Many of the state officials interviewed emphasized that the development of relationships with participating physicians is critical to keeping physicians enrolled and active in the program. Generally, case-study states reported that physicians accept the PCCM system and often prefer it over an MCO network. One of the physicians interviewed said that he likes the simple logic of PCCM -- linking the patient directly with a PCP. The case management fee is an incentive for the PCP to establish that relationship with his or her patients. As Chart K demonstrates, the case-study states cultivate this willingness to participate by providing information, support, and opportunities for physician input.
Training and Education
All case-study states report that provider education is an ongoing process. It does not end with the approval of the contract, nor can it be limited to the physician only; it must include other health professionals and office staff within the practice. Four of the eight case-study states issue periodic newsletters to inform providers about various policy and financial issues related to PCCM. Specific examples of training/education efforts include:
- Field staff for Florida's MediPass program go to provider offices to deliver training and technical assistance, as do MEDALLION provider relations staff in Virginia. They also conduct regional trainings.
- Iowa's enrollment broker conducts training for the PCPs, including providing information about how to coordinate their patients' care with the state's behavioral health plan.
- In Texas, provider relations representatives employed by the plan administrator are based in the six service areas for PCCM STAR. They conduct provider education, contract compliance sessions, and in-service training routinely and upon request.
States also provide support services to PCPs to assist them with their daily practices and contract responsibilities. Most states maintain a hotline that can assist providers with questions about member eligibility, covered services, authorization requirements, and other issues. Field staff help PCPs work with members who may not understand the program and help problem-solve contract compliance issues.
- Oklahoma provides a toll-free information line for providers and a nurse-advice line that offers 24-7 fill-in coverage, that is, 24 hours a day, 7 days a week, for the PCP so that he/she can meet the contract requirements of a PCP. Staff within the nurse-advice service also follow up with members who appear to be using the emergency room excessively. Exceptional Needs Coordinators (ENCs) have been hired by Oklahoma's Medicaid agency to assist persons with special needs in managed care. One of their functions is to assist PCPs with arranging specialty care that the special needs member may require. They have also provided training to providers about the special needs populations that are required to enroll in managed care. The ENCs work in partnership with provider relations staff, providing a team approach to addressing the physician's concerns.
- Primary care physicians participating in North Carolina's ACCESS II and III initiatives have found the case management provided to their patients by the network to be an asset to their practice. Case managers at the network level, supported by the network's portion of the case management fee, help the physicians coordinate the care of their patients.
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.
Input from PCPs
Many states establish both formal and informal mechanisms by which providers have input into the program. They conduct provider satisfaction surveys, hold focus groups, and organize work groups to address specific program issues. Several states have provider advisory committees for their managed care programs as well as other forums for provider input so that they can maintain ongoing communication with the provider community.
- Alabama has formed the Patient 1st Advisory Council, composed of ten physicians who serve as policy advisors to the Agency. One of their first recommendations was to tighten the contract language to encourage compliance with PCP requirements, particularly in the area of 24-7 coverage.
- Iowa has a Managed Health Care Advisory Committee, composed of six physicians from the state's service regions who provide input to the state on both the MCO and PCCM programs.
- Maine formed a Physician Advisory Committee in June 2000 so that physicians can have ongoing input into the Maine PrimeCare program. The committee is co-chaired by the state Medicaid agency's medical director and the Maine PrimeCare director.
- Oklahoma schedules periodic regional meetings for physicians so that they can give their feedback to the Medicaid agency about various managed care program issues.
- North Carolina has asked physicians to define best practices for the purpose of developing quality improvement measures for the ACCESS II and III programs. The physicians have chosen their own performance measures and, according to state officials, have probably set higher standards for themselves than the state program would have.
Physician satisfaction surveys and anecdotal reports indicate that physicians are generally happy with their participation in PCCM programs. After some initial skepticism, they are satisfied with the case management fee and find that it adds a significant monthly payment to their practice for prevention and patient education activities. They are also glad to be in charge of their patients and not be required to go through an intermediate authorization process. From state officials' comments, physicians seem to want to work with their states to improve the quality of their respective PCCM programs.