Mind the mental health gaps as private practice role expands
On Feb. 9, Dr. Sam Hickcox, the director of Nova Scotia’s office for mental health and addictions, announced that the commitment to allow Nova Scotians to access mental health care from private practitioners is underway.
Though much has yet to be worked out, it is possible that under the new plan Nova Scotians would access mental health private practitioners in much the same way that they access physicians. The patient would seek care from an approved mental health practitioner and the mental health clinician would invoice MSI directly for the care they are providing.
This effort to make mental health services more available would be difficult to criticize and we certainly agree in principle that it is a good idea. We do offer some caution, however, out of fear that such a plan may not actually make mental health services more available to the most in-need, marginalized and vulnerable Nova Scotians.
We are two mental health clinicians working at The Peoples’ Counselling Clinic in Halifax, a small, nonprofit, community based, pro bono mental health clinic established in 2017. We offer free therapy to marginalized groups and provide contracted services to special populations, like clients of the local domestic violence court. The work we do targets under-served people who are poorly served or categorically excluded from accessing mental health care through current free, publicly available mental health services. Such folk are rarely able to access mental health care through employee benefits.
HOW IT WORKS
Few people understand that the frontline of our current universal health-care system in Canada, the family physician, is not an employee of a non-profit health-care delivery system. Rather, most physicians in Nova Scotia are either a part of a group or singley incorporated for-profit medical enterprise.
This has resulted in a system where physicians can make more money seeing relatively healthy clients in brief medical office (or telephone or online) visits. Meanwhile, patients with complex medical needs who require more time and attention from their physicians are being told they should only bring one medical request per visit to their physician. This results in a lack of truly comprehensive medical care for the high-needs client. We hope that this systemic problem is not replicated in a universal mental health plan.
The idea behind opening MSI billing codes to private practitioners of various mental health disciplines (social workers, psychologists, counselling therapists) could be attractive on the surface if some way could be assured that clients with the greatest needs were able to be ensured the greatest access to competent and comprehensive care. As we are seeing in primary health care, this sort of care is best delivered not by a private-fee-for-service physician but in a comprehensive medical care centre with salaried medical practitioners able to provide care in a multi-disciplinary team of physicians, nurse practitioners, nurses, dieticians, social workers and other allied health professionals. The North End Community Health Centre is perhaps the clearest example of such a practice model. Sadly, this model has not been replicated in many places.
BUILT-IN BIAS
Our health system is steeped in racism, classism, homophobia, transphobia, heteronormativity, ableism, colonialism, stigma against adverse experiences with mental health and addiction, and other inequities that have resulted in health disparities for populations marginalized by these influences.
If the government of Nova Scotia is seeking to make mental health service delivery more accessible, it may do well to bypass the idea of indiscriminately opening up MSI billing codes to privatefor-profit practitioners and work specifically with nonprofit, community-based practitioners who are already providing mental health services to high-needs populations as the place to start. To do otherwise may result in further marginalizing those who are least serviced by our current mental health system.
What we predict will happen if MSI billing is used for private mental health care is that private practitioners would be incentivized to see the easiest of clinical cases; white, upper middle-class, relatively well-adjusted individuals who have very real clinical problems but are certainly not those with the greatest or most complex needs. We urge the government to champion a more robust plan that would somehow incentivize practitioners to work with clients who require more time and care.
We doubt anyone truly wants to recreate the problems in access that currently plague our current public mental health and medical care systems.
“... private practitioners would be incentivized to see the easiest of clinical cases; white, upper middle-class, relatively welladjusted individuals who have very real clinical problems but are certainly not those with the greatest or most complex needs.”