All of the case-study states reported that their PCCM programs produce savings when compared to fee-for-service programs. Some concern was expressed, however, about what impact the BBA requirements for emergency room usage would have on future savings. As discussed in the Evolution of PCCM section, the BBA requires Medicaid agencies to pay hospitals and physicians for emergency room visits using the prudent layperson standard. All but one of the case-study states (Virginia) indicated that they believed this new language essentially required them to pay for all emergency room visits. Some case-study states reported that PCPs also believed that the new language hampered their ability to manage their patients' emergency room usage. Given that much of the savings from PCCM programs results from improved state and PCP management to prevent inappropriate emergency room visits, they felt this new language would reduce the amount of cost savings that PCCM programs produce.