Emerging Practices in Medicaid Primary Care Case Management Programs. Chapter 2: Background: Evolution of PCCM

The Omnibus Budget Reconciliation Act (OBRA) of 1981 allowed state Medicaid programs to implement both PCCM and risk-based managed care programs, pending HCFA(now known as CMS) waiver approval. HCFA(now known as CMS) approval required that the state satisfy two requirements.

• The case management restrictions must not "substantially impair access" to primary care services of "adequate quality where medically necessary;" and
• The case management restrictions must be "cost effective."³

Many states focused their first efforts in managed care on PCCM programs, with the goal of moving to risk-based contracting later.

As of 1998, 13 percent of all Medicaid beneficiaries (4.1 million people) were served through PCCM providers in 29 states. ¹⁵ Although the number of states has fallen from a high of 33 in 1994 (see Chart A), the number of beneficiaries since that time has risen (from 2.4 million in 1994).¹⁶

The National Academy for State Health Policy (NASHP) has conducted four surveys of state Medicaid managed care programs since 1990. The information collected from all 50 states and the District of Columbia gives a strong sense of the evolution of PCCM programs. The information in this section is taken from the most recent edition of Medicaid Managed Care: A Guide for States.¹⁷

Chart A.

Both external and internal factors have driven the evolution of states' PCCM programs. The most significant external factors are the Balanced Budget Act and the changing marketplace for risk-based MCOs.

As PCCM programs have matured, states have turned their focus from simply expanding access to developing methods for better management of their providers. States have learned many network management principles from MCOs, and are increasingly seeking to use these principles in managing their PCCM programs. Ensuring that Medicaid beneficiaries receive quality care is becoming a particularly important activity, as states put tighter language into their PCP contracts and dedicate staff to monitoring compliance with the stricter standards. Programs now often include strict provider credentialing, member surveys, care coordinated across multiple providers and conditions, 24-hour member services, selective provider contracting, HEDIS reporting, member education, disciplined utilization management, disease management programs, complaint log reviews, GeoAccess provider network analytic tools, provider profiles, and other approaches typically associated with MCOs.²²

North Carolina is a good example of this expansion of focus. The goal of the original ACCESS program (started in 1991) was to increase access to primary and preventive care. ACCESS II and III (started in 1998) have an additional goal: to help physicians with large Medicaid populations manage their patients in order to improve the quality of care provided, as well as to increase access and cost effectiveness. Further, the state seeks to promote community-based systems of care by retaining dollars in the local delivery system and developing an ongoing commitment to community needs and values.

The bulk of this paper focuses on current innovations in eight states' PCCM programs. The areas with the most frequent activities are described first.

3. Deborah A. Freund, Medicaid Reform: Four Studies of Case Management (Washington, DC: American Enterprise Institute, 1984).

4. Maren D. Anderson, Peter D. Fox, "Lessons Learned from Medicaid Managed Care Approaches," Health Affairs 6, no. 1 (Spring 1987): 71-88.

5. See Note 2.

6. Originally, prior authorizations were typically required for emergency room use as well, but this practice is now prohibited by the BBA (see below).

7. Neva Kaye, "PCCM Contracting and Quality Monitoring", Medicaid Managed Care: A Guide for States (Second Edition) (Portland, ME: National Academy for State Health Policy, 1995), 115-135.

8. T.C. Rosenthal et al., "Medicaid Primary Care Services in New York State: Partial Capitation vs. Full Capitation," Journal of Family Practice 42, no. 4 (April 1996): 362-368.

9. A. Muller, J.A. Baker, "Evaluation of the Arkansas Medicaid Primary Care Physician Management Program," Health Care Financing Review 17, no. 4 (Summer 1996): 117-133.

10. J.A. Schoenmann, W. N. Evans, C. L. Schur, "Primary Care Case Management for Medicaid Recipients: Evaluation of the Maryland Access to Care Program," Inquiry 34, no. 2 (Summer 1997): 155-170.

11. A. Gadomski, P. Jenkins, M. Nichols, "Impact of a Medicaid Primary Care Provider and Preventive Care on Pediatric Hospitalization," Pediatrics 101, no. 3 (March 1998): E1.

12. Robert E. Hurley, J.E. Paul, Deborah A. Freund, "Going into Gatekeeping: an Empirical Assessment," Quality Review Bulletin 15, no. 10 (Oct. 1989): 306-314.

13. Stephen H. Long, Russell F. Settle, "An Evaluation of Utah's Primary Care Case Management Program for Medicaid Recipients," Medical Care 26, no. 11 (Nov. 1988): 1021-1032.

14. See Note 13.

15. See Note 2.

16. See Note 2.

17. See Note 2.

18. Complete information about the BBA and Medicaid managed care, including the actual text and a series of letter to states from HCFA(now known as CMS) regarding the BBA, is available at http://www.hcfa.gov/medicaid/bbahmpg.htm.

19. According to the letter from Timothy Westmoreland (Director, HCFA(now known as CMS) Center for State and Medicaid Operations) dated April 18, 2000, an emergency medical condition is "a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part."

20. M. Gold, et al., Medicare Managed Care: Preliminary Analysis of Trends in Benefits and Premiums, 1997-1999. (Washington, DC: Mathematica Policy Research Inc., 1999).

21. Susan Felt-Lisk, The Changing Medicaid Managed Care Market: Trends in Commercial Plans' Participation. (Washington, DC: Mathematica Policy Research Inc., 1999).

22. Charles Milligan, "States Building Second-Generation Primary Care Case Management Programs in Medicaid Managed Care, Competing Against HMOs," News and Strategies for Managed Medicare and Medicaid 6, no. 8 (Feb. 28, 2000): 6-7.