Emerging Practices in Medicaid Primary Care Case Management Programs. Impact


PCCM programs have been successful in increasing the access of Medicaid beneficiaries to primary care physicians and creating medical homes, but the impact on costs is more mixed. In certain studies, access and utilization of primary care were noticeably improved, due largely to these provider-patient relationships. While some states showed reduced costs (including New York, 8 and Arkansas 9, no reduction was found in others (including Maryland,1011 Missouri,12 and Utah).13 In some of the latter states, utilization patterns for emergency rooms, specialty care, and prescription drugs remained unchanged. Possible explanations for this include:

  • Traditionally-run PCCM programs usually provide little incentive for either physicians or beneficiaries to change their behavior. Since services are reimbursed fee-for-service, more services equal greater reimbursement. The referral process for specialty and hospital care, by itself, does not cut down on this care. In some states, such as Utah, procedures do not exist for denying reimbursement for a Medicaid beneficiary receiving unauthorized services, so specialists and emergency rooms have no economic incentive to deny care to patients who self-refer.14
  • With greater access to primary care, it is possible that more health problems that require additional care, such as prescription drugs or specialty care, may be detected.


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