Emerging Practices in Medicaid Primary Care Case Management Programs

Chapter 5:
Quality Improvement

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States are increasingly active in monitoring and encouraging quality improvements in PCCM; many are using methods similar to those used within MCOs or to those used to manage their MCO contractors. Many of the case-study states have developed processes for monitoring quality and for passing this information back to PCPs in order that they can improve their performances. Some use HEDIS measures; some compare across PCCM and MCO programs or across Medicaid and commercial populations. Also, states are implementing a greater number of strategies for serving members, such as member help lines, nurse advice lines, greater educational efforts, and health assessments.

Quality Monitoring

The case-study states conduct a variety of activities related to quality monitoring and improvement, many of which have traditionally been associated with MCOs. As Chart L indicates, all eight states conduct member satisfaction surveys (often the CAHPS survey) and/or focus groups. All monitor 24-hour access; most monitor utilization. Six (Florida, Iowa, North Carolina, Oklahoma, Texas, and Virginia) conduct focused studies (on such state-chosen topics as asthma, immunization [either children or older adults], prenatal care and pregnancy outcomes, access for populations with special needs, hypertension, diabetes, dementia, and EPSDT screening); Maine has contracted an NCQA reviewer to improve methods for designing, tracking, and reporting these studies. Oklahoma is nearing completion on an encounter data validation study for their capitated PCCMs. Five (Florida, North Carolina, Oklahoma, Texas, and Virginia) have contracted with external quality review organizations (EQROs) to conduct reviews of medical records; (24) three of these states (Florida, Texas, and Virginia) also conduct medical records reviews internally. Iowa and Maine also conduct internal medical records reviews.
Chart L:
Quality Activities
State Program Quality Activities Included
Alabama Patient 1st Claims data examined for utilization (Medicaid agency), computer generated survey on Medicaid beneficiaries based on services received (e.g., ER use), monitoring 24-hour access
Florida MediPass Random medical records reviews (independent agency and Medicaid), disease management, focused studies, member surveys/focus groups, monitoring 24-hour access
Iowa MediPASS Focused studies, member surveys/focus groups, monitoring 24-hour access, HEDIS measurements, random medical record review, Managed Health Care Advisory Committee review and oversight of all quality activities
Maine Maine PrimeCare Random medical records reviews (Medicaid agency), CAHPS surveys, 24-hour access monitoring
MaineNET/ Partnership PCP must do annual preventive screen, results sent to be used as quality indicator
North Carolina ACCESS I Random medical records reviews (PRO), focused studies, member surveys/focus groups, HEDIS (generated from claims data), monitoring 24-hour access
ACCESS II Uniform standards of care, standard set of performance measures, local responsibility for quality (work with providers on-site), uses NCQA to credential PCCM in some networks, pediatric asthma care and diabetes care quality measurement projects
Oklahoma SoonerCare Choice PCCM Model PRO review (random medical records reviews), uses HEDIS to compare PCCM and MCOs in urban areas, focused studies surveys/focus groups, QARI and modified QISMC, quality assurance committee, encounter data validation study in process, monitoring 24-hour access, enrollee surveys
Texas Texas Health Network PCCMs credentialed and recredentialed every 2 years using QARI, Texas Dept. of Health, and NCQA standards, random medical records reviews (independent agency and Medicaid), member surveys/focus groups, focused studies, Quality Management/ Improvement Committee meets quarterly, special project on diabetes, complaints, appeals, auditing 24-hour access, annual community health needs assessments
Virginia MEDALLION Random medical records reviews (PRO and Medicaid), disease management program evaluates health outcomes, focused studies, member surveys, drafting provider profiling reports, monitoring 24-hour access

Iowa's Birth Outcomes Study is an example of a focused study. The goal of the study was to compare risk-adjusted quality of care provided to Medicaid mothers and babies in fee-for-service, PCCM, and MCOs. All included records were of mothers who were enrolled for at least 18 months of Medicaid eligibility, including during the pregnancy, and enrolled in the same MCO during the last two months of pregnancy. The study was performed in two stages: comparing outcomes of PCCM and MCO programs in 1999, and MCO and fee-for-service in 2000. In 1999, the sample included 741 PCCM members and 532 MCO members. Conclusions included: PCCM neonates had longer lengths of stay for very low birth weights, but MCO neonates had longer stays for low birth weights; slightly less than 50 percent of mothers in both payment systems had received adequate prenatal care; and maternal and neonatal mortality outcome scores in both programs were better than national averages.

Some states have implemented certain program components/features that are showing success in quality monitoring and improvement.

Chart M:
Maine PrimeCare Primary Care Physician Incentive Payment Program Scoring System
Goal Weight Measures
Reduce disincentives to having higher Medicaid patient panels 40%
  • Average panel size (unduplicated Medicaid patients)

  • Maine PrimeCare costs (per member per month)

  • Percentage requesting to change PCPs

Reduce inappropriate emergency room utilization


  • Average number of ER visits (per patient per year)

  • Percentage of ER users having repeat ER visits

  • ER patients (list of names attached)

  • Potentially avoidable hospitalizations (admission rates per 1000 Medicaid clients per year

    1. Asthma

    2. . Pneumonia

    3. Severe ENT infections

    4. Kidney UTI

    5. Congestive heart failure

    6. Gastroenteritis

  • Hospitalized patients with above conditions (list of names attached)

Increase the utilization of preventive services 30%
  • Average number of EPSDT encounters (per patient per year)

  • Number of EPSDT/Bright Futures forms required/number of EPSDT visits billed

  • Percentage of children age 0 to 20 with 1 or more EPSDT visits in the last year

  • Well-child visits in first 15 months of life (percentage of patients having 5 or more visits)

  • Well-child visits in 3rd, 4th, 5th, and 6th years of life (percentage with a well-child visit in the past year)

  • Adolescent well-care visits: ages 12-21 years (percentage with a well-care visit in the past year)

  • Cervical cancer screening (percentage of women age 21 to 64 with a Pap smear in the past year)

  • Breast cancer screening (percentage of women age 52 to 70 with a mammogram in the past 2 years)

  • Pre-natal care in the first trimester (percentage of women starting pre-natal care within the first trimester)

  • Diabetes — retinal exams (percentage of diabetics with a dilated retinal exam in the past year)

  • Diabetes — HgbAlc (percentage of diabetics with an HgbAlc test in the past year)

  • Diabetes — Lipid Tests (percentage of diabetics with a Lipid test in the past year)

  • Lead screening rates: 1st year

  • Lead screening rates: 2 year olds

Oklahoma formerly used QARI and now relies on modified QISMC standards to compare PCCM and MCOs. Texas uses QARI standards. Oklahoma will soon begin on-site reviews with a sample of providers; focus areas will include finance, care management, professional services, and member services.

Florida, Virginia, Texas, and Maine conduct periodic provider surveys to gauge their satisfaction with the PCCM program; Maine surveys both PCPs and office staff. Maine PrimeCare is in the process of piloting a FAACT survey to assess the delivery of care to children up to the age of four and will be surveying adolescent members using a tool also developed by FAACT.

Member Services

Services designed to facilitate membership are essential components of high quality health care. Some member services are offered in all the case-study states - complaint and grievance processes, member help lines run internally or by enrollment brokers, enrollee interpreter/translation services, new member handbooks and materials, and the provision of lists of participating PCPs to new members. Chart N lists some of the member services offered in the case-study states.
Chart N:
Member Services
State Program Member Services Included
Alabama Patient 1st Member hotline, grievance/complaint process, targeted case management for medically at-risk or non-compliant patients, enrollee interpreter/translation services
Florida MediPass Member hotline, grievance/complaint process, disease management, enrollee interpreter/translation services
Iowa MediPASS Member hotline, grievance/complaint process, newsletter mailings, member handbook and Medicaid guide routinely sent to members, enrollee interpreter/translation services
Maine Maine PrimeCare Member hotline, grievance/complaint process, enrollee interpreter/translation services
MaineNET/ Partnership MaineNET: PRA-Plus screen, preventive health screen complaint/grievance process, enrollee interpreter/translation services
Partnership: above, plus local care coordinator works with physician
North Carolina ACCESS I Member hotline, grievance/complaint process, local managed care representative serves as resource for each county, enrollee interpreter/translation services
ACCESS II Incentives for members to see PCCMs, member hotline, grievance/complaint process, local managed care representative serves as resource for each county, enrollee interpreter/translation services
Oklahoma SoonerCare Choice PCCM Model Member services department, nurse advice hotline, grievance/ complaint process, case management, member handbook, enrollee hotline, information mailings on benefits and preventive health topics, enrollee interpreter/translation services
Texas Texas Health Network Nurse advice hotline, customer service help line, prenatal care line for new pregnant members, utilization management help line, grievance/complaint process, ombudsman program (Harris service area only), case management, outreach workers link with health-related and socioeconomic community resources, community-based member health education, community I&R database, case management staff coordinate care for all members who meet criteria, member education materials, newsletter, enrollee interpreter/translation services
Virginia MEDALLION Member hotline, grievance/complaint process, enrollee interpreter/translation services

Additional efforts made by the case-study states include:

Oklahoma does extensive outreach to newly eligible Aged/Blind/Disabled (ABD) Medicaid beneficiaries, including outbound telephone calls, direct mail, and enrollment fairs. Exceptional Needs Coordinators and other state medical staff complete health profiles of these new members whenever possible. Each profile is sent to the enrollee's chosen PCP, in order to provide that PCP with a medical history of his/her new patient

Disease Management

Disease management strategies can be seen as both a form of quality improvement and a type of member services. The system is better served through appropriate utilization of services leading to lower overall costs; the chronically ill person is better served by having systematic health care that is state-of-the-art for his/her particular illness.

Three case-study states (Florida, North Carolina, and Oklahoma) have developed formalized disease management structures and approaches. Florida has chosen to contract with disease management organizations; sites in North Carolina's ACCESS II and III programs and Oklahoma's program have chosen to develop internal programs. Texas has implemented a special project on diabetes as a pre-curser to a formal disease management program. The Virginia Medicaid agency has a disease management program, but this is considered separate from its PCCM program; the two programs intersect if the PCCM member happens to require disease management assistance.

Florida has hired disease management organizations (DMOs) to serve patients with six chronic illnesses.

Each contractor must guarantee the state 6.5 percent annual savings compared to adjusted baseline per member per month spending for PCCM members with these illnesses.

Approximately 100,000 Floridian PCCM members qualify for one of these DM programs. On a monthly basis, the Medicaid agency analyzes the claims of PCCM members to identify CPT codes that relate to the six illnesses listed above. The state created a claims analysis hierarchy with the first cut for HIV/AIDS, the second for hemophilia, and on down the list. Therefore, a person with both HIV/AIDS and asthma will be served by the HIV/AIDS DMO. The names of individuals with these CPT codes are sent to the appropriate DMOs, which are required to send letters within 30 days informing these individuals about the program. These individuals are automatically enrolled unless they choose to opt out. The DMOs are required to work with the individuals' PCPs. Many DMOs offer additional benefits to participants, such as glucometers for people with diabetes.

The Florida HIV/AIDS DMO distributed to physicians a CD-ROM with state-of-the-practice protocols and guidelines. It provides a comprehensive source of the most up-to-date information for the medical community and a baseline of information in support of the DM initiative. (26)

All North Carolina's ACCESS II and III sites have implemented internal asthma disease management programs. One site is currently running diabetes disease management programs; all sites will have such programs within the next year. The sites chose asthma as the first DM initiative based on the following principles: (27)

The core elements of the Asthma Disease Management Program were developed by the sites themselves with the help of state staff. The four core elements are listed below and further detailed in Appendix B.

With these core elements in place, the participating sites implemented a number of asthma management initiatives.

The group also developed quarterly performance measures for the Asthma Disease Management Program. These take into account both outcomes (e.g., emergency room use rate for asthma) and process (e.g., proportion of asthma patients with an asthma management plan). Outcome information is gathered from claims data. Process information is obtained through chart reviews.

In Oklahoma, participating physicians assess their practices related to diagnosis and treatment. They are expected to follow the National Asthma Education and Prevention (NAEP) guidelines recommended by the National Heart, Lung, and Blood Institute. The state offers on-site assistance, patient education, and monitoring materials. Physicians benefit from participation because they are able to apply what they learn, along with the program materials (encounter forms, self-assessment and action plans, patient education brochures) to their entire asthma patient population. Oklahoma is also considering a collaborative on depression and a diabetes disease management program.


24. Maine used an EQRO in the past; these reviews are now conducted by state staff.

25. The model of rapid cycle quality improvement was developed by the Institute for Healthcare Improvement. It focuses on the processes of "plan, do, study, and act", and stresses setting aims, establishing measures, and making system changes to remove barriers to care.

26. Vernon K. Smith, Terrisca Des Jardins, and Karin A. Peterson, Exemplary Practices in Primary Care Case Management: A Review of State Medicaid PCCM Programs (Princeton, NJ: Center for Health Care Strategies, Inc., 2000), 62.

27. Bulleted North Carolina information in this section taken from: Department of Health and Human Services, "ACCESS II and III Plans Asthma Disease Management Program", ACCESS II and III Update no. 2 (July 2000), 1-8.

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