Overview of chronic disease management services

Chronic disease management (CDM) services

Chronic disease management (CDM) services are GP services on the Medicare Benefits Schedule (MBS) and are available to people with a chronic or terminal medical condition. Under these services, a chronic medical condition is defined as one that has been or is likely to be present for 6 months or longer (Department of Health 2014a). This could include conditions such as asthma, cancer, cardiovascular disease, diabetes, musculoskeletal conditions or stroke. There is no list of eligible conditions for these services. Whether a patient is eligible for a CDM service or services is essentially a matter for the GP to determine, using their clinical judgement and taking into account both the eligibility criterion and the general guidance (Department of Health 2014b).

CDM services cover the coordination, creation and review of several care planning tools.

General Practitioner Management Plan (GPMP)

A GP Management Plan (GPMP; MBS items 721, 229) can help people with chronic medical conditions by providing an organised approach to care (Department of Health 2014c). A GPMP is a plan of action agreed between a patient and their GP. The plan identifies the patient’s health and care needs, sets out the services to be provided by the GP, and lists the actions the patient can take to help manage their condition.

For patients with type 2 diabetes, a GPMP provides Medicare-subsidised care from selected allied health care providers for group allied health treatment services. Eligible allied health services include diabetes education services, exercise physiology and dietetics. This is in addition to individual allied health services made available through Team Care Arrangement (TCAs). See Allied health services.

Team Care Arrangements (TCAs)

Patients with complex care needs requiring multidisciplinary care are eligible for Team Care Arrangements (MBS items 723, 230). These will help coordinate more effectively the care needed from a patient’s GP and other health or care providers. TCAs require a GP to collaborate with at least two other health or care providers who will give ongoing treatment or services.

TCAs provide access to Medicare-subsidised care from selected allied health care providers for individual treatment services. Eligible allied health services include Aboriginal and Torres Strait Islander health services, diabetes education services, audiology, exercise physiology, dietetics, mental health services, occupational therapy, physiotherapy, podiatry, chiropractic services, osteopathy, psychology and speech pathology. See Allied health services.

Review of GPMPs and TCAs

It is recommended that plans be regularly reviewed by the GP and patient (MBS items 732, 233). A review involves checking that a patient’s goals are being met through the plan and provides an opportunity to make any adjustments needed.

Multidisciplinary care plan

These services allow primary care medical practitioners to contribute to a multidisciplinary care plan prepared by another health or care provider for a person with a chronic or terminal medical condition and complex care needs (MBS items 729, 231, 731, 232).

It is important to note that items 229, 230, 231, 232 and 233 were not available until 1 July 2018.

Care for people with chronic conditions in Australia

In Australia, most care for people with chronic conditions is provided in the primary health care setting (AIHW 2020a). Primary health care encompasses a range of services delivered outside the hospital and represents the front line of Australia’s health care system (AIHW 2020b). While GPs are the cornerstone of primary health care in Australia, care can also be provided through nurses, allied health professionals, pharmacists, dentists and Aboriginal and Torres Strait Islander health workers and practitioners (Department of Health 2018). Effective primary health care supports people to manage complex and chronic conditions, thereby improving their health and wellbeing and reducing the need for specialist services and hospitalisations.

The CDM services profiled in this report are one option available to manage chronic conditions in primary care. In 2019, there were 161 million GP attendances claimed through Medicare (including CDM services) (Department of Health 2019). Outside of the CDM services, people may manage their chronic conditions with their GP through standard consultations, or through other specialised GP Medicare services. Examples of specialised GP Medicare services which may be beneficial to people with chronic conditions include:

  • GP health assessments: an assessment of a patient's health and physical, psychological and social function to identify opportunities for early intervention and care, for target population groups
  • GP Mental Health services: assessments, care planning and treatment for patients with mental health conditions
  • Diabetes cycles of care: services including specific checks and measures to encourage effective management of diabetes mellitus
  • Asthma cycles of care: services including specific checks and measures to encourage effective management of moderate to severe asthma (AIHW 2020c).

Since 2007, some private health insurers have also provided chronic disease management programs (CDMPs) as part of their Broader Health Cover services for members. The aim of these CDMPs has been to prevent or substitute for hospitalisation or help patients with chronic disease better manage and reduce the effects of that disease (Biggs 2013). A detailed analysis of the role of CDMPs is beyond the scope of this report. For more information, please see chronic disease management: the role of private health insurance.

Overview of CDM item use

The public health measures introduced during 2020 to help control the spread of COVID-19 led to substantial changes in the way Australian’s were provided with and accessed health services. To account for the impact of COVID-19, this report separates the use of CDM services prior to 2020 and during 2020. Most results cover the period January—December 2019. For services used during 2020, see Impact of COVID-19 on CDM and Medicare-subsidised allied health services.

More than 3.8 million Australians had at least one CDM service in 2019 (Table 1). Preparation of a GP Management Plan (GPMP) was the most used item, accessed by 2.9 million patients (114 per 1,000 population), followed by the Coordination of Team Care Arrangements (TCAs) with 2.5 million patients (97 per 1,000 population). It is common for patients to have both a GPMP and TCAs, with almost 2.4 million patients having both services in 2019. This represents 83% of GPMP patients having TCAs, and 97% of TCAs patients having a GPMP.

A review of a patient’s GPMP or TCA is recommended to occur every 6 months, or as clinically necessary (Department of Health 2014d). In 2019, 1.8 million patients had a review of their GPMP and/or TCAs. See Review of GPMP and TCAs for further analysis of the review service.

By comparison, the services for Contribution or Review of a Multidisciplinary Care Plan are much less frequently used, particularly for patients living in the community. Around 96,600 aged care residents had this service, representing just over half (53%) of the permanent residential aged care population at 30 June 2019 (AIHW 2021).

What are chronic disease management services?

General practitioner management plans (GPMPs; MBS items 721, 229) and Team Care Arrangements (TCAs; MBS items 723, 230) are chronic disease management (CDM) services available on the Medicare Benefits Schedule (MBS) for people with a chronic or terminal medical condition. 

A GPMP is a plan of action agreed between a patient and their GP.

TCAs provide access to Medicare-subsidised care from selected allied health care providers for individual treatment services. 

For more information, please see chronic disease management services.

Table 1: CDM services, number of services and patients, 2019
CDM service Item number Number of services Rate of services per 1,000 population (crude) Number of patients Rate of patients per 1,000 population (crude)

Preparation of a GP Management Plan (GPMP)

721,229

2,896,875

114.2

2,892,090

114.0

Coordination of Team Care Arrangements (TCAs)

723,230

2,463,722

97.1

2,459,582

97.0

Review of a GP Management Plan or Coordination of a Review of Team Care Arrangements

732,233

3,951,162

155.8

1,770,147

69.8

Contribution to a Multidisciplinary Care Plan, or to a Review of a Multidisciplinary Care Plan, for a patient who is not a care recipient in a residential aged care facility

729,231

2,334

0.1

2,253

0.1

Contribution to a Multidisciplinary Care Plan, or to a review of a multidisciplinary care plan, for a resident in an aged care facility

731,232

158,996

6.3

96,607

3.8

Total CDM service

 

9,473,089

373.5

3,832,164

151.1

Notes

  1. Rates in this web report are calculated using the Australian Bureau of Statistics (ABS) Estimated Resident Population (ERP) as at 30 June 2019, based on the data from the 2016 Census of Population and Housing.
  2. Totals and subtotals of patients may be less than the sum of each service group as a patient may receive more than one type of service but will be counted only once in the relevant total.     

Source: AIHW analysis of MBS data maintained by the Department of Health and Aged Care and sourced from Services Australia.
 

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