Time for better chronic disease management in primary care

Living with a chronic disease, such as heart disease, diabetes or asthma, is hard work. Today the federal government announced its intention to “revolutionise” the way chronic diseases and complex conditions are cared for.

Details are thin about what this health care revolution will look like. And while the early signs are promising, the task ahead is large.

The report of the 2015 Primary Health Care Advisory Group, released today, includes recommendations to change the way health care is managed and funded.

Three key concepts seem to drive the recommendations – the need for continuity of care, flexible modes of delivery of health care and data to drive continuous quality improvement.

The key enablers to drive this reform are:

• patient registration (when a patient nominates a preferred practitioner and practice for care and attends there for health care)
• multidisciplinary teams
• data sharing between health care providers, planners and funders
• a new funding mechanism (bundled payments rather than fee-for-service).

All ideas are evidence-based and none are new. Evidence supporting these types of interventions has existed since the development of the Chronic Care Model in 1990s.

How would the changes affect people with chronic conditions?

If you are one of the 65,000 patients from one of the 200 practices that takes part in the proposed trial what can you expect?

Most probably you will have to agree to register with the practice for your chronic disease health care and agree to attend that practice for care. In return, you are likely to receive access to a multidisciplinary team and you will have more options about how you receive health care.

If all goes well, you would have fewer trips to the clinic, your conditions would be monitored more closely using more intelligent medical software systems and you would feel cared for, known about and healthy.

You would have access to good information about your health care conditions and you would always feel well informed. You would know that your health-care providers were also well informed.

When you needed care, you would get it. It might be via secure email, phone or web rather than face to face. And less time spent in waiting rooms.

If all this goes well – and the medications and lifestyle changes suit you, and you are well-supported and co-ordinated – chances are you will spend less time in hospital due to your chronic illness flaring up or complications developing.

What gets in the way of achieving these outcomes?

Some lessons can be learned from the 1994 co-ordinated care trials, which tested different models for co-ordinating care, and the more recent diabetes care project, which tested whether care plans, data-driven feedback, flexible funding and case management could lead to improved diabetes care.

The co-ordinated care trials showed some promise but were costly to implement and too costly to scale up. They were difficult to replicate and few were sustained outside the trial environment.

The impact of the diabetes care project was also disappointing. The diabetes care project included many of the elements suggested in today’s report, such as bundled payments, yet only small gains were made in health outcomes and the cost-effectiveness of the model was not proven. The bundled payment used in the diabetes care project was viewed as inadequate.

Making improvements in chronic disease management is going to require strong buy-in from all stakeholders. The newly proposed model is the first step towards practices being held accountable for health-care outcomes. This must be done in a way that enhances rather than damages the patient-practitioner relationship.

One of the biggest challenges will be to work out exactly how much the government should pay a practice for providing a person with all their chronic disease care in a year. The report recommends that the payment should take into account complexity, using a three-tiered system. Addressing complexity is essential. It’s also where the whole concept could become unstuck.

GP payment is a another potential sticking point. Working out how an individual GP will get their fair share of the chronic disease payment is likely to make for interesting negotiations and new ways of working for practice managers. Female GPs will be vulnerable to further pay inequities as they are less likely to be practice owners and more likely to work part-time.

It is also not clear whether the recommended “bundled payment” would include more radical models whereby the practice has to fund payment for pathology, imaging and medications from the “bundled payment”.

The caveat that fee-for-service visits can be charged for episodic care unrelated to the chronic condition presents another challenge. While it makes sense that not all care is related to a chronic condition, allowing fee-for-service payments alongside the bundled payment reduces the likely cost-effectiveness of any proposed model. This is especially so if this is done in a way that requires administrative and clinical time to be spent deciding whether it is an “unrelated” condition, or not.

It will be a challenge to get eligible practices and patients to sign on to the trial. This took much time and effort in the co-ordinated care trials and the diabetes care project. There will need to be very clear messaging that engages practices and consumers and explains just what they stand to gain (and lose) from the proposed changes. Primary Health Networks, regional bodies that coordinate care, should be able to play a key role here.

It will be important to recognise the diversity of practices and the regional differences. Ensuring new payment models reduce inequity will require careful use of weightings to adequately reward the practices caring for disadvantaged groups.

The final challenge will be around the use of routinely collected clinical data to monitor health outcomes. Using clinical data to develop the prediction tools and real-time clinical decision support alluded to in the report will require ongoing investment in the expertise and IT infrastructure required to do this work.

The Australian health care system is currently served by multiple clinical software systems across the primary care and hospital sectors. At present it is difficult to link the data to make sense of the entire patient journey.

Health care should make life easier, not harder. The proposed reforms are promising and long overdue. They will be challenging to implement but the time has come to do so.

Jane Gunn receives funding from the National Health and Medical Research Council for trials of new models of care for depression and diabetes. She is on the Board of Eastern Melbourne PHN. She is a member of the National Prescribing Service Data Governance Advisory Committee.