Dear Frances Mirabelli and the APS Board of Directors,

Re: APS Submission to the MBS Review dated 11Aug18

Although there are several welcome recommendations in this submission, the following is of very significant concern:

1. Competence and best practice intervention

The recommendations made restrict Medicare rebates for certain assessment and treatment services to psychologists with particular Area of Practice Endorsement (AoPE) or those who “can demonstrate equivalent competence” (no details provided). These restrictions are unnecessary given that to both gain and maintain registration as a psychologist, an individual must demonstrate the ability to practice within their limits of competence. If they do not, the individual will be subject to processes governed by AHPRA. Specifying these restrictions implies (without evidence) that psychologists are likely to breach ethical requirements and practice outside their areas of competence.
There are many pathways to competence (and expertise) in assessment and treatment of individuals with psychological disorders. All generally involve university training in addition to ongoing supervised practice, professional development, and experience. It is inaccurate to consider that only one type of university training (ie a particular Masters or Doctorate) and one type of supervised practice and professional development (ie the registrar program) results in competence or expertise in this area. Equally, completion of a 2 year clinical post grad university program and 2 years of supervised practice and professional development (ie the clinical registrar program) could not practically provide a psychologist with experience in assessing and treating all disorders within all client populations within Australia. The evidence to date is that there is no difference in outcomes between clinically endorsed and other registered psychologists providing Better Access services (Pirkis et al., 2011).
Second, restricting the interventions that a psychologist can use when providing these services contradicts current best practice. Scott Miller (currently providing training through the APS Institute) often refers to this quote: “Evidence based practice is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences” (APA, 2006). It is not about specifying treatment approaches and disorders in reality do not fit in neat boxes.

2. Impact on the profession

Restricting Medicare rebates to services provided by certain AoPE psychologists would result in significant loss of work, livelihood, and career prospects for a large number of psychologists competent to provide these services. In addition, there is no evidence to support a continued framework where the clients of certain AoPE psychologists receive a higher Medicare rebate than clients of other competent psychologists for the same service.
Other foreseeable risks to psychologists restricted to Level 1 services are:
- The government could further lower the Level 1 services rebate to fund Level 2 and 3 services.
- Referrers could direct those with milder needs to online and self-help resources (as GPs are being encouraged to do) and allocate those who they wish to send to a psychologist to a more complex category so they can access a higher rebate and more sessions.
- Clients could take legal action towards psychologists for previously providing them Level 2 or 3 services as the framework implies the psychologist wasn’t competent to provide these services.
- What Medicare does, others (eg Centrelink) have previously followed. Therefore, these losses for psychologists could extend beyond Medicare work.
- The reputation of the profession could be affected.

3. Impact on clients

Restricting Medicare rebates to services provided by certain AoPE psychologists would restrict both overall access to psychology services for clients and their choice of preferred provider. In particular:
- There would be an insufficient number of psychologists overall to meet the current need for services or to work with specific populations (eg indigenous, low SES, rural, at risk).
- Clients would be out of pocket unnecessarily (eg as they have to see a AoPE psychologist as well, or because they can’t get a rebate for their preferred psychologist).
- It would risk treatment for clients considered Level 2 or 3 already part way through an intervention.
- Clients could be referred to less experienced (but endorsed) psychologists over those with more expertise in areas relevant to client needs.

4. Perception of the APS

A significant number of paying APS members are feeling shocked, betrayed, disgusted, deceived and not represented upon reading the APS submission. Several of the recommendations appear to breach both the Code of Ethics and the mission of the APS. Particularily relevant are the following Ethical Standards:
- A.2.2. Psychologists act with due regard for the needs, special competencies and obligations of their colleagues in psychology and other professions.
- A.2.4. When psychologists in the course of their professional activities are required to review or comment on the qualifications, competencies or work of a colleague in psychology or another profession, they do this in an objective and respectful manner.
- C.2.2. Psychologists take reasonable steps to correct any
misrepresentation made by them or about them in their
professional capacity within a reasonable time after becoming aware of the misrepresentation.

Yours Sincerely,

The Undersigned Psychologists.

(Collated from discussion in the "Australian Psychologists" Facebook Group)

** This open letter was delivered to Frances Mirabelli on the 19Sep18 with 1064 signatures: 784 General / 127 Provisional / 15 Endorsed (Clinical) / 71 Endorsed (other than Clinical) / 493 Medicare Providers / 543 APS Members / 15 APS Volunteers.