Inflation anybody?

Sep 05, 2023

Somebody asked "How much does a course of ECT cost?" That's not an easy question to answer as there are a lot of variables, including that we live in inflationary times. In Brisbane, electricity has gone from 25c/kwh in July 2022 to 38.5c last week, 54% increase in 13 months. That's pretty amazing considering power in Qld is generated from coal and natural gas, which are sold on fixed, long-term contracts. The spot price for fossil fuels has been up and down (blame the Russians for blowing up their Nordstream pipeline they'd just finished at a cost of $12billion) but the contract price hasn't budged. Meantime, a large pack of Metamucil has jumped from $24.00 to $44.00; a 1kg pack of powdered milk, previously $5.80 is now a nice round $10.00; and Tasmanian salmon today was $44.00/kg, up from $26.00 two years ago.

I suppose then it's not surprising that psychiatry has been feeling the financial pressure. Fortunately, psychiatrists have a benevolent government to look after their needs. From March 2024, the Medicare rebate for ECT will rise. This is the amount Medicare (the national health insurer) refunds to a patient who has paid for ECT in a private hospital. Let's say Mrs Jones is admitted to a private hospital to have a course of ECT, normally about twelve episodes. I say "Mrs Jones" because ECT is and always has been a treatment administered to middle-class, middle-aged women by men. It does not imply that women are more prone to mental disorder than men (they're not) or that "they can't take it" (they can) or they're more likely to suicide than men (most emphatically not), it's just one of those jolly traditions that the people who get most ECT (a treatment for the most severe disorders, especially to prevent suicide) are the people who need it least, who are least likely to object and who are most likely to pay. Young tradesmen, who have the highest suicide rate in the country and not much money, almost never get ECT.

Anyway, at three episodes a week, Mrs Jones will need to be there for four weeks plus a few days before and after, say five weeks in all. At a minimum of $700 per day for a shared room, that's nearly $25,000. Her health insurance will pay most of it but private rooms cost a heap more and there are dozens of other costs, as we all know. The cost of ECT itself consists of three items, the psychiatrist's fee, the hospital fee and the anaesthetist's fee. The only figure I have ever seen was from six years ago when a patient was quoted $620.00 per ECT, about one third to each player, so twelve would have cost her nearly $7,500. After the various rebates and refunds, she would have been about $4,000 out of pocket, plus various hospital fees, probably $7,000 for the lot. That was based on the standard rebate for ECT, which was then $72.40 but private psychiatrists normally charge up to three times that. The patient pays the difference, called the gap fee. Now what are they actually getting in return for all this money?

In the mid-1970s, when I was training in public hospitals, patients were wheeled in, wrist bands checked, then a nurse put an oxygen mask on them. The anaesthetist inserted a butterfly cannula on the back of the hand, checked pulse and blood pressure, then gave the anaesthetic agent (in those days, it was thiopentone), waited a few moments for it to work, then gave a dose of a muscle-blocking agent. That took about 30 seconds, then the medical officer (not the psychiatrist, they were never there) put the electrodes on the patient's temple and either dialled a number or pressed a button. The seizure lasted a minute or so and a few minutes later, when the patient was breathing regularly, the whole troop moved on to the next bed. Dead easy.

For the psychiatrist, ECT is a breeze. In 2019, the Royal Australian and New Zealand College of Psychiatrists issued practice guidelines for ECT which go on about the psychiatrist's "expertise" and "skills" and "training" but truth is, it's money for jam. A few minutes standing around talking to the nurses and the anaesthetist, then a starring role holding something to an unconscious head for a few seconds, then stand back, arms folded and watch the action. Such as it is. A faint twitching around the mouth and eyes, maybe the feet arching a little and that's about it these days. And $74.55 richer for the experience, maybe ten minutes if the staff are a bit slow, so six of them an hour quickly adds up - except nobody charges the base fee. It's two to three times that, which works out at about $1300 or more an hour. Not bad money for doing essentially nothing.

The college has a nice handout on their website that talks about how important ECT is in dealing with severe mental "illness," how it can prevent suicide, etc., and how it works. In particular, it is important for people to consent:

The ability to consent is essential for people considering ECT and is sought in accordance with principle 5 of the RANZCP Code of Ethics.

All very reassuring but it doesn't say anything about how ECT is banned in some parts of the world and severely restricted in most other parts. In Australia, UK and US, which are among the biggest users of ECT in the world, it is very largely reserved for nice middle-aged ladies who don't whinge and complain when told they will get it. Not that it matters, of course: if a patient is told "You need ECT" but declines the offer, that patient will simply be detained under the Mental Health Act and will get it anyway. In different countries, nurses give ECT; I've certainly seen medical students holding the electrodes, so it doesn't involve much skill. In Norway, it can only be given in government hospitals, which means there's no money in it for the private sector, not least because there's a permanent eight week waiting list. In Italy, where it was invented in 1938, it is severely restricted and only about 15% of the population even have access to a hospital using it.

For myself, working half in public hospitals and in remote areas, and half in private practice, I never used it. I didn't wake up one morning and decide: "That's it, no more ECT." Instead, it just happened that I could always find a cause for the patient's misery and deal with it, and gradually forgot about ECT. My attitude is simply this: If I can work for 45 years in difficult to very difficult conditions and not use it, so too can every psychiatrist in the country. Psychiatrists use ECT for one of three reasons [1, 2]:

1. "I believe all mental illness is a case of brain illness and ECT is specific for this condition."
2. "I have reached the limit of my skills. I don't know what else to do."
3. "It pays remarkably well."

Of Reason (1), the college says: "Current evidence suggests that ECT may correct abnormalities in brain functioning associated with depression and other mental illnesses." Note how this is hedged with wishy-washy language. Imagine if, at the beginning of the pandemic, governments had said "Current evidence suggests that Covid-19 spreads via droplet infection and wearing masks may reduce the risk." Nobody would have worn a mask. The reason they use this language with ECT is just because nobody has the faintest clue how it works, if it works at all.

According to the college, ECT should be used when it is "clinically-indicated," but that means nothing. "Clinically-indicated" is one of those artfully misleading terms like "evidence-based" or "biopsychosocial" that sound terribly scientific but can't be defined. Clinically-indicated should mean that any two practitioners looking at the same patient will reach the same conclusion on diagnosis and management, but that doesn't happen in psychiatry. One shrink will say "She needs emergency ECT" while the next says "She needs to see a divorce lawyer." Moreover, how can ECT be clinically indicated in one country and not in the next, or even in the next state or province? How is it that some psychiatrists give ECT to practically everybody who comes through the door, and others never use it? "Clinical indication" means no more than "I'll give it if I feel like it."

Reason (2): "I don't know what else to do." I always found that actually taking a history, sitting with the patient and going through his or her life in detail, dictated what to do but these days, it seems psychiatrists are too busy to take histories. That boring task it left to nurses and others, who go through a questionnaire and tick boxes. The psychiatrist flicks through the (mostly empty) pages, asks a few questions, scribbles a signature and says "Book him for ECT."

Reason (3): Yes, it does pay remarkably well, much better than struggling to get words out of somebody who isn't talking, or trying to understand somebody who talks too much, but guess what? As of March 1st next year, it's going to pay very much better. 118% better, to be precise. Damn that inflation, I say.

According to the college newsletter of June 22nd 2023, the Medicare rebate will jump from the current $74.55 to an eye-watering $162.55. Which means private patients will pay about $250-300 for a few minutes of their psychiatrist's precious time. The reason given in the Medicare Benefits Schedule Review Taskforce Taskforce findings for psychiatry says:

Item 6. Revise the schedule fee for item 14224 - electroconvulsive therapy:
The fee for electroconvulsive therapy should be revised to better account for the time and
complexity associated with delivering this service

Time and complexity. I see. It must have changed a lot since I last saw it: administering ECT, as we regularly joked, took all the training, intellectual effort and manual dexterity of opening a can of beer. But wait, a missive from the Dept of Health, no less, which states inter alia:

In reference to ECT (item 14224), on 1 March 2024 the schedule fee for this item is expected to increase from $77.05 to $168.40 in order to align the fee for ECT with the fee for Repetitive Transcranial Magnetic Stimulation (rTMS) treatment items (14217 and 14220). Please note that this exact fee is subject to change due to indexation.

Make that $168.40, they must be expecting more of that damned inflation in the next six months, and the wealthy need to be protected against the ravages of inflation, don't they. But if their major reason is to level it with TCMS, then we have the makings of a continual leap-frog race between these two.

I will try to get a copy of the submission by the college to the Health Dept but regardless of anything they said, psychiatrists give ECT because they want to. As of March 1st 2024, they will have a lot more reason to want to give it. I predict a sudden, massive increase in ECT usage next year, which is on a par with predicting the cockatoos will strip all the fruit from my nectarine tree: because they can. The private hospitals will be laughing all the way to their banks in the Bahamas but we can be certain of one thing: the suicide rate will not go down because the people who will get the extra ECT will be the same middle-class, middle-aged women who weren't going to kill themselves; who would have got better anyway with a bit of support and the sort of understanding that should come from a careful history; and who always pay their bills.

Niall McLaren on Critical Psychiatry

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