Advice on organizational structure emphasized the need for sufficient state investment of personnel and resources:
The most frequent advice given by case-study states is to use the principles and tools of MCOs, such as prior authorization, performance standards, benchmarks, and quality strategies. This was asserted by the majority of case-study states. Other advice includes
Emerging Practices in Medicaid Primary Care Case Management Programs. Chapter 9: Lessons Learned: State Perspectives
Those who participated in the interviews conducted for this report provided a wealth of information on how their Medicaid PCCM programs have evolved and the actions they have taken to get their programs to their present incarnations. These state officials had a myriad of advice to share with states looking to replicate the innovations they have im
37. Specifically, the BBA exempts the following populations from mandatory enrollment in Medicaid managed care; dual Medicare-Medicaid eligibles; American Indians/Alaska Natives who are members of federally recognized tribes; and children who are eligible for SSI, in home and community-based settings, in foster care or other out-of-home placement,
Emerging Practices in Medicaid Primary Care Case Management Programs. Enrollment of Special Needs Populations
A few of the case-study states have made specific accommodations in their enrollment processes for special needs populations. The practices of Alabama and Oklahoma are of particular interest.
The enrollment process is fairly standard from state to state, and PCCM programs face similar issues and challenges in developing systems that provide adequate information and notification to members. States are increasingly using private vendors to conduct enrollment and other functions for their managed care programs. Six of the eight case-study
State Medicaid programs include several eligibility groups in their PCCM programs. With the exception of the MaineNET/Partnership program, the eight case-study states require mandatory participation of certain eligibility groups. Most states selected AFDC/TANF eligibles and related eligibility categories for initial enrollment in their Medicaid ma
33. See Note 27. 34. The P ra Plus tool is designed to identify older adults at high risk medical risk within the next four years, particularly those at highest risk for inpatient care (P ra = Probability of Repeat Admissions). Copyright 1996 by the Regents of the University of Minnesota. 35. For more information on this initiative, see th
Several case-study states have designated care coordinators to assist Medicaid beneficiaries in PCCM programs. North Carolina officials reported that care management, targeted appropriately, has been critical to the success of ACCESS II and III. Many networks have hired their own care managers and developed individual care management initiatives.
In Maine, MaineNET and Partnership staff perform initial and annual assessments on each member. Initial assessments use the P ra Plus tool 34 , designed to identify people at high risk of hospitalizations unless they obtain additional medical or social support services to lower their risk, as well as to identify needs for cognitive or dementia fol
Referral policies can impact PCCM programs in several ways. First, case-study states reported that the more rigorous the policies, the more accountability is built into the system. On the other hand, more rigorous policies can create obstacles for PCPs as well as their patients, which may discourage the PCPs' continued participation in the program
States require PCPs to directly provide or authorize through referral a full range of Medicaid services. Chart O illustrates services commonly provided or authorized by the PCP in the eight case-study states. These states uniformly include primary and preventive services; however, several states allow Medicaid beneficiaries to obtain EPSDT service
28. See Note 2 for source of all 1998 information. 29. California reported using both methods and is, therefore, counted twice in these statistics.
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 hospita
Emerging Practices in Medicaid Primary Care Case Management Programs. Financial Incentives for Performance
As reported in other National Academy for State Health Policy work, 32 states have begun to create financial incentives for good MCO performance. Two case-study states have extended this concept to their PCCM programs. Both use bonus payments to enhance the medical home concept by rewarding PCPs who provide the best access to key primary care ser
The BBA's definition of a PCCM provider 31 does not exclude providers who are capitated for providing services, thus creating a new class of capitated PCCM programs. HCFA(now known as CMS), however, also considers PCPs in capitated PCCM programs to be either PHPs or MCOs (depending on the package of capitated services) and regulates them as such.
Paying a case management fee plus fee-for-service is the dominant payment method among the eight case-study states. Only one, Oklahoma, did not use this reimbursement method, since it pays a capitated rate. (This system is detailed later in this section.) Among the seven case-study states that pay case management fees, $3 per person per month is
Early PCCM programs were implemented when Medicaid reimbursement rates to physicians were extremely low compared to the rates of other payers. Many Medicaid agencies were concerned about retaining sufficient provider participation to offer adequate access to primary and preventive care. As a result, contracted PCPs were not asked to accept any fin
24. Maine used an EQRO in the past; these reviews are now conducted by state staff. 25. The model of rapid cycle quality improvement was developed by the Institute for Healthcare Improvement. It focuses on the processes of "plan, do, study, and act", and stresses setting aims, establishing measures, and making system changes to remove barriers t