Emerging Practices in Medicaid Primary Care Case Management Programs. Quality Monitoring


The case-study states conduct a variety of activities related to quality monitoring and improvement, many of which have traditionally been associated with MCOs. As Chart L indicates, all eight states conduct member satisfaction surveys (often the CAHPS survey) and/or focus groups. All monitor 24-hour access; most monitor utilization. Six (Florida, Iowa, North Carolina, Oklahoma, Texas, and Virginia) conduct focused studies (on such state-chosen topics as asthma, immunization [either children or older adults], prenatal care and pregnancy outcomes, access for populations with special needs, hypertension, diabetes, dementia, and EPSDT screening); Maine has contracted an NCQA reviewer to improve methods for designing, tracking, and reporting these studies. Oklahoma is nearing completion on an encounter data validation study for their capitated PCCMs. Five (Florida, North Carolina, Oklahoma, Texas, and Virginia) have contracted with external quality review organizations (EQROs) to conduct reviews of medical records; 24 three of these states (Florida, Texas, and Virginia) also conduct medical records reviews internally. Iowa and Maine also conduct internal medical records reviews.

State Program Quality Activities Included
Chart L:
Quality Activities
Alabama Patient 1st Claims data examined for utilization (Medicaid agency), computer generated survey on Medicaid beneficiaries based on services received (e.g., ER use), monitoring 24-hour access
Florida MediPass Random medical records reviews (independent agency and Medicaid), disease management, focused studies, member surveys/focus groups, monitoring 24-hour access
Iowa MediPASS Focused studies, member surveys/focus groups, monitoring 24-hour access, HEDIS measurements, random medical record review, Managed Health Care Advisory Committee review and oversight of all quality activities
Maine Maine PrimeCare Random medical records reviews (Medicaid agency), CAHPS surveys, 24-hour access monitoring
MaineNET/ Partnership PCP must do annual preventive screen, results sent to be used as quality indicator
North Carolina ACCESS I Random medical records reviews (PRO), focused studies, member surveys/focus groups, HEDIS (generated from claims data), monitoring 24-hour access
ACCESS II Uniform standards of care, standard set of performance measures, local responsibility for quality (work with providers on-site), uses NCQA to credential PCCM in some networks, pediatric asthma care and diabetes care quality measurement projects
Oklahoma SoonerCare Choice PCCM Model PRO review (random medical records reviews), uses HEDIS to compare PCCM and MCOs in urban areas, focused studies surveys/focus groups, QARI and modified QISMC, quality assurance committee, encounter data validation study in process, monitoring 24-hour access, enrollee surveys
Texas Texas Health Network PCCMs credentialed and recredentialed every 2 years using QARI, Texas Dept. of Health, and NCQA standards, random medical records reviews (independent agency and Medicaid), member surveys/focus groups, focused studies, Quality Management/ Improvement Committee meets quarterly, special project on diabetes, complaints, appeals, auditing 24-hour access, annual community health needs assessments
Virginia MEDALLION Random medical records reviews (PRO and Medicaid), disease management program evaluates health outcomes, focused studies, member surveys, drafting provider profiling reports, monitoring 24-hour access

Iowa's Birth Outcomes Study is an example of a focused study. The goal of the study was to compare risk-adjusted quality of care provided to Medicaid mothers and babies in fee-for-service, PCCM, and MCOs. All included records were of mothers who were enrolled for at least 18 months of Medicaid eligibility, including during the pregnancy, and enrolled in the same MCO during the last two months of pregnancy. The study was performed in two stages: comparing outcomes of PCCM and MCO programs in 1999, and MCO and fee-for-service in 2000. In 1999, the sample included 741 PCCM members and 532 MCO members. Conclusions included: PCCM neonates had longer lengths of stay for very low birth weights, but MCO neonates had longer stays for low birth weights; slightly less than 50 percent of mothers in both payment systems had received adequate prenatal care; and maternal and neonatal mortality outcome scores in both programs were better than national averages.

Some states have implemented certain program components/features that are showing success in quality monitoring and improvement.

  • Provider profiling: Maine uses provider profiling as part of its incentive payment system for physicians in the PCCM program. On a quarterly basis, pediatricians, family practices/group practices, internists, and OB/GYNs receive scores for measures related to each of the goals shown in Chart M. They are then ranked with other members of their provider group. Quarterly payments are made to physicians within the top 20th percentile within each provider group. (For more information on the payment structure, please see the Finance section of this report.) Although in cases of group practices or physicians working for hospitals, the physicians may not see the payments; the profile reports are sent directly to each physician. Both state officials and a physician interviewed for this study agreed that physicians appreciate obtaining this information. State officials noted that PCPs pay close attention to the scores and rankings; the state receives approximately 25 calls after each profile is released from physicians seeking ways to improve their scores.
  • Texas also distributes provider profiles, which are risk-adjusted and have peer group comparisons, to providers. Outliers are identified and education performed. Alabama will begin distributing provider profiles in Spring 2001. MaineNET monitors practice profiles in demographics, clinical practice, quality indicators, utilization, and cost; however, this information is for state use only. Virginia and North Carolina are currently determining the indicators to be included in future provider profiles. A physician from a state without provider profiling who was interviewed for this study asserted that he would appreciate having the opportunity to compare his performance with that of his peers.
Goal Weight Measures
Chart M:
Maine PrimeCare Primary Care Physician Incentive Payment Program Scoring System
Reduce disincentives to having higher Medicaid patient panels 40%
  • Average panel size (unduplicated Medicaid patients)

  • Maine PrimeCare costs (per member per month)

  • Percentage requesting to change PCPs

Reduce inappropriate emergency room utilization


  • Average number of ER visits (per patient per year)

  • Percentage of ER users having repeat ER visits

  • ER patients (list of names attached)

  • Potentially avoidable hospitalizations (admission rates per 1000 Medicaid clients per year

    1. Asthma

    2. . Pneumonia

    3. Severe ENT infections

    4. Kidney UTI

    5. Congestive heart failure

    6. Gastroenteritis

  • Hospitalized patients with above conditions (list of names attached)

Increase the utilization of preventive services 30%
  • Average number of EPSDT encounters (per patient per year)

  • Number of EPSDT/Bright Futures forms required/number of EPSDT visits billed

  • Percentage of children age 0 to 20 with 1 or more EPSDT visits in the last year

  • Well-child visits in first 15 months of life (percentage of patients having 5 or more visits)

  • Well-child visits in 3rd, 4th, 5th, and 6th years of life (percentage with a well-child visit in the past year)

  • Adolescent well-care visits: ages 12-21 years (percentage with a well-care visit in the past year)

  • Cervical cancer screening (percentage of women age 21 to 64 with a Pap smear in the past year)

  • Breast cancer screening (percentage of women age 52 to 70 with a mammogram in the past 2 years)

  • Pre-natal care in the first trimester (percentage of women starting pre-natal care within the first trimester)

  • Diabetes — retinal exams (percentage of diabetics with a dilated retinal exam in the past year)

  • Diabetes — HgbAlc (percentage of diabetics with an HgbAlc test in the past year)

  • Diabetes — Lipid Tests (percentage of diabetics with a Lipid test in the past year)

  • Lead screening rates: 1st year

  • Lead screening rates: 2 year olds


  • Local accountability: North Carolina's ACCESS II and III networks are required to follow uniform standards founded on evidence-based best practices measured through a standard set of performance measures. Each network is responsible for quality monitoring and improvement; state staff work on-site with these networks to facilitate a rapid cycle quality improvement process. 25 Local networks define and select performance measures. Examples of quality improvement initiatives include: identifying and decreasing inappropriate emergency room use, improving processes for referrals and prescriptions, managing inpatient admissions through education and follow-up, developing a health screening process to identify members needing case management, and program-wide asthma and diabetes disease management programs.
  • Use of HEDIS/other measures: Iowa, Maine, North Carolina, and Oklahoma use HEDIS measures to monitor PCCM providers. Oklahoma uses this data to compare its PCCM and MCO Medicaid programs in urban areas. Maine compares PCCM, MCO, and fee-for-service Medicaid programs, as well as commercial programs, across 15 measures. Iowa uses HEDIS for internal analysis; the first series of results were provided through an independent organization in August 2000.

Oklahoma formerly used QARI and now relies on modified QISMC standards to compare PCCM and MCOs. Texas uses QARI standards. Oklahoma will soon begin on-site reviews with a sample of providers; focus areas will include finance, care management, professional services, and member services.

  • Advisory committees: Alabama, Iowa, Maine, and Texas have quality improvement committees, usually composed of participating physicians. Oklahoma's newly formed committee looks at all forms of Medicaid (fee-for-service, PCCM, and MCO) and has a physician participating in PCCM. Maine PrimeCare has a physician advisory committee; MaineNET/Partnership has a clinical advisory group which requires the participation of at least one PCP from each pilot site. These advisory committees deal with issues other than those strictly of quality, such as confidentiality concerns. (For more information on these committees, see the Primary Care Providers section of this report.)
  • Community health needs assessments: Texas counties conduct annual community health needs assessments in six regions, surveying both members and physicians. These assessments form the basis for planning educational efforts. Educational topics resulting from these assessments include pediatric illnesses, otitis media, and sexually transmitted diseases (STDs).
  • Targeted surveys (in addition to all-member satisfaction surveys): Alabama generates a list (from computer databases) of Medicaid beneficiaries who have used specific services (e.g., emergency room) and sends surveys to the people on this list. This survey asks four or five questions on such issues as patient wait times and satisfaction. State officials use the survey as a concentrated way to determine specific needs for a doctor or service.

Florida, Virginia, Texas, and Maine conduct periodic provider surveys to gauge their satisfaction with the PCCM program; Maine surveys both PCPs and office staff. Maine PrimeCare is in the process of piloting a FAACT survey to assess the delivery of care to children up to the age of four and will be surveying adolescent members using a tool also developed by FAACT.

  • Pharmacy management: Florida, Oklahoma, Texas, and Maine have pharmacy management structures in place for their Medicaid managed care programs, including PCCM. Florida limits the number of brand-name pharmaceuticals (for which a generic equivalent exists) to four in both the PCCM and fee-for-service Medicaid programs, after which the PCP must get prior authorization. Texas identifies overutilizers of pharmacy services and performs outreach, often linking the member with plan services that include member education and case management. All MaineNET PCPs must participate in the MaineNET Pharmacy Management Program, which focuses on polypharmacy and medication review, appropriate prescribing within targeted chronic conditions, and cost-effective prescribing within targeted major drug categories, through information provided by the Medicaid Physician Directed Drug Initiative. The state provides ongoing pharmacy reports for each MaineNET member to his/her PCP, including all prescriptions filled. The Maine Medicaid agency's narcotics project for pain management has a physician to oversee the pharmacy use of beneficiaries (including Maine PrimeCare members) who have large numbers of pain prescriptions, such as oxycontin.

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