Emerging role of the Australian private health insurance sector in providing chronic disease management programs: current activities, challenges and constraints.

Objective This study explored the current activities of a sample of Australian private health insurance (PHI) funds to support the care of people living with chronic conditions, following changes to PHI legislation in 2007 permitting funds to cover a broader range of chronic disease management (CDM) services. Methods A qualitative research design was used to gather perspectives from PHI sector representatives via semistructured interviews with eight participants. The interview data were analysed systematically using the framework analysis method. Results Three main types of activities were most commonly identified: (1) healthcare navigation; (2) structured disease management and health coaching programs; and (3) care coordination services. These activities were primarily conducted via telephone by a combination of in-house and third-party health professionals. PHI funds seem to be taking a pragmatic approach to the type of CDM activities currently offered, guided by available data and identified member need. Activities are focused on people with diagnosed chronic conditions exiting hospital, rather than the broader population at-risk of developing a chronic condition. Conclusions Despite legislation permitting PHI funds to pay benefits for CDM services being in place for more than 10 years, insurers are still in an early stage of implementation and evaluation of CDM activities. Primarily due to the regulated scope of PHI coverage in Australia, participants reported several challenges in providing CDM services, including identifying target groups, evaluating service outcomes and collaborating with other healthcare providers. The effectiveness of the approach of PHI funds to CDM in terms of the groups targeted and outcomes of services provided still needs to be established because evidence suggests that population-level interventions that target a larger number of people with lower levels of risks are likely to have greater benefit than targeting a small number of high-risk cases. What is known about the topic? Since 2007, PHI funds in Australia have been able to pay benefits for a range of out-of-hospital services, focused on CDM. Although a small number of program evaluations has been published, there is little information on the scope of activities and the factors influencing the design and implementation of CDM programs. What does this paper add? This paper presents the findings of a qualitative study reporting on the CDM activities offered by a sample of PHI funds, their approach to delivery and the challenges and constraints in designing and implementing CDM activities, given the PHI sector's role as a supplementary health insurer in the Australian health system. What are the implications for practitioners? Current CDM activities offered by insurers focus on health navigation advice, structured, time-limited CDM programs and care coordination services for people following a hospital admission. There is currently little integration of these programs with the care provided by other health professionals for a person accessing these services. Although the role of insurers is currently small, the movement of insurers into service provision raises considerations for managing potential conflicts in having a dual role as an insurer and provider, including the effectiveness and value of services offered, and how these programs complement other types of health care being received.