Emerging Practices in Medicaid Primary Care Case Management Programs. Internal Drivers for Evolving PCCM Programs


As PCCM programs have matured, states have turned their focus from simply expanding access to developing methods for better management of their providers. States have learned many network management principles from MCOs, and are increasingly seeking to use these principles in managing their PCCM programs. Ensuring that Medicaid beneficiaries receive quality care is becoming a particularly important activity, as states put tighter language into their PCP contracts and dedicate staff to monitoring compliance with the stricter standards. Programs now often include strict provider credentialing, member surveys, care coordinated across multiple providers and conditions, 24-hour member services, selective provider contracting, HEDIS reporting, member education, disciplined utilization management, disease management programs, complaint log reviews, GeoAccess provider network analytic tools, provider profiles, and other approaches typically associated with MCOs.22

North Carolina is a good example of this expansion of focus. The goal of the original ACCESS program (started in 1991) was to increase access to primary and preventive care. ACCESS II and III (started in 1998) have an additional goal: to help physicians with large Medicaid populations manage their patients in order to improve the quality of care provided, as well as to increase access and cost effectiveness. Further, the state seeks to promote community-based systems of care by retaining dollars in the local delivery system and developing an ongoing commitment to community needs and values.

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