Primary care case management (PCCM) is a system of managed care used by state Medicaid agencies in which a primary care provider (PCP) is responsible for approving and monitoring the care of enrolled Medicaid beneficiaries, typically for a small monthly case management fee in addition to fee-for-service reimbursement for treatment. The Health Care Financing Administration (HCFA(now known as CMS)) in the Department of Health and Human Services (DHHS), defines PCCM services as "case management-related services, including the locating, coordinating, and monitoring of health care services provided by a physician, physician group practice, or an entity employing or having other arrangements with physicians (including nurse practitioners, certified nurse midwives, and physician assistants at the state's option), under a PCCM contract with the state." 1 As of June 30, 1998, 29 states had Medicaid PCCM programs.
PCCM programs have evolved significantly since HCFA(now known as CMS) first authorized implementation in 1981. The purposes of this paper are to examine this evolution and illustrate the current practices in PCCM programs in eight states that have developed a broad range of implementation strategies.
National Academy for State Health Policy (NASHP) staff utilized several methods to study PCCM programs during October/November 2000:
- A review was completed of the available literature on PCCM programs and their evolution. This included an analysis of trends in the state use of Medicaid PCCM from NASHP's Medicaid Managed Care: A Guide for States (Fourth Edition). 2
- Telephone interviews were conducted with Medicaid officials and others implementing PCCM programs in seven states: Alabama, Florida, Iowa, North Carolina, Oklahoma, Texas, and Virginia. Officials in the eighth state, Maine, were interviewed in person. NASHP staff spoke with a total of 24 people in one-and-a-half-hour interviews. Interviewees discussed the major features of their programs, program evolution, strengths and weaknesses, and lessons learned.
- Physicians in two states were interviewed by telephone. These interviews lasted approximately half an hour and focused on the physicians' motivations for participating in the program and what they viewed as strengths and weaknesses.
The eight states studied (Alabama, Florida, Iowa, Maine, North Carolina, Oklahoma, Texas, and Virginia) were chosen for the range of strategies used in their PCCM programs. These programs vary in age (from one to ten years) and size (from several pilot sites to statewide). What also varies is the place of PCCM within the Medicaid managed care picture: some states implemented these programs with the intent that they would continue indefinitely, while others planned to phase them out in favor of Managed Care Organizations (MCOs). A few states still intend to reduce or eliminate the PCCM system for MCO-based programs, while others are moving in the opposite direction. What these states have in common is a desire for increased accountability among their provider networks, in order to ensure high quality care for Medicaid beneficiaries. The PCCM programs studied are
- Alabama's Patient 1st, initiated in 1997, operates statewide for TANF, SOBRA children, Aged/Blind/Disabled Medicaid beneficiaries, and CHIP beneficiaries.
- Florida's MediPass, initiated in 1992, operates statewide for poverty-related and Blind/Disabled Medicaid beneficiaries, CHIP beneficiaries, and children in foster care. It includes disease management programs throughout the state and a provider service network in two counties.
- Iowa's MediPASS, started in 1990, operates in 92 of the state's 99 counties and covers poverty-related Medicaid beneficiaries and CHIP beneficiaries. The Medicaid program also contracts with a behavioral health organization for all Medicaid beneficiaries.
- Maine PrimeCare, started in 1994, became operational statewide in January 2001; it covers poverty-related Medicaid beneficiaries and CHIP (Medicaid expansion) beneficiaries. MaineNET/Partnership, started in 2000, operates in three pilot PCP sites and covers Medicaid beneficiaries who are either adults with disabilities or elderly. MaineNET participants obtain primary and acute services from their PCP. Partnership participants are people who are receiving long-term care services in the community; in addition to obtaining primary/acute services from their PCP, they also work with a care coordinator.
- North Carolina ACCESS I, started in 1991, is a standard PCCM model that operates in 99 of the state's 100 counties and covers poverty-related and Aged/Blind/Disabled Medicaid beneficiaries. ACCESS II and III, both begun in 1998, are enhanced case management demonstration projects that build on ACCESS I and share its features. ACCESS II has six locally integrated networks and one statewide physician network; ACCESS III includes two countywide plans. Networks typically include physicians, hospitals, public health departments, and other providers. Both ACCESS II and III focus on the development of a local infrastructure that is responsible for an enrolled population and improved quality of care.
- Oklahoma's SoonerCare Choice PCCM Model, begun in 1996, operates in 61 counties (as of January, 2001) and serves poverty-related and Aged/Blind/Disabled Medicaid beneficiaries and CHIP (Medicaid expansion) beneficiaries. Primary/preventive care and case management services are capitated, and specialty services are paid fee-for-service; PCPs also receive a bonus for meeting EPSDT screening goals.
- Texas Health Network, started in 1993 as part of the state's STAR (Medicaid managed care) program, operates in six of the state's eight service areas (in 37 counties); it serves poverty-related Medicaid beneficiaries. STAR+PLUS has operated since 1998 in the Harris Service Area (containing Houston); it serves SSI children and people who meet certain eligibility criteria of the Department of Mental Health and Mental Retardation. The El Paso region has a partially capitated PHP that is being phased out.
- Virginia's MEDALLION, started in 1992, operates in 66 counties and 26 cities. It serves poverty-related and Aged/Blind/Disabled Medicaid beneficiaries and CHIP beneficiaries.
1. HCFA(now known as CMS), letter from Sally K. Richardson, Director, Center for Medicaid and State Operations, PCCM Services Without Waiver, Jan. 21, 1998.
2. Neva Kaye, Cynthia Pernice, Helen Pelletier (Editor), Medicaid Managed Care: A Guide for