Emerging Practices in Medicaid Primary Care Case Management Programs. Evolution

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.

• Use of PCCM by Population

  • Since 1990, states have primarily used PCCM programs to enroll people in the following Medicaid categories of eligibility: AFDC/TANF, poverty level pregnant women, and poverty level children. Medicaid use of PCCM programs for these populations has been fairly stable and very high. Also relatively stable is the use of PCCM for institutionalized populations as a percentage of states with PCCM programs; this has remained fairly low. As Chart B illustrates, states' use of PCCM programs to enroll other populations has fluctuated between 1990 and 1998. Among the states that operate PCCM programs, the number choosing to enroll SSI children increased dramatically; those choosing to enroll SSI adults living in the community dropped and then gained ground.

    Subpopulations excluded or exempted from PCCM programs have remained fairly constant. Most frequently excluded/exempted are: Medicare dual eligibles (excluded in 83 percent of the 29 states operating PCCM programs in 1998), people receiving long-term care in institutions (excluded in 79 percent in 1998) or in the community (excluded in 69 percent in 1998), and people with other insurance (excluded/exempted in 69 percent in 1998). Other subpopulations excluded/exempted from state PCCM programs included: children in foster care (in 62 percent of the states), children with special health care needs (in 31 percent), and American Indians/Alaska Natives (in 28 percent).

    Chart B:

    

• Enrollment Policies

  • States are increasingly mandating enrollment in PCCM for their Medicaid beneficiaries. As Chart C illustrates, in 1990, 63 percent of the 19 states with PCCM programs (a total of 12 states) mandated enrollment; 47 percent (nine states) made enrollment voluntary. (These add up to over 100 percent, as states may use both mandatory and voluntary enrollment, depending on geographic region, population group, or some other factor.) By 1998, 93 percent of the 29 states operating PCCM programs (a total of 27 states) mandated enrollment; 17 percent (five states) made enrollment voluntary.

    Chart C:

    

    States have increasingly used enrollment brokers for their PCCM programs, from 10 states in 1996 to 16 in 1998 — a 40 percent increase. Five states (17 percent of the 29 states with PCCM programs) reported involving community-based organizations in informing and outreach for PCCM in 1998, although the most common venue for informing was the welfare/social service agency (used in 20 states). Other commonly used venues include: the beneficiary's home (18 states), point of service/provider locations (17 states), health fairs (14 states), and community-sponsored events (13 states). Brochures/flyers mailed directly to the beneficiary were the most common way to inform; phone calls were another common informing technique. In most states, beneficiaries were allowed to phone in their PCP selection in order to make enrollment more convenient

    Chart D:

    

• Providers

  • Allowable PCCM primary care providers (PCPs) are typically those who can provide the full range of Medicaid primary care services. All states with PCCM programs allow individual primary care physicians (MDs or DOs) to serve as PCPs (the chart on the previous page); nearly all (27 states, or 93 percent of the 29 states with PCCM programs in 1998) allow physician groups or clinics (including Federally Qualified Health Centers, Community Health Centers, Rural Health Centers, local public health departments, Maternal and Child Health clinics, Indian Health Service clinics and tribal clinics) to do so. As Chart D indicates, states are increasingly allowing specialists to participate as PCPs, as long as they can provide the required services. This may reflect the increase in the number of states enrolling SSI populations, many of whom may already have established relationships with specialists who act as their PCPs. More than half the states with PCCM programs are also allowing physician extenders (nurse practitioners, physician assistants, and nurse midwives) as PCPs. This may relate, in part, to the use of PCCM in rural areas, where physicians may be more scarce.

    Chart D:

    

• Services

  • Chart E:

    

    States require PCPs to directly provide, or authorize through referral, a full range of Medicaid primary care services. Chart E illustrates services commonly provided or authorized by the PCP. Not surprisingly, the most commonly provided/authorized services are physician, inpatient hospitalization, and outpatient diagnostic.

• Quality Activities

  • States are increasingly monitoring quality of care in PCCM programs using multiple strategies. As evidenced in Charts F and G, the strategies with the greatest increased use by states include: spot-checking 24-hour availability of PCPs (from 11 states or 58 percent of the 19 states with PCCM programs in 1990 to 25 states or 86 percent of the 29 states with programs in 1998); member survey/focus groups (from 13 states or 68 percent in 1990 to 25 states or 86 percent in 1998); member hotlines (from nine states or 47 percent in 1990 to 24 states or 83 percent in 1998); and random medical record review (from 13 states or 68 percent in 1990 to 24 states or 83 percent in 1998). Other methods include focused studies, PCCM provider performance feedback, monitoring voluntary disenrollments of members, provider hotlines, disenrollment surveys, on-site state reviews/audits, desk reviews/audits, and ombudsman programs.

    Chart F:

    

    Chart G:

    

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