Submission to. MBS Review Taskforce Eating Disorders Working Group
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- Derek Hodges
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1 Submission to MBS Review Taskforce Eating Disorders Working Group Contact: Dr Vida Bliokas President ACPA
2 Introduction The Australian Clinical Psychology Association (ACPA) represents those clinical psychologists who hold the qualifications required by the Psychology Board of Australia (PsyBA) for endorsement in clinical psychology. ACPA recognises that the current Medicare Benefits Schedule (MBS) review process will be of great importance to the future health care of all Australians. ACPA is committed to contributing to this review process, particularly in relation to the Mental Health Services items. We are aware that the Mental Health Reference Group and the Allied Health Reference Group of the Medicare Benefits Schedule Review Taskforce have now been established, and that these Groups will be responsible for providing recommendations to the General Practice and Primary Care Clinical Committee. We appreciate the opportunity to make an updated submission for consideration. This document outlines key issues identified by the ACPA Board and membership relating to the Medicare Taskforce Report from the Eating Disorders Working Group, with a particular focus on responding to the questions posed to stakeholders in the Letter to Stakeholders accompanying the report. Strategic revisions to the MBS are recommended to align the MBS with evidence-based treatment, thereby improving service provision, increasing engagement, enhancing treatment outcomes, and managing costs. General Comments Firstly, we note that the report recommends the creation of a new MBS item for severe Anorexia Nervosa which allows for 40 psychological sessions and 20 dietetic sessions. This would be a significant improvement on the current MBS; however, it is common for these patients to require 50 psychological consultations, especially in the case of co-morbidities, which are common in this patient group (Fairburn, 2008). Throughout our responses we refer to the 40 sessions as outlined in the report; however, we recommend that 50 psychological sessions be allowed for under the proposed item to ensure appropriate intervention. Secondly, although within the report it is acknowledged that the MBS does not currently provide for enough sessions to provide evidence-based treatment for most eating disorders, there are some comments in the report, and particularly in the opening summary, which might be taken to imply that the current MBS does provide adequate treatment for some patients with eating disorders. As the 2
3 report is currently worded, it is likely that there will be misunderstanding about the adequacy of the MBS for eating disorder patients apart from those with severe Anorexia Nervosa. We recommend the report clearly state that mild eating disorders require approximately 20 treatment consultations, moderate eating disorders require approximately 30 treatment consultations, and severe eating disorders require approximately 50 treatment consultations (including any patient with AN of any severity) (Treasure & Schmidt, 2013). Thirdly, we affirm the Working Group s recommendations regarding family therapy as an evidencebased treatment for eating disorders. It is common that within the course of family therapy, it will be clinically indicated that some family members attend a consultation without the patient present (e.g. parents). We recommend that allowance be made for consultations to occur without the patient present under the MBS item, with suitability for these sessions to be determined by the clinical judgement of the health professional providing the psychological consultations and to be reviewed at the regular reviews (recommendations regarding regular reviews are discussed under Recommendation 1.1 below). Specific Feedback Recommendation 1.2 Are there particular issues or considerations that should be covered in the treatment and management plan created by the psychiatrist or paediatrician? Requiring a psychiatrist or paediatrician to diagnose severe Anorexia Nervosa and create a treatment and management plan will add a significant barrier to accessing treatment for many patients. There are typically long waiting periods to see these health professionals, even in the private setting, which would delay the commencement of treatment. Further, there are usually substantial costs associated with these consultations, which would disadvantage many patients. 3
4 Currently, general practitioners (GPs) are able to diagnose Anorexia Nervosa and create a Mental Health Treatment Plan under the MBS, regardless of the severity of the Anorexia Nervosa. We recommend that GPs similarly create treatment and management plans under the proposed MBS consultation item for severe Anorexia Nervosa. Alternatively, should a second health professional be required to be involved in the management of this patient group in addition to the GP, we recommend that this can be done at a later review stage (e.g. after 10 sessions have been completed), or that this can be conducted by a wider range of health professionals working in the eating disorder field (see feedback regarding credentialing for further consideration of which health professionals should be recognised to provide treatment under the proposed MBS consultation item). It is intended that the new item will be specifically targeted to patients with severe anorexia nervosa. The Diagnostic and Statistical Manual of Mental Disorders provides a definition of severe anorexia based on BMI. What other factors should be considered for defining service for the purposes of eligibility for the new item? E.g. chronicity of the condition, rapidity of weight loss, psychological comorbidities. Further, basing eligibility on BMI alone will place some patients in a position of needing to deteriorate to become eligible for the evidence-based treatment for the status of their condition. This is both ethically problematic, and in conflict with the overarching aim of the MBS Review to enable prevention and early treatment. Regardless of which criteria are used to define severe, if other MBS items relevant to the treatment of eating disorders are not also adjusted to enable all patients with eating disorders to access an appropriate number of sessions in line with the evidence-based treatment, patients will face this dilemma of being too well to access appropriate treatment. However, using a simplistic criterion such as BMI will make this particularly problematic. We recommend that eligibility for the new MBS item be based on medical and psychiatric risk, the level of malnutrition, frequency of eating disorder behaviours, and the level of disability and distress. These criteria would therefore also enable any patient with a severe eating disorder to access appropriate treatment, not just those with Anorexia Nervosa. These criteria can be assessed via 4
5 medical and psychiatric assessment, including the use of the Eating Disorders Examination Questionnaire (Fairburn & Beglin, 1994). While we understand the current report focuses on the MBS in relation to severe Anorexia Nervosa, we also recommend that MBS items are adjusted to enable appropriate treatment for anyone with an eating disorder (for anyone with Anorexia Nervosa, the same number of sessions proposed under the new consultation item for severe Anorexia Nervosa; for patients with other forms of eating disorders, allow eligibility for up to 24 psychological sessions per year, see above under General Comments ). This will address the concern regarding patients needing to deteriorate to access adequate treatment and is also in line with the aims of delivering early intervention. Existing MBS item 319 provides for psychiatry consultations for groups determined to have high care needs based on clinical diagnosis (including patients with anorexia nervosa) and for patients aged over 18 an assessment on the Global Assessment of Functioning Scale (GAF) as having a score of less than 50. Should the GAF be used for the purposes of determining eligibility for the proposed new item? The GAF has not been used in the DSM assessment system since It has been criticised for being subjective, among other limitations. We recommend eligibility for the new item be determined through assessing medical and psychiatric risk, the level of malnutrition, frequency of eating disorder behaviours, and the level of disability and distress, as outlined above. Would it be appropriate to specify a particular point (e.g. based on time or the number of services accessed) for review of the treatment plan/patient progress or should this be determined by clinical judgement? 5
6 Given the complex and changing nature of Anorexia Nervosa, regular specified reviews would be appropriate rather than relying solely on clinical judgement. However, these reviews should not be required to be completed by a psychiatrist/paediatrician only, as this will add barriers to treatment, as outlined above. Instead, we recommend these reviews be conducted by a GP, psychiatrist or paediatrician. Research with adolescents and adults suggest that treatment response at session five is highly predictive of outcomes at session 20 or end of treatment (Doyle et al, 2010). We therefore recommend a review after session five to allow for early detection of poor response to treatment and any associated adjustments be made to treatment. However, due to logistical limitations, it is sometimes not possible to conduct a review after session five without causing delays to treatment. We therefore recommend a review as close to session five as practicable, and before session eight. Ongoing reviews are also recommended to assess response throughout treatment, and for any concerns to be identified promptly. We recommend reviews after every five to eight sessions, or within six weeks. Note, the above session numbers for review points refer to the 40 psychological sessions proposed under the new MBS item rather than also including the 20 dietetic sessions, i.e. reviews after every five to eight psychological consultations, regardless of the number of dietetic consultations provided within that time. Are there any impediments for patients with severe anorexia accessing the care model outlined in this recommendation? For some patients, distance from health professionals may be an impediment to accessing the outlined care model. While this is a concern predominantly for patients living in rural and remote areas, some patients in urban areas may also be affected. We recommend treatment be available via tele-health for those living in rural and remote areas, and for patients living in urban areas who experience this barrier, tele-health should be available at the discretion of the referring health professional. However, we also recommend that patients attend consultations in person for assessment and then as required based on clinical judgement, to allow for physical examinations to be conducted for assessment and ongoing monitoring. 6
7 As outlined above, requiring an assessment from a psychiatrist or paediatrician only will create a barrier to accessing care in a timely manner due to waiting lists and costs associated with these consultations. Are there any particular issues for patients in rural and remote areas which should be considered? As outlined above, patients in these areas will have limited access to services so provision of treatment via tele-health is recommended, with regular in-person assessment for effective medical monitoring by a GP, or where a GP is not available, with another health professional as appropriate. Recommendation 1.2 Are there particular issues which should be considered by future processes or work examining MBS mental health services specifically relating to the treatment needs of patients with eating disorders? As outlined in the general comments above, the current MBS mental health services do not allow for evidence-based treatment for any eating disorder. We recommend that this be reviewed urgently within the current MBS Review, rather than via future processes. Recommendations The Working Group identified some issues and amendments that could be made to the existing MBS arrangements which could improve delivery of care for patients with eating disorders. Are there 7
8 any other significant issues with the existing MBS infrastructure that have not been identified? As outlined in the general comments above, the current MBS arrangements do not allow for family members of a patient with an eating disorder to be seen without the patient present. It is common that this would be clinically indicated, particularly when treating child or adolescent patients. We recommend that there is allowance for some of the 40 sessions to be conducted without the patient present. Recommendations 3.1 What information would be most beneficial for GPs to receive? GPs would benefit from receiving information on screening for eating disorders, and the assessments recommended (medical and psychiatric). The National Eating Disorders Collaboration has developed resources for this purpose. GPs would also benefit from receiving information about local eating disorder services. If a credentialing process is established, GPs would also benefit from receiving a directory of local credentialled health professionals. What would the best mechanism for this information to be delivered? The National Eating Disorders Collaboration has developed dissemination methods, and we recommend these be reviewed to inform delivery mechanisms for this information. 8
9 What role should Primary Health Networks (PHNs) play in this context? PHNs can disseminate the above information, including increasing awareness of any changes to the MBS and how to refer under the new item. PHNs can also provide training in the identification, assessment and treatment of eating disorders. Recommendation 3.2 Are there impediments to the development and broad adoption of eating disorder specific training in your profession? Clinical psychologists are aware of the medical and psychiatric complexity of patients with eating disorders, and the immense limitations inherent in providing appropriate treatment under the current MBS. This can limit the number of clinical psychologists choosing to undertake this work. However, with the additional treatment sessions available as proposed in the report, clinical psychologists are likely to be more willing to pursue this work and also to undertake further training in this area, as it will be perceived that, because of the increase in session numbers, it will be possible to provide evidence-based treatments more appropriately. Recommendation 3.3 Do you feel that a credentialing process specific for eating disorders is necessary? Given the high complexity of this patient group, additional professional development and supervision is required to provide safe and effective treatment, particularly for professionals with limited specific 9
10 accredited training in mental health. A credentialing process specific to eating disorders will ensure this. Some health professionals accept all referrals regardless of whether they have completed additional training in eating disorders beyond the training they received in their standard professional training (e.g. university training). This puts patients at risk both physically and psychologically, and there is no certainty that patients will receive evidence-based treatment under these circumstances. In general, credentialing is necessary to ensure patients receive appropriate treatment and are adequately monitored throughout the treatment course. With respect to clinical psychologists, those with accredited postgraduate qualifications have completed a minimum of eight years education and training in psychology and mental health, particularly in assessments and interventions in moderate to severe mental health conditions. A credentialing process would need to acknowledge this high base-line level of competence. Credentialing must also come with suitable cost and time demands on practitioners. What would be the implications of the establishment of a credentialing process on patient access to appropriate care? In the short term, a credentialing process would result in fewer health professionals providing treatment to patients with eating disorders, resulting in longer wait times and fewer locations for patients to access treatment. However, a credentialing process would ensure the quality of treatment provided and adequate monitoring of patient safety, so that when a patient accesses care it is appropriate and safe care possible. We recommend a transition period while a credentialing process is developed and implemented, so that the recommended changes to the MBS outlined in the report can be introduced as soon as possible to meet patient needs. 10
11 Recommendation 3.4 Is there other information that would be appropriate to provide to Primary Health Network (PHNs) to assist to improve the delivery of care to patients with eating disorders at the local level? We affirm the information outlined in the report. Overall questions What is the role of the MBS in the delivery of treatment for patients with eating disorders in the context of public sector services and state funded specific eating disorder services/clinics? Under the MBS, it is possible to provide timely treatment for eating disorder patients across many locations throughout Australia, and in a more cost-efficient manner than setting up specific services/clinics. Eating disorder services/clinics also play a role, especially for ongoing research, training, supervision and development of the field (including developing resources), but these will not be distributed across the country as widely as private practitioners providing treatment under the MBS. The MBS has the role of ensuring that models of funding enhance the multidisciplinary and stepped care approaches that constitute best practice and evidence, rather than hinder them. MBS funding models must allow easy flow between practitioners and sectors, to best meet patient needs. 11
12 References Doyle, P.M. et al (2010). Early response to family-based treatment for adolescent anorexia nervosa. International Journal of Eating Disorders, 43, Fairburn, C. G., & Beglin, S.J.. (1994). Assessment of eating disorder psychopathology: interview or self-report questionnaire? International Journal of Eating Disorders, 16, Treasure, J. & Schmidt. U. (2013). The cognitive-interpersonal maintenance model of anorexia nervosa revisited: a summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating Factors. Journal of Eating Disorders 2013, 1:13 12
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