Submission to the State Insurance Regulatory Authority on WorkCover (Psychology and Counselling Fees) order 2018

Transcription

1 Submission to the State Insurance Regulatory Authority on WorkCover (Psychology and Counselling Fees) order 2018 Prepared by: Mr Paul Gertler for The Australian Clinical Psychology Association contact: Dr Judy Hyde

2 The Australian Clinical Psychology Association (ACPA) represents clinical psychologists who hold the qualifications established by the Psychology Board of Australia (PsyBA) for practice as a clinical psychologist. ACPA thanks you for the opportunity to comment on the WorkCover (Psychology and Counselling Fees) order WorkCover cases can be complex and demanding of clinical knowledge and expertise to differentiate pre-conditions that impact on recovery from injury and direct injury-related disabilities. These cases are currently being treated primarily by generalist psychologists who have no accredited qualifications in professional or clinical psychology, and are less able to assess and treat those presenting for services under WorkCover. The current fee structure for WorkCover services for psychologists places barriers for clinical psychologists to provide these services in the following ways: 1. The gazette fee schedule does not adequately differentiate between generalist and clinical psychologists. Generalist psychologists are required only to hold an undergraduate degree in the science of psychology plus two years of supervised practice. Clinical psychologists are required to undertake an additional accredited Master (two year) or Doctoral degree (three year) in the application of clinical psychology, plus a registrar program to bring the total of post-graduate training to four years, making a total of eight years of training. The fee structure for WorkCover is flawed in not recognizing this distinction, as does Medicare, and gazettes fees, unlike the Motor Accident Authority, resulting in less qualified generalist psychologists being attracted to provide WorkCover services, and those with accredited qualifications in clinical psychology not undertaking this complex work, for which they are trained. 2. The maximum gazetted fee for standard service is inadequate for clinical psychologists. The gazetted maximum fee for regular treatment services is currently $ That is well below the current hourly fee recommended by the Australian Psychological Society (APS) set at $246 for generalist psychologists. While it is common for registered psychologists to deviate from the APS recommended fee most clinical psychologists, with accredited specialised qualifications that are sufficiently skilled and experienced to treat injured workers, charge well above the gazetted rate and closer to, matching or more than the APS rate of $246 per hour. The reality for many of NSW s injured workers is that they will not be able to access high quality psychological support and will be referred on to inexperienced and less qualified registered psychologists who are in need of clientele. 3. Many clinical psychologists in private practice are reluctant to take on insurance claimants because of the perception that there is more documentation required and a higher degree of accountability. There are other therapeutic issues, such as having to report to a third party, and the concerns that they have for client privacy and confidentiality. The low fee is a further disincentive. Most experienced clinical psychologists do not take on injured workers because of these complexities. As such injured workers miss seeing higher quality clinical psychologists and as a result their recovery is set back. This could have an impact on their ability to return to work. 4. The fee schedule does not consider the duration of treatment sessions. The maximum gazetted rate does not specify a session duration and there is only one session paid per day. Therefore, it is a disincentive to offer longer sessions that would be necessary for treating complex conditions such as post-traumatic stress disorder (PTSD). In PTSD, it is recommended that treatment include a component of exposure-based trauma-focused therapy as per the Australian PTSD treatment guidelines published by Phoenix Australia (Centre for Posttraumatic Mental Health). In order to safely conduct exposure therapy it is important to allow sufficient time in session to

3 ensure that the client does not leave the session in a state of distress. The guidelines recommend that therapists allow 90 minutes for an exposure therapy session as specified below: [Recommendation] GPP52: Sessions that involve imaginal exposure may require up to 90 minutes to avoid premature termination of therapy while anxiety is still high, and to ensure appropriate management of distress (Phoenix 2013, p.10). 5. The fee schedule is inadequate as it relates to providing reports. This is a broader issue which should also include an examination of the Allied Health Recovery Request (AHRR) form. The initial AHRR attracts a fee of $35.60 and the time cost of preparing subsequent AHRRs is not recoverable at all. The AHRR requires a substantial amount of time to complete and includes information that would not be relevant in a standard initial interview, such as a comprehensive discussion about the injured workers occupational duties. Because it includes a question about the agreement of the worker to the plan it means that the process of writing the AHRR intrudes into therapy time. The fact that the AHRR attracts a low fee, or no fee, is a further disincentive to experienced clinical psychologists who are in high demand. The AHRR format does not allow for a nuanced and informative report on the client s progress. There might be further detail that the clinical psychologist wishes to convey, but to do so the insurer must request a report. Again, this is at a relatively low rate and requires the clinical psychologist to contact the insurer to alert them to this issue with no reimbursement for their time. 6. The fee schedule is inadequate as it relates to the multi-disciplinary management of injured workers recovery. The State Insurance Regulatory Authority (SIRA) encourages the collaboration of treatment providers in the management of injured workers. Because many injured workers referred for psychological therapy also have significant physical injuries there is an increased need for multi-disciplinary collaboration. A common example is that of people with chronic pain conditions for whom it is critical that the treating psychologist have an understanding of their physical capacity and the impact of medications. As such it is critical to discuss the management of the case with the nominated treating doctor, physiotherapist, orthopaedic surgeon, etc. However, the maximum fee payable for case conferences and reports is set at the same rate of $ For highly experienced and qualified clinical psychologists, who have great demand for their time, this places the burden of poor recompense for their time in the management of injured workers. 5. The travel rate is extremely inadequate. In cases where it is necessary to travel to see an injured worker, such as when there is physical disability affecting the person s mobility, the travel rate is a very low rate for the use of a private vehicle which is based on distance travelled. This is currently $0.66 per kilometre. If the psychologist is based in an urban area it may take half an hour to travel 10 kilometres leading to a reimburse of time and travel expenses (fuel, tolls, running costs) of $6.60 for 30 minutes. This is another disincentive to take on the treatment of injured workers. 6. Recognition of the different maximum rates relating to severe injuries. In 2017 SIRA correctly acknowledged that certain clinical populations had needs beyond those of other injured workers. They delineated people with severe injuries that had compounding problems that meant their treatment was more complex, and therefore the maximum fees order did not apply. This included people with traumatic brain injuries, spinal injuries, amputations, burns and acquired blindness. The fee schedule specifies that if psychologists wish to charge different fees for a severe injury that this must be negotiated with insurer. In practice, it has been difficult for clinical psychologists, who are most able to serve complex populations, to obtain agreement of insurers to allow the setting of more

4 appropriate rates. The fee schedule should include the provision for the psychologist to appeal directly to SIRA if they are unhappy with the fee. 7. Differential fees for emergency workers in Treasury Managed Fund (TMF). In 2017 the fee schedule was amended to allow psychologists to charge different fees for an injured emergency services worker in a TMF agency. This was a welcome change that acknowledged SIRA promoting the interests of some workers who had been injured in the service of others. However, there are many other workers in NSW who are employed in similarly valid occupations who are denied this differential benefit. Because of this differential rate there is an incentive to take on emergency workers ahead of other injured workers. This differentiation of fee presumes that emergency workers cases are more complex and require more intervention, however there is no evidence to support this assertion. In clinical practice, it is common to find that workers in non-emergency occupations have significant psycho-pathology, such as the existence of complex PTSD. Conclusions and recommendations The current fee schedule is problematic for several reasons. Primarily, the lack of differentiation between services provided by generalist vs clinical psychologists leads to a lack of capacity for referrers to provide adequate psychological treatment for more complex presentations, where greater expertise is required. This difficulty is amplified by the relatively low fee for services provided by clinical psychologists providing a disincentive for those more qualified to provide services under the WorkCover system. As a consequence, injured workers are forced to rely upon less qualified generalist psychologists and counsellors. The fee schedule is inadequate in comparison with the recommended fee schedule of the APS, which is the benchmark for generalist psychologists, but does not provide guidelines for clinical psychologists. Clinical psychologists have high demands on their time and are therefore reluctant to take on injured workers where there is less remuneration of their time, greater demands for reporting and inadequate arrangements for the multi-disciplinary management of cases where there is both psychological and physical injury. From 2017 SIRA has acknowledged the complexities of severe injuries and emergency workers but in practice it is difficult to apply appropriate fees because the fee schedule requires psychologists to negotiate this with insurers. Finally, while emergency workers do often have complex presentations that require more extensive treatment, other injured workers may have similarly complex presentations, making the differential fee structure seem unfair. In order to address the identified problems with the fee structure ACPA recommends that SIRA abandon the current gazetted fee schedule and instead adopt a differential fee structure for generalist and clinical psychologists, as does Medicare and the Motor Vehicle Authority of NSW, based on the APS recommended fee schedule for generalist psychologists, and taking account of the additional high-level training of clinical psychologists. This includes adequate remuneration for the time spent in assessment, treatment, case conferencing and reporting. Adopting the APS fee schedule as the base schedule will remove the key disincentives for experienced and highly qualified clinical psychologists to provide services to injured workers in NSW. It will increase competition for service provision to injured workers allowing insurers to choose the best qualified and most relevantly experienced providers. References: Australian Psychological Society (2017). APS National Schedule of Recommended Fees (not including G.S.T.) and item numbers* for psychological services: The Recommended Fee Schedule in place from 1 July 2017 until 30 June 2018 (see attached).

5 Phoenix Australia (2013). Australian PTSD treatment guidelines. Guidelines.pdf downloaded

6 APS National Schedule of Recommended Fees (not including G.S.T.) and item numbers* for psychological services The Recommended Fee Schedule in place from 1 July 2017 until 30 June 2018 SERVICE DESCRIPTION Initial consultation Subsequent consultation SERVICE TIME (mins; non-billable work associated with service not included 1 ) Item number* IO1 IO2 IO3 IO4 IO5 IO6 IO7 Recommended fee** n/a $135 $187 $246 $303 $357 $462 Item number SO1 3 SO2 SO3 SO4 SO5 SO6 SO7 Recommended fee $68 $135 $187 $246 $303 $357 $462 4 Item number PA1 PA2 PA3 PA4 PA5 PA6 PA7 Psychological assessment Clinical psychological assessment 5 Item number CA1 CA2 CA3 CA4 CA5 CA6 CA7 6 Item number NA1 NA2 NA3 NA4 NA5 NA6 NA7 Neuropsychological assessment 7 Item number RO1 RO2 RO3 RO4 RO5 RO6 RO7 Report preparation 8 Item number CO1 CO2 CO3 CO4 CO5 CO6 CO7 Case conference Recommended fee $68 $135 $187 $246 $303 $357 $462 Telephone consultation Travel time Family or other group (of 2 clients) Family or other group (of 3 to 4 clients) Family or other group (of 5 or more clients) Item number PO1 PO2 PO3 PO4 PO5 PO6 PO7 Recommended fee $68 $135 $187 $246 $303 $357 $462 Item number TO1 TO2 TO3 TO4 TO5 TO6 TO7 Recommended fee $49 $81 $122 $162 $203 $244 $284 Item number F21 F22 F23 F24 F25 F26 F27 Recommended fee (Per person) n/a $68 $93 $123 $151 $178 $231 Item number F31 F32 F33 F34 F35 F36 F37 Recommended fee (Per person) n/a $45 $62 $82 $101 $119 $154 Item number F51 F52 F53 F54 F55 F56 F57 Recommended fee (Per person) n/a $27 $37 $49 $61 $71 $92 Attendance 9 at court Item number LO1 10 LO2 LO3 11 LO4 LO5 LO6 LO7 12 or legal briefings 13 Recommended fee n/a $246 $280 $369 $454 $535 $694 Clinical file review and photocopying of file records for subpoena or other reasonable purposes 14 Item number PC The item provides for a standard fee of $143 plus 25 cents per page for files over 50 pages in length For explanations of the notated numbers 1 to 13, please see footnotes on next page. In general on this schedule, where no fee is listed (as with many '1' codes) it is assumed that the relevant '2' item number applies or a time-based proportion of the '2' recommended fee. * These item numbers are not to be confused with the Medicare Benefits Schedule (MBS) item numbers ** Recommended fees do not include GST (where applicable) Disclaimer: These fees are recommended only. Members are able to vary these fees at their discretion. Page 1

7 Notes and guidelines on the application of the APS SCHEDULE OF RECOMMENDED FEES AND ITEM NUMBERS FOR PSYCHOLOGICAL SERVICES Please ensure that clients are aware of the details of consulting fees prior to commencing the professional relationship. Guidelines for preparation of accounts*** The account should show: A. Psychologist's Provider Number(s):... (where relevant) B. Name(s) of person(s) seen:... Date of service:... Service description:... Item number:... In order to avoid confusion, it is advisable not to show any further detailed description of the service provided, as the item number indicates this.**** C. APS recommended fee (according to item number): $... D. Agreed payable fee (as negotiated with the client and if different from the recommended fee): $... Cancellation fees Fees for cancellation of appointments made for psychological services can be justified if no replacement service is billed for the lost time. The policy for charging of cancellation fees should be discussed with the client or the service requester. Written information detailing the policy on cancellations should be available for clients and referring agencies (e.g., on a printed information sheet or detailed on appointment cards). The following is a general guideline only. In the instance of a minute service, the recommended cancellation fees are: 0 24 hours notice: Full fee hours notice: 50% of fee 48 hours 7 days notice: 25% of fee *** Medicare Australia has its own requirements and procedures for accounts that you should be familiar with if providing services under the Medicare Benefits Schedule (MBS). These are set out on the APS website. **** Some health funds are requesting inclusion of diagnostic information on accounts. You should only include this information where there has been an explicit arrangement between the health fund and client. If this is part of their contractual arrangement, you may be obliged to include such details. Otherwise, it may contravene confidentiality requirements. If these items parallel Medicare Australia rebatable items but the client chooses to claim against their health fund, inclusion of the words "not being claimed under Medicare" may assist client claims. Footnotes 1. These fees are calculated on the assumption of 66% productivity one hour of billable time will involve an additional average of half an hour of associated non-billable professional time (e.g., referral source letters, phone calls, test scoring etc.). This productivity ratio is assumed to decrease slightly for items of less than 46 minutes and increase slightly for items over 60 minutes. 2. The fee rate for services estimated to be of more than two hours in duration should be negotiated with the client or referral source. In this case, the appropriate item number prefix should be followed by an 'X' to indicate extended service, e.g., NAX or ROX. 3. This item is only used for brief client contact related to ongoing management/treatment (e.g., brief client consultation, ward round etc.). Note that this item is not considered appropriate for writing letters to referral sources, phone calls, etc. which are considered non-billable items (refer to footnote 1). 4. Time spent on face-to-face client interviewing or testing of intellectual, personality, interests or other capacities or traits for the purpose of educational, vocational or other assessment or guidance. 5. Time spent on face-to-face interviewing or testing by an appropriately qualified psychologist for purpose of assessment or diagnosis of psychopathology. Note that it is the ethical responsibility of the psychologist only to provide services that are within the limits of the psychologist s area of training and competence. 6. Time spent on face-to-face interviewing or testing by an appropriately qualified psychologist for purpose of assessment of brain functioning. Note that it is the ethical responsibility of the psychologist only to provide services that are within the limits of the psychologist s area of training and competence. 7. A report is a psychological service that is directly requested by the referring agency or client. Thus reports prepared for clients are usually done so on the basis of explicit written consent from the client or legal guardian. A report is a structured presentation typically including such components as relevant psychosocial history, history of presenting issues, present condition, test results, opinion and intervention recommendations. Professional letters to medical or other referral agencies concerning treatment needs of the client are not considered to constitute reports (refer to footnote 1). For clients requesting reports, it is the responsibility of the psychologist to clarify the procedures and costs involved prior to report preparation. For extended reports, it is the responsibility of the psychologist to negotiate fee arrangements with the referring agency prior to preparation of the report. This would normally be the equivalent pro rata of the hourly rate. Note that report preparation time is inclusive of relevant file and document review. General guidelines for report length and item numbers: RO2 = 1 page* brief supplementary reports e.g., request for elaboration on a previously submitted report RO3 = 1-2 pages short report RO4 = 2-3 pages short report RO5 = 3-4 pages standard report RO6 = 4-5 pages standard report RO7 = 5-6 pages extended * A4 single-spaced, typed, full page, excluding spaced preamble or other non-text material (This guideline is not to be interpreted rigidly and report length and charging arrangements may vary according to the specific requirements of the requesting agency). 8. A Case Conference is a consultation between professionals and others who are directly involved in the provision of services to the same client. 9. Attendance includes waiting time and provision of testimony. 10. The recommended rate for attendance at Court for any time less than one hour is $ Times for these services are based on 1.5 x APS recommended fee, to take into account the additional complexity, intensity and disruption of this service. 12. For prolonged attendance items of more than two hours, each additional and consecutive hour after the initial two hours may be charged at the rate of 1.5 x APS recommended fee or by negotiation. 13. Travel time to/from Court or briefings as per Travel items TO1 TO6. Travel times of more than two hours are by arrangement. Motor vehicle travel in excess of 2 hours may incur the additional cost of 74 cents/ per km travelled. Air travel to be business class fare and insurance; accommodation at minimum of 4-star hotel and breakfast. 14. Psychologists should be aware that individuals may have an enforceable right of access to their health information under relevant health records and/or privacy legislation in the relevant jurisdiction and specified or regulated fees may apply for some activities when a person seeks access to their records. Psychologists should familiarise themselves with the relevant privacy and health records legislation and the requisite fees. Feedback on the Schedule and guidelines is welcomed; please forward to APS National Office APS-IS-SRF-P1 Page 2