Clinical College Survey – Report by Chair

United Profession – Equality of Practitioner – Freedom of Treatment

In December RAPS was provided with information about a Clinical College survey sent to theirs members in October and November last year in preparation for their submission to the Medicare Item Number Review, currently in process.

The MBS Item number review which is currently underway has also stimulated the Australian Association of Psychologists Inc. (aapi) – a group of general registered psychologists – to put out a petition calling for a One-tier system which has attracted over 2,136 signatures so far.

On December 7: The Chair of the Clinical College emailed members:

Dear …

Title: Update on Medicare Item Doodle Poll – my thanks to members!

A very brief email to thank members who have stepped up since Monday and added their views to the poll. With a total of 700 respondents I feel confident that the committee has a reasonable idea of members views. The figures did not change markedly, if anything there was a stronger belief that the Two Tier system was in the best interest of clients (89% support) and crucial to industry (84% support), with an increasing risk to our membership (79% would consider not renewing membership) if the APS does not promote the Two Tier system to government. The implication of the trend is that any further data would only strengthen this view, so the poll will now be closed. Further comments can be posted on the Forum or sent to me via email.

I am aware that a petition is being promoted amongst a group of generalist psychologists (not APS) seeking 100 signatures to argue for the removal of two tiers. Clearly were we to need to counter that petition, our membership could provide a much stronger petition in the opposition direction. We need a diverse and united workforce in the evolving Mental Health landscape so lets hope it does not come to that!

Have a good weekend,



Results of the Original Clinical College Survey on November 2016:

RAPS was very pleased to note a handful of courage’s and thoughtful comments from some members of the Clinical College about the short comings of the two-tier system!

The survey states: This poll is to understand members’ view of the two tier Medicare system and their willingness to participate in advocacy. It contained six questions:

  1. I believe 2-tier Medicare is critical to industry functioning.
  2. I believe it is a benefit to clients.
  3. It is essential for accurate referral pathways.
  4. I would be willing to visit Ministers.
  5. APS support of two-tier Medicare is an important consideration in my decision to renew my College membership.
  6. I would be willing to write to Government.

A total of 639 people participated in the poll.

  • 533 voted Yes to 1.
  • 564 voted Yes to 2.
  • 544 Yes to 3.
  • 155 would visit Ministers.
  • 497 indicated it was crucial to renewal of their college membership.
  • 354 would write to Government.

There were 62 comments, including:

“Some reoccurring arguments against the two-tier system include: 1) it creates a division in the psychology community, and 2) “equal pay for equal work”. In short, the ‘equal pay for equal work’ argument is misguided because we have to reimburse clinical psychologists for completing a program with higher requirements. The argument pertaining to division overlooks the fact that we need subdisciplines to cover the various aspects of psychology – we need clear diversity and a system that cultivates meritocracy.”

“I strongly support the APS advocating for more Medicare funded sessions for clients. For a high proportion of my clients, treatment has to end because they have run out of sessions, as opposed to their episode being resolved. Clients don’t have an option of paying for sessions at headspace where I work, so are unable to continue with me even if they have the capacity to pay. Medicare funded treatment of mental illness should be informed by research rather than a government prescribed arbitrary number.”

“The two tier system is appropriate and reflects clinical psychologists’training and expertize in more complex, psychiatric cases. I have picked up on psychotic depression early on several occasions resulting in those clients getting appropriate treatment sooner. I’d like the APS to advocate for the return of ‘special circumstances’ sessions. I’ve been caught out a few times when rebated sessions ran out for suicidal clients. Scary.”

“I have to agree with my peers who support the two tiered system. As an experienced registered nurse I followed the postgrad pathway as I wanted to ensure that I had the necessary competency to work as a psychologist.

The training I received was exemplary and the experiences and knowledge that I have gained have assisted me to provide the appropriate care for each individual client. I would consider leaving the profession not just the APS if this were to change. I bulk bill and the current system my service.”

“Given the degree of training required to gain my clinical doctorate, I believe in the two tier-ed system as accurately helping clients to access appropriate care. I would also appreciate the APS advocating for the return of an 18 session/yr model as I believe this is crucial in being able to adequately support a proportion of my clients.”

“I have to agree with my peers who support the two tiered system. As an experienced registered nurse I followed the postgrad pathway as I wanted to ensure that I had the necessary competency to work as a psychologist.

The training I received was exemplary and the experiences and knowledge that I have gained have assisted me to provide the appropriate care for each individual client. I would consider leaving the profession not just the APS if this were to change. I bulk bill and the current system my service.”

“Given the degree of training required to gain my clinical doctorate, I believe in the two tier-ed system as accurately helping clients to access appropriate care. I would also appreciate the APS advocating for the return of an 18 session/yr model as I believe this is crucial in being able to adequately support a proportion of my clients.”

“In keeping with the NHS in the UKand other health systems the world over evidenced-based short-term psychodynamic psychotherapy – Dynamic Interpersonal Therapy (DIT), like CBT and IPT should be recognised as an endorsed Medicare/ATAPS approach.”

“I have completed the 4+2 route, working in mental health for several years, then completed a masters of clinical psychology. There are many generalist psychologists who provide some excellent services and they need to be valued and supported. Their current rebate is too low.

Completing post grad training is expensive and requires a great deal of personal sacrifice. I do feel the additional training further honed my capacity to work with complex clients. Hence I support the 2 tier system.”

“The clin psych rebate reflects the additional and rigorous training undertaken to gain endorsement. Often seeing more complex cases than generalist psychologists, the current rebate does not currently adequately reflect the workload involved. 10 Medicare funded sessions are not enough for 50% of patients seen – particularly when working with children. Increasing to 12 sessions as standard, and reinstating the additional exceptional circumstances would better serve clients who can’t afford private fees.”

“It’s important to realise that you cannot practice in a government institution or hospital without being a clinical psychologist / why should this be less or negated in private practices and Medicare? Otherwise you will loose advanced study in psychology This also legitimises our profession internationally.”

“Clinical Masters training includes specialised placements (in the case 1,000 hours) in addition to the academic work. I think those advocating for the one tier assume they would be provided with the $124 rate. Experience suggests the $124 clinical rate would be frozen at this level until the $85 cohort caught up at the CPI rate per annum. I agree that clinical psychologist should be expected to see more complex cases and for there to be a return to an additional set of sessions on GP review.”

“If there is no recognition for our extra training why would there be any need to upskill. We need financial recognition for clinical training and financially it is often of benefit as client outcomes may be met unless number of sessions.”

“Medicare rebate and recommended fees should be commensurate with training, as it is with any other specialisation. As clinicians we are frequently working in high risk areas, with vulnerable populations, both children and adults, and the rebate paid should reflect this. Not only have we seen a freeze on Medicare rebates since July 2012, we have also had a reduction in number of sessions available for clients. Adequate financial reimbursement is essential to provide quality of service and practice costs.”

“I believe referring practitioners should be able to nominate the specialist area of the psychologist they are referring to but I don’t necessarily believe that clients get a lower rebate for seeing other psychs – this disadvantages clients who simply want to see a psych to get help. If ending the two tiers means we all drop to a lower level I am totally against this. If it means there is 1 higher level, I am less concerned. There are genuine costs to run a quality practice & clients need help paying fees.”

“I agree with the principal of a two-tier system, however I would believe the higher rebate should be applied to all endorsements within psychology, not just clinical. I would also like to see generalist psychologists having clearer pathways to being able to obtain an endorsement of specialty, based upon experience and competencies. However, what would be more beneficial for client population is funding for more than 10 sessions under a MHCP, rather than a tier two system.”

“Understanding the different levels of training for and specialisations of psychologists in the health field may be useful information for the public to have when choosing a health professional. The different levels of remuneration via Medicare reflects the time spent in formal training and is consistent with other health professions and rebate principles.”

“Having completed a Masters in Counselling Psych and been registered, then completed a Clinical Psych Doctorate – I am aware of the different skill set gained from the Clinical qualification. There is a need for the 18 session option, particularly when working with child clients, particularly now PHN changes have started to change services in rural areas.”

“It is wrong to say that clinical psychologists are more highly trained than other psychs who have completed a Master. The various Master courses are all the same length – they just have a different focus. It would be more reasonable to pay endorsed psychologists a higher rate in recognition of the additional supervision they have received. The two tiered system creates division within the profession. GPs who work with children don’t get paid less”

“If we do not need a two-tier system, then we do not need further education after a four-year degree qualification. It is reasonable and common that higher trained people are better payed in all areas of employment.”

“Considering the large proportion of clinical psychologists currently in the profession, it would be surprising if this poll favoured the abolition of the 2-tiered system. As far as I am aware, there is little evidence that suggests clinical psychologists obtain better client outcomes than other psychologists, and so the provision of the higher Medicare rebate makes little economic sense.”

“The medical model has two tiers, GP’s or General Practitioners and Specialists , including psychiatrists. To have two tiers within psychology is consistent with the medical practice. Clients are more able to be educated tell the difference between the two tiers to obtain specialist skills if they so choose. So often I have clients who have been to a generalist psych and the only treatment available was ventilating their feelings. They had never heard of CBT or any other models. There is a difference in the …”

“Practising as a clin psych since 2000 and working in private practice since 2012. Constantly referred complex children requiring assessment/diagnosis and completion of reports to help with funding within schools, carer benefits, NDIS and to help inform ongoing work of Paeds and Child Psychiatrists. The level of work required in these cases far exceeds 10 sessions. I’m in a lower income, low resource area, don’t charge Sydney prices, tossing in pro bono work due to duty of care – subsidising Comm.Health!”

“I have been working in private practice since 2000. It was a retrograde step to reduce Better Access from 18 to 10 sessions for Clinical Psychologists. Once you have committed to taking on complex cases you cannot leave them stranded after 10 sessions. I know many of my colleagues who are offering pro bono services after about September each year for clients who cannot afford sessions without a rebate. This puts undue financial pressure on psychologists and guilt on clients who want to be able to pay.”

“As a student in 4th year psychology at the moment, and a practicing counsellor with a Master of Counselling degree (UQ), I am considering clinical vs. general registration. While I understand clinical offers some unique training, I believe the amount of work to become clinical is not as much as the $85 vs. $125 tiered rebate would suggest. If anything, the $85 should be closer to or equal to $125 to reflect the hard work general psychologists also must do to become registered and offer quality service.”

“The two tier system is very necessary and extremely fair to those of us who have clinical training and endorsement. Hence, I’m echoing other comments about the necessity for a two tier system to provide the appropriate endorsement, acknowledgement and remuneration for the rigorous specialist clinical training undertaken by some. I would be extremely angry and unhappy if APS did not continue to support the two tier system, and withdraw my registration with them if they advocated otherwise.”

“I have worked with some great registered psychologists, social workers and nurses in public mental health. However, the two tier system recognises a rigorous process for achieving specialist endorsement, including further training, experience and supervision. This compares to the medical model, where GPs are generalists and medical specialists attract higher rebates. Clinical psychologists are being recognised as specialists in assessing and treating complex mental health issues.”

“There is diversity in Psychologists’ professional training. The two tier system accurately reflects that Clinical Psychologists undergo extensive, specialist, clinical training, therefore, are more qualified than those who have not done that training.”

“It is self evident that professionals who have had recognized additional specialist training ought to be recognized and remunerated as such. Also, for the complex cases clinical psychologists often see, a maximum sessions of ten sessions year is inadequate. My continued membership of the APS is contingent on the two tier system remaining.”

“It is reasonable to ask clinical psychologists to work with clients who have more complex issues, and to provide additional sessions.”

“Whilst I have no doubt there are some excellent non-clinical psychologists practising all around Australia, I can vouch for the difference that my clinical training made in my professional practice and outcomes for patients. There is no doubt in my mind this sharpened my focus on effective treatments for a clinical population. As such, a two-tiered system reflects this level of specialised focus.”

“It’s not true that clinical psychologists have “spent considerably more time & finance at university in order to obtain a much higher and extensive qualification” than other masters qualified psychologists.

There are many non-clin psychologists who are exemplary practitioners; I know a number I would preferentially refer to rather than a clin psychologist. The two-tiered system has played a significant part in reducing the diversity of psychology specialisations, a bad thing for the profession as a whole.”

“I was a 4 year degree psychologist for many years before I returned to university and obtained my Masters in Clinical Psychology. I thought I was as good a psychologist as those with a Masters before that but I didn’t know what I didn’t know. It was extremely stressful and I took two years out of the workforce to complete it. I then obtained work as a clinical psychologist at a public psychiatric hospital and gained extensive experience in mental health. The two-tied system is appropriate.”

“I absolutely support the two-tiered system as clinical psychologists have spent considerably more time, and finance, at university in order to obtain a much higher and extensive qualification. This involves a greater understanding of mental illness and the appropriate forms of clinical treatment, we have taken more training to study. I believe we should insist on the necessity of many more Medicare rebated sessions, as many of our patients are more complex in nature and would require more of our skills.”

“I think that PHNs taking control of mental health funding is an equally vital issue for the APS to address very strongly on members’ behalf. Two-tier will be irrelevant if Better Access ceases.”

“I strongly support the two-tiered system as clinical psychologists have spent considerably more time, and finance, at university in order to obtain a much higher and extensive qualification. This involves a greater understanding of mental illness and the appropriate forms of clinical treatment, than can be studied just at graduate level. I also believe we should insist on the necessity of many more Medicare rebated sessions, given the difficult patients we work with, and our specialities in serious …”.

“I completely concur with Anne Galambosi’s comments. Those of us who have taken the time and expense to increase our capacity and expertise in providing treatment to our clients should not be held at the same level or be regarded in the same manner as those who have not done this. In no other field is greater education and training given equal merit with lower levels.”

“I agree that money could be saved by referrals to clinical psychologists being treated as per any medical speciality without the requirement of a MHCP or review at 6 sessions. This could allow for greater number of sessions e.g. Reinstatement of 12 and 18 in exceptional circumstances per year as originally introduced. A two tier system is esssential – – -additional training pathways need to be financially rewarded otherwise less will do the additional training leading to less specialized expertise.”

“It is time we took a stronger stand on the irrelevance of the Mental Health Care Plan and the need for a six session Review!! We must advocate for a normal referral from the GP to the psychologist. The money that this would save Medicare could then be allocated to more sessions per annum. At least let us get up to 12. (more would be good). This may upset some doctors who would lose out on this item, but I think most GP’s would be happy to do away with the extra paperwork.”

“Early on in my training I completed the 4+2 pathway with extra training and supervision resulting in pretty good clinical skills. The completion of a Clin Masters years later resulted in the sharpening of my clinical skills and highly developed ability to assess, diagnose, develop individualised case formulations to guide treatment and evaluate outcomes. This is specialised training and I believe it should be recognised as such.”

“I do think that although all of us train in psychology, the Medicare rebate system is relevant to mental health, and not all of our specialties should be looking to be financially considered under this system.”

“1. As our services seem to be more and more medicalised within this Medicare rebate system, surely clinical psychologists must be viewed as specialists within the mental health sphere – General practitioners/Registered psychologists comprise Tier 1 (divisive term anyway) and Medical specialists (gynae, orthopaedic surgeon etc)/Clinical psychologists Tier 2. I support other endorsed specialities receiving Tier 2 rebate in the realm of mental health assessment and treatment.”

“Like any role in society, further education/training is usually rewarded. Endorsement reflects this additional training. In recent networking for my priv practice, the title does carry an understanding of greater expertise with GP’s. GP’s have also expressed to me that in many cases more sessions are warranted.”

“We train as specialists, we practice as specialists, we should be recognised and renumerated as specialists.”

“I think the two tier system is important. Having done both pathways essentially as I did my postgraduate training later, it did enhance my skills. However, I was still arguably a better clinician than post graduates prior to my advanced training because of my experience and thirst for knowledge/supervision etc. I would like to see generalist psychologists be able to work towards clinical college membership again. This would have to a be very rigorous process including experience and training.”

“Clinical psychologists have been screened for their ability to take up further training in mental health and have been rigorously tested and accredited. Then, they are available to offer assessment and care to those with more severe or complex needs. Due to the higher rebates they are able to offer a higher proportion of bulk-billing than general psychologists – absolutely essential in the support of economically disadvantaged people. This would end under a one-tier system.”

“The removal of a two tier system would be a disincentive for specialised and additional training in psychology and mental health (i.e. clinical post-graduate degree). Therefore this would eventually disadvantage the Australian community in that people with serious mental health disorder would have less well trained options for evidence based treatment.”

“The two-tier funding model reflects the additional specialised training in specific areas of acute and chronic mental health conditions that clinical psychologists treat. Further the populations clinicals see often are not able to pay any gap payment as financial resources are very often limited or non existent. The two tier model supports clients in significant distress and who are financially disadvantaged and changes would affect these groups particularly. I support the continuation of the two tier model.”

“The 2 Tier system reflects the significant extra training clinical psychologists have completed. Unfortunately many GPs do not understand the difference between generalist and clinical psychology skills and often refer patients with serious mental health conditions to a generalist who has not been trained to treat those with severe presentations. The damage is not to the industry, it is to the clients who are paying for a service but not receiving the skill level required.”

“I think it damages our industry by creating division and a pseudo-hierarchy. I think it should go.”

“The public mental health system is poorly funded. What this means for clinical psychologists is there is an ever increasing presentation of clients with serious mental health disorders. Some of these clients pose a risk to themselves and the community. For these reasons, having access to services provided by a clinical psychologist is essential.”

“As a clinician that was a registered psychologist who then returned to do my clinical training (now a clin psych registrar) the level of training, knowledge, experience and confidence I have gained through this has been invaluable. I truly believe it has made me a better clinican. I back the two tier system 100%.”

“A two tier system is appropriate so that the clients of all psychologists can benefit. Psychologists with an area of practice endorsement and Medicare access should be able to offer the higher tier to their clients. The ten session limit is an ignorant policy response.”

“A two tier system should remain and is reflective of higher academic qualification and trained skills. I am supportive of master program where entry is accessible for experienced 4 year psychologists who can then travel a path way to the higher tier.”

“Clinical psychology training is longer & more specialised than pathways to general registration therefore a higher rebate should apply to clinical psychology items.”

“People with complex psychological issues should be referred to psychologists trained to deal with these. Clients in this case are very likely to need more than ten sessions per year and this should be driven by the treating psychologist and not the referring GP. GP’s make the referral to the appropriate person but cannot decide on treatment length or when the person should return for a review.”

“I believe the number of sessions for psychological treatment of complex or severe mental health problems should be the decision of the psychologist – GPs aren’t limited in the number of sessions they can provide for a patient for a physical problem so why should a mental health issue be any different? Two-tier is required to reflect training, skills and greater complexity of issues addressed by endorsed psychologists, who are specialists.”

“I would additionally like to add unlimited sessions. A Mental Health Nurse gets unlimited sessions and they do not have the qualifications that we do. Frankly it is dangerous. Those clients with severe mental illness are not getting the due care they need.”

“I think it would be great to have a lower tier for registered psychologists, and a higher tier for an endorsed psychologist – with higher rates for all endorsement types, regardless of whether it is clinical, forensic, counselling, etc. I also think Psychologists need to be paid a higher medicare rate for Saturday afternoons, similar to GPs.”

“I would renew college membership if the APS supports the two-tier system.

“The 2 tier Medicare system makes provision for GPs to ensure they are referring clients with complex psychiatric presentations to psychologists who have met minimum training standards.”

“Hi, where are the options for those who don’t support the two-tier arrangement?”

“While I do understand there are some great registered psychologists out there, unfortunately there are also some very poor examples. Until a better system comes along having a two tier system is the best way of ensuring – within the current system – that endorsed psychologists meet minimum requirements for education and training.”

“I would definitely leave APS if it decided not to support the two tier system.”