Emerging Practices in Medicaid Primary Care Case Management Programs. State Variations in PCCM Administration

Texas STAR program, the state's Medicaid managed care program, is comprised of three models: MCO, PHP and PCCM (Texas Health Network). The administration of Texas Health Network program resembles that of a managed care organization. According to state officials, the PCCM program is a state-administered health plan. The state has entered into several contracts for program operation but does not require its contractors to assume any financial risk. The state Medicaid agency has developed what they describe as an enhanced PCCM model, featuring increased member services, significant case management, improved services to providers, and linkages between services. Texas Health Network began as a pilot program and has gradually expanded to six service areas in the state. The state now has the following four separate contracts for the administration of the program:

• plan administration;
• enrollment;
• claims processing; and
• certain quality improvement activities.

Originally, claims processing was included in the plan administrator's responsibilities, but state officials subsequently decided that there would be better checks and balances if the functions were not combined.

The core of Texas Health Network is the contracted plan administrator. This contractor is responsible for provider network development and contracting, provider services, member services, case management, utilization management, and health and wellness education. Field staff are located in the six regional service areas in which the STAR program has implemented the PCCM model, where they can provide information and assistance directly to both members and network providers. In addition to negotiating contracts with PCPs, the plan administrator has the authority to negotiate state contracts with hospitals. Using claims data that is provided through the fiscal agent, the contractor sets hospital payment rates for PCCM members.

State staff maintain that having a plan administrator is a great asset to the program, because it allows for greater flexibility in managing the resources dedicated to the program and, ultimately, better program support. The plan administrator can provide adequate staffing and resources to the program, without state limitations on personnel and on the transfer of funds between categories. Staff note that the burden is on the state to ensure that sufficient funds are in the contract so that the administrator can do the work required. State Medicaid agency staff work closely with plan administrator staff, viewing the contractor as the state's administrator of the PCCM program. The state retains the authority for policy development and decisions. Financial goals are set for the plan administrator, and the contract is monitored quarterly through selected financial measures, required reporting, and state contract oversight.

North Carolina has embraced the concept of state and local partnerships in the development and implementation of its PCCM program. State agency officials view the development of infrastructure at the local level to be one of the most important aspects of their successful PCCM initiatives. The state began Carolina ACCESS as a small PCCM demonstration in 1991, and expanded by county, achieving statewide coverage in 1999. The Medicaid agency funds a position at the regional level to work with both members and providers. Known as a managed care representative, this individual is based at the regional social services office and provides a link with the various providers and services in the community. By taking a gradual county-by-county approach and providing representation and accountability within the community, state officials believe that their agency built credibility and an acceptance of the ACCESS program, as well as preparing each region prior to implementation.

The ACCESS II and III programs began with the state issuing a letter in 1997 to the 35 provider groups in the state that had the largest number of Medicaid patients, to gauge their interest in participating in a PCCM program that focused on quality as well as access, in exchange for a greater case management fee. The response was overwhelmingly positive, so the state issued a Request for Proposals (RFP), asking respondents to propose how they would partner with the other providers in their area to manage the care of their members. ACCESS II and III are network-driven, combining physicians, hospitals, public health, social services, and other community-based services.

Currently, there are seven ACCESS II sites serving local regions, with the exception of a large provider network that spans 32 counties. The two ACCESS III sites are countywide networks composed of physicians, hospitals, health departments, departments of social services, and other community providers. The ACCESS II and III networks are paid an enhanced case management fee of $5.00 per member per month. The PCP receives the usual monthly $2.50 case management fee per patient ²³, and the remaining $2.50 goes to the network's administrative entity for case management and administrative functions related to the network's enrolled population. With this network approach to PCCM, case management is an expectation of not only the individual PCP but also of the ACCESS II and III networks. In addition, the networks are expected to build a community service delivery infrastructure and promote collaboration among providers.

North Carolina has invested in the development of local infrastructures with each of the ACCESS programs. The state has promoted an enhanced model of PCCM and has helped the networks build service delivery collaboration at the local level to avoid duplication. State officials firmly believe that partnerships — both within communities and between the state and local providers — are essential to the long-term success and sustainability of North Carolina's PCCM system.

MaineNET is a voluntary PCCM program for Maine's elderly and disabled adults. A second component of the program, the MaineNET/Partnership, serves Medicaid beneficiaries who are receiving long-term care at home through the state's Home and Community-based Waiver (HCBS) program. MaineNET/Partnershipis a program of the Maine Department of Human Services (DHS), but it is a complex program that involves multiple agencies, both state and private, in its administration.

Within DHS, the Medicaid agency is responsible for the overall administration of the program and the state unit on aging is responsible for policy development and implementation. The enrollment broker under contract with the Medicaid agency conducts enrollment, as it does for Maine PrimeCare. The state unit on aging administers two separate contracts for services related to Medicaid members who are eligible for long-term care services, including those beneficiaries who are eligible for the Partnership component of MaineNET. One contract is responsible for the determination of medical eligibility for long-term care services; the other arranges long-term care services for those found eligible. In the case of Partnership members, this contractor (the Health Care Coordinating Agency [HCCA]) provides a care coordinator who manages the member's home- and community-based long-term care services.

The Medicaid agency contracts with selected physician practices to participate as MaineNET/Partnership PCPs. These practices are selected based on the high number of patients in the Home and Community Based Services (HCBS) waiver program. The practices develop collaborative agreements with HCCA so that a care coordinator can be located at the MaineNET/Partnership practice.