A new way to address chronic disease in primary care

Amanda Biggs, Social Policy

Key issue
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 asthma and type 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 outcomes, one 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.

A new way to address chronic disease in primary care

Further reading