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
Emerging Practices in Medicaid Primary Care Case Management Programs. Components and Innovations in Current PCCM Programs
The bulk of this paper focuses on current innovations in eight states' PCCM programs. The areas with the most frequent activities are described first.
Emerging Practices in Medicaid Primary Care Case Management Programs. Internal Drivers for Evolving PCCM Programs
As PCCM programs have matured, states have turned their focus from simply expanding access to developing methods for better management of their providers. States have learned many network management principles from MCOs, and are increasingly seeking to use these principles in managing their PCCM programs. Ensuring that Medicaid beneficiaries recei
Emerging Practices in Medicaid Primary Care Case Management Programs. Changes in the MCO Marketplace
A study of 15 states with the greatest number of Medicaid managed care members found annual MCO withdrawal rates of 18 percent in 1997 and 15 percent in 1998, compared with 7 to 8 percent each year from 1994 to 1996. 20 In 1998, on average, one commercial MCO entered the Medicaid market for every six MCOs that exited; in 1997, the ratio was close
The Balanced Budget Act of 1997 included provisions specifically affecting PCCM programs. For example, states can now require Medicaid beneficiaries to enroll in managed care, including PCCM programs, by amending their state plans rather than seeking a waiver. The only populations excluded from this state plan option are certain children with spec
Emerging Practices in Medicaid Primary Care Case Management Programs. External Drivers for Evolving PCCM Programs
Both external and internal factors have driven the evolution of states' PCCM programs. The most significant external factors are the Balanced Budget Act and the changing marketplace for risk-based MCOs.