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Preparing for the New MBS Chronic Disease Management Framework: What GPs Need to Know

The Australian Government has announced significant changes to the Medicare Benefits Schedule items for chronic disease management, with implementation now deferred until 1 July 2025. These changes represent the first major overhaul of the framework in almost two decades and aim to modernise and streamline chronic disease management in general practice.

As GPs, we have a critical opportunity to prepare for these changes while continuing to deliver high-quality care to our patients with chronic conditions. This article outlines the upcoming changes and provides practical strategies for GPs to prepare their practices and enhance chronic disease management approaches.

What's Changing in Chronic Disease Management?

From 1 July 2025, several key changes will be implemented:

  1. Simplified Documentation: The current GP Management Plan (GPMP) and Team Care Arrangements (TCA) will be replaced with a single GP Chronic Condition Management Plan, reducing administrative complexity.

  2. MyMedicare Registration Link: Patients registered with MyMedicare will need to access management plans through their registered practice, strengthening continuity of care.

  3. Enhanced Review Processes: The fee structure will be equalised between developing and reviewing plans, incentivising regular reviews. Patients will need their plan established or reviewed within the previous 18 months to maintain access to allied health services.

  4. Formalised Referral Processes: Referrals for allied health services will become more consistent with other referral arrangements.

  5. Transition Protection: Existing patients with GPMPs and TCAs will benefit from transition arrangements to ensure continuity of care.

Why These Changes Matter

These reforms were recommended by the MBS Review Taskforce in response to:

  • Evolving chronic disease burden in Australia
  • Changing patient expectations around care coordination
  • Technological advancements supporting multidisciplinary team communication
  • Need for streamlined, patient-centred care models

The overarching goal is to simplify processes for healthcare professionals while promoting continuity of care, encouraging regular reviews, and supporting effective communication between members of a patient's healthcare team.

Preparing Your Practice for the Changes

Audit Your Current Chronic Disease Management Processes

  • Review your current chronic disease register and identify patients with existing GPMPs and TCAs
  • Assess how many plans will require review in the 18 months following July 2025
  • Identify patients who will need transition support

Practice tip: Create a spreadsheet to track patients with chronic conditions, including their last GPMP/TCA date, to prioritise reviews as the implementation date approaches.

Strengthen Your MyMedicare Integration

  • Encourage patients with chronic conditions to register for MyMedicare
  • Consider assigning staff to assist patients with MyMedicare registration during practice visits
  • Update practice materials to explain the benefits of MyMedicare registration, particularly for chronic disease management

Practice tip: Include MyMedicare registration information in your chronic disease recall communications.

Enhance Multidisciplinary Team Relationships

  • Review and update your referral networks with local allied health providers
  • Consider organising practice-level meetings with key allied health partners to discuss the upcoming changes
  • Develop standardised communication channels with allied health providers to prepare for the new referral processes

Practice tip: Create a directory of preferred allied health providers with their communication preferences and referral requirements.

Update Practice Software and Templates

  • Contact your practice software provider about updates required for the new single management plan format
  • Begin developing draft templates based on available information about the new plan requirements
  • Plan staff training on new documentation processes

Plan Patient Communication Strategies

  • Develop clear, simple explanations of the changes for patients
  • Create FAQs for practice staff to use when discussing the changes
  • Consider how to explain the 18-month review requirement to ensure patients understand its importance

Improving Chronic Disease Management Beyond MBS Changes

While preparing for the MBS changes, GPs can also implement broader improvements to chronic disease management:

Adopt a Population Health Approach

  • Use your practice data to identify trends and gaps in chronic disease care
  • Implement targeted screening programs for high-risk populations
  • Consider community-specific factors influencing chronic disease in your patient cohort

Embrace Digital Health Tools

  • Optimise use of My Health Record for chronic disease documentation
  • Consider secure messaging platforms that improve communication with the care team
  • Explore telehealth options for routine chronic disease monitoring, particularly for patients with mobility issues

Enhance Patient Self-Management Support

  • Develop or source condition-specific educational resources
  • Consider group education sessions for common chronic conditions
  • Explore digital tools that support patient self-monitoring and management

Focus on Preventative Care

  • Incorporate preventative health discussions into chronic disease appointments
  • Develop practice-wide approaches to addressing modifiable risk factors
  • Consider implementing structured lifestyle modification programs

The upcoming changes to the MBS Chronic Disease Management items represent both a challenge and an opportunity for Australian general practice. By preparing thoroughly and viewing these changes as a catalyst for broader improvements in chronic disease care, GPs can enhance patient outcomes while creating more efficient practice workflows.

The delay in implementation until July 2025 provides valuable time to prepare our practices, strengthen our multidisciplinary networks, and ensure a smooth transition for our patients with chronic conditions. By taking proactive steps now, we can ensure we're ready to embrace these changes and improve chronic disease management at both individual and population levels.

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