Chronic disease represents a significant long-term challenge for the Australian healthcare system in terms of the number of people affected (or at risk) and the morbidity, mortality and health system expenditure associated with these diseases. Current health system reform efforts are focussed on improving governance and funding of the health system to meet this challenge.2 These refonn proposals are underpinned by a strengthened primary healthcare system in Australia. As such, the structure of current chronic disease management programs in primary care - particularly those offered under Medicare - requires examination in order to inform the reform process.
This analysis will consider the current Medicare Benefit Schedule (MBS) framework for GP (General Practitioner) chronic disease management (Table 1 ), and its integration with other aspects of the health and community care system in line with the Chronic Care Model (CCM). The CCM is an internationally recognised framework for improved chronic disease management.3 A hypothetical patient scenario will be used to examine the MBS service response to chronic disease. Although this represents a single case study approach to a complex system, the scenario is one that the system should be able to respond to in a straightforward manner. The MBS service response to this hypothetical patient will be considered according to the various stages of patient care: (a) assessment and care planning; (b) interventions and ongoing management; and (c) monitoring, reporting and review. The involvement of other areas of the health and community care system - for example, state-funded services - will also be considered. The final part of the discussion will explore issues around health system integration, both within the MBS and between the MBS and other elements of the health system that the case study demonstrates.
Hypothetical patient scenario
The hypothetical patient for this case study of MBS chronic disease management is a 68-year-old Type 2 diabetic male with the following clinical and psychosocial background:
* Clinical indicators: consistently suboptimal diabetes and blood pressure control; elevated lipid levels (HbA|c 9%; blood pressure 145/95 mm Hg; total cholesterol 5.7 mmol L-1). Intennittent self-monitoring of blood glucose levels.
* Disease complications: current superficial foot ulceration; not infected and manageable in ambulatory setting. No previous indications of diabetic nephropathy or retinopathy (last eye exam 6 months ago).
* Risk factors: obese (body mass index of 30.5 kg m""); suboptimal diet; physically inactive. Non-smoker, low alcohol consumption.
* Multimorbidity: pre-existing depression, with increasing psychological issues stemming from current medical situation (stress, anxiety, frustration).
* Social situation: pensioner, divorced, lives alone. One adult son (residing interstate).
* Immunisation status: all immunisations up to date.
* Current medications: metformin ( 1 g twice daily); pioglitazone (45 mg daily); Perindopril (5 mg daily); atorvastatin (40 mg daily); sertraline (100 mg daily). Previous intolerance of sulfonylurea side effects; no known allergies.
Although it is not possible to estimate the exact likelihood of a GP encountering such a patient, available data demonstrates that the broad characteristics of this patient are not uncommon. Of all diabetics in Australia, -15% are males aged between 65 and 74; of these, -70% are classified as being either overweight or obese. In terms of other diseases and risk factors, 27% of diabetics aged over 65 years report having one or more cardiovascular diseases, and 15% of all diabetic males report high or very high levels of psychological distress.
Assessment and care planning
The initial GP assessment of this patient would consider the immediate issue of the superficial foot ulceration and any other potential diabetic complications, as well as longer term goals of optimising glycaemic control, blood pressure, lipids, risk factor profile and self-management capacity. …