Medicare and Chronic Disease Management: Integrated Care as an Exceptional Circumstance?
Taylor, Michael J., Swerissen, Hal, Australian Health Review
Chronic disease represents a significant challenge to the design and reform of the Australian healthcare system. The Medicare Benefits Schedule (MBS) provides a framework of numerous chronic disease management programs; however, their use at the patient level is complex. This analysis of the MBS chronic disease framework uses a hypothetical ease study of a diabetic patient (with disease-related complications and a complex psychosocial background) to illustrate the difficulties in delivering appropriate multidisciplinary chronic disease care under the MBS. The complexities at each step - from care planning, service provision, and monitoring and review - are described, as are the intricacies involved in providing patient care under different MBS programs as well as those in the broader health and community care system. As demonstrated by this case study, under certain circumstances the provision of truly integrated care to this hypothetical patient would constitute an 'exceptional circumstance' under the MBS. Although quality improvement efforts can improve functioning within the limitations of the current system, system-wide reforms are necessary to overcome complexity and fragmentation.
What is known about the topic? Chronic disease management requires optimal health system design to provide appropriate patient care. In Australia, the Medicare Benefits Schedule (MBS) provides chronic disease-focussed programs, but the multitude of available programs and items are administratively complex, overlapping and subject to claiming incompatibilities.
What does this paper add? This paper illustrates the complexity of the various MBS programs for chronic disease management using a case study of the potential service response to a single diabetic patient with disease-related complications and a complex psychosocial background. This analysis illustrates the manifold problematic interactions and incompatibilities that may arise in relation to this hypothetical patient.
What are the implications for practitioners? Under the current MBS framework, providing patients with optimum chronic disease management requires both clinical and administrative skill on the part of GPs. Time spent on administrative requirements is time away from clinical care. Although quality improvement efforts may improve functioning within the existing system to a certain extent, broader system reforms are necessary to support optimal chronic disease management in Australia.
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. …