Disease management strategies can be seen as both a form of quality improvement and a type of member services. The system is better served through appropriate utilization of services leading to lower overall costs; the chronically ill person is better served by having systematic health care that is state-of-the-art for his/her particular illness.
Services designed to facilitate membership are essential components of high quality health care. Some member services are offered in all the case-study states - complaint and grievance processes, member help lines run internally or by enrollment brokers, enrollee interpreter/translation services, new member handbooks and materials, and the provisi
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.
Emerging Practices in Medicaid Primary Care Case Management Programs. Chapter 5: Quality Improvement
States are increasingly active in monitoring and encouraging quality improvements in PCCM; many are using methods similar to those used within MCOs or to those used to manage their MCO contractors. Many of the case-study states have developed processes for monitoring quality and for passing this information back to PCPs in order that they can impr
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 i
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, whil
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 pr
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
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 tha
Provider participation is one of the cornerstones of a PCCM program. States with successful PCCM programs have worked hard to gain that participation. The case-study states report that they have learned that the time initially invested in educating physicians and practice office staff during the recruitment process pays off in physician participat
Emerging Practices in Medicaid Primary Care Case Management Programs. Who Can Be a Primary Care Provider?
Generally, PCPs in PCCM programs are those physicians who practice primary care, such as pediatricians, family practitioners, general practitioners, internists, and in some instances, obstetricians and gynecologists. States also contract with providers in those settings where many Medicaid beneficiaries customarily seek care: Federally Qualified H
Emerging Practices in Medicaid Primary Care Case Management Programs. Chapter 4: Primary Care Providers
Primary care providers are the heart of a PCCM program. All eight case-study states emphasized the importance of establishing adequate networks of PCPs and of developing relationships with those providers. As one official noted, states must take providers seriously and know how to support and serve them in order to have a successful PCCM program.
23. The PCP receives $3.00 for the first 250 patients on his/her panel and $2.50 per patient thereafter.
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 Servi
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 demonstrati
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 sever
Six of the eight case-study states contract with private entities to perform enrollment functions for PCCM. Alabama and North Carolina retain that function within their state and county governments. In each of the six states, the enrollment broker provides services for MCO enrollment as well. Maine's enrollment broker is also responsible for provi
Emerging Practices in Medicaid Primary Care Case Management Programs. Chapter 3: Organizational Structure and Administration
Several of the case-study states have made significant changes in the administration of their PCCM programs, creating organizational arrangements that more closely resemble contracted managed care networks. Whether state-administered or through contract agreements, these states have identified distinct functions for administration, such as enrollm
3. Deborah A. Freund, Medicaid Reform: Four Studies of Case Management (Washington, DC: American Enterprise Institute, 1984). 4. Maren D. Anderson, Peter D. Fox, "Lessons Learned from Medicaid Managed Care Approaches," Health Affairs 6, no. 1 (Spring 1987): 71-88. 5. See Note 2. 6. Originally, prior authorizations were typically requi