Decline with a capital D: long-term changes in general practice consultation patterns across Australia.

OBJECTIVE: To determine changes in the pattern of use of standard general practice consultations, and the degree to which any changes are offset by the use of special Medicare Benefits Schedule (MBS) items. DESIGN, PARTICIPANTS AND SETTING: Population-based retrospective analysis of age- and sex-standardised Medicare claims data (1994-2009) on the utilisation of general practice standard consultations (Levels A, B, C and D) alone and in combination with health assessments and care plans and other special MBS items. RESULTS: Utilisation rates of Level C and D (long) consultations increased consistently from 1994 to 2004, but by 2009 a considerable decline had occurred. A reverse of this pattern was observed for Level A (short) consultations. When utilisation rates for special items and long consultations were combined, the combined utilisation rate followed an upward trend until 2007, but also declined in 2008 and 2009. CONCLUSIONS: The decline in the use of Level C and D consultations in recent years has been dramatic and accompanied by an increase in use of Level A consultations. While the use of special items has offset the decline in long consultations, this compensating effect has weakened in the past 2 years. This pattern is at odds with health policy objectives that rely on long consultations to provide preventive care and chronic disease management. Given the current situation, the recently introduced Medicare reforms (May 2010), including changes to Levels B, C and D consultation item descriptors, may not be sufficient to change consultation patterns.

Medicare and chronic disease management: integrated care as an exceptional circumstance?

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 case 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.

Reforming funding for chronic illness: Medicare-CDM.

Chronic diseases are a major challenge for the Australian health care system in terms of both the provision of quality care and expenditure, and these challenges will only increase in the future. Various programs have been instituted under the Medicare system to provide increased funding for chronic care, but essentially these programs still follow the traditional fee-for-service model. This paper proposes a realignment and extension of current Medicare chronic disease management programs into a framework that provides general practitioners and other health professionals with the necessary "tools" for high quality care planning and ongoing management, and incorporating international models of outcome-linked funding. The integration of social support services with the Medicare system is also a necessary step in providing high quality care for patients with complex needs requiring additional support.

Toward greater integration of the health system.

As demand for hospital and emergency services grows there will be pressure to improve the integration of primary, acute and continuing care services. Research on ambulatory sensitive care conditions suggests that a significant proportion of hospital use is potentially preventable by primary health and community care services. The desire for better health outcomes and reduced use of acute care suggests a greater focus on primary health and community care. Reforms have generally emphasised planning, funding and regulatory mechanisms including brokered management of services for an enrolled population, capitation payments and pooled funding across primary, acute and continuing care, the development of coordinated service pathways and the consolidation of responsibility for costs and outcomes. Australia's division of funding, regulatory and planning responsibilities across jurisdictions introduces a unique set of challenges to address these issues. Nevertheless, there are a number of options better aligning Commonwealth and State initiatives through the Australian Health Agreements and funding for range of primary health and community care finding programs.