31 October Professor Bruce Robinson Chair, Medicare Benefits Schedule Review Taskforce Department of Health

Transcription

1 31 October 2018 Professor Bruce Robinson Chair, Medicare Benefits Schedule Review Taskforce Department of Health By to: Dear Professor Robinson Re: Report from the Eating Disorders Working Group (EDWG) Thank you for seeking the views of Royal Australian and New Zealand College of Psychiatrists (RANZCP) on the Medicare Benefits Schedule (MBS) Review Taskforce Report from the Eating Disorders Working Group (EDWG). The RANZCP welcomes the report and agrees that treatment of eating disorders is best supported through a multidisciplinary approach. However given that some of the issues identified may also be relevant to other mental illnesses, the RANZCP suggests that it may be appropriate to wait for the reports from other relevant clinical committees, including the Psychiatry Clinical Committee and the Mental Health Reference Group, prior to finalising any recommendations. The RANZCP is supportive of the Taskforce as a way of enhancing modern and effective mental health services to the community and to adequately address the needs of those suffering from mental illness. The RANZCP looks forward to continued engagement with the Taskforce as the review progresses. To discuss any of the issues raised in the attached submission, I can be contacted via Rosie Forster, Executive Manager, Practice, Policy and Partnerships via rosie.forster@ranzcp.org or by phone on (03) Yours sincerely Dr Kym Jenkins President Ref: 1278o 309 La Trobe Street, Melbourne VIC 3000 Australia T F ranzcp@ranzcp.org ABN

2 Submission to the Medicare Benefits Review (MBS) Review Taskforce Report from the Eating Disorders Working Group November 2018 advocating for equitable access to services 309 La Trobe Street, Melbourne VIC 3000 Australia T F ranzcp@ranzcp.org ABN

3 About the Royal Australian and New Zealand College of Psychiatrists The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is a membership organisation that prepares doctors to be medical specialists in the field of psychiatry, supports and enhances clinical practice, advocates for people affected by mental illness and advises government on mental health care. The RANZCP is the peak body representing psychiatrists in Australia and New Zealand and as a bi-national college has strong ties with associations in the Asia-Pacific region. The RANZCP represents over 6000 qualified psychiatrists in Australia and New Zealand. Psychiatrists are clinical leaders in the provision of mental health care and use a range of evidence-based treatments to support a person in their journey to recovery. Summary The RANZCP is pleased to provide this submission on the Medicare Benefits Schedule (MBS) Review Taskforce Report from the Eating Disorders Working Group (EDWG). The RANZCP acknowledges that there are no major outstanding issues with the existing psychiatrist consultation MBS item group that impact on the delivery of psychiatry services specifically to people with eating disorders, although notes that there are areas that can be enhanced for psychiatry more generally, as outlined in the RANZCP submission to the MBS Review Taskforce in 2015 and supplementary submission to the MBS Review Taskforce in It is noted that the majority of the changes proposed in this reports will have the greatest impact on how general practitioners (GPs) and allied health professionals can deliver improved services for people with eating disorders. The RANZCP acknowledges that treatment of eating disorders is best supported through a multidisciplinary approach and therefore welcomes the direction of the changes proposed. However given that some of the issues identified will be relevant to other mental illnesses, the RANZCP suggests that it may be appropriate to wait for the reports from other relevant clinical committees, including the Psychiatry Clinical Committee and the Mental Health Reference Group, prior to finalising any recommendations. In developing its response, the RANZCP has focused its feedback on the key recommendations outlined by the EDWG and directed questions as requested. Recommendation 1.1: Create a new MBS consultation item for the treatment and management of a patient with severe anorexia nervosa, as diagnosed by a psychiatrist or paediatrician The RANZCP broadly supports the new MBS consultation item number for the treatment and management of a patient with severe anorexia nervosa, as diagnosed by a psychiatrist or paediatrician that allows for up to 40 psychological sessions and up to 20 dietitian sessions per year. The ability for people to access the services they need under the MBS to promote recovery is supported by the RANZCP. In particular multidisciplinary care is supported, and the value to people with anorexia nervosa in being able to access an increased number of psychological sessions, and the ability to access dietitian services, is recognised. It is noted that the proposed item number is limited to anorexia nervosa, rather Royal Australian and New Zealand College of Psychiatrists submission Page 1 of 5

4 than other eating disorders. The RANZCP accepts this on the basis that anorexia nervosa is a severe and complex disorder for which the evidence base supports lengthy psychological treatment and appropriate nutritional management (Hay et al., 2014). The RANZCP acknowledges that there are other complex psychiatric disorders that may also benefit from expanded psychological services, and that the level of support required will frequently vary depending on clinical need. It is understood that these issues are currently being discussed by the Psychiatry Clinical Committee and the Mental Health Reference Group. In regard to diagnosing severe anorexia nervosa, the definition within the Diagnostic and Statistical Manual of Eating Disorders 5 (DSM 5) based on BMI is noted. The DSM 5 provides a scale of severity for people with eating disorders, with body mass index (BMI) used as the major indicator. Patients with severe anorexia are defined by a BMI of 15 to The RANZCP has serious concerns that including the word severe prior to anorexia nervosa within the item descriptor will have the unintended consequence of restricting this item to patients with severe anorexia, as defined by a BMI of 15 to Although it is acknowledged in the report that best practice also suggests that the rapidity of weight loss, medical stability, psychological distress, suicide risk, and response to previous treatment be incorporated into the clinical assessment of a patient with anorexia nervosa, no specific definition of severe anorexia nervosa is provided. The RANZCP is concerned that this may lead to the assumption that the DSM 5 BMI range is the cut-off for eligibility for this item, when there is no evidence to support basing severity ratings on BMI level (Machado et al., 2017). Restricting access to those with a BMI will most likely result incredibly few people with anorexia nervosa getting access to life-saving evidence-based treatment as defined under recommendation 1.1. The EDWG report acknowledges that only 0.3% of patients with eating disorders will meet the narrow BMI criteria for treatment. Most of these patients will be medically unstable, requiring admission to hospital, and therefore unable to utilise or benefit from the proposed new item number. This is based on research, such as the Minnesota semi-starvation study, and clinical experience by eating disorder specialists, showing that treatment is unlikely to be effective until the brain is renourished to BMI of over 16 or 17, which means that many services do not offer psychological treatment to patients with a BMI below 16. All cases of anorexia nervosa are serious, life-threatening, complex illnesses, and there is good quality evidence to support 40 sessions of enhanced cognitive behaviour therapy (CBT-e)/ Specialist Supportive Clinical Management (SSCM) for people with BMI of 17.5 or less (Signorini et al., 2018; Fairburn et al., 2003; Hay et al., 2014). Maintaining a BMI definition of eligibility further risks patients feeling a perverse incentive to lose weight to access treatment. The RANZCP understands that as part of this consultation process the EDWG is seeking stakeholders views as to appropriate eligibility for this item. To avoid the use of the DSM 5 definition of severe anorexia nervosa being utilised, it is recommended that the proposed item number be reworded to ensure that the use of the term severe is not taken to mean in the context of the DSM 5 definition. Whilst acknowledged that there may be other factors that could potentially determine eligibility for this item (e.g. chronicity of condition, rapidity of weight loss, psychological co-morbidities) the RANZCP supports that psychiatrists and paediatricians are adequately trained to make a diagnosis using their clinical expertise without any specific requirements of eligibility needing to be defined. The RANZCP does not support the suggestion that the Global Assessment of Functioning Scale (GAF) be used as eligibility for this MBS item, as per existing item 319. As highlighted in its submission to the MBS Review Taskforce in regard to item 319, to be assessed as having a score less than 50 a patient Royal Australian and New Zealand College of Psychiatrists submission Page 2 of 5

5 would have shown no or little response to appropriate psychiatric treatment and be asked to agree to a diagnosis of considerable impairment, which brings issues of associated stigma (Anaf and Jewell, 2007). Whilst acknowledging that anorexia nervosa is a severe disorder, using the GAF as an eligibility criteria may also limit accessibility of this item number, with those who are attempting to re-join the workforce or education not being able to receive treatment. The RANZCP does not consider it necessary to specify a particular point (e.g. based on time or the number of services accessed) for review of the treatment plan/patient progress, as it is believed that this can be determined adequately by clinical judgement. Key priorities for service delivery under the MBS include preventing service fragmentation and ensuring quality consultations. It should therefore be considered that the number of services required depends on the individual patient s needs, rather than determining a set number of consultations at the beginning of treatment. The RANZCP believes it important that, particularly when patients have complex disorders, there should be continued oversight and clinical leadership from a psychiatrist to ensure best possible outcomes. Continued communication and collaboration between all those involved in the treatment of the patient is essential, in line with RANZCP guideline Best practice referral, communication and shared care arrangements between psychiatrists, general practitioners and psychologists. The RANZCP believes that the proposed MBS item number as outlined does not pose any significant barriers to service accessibility. It is acknowledged that people in rural and remote areas have more limited access to psychiatric care (Meadows et al., 2015) as an outcome of workforce maldistribution. The RANZCP proposed a number of general strategies in its submission to the MBS Review Taskforce in 2015, including the introduction of an MBS rural loading and expanding telehealth, to build on the range of strategies relating to training, workforce, and innovative models of service delivery aimed at enabling rural communities to access a full range of mental health services as near to their place of residence as possible. Recommendation 1.2: any future work on the MBS items for mental health services consider the needs of patients with moderate cases of eating disorders with a view of increasing access to appropriate evidence based care The RANZCP supports that future work on the MBS items for mental health services consider the needs of patients with moderate cases of eating disorders with a view to increasing access to appropriate evidence based care. For bulimia nervosa and binge eating disorder, the evidence is unequivocal that 20 sessions of CBT-e is the most effective treatment, support that services be provided to reflect this evidence. As previously noted, in addition to eating disorders there are range of psychiatric disorders that could benefit from increased access to care, particularly those that would benefit from longer term psychological intervention, including for example obsessive-compulsive disorder, borderline personality disorder, and major depressive disorder. Royal Australian and New Zealand College of Psychiatrists submission Page 3 of 5

6 Recommendations : Expand access to allied health and other clinicians The RANZCP is supportive of suggested amendments to the existing MBS arrangements that could improve delivery of care for patients with eating disorders. This includes expanding access to case conference MBS items to allied health professionals who are trained the treatment of eating disorders. The RANZCP has previously identified the a need for increased flexibility in regard to psychiatry case conferences which are an important area of practice but frequently administratively burdensome leading to them being underutilised to the detriment of the patient. It therefore is supportive of measures to improve this more generally across the MBS. Issues relevant to training are identified in the responses to recommendation 3.3 below. The RANZCP further supports including family-based therapy under the items for focussed psychological strategy services, in line with evidence-based practice. The RANZCP notes the issues the EDWG has identified in its letters to relevant Clinical Committees under the MBS. In particular the RANZCP notes the memorandum to the Principles and Rules Committee which recommends that in instances where a psychiatrist is unable to consult with a patient in same physical location, a new MBS item be created to allow psychiatrists to supervise other health professionals who do not have adequate qualifications specific to eating disorders. The RANZCP understands that this would be contingent on a diagnosis by a psychiatrist or paediatrician, and that the psychiatrists would continue to partake in treatment planning and supervision. The RANZCP supports this as a way of improving access in rural and remote areas. In its supplementary submission to the MBS Review Taskforce, the RANZCP recommended provision for support for psychiatrists to offer consultation-liaison work in a primary care setting would help support patients. This would be particularly valuable in rural and remote areas, and other areas where the availability of psychiatrists in limited. It was suggested that one way to deliver this is through the introduction of an MBS item for a GP to consult with a psychiatrist about a patient. This would assist GPs in managing patients with mental illness locally and potentially reduce the need for referral to a psychiatrist. This approach is consistent with the Australian Government s commitment to a stepped care approach to mental health to improve the efficiency and sustainability of the mental health system. The RANZCP remains willing to discuss how to provide this intervention for clinical support for the GP, in collaboration with GPs and other health professionals as relevant, in the context of the recommendation from the EDWG. The RANZCP notes however that the benefits of this approach would not be limited to eating disorders. Recommendation 3.1: Further support and education should be provided to GPs about locally available services for patients with eating disorders and their families The RANZCP is supportive of the Primary Health Networks (PHNs) having a role in providing this information, and would be pleased to work to provide information as required. Recommendation 3.2: Professional associations and other relevant training organisations should develop specific training, education and clinical guidance for working with people who have eating disorders Royal Australian and New Zealand College of Psychiatrists submission Page 4 of 5

7 The RANZCP notes that its training program currently provides training for psychiatrists in the treatment of eating disorders, and clinical guidance is provided through the development of the RANZCP s clinical practice guidelines for the treatment of eating disorders in A range of implementation strategies, including continuing professional development, have been put in place to inform psychiatrists clinical practice, including those working in private practice. The RANZCP does not see that the proposed recommendation presents any specific impediments to the current training program or continuing education program for psychiatrists. However, the RANZCP is aware that workforce shortages remain a significant issue across psychiatry. Psychiatrists remain central to the mental health care team and at the core of mental health specialist services as leaders and experts in service delivery, even with a diversifying workforce. It is therefore imperative that there are adequate opportunities to train psychiatrists in the management and treatment of mental disorders, including eating disorders. Recommendation 3.3: A credentialing process should be established, specific to practitioners that provide treatment for patients with eating disorders The RANZCP is supportive in principle of a credentialing process being established, specific to practitioners that provide treatment for patients with eating disorders as a way of maintaining high standards of practice and improving patient outcomes. However it is noted that no specific credentialing process has been established for other diagnoses for which l mental health services are provided under the MBS. Therefore the suggestion for one for practitioners involved in the treatment of eating disorders is an additional proposed requirement. However, if anorexia nervosa is to get its own MBS item number, there may be merit in developing a specific training and credentialing process for anorexia nervosa as a requirement for the item to be delivered effectively. In terms of how this would be implemented in practice, the RANZCP would assume that each relevant professional association would develop its own training program that would be accredited by an independent body. The RANZCP is concerned that this process of development and accreditation is likely to be lengthy and this could create barriers to access to services for anorexia nervosa in the short to medium term. Recommendation 3.4: The Department of Health to write to the 31 Primary Health Networks (PHNs) on behalf of the Working Group to increase awareness about evidencebased clinical pathways for the treatment of people with eating disorders The RANZCP is supportive of the Department of Health communicating with PHNs to increase awareness about evidence-based clinical pathways for the treatment of people with eating disorders. The RANZCP would be pleased to work with the Department of Health in advising on appropriate clinical pathways. The RANZCP notes that the role of the MBS in the delivery of treatment for patients is only one aspect of service delivery. It is acknowledged that public sector services and state funded specific eating disorder services/clinics also exist. In anorexia nervosa recommended treatment as an outpatient or day patient in most instances (i.e. in the least restrictive environment), with hospital admission for those at risk of medical and/or psychological compromise. The MBS model allows for the provision of outpatient care, engaging a multidisciplinary team. There are reports that public sector mental services are increasingly Royal Australian and New Zealand College of Psychiatrists submission Page 5 of 5

8 difficult to access and, as such, many patients with a range of psychiatric disorders are unable to access specialist psychiatric care. Timely and affordable access to psychiatry and other health professional outpatient appointments is therefore critically important to people affected by serious and severe chronic, acute and intermittent mental illness. This can prevent illness progression or relapse, and avoid such patients presenting in crisis situations at public hospitals, or through admission at a private hospital where the patient has adequate private health insurance cover. The causes of this are multifactorial, and possible solutions occur at multiple levels, including adequate funding of public mental health services. Although these are outside of the scope of the Taskforce, there are many initiatives that could be addressed through the MBS that could remove impediments to practice, and incentivise good practice and communication to better meet consumer needs, as demonstrated through the proposed model for eating disorders. References Anaf G and Jewell P. (2007) Medicare Item 319 after 10 Years: A Range of Concerns. Australasian Psychiatry 15: Fairburn CG, Cooper Z and Shafran R. (2003) Cognitive behaviour therapy for eating disorders: A transdiagnostic theory and treatment. Behaviour research and therapy 41: Hay P, Chinn D, Forbes D, et al. (2014) Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of eating disorders. Australian & New Zealand Journal of Psychiatry 48: Machado PP, Grilo CM and Crosby RD. (2017) Evaluation of the DSM 5 severity indicator for anorexia nervosa. European Eating Disorders Review 25: Meadows GN, Enticott JC, Inder B, et al. (2015) Better access to mental health care and the failure of the Medicare principle of universality. The Medical Journal of Australia 202: Signorini R, Sheffield J, Rhodes N, et al. (2018) The effectiveness of enhanced cognitive behavioural therapy (CBT-E): A naturalistic study within an out-patient eating disorder service. Behavioural and cognitive psychotherapy 46: Royal Australian and New Zealand College of Psychiatrists submission Page 6 of 5