.

As noted already in section 6.2.2, it is important to acknowledge that some consumers who did not receive Better Access allied health services may have received psychological services from other sources.

6.3 VOLUME OF SERVICES DELIVERED BY ALLIED HEALTH PROFESSIONALS

The analyses in this section profile the number of Psychological Therapy Services items or Focussed Psychological Strategies items received in each calendar year since Better Access was introduced.

6.3.1 HOW MANY BETTER ACCESS PSYCHOLOGICAL SERVICES ARE DELIVERED BY ALLIED HEALTH PROFESSIONALS TO EACH CONSUMER WITHIN A CALENDAR YEAR?

Tables 6.7 and 6.8 summarise the distribution of total number of Better Access psychological services in calendar years 2007 and 2008 respectively, for all psychological services and grouped by provider type.

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Table 6.7 Total number of Better Access psychological services in calendar year 2007, for all psychological services and by provider type.

Persons

Services

Percentage of persons receiving number of allied

health services within range:

Total N

Total N

Max. per

person

Median

Mean

1‐6

7‐12

13‐18

19+ All psychological services 314,410 1,586,362 30 4 5.0 73.5 21.6 4.8 0.1 Provider type:a

Clinical psychologist 98,612 507,367 30 4 5.1 72.2 22.7 5.0 0.1 General psychologist 213,963 1,015,656 30 4 4.7 76.3 19.6 4.0 0.1

Any psychologist 302,531 1,523,023 30 4 5.0 73.6 21.6 4.8 0.1 Occupational therapist 2,011 10,444 20 4 5.2 72.0 22.4 5.6 0.0 Social worker 10,918 52,895 22 4 4.8 76.0 19.5 4.5 0.0

Non‐psychologist allied health

12,921

63,339

22

4

4.9 75.3 20.0 4.7 0.0

Data have regard to all claims processed up to and including 30 April 2009. a Person counts for Provider types are not mutually exclusive.

Table 6.7 shows that, for all psychological services regardless of provider, the median number of services received in 2007 was 4. The distribution across service ranges showed that approximately three‐quarters of people who received psychological services received between 1 and 6. A further 22% received between 7 and 12, and 4.8% received between 13 and 18. The table also shows that the distribution was similar across all allied health provider types. The 2008 data showed some modest increases in services received compared to 2007, and an increase in the overall median number of services received from 4 to 5 (Table 6.8).

Given that consumers are able to claim up to 12 Better Access allied health services (18 in exceptional circumstances), and a further 12 group services, in a calendar year, the median of 4‐5 services may appear low. This will, in part, reflect the fact that the period of eligibility for using these services is the calendar year, regardless of when in that year the GP Mental Health Treatment Plan is conducted. That is, consumers whose Plan was conducted towards the end of the year will have less time in which to use the allied health services than people whose Plan was conducted earlier in the year.

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Table 6.8 Total number of Better Access psychological services in calendar year 2008, for all psychological services and by provider type.

Persons

Services

Percentage of persons receiving number of allied

health services within range:

Total N

Total N

Max. per

person

Median

Mean

1‐6

7‐12

13‐18

19+ All psychological services 449,130 2,309,897 30 5 5.1 72.7 20.8 6.4 0.1 Provider typea:

Clinical psychologist 151,587 785,174 30 4 5.2 72.3 21.2 6.5 0.1 General psychologist 289,785 1,400,485 30 4 4.8 75.4 19.1 5.4 0.1

Any psychologist 427,601 2,185,659 30 4 5.1 73.0 20.7 6.3 0.1 Occupational therapist 3,701 21,193 28 4 5.7 68.3 21.9 9.3 0.6 Social worker 20,157 103,045 23 4 5.1 73.0 20.7 6.3 0.0

Non‐psychologist allied health

23,836

124,238

28

4

5.2 72.2 20.9 6.8 0.1

Data have regard to all claims processed up to and including 30 April 2009. a Person counts for Provider types are not mutually exclusive.


Two aspects of the Better Access service delivery protocol were explored. The first of these related to the patterns of care delivered following a GP Mental Health Treatment Plan. Analyses revealed that:

• Approximately 21% of Better Access consumers who received a GP Mental Health Treatment Plan received a GP Mental Health Treatment Review, a ratio of approximately 5:1. In terms of services provided, the ratio of Plans to Reviews was approximately 3.5:1.

• Overall, 58.2% of Better Access consumers received at least one allied health service following their first Plan. Conversely, 41.8% did not.

• The extent to which Better Access consumers received allied health services following a GP Mental Health Treatment Plan varied according to age, gender, region of residence and level of socio‐economic disadvantage. Older people aged 65 years or more had the highest percentage of non‐receipt of allied health services following a Plan (53.3%), whereas people aged 15 years or less had the lowest percentage (29.8%). The percentage for all other age groups was similar to the average for all Better Access consumers of 41.8%.

• The percentage of non‐receipt of Better Access allied health services following a Plan was somewhat higher for males (44.0%) than females (40.6%). Non‐receipt of Better Access allied health services following a Plan increased considerably as level of geographical remoteness increased, being 19.6% lower for people in other rural areas, and 47.8% lower for people in remote areas. Non‐receipt of Better Access allied health services following a Plan increased as level of socio‐economic disadvantage increased. Non‐receipt of Better Access allied health services following

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a first Plan were 14.6% higher for people in capital cities, but were 14.4% lower for people in other rural areas and 15.1% lower for people in remote areas.

The second aspect of the Better Access service delivery protocol explored was the volume of allied health services delivered in a calendar year. Analyses revealed that:

• Among all consumers who received Better Access psychological services in 2007 and 2008, around 75% received between one and six, 20% received between seven and 12, and 5% received between 13 and 18. This suggests that the protocol is being interpreted appropriately by providers.

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CHAPTER 7: INTERDISCIPLINARY CARE

7.1 OVERVIEW

This chapter presents findings relating to Evaluation Question 5: To what extent has the Better Access initiative provided interdisciplinary primary mental health care for people with mental disorders? Specifically, it explores rates of uptake and service use of various combinations of MBS‐subsidised Better Access items for the total Australian population, and for key subgroups.

The question of the extent to which the Better Access initiative has provided interdisciplinary primary mental health care for people with mental disorders can only be partially addressed using MBS data. Certain MBS item numbers are quite prescriptive about the involvement of providers. For example, the psychologist item numbers all require a referral from a GP, but it is beyond the scope of the MBS data to determine the nature of the interactions between different providers. There is, however, scope for determining whether particular individuals are receiving care from more than one provider (e.g., a psychologist and a psychiatrist), and to explore these patterns by rurality, age group, sex and socio‐economic disadvantage. Nonetheless, it will be difficult to draw definitive conclusions about whether the care they are providing is collaborative and co‐ordinated.

Interdisciplinary care was examined via the following research questions:

1. What is the distribution of uptake and service use across different combinations of MBS Better Access items?

2. Do patterns of interdisciplinary care vary according to socio‐demographic characteristics?

7.2 WHAT IS THE DISTRIBUTION OF UPTAKE AND SERVICE USE ACROSS DIFFERENT COMBINATIONS OF MBS BETTER ACCESS ITEMS?

A detailed profile was undertaken of the extent to which Better Access consumers used different combinations of the Better Access MBS items. To do this the items were grouped as follows:

GPPR: GP Mental Health Treatment Plan and Review items (2710 and 2712)

GPC: GP Mental Health Consultation items (2713)

CP: Consultant Psychiatry items (291, 293, 296, 297, 299)

PTS: Psychological Therapy Services items (80000, 80005, 80010, 80015, 80020)

FPS: Focussed Psychological Strategies – Allied mental health items (80100, 80105, 80110, 80115, 80120, 80125, 80130, 80135, 80140, 80145, 80150, 80155, 80160, 80165, 80170)

These groupings were chosen for two reasons. Firstly, although Focussed Psychological Strategies can be provided by several types of allied health professionals (general psychologists, social

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workers and occupational therapists), the array of services provided are the same. The services provided by clinical psychologists (Psychological Therapy Services) are grouped separately because the intent of the service is different from that of Focussed Psychological Strategies. Secondly, the groupings distinguish between services provided by GPs for the purposes of planning and review, from those provided as consultation items.

Patterns of Better Access service use in terms of the various combinations in which people used these items were then explored. Analysis focused on patterns of care over the entire period of available data (i.e., the December 2006 quarter to the March 2009 quarter). This decision was made because Better Access treatment ‘episodes’ can continue across calendar years. Applying annual cut‐offs to the data would potentially censor (i.e. truncate) an episode and thus underestimate the extent of interdisciplinary care, both in terms of the proportion of people who received interdisciplinary care and the volume of services they received.

The potential effects of such censoring are illustrated by revisiting the 3 examples of Better Access care patterns shown in the previous chapter. These are illustrated again in Figure 7.1. If the period of interest for analysis was restricted to calendar year 2007, for example, Person A would be correctly categorized of this person has having received interdisciplinary care in that year, and the number of services they received as part of their interdisciplinary care would also be correct. Person B, however, would be categorised as not having received interdisciplinary care because only their GP Mental Health Treatment Plan service would be counted. Person C would be correctly categorized as having received interdisciplinary care, but only two of the services they received would be counted. It is acknowledged however, that even by including all available data, there will still be some censoring effects. That is, interdisciplinary care may still be underestimated for people with ongoing episodes that are not complete by the end of the period covered by the data.

Figure 7.1 Simple examples of Better Access care patterns.

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Table 7.1 lists each possible combination of the five item groups (GPPR, GPC, CP, PT and FPS), and presents the total number of persons who have used that combination and the total number of services received within that combination, in descending order of uptake. Table 7.2 contains the same information, but is presented in descending order of the total number of services received.

Of the 31 possible item group combinations, 3 combinations were used by more than half (58%) of all Better Access service users, and 7 combinations were used by 87% of all Better Access users (shaded cells; Table 7.1). The 3 combinations with greatest population uptake involved one or other type of GP care only (GPPR alone, GPC alone), and GP Mental Health Treatment Plan or Review services in combination with Focused Psychological Strategies (GPPR+FP). The 7 combinations with greatest population uptake involved combinations that included GP services alone (GPPR alone, GPC alone, GPPR+GPC), 3 of the 4 the combinations involving GP care plus one of the either psychological therapies or focused psychological strategies (GPPR+FP, GPPR+PT, GPPR+GPC+FP), and Consultant Psychiatry services alone (CP alone).

When examined in terms of number of services used, there were 3 combinations that were used by 55% of all Better Access service users, and 7 combinations used by 77% of all Better Access users (shaded cells; Table 7.2). The 7 items that accounted for the greatest number of services involved all of the combinations relating to GP services alone (GPPR alone, GPC alone, GPPR+GPC), and all of the combinations involving GP care plus one of the either psychological therapies or focused psychological strategies (GPPR+FP, GPPR+PT, GPPR+GPC+FP, GPPR+GPC+PT). The 3 most frequently used combinations all involved combinations of GP care plus psychological care, reflecting the Better Access protocols relating to the number and timing of services permitted.

In summary, these patterns indicate that the majority of people using Better Access services were provided these services by GPs alone (44.9% of consumers) or by combinations recorded in the Better Access data as involving GPs and allied health professionals only (39.7%).

Interestingly, 16.4% of people were recorded in the Better Access data as having received only GP Mental Health Consultation items (2713). It is beyond the scope of the data to determine the reasons that GPs may have elected to use this item without a prior GP Mental Health Treatment Plan (item 2710). However the data show that the average number of GP Mental Health Consultation items per consumer is only 1.7 (i.e. 442180 services / 255, 991 persons). This suggests that this item may be being used in instances where the GP considers the mental health issue does not require intensive treatment.

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Table 7.1 Patterns of interdisciplinary care among people who any Better Access MBS item, in descending order of population use, December 2006 quarter to March 2009 quarter.

Total persons Total services used

N persons

% of total persons

N services

% of total services

GPPR alone 331,021 21.2 382,935 5.0

GPPR+FPS 317,239 20.3 2,197,858 28.6

GPC alone 255,991 16.4 442,180 5.8

GPPR+PTS 131,864 8.5 955,873 12.4

GPPR+GPC 112,412 7.2 466,215 6.1

CP alone 101,389 6.5 109,785 1.4

GPPR+GPC+FPS 98,429 6.3 1,069,902 13.9

GPPR+GPC+PTS 36,736 2.4 421,756 5.5

FPS alone 22,082 1.4 92,477 1.2

GPPR+PTS+FPS 21,607 1.4 282,617 3.7

GPPR+CP+FPS 20,137 1.3 204,254 2.7

GPPR+CP 16,630 1.1 38,730 0.5

GPPR+GPC+CP+FPS 13,875 0.9 222,438 2.9

GPC+CP 13,285 0.9 47,523 0.6

PTS alone 12,193 0.8 57,488 0.7

GPPR+GPC+PTS+FPS 10,499 0.7 188,743 2.5

GPPR+GPC+CP 10,298 0.7 66,938 0.9

GPPR+CP+PTS 9,529 0.6 101,383 1.3

GPPR+GPC+CP+PTS 5,622 0.4 92,963 1.2

GPPR+CP+PTS+FPS 3,363 0.2 57,878 0.8

CP+FPS 3,170 0.2 23,706 0.3

GPPR+GPC+CP+PTS+FPS 3,057 0.2 74,410 1.0

CP+PTS 2,763 0.2 22,465 0.3

GPC+FPS 2,160 0.1 14,218 0.2

PTS+FPS 1,286 0.1 14,786 0.2

GPC+PTS 891 0.1 6,620 0.1

GPC+CP+FPS 664 0.0 6,709 0.1

GPC+CP+PTS 501 0.0 5,277 0.1

CP+PTS+FPS 437 0.0 6,910 0.1

GPC+PTS+FPS 121 0.0 1,804 0.0

GPC+CP+PTS+FPS 81 0.0 1,438 0.0

Total 1,559,332 7,678,279

Data have regard to all claims processed up to and including 30 April 2009. Shaded cells indicate item combinations used by 5% or more of total persons using Better Access services. GPPR, GP Mental Health Treatment Plan and Review items (2710 and 2712); GPC, GP Mental Health Consultation items (2713); CP, Consultant Psychiatry items (291, 293, 296, 297, 299); PTS, Psychological Therapy Services items (80000, 80005, 80010, 80015, 80020); FPS, Focussed Psychological Strategies – Allied mental health items (80100, 80105, 80110, 80115, 80120, 80125, 80130, 80135, 80140, 80145, 80150, 80155, 80160, 80165, 80170).

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Table 7.2 Patterns of interdisciplinary care among people who any Better Access MBS item, in descending order of services used, December 2006 quarter to March 2009 quarter

Total services used Total persons

N services

% of total services

N persons

% of total services

GPPR+FPS 2,197,858 28.6 317,239 20.3

GPPR+GPC+FPS 1,069,902 13.9 98,429 6.3

GPPR+PTS 955,873 12.4 131,864 8.5

GPPR+GPC 466,215 6.1 112,412 7.2

GPC alone 442,180 5.8 255,991 16.4

GPPR+GPC+PTS 421,756 5.5 36,736 2.4

GPPR alone 382,935 5.0 331,021 21.2

GPPR+PTS+FPS 282,617 3.7 21,607 1.4

GPPR+GPC+CP+FPS 222,438 2.9 13,875 0.9

GPPR+CP+FPS 204,254 2.7 20,137 1.3

GPPR+GPC+PTS+FPS 188,743 2.5 10,499 0.7

CP alone 109,785 1.4 101,389 6.5

GPPR+CP+PTS 101,383 1.3 9,529 0.6

GPPR+GPC+CP+PTS 92,963 1.2 5,622 0.4

FPS alone 92,477 1.2 22,082 1.4

GPPR+GPC+CP+PTS+FPS 74,410 1.0 3,057 0.2

GPPR+GPC+CP 66,938 0.9 10,298 0.7

GPPR+CP+PTS+FPS 57,878 0.8 3,363 0.2

PTS alone 57,488 0.7 12,193 0.8

GPC+CP 47,523 0.6 13,285 0.9

GPPR+CP 38,730 0.5 16,630 1.1

CP+FPS 23,706 0.3 3,170 0.2

CP+PTS 22,465 0.3 2,763 0.2

PTS+FPS 14,786 0.2 1,286 0.1

GPC+FPS 14,218 0.2 2,160 0.1

CP+PTS+FPS 6,910 0.1 437 0.0

GPC+CP+FPS 6,709 0.1 664 0.0

GPC+PTS 6,620 0.1 891 0.1

GPC+CP+PTS 5,277 0.1 501 0.0

GPC+PTS+FPS 1,804 0.0 121 0.0

GPC+CP+PTS+FPS 1,438 0.0 81 0.0

Total 7,678,279 1,559,332

Data have regard to all claims processed up to and including 30 April 2009. Shaded cells indicate item combinations comprising 5% or more of total Better Access services used. GPPR, GP Mental Health Treatment Plan and Review items (2710 and 2712); GPC, GP Mental Health Consultation items (2713); CP, Consultant Psychiatry items (291, 293, 296, 297, 299); PTS, Psychological Therapy Services items (80000, 80005, 80010, 80015, 80020); FPS, Focussed Psychological Strategies – Allied mental health items (80100, 80105, 80110, 80115, 80120, 80125, 80130, 80135, 80140, 80145, 80150, 80155, 80160, 80165, 80170).

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7.3 DO PATTERNS OF INTERDISCIPLINARY CARE VARY ACCORDING TO SOCIO-DEMOGRAPHIC CHARATERISTICS?

Analyses were then undertaken to explore the extent of broadly‐defined interdisciplinary care. This required a distinction to be made between which item combinations would be considered interdisciplinary care and, conversely, which would be considered mono‐disciplinary care. Mono‐disciplinary care was considered to include those item combinations that involved services provided by a GP only. All other combinations were regarded as indicating interdisciplinary care. As can be seen from Tables 7.1 and 7.2, this latter group includes item combinations that represent only allied health professional items or only consultant psychiatrist items. It was considered that, as these services require referral from a GP or another specialist such as a paediatrician, they should be regarded as interdisciplinary care even though those referrals are not represented in the Better Access dataset. Expressed another way, the classification of interdisciplinary care could be regarded as an indicator of specialist care (vs. primary care only). These groupings are quantified in Table 7.3, which shows that 44.9% of persons who received Better Access services received services from a GP only, and 55.1% received interdisciplinary Better Access care.

Table 7.3 Summary of interdisciplinary care groupings, as represented in the Better Access data, December 2006 quarter to March 2009 quarter

Total persons Total services used

N persons

% of total persons

N services

% of total services

Services provided by a GP alone 699,424 44.9 1,291,330 16.8

Services provided by a GP plus an allied health professional or psychiatrist 716,588 46.0 6,059,332 78.9

Services provided by an allied health professional or psychiatrist (but no GP) 143,320 9.2 327,617 4.3

Total 1,559,332 7,678,279


Table 7.4 provides a profile of the receipt of interdisciplinary Better Access care, operationalised as above, according to age, gender, region and socio‐economic status. The rates were calculated using the 2008 population as the denominator, and assume that the population remained constant over the period of observation. The rates are therefore a cumulative rate for the 29 months covered by the period included in the December 2006 quarter to the March 2009 quarter. The table shows that:

• The cumulative rate of any Better Access care over was 72.0 per 1,000 total population. The cumulative rate of interdisciplinary Better Access care over the same period was 39.7 per 1,000 total population.

• The percentage of Better Access consumers receiving interdisciplinary care was highest among young people aged less than 15 years (71.1% of Better Access consumers in this age group, 28.9% higher than for Better Access consumers overall).

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• The percentage of Better Access consumers receiving interdisciplinary care was lowest among young people aged 65 years and over (44.0% of Better Access consumers in this age group, 20.2% lower than for Better Access consumers overall).

• The percentage of Better Access users receiving interdisciplinary care was equal for males and females.

• The percentage of Better Access users receiving interdisciplinary care decreased as remoteness increased. For people in other rural areas, the percentage was 46.8% (15.1% lower than for Better Access consumers overall), and for people in remote areas it was 33.2% (39.9% lower than for Better Access consumers overall). However it should be noted that some consumers, particularly those people in non‐metropolitan areas, may be receiving psychological services via the ATAPS program (which are not recorded by Medicare).

• The proportion of Better Access users receiving interdisciplinary care decreased as level of socio‐economic disadvantage increased. For people in the least disadvantaged areas, the percentage was 62.5% (13.4% higher than for Better Access consumers overall), whereas for people the most disadvantaged areas it was 48.0% (12.9% lower than for Better Access consumers overall).

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Table 7.4 Cumulative rates of interdisciplinary care and all Better Access care, December 2006 quarter to March 2009 quarter.

Interdisciplinary Better Access care

Any Better Access care

Percentage of Better Access

users receiving interdisciplinary

care N

persons % of

persons

Rate (per

1,000) N

persons % of

persons

Rate (per

1,000) Age group

0‐14 years 70,914 8.3 17.2 99,777 6.5 24.2 71.1 15‐24 years 124,481 14.6 41.5 234,387 15.2 78.2 53.1 25‐34 years 172,781 20.3 57.9 314,036 20.3 105.2 55.0 35‐44 years 191,418 22.5 61.5 340,578 22.1 109.4 56.2 45‐54 years 150,857 17.7 51.0 272,486 17.7 92.1 55.4 55‐64 years 91,511 10.8 37.9 170,632 11.1 70.7 53.6 65+ years 49,029 5.8 17.3 111,445 7.2 39.4 44.0

Gender Male 319,468 37.5 30.0 576,600 37.4 54.1 55.4 Female 531,523 62.5 49.4 966,741 62.6 89.8 55.0

Regiona Capital cities 590,255 69.4 43.3 1,023,271 66.3 75.1 57.7 Other metropolitan centres 76,702 9.0 43.8 137,464 8.9 78.5 55.8 Rural centres 103,094 12.1 37.0 205,111 13.3 73.5 50.3 Other rural areas 75,846 8.9 28.2 162,130 10.5 60.3 46.8 Remote areas 5,094 0.6 9.1 15,365 1.0 27.4 33.2

Socio‐economic disadvantageb Quintile 5 (Least disadvantage) 263,767 31.0 48.0 421,725 27.3 76.7 62.5 Quintile 4 194,036 22.8 42.1 337,697 21.9 73.3 57.5 Quintile 3 164,931 19.4 37.6 314,745 20.4 71.7 52.4 Quintile 2 130,975 15.4 34.9 266,641 17.3 71.0 49.1 Quintile 1 (Most disadvantage) 97,282 11.4 30.7 202,533 13.1 63.9 48.0

All Better Access itemsc 850,991 100.0 39.7 1,543,341 100.0 72.0 55.1

Data have regard to all claims processed up to and including 30 April 2009. Rates are crude rates. a Region based on RRMA classification. b Socio‐economic disadvantage based on IRSD classification. c Total persons includes only individuals with data available on all socio‐demographic characteristics, and thus may differ from the totals shown in Tables 7.1 and 7.2.



What is the distribution of uptake and service use across different combinations of MBS Better Access items?

• People using Better Access services were most commonly provided these services by GPs alone (44.9% of consumers) or by combinations of Better Access items involving GPs and allied health professionals only (39.7%).

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Do patterns of interdisciplinary care vary according to socio‐demographic characteristics?

• Overall, interdisciplinary Better Access care was received by 55.1% of all Better Access users.

• The cumulative rate of interdisciplinary Better Access care over the period covered by the December 2006 quarter to the March 2009 quarter was 39.7 per 1,000 total population; the cumulative rate of Better Access care was 72.0 per 1,000 total population.

• Receipt of interdisciplinary Better Access care varied according to gender, age and region. Most notably, compared to the average across all Better Access consumers, rates of interdisciplinary care were 15% lower in other rural areas and 33% lower in remote areas.

• Rates of interdisciplinary care also decreased as level of socio‐economic disadvantage increased. Specifically, rates of interdisciplinary care were 13% higher among people in the least disadvantaged areas, and 13% lower among people from the most disadvantaged areas, compared to Better Access consumers overall.

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CHAPTER 8: IMPACT ON PRESCRIBING

8.1 OVERVIEW

This chapter presents findings relating to Evaluation Question 6 which asks: To what extent has the Better Access initiative impacted on the use of medications commonly prescribed for treatment of mental disorders, in particular antidepressant medications?

To assess whether the Better Access initiative has impacted on the use of medications commonly prescribed for treatment of mental disorders analyses combining MBS and PBS data were undertaken. Firstly, analyses examined whether there been a change in demand for PBS‐subsidised antidepressant and anxiolytic medications, at the level of Division of General Practice, since the introduction of Better Access. Division‐level analyses were conducted comparing supply of these medications for the two years prior to the introduction of Better Access, with the period of available data after the introduction of Better Access (i.e. up to the March 2009 quarter). Secondly, analyses examined whether Better Access uptake has impacted on demand for antidepressant and anxiolytic medications, since the introduction of Better Access.

For the purpose of these analyses, the focus was restricted to antidepressant and anxiolytic medications as these are the principal pharmacological agents used in the treatment of affective and anxiety disorders, which are the key disorders targeted by Better Access. Evidence‐based treatments for affective and anxiety disorders include antidepressant and anxiolytic medications, as well as psychological therapies such as cognitive behavioural therapy.45 The medical treatment of depression is based on antidepressant medications. Antidepressants have, over time, replaced benzodiazepines (the class of medications that traditionally comprises anxiolytics) as the preferred medication for longer term management of anxiety disorders, including obsessive compulsive disorder and panic disorder.46 The primary application of benzodiazepines is now for the short‐term treatment of anxiety disorders.46, 47

The following series of research questions was examined:

1. Has there been a change in demand for antidepressant and anxiolytic medications since the introduction of Better Access?

2. Has there been a change in demand for antidepressant and anxiolytic medications since the introduction of Better Access among people eligible to receive medications at a concession price?

3. What is the relationship between Better Access uptake and demand for antidepressant and anxiolytic medications at a Division level?

8.2 HAS THERE BEEN A CHANGE IN DEMAND FOR ANTIDEPRESSANT AND ANXIOLYTIC MEDICATIONS SINCE THE INTRODUCTION OF BETTER ACCESS?

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Patterns of antidepressant medication supply were examined. The rate of persons supplied PBS‐subsidised antidepressant medications ranged from 63.5 per quarter per 1,000 total population in the December 2004 quarter to 59.3 per quarter per 1,000 in the December 2009 quarter (see Figure 8.1). Scripts for PBS‐subsidised antidepressant medications ranged from 170.3 per 1,000 total population to 166.4 per 1,000 total population over the same period (see Figure 8.2). Figures 8.1 and 8.2 also show the rate of persons using Better Access services after the initiative was introduced in November 2006.

Fig 8.1 Persons using Better Access items and PBS‐subsidised antidepressant medications, December 2004 quarter to December 2009 quarter (rate per 1,000 population).

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Fig 8.2 Persons using Better Access services and scripts supplied for PBS‐subsidised antidepressant medications, December 2004 quarter to December 2009 quarter (rate per 1,000 population).

Analyses were undertaken to examine whether patterns of antidepressant supply had changed since the introduction of Better Access. As Better Access was introduced part‐way through the December 2006 quarter, the following analyses exclude the December 2006 quarter. By doing this, analyses could be undertaken to compare two full years pre‐Better Access and three full years post‐ Better Access, which has the advantage of minimising the influence of seasonal patterns.j

In order to address whether Better Access has resulted in a change in demand for these medications, analyses must to assess whether any apparent decrease in antidepressant supply is modified after the introduction of Better Access. To achieve this, a series of negative binomial regression analyses (see section 2.3.4 for more information) were used to estimate the trends in medication supply for the pre‐Better Access period and the post‐Better Access period, and to determine whether a change in trend had occurred between these two time periods. Table 8.1 presents the results of these analyses for PBS‐subsidised antidepressant medication supply. The results suggest that the rate of persons using antidepressant medications decreased by 1.1% per j As shown in Figures 8.1 and 8.2 medication supply is higher in the latter part of each year. This peak is due to the safety net provisions in the PBS. “These provisions were introduced to ensure patients with multiple medical conditions, who genuinely need a number of medications, are not prevented financially from obtaining them. Once the out‐of pocket threshold safety net level is reached, prescriptions on the scheme are either free, or available at greatly reduced copayment amount. The safety met period is the calendar year, and the highs and lows are due to stockpiling of medication once the safety net level is reached.”48. Australian Government Department of Health & Ageing. Australian Statistics on Medicines. Canberra: Commonwealth of Australia; 2009. (p.12).

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quarter (RR = 0.989; P = 0.010) in the two years before the introduction of Better Access but increased by 0.9% per quarter in the three years after the introduction of Better Access (RR = 1.009; P = <0.001). The ratio of the post‐Better Access trend to the pre‐Better Access trend was statistically significant (RR = 1.020; P = <0.001), indicating a significant change in trend. That is, the small but significant decline in antidepressant supply occurring during the two year prior to Better Access, was reversed in the period following the introduction of Better Access.

Table 8.2 shows that prior to the introduction of Better Access, the rate of scripts supplied was stable. Following the introduction of Better Access, there was a significant increase in scripts supplied for antidepressants. The change in trend was statistically significant.

Table 8.1 Estimated change in trends for uptake of PBS‐subsidised antidepressant medications, before and after the introduction of Better Access

Trend pre‐Better Access

Trend post‐Better Access

Ratio of trendsa

RR (95% CI) P RR (95% CI) P RR (95% CI) P

Antidepressant medication use Persons using medication 0.989 (0.981‐0.997) 0.010 1.009 (1.004‐1.014) <0.001 1.020 (1.010‐1.030) <0.001 Scripts supplied 0.989 (0.970‐1.008) 0.251 1.015 (1.004‐1.025) 0.006 1.026 (1.004‐1.049) 0.020

2004 through 2008 figures have regard to all claims processed up to and including August 2009; 2009 figures have regard to all claims processed up to and including June 2010. RR, rate ratio; CI, confidence interval. Data exclude the December 2006 quarter. a The ratio of the post‐Better Access trend to the pre‐Better Access trend.

Patterns of anxiolytic medication supply were examined using the same procedures as for antidepressant medications. The rate of persons supplied anxiolytic medications ranged from 17.9 per quarter per 1,000 total population in the December 2004 quarter to 16.1 per quarter per 1,000 total population in the December 2009 quarter (see Figure 8.3). Scripts for anxiolytic medications ranged from 44.2/1,000 per quarter to 39.5/1,000 per quarter over the same period (see Figure 8.4). Figures 8.3 and 8.4 also show the rate of persons using Better Access services after the initiative was introduced in November 2006.

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Fig 8.3 Persons using Better Access items and PBS‐subsidised anxiolytic medications, December 2004 quarter to December 2009 quarter (rate per 1,000 population)

Fig 8.4 Persons using Better Access services and scripts supplied for anxiolytic medications, December 2004 quarter to December 2009 quarter (rate per 1,000 population).

Table 8.2 shows the results of the comparison of the trends in PBS‐subsidised anxiolytic medication supply for the pre‐ and post‐Better Access periods. In contrast to the findings for

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antidepressants, there was no significant change in trend for supply of anxiolytic medications, with time trends stable across the pre‐ and post‐ Better Access periods.

Table 8.2 Estimated change in trends for uptake of PBS‐subsidised anxiolytic medications, before and after the introduction of Better Access



Ratio of trendsa

RR (95% CI) P RR (95% CI) P RR (95% CI) P Anxiolytic medication use Persons using medication 0.991 (0.978‐1.005) 0.206 1.000 (0.994‐1.006) 0.943 1.009 (0.995‐1.023) 0.202 Scripts supplied 0.992 (0.974‐1.011) 0.402 1.000 (0.992‐1.008) 0.983 1.008 (0.989‐1.027) 0.420


It is important to acknowledge a major limitation of the previous analyses, which is that data from the PBS alone may be misleading because it only records subsidised medicines. It is estimated that approximately 75% of antidepressant medication prescriptions and 73% of anxiolytic medication prescriptions dispensed by pharmacies are recorded on the PBS.49 Over‐the‐counter medications, and non‐subsidised medications (e.g., where the entire cost of the medication is covered by the consumers’ co‐payment) are not captured. Further, when particular medications recorded on the PBS fall below the payment threshold, they are no longer recorded by the PBS. This is particularly important for the antidepressant group of medications because several commonly prescribed medicines came off patent in the period shortly preceding Better Access commencement (e.g., fluoxetine in 2004 and sertraline in 2006).50 As a result new generic products were released, the cost of which fell below the PBS payment threshold. This is likely to explain the apparent decreasing trend in the rate of persons using antidepressant medications in the two years prior to the introduction of Better Access.

8.3 HAS THERE BEEN A CHANGE IN DEMAND FOR ANTIDEPRESSANT AND ANXIOLYTIC MEDICATIONS SINCE THE INTRODUCTION OF BETTER ACCESS AMONG PEOPLE ELIGIBLE TO RECEIVE MEDICATIONS AT A CONCESSION PRICE?

The following analyses focus on the population of concession card holders. Here, the intent is to examine whether the increased rates of medication use after the introduction of Better Access might be greater among people for whom cost may have previously been a barrier to accessing some mental health services. Table 8.3 shows the results of the comparison of the trends in PBS‐subsidised antidepressant medication supply for the pre‐ and post‐Better Access periods for concession card holders. Prior to the introduction of Better Access, the number of persons using antidepressants and rate of scripts supplied was stable. Following the introduction of Better Access, there was a significant increase in the number of persons using antidepressants and scripts supplied for antidepressants. The change in trend was statistically significant for persons using medications.

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In interpreting these results it is assumed that the stable trend in concession card holders using antidepressant medications in the period prior to Better Access (compared to the small downward trend in the total population shown in section 8.2) occurs because the effect of medications falling below the co‐payment threshold is not an issue for this group. The growth in persons using and scripts supplied for PBS‐subsidised antidepressants post‐Better Access however, was the same for concession card holders (1.0% and 1.5% per quarter, respectively) as for the total population (0.9% and 1.5% per quarter; see section 8.2).

Table 8.3 Estimated change in trend for uptake of PBS‐subsidised antidepressant medications, before and after the introduction of Better Access, among people eligible to receive these medications at a concession price.



Ratio of trendsa

RR (95% CI) P RR (95% CI) P RR (95% CI) P

Antidepressant medication use Persons using medication 1.002 (1.005‐1.019) 0.636 1.010 (1.006‐1.014) <0.001 1.008 (1.001‐1.016) 0.037 Scripts supplied 1.000 (0.981‐1.020) 0.971 1.015 (1.006‐1.024) <0.001 1.015 (0.994‐1.036) 0.160


In contrast to the findings for antidepressants, there was no significant change in trend for persons using or supply of PBS‐subsidised anxiolytic medications for concession card holders, with time trends stable across the pre‐ and post‐ Better Access periods. The stable trends in persons using and scripts supplied for anxiolytic medications post‐Better Access was consistent with the results for the total population (see section 8.2).

Table 8.4 Estimated change in trend for uptake of PBS‐subsidised anxiolytic medications, before and after the introduction of Better Access, among people eligible to receive these medications at a concession price.



Ratio of trendsa

RR (95% CI) P RR (95% CI) P RR (95% CI) P Anxiolytic medication use Persons using medication 0.993 (0.985‐1.002) 0.136 0.999 (0.995‐1.003) 0.539 1.005 (0.996‐1.014) 0.240 Scripts supplied 0.992 (0.979‐1.007) 0.297 0.998 (0.992‐1.004) 0.558 1.006 (0.991‐1.020) 0.435


8.4 WHAT IS THE RELATIONSHIP BETWEEN BETTER ACCESS UPTAKE AND DEMAND FOR ANTIDEPRESSANT AND ANXIOLYTIC MEDICATIONS AT A DIVISION LEVEL?

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To examine the relationship between Better Access uptake and medications supplied, analyses were focused on the 2009 calendar year as these data are assumed to better represent established patterns of Better Access utilization than earlier years. Negative binomial regression analyses (see section 2.3.4 of this report for further information) were conducted separately for antidepressant and anxiolytic medications, to quantify the effect of Better Access uptake on medication supply within Divisions. The models used PBS‐subsidised antidepressant or anxiolytic medication supply (persons using or scripts supplied, as appropriate), as the dependent variable, and adjusted for the size of the population in each Division by incorporating the logarithm of the population size as an offset term. The predictor was the rate of persons using Better Access services (per 1,000) in the Division.

Table 8.5 shows the summary statistics for PBS‐subsidised antidepressant and anxiolytic medication supply and Better Access uptake for the 113 Divisions of General Practice in Australia in 2009.

Table 8.5 Summary statistics for PBS‐subsidised antidepressant and anxiolytic medication supply and Better Access uptake in 113 Divisions of General Practice in Australia, 2009

Summary statistics Division level measures Range Mean SD Persons using antidepressant medications (per 1,000) 21.0‐121.2 85.0 20.2 Antidepressant medication scripts supplied (per 1,000) 133.4‐1,333.7 624.7 180.8 Persons using anxiolytic medications (per 1,000) 4.3‐53.8 28.7 9.0 Anxiolytic medication scripts supplied (per 1,000) 17.1‐285.5 147.8 52.8 Better Access users (per 1,000) 14.2‐82.4 49.5 13.4

2009 PBS figures have regard to all claims processed up to and including June 2010. 2009 MBS figures have regard to all claims processed up to and including 30 April 2010. SD, standard deviation.

Table 8.6 presents the results of the regression analyses for antidepressant medications. These show that the rate of persons supplied with antidepressant medications increased significantly as the percentage of the population in the Division using Better Access services increased. A similar effect was found for scripts supplied.

Table 8.6 Negative binomial regression estimates of rate ratios with 95% CIs for PBS‐subsidised antidepressant medication supply, 2009

RR 95% CI P Persons using antidepressant medications

Better Access users (per 1,000) in Division 1.005 1.002‐1.009 0.004 Antidepressant medication scripts

Better Access users (per 1,000) in Division 1.005 1.001‐1.010 0.029

2009 figures have regard to all claims processed up to and including June 2010. RR, rate ratio; CI, confidence interval.

Table 8.7 presents the results of the regression analyses for anxiolytic medications. These show that the rate of persons supplied with anxiolytic medications increased significantly as the percentage of the population in the Division using Better Access services increased. A similar

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effect was found for scripts supplied. Interestingly, the effect was stronger for anxiolytic medications than for antidepressant medications.

Table 8.7 Negative binomial regression estimates of rate ratios with 95% CIs for PBS‐subsidised anxiolytic medication supply, 2009

RR 95% CI P Persons using anxiolytic medications

Better Access users (per 1,000) in Division 1.011 1.006‐1.016 <0.001 Anxiolytic medication scripts

Better Access users (per 1,000) in Division 1.013 1.008‐1.018 <0.001

2009 figures have regard to all claims processed up to and including June 2010. 2009 MBS figures have regard to all claims processed up to and including 30 April 2010. RR, rate ratio; CI, confidence interval.

These analyses were then repeated in order to examine persons using, and scripts supplied for, antidepressant and anxiolytic medications among concession card holders. Table 8.8 shows the summary statistics for PBS‐subsidised antidepressant and anxiolytic medication supply and Better Access uptake for the 113 Divisions of General Practice in Australia in 2009.

Table 8.8 Summary statistics for PBS‐subsidised antidepressant and anxiolytic medication supply among concession card holders and Better Access uptake in 113 Divisions of General Practice in Australia, 2009

Summary statistics Division level measures Range Mean SD Persons using antidepressant medications (per 1,000) 9.2‐107.4 67.8 20.1 Antidepressant medication scripts supplied (per 1,000) 54.5‐1,221.5 510.2 177.7 Persons using anxiolytic medications (per 1,000) 4.0‐53.3 28.0 8.9 Anxiolytic medication scripts supplied (per 1,000) 15.6‐282.4 145.5 52.6 Better Access users (per 1,000) 14.2‐82.4 49.5 13.4

2009 figures have regard to all claims processed up to and including June 2010. 2009 MBS figures have regard to all claims processed up to and including 30 April 2010. SD, standard deviation.

Table 8.9 shows that the rate of persons supplied with antidepressant medications increased significantly as the percentage of the population in the Division using Better Access services increased. Results for concession card holders were the same as those for the total population. Table 8.9 Negative binomial regression estimates of rate ratios with 95% CIs for PBS‐subsidised antidepressant medication supply among concession card holders, 2009

RR 95% CI P Persons using antidepressant medications

Better Access users (per 1,000) in Division 1.006 1.001‐1.011 0.020 Antidepressant medication scripts

Better Access users (per 1,000) in Division 1.005 1.000‐1.011 0.060


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Table 8.10 presents the results of the regression analyses for anxiolytic medications. These show that the rate of concession card holders supplied with anxiolytic medications increased significantly as the percentage of the population in the Division using Better Access services increased. A similar effect was found for scripts supplied. Again, the effect was stronger for anxiolytic medications than for antidepressant medications. Results for concession card holders were the same as those for the total population.

Table 8.10 Negative binomial regression estimates of rate ratios with 95% CIs for PBS‐subsidised anxiolytic medication supply among concession card holders, 2009

RR 95% CI P Persons using anxiolytic medications

Better Access users (per 1,000) in Division 1.011 1.006‐1.016 <0.001 Anxiolytic medication scripts

Better Access users (per 1,000) in Division 1.013 1.007‐1.019 <0.001



Has there been a change in demand for antidepressant and anxiolytic medications since the introduction of Better Access?

• Using Division level data, a significant change in trends for PBS‐subsidised antidepressant supply was observed in the two years pre‐ and the three years post‐ the introduction of Better Access. The rate of persons using antidepressant medications appeared to decrease slightly in the two years before the introduction of Better Access, however it is acknowledged that this is likely to reflect some high uptake medications coming off patent during this period. The rate of persons using antidepressant medications increased significantly (1.0% per quarter, on average) in the three years after the introduction of Better Access. The rate of scripts supplied also increased significantly (1.5% per quarter, on average) post‐Better Access.

• In contrast, there was no significant change in trend for rates of PBS‐subsidised anxiolytic supply pre‐ and post‐Better Access, with rates stable in both periods.

To what extent has Better Access uptake impacted on demand for antidepressant and anxiolytic medications?

• A positive association was found between Better Access uptake and medication use at a Division level in 2009. The rate of persons within a Division using PBS‐subsidised antidepressant medications, and the rate of scripts supplied, increased as the percentage of persons using Better Access increased. Similarly, the rate of persons within a Division using PBS‐subsidised anxiolytic medications, and the rate of scripts supplied, increased as the rate of persons using Better Access increased.

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CHAPTER 9: IMPACT ON RELATED PROGRAMS

9.1 OVERVIEW

This chapter presents findings relating to Evaluation Question 7 which asks: To what extent has the Better Access initiative impacted on related MBS services? Specifically, Division‐level analyses were conducted in which provision of non‐Better Access mental health MBS services was examined over time in order to determine demand for these services had changed since the introduction of Better Access. These analyses explored the impact of Better Access uptake on non‐Better Access mental health MBS services uptake in the period after the introduction of Better Access. Similar analyses using Division level data were also undertaken looking at uptake of psychological services under the Access to Allied Psychological Services projects.

The following series of research questions was examined separately for the two program areas:

A. Non‐Better Access mental health MBS items

1. Has there been a reduction in demand for non‐Better Access mental health MBS services since the introduction of Better Access?

2. Do patterns of demand for non‐Better Access mental health MBS services differ between metropolitan and rural or remote regions?

3. What is the relationship between Better Access uptake and demand for non‐Better Access mental health MBS services at a Division level?

4. Does the relationship between Better Access uptake and demand for non‐Better Access mental health MBS services at a Division level differ between metropolitan and rural or remote regions?

B. Psychological services provided under the Access to Allied Psychological Services projects

5. Has there been a reduction in demand for ATAPS psychological services since the introduction of Better Access?

6. Do patterns of demand for ATAPS psychological services differ between metropolitan and rural or remote regions?

7. What is the relationship between Better Access uptake and demand for ATAPS psychological services at a Division level?

8. Does the relationship between Better Access uptake and demand for ATAPS psychological services at a Division level differ between metropolitan and rural or remote regions?

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9.2 HAS THERE BEEN A REDUCTION IN DEMAND FOR NON-BETTER ACCESS MENTAL HEALTH MBS SERVICES SINCE THE INTRODUCTION OF BETTER ACCESS?

Figures 9.1 and 9.2 show the rates of uptake of Better Access and non‐Better Access MBS items from the December 2004 quarter (i.e. 2 years prior to the commencement of Better Access) to the March 2009 quarter across all 113 Divisions of General Practice, for persons and services respectively.

Fig 9.1 Persons using Better Access and other mental health MBS items, December 2004 quarter to March 2009 quarter (rate per 1,000 population), for 113 Divisions of General Practice

Fig 9.2 Better Access and other mental health MBS services used, December 2004 quarter to March 2009 quarter (rate per 1,000 population), for 113 Divisions of General Practice

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The rate of persons using non‐Better Access mental health MBS items was 8.0 per 1,000 total population in the December 2004 quarter and 6.8 per 1,000 in the March 2009 quarter. The rate of non‐Better Access mental health items used was 24.3 per 1,000 total population in the December 2004 quarter and 19.2 per 1,000 in the March 2009 quarter.

To examine whether the patterns of uptake of non‐Better Access mental health MBS items had changed since Better Access was introduced, the trend for the pre‐Better Access period (December 2004 quarter to September 2006) was compared to the trend for the post‐Better Access period (March 2007 quarter to the March 2009 quarter). Analyses found that rates of persons using non‐Better Access mental health MBS items, and services used, were stable in the pre‐ and post‐Better Access periods. There was no significant change in trend for either persons using services, or total services used (see Table 9.1).

Table 9.1 Estimated change in trends for uptake of MBS‐subsidised non‐Better Access mental health services, before and after the introduction of Better Access



Ratio of trendsa

RR (95% CI) P RR (95% CI) P RR (95% CI) P Persons using services 1.008 (0.989‐1.026) 0.417 0.989 (0.973‐1.005) 0.188 0.982 (0.958‐1.006) 0.141 Services used 1.006 (0.983‐1.029) 0.615 0.986 (0.967‐1.005) 0.151 0.980 (0.951‐1.010) 0.189

Data have regard to all claims processed up to and including 30 April 2009. RR, rate ratio; CI, confidence interval. Data exclude the December 2006 quarter. a The ratio of the post‐Better Access trend to the pre‐Better Access trend.

9.3 DO PATTERNS OF DEMAND FOR NON-BETTER ACCESS MENTAL HEALTH MBS SERVICES DIFFER BETWEEN METROPOLITAN AND RURAL OR REMOTE REGIONS?

Trends in uptake of non‐Better Access mental health MBS items for metropolitan and rural or remote regions were examined separately. Because Divisions may encompass areas with varying levels of urbanicity or remoteness, areas classified as Metro or Metro/Rural were deemed metropolitan, using the classification developed by the Primary Health Care Research and Information Service25 (see section 2.2.3 for further information). All other Divisions were deemed rural or remote.

Figures 9.3 and 9.4 show the rates of uptake of Better Access and non‐Better Access MBS items from the December 2004 quarter (i.e. 2 years prior to the commencement of Better Access) to the March 2009 quarter for metropolitan Divisions, for persons and services, respectively.

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Fig 9.3 Persons using Better Access and non‐Better Access MBS items, December 2004 quarter to March 2009 quarter (rate per 1,000 population), metropolitan Divisions

Fig 9.4 Better Access and non‐Better Access MBS services used, December 2004 quarter to March 2009 quarter (rate per 1,000 population), metropolitan Divisions

The rate of persons using non‐Better Access services in metropolitan Divisions ranged from 9.3 per 1,000 total population in the December 2004 quarter to 7.9 per 1,000 in the March 2009 quarter. The rate of non‐Better Access services used ranged from 29.1 per 1,000 total population in the December 2004 quarter to 22.9 per 1,000 in the March 2009 quarter.

Analyses were undertaken to examine whether the patterns of uptake of non‐Better Access mental health services in metropolitan Divisions had changed since Better Access was introduced. The trend for the pre‐Better Access period (December 2004 quarter to September

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2006) was compared to the trend for the post‐Better Access period (March 2007 quarter to the March 2009 quarter). Trends were stable in both periods. There was no significant change in trend for either persons using services, or total services used (see Table 9.2).

Table 9.2 Estimated change in trends for uptake of MBS‐subsidised non‐Better Access mental health services, before and after the introduction of Better Access, metropolitan Divisions



Ratio of trendsa


Data have regard to all claims processed up to and including 30 April 2009. RR, rate ratio; CI, confidence interval. Data exclude the December 2006 quarter. a The ratio of the post‐Better Access trend to the pre‐Better Access trend.

Figures 9.5 and 9.6 show the rates of uptake of Better Access and non‐Better Access MBS items from the December 2004 quarter (i.e. 2 years prior to the commencement of Better Access) to the March 2009 quarter for rural and remote Divisions.

Fig 9.5 Persons using Better Access and non‐Better Access MBS items, December 2004 quarter to March 2009 quarter (rate per 1,000 population), rural and remote Divisions

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Fig 9.6 Better Access and non‐Better Access MBS services used, December 2004 quarter to March 2009 quarter (rate per 1,000 population), rural and remote Divisions

The rate of persons using non‐Better Access services in rural and remote Divisions ranged from from 3.8 per 1,000 total population in the December 2004 quarter to 3.1 per 1,000 in the March 2009 quarter. The rate of non‐Better Access services used ranged from 9.1 per 1,000 total population in the December 2004 quarter to 7.4 per 1,000 in the March 2009 quarter.

Analyses were then undertaken to examine whether the patterns of uptake of non‐Better Access mental health services in rural and remote Divisions had changed since Better Access was introduced. The trend for the pre‐Better Access period (December 2004 quarter to September 2006) was compared to the trend for the post‐Better Access period (March 2007 quarter to the March 2009 quarter). There was no significant change in trend for either persons using services, or total services used (see Table 9.3).

Table 9.3 Estimated change in trends for uptake of MBS‐subsidised non‐Better Access mental health services, before and after the introduction of Better Access, rural and remote Divisions



Ratio of trendsa


Data have regard to all claims processed up to and including 30 April 2009. a The ratio of the post‐Better Access trend to the pre‐Better Access trend.

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9.4 WHAT IS THE RELATIONSHIP BETWEEN BETTER ACCESS UPTAKE AND DEMAND FOR NON-BETTER ACCESS MENTAL HEALTH MBS SERVICES AT A DIVISION LEVEL?

T o examine the relationship between Better Access uptake and the use of non‐Better Access mental health MBS items, analyses focused on the period since the introduction of Better Access. Specifically, analyses were restricted to 2008 data (the most recent data available for non‐Better Access mental health MBS items), as these were considered more likely to be representative of established service use patterns. Figures 9.7 and 9.8 show the patterns of uptake of Better Access and non‐Better Access MBS items across all 113 Divisions of General Practice, for persons and services, respectively.

Fig 9.7 Persons using Better Access and non‐Better Access MBS items, 2008 (rate per 1,000 population), across 113 Divisions of General Practice

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Fig 9.8 Total Better Access and non‐Better Access MBS items used, 2008 (rate per 1,000 population), across 113 Divisions of General Practice

Table 9.4 shows the summary statistics for non‐Better Access mental health MBS items and Better Access uptake for the 113 Divisions of General Practice in Australia in 2008. The mean rate of persons using non‐Better Access mental health MBS items per Division was 10.2 per 1,000 total population, with a range of 0.9 to 30.5 per 1,000. This is, on average, around one‐quarter the rate of persons using Better Access items (mean per Division of 41.3 per 1,000 total population). The mean rate of non‐Better Access mental health MBS items used per Division was 70.3 per 1,000 total population, with a range of 2.7 to 317.7 per 1,000. This is, on average, around half the rate of persons using Better Access items (mean per Division of 156.5 per 1,000 total population).

Table 9.4 Summary statistics for non‐Better Access mental health MBS items and Better Access uptake in 113 Divisions of General Practice in Australia, 2008

Summary statistics Division level measures Range Mean SD Persons using non‐Better Access mental health MBS items (per 1,000) 0.9‐30.5 10.2 5.9 Non‐Better Access mental health MBS items used (per 1,000) 2.7‐317.7 70.3 59.4 Better Access users (per 1,000) 12.1‐75.7 41.3 11.9 Better Access services used (per 1,000) 23.6‐398.1 156.5 67.9

Data have regard to all claims processed up to and including 30 April 2009. SD, standard deviation.

The relationship between the uptake of non‐Better Access mental health MBS items and Better Access items using negative binomial regression analyses (see Chapter 2 for further information) was examined in order to quantify the effect of Better Access uptake on non‐Better Access item uptake within Divisions. The first model used total persons using non‐Better Access MBS mental health items in the Division as the dependent variable, and adjusted for the size of the population in each stratum of the dataset by incorporating the logarithm of the population size

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as an offset term. The main predictor was the rate of Better Access users (per 1,000) in the Division. The second model used total non‐Better Access MBS mental health services in the Division as the dependent variable, and adjusted for the size of the population in each stratum of the dataset by incorporating the logarithm of the population size as an offset term. The main predictor was the rate of Better Access services used (per 1,000) in the Division. Consideration was given to controlling for GP supply in each Division, using the proportion of full‐time weighted equivalent GPs in the Division (GP FWE). However, the relatively high correlation between GP FWE and Better Access population uptake rate (r = 0.580; P < 0.001) precluded this.

Tables 9.5 and 9.6 present the results of the regression analyses. These show that Divisions with relatively higher rates of persons using Better Access items also have relatively higher rates of persons using non‐Better Access mental health MBS items (Table 9.5). The same was true for the relationship between Better Access and non‐Better Access services used (Table 9.6).

Table 9.5 Negative binomial regression estimates of rate ratios with 95% CIs for persons using any non‐Better Access mental health MBS item, 2008

Rate ratio 95% CI P Better Access users (per 1,000) in Division 1.039 1.030‐1.047 <0.001

Table 9.6 Negative binomial regression estimates of rate ratios with 95% CIs for total non‐Better Access mental health MBS items used, 2008

Rate ratio 95% CI P Better Access services used (per 1,000) in Division 1.010 1.009‐1.012 <0.001

9.5 DOES THE RELATIONSHIP BETWEEN BETTER ACCESS UPTAKE AND DEMAND FOR NON-BETTER ACCESS MENTAL HEALTH MBS SERVICES AT A DIVISION LEVEL DIFFER BETWEEN METROPOLITAN AND RURAL OR REMOTE REGIONS?

Analyses were then undertaken to examine whether the impact Better Access uptake on non‐Better Access mental health MBS items differed between metropolitan and rural or remote areas. Figures 9.9 and 9.10 show the patterns of uptake of Better Access and non‐Better Access MBS items across all metropolitan Divisions of General Practice.

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Fig 9.9 Persons using Better Access and non‐Better Access MBS items, 2008 (rate per 1,000 population), metropolitan Divisions of General Practice

Fig 9.10 Total Better Access and non‐Better Access MBS items used, 2008 (rate per 1,000 population), metropolitan Divisions of General Practice

Table 9.7 shows the summary statistics for non‐Better Access mental health MBS items, separately for Divisions classified as metropolitan and rural or remote, and Better Access uptake in 2008.

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Table 9.7 Summary statistics for non‐Better Access mental health MBS items, separately for metropolitan and rural/remote Divisions, and Better Access uptake, 2008

Summary statistics Division level measures Range Mean SD Metropolitan Divisions Persons using non‐Better Access mental health MBS items (per 1,000) 3.0‐30.5 14.0 5.2 Non‐Better Access mental health MBS items used (per 1,000) 17.8‐317.7 104.3 60.3 Better Access users (per 1,000) 18.4‐75.7 46.7 8.7 Better Access services used (per 1,000) 54.7‐398.1 191.9 54.2 Rural or remote Divisions Persons using non‐Better Access mental health MBS items (per 1,000) 0.9‐13.3 5.7 2.5 Non‐Better Access mental health MBS items used (per 1,000) 2.7‐85.5 28.9 16.6 Better Access users (per 1,000) 12.1‐64.0 35.0 12.1 Better Access services used (per 1,000) 23.6‐248.0 113.9 57.2


Tables 9.8 and 9.9 present the results of the regression analyses for metropolitan regions. These show that metropolitan Divisions with relatively higher rates of persons using Better Access items also have relatively higher rates of persons using non‐Better Access mental health MBS items (Table 9.8). The same was true for the relationship between Better Access and non‐Better Access services used (Table 9.9).

Table 9.8 Negative binomial regression estimates of rate ratios with 95% CIs for persons using any non‐Better Access mental health MBS item, 2008, metropolitan regions


Table 9.9 Negative binomial regression estimates of rate ratios with 95% CIs for total non‐Better Access mental health MBS items used, 2008, metropolitan regions


Patterns in rural and remote regions were then considered. Figures 9.11 and 9.12 show the patterns of uptake of Better Access and non‐Better Access MBS items across all rural and remote Divisions of General Practice.

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Fig 9.11 Persons using Better Access and non‐Better Access MBS items, 2008 (rate per 1,000 population), rural and remote Divisions of General Practice

Fig 9.12 Total Better Access and non‐Better Access MBS items used, 2008 (rate per 1,000 population), rural and remote Divisions of General Practice

Tables 9.10 and 9.11 present the results of the regression analyses for metropolitan regions. Almost identical results were found for rural and remote Divisions as for metropolitan Divisions. Rural and remote Divisions with relatively higher rates of persons using Better Access items also have relatively higher rates of persons using non‐Better Access mental health MBS items (Table

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9.10). The same was true for the relationship between Better Access and non‐Better Access services used (Table 9.11).

Table 9.10 Negative binomial regression estimates of rate ratios with 95% CIs for persons using any non‐Better Access mental health MBS item, 2008, rural and remote regions


Table 9.11 Negative binomial regression estimates of rate ratios with 95% CIs for total non‐Better Access mental health MBS items used, 2008, rural and remote regions


9.6 HAS THERE BEEN A REDUCTION IN DEMAND FOR ATAPS PSYCHOLOGICAL SERVICES SINCE THE INTRODUCTION OF BETTER ACCESS?

The next series of analyses considered the impact of Better Access on psychological services delivered under the Access to Allied Psychological Services (ATAPS) projects. Figures 9.13 and 9.14 show the rates of uptake of Better Access and non‐Better Access MBS items from the December 2004 quarter (i.e. 2 years prior to the commencement of Better Access) to the March 2009 quarter across all 113 Divisions of General Practice, for persons and services respectively.

Fig 9.13 Persons using Better Access and ATAPS, December 2004 quarter to March 2009 quarter (rate per 1,000 population), for 113 Divisions of General Practice

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Fig 9.14 Better Access items used and ATAPS sessions delivered, December 2004 quarter to March 2009 quarter (rate per 1,000 population), for 113 Divisions of General Practice

The rate of persons using ATAPS ranged from 0.28 per 1,000 total population in the December 2004 quarter to 0.56 per 1,000 in the March 2009 quarter. The rate of ATAPS sessions delivered ranged from 0.78 per 1,000 total population in the December 2004 quarter to 1.53 per 1,000 in the March 2009 quarter.

Analyses examined whether the patterns of uptake of ATAPS had changed since Better Access was introduced. The trend for the pre‐Better Access period (December 2004 quarter to September 2006) was compared to the trend for the post‐Better Access period (March 2007 quarter to the March 2009 quarter). Rates continued to grow in the post‐Better Access period, although the rate of growth was significantly slower than in the pre‐Better Access period (see Table 9.12).

Table 9.12 Estimated change in trends for uptake of ATAPS, before and after the introduction of Better Access



Ratio of trendsa

RR (95% CI) P RR (95% CI) P RR (95% CI) P Persons using services 1.139 (1.108‐1.172) <0.001 1.036 (1.010‐1.063) 0.007 0.909 (0.875‐0.945) <0.001 Services used 1.145 (1.114‐1.177) <0.001 1.038 (1.013‐1.064) 0.003 0.907 (0.873‐0.941) <0.001


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9.7 DO PATTERNS OF DEMAND FOR ATAPS PSYCHOLOGICAL SERVICES DIFFER BETWEEN METROPOLITAN AND RURAL OR REMOTE REGIONS?

Figures 9.15 and 9.16 show the rates of uptake of Better Access and ATAPS from the December 2004 quarter (i.e. 2 years prior to the commencement of Better Access) to the March 2009 quarter for metropolitan Divisions., for persons and services respectively.

Fig 9.15 Persons using Better Access and ATAPS, December 2004 quarter to March 2009 quarter (rate per 1,000 population), metropolitan Divisions

Fig 9.16 Better Access items and ATAPS sessions delivered, December 2004 quarter to March 2009 quarter (rate per 1,000 population), metropolitan Divisions

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The rate of persons using ATAPS psychological services in metropolitan Divisions ranged from 0.21 per 1,000 total population in the December 2004 quarter to 0.45 per 1,000 in the March 2009 quarter. The rate of ATAPS psychological services used ranged from 0.65 per 1,000 total population in the December 2004 quarter to 1.30 per 1,000 in the March 2009 quarter.

Analyses examined whether the patterns of uptake of ATAPS psychological services in metropolitan Divisions had changed since Better Access was introduced. The trend for the pre‐Better Access period (December 2004 quarter to September 2006) was compared to the trend for the post‐Better Access period (March 2007 quarter to the March 2009 quarter). Rates continued to grow in the post‐Better Access period, although the rate of growth was significantly slower than in the pre‐Better Access period (see Table 9.13).

Table 9.13 Estimated change in trends for uptake of ATAPS, before and after the introduction of Better Access, metropolitan Divisions



Ratio of trendsa

RR (95% CI) P RR (95% CI) P RR (95% CI) P Persons using services 1.145 (1.106‐1.187) <0.001 1.039 (1.007‐1.072) 0.016 0.907 (0.865‐0.952) <0.001 Services used 1.148 (1.108‐1.190) <0.001 1.043 (1.010‐1.077) 0.010 0.908 (0.865‐0.953) <0.001


Figures 9.17 and 9.18 show the rates of uptake of Better Access MBS items and ATAPS from the December 2004 quarter (i.e. 2 years prior to the commencement of Better Access) to the March 2009 quarter for rural and remote Divisions., for persons and services respectively.

Fig 9.17 Persons using Better Access and ATAPS, December 2004 quarter to March 2009 quarter (rate per 1,000 population), rural and remote Divisions

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Fig 9.18 Better Access items used and ATAPS sessions delivered, December 2004 quarter to March 2009 quarter (rate per 1,000 population), rural and remote Divisions

The rate of persons using ATAPS in rural and remote Divisions ranged from 0.49 per 1,000 total population in the December 2004 quarter to 0.93 per 1,000 in the March 2009 quarter. The rate of ATAPS psychological services ranged from 1.20 per 1,000 total population in the December 2004 quarter to 2.29 per 1,000 in the March 2009 quarter.

Analyses were undertaken to determine whether the patterns of uptake of ATAPS in rural and remote Divisions had changed since Better Access was introduced. The trend for the pre‐Better Access period (December 2004 quarter to September 2006) was compared to the trend for the post‐Better Access period (March 2007 quarter to the March 2009 quarter). These analyses showed that rates had stabilised in the post‐Better Access period, representing significant change in trend from the strong growth in the pre‐Better Access period (see Table 9.14).

Table 9.14 Estimated change in trends in uptake of ATAPS, before and after the introduction of Better Access, rural and remote Divisions



Ratio of trendsa

RR (95% CI) P RR (95% CI) P RR (95% CI) P Persons using services 1.133 (1.091‐1.178) <0.001 1.033 (0.997‐1.070) 0.074 0.911 (0.864‐0.961) 0.001 Services used 1.141 (1.097‐1.187) <0.001 1.034 (0.998‐1.070) 0.061 0.906 (0.859‐0.955) <0.001


Taken together, these findings indicate two key points. Firstly, as shown in Figures 9.15‐9.18, ATAPS has greater penetration in rural and remote areas, relative to metropolitan areas. In contrast, Better Access has greater penetration in metropolitan areas, as compared to rural and remote areas. Additional regression analyses confirm that rates of ATAPS population uptake were twice as high in rural and remote areas compared to metropolitan regions in the pre‐Better

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Access period (RR = 2.098, 95% CI 1.861‐2.366, P < 0.001), and were two and a half times greater in rural and remote areas compared to metropolitan areas (RR = 2.553, 95% CI 2.258‐2.886; P < 0.001) in the post‐Better Access period. Rates of Better Access population uptake were one‐third lower in rural and remote areas than in metropolitan regions (RR = 0.697, 95% CI 0.668‐0.722; P <0.001). Secondly, although rates of ATAPS uptake appear to have slowed since the introduction of Better Access, the reach of ATAPS services into rural and remote areas does not appear to have diminished. If anything it appears to have increased.

9.8 WHAT IS THE RELATIONSHIP BETWEEN BETTER ACCESS UPTAKE AND DEMAND FOR ATAPS PSYCHOLOGICAL SERVICES AT A DIVISION LEVEL?

Analyses then examined the relationship, within Divisions, between the uptake of Better Access and ATAPS. These focused on the period since the introduction of Better Access. Specifically, analyses were restricted to 2008 data, as this was considered these more likely to be representative of established service use patterns than earlier data. Figures 9.19 and 9.20 show the patterns of uptake of Better Access and ATAPS by Division of General Practice.

Fig 9.19 Persons using Better Access and ATAPS, 2008 (rate per 1,000 population), by Division of General Practice

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Fig 9.20 Total Better Access items used and ATAPS sessions delivered, 2008 (rate per 1,000 population), by Division of General Practice

Table 9.15 shows the summary statistics for non‐Better Access mental health MBS items for Divisions of General Practice in Australia, in 2008.

Table 9.15 Summary statistics for ATAPS and Better Access uptake for Divisions of General Practice in Australia, 2008

Summary statistics Division level measures Range Mean SD Persons using ATAPS (per 1,000) 0.02‐13.9 2.4 2.7 ATAPS sessions delivered (per 1,000) 0.11‐49.6 9.7 9.9 Better Access users (per 1,000) 12.1‐75.7 41.3 11.9 Better Access services used (per 1,000) 23.6‐398.1 156.5 67.9


The relationship between uptake of ATAPS and Better Access was examined using negative binomial regression models. The first model used total persons using ATAPS in the Division as the dependent variable, and adjusted for the size of the population in each stratum of the dataset by incorporating the logarithm of the population size as an offset term. The main predictor was the rate of Better Access users (per 1,000) in the Division. The second model used total ATAPS sessions delivered in the Division as the dependent variable, and adjusted for the size of the population in each stratum of the dataset by incorporating the logarithm of the population size as an offset term. The main predictor was the rate of Better Access services used (per 1,000) in the Division.

Tables 9.16 and 9.17 present the results of the regression analyses. These show that Divisions with higher rates of persons using Better Access items have significantly lower rates of persons

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using ATAPS (Table 9.15). A similar result was found for the relationship between Better Access items used and ATAPS sessions delivered (Table 9.16).

Table 9.16 Negative binomial regression estimates of rate ratios with 95% CIs for persons using ATAPS, 2008

Rate ratio 95% CI P Better Access users (per 1,000) in Division 0.978 0.965‐0.992 0.002

Table 9.17 Negative binomial regression estimates of rate ratios with 95% CIs for total ATAPS sessions delivered, 2008

Rate ratio 95% CI P Better Access services used (per 1,000) in Division 0.996 0.994‐0.998 0.001

9.9 DOES THE RELATIONSHIP BETWEEN BETTER ACCESS UPTAKE AND DEMAND FOR ATAPS PSYCHOLOGICAL SERVICES AT A DIVISION LEVEL DIFFER BETWEEN METROPOLITAN AND RURAL OR REMOTE REGIONS?

Analyses were then undertaken to examine whether the relationship between Better Access and ATAPS differed between metropolitan and rural or remote areas.

Table 9.18 shows the summary statistics for ATAPS uptake, separately for Divisions of General Practice classified as metropolitan and rural or remote, and Better Access uptake in 2008.

Table 9.18 Summary statistics for ATAPS uptake, separately for metropolitan and rural/remote Divisions, and Better Access uptake, 2008

Summary statistics Division level measures Range Mean SD Metropolitan Divisions Persons using ATAPS (per 1,000) 0.02‐8.00 1.4 1.5 ATAPS sessions delivered (per 1,000) 0.11‐45.7 6.6 7.9 Better Access users (per 1,000) 18.4‐75.7 46.7 8.8 Better Access services used (per 1,000) 54.7‐398.1 192.1 54.6 Rural or remote Divisions Persons using ATAPS (per 1,000) 0.06‐13.9 3.6 3.2 ATAPS sessions delivered (per 1,000) 0.23‐49.6 13.4 10.9 Better Access users (per 1,000) 12.1‐64.0 35.0 12.1 Better Access services used (per 1,000) 23.6‐248.0 113.9 57.2


Tables 9.19 and 9.20 present the results of the regression analyses for metropolitan regions. These show that metropolitan Divisions with higher rates of persons using Better Access items also have higher rates of persons using ATAPS (Table 9.19). However there was no corresponding relationship found between Better Access items used and ATAPS sessions delivered (Table 9.20).

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Table 9.19 Negative binomial regression estimates of rate ratios with 95% CIs for persons using ATAPS, 2008, metropolitan regions.


Table 9.20 Negative binomial regression estimates of rate ratios with 95% CIs for ATAPS sessions delivered, 2008, metropolitan regions.


Tables 9.21 and 9.22 present the results of the regression analyses for rural and remote regions. These show that rural and remote Divisions with higher rates of persons using Better Access had significantly lower rates of persons using ATAPS (Table 9.21). A similar, although less strong, effect was found for the relationship between Better Access items used and ATAPS sessions delivered (Table 9.22).

Table 9.21 Negative binomial regression estimates of rate ratios with 95% CIs for persons using ATAPS, 2008, rural or remote regions


Table 9.22 Negative binomial regression estimates of rate ratios with 95% CIs for ATAPS sessions delivered, 2008, rural or remote regions



Analyses showed no evidence, at a Division level, of any reduction in demand for non‐Better Access mental health MBS related to the introduction of Better Access. Rates of non‐Better Access MBS item use were stable in the two years before and after the introduction of Better Access. However Divisions with higher uptake of Better Access also had significantly higher uptake of other mental health MBS items. This was the case in both metropolitan and rural and remote regions.

The uptake of ATAPS psychological services has been increasing overall since late 2004. Rates of uptake of ATAPS psychological services continued to grow in the post‐Better Access period, although the rate of growth was significantly slower than in the pre‐Better Access period. Further analysis showed that this pattern was true for metropolitan regions, whereas in rural and remote regions, uptake had stabilised after the introduction of Better Access.

Other patterns varied according to rurality/urbanicity. ATAPS psychological services have proportionally greater penetration into rural and remote regions than metropolitan regions (whereas the reverse is true for Better Access). This pattern was not affected by the introduction

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of Better Access. If anything, the relative reach of ATAPS into rural and remote regions appears have increased.

At a Division level, overall demand for ATAPS psychological services appears to be related to patterns of demand for Better Access services. Divisions with higher population uptake of Better Access appeared to have lower population uptake of ATAPS psychological services. Higher rates of Better Access services used were also associated with lower rates of ATAPS psychological services used. However, further analysis revealed that this pattern differed according to rurality. In metropolitan regions, Divisions with higher uptake of Better Access also had significantly higher population uptake of ATAPS psychological services, but not higher rates of services used. In contrast, in rural or remote regions, Divisions with higher uptake of Better Access had significantly lower population uptake of ATAPS psychological services, and lower rates of ATAPS psychological services used.

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CHAPTER 10: DISCUSSION

10.1 OVERVIEW

The aim of this report was to present the findings of an in‐depth analysis of administrative MBS and other data in relation to each of the seven evaluation questions posed in Component B of the Evaluation of the Better Access to Psychiatrists, Psychologists and GPs through the Medicare Benefits Schedule initiative. Better Access is the first program to make significant levels of Medicare reimbursement available to allied health professionals for delivering mental health services. As such, the program has attracted considerable debate around the issues of access, affordability, equity, interdisciplinary care and impact on related services which have been considered in the current evaluation. This discussion chapter interprets the findings from the current study and contextualises them in relation to other available data and commentaries. It also includes a brief review of issues relating to the evaluation questions covered by Component B that were beyond the scope of the present evaluation.

10.2 INTERPRETATION OF FINDINGS

10.2.1 TO WHAT EXTENT HAS THE BETTER ACCESS INITIATIVE PROVIDED ACCESS TO MENTAL HEALTH CARE FOR PEOPLE WITH MENTAL DISORDERS? ACROSS ALL OF AUSTRALIA? ACROSS ALL AGE GROUPS?

Analysis showed that the uptake of Better Access has been substantial. In 2007, one in every 30 Australians received at least one Better Access service. In 2008, one in every 23 did so, and in 2009, one in every 19 did so. Most commonly, Better Access consumers made use of services delivered by GPs under the GP Mental Health Treatment Services items. These were followed by services delivered by psychologists under the Focussed Psychological Strategies and Psychological Therapy Services item numbers. Services delivered by psychiatrists under the Consultant Psychiatry item numbers and services delivered by social workers and occupational therapists under the Focussed Psychological Strategies item numbers were far less commonly utilised. Consistent with earlier reports,12, 51, 52 uptake increased dramatically in the first years of the initiative. Whilst the program has continued to grow, the rate of growth has slowed substantially.

The results of the analysis can further inform some of the debates about Better Access in relation to its accessibility. The first of these relates to the question of whether Better Access is meeting the needs of new consumers, who may previously have had difficulties accessing mental health services due to barriers of cost or location, or whether it is just providing a new avenue of treatment for people who were already receiving care. Although the analysis of MBS data cannot answer this question definitively, because the MBS data do not include individual‐level information about use of other mental health services, analyses were undertaken to examine whether the program is attracting consumers who are new to Better Access or, conversely, is providing services to a consistent group of people on an ongoing basis. These showed that 68% of people who received any Better Access services in 2008, and 57% in 2009, had not previously

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received these services. This findings suggests that the program is continuing to attract a substantial proportion of new consumers. Further analyses showed that the proportion of new consumers of allied health services was 71.4% in 2008 and 62.9% in 2009. This is consistent with findings from previous surveys of Australian psychologists who report that around 70% of their Better Access clients have not previously consulted a psychologist.53, 54 The figures are also consistent with evidence from an analysis of data from the 2007 NSMHWB which estimated that 62% of people who used Better Access allied health services in 2007 had not previously used allied health services.37 The figures are somewhat higher than a previous finding that 47% of ATAPS clients had not had any prior contact with mental health care,12 most likely because ‘mental health care’ may have included providers other than allied health professionals. Together, these findings suggest that Australia’s primary mental health care reforms are meeting previously‐unmet need. Having said this, it is acknowledged that the approach taken here uses a necessarily limited definition of a ‘new’ consumer and may have included people who, although new to Better Access, are existing consumers of other parts of the mental health system.

A second concern regarding Better Access is that it does not cater well to young people. Analyses showed that uptake rates for Better Access increased with age, peaking among adults in the 25‐34 and 35‐44 year age groups and then decreasing with age. These findings are broadly consistent with those of Russell,51 who found that that despite making up 19.4% of the Australian population, children and adolescents aged 0 to 14 years received only 7.4% of total Better Access services in 2008. The picture was more complex when the rates of uptake of specific groups of Better Access items was considered. Although young people showed the lowest uptake of GP and Consultant Psychiatry items, their uptake of Psychological Therapy Services and Focussed Psychological Strategies items was higher than that of older people. It should also be noted that relatively lower access by young people is not unique to Better Access: young people access all mental health services less often than other members of the population5, 27, 40 possibly because they are less likely to perceive that they have a need for mental health care.41, 42 Alongside the lower rates for young people, it was also found that the growth in uptake between 2007 and 2009 has been substantially greater for young people aged 0‐14 years than for other age groups, particularly for the GP Mental Health Treatment, Psychological Therapy and Focussed Psychological Strategies items.

A third concern regarding Better Access is that it provides services to people who live in urban areas (where most private health professionals practice), and that people in rural and remote areas are not so well served.55‐57 Again, the picture was complex, and levels of access varied according to the items under consideration. For the GP and Focussed Psychological Strategies items, the level of access was the same in rural centres as it was in capital cities, but it was reduced in other rural areas and particularly in remote areas. For Consultant Psychiatry and Psychological Therapy Services items, it showed a steady decrease across each category of geographical region from capital cities to remote areas. The growth in uptake between 2007 and 2009 tended to be higher for people from non‐capital city areas.

A final concern with Better Access is that although it has improved access for people in affluent areas, it has had no impact in areas with high levels of socio‐economic disadvantage. Once again, analyses showed that there were differential levels of impact, depending on the group of items under consideration. Uptake rates for Psychological Therapy Services items and, to a lesser extent, Consultant Psychiatry items, decreased as levels of socio‐economic disadvantage increased. By contrast, uptake rates for GP Mental Health Treatment and Focussed Psychological Strategies items were somewhat lower only for persons residing in the most disadvantaged

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areas. However growth in uptake between 2007 and 2009 tended to increase as level of socio‐economic disadvantage increased. This was true for all item groups.

10.2.2 TO WHAT EXTENT HAS THE BETTER ACCESS INITIATIVE PROVIDED ACCESS TO AFFORDABLE CARE?

Concerns have also been raised about the affordability of subsidised Better Access services due to remaining out‐of‐pocket costs to the consumer. For example, some commentators 56, 58 have presented evidence that only a minority of Better Access services with clinical and registered psychologists are bulk‐billed, and that these consultations still incur a significant co‐payment for consumers due to the gap between Medicare rebates and the fee recommended by the Australian Psychological Society (APS).

Analyses showed that, overall, more than half of the Better Access services delivered were bulk‐billed (53.6% in 2007, 56.5% in 2008 and 58.6% in 2009). Of services for which a co‐payment was made, the average co‐payment was around $35. Having said this, there was considerable variation according to the type of provider who delivered these services. In 2009, only 7.3% of services delivered under the GP items involved a co‐payment by the consumer, whereas up to two thirds of the services delivered under the Consultant Psychiatrist (63.7%), Psychological Therapy Services (65.4%) and Focussed Psychological Strategies (57.4%) items did so. Findings from previous research suggest, however, that the majority of providers have a policy of bulk‐billing at least some consumers. For example, 2007 and 2008 surveys of APS members who provided psychology services under the Better Access initiative found that 56‐66% of these psychologists reported that they bulk‐billed at least some clients.59, 60 Similarly, the average co‐payment varied according to provider type, being lowest for GP items ($20), close to the overall average for Psychological Therapy Services items ($32) and Focussed Psychological Strategies items ($37), and highest for Consultant psychiatrist items ($82). The percentage of services requiring a co‐payment decreased by 10.8% between 2007 and 2009. For services requiring a co‐payment, the average co‐payment increased between 2007 and 2009 by 4.5%.

The proportion of services that were bulk‐billed increased as the level of remoteness and level of relative socio‐economic disadvantage increases. The average co‐payment was highest among people in remote areas ($38) and people in capital cities ($37) than those in other regions ($31‐$33). The average co‐payment decreased as level of relative socio‐economic disadvantage increased (from $38 to $33).

There were some variations in average co‐payments according to socio‐demographic characteristics and provider type. Most notably, average co‐payments were: lower among people aged 65 years and over for GP, Psychological Therapy Services and Focussed Psychological Strategies items; lower for people aged < 15 years for Consultant Psychiatrist and Occupational Therapist services; higher among people in remote locations for GP, Psychological Therapy Services and Consultant Psychiatrist items; and lower among people in areas of greatest socio‐economic disadvantage for GP services.

10.2.3 TO WHAT EXTENT HAS THE BETTER ACCESS INITIATIVE PROVIDED EQUITABLE ACCESS TO POPULATIONS IN NEED?

Another area of concern regarding Better Access services relates to whether services are being delivered equitably in the Australian population. It has been suggested that the initiative is

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providing services to a number of people who may not have a clinical need for these treatments, and who live in affluent and urban areas (where most allied health professionals practice), while at‐risk groups (e.g., young people, people in rural areas or poorer urban areas, people with low income) with legitimate need may be missing out.

Analyses designed to examine whether mental health services are being equitably distributed in the Australian population were undertaken. Specifically, these examined whether the prevalence of need for mental health treatment was predictive of total Better Access services used and allied health Better Access services used, at the level of Division of General Practice. They also considered the extent to which other factors, such as potential to access treatment and other Division characteristics, were also predictive of Better Access service use.

Analyses showed that, at a Division level, rates of total and allied health Better Access services were associated with levels of mental health need. However other factors were also found to play a part in explaining rates of Better Access service use. Higher rates of total and allied health Better Access services used were found in Divisions that have higher rates of GP supply, and Divisions located in Victoria. Lower rates of Better Access services used were found in Divisions with relatively more people living in socioeconomically disadvantaged areas and Divisions with relatively more people living in remote locations. The model explained just over half the variation in total Better Access (54.7%) and allied health Better Access services (51.0%) used. In summary, these results suggest that, while need (or demand) for Better Access service is important, supply factors are also important.

Several of the results from the models warrant additional comment. Firstly, variables relating to potential to access services (GP supply, remoteness, state/territory) collectively contributed a slightly larger proportion (approximately 6.5% more) of the variance in total Better Access services used than allied health Better Access services used, whereas socioeconomic disadvantage contributed a similar proportion of additional variance in total (8.19%) and allied health (8.17%) Better Access services used, after all other variables were taken into account. Mental health need contributed a slightly larger proportion of the additional variance explained in allied health (6.10%) than total (3.27%) Better Access services used, after variables relating to potential to access services were taken into account. Secondly, the models showed that state/territory variation was an important factor, even after controlling for other variables in the model, including those measuring potential to access treatment (GP workforce supply and remoteness). These differences may reflect supply of allied health professionals and psychiatrists. Thirdly, remoteness of the population within Division was found to be an important predictor of service use. It should be noted, however, that examining need for Better Access services in isolation from other components of the mental health system, as was done in the current study, does not take into account the fact that need in some populations may be met by other available services. In the case of remote communities, the ATAPS projects may be covering at least some of the need that cannot be met by Better Access.

It is also useful to consider the findings of the current study in the context of other, relevant studies. Only one published study to date has examined the relationship between need for mental health treatment and Better Access service use. This previous report37 used individual‐level data from the 2007 NSMHWB to explore the use of Better Access services provided by allied health professionals among people with a need for mental health treatment. This study found that most people estimated to have used Better Access services provided by allied health professionals in the first year of the initiative had a 12‐month ICD‐10 mental disorder (81.7%) or

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another indicator of treatment need (11.5%), i.e., a lifetime ICD‐10 disorder, 12‐month symptoms (but no lifetime diagnosis) for at least one disorder, or lifetime hospitalisation for a mental health problem. The study also found that, among people with a 12‐month affective or anxiety disorder, the probability of Better Access service use was predicted by having more complex needs (e.g., more severe disorder, comorbid affective and anxiety disorder) but not by urbanicity (i.e., living in an urban area versus a rural or remote area), residing in an area of relatively lower socio‐economic disadvantage, or other socio‐demographic factors (such as age and gender). In other words, the previous study was more suggestive of Better Access providing equitable access for people in need.

There may be several methodological reasons for the apparent discrepancy between these two sets of findings. The first relates to the populations under study. In the current study, the regression analyses considered use of Better Access services in the entire Australian population, with level of mental health need used as the main predictor of interest. In the previous study, the regression analyses were restricted to people defined as having need, either: (1) people who had used Better Access services (a form of expressed need); or (2) people with narrowly‐defined mental health need (i.e. a 12‐month affective or anxiety disorder; a form of comparative need). The second relates to the dependent variable of interest. In the current study, the rates (i.e. amounts) of service use (in the general population) were examined, whereas the previous report examined whether individuals (with need) were or were not users of Better Access services. The third relates to differences in the measurement of mental health need. The current study relied on a synthetically modelled measure of mental health need (based on information about age, gender, and section of state) at a Division level, whereas the previous report was able to measure need directly at an individual level. In addition, the current study used a broadly defined measure of mental health need, whereas the previous report focused on people with mental health needs as defined by the presence of 12‐month affective or anxiety disorders. A fourth relates to differences in the independent variables used in the two studies. The previous study was unable to examine the effects of remoteness on the probability of Better Access service use, as the geographical classification available for analysing the 2007 NSMHWB subsumed all non‐metropolitan areas into a single category. It also focused on whether probability of Better Access service use was higher among people in the least socio‐economically disadvantaged areas, rather than whether it was lower for people in the most disadvantaged areas. A fifth relates to the ecological nature of the current study. Analyses were conducted using aggregate (as opposed to individual‐level) data, and it cannot be assumed that conclusions based on group‐level data will hold true at the individual level. The use of Division‐level data also meant that only a limited range of independent variables was available. For example, it would have been useful to look at supply of allied health professionals and psychiatrists per Division, but these data were not available for the current work.

Taken together the two studies provide complementary perspectives on equity with respect to the Better Access initiative. Both studies are consistent in showing that mental health need is associated with Better Access service use. The current study suggests that, at a population level, need is an important determinant of the extent of Better Access service uptake rates, although there are also some inequities. Namely, these services are used to a greater extent in areas that are likely to have higher rates of appropriate health care professionals, and used to a lesser extent in remote and socio‐economically disadvantaged areas. The previous study, which focused on access to Better Access services within the populations defined as having need, suggests that the vast majority of Better Access services users have a need for treatment, and

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that use of Better Access services is driven by clinical factors (i.e. having more complex needs), but not by socio‐demographic or socio‐economic factors.

10.2.4 TO WHAT EXTENT HAS THE BETTER ACCESS INITIATIVE PROVIDED EVIDENCE-BASED MENTAL HEALTH CARE TO PEOPLE WITH MENTAL DISORDERS?

Evidence‐based mental health care refers to the provision of care that, according to current best evidence, gives a person with mental illness the best possible chance of recovery or remission. The data available for the current evaluation did not permit an examination of whether the care provided at individual sessions was evidence‐based (although, as noted earlier, Better Access is premised on evidence‐based treatments such as cognitive behavioural therapy), but it was possible to explore whether certain patterns of service delivery were evident that might give some indications of the extent to which evidence‐based care was being delivered. Hence it was renamed ‘protocol‐based care’.

Two examples of protocol‐based care were considered. The first of these related to the patterns of care delivered following a GP Mental Health Treatment Plan. The Better Access protocol dictates that a GP Mental Health Treatment Plan is required in order for a referral to be made from a GP to an allied health professional for Psychological Therapy Services or Focussed Psychological Strategies. It also recommends that at the end of treatment with the allied health professional, the consumer should be referred back to the GP for a review. The rationale underpinning this protocol is that this promotes good continuity of care. Analyses estimated that approximately one fifth of consumers received both a GP Mental Health Treatment Plan and a GP Mental Health Treatment Review, which is perhaps less than ideal, and may suggest a need for educational strategies to encourage the use of the Review item by GPs. It should be noted, however, that the fact that the GP Mental Health Treatment Review item was not used does not necessarily mean that a review has not occurred. It is possible that other items are being used to capture the content of the session in which the review occurs.

The relationship between GP Mental Health Treatment Plans and Psychological Therapy Services or Focussed Psychological Strategies was also explored. Analyses showed that 58% of Better Access consumers received at least Better Access one allied health service following their first Plan. Conversely, 41.8% did not. The extent to which this occurred varied according to age, gender, region of residence and level of socio‐economic disadvantage. Older people aged 65 years or more had the highest percentage of non‐receipt of allied health services following a Plan (53.3%), whereas young people aged 15 years or less had the lowest percentage (29.8%). Non‐receipt of Better Access allied health services following a Plan was somewhat higher for males (44.0%) than females (40.6%). Analyses also showed that the likelihood of non‐receipt of Better Access allied health services following a Plan increased considerably as level of geographical remoteness increased, being 19.6% lower for people in other rural areas, and 47.8% lower for people in remote areas. In addition, non‐receipt of Better Access allied health services following a Plan increased as level of socio‐economic disadvantage increased. Non‐receipt of Better Access allied health services following a first Plan were 14.6% higher for people in capital cities, but were 14.4% lower for people in other rural areas and 15.1% lower for people in remote areas. These findings may, in part, reflect the lack of availability of allied health professionals in non‐metropolitan regions, and possibly barriers relating to cost in people from socio‐economically disadvantaged areas. It should be noted, however, that consumers who did not receive Better Access allied health services may have received psychological services from other sources, for

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example: from allied health professionals under the ATAPS program (which is not recorded in the MBS); from their GP, which may be recorded using the Better Access GP Mental Health Consultation item (2713) or under another MBS item; or via privately funded services. Nonetheless, there may be a need to consider alternative frameworks or mechanisms for referrals under Better Access.

The second example of protocol‐based care was the number of psychological services delivered by allied health professionals per person per calendar year. The protocol dictates that once an individual is referred by a GP to an allied health professional, he or she can receive six sessions of psychological care. Following a review by the GP, he or she may be offered a further six sessions. In exceptional circumstances, he or she may be offered a further six still, following a second review by the GP. This protocol is designed to promote good communication between providers, and to maximise efficiency of service delivery. Analyses were undertaken for all individuals who received psychological services in 2007 and 2008. These showed that, in both calendar years, around 75% received between one and six, 20% received between seven and 12, and 5% received between 13 and 18. This suggests that the protocol is being interpreted appropriately by providers.

10.2.5 TO WHAT EXTENT HAS THE BETTER ACCESS INITIATIVE PROVIDED INTERDISCIPLINARY PRIMARY MENTAL HEALTH CARE FOR PEOPLE WITH MENTAL DISORDERS?

Prior to Better Access, various studies had found that few Australians consulted multiple providers for mental health issues61 and, if they did, collaboration between these providers was poor7‐9 despite there being ‘… clear evidence that the best quality mental health services are delivered through collaborative care”. 58, p. 194 For this reason, one of the principles underpinning Better Access is that of interdisciplinary care. However some commentators have argued that the fee‐for‐service model underpinning Better Access does not provide a foundation for structural arrangements, such as co‐location of GPs and allied health professionals, that may promote interdisciplinary care.56, 58

More than half (55.1%) of Better Access users were estimated to have received interdisciplinary care, most commonly from combinations of GPs and allied health professionals. The remainder (44.9%) received GP care alone. The percentage of Better Access consumers receiving interdisciplinary care was the same in other metropolitan areas as in capital cities, and only slightly lower in rural centres, but was 15% lower in other rural areas and 33% lower in remote areas compared to all Better Access consumers combined. Rates of interdisciplinary care also decreased as level of socio‐economic disadvantage increased. Specifically, in metropolitan areas rates of interdisciplinary care were 13% lower among people from the most disadvantaged areas, compared to all Better Access consumers combined.

A number of caveats should be noted in interpreting the findings regarding interdisciplinary care. Firstly, it is acknowledged that the definition of interdisciplinary care used in the current study is narrow, being limited to services available via Medicare. Whilst they do provide an accurate picture of the extent of interdisciplinary care provided under the Better Access Medicare items, they are an underestimate of interdisciplinary care if considering the full range of treatment options available. For example, some consumers, particularly those people in non‐metropolitan areas, may be receiving psychological services via the ATAPS program (which are not recorded by Medicare). Secondly, the data available for the current evaluation also did not enable an

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examination of the models under which allied health professionals work with GPs and other providers, and whether or not Better Access encourages co‐location or other structural arrangements that may promote interdisciplinary care.

10.2.6 TO WHAT EXTENT HAS THE BETTER ACCESS INITIATIVE IMPACTED ON THE USE OF MEDICATIONS COMMONLY PRESCRIBED FOR TREATMENT OF MENTAL DISORDERS, IN PARTICULAR ANTIDEPRESSANT MEDICATIONS?

As noted earlier, several studies conducted prior to the introduction of Better Access had found that GPs were overwhelmingly the most common providers of mental health care in Australia.5 Concerns had been expressed that the treatment provided by GPs, was more often pharmacological than non‐pharmacological,42 despite there being good evidence that non‐pharmacological interventions, such as counselling, monitoring, and self‐directed and therapist‐directed therapies may be equally efficacious or preferable treatment options for mild to moderate mental illness.62, 63

The current evaluation took the opportunity to examine patterns of prescribing pre‐ and post‐ the introduction of Better Access. There was no a priori hypothesis about the direction of any change. On the one hand, it might have been reasonable to expect levels of prescribing to go down, because of the greater ability of referral sources for non‐pharmacological treatments. On the other hand, it might have been equally plausible that there would be an increase in prescribing, because Better Access may have increased GPs’ knowledge and/or recognition of mental illness, and/or consumers’ access to other medical practitioners (i.e., psychiatrists) who can prescribe these medications. Both of these possibilities were considered in the current evaluation.

Using Division level data, a significant change in trends for PBS‐subsidised antidepressant supply was found between the two years pre‐ and the three years post‐ the introduction of Better Access. The rate of persons using antidepressant medications appeared to decrease slightly in the two years before the introduction of Better Access, however it is acknowledged that this decrease likely to be accounted for some high uptake medications coming off patent during this period, and offset by a corresponding increase uptake in non‐subsidised medications. The rate of persons using antidepressant medications increased significantly (0.9% per quarter, on average) in the three years after the introduction of Better Access. The rate of scripts supplied also increased significantly (1.5% per quarter, on average) post‐Better Access. In contrast, rates of anxiolytic use were stable over the pre‐ and post‐Better Access periods.

A positive association was found between Better Access uptake and medication use at a Division level. The rate of persons within a Division using PBS‐subsidised antidepressant medications, and the rate of scripts supplied, increased as the percentage of persons using Better Access increased. Similarly, the rate of persons within a Division using PBS‐subsidised anxiolytic medications, and the rate of scripts supplied, increased as the rate of persons using Better Access increased.

Taken together, these findings tend to suggest that Better Access has had the effect of increasing consumers’ access not only to the non‐pharmacological treatments that underpin it, but to pharmacological therapies which have also been shown to have good evidence of effectiveness. It is acknowledged, however, that caution should be exercised in interpreting these findings. The PBS records subsidised medicines. It is estimated that approximately 75% of antidepressant

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medication prescriptions and 73% of anxiolytic medication prescriptions dispensed by pharmacies are recorded on the PBS.49 In addition, levels of antidepressant medication use prior to Better Access are likely to be underestimated in the current study because several commonly prescribed antidepressant medications came off patent in the two years preceding Better Access commencement.50 A further caution relates to the ecological nature of the analyses undertaken. It may be that the change in trend in antidepressant medication supply observed after the introduction of Better Access would have occurred even in the absence of Better Access. However the finding that Division‐level rates of medication supply were positively related to Division‐level rates of Better Access uptake lend some support for this interpretation.

10.2.7 TO WHAT EXTENT HAS THE BETTER ACCESS INITIATIVE IMPACTED ON RELATED MBS SERVICES?

In the evaluation of the introduction of a large‐scale initiative like Better Access, it is important not only to consider the program in its own right, but also to consider its impact on existing related programs. This was done by examining the relationship between Better Access and non‐Better Access mental health MBS items, and the relationship between Better Access and ATAPS. Both sets of analyses were conducted at the Division of General Practice level.

Analyses showed no evidence, at a Division level, of any reduction in demand for non‐Better Access mental health MBS related to the introduction of Better Access. Rates of non‐better Access MBS item use were stable in the two years before and after the introduction of Better Access. However Divisions with higher uptake of Better Access also had significantly higher uptake of other mental health MBS items. This was the case in both metropolitan and rural and remote regions.

The picture with ATAPS was more complex. ATAPS psychological services have proportionally greater penetration into rural and remote regions than metropolitan regions (whereas the reverse is true for Better Access). This pattern was not affected by the introduction of Better Access. At a Division level, overall demand for ATAPS psychological services was related to patterns of demand for Better Access services. Divisions with higher population uptake of Better Access appeared to have lower uptake of ATAPS psychological services. Higher rates of Better Access services used were also associated with lower rates of ATAPS psychological services used. However, further analysis revealed that this pattern differed according to rurality. In metropolitan regions, Divisions with higher uptake of Better Access also had significantly higher population uptake of ATAPS psychological services, but not higher rates of services used. In contrast, in rural or remote regions, Divisions with higher uptake of Better Access had significantly lower population uptake of ATAPS psychological services, and lower rates of ATAPS psychological services used. One possible interpretation is that, in metropolitan areas where there are more allied health providers, demand for services translates into higher uptake of both Better Access and ATAPS psychological services. In rural and remote regions, where there are fewer allied health providers, Better Access GP services may be partly meeting the demand for psychological services. This is consistent with evidence that people in rural and remote regions are more likely to receive Better Access care from GPs alone (see Chapter 7). In addition, rural Divisions have other avenues apart from ATAPS for providing mental health services, e.g., the Rural & Remote Program and More Allied Health Services Program (MAHS). It is also important to note that the extent of the relationship between Better Access and ATAPS is partly constrained by the fact that ATAPS services are limited by capped funding.

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These findings may suggest that Better Access is filling a gap in the mental health service delivery system that was not previously being met by other related services. However, the introduction of Better Access does not appear to have negated the need for these other services, particularly in rural/remote areas. This interpretation is consistent with that of Bassilios and colleagues52 who conducted an earlier analysis of the relationship between Better Access and ATAPS and concluded that these initiatives appear to be providing complementary services to potentially different areas of the Australian population.

10.3 ASPECTS OF THE EVALUATION QUESTIONS BEYOND THE SCOPE OF THIS REPORT

This section provides a brief summary of additional issues relating to the evaluation questions considered by Component B but that are beyond the scope the present evaluation.

The first issue relates to increasing access to services for ‘new’ consumers. Measures of whether Better Access has improved access to mental health services may include: (1) whether Better Access is bringing previously untreated cases (i.e. people who would otherwise not receive care) into treatment services; (2) whether Better Access is improving access for people who previously may have received less adequate care56 or, conversely; (3) whether Better Access users are people who were receiving mental health care under different means before the introduction of Better Access (for example, people who were previously paying for non‐subsidised psychological services). Investigation of these questions is beyond the scope of the data available for the present evaluation. However, a previous report has considered the latter question using data from the 2007 NSMHWB.37 This study estimated that 62.3% of Better Access service users had not previously received services form an allied health professional. A recent APS survey found that psychologists who provide Better Access services reported that 70% of these clients had never consulted a psychologist prior to Better Access.60 These findings offer support for the contention that Better Access is providing services to a substantial proportion of ‘new’ consumers of allied health services, but cannot inform whether these consumers were previously receiving treatment from any other source. It may also be the case that, given its recency and breadth, Better Access is now the most popular choice of service for new consumers compared to other systems. More detailed research with current Better Access users and providers, including information about users’ former mental health care, will best elucidate this issue. Some information about this will be available through Component A.

A second issue relates to equity. Equitable access to mental health care refers to all members of the population having equal opportunity to use services regardless of age, location and cultural background. In the present report, this was evaluated by considering whether the rates of uptake of Better Access services across sociodemographic sub‐groups of the population was comparable to the rates of need (i.e., proportion of the population and prevalence of mental illness) in these subgroups. However, there are other, non‐demographic indicators of need that must be considered when evaluating whether mental health services are being distributed to those who most need them. These include illness severity and comorbidity.8 It may be argued that, for equitable access, people with more severe levels of disorder should be receiving a larger number of Better Access services than people with mild disorder. The MBS data available for the present evaluation could not determine whether Better Access is providing a greater number of services to people with high need due to severe or chronic illness because diagnostic information about

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consumers is not included in this dataset. Some support is offered by the analysis the qualitative reports of APS members who provide psychological services under Better Access, who have reported an increase in clientele being treated for “more severe mental health conditions” since the introduction of this initiative.60 The previously mentioned analysis of data from the 2007 NSMHWB also shows that severity of disorder is a principal determinant of Better Access service use.64 Further research involving individual level data from populations using Better Access services are needed to provide definitive conclusions on this issue.

A third issue relates the range of factors that may influence access to services. It is important to note that people’s access to mental health services is affected by multiple factors, including several beyond the influence of Better Access, and thus the scope of this evaluation. Facilitating the referral process to allied health professionals, and reducing the out‐of‐pocket cost of their services, are undoubtedly major steps forward to enhancing people’s access to evidence‐based mental health services. However, the availability of health professionals to provide these services is also key.8, 59, 65 For example, a person with mental illness may still be unable to consult a clinical psychologist at a subsidised rate if there are no or few professionals in their geographic area. This is known to be the case in rural and remote areas.10, 55, 65 This aspect of access (i.e., enhancing the mental health workforce) is to be addressed with other components of COAG’s National Action Plan on Mental Health.15 However, it is important to note with regards to the present evaluation that the considerable uptake of Better Access MBS items may still mask significant unmet demand for mental health services in some areas due to an inadequate mental health workforce.

Further factors that may influence the uptake of mental health care outside the availability of Medicare‐subsidised services include: (1) knowledge about the availability of, and individual eligibility to, Better Access services amongst potential consumers; (2) knowledge and perceived stigma about mental illness (and thus the willingness and ability to report symptoms to a doctor), and; (3) whether potential consumers choose to seek help for mental health symptoms.66 Each of these factors may, in part, explain why greater rates of Better Access uptake are not always seen among the people who may be considered to most need these services. That is, subgroups of the population who are at high risk of mental illness, or most require subsidised services due to socio‐economic disadvantage.37, 52 For example, it is possible that socio‐economically advantaged people are more aware of the availability of Better Access services, and thus better able to request a referral by their doctor. These factors cannot be addressed (nor evaluated) by improving overall access to services, but rather, additional, ongoing efforts to education about the availability of these services, and mental illness more generally.

10.4 KEY METHODOLOGICAL ISSUES

A key methodological limitation of the current evaluation relates to the use of aggregated datasets. The use of models based on variables measured at an aggregated level, i.e. at the level of Division of General Practice, has several advantages and disadvantages. In the current evaluation, a key advantage of using aggregated datasets was the capacity to combine data from multiple sources, without recourse to complicated record linkage procedures. However, such analyses may be subject to the ‘ecological fallacy’, which is the assumption that conclusions based on group‐level data will hold true at the individual level. Caution should be applied in interpreting the results of analyses based on aggregated datasets.

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A second issue relates to the period over which data describing uptake of Better Access and other services were available. In the current evaluation, data capturing Better Access services received up until the end of the March 2009 quarter (generally for 2004 through 2008 data), or until the end of April 2010 (generally for 2009 data and first quarter 2010 data) , were available. These data were provided in two stages, and were generated from two separate data extractions. The data provided in the initial data extraction were not revised in the subsequent extraction to capture adjustments for late claims, and thus may slightly undercount the number of services delivered. This also applied to the PBS data. Other caveats to the datasets and analyses used in this report are noted in the Method chapter, the individual results chapters, and earlier section of this Discussion chapter.

10.5 CONCLUSIONS

The current analysis of MBS and related data has shown that Better Access has improved access to evidence‐based, multi‐disciplinary mental health care for Australians. These improvements have occurred for people irrespective of their age and socio‐economic status, and regardless of where they live. The analyses show that young people, people in the lowest socio‐economic strata, and people in small rural and remote areas have not been as well served as their older, more affluent, urban counterparts. Over half of the sessions of care provided through Better Access are bulk‐billed, although – like other Medicare‐funded services – the proportion of bulk‐billed services is higher for GPs and lower for specialists (e.g., psychiatrists and psychologists). Those with greatest levels of financial need are the biggest beneficiaries of bulk‐billed services. High levels of uptake of Better Access services have not led to commensurate reductions in the use of other relevant mental health services or prescribing of antidepressant or anxiolytic medications. In fact, the opposite is true, which suggests that Better Access is a crucial piece in the web of Australian primary mental health care reforms, and is helping to meet previously‐unmet need. Before this conclusion can be definitively drawn, however, further work is required to profile the mental health status of people using Better Access services, and the outcomes of Better Access care. The study of consumers and their outcomes, which is being conducted as part of the current evaluation, will be helpful in this regard.

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APPENDIX 1. GLOSSARY

Access to Allied Psychological Services (ATAPS): A range of evidence‐based mental health care and psychological services provided under the Access to Allied Psychological Services projects, which is a component of the Better Outcomes in Mental Health Care program.

Age‐standardised: A method of adjusting the crude rate to eliminate the effect of differences in population age structures when comparing crude rates for different periods of time, different geographic areas and/or different population sub‐groups (e.g. between one year and the next and/or States and Territories, Indigenous and non‐Indigenous populations).67

Antidepressant medications: Medications to prevent or treat depression, e.g. the SSRIs or selective serotonin reuptake inhibitors, MAOI’s or monoamine oxidase inhibitors, tricyclic antidepressants, and others.

Anxiolytic medications: A class of drugs that relieve, reduce anxiety or prevent anxiety attacks, e.g. lorazepam, clonazepam, diazepam.

Better Access to Psychiatrists, Psychologists and GPs through the Medicare Benefits Schedule (Better Access) initiative: The purpose of the Better Access initiative is to improve treatment and management of mental illness within the community. The Better Access initiative aims to increase community access to mental health professionals and team‐based mental health care, with general practitioners encouraged to work more closely and collaboratively with psychiatrists, clinical psychologists, psychologists, social workers and occupational therapists.68

Better Outcomes in Mental Health Care (BOiMHC): A multi‐component program designed to improve access to mental health care for Australians.

Bulk billing: A payment option under the Medicare system. Bulk billing is where the Doctor charges the Government for medical care, and the patient/consumer is not out‐of‐pocket.

Chi‐square statistic: A test statistic that tests for the difference between observed and theoretical values.

Coefficient of variation: A measure of variability.

Confidence Interval (CI): A range of values calculated from the sample observations that is believed, with a particular probability, to contain the true parameter value, i.e. The 95% (p‐value = .05) and 99% (p‐value = .01) confidence intervals are the most commonly used.69

Co‐payment: A contribution made by the consumer towards medical treatment, i.e. a medical service, a doctor's visit, medication prescriptions.

Council of Australian Governments: A body consisting of the heads of the Australian federal, state, and territory governments that meets to discuss matters of national importance.70

Crude rate: A crude rate is the number of new cases (or deaths) occurring in a specified population per year, usually expressed as the number of cases per 100,000 population at risk.

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Days out of role: The number of days that respondent was unable to perform, or had to cut down on, their normal activities because of health problems.

Deflator: A statistical method used to convert current dollars (adjusted for inflation) in order to compare prices over time.

Division of General Practice: A geographically based network of general practitioners.

Focussed Psychological Strategies (FPS): Focussed Psychological Strategies are defined as specific mental health treatment strategies derived from evidence based psychological therapies; these include cognitive behavioural therapy, interpersonal therapy, psychotherapy and motivational interviewing. In the Better Access program, FPS services are provided by general (i.e. registered) psychologists, selected occupational therapists and social workers.

Full‐time weighted equivalent: The full‐time weighted equivalent is a measure of workload that takes into account the differing working pattern of individuals or professions.

Interdisciplinary care: A team of professionals from different health care disciplines dedicated to the ongoing and integrated care of individual(s) with a clinical condition.

Medicare: In Australia, Medicare is a publicly‐funded universal health care system, operated by the Commonwealth government as Medicare Australia.

Medicare Benefits Schedule: The Medicare Benefits Schedule (MBS) is a Department of Health and Ageing publication that provides details of the Medicare services subsidised by the Australian Government as part of Medicare.71

Multivariate regression: A generic term for methods designed to determine the relative contributions of different causes to a single event or outcome by involving a response variable and a set of explanatory variables.69

Negative binomial regression: Negative binomial regression is a standard method used to model over dispersed Poisson data.

Ordinary Least Squares (OLS): Ordinary least squares is a statistical approach to estimate unknown parameters in a linear regression model.

Pharmaceutical Benefits Scheme (PBS): The Pharmaceutical Benefits Scheme provides all Australian residents and eligible overseas visitors access to subsidised prescription medicine.71

Probability (P): The P value gives the probability of any observed difference having happen by chance.64

Psychological Therapy Services (PTS): Psychological Therapy Services include psycho‐education and cognitive behavioural therapy, with other evidence‐based therapies, such as interpersonal therapy, used if clinically indicated. In the Better Access program, PTSs are provided by clinical psychologists.

Psychotropic medications: A drug that affects brain activities associated with mental processes and behavior.72

R2 statistic: This represents the amount of the variation in the data that is explained by the regression model.69

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Rate Ratio (RR): A rate ratio is calculated to compare the ratio of events occurring at any given point in time.73

Standard error of the mean: A measure of how close the sample mean is likely to be to the population mean.64

Statistical Significance: In statistics "statistical significant" means probably true, or unlikely to have occurred by chance.

Statistical Local Area: Statistical Local Areas (SLAs) consist of one or more Census Collection Districts at a census date. They can be based on legal Local Government Areas or parts thereof, or any unincorporated area. They cover, in aggregate, the whole of Australia without gaps or overlaps.

The Index of Relative Socioeconomic Disadvantage (IRSD): An area‐based measure of relative socio‐economic disadvantage.21

Univariate analyses: Data involving a single measure on each subject or patient.69

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APPENDIX 2. LIST OF ABBREVIATIONS

ABS Australian Bureau of Statistics

DoHA Department of Health and Ageing

ATAPS Access to Allied Psychological Services

ATC Anatomical Therapeutic Classification

BOiMHC Better Outcomes in Mental Health Care

CI Confidence Interval

CIDI Composite International Diagnostic Interview

COAG Council of Australian Governments

CP Consultant Psychiatry items

DoHA Department of Health and Ageing

ERP Estimated resident population

FPS Focussed Psychological Strategies – Allied mental health items

FWE Full‐time weighted equivalent

GPC GP Mental Health Consultation items

GPPR GP Mental Health Treatment Plan and Review items

GPs General Practitioners

ICD‐10 International Classification of Diseases

IRSD The Index of Relative Socioeconomic Disadvantage

MBS Medicare Benefits Schedule

MHCA Mental Health Council of Australia

NSMHWB National Survey of Mental Health and Wellbeing

P Probability

PBS Pharmaceutical Benefits Scheme

PTS Psychological Therapy Services items

RPBS Repatriation Pharmaceutical Benefits Scheme

RR Risk Ratio

RRMA Rural, Remote and Metropolitan Areas

K10 Kessler Psychological Distress Scale (K10)

OLS Ordinary Least Squares

SPSS Statistical package for the Social Sciences

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SEIFA Socio‐Economic Indexes for Areas

SLA Statistical Local Area

WMH‐CIDI World Mental Health Survey Initiative version of the Composite International Diagnostic Interview

YLD Years Lived with Disability

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