Chronic disease management services among health check patients
Overview
This chapter presents exploratory analysis on the number and proportion of health check patients in 2023 who also received a chronic disease management (CDM) service in 2023, split by age group and sex.
CDM services are GP services on the MBS that are available to people with a chronic or terminal medical condition. A chronic medical condition is defined as one that has been or is likely to be present for 6 months or longer, including, but not limited to asthma, cancer, heart disease, diabetes, arthritis and stroke (Department of Health and Aged Care 2014).
CDM services include:
- GP Management Plans (GPMP), which provide an organised approach to care, emphasising regular reviews, tailored self-care strategies, and coordination of services with specialists.
- Team Care Arrangements (TCA), which coordinate care between the patient’s GP and allied health providers.
It is common for patients to have both a GPMP and TCAs, with 83% of GPMP patients having TCAs, and 97% of TCA patients having a GPMP in 2019 (AIHW 2022).
These types of comprehensive and coordinated care services are an important part of the attempts to address the high prevalence of chronic conditions among First Nations people (AIHW & NIAA 2020).
The rates of MBS services for both GPMPs and TCAs were around 1.5 times as high among First Nations people as among non-Indigenous Australians in 2017–18, after adjusting for age structure difference (AIHW 2020).
For more information about chronic disease management services, see Use of chronic disease management and allied health Medicare services and the Aboriginal and Torres Strait Islander Health Performance Framework website’s measure, 3.05 Chronic disease management.
For background information on health checks, see Health checks section.
This chapter presents information on the use of the following MBS items:
Table 5: List of MBS items for health checks and chronic disease management services
MBS item no. | Description | Mode of delivery |
|---|---|---|
715 | Health check provided by a GP | Face-to-face |
228 | Health check provided by a medical practitioner other than a GP (available from 1 July 2018) | Face-to-face |
92004 | Health check provided by a GP (available from 30 March 2020) | Videoconference |
92016 | Health check provided by a GP (available from 30 March 2020 to 30 June 2021) | Telephone |
92011 | Health check provided by a medical practitioner other than a GP (available from 30 March 2020) | Videoconference |
92023 | Health check provided by a medical practitioner other than a GP (available from 30 March 2020 to 30 June 2021) | Telephone |
721 | Preparation of a GP Management Plan by a GP | Face-to-face |
229 | Preparation of a GP Management Plan by a medical practitioner other than a GP | Face-to-face |
723 | Coordination of Team Care Arrangements by a GP | Face-to-face |
230 | Coordination of Team Care Arrangements by a medical practitioner other than a GP | Face-to-face |
732 | Review of a GP Management Plan or Team Care Arrangements by a GP | Face-to-face |
233 | Review of a GP Management Plan or Team Care Arrangements by a medical practitioner other than a GP | Face-to-face |
729 | Contribution to (or review of) a multidisciplinary care plan prepared by another provider, by a GP | Face-to-face |
731 | Contribution to (or review of) a multidisciplinary care plan prepared by another provider, by a GP (for residents of aged care facilities or hospital in-patients) | Face-to-face |
231 | Contribution to (or review of) a multidisciplinary care plan prepared by another provider, by a medical practitioner other than a GP | Face-to-face |
232 | Contribution to (or review of) a multidisciplinary care plan prepared by another provider, by a medical practitioner other than a GP (for residents of aged care facilities or hospital in-patients) | Face-to-face |
Note: Outside of MBS item descriptions above, the term 'GP' is used as a generic reference to all medical practitioners providing primary health care services.
The data include MBS items billed to Medicare by Aboriginal Community Controlled Health Services (ACCHSs) or other health services aimed at First Nations people, as well as by mainstream GPs.
Analysis does not include telehealth items corresponding to the chronic disease management services (92024–92028, 92055–92059).
The minimum time allowed between health checks is 9 months. People can therefore receive more than one health check in a year.
For items relating to preparation of a GP Management Plan (229, 721), patients can receive up to 1 of these services in a 12-month period in most cases.
For items relating to coordination of Team Care Arrangements (230, 723), patients can receive up to 1 of these services in a 12-month period in most cases.
For items relating to review of a GP Management Plan or Team Care Arrangements (233, 732), patients can receive up to 1 of these services in a 3-month period in most cases.
For items relating to a contribution to (or review of) a multidisciplinary care plan (231, 232, 729, 731), patients can receive up to 1 of these services in a 3-month period in most cases.
- For analysis of the proportion of people who received a health check, see the chapter, Health checks.
- People who received an MBS service are referred to as ‘patients’.
- All people who received a health check are assumed to be First Nations people.
- Health check patients in this chapter are reported based on the date of service, which was not necessarily the date that the service was processed by Services Australia. MBS services in this chapter were processed on or before 31 March 2024.
- Patients' age was calculated at 31 December 2023 (the end of the reference year presented). Patients may have moved abroad or died between their health check and the end of the year.
- Patients may have received the chronic disease management service before or after the health check.
AIHW (Australian Institute of Health and Welfare) (2020) Measure 3.05 Chronic disease management - Data findings, Aboriginal and Torres Strait Islander Health Performance Framework website, AIHW, Australian Government, accessed 22 May 2024.
AIHW 2022 Use of chronic disease management and allied health Medicare services, AIHW, Australian Government, accessed 22 May 2024.
AIHW & NIAA (National Indigenous Australians Agency) (2020) Measure 3.05 Chronic disease management, Aboriginal and Torres Strait Islander Health Performance Framework website, AIHW, Australian Government, accessed 22 May 2024.
Department of Health and Aged Care (2014) Chronic Disease Management Patient Information, Department of Health and Aged Care website, Australian Government, accessed 22 May 2024.