Amanda Biggs, Social
The rise in chronic diseases is putting health budgets under pressure and placing growing numbers of Australians at risk of serious complications and early death. Improving the management of chronic diseases in primary care is urgently needed. The ‘medical home’ model is a promising approach, but it faces a number of challenges.
A key issue facing policymakers is curbing the
impacts of the rise in chronic diseases. Chronic diseases are long-term
conditions with persistent, negative health effects. They include cancer,
arthritis, cardiovascular disease, type 2 diabetes, asthma, mental illness and
dental conditions. The Australian Institute of Health and Welfare (AIHW) estimates that in 2011, 90
per cent of deaths in Australia had a chronic disease as an underlying cause.
It also found
that half of all Australians have a chronic disease and 20 per cent have at
least two, and the incidence
is associated with ageing. Chronic diseases are complex and expensive to manage.
In 2008–09, the management of cardiovascular diseases, oral health issues,
mental disorders and musculoskeletal conditions alone cost the health system $27 billion.
Importantly, many chronic diseases are preventable—31 per cent of the burden
of disease is attributable to lifestyle factors such as smoking, overweight
and obesity, alcohol, physical inactivity and high blood pressure.
As the first point of medical care, primary care plays
a key role in preventing, delaying and reducing the progression of chronic
diseases. Australia has a well-developed primary care sector with general practitioners
(GPs) at the centre. GP services are funded primarily through the Medicare Benefits Schedule
(MBS), largely on a fee-for-service basis. Fee-for-service is considered
appropriate for treating episodic, acute illnesses but not
considered optimal for managing chronic diseases.
Various approaches to better manage chronic
diseases through the MBS have been implemented. In 2004, services provided by
allied health providers such as physiotherapists, dieticians and others were
added to the MBS under the Enhanced
Primary Care package. Team-based care for managing chronic disease was strengthened in
2005 with the addition of a number of chronic
disease management (CDM) items to the MBS. Practice
incentive payments (PIP) which encourage GPs to better manage patients with
2 diabetes are also available.
Despite these initiatives there remains room for
improvement. The Grattan
Institute estimates that only 25 per cent of patients with type 2 diabetes
get the recommended monitoring and treatment for their condition while poor
management of chronic disease is estimated to cost $320 million annually.
Recognising that improvements were needed, the Government established
a Primary Health Care Advisory Group (PHCAG) in 2015 to examine ‘innovative
care models for target groups such as those with complex, chronic disease’.
The PHCAG report
was provided to Government in late 2015. It recommended trialling a new model
of care for patients with chronic diseases—the Health Care Home (HCH)—and new
payment structures to incentivise care and replace traditional fee-for-service payments.
The HCH model involves the voluntary enrolment of a patient with a main
provider (usually their GP) who coordinates all aspects of their care, and
ensures care is flexible and team-based. Patients would be supported to become
partners in their care. The aim is to minimise preventable hospitalisations and
provide more integrated and coordinated care. Similar models have been developed
in overseas jurisdictions notably the US (where it is known as the patient-centred
medical home or PCMH), the UK, Canada and NZ.
The Government broadly accepted the PHCAG’s
recommendations. In March 2016, the Health
Minister announced $21 million for a two year trial of HCHs involving 200 medical
practices and 65,000 patients, supported by Primary
Health Networks (PHNs) and commencing in July 2017. A flexible payment
structure comprising upfront and quarterly payments to participating GPs that
would replace fee-for-service payments for these patients is proposed.
There is broad support politically for the medical
home model. During the 2016 election campaign the Labor
Party proposed ‘Your Family Doctor’ which it described as a patient-centred
medical home (PCMH)—similar to the HCH. It also includes voluntary enrolment
and a key role for PHNs. The Greens
also support voluntary enrolment for patients with chronic diseases; their
policy proposes to pay GPs $1,000 for each enrolled patient.
The trial of the HCH now looks
set to be implemented but it may face challenges. The HCH model relies on newly
established PHNs to manage implementation, but their capacity to do this
remains unclear. To make patients partners in care, the empowerment of patients
and their carers will be critical. There will be an urgent need to improve
health literacy among patients. ABS
data (2009) shows that just 41 per cent of adults were assessed as having
adequate health literacy but among those with fair or poor self-assessed health,
only one quarter had adequate health literacy. Research
indicates that social disadvantage is linked to poor health literacy, and older
Australians are particularly vulnerable because they are more likely to
experience both poor health literacy and a higher incidence of chronic diseases.
Improving co-ordination of care will require better
take-up of electronic health records and improved data collection, but progress
is hampered by a number
of challenges. How enrolled patients in the HCH will interact with other
parts of the health and social services sectors such as the aged care sector
and the National Disability Insurance Scheme (NDIS), also needs careful
consideration given these sectors are also undergoing changes. The extent to
which traditional fee-for-service items on the MBS would be available to enrolled
patients for medical treatment unrelated to their chronic disease is also unclear.
Some have warned
that the trial requires greater funding. Lastly, a sound evaluation will be
needed that also allows enough time for lessons to be learned.
Meanwhile, the evidence around the medical home model
is inconclusive. Evaluations
of the patient-centred medical home model in the US show variation in outcomes;
possibly reflecting its still embryonic development and experimental
implementation. While some studies do show positive
study of Ontario’s medical home model found GPs engaged in ‘cherry picking’
healthier patients at the expense of sicker patients, resulting in gaps for
vulnerable groups and suboptimal access to care.
The HCH trial is unlikely to require legislation.
World Health Organization (WHO), Preventing chronic diseases: a vital investment, 2005.
House of Representatives Standing Committee on Health, Inquiry into chronic disease prevention and management in primary care, 2016.
A Biggs, Medicare: a quick guide, Research paper series, 2016–17, Parliamentary Library, Canberra, 2016.
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