Emerging Practices in Medicaid Primary Care Case Management Programs. Executive Summary


Primary care case management (PCCM) is a system of managed care used by state Medicaid agencies in which a primary care provider is responsible for approving and monitoring the care of enrolled Medicaid beneficiaries, typically for a small monthly case management fee in addition to fee-for-service reimbursement for treatment. States began enrolling beneficiaries in their PCCM programs by the mid-1980s to increase access and reduce inappropriate emergency room and other high cost care. State use of PCCM grew steadily during the 1990s.

In many ways, early PCCM programs were more like traditional fee-for-service Medicaid than their managed care counterpart, risk-based programs. 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.

PCCM programs have evolved significantly over time. Each state has taken a slightly different approach, depending in part on the state's particular managed care environment. The eight states studied for this paper (Alabama, Florida, Iowa, Maine, North Carolina, Oklahoma, Texas, and Virginia) were chosen for the range of strategies used in their PCCM programs. What these states have in common is a desire for increased accountability among their provider networks, in order to ensure high quality care for Medicaid beneficiaries.

As PCCM programs have matured, state goals have changed from simply expanding access to better management of the quality of care provided. To this end, case-study states are using strategies in managing their PCCM programs that are similar to network management principles used by MCOs. 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 (Florida, North Carolina, Oklahoma), use of HEDIS or other measures to gauge PCP performance (Iowa, Maine, North Carolina, Oklahoma, Texas), individual and community health needs assessments (Maine, Texas), community-based preventive health educational campaigns (Maine, Texas), and nurse advice lines (Oklahoma, Texas).
  • 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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