Emerging Practices in Medicaid Primary Care Case Management Programs. Conclusions


As Medicaid managed care has evolved during the past decade, states have balanced the development of their PCCM programs with the growth and/or decline of risk-based managed care. Each state has taken a slightly different approach, depending in part on the state's particular managed care environment. Some states developed PCCM as a stepping stone to risk-based managed care, and therefore considered their MCO contracts as the predominant managed care system. That emphasis has been shifting, however, in those states that are experiencing a decrease in contractors as MCOs choose to exit Medicaid managed care. State officials in several of the case-study states commented that their states' initial expectations for the growth of managed care contracting have not been realized, and therefore, they are focusing more on PCCM as the major form of Medicaid managed care. Others, however, continue to anticipate expanding their risk-based programs.

Many states use the PCCM model of managed care in rural areas where there is not sufficient population density to support a contract with an MCO. Among the case-study states, Virginia and Oklahoma, in particular, have developed separate managed care initiatives to serve distinct areas of their respective states. PCCM is the managed care system in the states' rural areas, and MCO contracts are limited to urban areas. Several state officials note that physicians in rural areas are reluctant to join an MCO network, and prefer the PCCM model for serving their patients.

Among the eight case-study states, Alabama, Maine, and North Carolina rely almost exclusively on PCCM for their Medicaid managed care delivery systems. Alabama and Maine expected to see managed care contracting develop into the principal managed care system in their states, but in both instances that has not been the case. Alabama retains MCO contracting in pockets of urban areas but Patient 1st is its major managed care initiative. Maine had one contract with an MCO to serve certain areas of the state, but the state Medicaid agency discontinued that contract in December 2000 and is transitioning all members to Maine PrimeCare. In North Carolina, only one county has a mandatory MCO program; five counties have a choice between an MCO and North Carolina ACCESS; and in the remaining 93 counties, ACCESS is the mandatory managed care program.

Seeing PCCM as a significant piece of a long-term managed care strategy has led many case study state Medicaid agencies to make changes in their approaches. As PCCM programs have matured, state goals have evolved from simply expanding access to better management of the quality of care provided. States learned many network management principles from MCOs, and are increasingly using these strategies in managing their PCCM programs. The case-study states are employing innovative strategies in the areas of:

  • Organizational structure and administration, such as use of a plan administrator to implement the state's policies and decisions (Texas), programs focusing on population management (North Carolina), and a demonstration project geared to Medicaid beneficiaries who are receiving long-term care services at home (Maine).
  • Provider recruitment and retention, including a greater focus on supporting participating providers through specially designated provider outreach staff (Alabama, Florida, Virginia, Texas), provider hotlines (Alabama, Iowa, Maine, North Carolina, Oklahoma, Texas, Virginia), feedback mechanisms such as provider profiling (Maine, Alabama, Texas), and strategies to gain providers' input and suggestions (nearly all case-study states).
  • Quality activities, such as disease management programs, use of HEDIS or other measures to gauge PCP performance, individual and community health needs assessments, community-based preventive health educational campaigns, and nurse advice lines.
  • Finance modifications, such as incentive payment systems (Maine, Oklahoma) and capitating primary/preventive services (Oklahoma).
  • Service management, such as care coordinators within PCP offices for people eligible to receive long-term care services at home (Maine) and health needs assessments (Maine, North Carolina).
  • Enrollment functions, such as targeted processes used to facilitate the enrollment of populations with special needs (Alabama, Oklahoma).

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