580154 research-article2015
ANP0010.1177/0004867415580154ANZJP ArticlesChambers et al.
Research
The National Perinatal Depression Initiative: An evaluation of access to general practitioners, psychologists and psychiatrists through the Medicare Benefits Schedule
Australian & New Zealand Journal of Psychiatry 1–11 DOI: 10.1177/0004867415580154 © The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Georgina M Chambers1, Sean Randall2, Van Phuong Hoang3, Elizabeth A Sullivan4, Nicole Highet5, Maxine Croft6, Cathrine Mihalopoulos7, Vera A Morgan6, Nicole Reilly8 and Marie-Paule Austin8,9
Abstract Objective: To evaluate the impact of the National Perinatal Depression Initiative on access to Medicare services for women at risk of perinatal mental illness. Method: Retrospective cohort study using difference-in-difference analytical methods to quantify the impact of the National Perinatal Depression Initiative policies on Medicare Benefits Schedule mental health usage by Australian women giving birth between 2006 and 2010. A random sample of women of reproductive age enrolled in Medicare who had not given birth where used as controls. The main outcome measures were the proportions of women giving birth each month who accessed a Medicare Benefits Schedule mental health items during the perinatal period (pregnancy through to the end of the first postnatal year) before and after the introduction of the National Perinatal Depression Initiative. Results: The proportion of women giving birth who accessed at least one mental health item during the perinatal period increased from 88 to 141 per 1000 between 2007 and 2010. The difference-in-difference analysis showed that while there was an overall increase in Medicare Benefits Schedule mental health item access as a result of the National Perinatal Depression Initiative, this did not reach statistical significance. However, the National Perinatal Depression Initiative was found to significantly increase access in subpopulations of women, particularly those aged under 25 and over 34 years living in major cities. Conclusion: In the 2 years following its introduction, the National Perinatal Depression Initiative was found to have increased access to Medicare funded mental health services in particular groups of women. However, an overall increase across all groups did not reach statistical significance. Further studies are needed to assess the impact of the National Perinatal Depression Initiative on women during childbearing years, including access to tertiary care, the cost-effectiveness of the initiative, and mental health outcomes. It is recommended that new mental health policy initiatives incorporate a planned strategic approach to evaluation, which includes sufficient follow-up to assess the impact of public health strategies. Keywords Postnatal depression, policy analysis, psychosocial screening 1National
Perinatal Epidemiology and Statistics Unit, University of New South Wales (UNSW), Sydney, NSW, Australia for Population Health Research, Curtin University, Perth, WA, Australia 3Drug Policy Modelling Program (DPMP), National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia 4Faculty of Health, University of Technology, Sydney, NSW, Australia 5Centre of Perinatal Excellence (COPE), Melbourne, VIC, Australia 6Neuropsychiatric Epidemiology Research Unit, School of Psychiatry and Clinical Neurosciences, The University of Western Australia, Perth, WA, Australia 7Deakin Health Economics, School of Health and Social Development, Deakin University, Burwood, VIC, Australia 8Neuropsychiatric Epidemiology Research Unit, School of Psychiatry, University of New South Wales, Sydney, NSW, Australia 9St John of God Health Care, Sydney, NSW, Australia 2Centre
Corresponding author: Georgina M Chambers, National Perinatal Epidemiology and Statistics Unit, University of New South Wales (UNSW), Level 2, McNevin Dickson Building, Randwick Hospital Campus, Sydney, NSW 2031, Australia. Email: [email protected]
Australian & New Zealand Journal of Psychiatry Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on November 13, 2015
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ANZJP Articles
Introduction Mental health problems in the perinatal period (pregnancy to first postnatal year) are a major public health issue with significant morbidity and costs for mother, infant and society (Bauer et al., 2014; Burke, 2003; Kingston et al., 2012; Murray and Cooper, 1996). Postnatal depression and anxiety disorders affect around 15% of women, with up to 45% of cases beginning in pregnancy (Austin et al., 2010; Gavin et al., 2005). Recent estimates indicate that postnatal depression costs the Australian economy AUD433 million a year, along with a loss of 20,732 disability adjusted life years (Deloitte, 2012). Furthermore, the economic cost in one year of not treating perinatal mental health conditions was estimated to be in excess of AUD560 million for births in 2013 (PwC and COPE, 2014). While there are acceptable and effective treatments for perinatal depression (Dennis, 2004; Dennis and Stewart, 2004), perinatal screening guidelines differ worldwide, and more evidence-based research on the utility of perinatal depression screening is needed (Chaudron and Wisner, 2014; Thombs et al., 2014). In 2008, the beyondblue National Action Plan for Perinatal Health recommended universal psychosocial assessment of women during the perinatal period (beyondblue, 2008). This was followed by the Australian Commonwealth Government Department of Health’s National Perinatal Depression Initiative (NPDI) (2008– 2013). The NPDI included the development of clinical practice guidelines recommending routine antenatal and postnatal screening for depression using the Edinburgh Postnatal Depression Scale plus some form of psychosocial assessment (Austin et al., 2011a), new perinatal mental health services under the Access to Allied Psychological Services (ATAPS) initiative, training of primary health care professionals and community awareness and education (Australian Government Department of Health, 2009). Overall, AUD85 million was invested in the NPDI, made up of AUD30 million contributions from both Commonwealth and state and territory governments, AUD20 million from the Commonwealth to ATAPS specifically for perinatal mental health items and AUD5 million to beyondblue. ATAPS items are part of the Better Outcomes in Mental Health Care programme introduced in 2001 (Australian Government Department of Health, 2010), which allow general practitioners (GPs) to refer patients to allied health professionals, including psychologists, for subsidised mental health treatment funded through local primary care organisations (Medicare Locals) via state and territory governments. Australia’s universal health insurance scheme, Medicare, provides access to primary care services, public hospitals and subsidised pharmaceuticals to all Australians through a levy on tax payers. Medicare pays benefits or rebates for professional health services listed on the Medicare Benefits Schedule (MBS)
including mental health services provided by psychiatrists and, in more recent years, by GPs and allied health professionals. Alongside the introduction of the NPDI, there have been numerous other mental health policy initiatives introduced over the last decade. The Council of Australian Governments (COAG) committed AUD4.1 billion to mental health over 2006–2011 as part of the National Action Plan for Mental Health (COAG, 2013), funding 145 separate initiatives including ‘Better Access to Mental Health Care’ (frequently referred to as the ‘Better Access’ initiative) in November 2006. This scheme introduced a number of MBS items for selected mental health services, including items for psychological treatment with registered psychologists and other mental health professionals (Australian Government Department of Health, 2014). The 2006 Better Access initiative has led to a significant increase in access to, and utilisation of, Medicare funded mental health care. The number of patients accessing the newly introduced MBS items increased from 34 to 53 per 1000 between 2007 and 2009, with the number of services claimed through Medicare increasing from 2.7 million to 4.6 million over the same period. Individuals from ‘at-risk’ populations, such as the young, those from lower socioeconomic backgrounds and those in remote areas, have experienced lower rates of uptake, but have also experienced the greatest percentage increases in uptake over time (Pirkis et al., 2010, 2011). While the impact of the Better Access initiatives is relatively clear in terms of access to Medicare funded services at a population level, there has been no evaluation of how access to Medicare funded services for women giving birth has been affected by the introduction of NPDI (Austin et al., 2012), nor evaluation of the NPDI more broadly. An important point of contact with the health care system for women with perinatal mental illness or morbidity is through Medicare funded services, provided by a GP, psychologist or psychiatrist. Therefore, an evaluation of Medicare service utilisation is critical to understanding whether the NPDI has been effective in providing access to mental health care for women at this vulnerable time in their lives. This study aims to address this question by quantifying the uptake of MBS mental health items for women during the perinatal period before and after the introduction of the NPDI compared to a control group of women of similar age; the hypothesis being that the NPDI resulted in increased access to primary and secondary mental health care during the perinatal period.
Methods Data sources The Australian Government’s Department of Human Services, Medicare Information Service Branch provided an extract of monthly aggregate claims data for mental health MBS services undertaken during the perinatal period for women giving birth (perinatal women) between August
Australian & New Zealand Journal of Psychiatry Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on November 13, 2015
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Chambers et al. 2006 and December 2010 (the birth observation period). To capture the perinatal period for all women in the cohort, the extract included claims for services between 1 November 2005 and 31 December 2011 (the study period). The mental health MBS items included were as follows: psychiatric services – 291, 293, 296, 297, 299, 300, 302, 304, 306, 308, 310, 312, 314, 316, 318, 319, 320, 322, 324, 326, 328, 330, 332, 334, 3.36, 338, 342, 344, 346, 348, 350, 352, 353, 355, 356, 357, 358, 359, 361, 364, 366, 367, 369, 370, 855, 857, 858, 861, 864, 866, 14,224; GP services – 2702, 2710, 2712, 2713, 2721, 2723, 2725, 2727, 170, 171, 172, 2574, 2575, 2577, 2578, 2704, 2705, 2707, 2708, 4001; allied health (including psychologists) services – 109,68; 80,100; 80,105; 80,110; 80,115; 80,120; 80,000; 80,005; 80,010; 80,015; 80,020; 81,355; 10,956; 80,125; 80,130; 80,135; 80,140; 80,145; 80,150; 80,155; 80,160; 80,165; 80,170; 81,325; 81,000; 81,005; 81,010. This list is slightly different from the MBS-subsidised list of items specified by the Australian Institute of Health and Welfare (AIHW) (https://mhsa.aihw.gov.au/services/medicare/data-source/), because the AIHW list excluded important pregnancy counselling items, and included items not considered relevant for this population (e.g. electroconvulsive therapy). To identify women who had given birth and thus been exposed to the NPDI (perinatal women), the oldest woman of reproductive age (18–44 years) on a Medicare Card for which a baby had been added was identified as the mother of the child. The MBS mental health items claimed by that woman in the 9 months leading up to the birth and the 12 months following the birth (the perinatal period) were extracted and stratified by temporal period to birth (9 months leading to the birth, 1–6 months following the birth, 7–12 months following the birth), and provider type (GPs, allied health professionals and psychiatrists). Women were grouped by month of birth (August 2006 to December 2010), age at time of birth (
ANP0010.1177/0004867415580154ANZJP ArticlesChambers et al.
Research
The National Perinatal Depression Initiative: An evaluation of access to general practitioners, psychologists and psychiatrists through the Medicare Benefits Schedule
Australian & New Zealand Journal of Psychiatry 1–11 DOI: 10.1177/0004867415580154 © The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav anp.sagepub.com
Georgina M Chambers1, Sean Randall2, Van Phuong Hoang3, Elizabeth A Sullivan4, Nicole Highet5, Maxine Croft6, Cathrine Mihalopoulos7, Vera A Morgan6, Nicole Reilly8 and Marie-Paule Austin8,9
Abstract Objective: To evaluate the impact of the National Perinatal Depression Initiative on access to Medicare services for women at risk of perinatal mental illness. Method: Retrospective cohort study using difference-in-difference analytical methods to quantify the impact of the National Perinatal Depression Initiative policies on Medicare Benefits Schedule mental health usage by Australian women giving birth between 2006 and 2010. A random sample of women of reproductive age enrolled in Medicare who had not given birth where used as controls. The main outcome measures were the proportions of women giving birth each month who accessed a Medicare Benefits Schedule mental health items during the perinatal period (pregnancy through to the end of the first postnatal year) before and after the introduction of the National Perinatal Depression Initiative. Results: The proportion of women giving birth who accessed at least one mental health item during the perinatal period increased from 88 to 141 per 1000 between 2007 and 2010. The difference-in-difference analysis showed that while there was an overall increase in Medicare Benefits Schedule mental health item access as a result of the National Perinatal Depression Initiative, this did not reach statistical significance. However, the National Perinatal Depression Initiative was found to significantly increase access in subpopulations of women, particularly those aged under 25 and over 34 years living in major cities. Conclusion: In the 2 years following its introduction, the National Perinatal Depression Initiative was found to have increased access to Medicare funded mental health services in particular groups of women. However, an overall increase across all groups did not reach statistical significance. Further studies are needed to assess the impact of the National Perinatal Depression Initiative on women during childbearing years, including access to tertiary care, the cost-effectiveness of the initiative, and mental health outcomes. It is recommended that new mental health policy initiatives incorporate a planned strategic approach to evaluation, which includes sufficient follow-up to assess the impact of public health strategies. Keywords Postnatal depression, policy analysis, psychosocial screening 1National
Perinatal Epidemiology and Statistics Unit, University of New South Wales (UNSW), Sydney, NSW, Australia for Population Health Research, Curtin University, Perth, WA, Australia 3Drug Policy Modelling Program (DPMP), National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW, Australia 4Faculty of Health, University of Technology, Sydney, NSW, Australia 5Centre of Perinatal Excellence (COPE), Melbourne, VIC, Australia 6Neuropsychiatric Epidemiology Research Unit, School of Psychiatry and Clinical Neurosciences, The University of Western Australia, Perth, WA, Australia 7Deakin Health Economics, School of Health and Social Development, Deakin University, Burwood, VIC, Australia 8Neuropsychiatric Epidemiology Research Unit, School of Psychiatry, University of New South Wales, Sydney, NSW, Australia 9St John of God Health Care, Sydney, NSW, Australia 2Centre
Corresponding author: Georgina M Chambers, National Perinatal Epidemiology and Statistics Unit, University of New South Wales (UNSW), Level 2, McNevin Dickson Building, Randwick Hospital Campus, Sydney, NSW 2031, Australia. Email: [email protected]
Australian & New Zealand Journal of Psychiatry Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on November 13, 2015
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ANZJP Articles
Introduction Mental health problems in the perinatal period (pregnancy to first postnatal year) are a major public health issue with significant morbidity and costs for mother, infant and society (Bauer et al., 2014; Burke, 2003; Kingston et al., 2012; Murray and Cooper, 1996). Postnatal depression and anxiety disorders affect around 15% of women, with up to 45% of cases beginning in pregnancy (Austin et al., 2010; Gavin et al., 2005). Recent estimates indicate that postnatal depression costs the Australian economy AUD433 million a year, along with a loss of 20,732 disability adjusted life years (Deloitte, 2012). Furthermore, the economic cost in one year of not treating perinatal mental health conditions was estimated to be in excess of AUD560 million for births in 2013 (PwC and COPE, 2014). While there are acceptable and effective treatments for perinatal depression (Dennis, 2004; Dennis and Stewart, 2004), perinatal screening guidelines differ worldwide, and more evidence-based research on the utility of perinatal depression screening is needed (Chaudron and Wisner, 2014; Thombs et al., 2014). In 2008, the beyondblue National Action Plan for Perinatal Health recommended universal psychosocial assessment of women during the perinatal period (beyondblue, 2008). This was followed by the Australian Commonwealth Government Department of Health’s National Perinatal Depression Initiative (NPDI) (2008– 2013). The NPDI included the development of clinical practice guidelines recommending routine antenatal and postnatal screening for depression using the Edinburgh Postnatal Depression Scale plus some form of psychosocial assessment (Austin et al., 2011a), new perinatal mental health services under the Access to Allied Psychological Services (ATAPS) initiative, training of primary health care professionals and community awareness and education (Australian Government Department of Health, 2009). Overall, AUD85 million was invested in the NPDI, made up of AUD30 million contributions from both Commonwealth and state and territory governments, AUD20 million from the Commonwealth to ATAPS specifically for perinatal mental health items and AUD5 million to beyondblue. ATAPS items are part of the Better Outcomes in Mental Health Care programme introduced in 2001 (Australian Government Department of Health, 2010), which allow general practitioners (GPs) to refer patients to allied health professionals, including psychologists, for subsidised mental health treatment funded through local primary care organisations (Medicare Locals) via state and territory governments. Australia’s universal health insurance scheme, Medicare, provides access to primary care services, public hospitals and subsidised pharmaceuticals to all Australians through a levy on tax payers. Medicare pays benefits or rebates for professional health services listed on the Medicare Benefits Schedule (MBS)
including mental health services provided by psychiatrists and, in more recent years, by GPs and allied health professionals. Alongside the introduction of the NPDI, there have been numerous other mental health policy initiatives introduced over the last decade. The Council of Australian Governments (COAG) committed AUD4.1 billion to mental health over 2006–2011 as part of the National Action Plan for Mental Health (COAG, 2013), funding 145 separate initiatives including ‘Better Access to Mental Health Care’ (frequently referred to as the ‘Better Access’ initiative) in November 2006. This scheme introduced a number of MBS items for selected mental health services, including items for psychological treatment with registered psychologists and other mental health professionals (Australian Government Department of Health, 2014). The 2006 Better Access initiative has led to a significant increase in access to, and utilisation of, Medicare funded mental health care. The number of patients accessing the newly introduced MBS items increased from 34 to 53 per 1000 between 2007 and 2009, with the number of services claimed through Medicare increasing from 2.7 million to 4.6 million over the same period. Individuals from ‘at-risk’ populations, such as the young, those from lower socioeconomic backgrounds and those in remote areas, have experienced lower rates of uptake, but have also experienced the greatest percentage increases in uptake over time (Pirkis et al., 2010, 2011). While the impact of the Better Access initiatives is relatively clear in terms of access to Medicare funded services at a population level, there has been no evaluation of how access to Medicare funded services for women giving birth has been affected by the introduction of NPDI (Austin et al., 2012), nor evaluation of the NPDI more broadly. An important point of contact with the health care system for women with perinatal mental illness or morbidity is through Medicare funded services, provided by a GP, psychologist or psychiatrist. Therefore, an evaluation of Medicare service utilisation is critical to understanding whether the NPDI has been effective in providing access to mental health care for women at this vulnerable time in their lives. This study aims to address this question by quantifying the uptake of MBS mental health items for women during the perinatal period before and after the introduction of the NPDI compared to a control group of women of similar age; the hypothesis being that the NPDI resulted in increased access to primary and secondary mental health care during the perinatal period.
Methods Data sources The Australian Government’s Department of Human Services, Medicare Information Service Branch provided an extract of monthly aggregate claims data for mental health MBS services undertaken during the perinatal period for women giving birth (perinatal women) between August
Australian & New Zealand Journal of Psychiatry Downloaded from anp.sagepub.com at FLORIDA INTERNATIONAL UNIV on November 13, 2015
3
Chambers et al. 2006 and December 2010 (the birth observation period). To capture the perinatal period for all women in the cohort, the extract included claims for services between 1 November 2005 and 31 December 2011 (the study period). The mental health MBS items included were as follows: psychiatric services – 291, 293, 296, 297, 299, 300, 302, 304, 306, 308, 310, 312, 314, 316, 318, 319, 320, 322, 324, 326, 328, 330, 332, 334, 3.36, 338, 342, 344, 346, 348, 350, 352, 353, 355, 356, 357, 358, 359, 361, 364, 366, 367, 369, 370, 855, 857, 858, 861, 864, 866, 14,224; GP services – 2702, 2710, 2712, 2713, 2721, 2723, 2725, 2727, 170, 171, 172, 2574, 2575, 2577, 2578, 2704, 2705, 2707, 2708, 4001; allied health (including psychologists) services – 109,68; 80,100; 80,105; 80,110; 80,115; 80,120; 80,000; 80,005; 80,010; 80,015; 80,020; 81,355; 10,956; 80,125; 80,130; 80,135; 80,140; 80,145; 80,150; 80,155; 80,160; 80,165; 80,170; 81,325; 81,000; 81,005; 81,010. This list is slightly different from the MBS-subsidised list of items specified by the Australian Institute of Health and Welfare (AIHW) (https://mhsa.aihw.gov.au/services/medicare/data-source/), because the AIHW list excluded important pregnancy counselling items, and included items not considered relevant for this population (e.g. electroconvulsive therapy). To identify women who had given birth and thus been exposed to the NPDI (perinatal women), the oldest woman of reproductive age (18–44 years) on a Medicare Card for which a baby had been added was identified as the mother of the child. The MBS mental health items claimed by that woman in the 9 months leading up to the birth and the 12 months following the birth (the perinatal period) were extracted and stratified by temporal period to birth (9 months leading to the birth, 1–6 months following the birth, 7–12 months following the birth), and provider type (GPs, allied health professionals and psychiatrists). Women were grouped by month of birth (August 2006 to December 2010), age at time of birth (
