Emerging Practices in Medicaid Primary Care Case Management Programs. Chapter 1: Introduction

06/01/2001

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.

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