Academic journal article Australian Health Review

Reforming Funding for Chronic Illness: Medicare-CDM

Academic journal article Australian Health Review

Reforming Funding for Chronic Illness: Medicare-CDM

Article excerpt


Chronic diseases are a major challenge for the Australian health care system in terms of both the provision of quality care and expenditure, and these challenges will only increase in the future. Various programs have been instituted under the Medicare system to provide increased funding for chronic care, but essentially these programs still follow the traditional fee-for-service model. This paper proposes a realignment and extension of 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.

Aust Health Rev 2008: 32(1): 76-84

THE MOST RECENT REPORT on chronic disease in Australia indicates that 77% of the population have at least one chronic medical condition, and that chronic diseases (including cancers) account for more than 80% of the burden of disease and injury.1 Monitoring the cost of service utilisation by people with chronic disease is not comprehensive and estimates of costs are relatively crude. Nevertheless, in 2000-01 it was estimated that total health expenditure attributable to specific diseases was $50.1 billion (87.5% of total health expenditure); the major chronic diseases accounted for about $30 billion (60%) of all allocated health care expenditure.1

It is likely that demand for health and aged care services will rise dramatically with flow-on effects for health expenditure in the near future.2 In addition to existing chronic disease, risk factors for chronic disease are widely distributed in the Australian population; for example, 54% of adults are either overweight or obese and 21% smoke tobacco.1 Both chronic diseases and risk factors are disproportionately prevalent among the regional, low socioeconomic and Indigenous populations.1 While this would indicate an apparent need for longer general practitioner consultations with people in low socioeconomic areas, such consultations occur at lower rates than in more advantaged areas,3 although there is evidence of greater-than-average use of Medicare care planning items in disadvantaged areas.4

The level of general management of chronic disease in accordance with recommended care is surprisingly low. A major United States study demonstrated that chronic disease patients receive only 56.1% of recommended care, and adherence to recommended care varies according to the condition, from 64.7% for hypertension to 10.5% for alcohol dependence.5 A study of lowincome diabetic patients highlighted variability in the levels of recommended care processes such as HbA^sub 1c^ measurement (52.7% of patients receiving recommended care), blood pressure measurement (77.9%), lipid measurement (44.5%) and complete foot examination (3.3%).6 Beyond these process-of-care measures, the attainment of desirable outcomes was also low for indicators such as HbA^sub 1c^ levels (only 39.6% of patients achieving a level of ≤9.5%), blood pressure (30.0% ≤ 140/ 90 mmHg) and LDL cholesterol (23.5% < 30 mg/ dL).6 Preliminary Australian data from the National Primary Care Collaborative (NPCC) are similar: 48% of patients in Wave 1 (18 months' participation) achieving a blood pressure below the target of 140/90 mmHg and 35% of diabetic patients in Wave 2 (10 months' participation) with HbA^sub 1c^ levels below the target of 7%.7

The provision of care for chronic disease is a major challenge for health systems; primary and secondary prevention, disease self-management by patients, and integrated and coordinated service provision are well understood elements of chronic disease management used in approaches such as the Wagner model. …

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