Funder by the Department of Human Services Auspiced by Our Community

HOW MONEY (or lack of it) AFFECTS A CONSUMER'S CHOICES

Money has a big bearing on the sorts of services we are able to access.

In psychiatry the 'pay for service' principle is corrupted somewhat by services some of us are forced to receive and the fact that Medicare payments to private clinicians, as splendid as they are, have created a very strange category of clinical provider - 'publicly funded private medical clinicians' (thus called because they are largely paid through the public purse).

Private health insurance is not the answer for most of us. For a start, few of us can afford the premiums, even if they would cover us for 'mental illness'. In any case, the reality is that many of the cheaper plans (such as those aimed at young singles) do not include psychiatry. Read the fine print carefully.

Having said that, privately insured consumers who are in hospital may have gap fees fully reimbursed, or even paid upfront by their insurers.

More money matters are discussed below. See also the help sheet on Making sense of the Medicare Safety Net and the Pharmaceutical Benefits Scheme.


The consumer context

Mental health consumers span the socio-economic spectrum.

Whilst many consumers operate very 'normal' lives, tell few people about their status, and earn high incomes (and thus are able to pay for expensive medical or psychological interventions) many of us fall through the cracks.

Being a consumer not only dramatically affects income for many of us, but it is also costly. Medications are expensive, time off work is common, visits to clinicians are often very frequent.

The inability of the public system to cater to our needs is palpable and as consumers living in society we are as culpable as everyone else for the underfunding of services for all, including people who are homeless, isolated, drug users, prisoners, asylum seekers and the many with histories of trauma and abuse.

See the Our Consumer Place December 2012 newsletter item by Merinda Epstein, 'Plunging out of your social class,' for a discussion of social class and 'mental illness'. Those of us who started with less are even further disadvantaged.


Psychiatrists' fees

Unlike public services, which have state funding, private psychiatrists are paid largely through Medicare, which comes from the Commonwealth.

Fees charged by private psychiatrists vary enormously. There are no recommended fees set by the Royal Australian and New Zealand College of Psychiatry (RANZCP) - the peak body for psychiatrists in Australia. Medicare and the Australian Medical Association (AMA) provide a fee schedule but as a guideline only.

Medicare provides a rebate on many psychiatric services, such as standard consultations. This rebate is based on what is called the 'Scheduled Fee', which is determined by the Federal Government. If the fee our doctor charges us is greater than the Scheduled Fee, we will have to pay the difference (this is called the 'gap' payment).

Note that fees for medical reports, missed appointments and other items are not usually covered under Medicare so we often have to pay the full cost for these.

It's also very important to note that a referral from a GP to a psychiatrist is necessary to claim Medicare rebates - you can't just roll up. These referrals most commonly cover a short period of time. For longer-term treatment, common in psychiatry, we need a special referral if we want to avoid having to keep going back to the GP and paying just to pick up a piece of paper.

Private psychiatrists tend to have practices clustered around the more affluent suburbs of Melbourne. They usually charge high fees. General practitioners in less affluent areas tend to appreciate the financial constraints on many of us so speak to your GP about the fact that money is an issue when referral is being discussed.

Sometimes psychiatrists have a sliding scale of fees which means that those with the greatest capacity to pay will pay more and people on pensions are 'bulk billed' - this means that we are only charged the fee that Medicare will pay in full, with Medicare charged directly, so that the patient does not have to do anything but sign a form in the doctor's rooms. In between, there may be incremental charges on a sliding scale. We even know of one regional psychiatrist who reduces the fees by the cost of the petrol needed to attend the session.

Psychiatrists also have different policies around how payments are made. Some insist on payment being made on the day. You may need to pay both the Medicare-refundable fee (which you will need to claim back later), and the gap (if any). Others will require you to pay only the gap, which could be as little as $10-$15 for a 50-minute session.

Payment as part of 'therapy'

Many of us have heard psychiatrists arguing that we should be paying them more because it's part of taking responsibility for our own mental health. The arguments they often give are:

We question whether it is the monetary incentive that we need in order to disentangle ourselves from some professional relationships. There are many things that clinicians themselves do that make it hard for some of us to move on. The reality is that psychiatrists are dependent on us as well - at least, they are dependent on our money. This is rarely mentioned.

Avoiding getting stung

Long appointments and frequent visits are common in psychiatry. Added to other medical costs, some of which are directly related to the physical impost of 'mental illness' on our lives, it can mean a lot of money.

Ask the psychiatrist during your first visit about his or her fee structure. Try to arm yourself with knowledge about Medicare safety nets before you go so you can ask informed questions before you commit to a relationship that you can't afford.

Try not to be embarrassed about discussing your financial limitations. Most of us have them. Anyway, you can learn a lot about the psychiatrist's attitudes to many things by engaging with them about money matters.

Who pays the bill?

One interesting issue raised by many young consumers is the negative effect on their mental health of clinicians allowing parents to pay for the therapy their adult children cannot afford. It's a matter of ethics. If the issues being explored are intrinsically to do with family then accepting charity from those implicated in the problem makes things worse for many.

It is always OK to speak to clinicians about your capacity to pay. Talk to the therapist, or ask your GP if he/she can refer you to a bulk billing psychiatrist who is interested in psychotherapy, or some other more affordable option.


Allied health services

Medicare rebates are now available for some mental health services through the Federal Government's Better Access initiative.

If we are eligible we can receive up to 12 individual allied mental health services per calendar year.

Specified Medicare-funded services are available only for patients with a 'mental disorder' who have been referred by a GP or psychiatrist, and who have a Mental Health Care Plan.

Allied mental health services that can be provided under this initiative include psychological therapy services provided by eligible clinical psychologists, and focussed psychological strategies provided by eligible psychologists, social workers and occupational therapists.

If you are not sure if a particular practitioner or service is eligible for a Medicare rebate, make sure you ask. The service provider will know the answer immediately.

You can find out more information about Medicare rebates for mental health services, including a list of eligible 'disorders', here.

All of this aside, most clinical psychologists and counsellors in private practice are fully fee-for-service and thus out of reach for many of us.

There's a systemic aberration which means more than 80% of practicing psychologists work in wealthier suburbs of large cities where there is a sufficient number of people prepared to pay for their services. This means they are placed with little relationship to the distribution of need.

Of course, there are some clinicians who work in poor, regional or country areas, and some who have a sliding fee scale. The problem with them, however, is always their waiting lists.


Clinicians as small business operators

Our community sometimes forgets that doctors, psychologists and counsellors working in private practices are running small businesses. We may be surprised and sometimes even angered by the charging of extra fees or the refusal to undertake extra tasks that come outside those things that are covered under Medicare.

Clinicians must take some responsibility for the angst this can generate. While in some circumstances they seem to want to sit above the grubbiness of the marketplace, adhering to lofty ideals and principles of serving the sick and the dying, it's clear that most are also clearly interested in making money. In fact, many specialists make huge amounts of money. The community is not blind to this. It can therefore be very aggravating when a seemingly paltry request is refused or charged for.

GPs and other primary care providers such as clinical psychologists sometimes charge for the phone calls, the letters, and the meetings that enable the communication we want and need to take place. They might have a policy that all patients have to come into their rooms (and pay a consultation fee) when they pass on information to another clinician.

Within reason, such charges do in fact make sense - such clinicians are in fact running small businesses.

Of course, there are also cases of great generosity among clinicians. GP practices in very poor areas often bulk bill everyone and few hesitate to communicate with whichever specialist we need for free. Other practices may charge for consultations but not charge excess for letters or other forms of communication. Most will bulk bill all pensioners.

There is absolutely nothing wrong with calmly asking the practice manager or your doctor for a list of fees for all items charged, as well as consultation. That way you will start off with your eyes wide open and won't get nasty surprises along the way.