Emerging Practices in Medicaid Primary Care Case Management Programs. Chapter 9: Lessons Learned: State Perspectives

Those who participated in the interviews conducted for this report provided a wealth of information on how their Medicaid PCCM programs have evolved and the actions they have taken to get their programs to their present incarnations. These state officials had a myriad of advice to share with states looking to replicate the innovations they have implemented.

• Overall Advice

  • The most frequent advice given by case-study states is to use the principles and tools of MCOs, such as prior authorization, performance standards, benchmarks, and quality strategies. This was asserted by the majority of case-study states. Other advice includes

    • Know what the desired accomplishments are, from day one; have specific goals and steps for reaching them; and communicate these goals and steps to key players (including providers).
    • To work well, the program must be both provider- and beneficiary-focused.
    • Evolve slowly: start small and learn from pilot sites before expanding.
    • Keep building a base of political support for the program.

• Organizational Structure

  • Advice on organizational structure emphasized the need for sufficient state investment of personnel and resources:

    • The state investment must be long-term for the PCCM project to show results; building the right infrastructure is an ongoing process and was often more difficult than expected.
    • Dedicate significant internal resources with multiple staff who can respond to questions and concerns from members and providers. Locating these staff at the local level will increase buy-in, as their knowledge of community services makes them more effective resources for providers and members.
    • Consider how local communities can be empowered to change the service delivery system. Partnering with localities takes a long time and creates a great deal of work, but the resulting program can be very successful.
    • In contracting with a plan administrator, include an adequate reimbursement rate in order to be able to expect best practices.

• Providers

  • Case study state officials agreed that provider commitment is the key to their success. Their advice stressed identifying and implementing ways to obtain the buy-in of a wide variety of providers.

    • Meet with medical societies and other key players who can positively influence providers to participate in the program.
    • Face-to-face communication with providers (both PCPs and practice staff) is key to good state-provider relations.
    • Set expectations for providers from the beginning; make clear that this is not just another fee-for-service program.
    • Do your homework in communities before beginning to recruit providers: physically inspect offices and meet with all practice staff.
    • It is critical for state staff to support providers on an ongoing basis, to take their concerns seriously, and to develop new ways to better serve them.
    • Allow providers to police themselves; second-guessing their decisions does not work. The state's job is to provide the tools to facilitate that process (e.g., utilization review, provider profiling, information on best practices) and to work with outliers to get their practices in line with state expectations.
    • Work with providers to modify inappropriate patient behaviors (e.g., emergency room use).

• Quality Activities

  • Case-study states have implemented a broad range of mechanisms to ensure high quality care for members. Therefore, their advice covers a wide range of issues.

    • Have a plan, from the start, for quality improvement processes.
    • Use multiple methods for obtaining beneficiary and provider feedback.
    • Include physicians on advisory committees so that messages and recommendations are more palatable to their peers and greater PCP buy-in for program policies can be obtained.
    • Provide a base for member outreach and education activities; conduct such activities on an ongoing basis.
    • Hands-on beneficiary education can promote appropriate emergency room use and facilitate access to timely preventive care.
    • Disease management programs are beneficial for the state, PCPs, and beneficiaries.

• Finance

  • States with incentive payment systems noted that these systems can be very effective in reinforcing the state's key program goals.

• Service Management

  • States with active care coordination components to their PCCM programs reported that providers and beneficiaries found them very helpful. Other recommendations included

    • Recognize that the referral process is key to managing services
    • Make prior authorization and other state-required procedures as hassle-free as possible for providers.
    • Employ care coordinators who are familiar with the community and available resources. Collaborate with existing services (e.g., WIC).

• Enrollment

  • State advice on enrollment focused mostly on additional roles a contracted enrollment broker can play.

    • Use the enrollment broker to recruit providers, in order to learn the area before starting member enrollment.
    • Use the enrollment broker for member education.
    • Do not try to enroll a great number of people into a mandatory program all at once; providers prefer to have new patients trickle in, rather than adding 100 new patients on any given day.

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