Emerging Practices in Medicaid Primary Care Case Management Programs

June 2001

Joanne Rawlings-Sekunda
Deborah Curtis
Neva Kaye
National Academy for State Health Policy

Produced for the
U.S. Department of Health and Human Services
Office of the Assistant Secretary for Planning and Evaluation

Contents

Acknowledgments

Executive Summary

Chapters

1. Introduction
   • Studied States
2. Background: Evolution of PCCM
   • First Wave
     • Intent
     • Characteristics
     • Impact
   • Evolution
     • Use of PCCM by Population
     • Enrollment Policies
     • Providers
     • Services
     • Quality Activities
   • External Drivers for Evolving PCCM Programs
     • Balanced Budget Act (BBA)
     • Changes in the MCO Marketplace
   • Internal Drivers for Evolving PCCM Programs
   • Components and Innovations in Current PCCM Programs
3. Organizational Structure and Administration
   • Third Party Contracting
   • State Variations in PCCM Administration
     • Texas: Texas Health Network
     • North Carolina: ACCESS
     • Maine: MaineNET/Partnership
4. Primary Care Providers
   • Who Can Be a Primary Care Provider?
   • Provider Recruitment
   • Provider Retention
     • Training and Education
     • Support
     • Feedback to PCPs
     • Input from PCPs
5. Quality Improvement
   • Quality Monitoring
   • Member Services
   • Disease Management
6. Finance
   • Case Management Fees
   • Capitation
   • Financial Incentives for Performance
   • Savings
7. Service Management
   • Referral Policies
   • Health Needs Assessments
   • Care Coordination
8. Enrollment
   • Populations Enrolled
   • Enrollment Process
   • Enrollment of Special Needs Populations
9. Lessons Learned: State Perspectives
   • Overall Advice
   • Organizational Structure
   • Providers
   • Quality Activities
   • Finance
   • Service Management
   • Enrollment

Conclusions

Appendices

1. Appendix A: Case Study States' Contacts
2. Appendix B: North Carolina ACCESS II & III Core Elements of the Asthma Disease Management Program
3. Appendix C: Case Study States' Enrollment Policies

Acknowledgments

This document could not have been produced without the support of the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (DHHS/ASPE). Special thanks go to Jennifer Tolbert for her direction and encouragement.

Thanks also go to the many state officials who participated in interviews and reviewed the draft:

• Kimberly Davis Allen and Jacqueline Gray of Alabama
• Maresa Corder of Florida
• Dennis Janssen, Diana Kading, and Dann Stevens of Iowa
• Deborah Blanchette, Katherine Levasseur, Brenda McCormick, and Gino Nalli of Maine
• Denise Levis, Jeffrey Simms and Torlen Wade of North Carolina
• Nancy Austin, Charlene Benson, Melinda Jones, and Rebecca Pasternik-Ikard of Oklahoma
• Jill Melton, Susan Milam, Dee Sportsman,and Cynthia Walker of the state of Texas, and Carla Barnes, Vicki Jones, Ann Prescott, and Sandy Tyler of Birch and Davis (the plan administrator for Texas' PCCM program)
• Scott Cannady of Virginia

Finally, the authors would like to thank the physicians who agreed to be interviewed for the report:

• Roger Hofford, M.D., of Virginia
• Burtt Richardson, M.D., of Maine

We appreciate that these individuals took time from their very busy schedules in order to help us better understand their primary care case management programs. We salute them for their hard work in developing and administering these innovative programs.

Executive Summary

Primary care case management (PCCM) is a system of managed care used by state Medicaid agencies in which a primary care provider is responsible for approving and monitoring the care of enrolled Medicaid beneficiaries, typically for a small monthly case management fee in addition to fee-for-service reimbursement for treatment. States began enrolling beneficiaries in their PCCM programs by the mid-1980s to increase access and reduce inappropriate emergency room and other high cost care. State use of PCCM grew steadily during the 1990s.

In many ways, early PCCM programs were more like traditional fee-for-service Medicaid than their managed care counterpart, risk-based programs. Some states developed PCCM as a stepping stone to risk-based managed care, and therefore considered their MCO contracts as the predominant managed care system. That emphasis has been shifting, however, in those states that are experiencing a decrease in contractors as MCOs choose to exit Medicaid managed care.

PCCM programs have evolved significantly over time. Each state has taken a slightly different approach, depending in part on the state's particular managed care environment. The eight states studied for this paper (Alabama, Florida, Iowa, Maine, North Carolina, Oklahoma, Texas, and Virginia) were chosen for the range of strategies used in their PCCM programs. What these states have in common is a desire for increased accountability among their provider networks, in order to ensure high quality care for Medicaid beneficiaries.

As PCCM programs have matured, state goals have changed from simply expanding access to better management of the quality of care provided. To this end, case-study states are using strategies in managing their PCCM programs that are similar to network management principles used by MCOs. The case-study states are employing innovative strategies in the areas of:

• Organizational structure and administration, such as use of a plan administrator to implement the state's policies and decisions (Texas), programs focusing on population management (North Carolina), and a demonstration project geared to Medicaid beneficiaries who are receiving long-term care services at home (Maine).

• Provider recruitment and retention, including a greater focus on supporting participating providers through specially designated provider outreach staff (Alabama, Florida, Virginia, Texas), provider hotlines (Alabama, Iowa, Maine, North Carolina, Oklahoma, Texas, Virginia), feedback mechanisms such as provider profiling (Maine, Alabama, Texas), and strategies to gain providers' input and suggestions (nearly all case-study states).
• Quality activities, such as disease management programs (Florida, North Carolina, Oklahoma), use of HEDIS or other measures to gauge PCP performance (Iowa, Maine, North Carolina, Oklahoma, Texas), individual and community health needs assessments (Maine, Texas), community-based preventive health educational campaigns (Maine, Texas), and nurse advice lines (Oklahoma, Texas).
• Finance modifications, such as incentive payment systems (Maine, Oklahoma) and capitating primary/preventive services (Oklahoma).
• Service management, such as care coordinators within PCP offices for people eligible to receive long-term care services at home (Maine) and health needs assessments (Maine, North Carolina).
• Enrollment functions, such as targeted processes used to facilitate the enrollment of populations with special needs (Alabama, Oklahoma).

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