South East Queensland Research Network

Incentives & Disincentives in General Practice

Chronic Disease Management

Dr. Ian Williams1Libby Holden2, Lily Cheung2,

Prof Liz Patterson2, Dr Jane Smith3, Xanthe Golenko2,, Robyn Chambers1

1: Camp Hill Medical Centre, 2: Griffith University, 3: Mudgeeraba Medical Centre

South East Queensland Research Network

Aims & Rationale

Aims:• To explore the impacts of chronic disease management (CDM) incentives

on general practice service providers• To identify opportunities of improvements to CDM care management and

optimal use of CDM incentives

Rationale:• Chronic disease responsible for 80% of total of burden of disease (1)• Only 50% of Australian CDM patients are receiving optimal care (2)• Chronic disease patients have complex needs (2)• Medicare CDM items are intended to provide incentives to GPs (3)• Problems with some Medicare items flagged by GPs in SEQRN

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Methods – study design

Exploratory, qualitative research design• Phase 1 – discipline specific focus groups• Phase 2 – in-depth interviews with staff from

nine practices• Phase 3 – extrapolation of findings and

collaboratively develop recommendation

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Methods: Sampling frame

Mix of:

• high, med, low incentives use

• Solo, 2-5, 6+ GPs

• non, part, full computerized

• Urban, outer metro, rural

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Methods: study participants

• Phase 1: range of individuals from eight different practices – discipline specific focus groups

• Phase 2: practice principal/or GP, Practice Manager & Practice Nurse from nine practices (only 4 same as practices from phase 1)

• Phase 3: yet to occur, plan to consult with all who participated in either phase 1 or 2

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Results: Study sample for phase 2

• Nine practices

• 6 Practice GP Principals, 3 GPs

• 7 Registered Nurses, 2 Enrolled Nurse

• 9 Practice Managers

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Results: Study Sample (cont)

age sex Yrs in GP Yrs in this practice

Qualifications

Practice Principal/GP

All >45 yr except 1 @ 35-44

5 males 4 females

All >10 yr except 1

3: <5yrs4: 6-20yr2: >20yrs

5 FRACGPAll MBBS

Practice Nurse

1: <35yr2: 35-44yr3: 45-54yr 2: >55yr

9 females All <10 yr except 2

All < 5 yrs except 2

6: RN2: EN1 unrecorded

Practice Manager

4: 35-44yr3: 45-54yr2: > 55yr

9 females 1: <10yr6: 10-20yr2: >20yr

6: < 10yr3: 10-20yr

3: nil 1: EN,1:RN1 Cert, 1: Dip, 1: BComm1:FAAPM

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Results: Overall issues mapped

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Results: key themes

• Medicare related issues• Financial viability• Patient outcomes• Training & support• Service models: ● staff roles ● systems

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Medical (level 2)

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Financial viability (level 2)

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Patient outcomes/impacts (level 2)

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Training & support (level 2)

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Service Models (level 2)

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Discussion: key messages

• Variation in practice structures, role delineation, software systems, and referral networks

• No apparent link between practice structure & CDM income

• Fine balance between patient care and practice viability

• Conflicting views on financial viability

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Discussion: key messages (cont)

• Improved patient outcomes reported by practice staff:

↟patient care monitoring ↡ acute care episodes

↟quality of care↟patient engagement in & expectations of care

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Discussion: key messages (cont)

• Medicare disincentives:◊ inconsistent &/or poor access to information on patient eligibility◊Need for improved systems at Medicare level before rolling out new items◊Need for consistent & transparent requirements from Medicare• Value of NPCC involvements for developing

standardised systems at practice level

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Discussion: key messages (cont)

• Variable barriers & enablers for nurses o Barrier - need for infrastructure (e.g.

confidential room) for RN role, time pressures, changing expectations e.g. bring in $ to cover wages

o Enabler – ↟satisfaction from ↟ patient interaction & ability to work positively re patient care, improved team approach & rapport building with GP

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Implications & Recommendations:

Medicare to consider: ◊ the value of CDM MBS items based on nursing care only e.g. education, preventative health care & monitoring role e.g. hypertension ◊ that systems & training is required before implement new Medicare items

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Implications & Recommendations:

Public / policy level debate on:

The funding of general practice based on quality of care outcomes rather than episodic care

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Acknowledgements:

• Study Participants

• RACGP funding

• Griffith PHCRED funding• South East Queensland Research Network

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References1. National Health Priority Action Council, National Chronic disease

Strategy, Australian Government Department of Health and Ageing, Editor. 2006, Australian Health Ministers' conference 2005.

2. Infante, F.A., et al., How people with chronic illnesses view their care in general practice: a qualitative study. Medical Journal of Australia, 2004. 181(2): p. 70-73.

3. Department of Health and Aging, Chronic Disease Management (CDM) Medicare Items: Q & As Updated with November 2006 MBS fees