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AMA Chronic Disease Plan: Improving Care for Patients with Chronic and Complex Care Needs – Revised 2012

The care needs of Australians are becoming more complex with the ageing population and increasing incidence of chronic disease. Increasingly patients are suffering from multiple chronic conditions, which complicate their care needs. Existing Medicare funded chronic disease management arrangements are too limited, cumbersome, difficult for patients to access, and are wrapped up in red tape and bureaucracy. The current arrangements also mean that more people end up in hospital to have their conditions managed. The AMA believes there is a better way to help patients get better care for their chronic and complex care needs. This document outlines new arrangements to better support GPs to provide patients with chronic and complex disease with access to multidisciplinary care and essential support services, a simple yet comprehensive and affordable plan that will have benefits across the health system.

10 Jul 2010

The care needs of Australians are becoming more complex with the ageing population and increasing incidence of chronic disease. Increasingly patients are suffering from multiple chronic conditions, which complicate their care needs.

Existing Medicare funded chronic disease management arrangements are too limited, cumbersome, difficult for patients to access, and are wrapped up in red tape and bureaucracy. The current arrangements also mean that more people end up in hospital to have their conditions managed.

The AMA believes there is a better way to help patients get better care for their chronic and complex care needs. This document outlines new arrangements to better support GPs to provide patients with chronic and complex disease with access to multidisciplinary care and essential support services, a simple yet comprehensive and affordable plan that will have benefits across the health system.


1. Introduction 

The AMA recognises the need for more efficient arrangements to support the provision of well-coordinated multidisciplinary care to patients with chronic and complex disease. If access to coordinated multidisciplinary care is improved then patients will benefit, the number of avoidable hospital admissions can be reduced, and long-term savings to the health system will be generated. 

The AMA supports a comprehensive approach to the management of chronic and complex disease based on arrangements that:

  • Provide GP-coordinated access for patients to services based on clinical need;
  • Provide a patient’s usual GP with the support they need to improve the care they can provide/organise for patients with chronic and complex disease; 
  • Support GPs to facilitate access for their patients to other members of a multi-disciplinary primary care team;
  • Continue to ensure that funding follows the patient; 
  • Lead to better collaboration with existing service providers; and
  • Simplify and enhance the existing MBS chronic disease arrangements.

The AMA believes that significant gains can be made in improving care for patients with chronic and complex care needs by improving existing systems and processes so that they provide GPs and their patients with the support they need.

In considering this issue, it is important to recognise that current MBS arrangements are meeting the needs of most patients. The Government’s own draft Primary Care Strategy said in this regard that supported by the Medicare Benefits Schedule (MBS), most Australians have good access to affordable services provided through general practice, have a choice of provider, and have been supported in their access to many specialist and diagnostic services.

2. Background

2.1Care for patients with chronic and complex needs

The care needs of Australians are becoming more complex with the ageing population and increasing incidence of chronic disease. Increasingly patients are suffering from multiple chronic conditions, which complicate their care needs. These patients need the services of a range of medical and allied health services in managing their conditions. Care in this environment can easily become fragmented unless that care is coordinated and appropriate referral and reporting mechanisms are in place to monitor the patient's progress in line with their treatment and management plan. 

The increasing burden of chronic disease has a significant cost impact on Australia's health system. Fifty percent of GP consultations involve patients with a chronic disease, such as heart disease, cancer or diabetes1. This cost of chronic disease is further added to with at least 10% of hospitals stays for patients with chronic conditions potentially preventable had timely and adequate non-hospital health care been provided2. The Australian Institute of Health and Welfare reported that in 2007-08 there were 33.6 potentially preventable admissions per 1,000 people and that more than half of those were due to chronic conditions3. With preventable admissions costing over $1.3 billion a year4  there is an incentive for Government to support more coordinated care in order to keep people out of hospital by better caring for them in the community. 

Coordinated care ensures the patient receives the care and services they need to better manage their health in a community setting and prevents avoidable hospital admissions.

2.2Evidence from the research 

The benefits of coordinated care are recognised around the world. In 2011 the World Medical Association issued a statement on the Global Burden of Chronic Disease5. In this statement the WMA advocates for the promotion of prevention health strategies, team based chronic disease management, and continuity of care for patients with chronic disease and this was backed by findings from a number of studies.

The Coordinated Care Trials in Queensland in 2008 for example, demonstrated that coordinated care reduced hospital admissions by up to 25%, reduced inpatient costs by 26%, reduced patients rate of depression and improved their quality of life6. The trial demonstrated that when all costs are included (MBS, PBS, hospital etc), service provision costs can be reduced by 8%. In addition, the trial found that when patients were connected to community models rather than acute models of care that they were more active in their own health maintenance.

In 2005 SA HealthPlus successfully implemented a generic model of coordinated care with improved health and wellbeing outcomes7. Evidence gathered suggested that the key components of the model were the programs and goal approach, the care plan, and service coordinators working with general practitioners and patients. It was determined that costs savings in the short term were best achieved by better targeting those patients who would benefit the most from coordinated care. Those patients most likely to benefit are those who:

  • are not already linked with services, 
  • lack knowledge of their condition, 
  • are depressed, 
  • lack motivation to change behaviour,
  • have lifestyle risk factors, and
  • conditions are poorly controlled.

Further, the study concluded that better targeting of coordination activities should be based on patients who have had a prior admission to hospital and a potential to improve self-management.

A systematic review8 of various care coordination strategies has found that in more than 50% of studies all were associated with improved health and/or patient satisfaction. The strategies identified for the review were classified into two groups: i) communication and support for providers and patients, and (ii) structural arrangements to support coordination. Those interventions that used multiple strategies were found to be more successful than those using single strategies.  

Another study, an analysis of community care models in North Carolina, USA, has demonstrated that the potential health system cost savings models of comprehensive and proactive primary care should generate are between 7% to 15%9. The study concluded that cost savings were associated with reduced costs for emergency room visits, inpatient hospital admissions, and other services as patients receive improved access to primary care, prescription drugs, and other appropriate treatments for chronic conditions. These were the expected cost savings from future medical services that would have but were avoided by earlier intervention.

Overall the evidence suggests that coordinated care is: beneficial for patients; improving their health and wellbeing; and is beneficial to the health system (because it reduces the costs that would eventuate through poorer health outcomes and avoidable hospital admissions).

2.3Effective care coordination

The AMA believes effective care coordination involves: 

  • Care that is led by the patient’s usual GP and based on clinical need.
  • Actively involving the patient in goal setting and decision-making.
  • Enabling patients to better understand and manage their condition.
  • Funding that follows the patient, i.e. through the existing Medicare Benefits System (MBS), and supports the provision by GPs of initial and ongoing care.
  • Funding that supports the coordination and transition of patient care between health care providers and across health care and community sectors.

2.4Current MBS arrangements for funding chronic and complex care needs

Current Medicare arrangements provide support to patients so that they can see a GP when they need to. MBS funding follows the patient and the rebate is directly linked to the provision of a service by a GP. Patients with chronic and complex disease can also access some allied health on referral from a GP in defined clinical circumstances. The Government only pays for the services that are delivered. 

Where patients face significant out-of-pocket costs for out-of-hospital services, the Medicare Safety Net will pick up 80% of these costs once certain thresholds are reached. 

In addition, patients with total net (out of pocket) medical expenses of over $1,500 in certain categories (including Medicare payable items) can claim through the income tax system a 20% rebate on those expenses.

3. GP-coordinated care for patients with chronic and complex diseases

GPs are highly trained professionals who are accountable to their patients and work within established codes of professional conduct. GPs are the highest trained general health professional assessing and managing patient care according to their individual overall health needs. The AMA considers GPs are the best placed health professional to lead coordinated care for patients with chronic and complex disease.  

GPs are the most visited health professional, with about 85% of the population seeing a GP at least once a year10. The National Health and Hospital Reform Commission (NHHRC) recognised this (GPs being the most visited health professional), proposing to build on it by improving access to a more comprehensive and multidisciplinary range of primary health care and specialist services in the community. The NHHRC also recognised the value that a ‘medical home’ provided to patients in ensuring coordinated care11. AMA research shows that 88% of people have a usual family doctor12 and therefore a ‘medical home’. Having a trusted family doctor is good for your health, with research showing that people who have an ongoing relationship with a family doctor have better health outcomes and lower death rates. 

GPs manage a vast array of conditions with over one-third of the problems they manage chronic in nature. The chronic problems most often managed by GPs being hypertension, depressive disorder, diabetes, lipid (cholesterol-related) disorders, chronic arthritis, oesophageal disease and asthma13. Since 1998-99 there has been statistically significant increases in the management rate of each of these conditions, except asthma, which has been declining.

The Government has acknowledged the value in GP-coordinated care for patients with chronic and complex diseases by funding the Department of Veterans’ Affairs (DVAs) Coordinated Veterans Care (CVC) program. The AMA was involved throughout the program’s design and as such it upholds and supports the GPs role in providing clinical leadership and oversight to the coordination of patient care. Building on existing funding mechanisms, the program sets a benchmark for the management of chronic and complex diseases. With a few changes to expand current funding arrangements this benchmark could be extended throughout the rest of the community in order to proactively manage and care for patients, preventing avoidable hospital admissions and saving scarce health resources in the process. 

4. AMA model for improving care of patients with complex and chronic disease

Australia’s high-quality primary health care system is built on the solid foundation of the role of the GP. GPs could do more to provide access to multidisciplinary care and support services for patients with chronic and complex disease. However, existing chronic disease management arrangements are too limited, cumbersome, difficult for patients to access, unreflective of established referral practices and are wrapped up in red tape and bureaucracy. 

To deliver real benefits for patients and maximise the impact of available funding, new arrangements need to be put in place that better support GPs to provide patients with chronic and complex disease with access to multidisciplinary care and essential support services. 

The NHHRC suggested “An enhanced Medicare in the future”14 that:

  • Supplements medical services with a broad package of health services (allied health, nursing and other health professionals) to support complex and continuing care;
  • In addition to personal individual consultations, encourages and supports team-based and multidisciplinary care;
  • Adds to current benefits as it pays for a mix of private and publicly delivered services (expanded to cover state-funded primary health care services, public hospital outpatient specialist services and selected allied health and other health professional services);
  • Adds greater scope to support stronger focus on prevention, health promotion, early intervention and wellbeing, including supporting people in self-management;
  • Supports a broader range of specified services by health professionals providing care within their defined scope of practice (and provided it is safe and cost-effective) and for innovative, collaborative care models within services;
  • Supports the development of more integrated safety net arrangements that protect people from unaffordable costs; and
  • Also pays for different types of services – email, telephone, telehealth (e.g. video conferencing) – that do not involve the physical presence of the patient. Payment for these services may be part of episodic payment or grant payments.

The AMA plan provides a comprehensive and coordinated care for patients with complex and chronic disease, which satisfies the intentions of the NHHRC goals as detailed above.

4.1Level 1 - GP Management Plans

GP Management Plan (GPMP) arrangements in the MBS provide a structured approach to caring for patients with chronic and complex disease, although presently they do not provide patients with access to allied health and other support services. To provide access to allied health services GPs must also prepare a team care arrangement, which involves additional red tape. 

We know that early intervention helps to improve health outcomes and in this regard initial access to a limited number of multidisciplinary and other support services through GPMPs could yield significant benefits for patients. The GPMP pathway could also provide access to medically appropriate preventive health services for individuals at high risk, e.g. developmental delay in children.

The AMA believes that GPMP arrangements should be simplified and reformed so that they provide “automatic” access to a predetermined number of GP referred services. On referral from a patient’s usual GP, GPMP arrangements should provide patients with access to:

  • Five funded visits to allied health services per annum15
  • Parenting programs for children at risk; and
  • Selected home aids including home safety, mobility aids, vital call, diabetes equipment, continence aids and therapeutic appliances.

This arrangement is similar to that in place with the Department of Veterans’ Affairs (DVA), which enables access to allied health providers upon referral from a medical practitioner, typically the patient’s usual GP.  

Unlike the existing Team Care Arrangement (TCA) item that provides patient access to allied health services, the requirement for the GP to consult with other care providers prior to referral would be removed under this revised arrangement for the GPMP. Prior consultation with allied providers is burdensome and does not accord with accepted medical practice. When patients are referred by GPs for services from other health care providers, such as other specialists, they are not subject to the same level of prescription and red tape that the current TCAs impose.  

In relation to home aids, we believe that it would be possible for Medicare Australia to contract with relevant suppliers for the provision of these services, much like the DVA does for veterans needing extra support to continue living at home. 

4.2GP Management Plan Review

The existing GP Management Plan Review item in the MBS should be retained in order to check patients progress against the plan and to make amendments to the plan if clinically required. If in the GPs opinion, extra clinically relevant allied health services are required, the review item should enable access to additional referred services.

Where the GP determines upon subsequent review that a patient’s likely health outcomes are not improving,  there is a significant risk of hospitalisation or rehospitalisation due to their condition/s, and that they would benefit from a more coordinated approach to their care, the GP may consider the patient eligible for access to a coordinated care program. 

4.3Level 2 - Coordinated Care for patients that need more support

The Coordinated Care program, administered through Medicare Australia, would provide those patients with chronic and complex disease that need greater support than can be provided through a GPMP, particularly those at risk of a preventable hospital admission, with streamlined and coordinated access to a range of services relevant to their clinical needs. 

Similar to the DVA’s Coordinated Veterans’ Care (CVC) program, access to the program would be determined by the GP upon the completion of an eligibility assessment. If the patient is assessed as eligible and is willing to participate in the program the GP (with the assistance of a Practice Nurse or Aboriginal Health Worker) will conduct a needs assessment and develop a Comprehensive Plan for Coordinated Care, which is shared with the patient. The needs assessment and resulting Comprehensive Plan for Coordinated Care will essentially be a revised and simplified version of the current TCA item.

The AMA accepts that strict eligibility guidelines would need to be developed to govern access to the program, including the requirement for the patient to already have a current GPMP in place. Patients would only be eligible to access the program where they were assessed by their usual GP as requiring and likely to benefit from additional support beyond that which is available through a GPMP.  

Under a Comprehensive Care Plan for Coordinated Care, the GP funded access should be available to the following:

  • GP-referred allied health and nursing services;
  • A broader range of home aids, ramps for disability, home safety, mobility aids, wheel chairs and vital call;
  • Transport services to assist with access to medical or allied health care;
  • An enhanced safety net for medications; 
  • Dressings; and
  • Education programs.

The program would retain a review mechanism similar to existing MBS review items in order to assess a patient’s progress and ongoing eligibility for this extra support. 

GPs may enlist the assistance of a Practice Nurse or Aboriginal Health Worker to act as a Care Coordinator for the patient. The Care Coordinator:

  • coordinates patient access to referred services, liaising where required with providers to identify available services, facilitating access (applications etc) and arranging appointments and transport if required;  
  • monitors patient health and wellbeing, and progress against the plan – via phone, home visit or videoconference –  providing regular feedback to the GP;
  • provides patient advice and education, where appropriate, on better managing their health and well being;
  • liaises with the patient’s carer as to patient’s progress against the plan or of any changes to the plan; 
  • liaises with emergency and/or hospital discharge departments; and
  • maintains patient records as to monitored action and coordination activities.

Under the program, GPs in addition to the relevant MBS items, would be supported with funding to prepare their practices for coordinated care with an additional payment per patient with a Comprehensive Care Plan for Coordinated Care and ongoing quarterly payments to support the additional services (e.g. monitoring, liaising, educating, coordinating etc.) provided on behalf of the patient.

This Care Coordination Model is line with the DVA’s CVC program to which the AMA was a key contributor. 

5. How does the AMA plan addresses the needs of patients with chronic and complex disease?

The AMA proposal is a comprehensive plan to address the needs of patients with chronic and complex disease. The AMA’s proposal:

  • Ensures that patients do not lose their entitlement to a Medicare rebate;
  • Ensures services are funded on an as needs basis and under arrangements that do not compromise the doctor/patient relationship; 
  • Means patients would have more choice and greater control over decisions about their health care;
  • Provides patients with multiple chronic conditions and related complex care needs with improved access to GP coordinated care services ensuring continuity of care;
  • Seeks to enhance proven existing arrangements so that they work better for patients;
  • Provides access to a broad range of allied health and other support services;
  • Supports proactive care and preventive medicine;
  • Respects the professionalism of GPs and the comprehensive care that they provide to patients;
  • Reduces the red tape burden on GPs; and
  • Is both clinically and cost effective. 

6. The role of Primary Health Care Organisations in Coordinated Care

The AMA acknowledges the potential reach of Primary Health Care Organisation (PHCOs), also known as Medicare Locals, in supporting and in coordinating services for people with chronic and complex disease. However, Medicare Locals need to be introduced in a way that is respectful of the existing role of GPs and other community based Specialists and in a fashion that seeks to maximise positive relationships and partnerships at all levels.

The AMA believes that the activities of Medicare Locals, should be to support and complement general practice. In this context, Medicare Locals will be of assistance to general practice by:

  • improving population health planning at the local level so as to help reduce the risk factors that lead to the development of chronic conditions; and 
  • organising allied health services in areas of unmet need so that GPs can provide patients with access to such services. 
Related document (Members only): 

Published: 10 Jul 2010