Emerging Practices in Medicaid Primary Care Case Management Programs. Chapter 7: Service Management

States require PCPs to directly provide or authorize through referral a full range of Medicaid services. Chart O illustrates services commonly provided or authorized by the PCP in the eight case-study states. These states uniformly include primary and preventive services; however, several states allow Medicaid beneficiaries to obtain EPSDT services, immunizations, OB/GYN services, and family planning services from providers other than their PCPs without a referral. These states commonly exclude dental, mental health/substance abuse services, residential care, and long-term care services.

• Referral Policies

  • Referral policies can impact PCCM programs in several ways. First, case-study states reported that the more rigorous the policies, the more accountability is built into the system. On the other hand, more rigorous policies can create obstacles for PCPs as well as their patients, which may discourage the PCPs' continued participation in the program.

    Referral policies vary among the eight case-study states, ranging from a requirement for paper referrals (which can be faxed to the state) prior to authorization to phone referrals with documented follow-up. State officials working solely with paper referrals noted that this is the largest source of complaints among PCPs; however, a physician interviewed noted that MCOs often have the same requirements, so it has become standard procedure.

    Several states expressed concerns that specialists or emergency room physicians were using referral authorization numbers repeatedly and without the PCP's knowledge. A recent study on PCCM programs found that Florida requires its new fiscal intermediary to implement a system to provide a unique number for each specialist referral. Upon need, the provider will place a call to an 800 number, where an automated system will generate a unique referral authorization number valid for 90 days.³³ Several states, such as Maine and North Carolina, send out periodic utilization reports showing referrals; the state follows up incidents with the specialist or emergency room staff in cases where the PCP claims not to have made a referral. Iowa reports on emergency room utilization and pharmacy utilization by members.

    Florida officials noted that they are tightening the prior authorization process by creating disincentives for PCPs to make frequent referrals. They are concurrently increasing their interaction with PCPs in order to make the system more user-friendly.

    Florida also manages pharmacy costs by imposing a four-drug limit on brand-name drugs that have generic counterparts. PCPs wishing to override this limit must seek authorization from the state's pharmacy benefits manager. State officials are pleased with the results of this policy.

    Iowa has a behavioral health organization (BHO) contracted to serve Medicaid beneficiaries, called the Iowa Plan. PCPs can provide mental health services to patients up to 12 times per year without authorization from the Iowa Plan; after the twelfth session, they must obtain this authorization. The state has worked to educate PCPs about the Iowa Plan in the hope that they will make referrals to the plan before the patient's twelfth visit. The state also encourages the Iowa Plan to coordinate with the PCP, since services that it provides may impact the general health of the member.

• Health Needs Assessments

  • In Maine, MaineNET and Partnership staff perform initial and annual assessments on each member. Initial assessments use the P_raPlus tool³⁴, designed to identify people at high risk of hospitalizations unless they obtain additional medical or social support services to lower their risk, as well as to identify needs for cognitive or dementia follow-up. The questionnaire is completed over the phone with the member by the enrollment broker for MaineNET members and the care coordinator for Partnership members. The enrollment broker reviews all questionnaires and calculates a score, which is relayed to the PCP. MaineNET developed its Periodic Preventive Screen with recommendations taken from the U.S. Preventive Task Force. It includes questions on level of function, need for assistance, current service utilization, medical history, preventive screens and immunizations, and follow-up needs. PCPs or care coordinators are to conduct this assessment with each member at least annually; a copy is sent to the state, as well as kept in the medical record.

    ACCESS II and III sites in North Carolina complete health needs assessments on all new members. These are frequently completed by care coordinators working with members. Oklahoma has also implemented health needs assessments to better coordinate care for newly enrolled ABD beneficiaries (as referenced in the Quality Improvement section, earlier in this report).

• Care Coordination

  • Several case-study states have designated care coordinators to assist Medicaid beneficiaries in PCCM programs. North Carolina officials reported that care management, targeted appropriately, has been critical to the success of ACCESS II and III. Many networks have hired their own care managers and developed individual care management initiatives. PCPs appreciate the functions undertaken by care coordinators, including conducting health needs assessments with all new members. For example, care coordinators in sites participating in the asthma disease management initiative³⁵ have

    • implemented a screening process to identify those members who would most benefit from case management;
    • reinforced compliance in managing asthma;
    • performed home visits for environmental assessments and patient education;
    • provided outreach and follow-up for PCP visits for checking compliance with home monitoring;
    • managed and coordinated referrals;
    • educated provider staff and implemented educational activities within the PCP's practice; and
    • assisted individual practices in implementing quality improvement activities.³⁶

    Oklahoma has three Exceptional Need Coordinators (ENCs) serving all Aged/Blind/Disabled Medicaid beneficiaries in PCCM in rural areas. The state is currently seeking to hire one more ENC and also mandates MCOs to employ ENCs in contract requirements. Two ENCs are RNs and the other is a social worker with extensive field experience; state officials are pleased with the combination of skills embodied in these three individuals. ENCs primarily serve Medicaid beneficiaries in PCCM or fee-for-service but also assist the ENCs within MCOs, as needed. PCPs call the state provider representative for their area in order to initiate contact with the ENCs; members can self-refer, or PCPs can call ENCs directly.

    In Texas, regional case managers employed by the plan administrator coordinate medical care (working with the PCP) and non-medical care for certain PCCM members. These workers link with health-related and socioeconomic community resources, working from community-specific information-and-referral databases that can be accessed through the state's web site. Case management staff, employed by the plan administrator, coordinate care for members who meet certain criteria.

    Iowa has 250 providers enrolled in a program in which they receive a periodic list of their members who are due for immunizations and EPSDT screening examinations. The Department of Human Services contracts with the Department of Public Health to provide such notification to all other PCCM members.

    MaineNET's Partnership program serves people who are eligible to receive long-term care services in the community. Upon voluntarily joining the program, these individuals work with a care coordination organization and the PCP to develop a care plan for long-term care services, including necessary social and community services. An employee of the care coordination organization, typically an RN or LSW, is located in the PCP's office. While members do have a choice of PCP, they work with the care coordinator assigned to that PCP's office. The care coordinator works with the member and PCP to implement the care plan through telephone coordination and in-home case management, coordinating services among providers as needed, as well as administering yearly risk screens. The care coordinator also serves as a resource to the PCP and staff, sharing knowledge of long-term care programs and informal services available. The PCP continues to provide primary and acute services and collaborates with the care coordinator on the care plan as necessary; the care coordinator may even attend office visits with the approval of both the PCP and the member. Average caseload per care coordinator is 50-60 clients; potential practice sites are considered for inclusion in the program if their practices have at least 50 potential Partnership clients who would support a full-time care coordinator. The state is currently developing performance measures for the care coordination piece of this program.

• Endnotes

  • 33. See Note 27.

    34. The P_ra Plus tool is designed to identify older adults at high risk medical risk within the next four years, particularly those at highest risk for inpatient care (P_ra = Probability of Repeat Admissions). Copyright 1996 by the Regents of the University of Minnesota.

    35. For more information on this initiative, see the Quality section of this report.

    36. North Carolina Department of Health and Human Services, "ACCESS II and III Plans Asthma Disease Management Program", ACCESS II and III Update no. 2 (2000), 7.

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