Each year the Australian government spends at least A$1 billion on planning, coordinating and reviewing the care of people with chronic diseases, such as diabetes and heart disease, in general practice.
Yet there are more than a quarter-of-a-million hospital admissions for health problems that potentially could have been prevented by better primary care for chronic disease.
Our report, Chronic Failure in Primary Care, published today, argues that primary care services are not working anywhere near as well as they should because the way we pay for and organise them through Medicare goes against what we know works.
Australia’s health system was designed to deal with infectious disease, wars and accidents. But the most significant burden on the health system today is chronic disease.
High cost of chronic disease
Three-quarters of Australians over the age of 65 have at least one chronic condition that puts them at risk of serious complications and premature death. Around 90% die from a chronic disease.
Six chronic conditions – heart disease, oral health problems, mental disorders, musculoskeletal conditions (including arthritis), respiratory disease (including asthma) and diabetes – account for about half of the total disease cost.
Most people with these conditions are seen by general practitioners in the primary care system. But we are failing to prevent and successfully manage chronic disease in primary care.
For example, about a million Australians have diabetes. These people have a two-fold higher risk of dying from heart, kidney and peripheral vascular disease (the latter from reduced blood circulation) than the general population.
They need help managing diet, exercise, smoking and alcohol use. They also need appropriate medication and regular monitoring. Primary care provided by general medical practitioners is the best place to get help.
However, analysis done for our report showed that only about a fifth of people with diabetes who see a GP have their blood pressure, blood sugar and body mass recorded each year. Only about 20% of these patients reach recommended clinical targets. Often, they get little in the way of advice or support for self-management.
The story is similar for other major chronic diseases including heart disease and chronic respiratory disease. Often, less than half of people with chronic disease get the care that is recommended. This results in much poorer patient outcomes than could be achieved.
Ineffective management of chronic conditions in primary care leads to worse health outcomes and higher costs.
Potentially preventable hospital admissions are estimated to be 7% of all admissions, 9% of hospital bed days and cost up to A$2 billion each year. Even if we use the more realistic estimates developed for our report, the costs are A$322 million per year.
Chronic disease support is already well-funded
The Commonwealth has tried to fix the problem by introducing assessment, planning, coordination, team management and review payments for GPs to better manage chronic disease, including mental health.
More than A$1.7 billion was spent on systems management, care planning and coordination for primary care in 2013-14. This included A$904 million for health assessment, management of chronic disease and mental health, and incentive payments for asthma and diabetes.
Practices received A$210 million in practice incentive payments to support infrastructure development and better practice. An additional A$661 million was spent supporting GPs and primary care through regional primary care networks, Medicare Locals (now Primary Health Networks).
Prevention and management of chronic disease in primary care is not easy. It requires sustained effort by people with chronic conditions working in partnership with a team of health professionals. The role of GPs is vital. Care must be planned rather than reactive; it must focus on the patient, rather than on health professionals, and it must focus on outcomes.
In Australia, the split in Commonwealth and state responsibilities has made good-quality prevention and care for chronic disease more difficult. The states are mainly responsible for public hospitals and the Commonwealth is responsible for GPs and primary care. As a result, the system for preventing and managing chronic disease is fragmented.
Performance targets are largely absent. There is little agreement about local care pathways, which guide how patients should be treated. Funding incentives are poorly designed and there is only limited support for service innovation and improvement.
So what’s the solution?
The focus of chronic disease funding needs to move away from a fee-for-service payment to doctors, towards a broader payment for clinics to practise integrated care.
The evidence shows that a consistent approach to clinical care pathways for specific chronic diseases can make a real difference to outcomes. And for that, we need much greater investment in supporting service development and innovation in primary care.
It’s not more money that’s needed. What we need is better organisation, incentives and management of primary care.
Existing Medicare funds spent on assessment, planning, coordination and systems development could be reallocated as follows:
- regional Primary Health Networks, which are already in place, should be strengthened
- health pathways that have been developed in New Zealand, the United States or Europe could be adapted and implemented in Australia
- established service development models such as the Australian GP Collaboratives could be extended to all areas.
The prevention and management of chronic disease is an urgent problem. Broader social and economic measures have the greatest potential for future prevention. But a consistent and coherent plan for primary care is urgently needed to manage the problem for people who are already at risk or have chronic disease now.