Stephen Leeder: Let’s manage care

THE challenge we all face as doctors is how to manage the rising tide of patients with chronic illness.

Our success in preventing death from heart disease is a fine example of our dilemma. Mortality rates have tumbled but patients who previously would have died live on with damage, which can progress over years to heart failure.

Cancer has become a chronic disease, requiring ambulatory care services for years with only short hospital admissions at diagnosis and initial treatment, and at the end of life.

We have good health services in Australia but they exist within formal boundaries of hospital, general practice and community care. Getting these elements together is a big deal.

The only equivalent challenge I know of is organising a 21st birthday where pillars of the family and factions of friends require diplomatic skills of a high order to be brought to a point of conviviality and harmony. Unlike the birthday party, the coordination of care for patients with serious and continuing illnesses is a long-term undertaking.

To succeed, coalitions have to be built to last. Putting the patient at the centre of it all sounds trite and is difficult to achieve, but is essential.

It is in this context that there is energetic worldwide interest in integrated or coordinated care, which is growing apace, driven by concerned clinicians, patients and health insurance agencies, and governments who have to pay for health care.

I spoke recently with a health minister who had undertaken a brief world tour to see how care was organised in Europe and the US. The same challenges were visible everywhere, and although local responses varied, managed, coordinated care was apparent in each country. “It’s the same everywhere I went”, the minister said.

There are a growing number of examples of how managed care can succeed.

McKinsey & Company, a global management consulting firm, has worked with health service providers in the US, the UK, France and Australia on ways care might be better provided for people with chronic problems.

Major health insurers, such as Kaiser Permanente in California with about 10 million health plan members, have been active in the introduction of coordinated or integrated care.

Meanwhile, Australia is moving cautiously.

One of the major elements of successful managed care is having one payer (an Australian example is the Department of Veterans Affairs) for all forms of care so that resources can be moved between the hospital, general practice and community to provide the most efficient care for the patient.

All managed care programs that have succeeded have expected discipline among doctors that many in Australia find irksome in concept, leading to protests. But there is support, particularly when doctors find that working in a managed environment, where their performance is monitored and where incentives are offered for high-quality care, is more congenial than they imagined.

It is true that effective information technology (IT) systems that permit records to be linked between service providers generally feature as part of effective managed care, but they are neither essential nor sufficient, though few programs lack them entirely.

Human communication among the providers and patients and carers is the critical dynamic in managed care. That’s fortunate because we still have some way to go before we have sufficient IT resources for coordinated care in Australia.

With good models of managed care and satisfied providers in other countries, Australia should consider its wider application here.

The opportunity to have a care system that works for the patients — wherever they are and at whatever stage of illness — is deeply attractive. A bonus is that with successful programs, costs generally come down.

Most patients need less hospital care and less medication confusion. Our health system needs less waste, particularly on duplicated tests.

With well run managed care, everyone wins.


Professor Stephen Leeder is the editor-in-chief of the MJA and emeritus professor of public health and community medicine at the University of Sydney.

Jane McCredie is on leave.