Emerging Practices in Medicaid Primary Care Case Management Programs. Feedback to PCPs


As PCCM programs have evolved, some states have developed reporting mechanisms to provide participating providers with information about the costs and service utilization of their patients. These reports vary in the level of detail that they provide; some simply provide aggregate information about service utilization of the physician's panel, while others compare utilization of the practice with that of other providers. A few states also include lists of services that individual patients have obtained to provide a comprehensive picture of the members' utilization histories.

  • North Carolina produces a quarterly utilization report for PCPs in ACCESS, including such targeted service reports as emergency room use. This gives the PCP information about where patients are seeking services. The PCP can then work with the local managed care representative to do some follow-up with patients who appear to have used services inappropriately. Physicians participating in ACCESS II and III receive similar utilization reports, with the addition of data from the initial risk assessments that are conducted with all ACCESS II and III members.
  • The Maine PrimeCare program produces the quarterly Maine Primary Provider Profile. The report provides information on cost and utilization in a number of areas, comparing the experience of the physician's Maine PrimeCare members and fee-for-service patients with those statewide in his/her specialty. In addition to member per month costs and utilization rates, the report also provides lists of the PCP's Maine PrimeCare members who have used the emergency room or been hospitalized within the quarter. The information in the quarterly report is used to determine incentive payments in the Primary Care Provider Incentive Payment system. (Please refer to the sections on Quality Improvement and Finance for more details.)

Feedback to the PCP is one of the key elements of provider satisfaction, according to the physicians interviewed for this report. One physician is very pleased with the utilization reports he receives from the state and likes how his practice information is compared to that of other physicians within his specialty. He believes that these reports help him and his colleagues manage their patients appropriately. He adds, however, that it is up to the PCP to respond to the comparative information and change his/her practice, if necessary. The other physician interviewed practices in a state that does not currently provide reports to the PCP on patient utilization. He would like to see data on his patients' utilization of services and would like to know how he compares to his peers. He is particularly concerned about his patients' use of the ER. He feels that this is the information that can make the difference between a PCCM program and a traditional fee-for-service program.

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