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New Medicare model for chronic disease management

05 February, 2008

Too many Australians with chronic conditions miss out on the care they need to maximise their health and well-being because our current health system is not designed to deliver high quality, prevention and management of chronic disease.

Expanding Medicare and giving the Commonwealth responsibility for all the (non-institutional) prevention and management of chronic disease will improve health outcomes for people with chronic conditions and help our health system meet the health care challenges presented by our ageing population.

This study is reported in the most recent edition of the Australian Health Review, the peer reviewed journal of the Australian Healthcare and Hospitals Association.

"We need to do better to deliver high quality health care to people with chronic diseases. Recent research from the National Primary Care Collaborative has shown that less than half of patients with chronic conditions being managed in general practice are achieving targets for blood pressure and blood glucose levels," study author Professor Hal Swerissen, Acting Dean, Faculty of Health Sciences, La Trobe University has said.

"This is a problem affecting the majority of our population. According to recent research 77% of the population has at least one chronic medical condition. Together, chronic diseases (including cancers) account for more than 80% of the total burden of disease and injury and account for about 60% of all allocated health care expenditure (in 2000-01). The incidence of chronic disease is likely to rise as our population ages, particularly given the high rates of risk factors such as overweight and obesity.

"Various programs have been instituted under the Medicare system, such as the Practice Incentives Program (PIP) and Service Incentives Payment (SIP), to provide increased funding for chronic care, but essentially these programs still follow the traditional fee-for-service model.

"This model typically focuses on short-term and relatively proscribed service delivery for episodes of care, and does not provide incentives for prevention and early intervention, as well as long-term, comprehensive and integrated management of chronic disease.

"A better approach is to realign and extend the current Medicare chronic disease management programs into a framework that provides general practitioners and other health professionals with the necessary “tools” for high quality care planning and ongoing management, and incorporating international models of outcome-linked funding.

"The integration of social support services with the Medicare system is also a necessary step in providing high quality care for patients with complex needs requiring additional support," Professor Swerissen said.

The proposed Medicare–Chronic Disease Management (Medicare–CDM) program builds upon the existing strategy and system components, moving beyond simple item number-driven, incremental change.

It involves the following three stages:

-  Entry assessment and categorisation complexity of patient needs to ensure program targeting;
- Care planning and funding levels based on the complexity of patient needs; and
- Monitoring, feedback and incentives to good practice and patient outcomes.

The entry assessment process would include a mechanism for the categorisation of patients according to their anticipated care planning needs. Patient categorisation should drive program eligibility, the mix of services provided and payments for services and outcomes.

Patients with more complex needs will, by definition, require more complex and detailed care planning and follow-up and thus would attract a higher level of resources. Payments for medical, nursing, allied health and home and community care services would be tied to the patient categorisation and care plans.

Medicare–CDM would facilitate the functional alignment of responsibility for chronic disease prevention and management across the Commonwealth and the states.

Effectively, the Commonwealth would take overall responsibility for non-institutional prevention and management of chronic disease through the Medicare program. This would include outpatient services for chronic disease currently provided through public hospitals. Consequential adjustments would need to be made to the Australian Health Care Agreements and the Home and Community Care program.

"The proposed Medicare–CDM program uses the current Medicare framework to provide comprehensive and coordinated health and community care to people with chronic conditions. It meets the government's requirements for accountability and would not increase the red tape burden for health professionals.

"I urge the Government and health policy makers to consider this proposal to help Australia meet the growing challenge of providing high quality care to people with chronic conditions," Professor Swerissen said.

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