BRAIN & MINDRESEARCHINSTITUTE

Mind the GapChallenges for Developing and Implementing an ABF model for Mental Health

Activity Based Funding Summit – 11 May 2012

Brisbane

Sebastian Rosenberg | Senior Lecturer

Topics to be discussed

› Introduction

› What we know about mental illness

› Key issues confronting mental health

› Key issues confronting ABF

› Fears about ABF

› Hopes for ABF

› Jobs to do

› Other issues in mental health beyond ABF

Background to this Paper

3

Lilian LazarevicSebastian Rosenberg

Published by the Mental Health Council of AustraliaMarch 2012www.mhca.org.au

What we know about Mental Health 1

› 38% of people in care in 1997

› 35% in 2007

› 13% of the burden of disease

› 6% of total health funding

› 1 in 5 adults per year

› 75% of all mental illness <25yrs

› Treatment rates for young men (16-24 yrs) are just 13%

What we know about Mental Health 2

› $6bn in spending each year

› Around 7% of this is community-based NGO PDRS type services

› Vast majority of the remainder is spent on hospital based mental health care, mostly acute

› Post-vention?!

› No evidence to support hospital-based mental health care (Knapp, Hawthorne etc)

› Considerable evidence that community-based mental health care is both effective and popular

Better Access Scheme: Nov 2006 – Nov 2011

$1.6bn spent on 15m services

Policies, Plans, Strategies and other diversions

Key Issues Confronting Mental Health 1

› How to reduce hospital-centric service?

› How to build earlier intervention?

› Services of the future are not built yet

› How to get fair share of funding?

› How to build modern workforce?

› What is the role of the new mental health commissions?

› How to entrench consumer rights?

Key Issues Confronting Mental Health 2

› Accountability: we don’t know:

- Suicide rate

- Death rate following contact with a service

- Homelessness

- Employment rate

- Education completion rate etc…

› Community-based reporting infrastructure weak

› No lingua franca – apples and pears, variability

› Standards exist but not applied

Key Issues Underpinning ABF

› Allocative and Technical efficiency – bang for buck

› Do no harm (at least at first)

› Common approaches

› Capacity to compare

› Hospital focus of ABF reforms

› Fairness, transparency

› ABF has led to a degree of specialisation in services – how would this work in mental health?

ABF Fears

› Will reinforce hospital as locus of care

› DRGs have weak explanatory power (better than nothing)

› DRG cost data in mental health not seen as reliable

› No robust classification for ED, outpatient or sub-acute care

› Will provide disincentive to develop new models, particularly in the community

› Will entrench disadvantage in mental health funding

ABF Hopes

› Provides a common way of describing care

› Growing community sector

› Historical/block funding delivered poor outcome

› Transparency to ensure MH$ spent in MH

› Benchmarking, comparison of different approaches – palpably lacking

› Access to new, rare growth funds

› Need to drive new service models – what is a hospital-based community mh service?

Jobs to Do

› Engage service providers in genuine work to build new classification systems and/or re-develop existing ones (MH-CASC etc)

› Urgent requirement to strengthen governance arrangements so that the mental health sector can engage in ABF work

› Need to ensure the ABF pricing model provides the right incentives

› Need for a relationship to be built between the IHPA and the mental health sector

› Need to consider overseas approaches

Payment by Results UK Model etc.

› Years to develop

› 21 ‘care clusters’ for contracting or commissioning services

› Clinical Decision Support Tool and Clustering Tool based on concept of ‘need’

› Standardised packages of care designed for each care cluster

› UK only shadowing implementation because of perceived high financial risk to providers

› Canadian InterRai SCIPP System – inpatients only

Other Issues Affecting Mental Health

› Getting the mental health commissions to work together

› Medicare locals as purchasers of community mental health care

› CoAG investment in sub-acute care – what is sub-acute mental health care?

› Partners in Recovery and individualised packages of care

› A National Mental Health Report Card - housing, employment, experiences of care

Conclusion

› There is strong evidence to support the delivery of community-based mental health care over hospital-based care

› ABF is coming to mental health, sector needs to join the debate

› Urgent need to build classification and costing infrastructure to support a system of ABF that is consistent with the evidence about what works in mental health care

› National readiness review across acute, outpatient, ED and community mental health services is required

› What to buy vs. How to buy – replicating last year not sufficient

Thank you

sebastian.rosenberg@sydney.edu.au