Primary Care Case Management (PCCM) is a way of running Medicaid Managed Care without HMOs. Recipients choose a Primary Care Provider (PCP) who acts as their "medical home". The PCP is responsible for managing their care including providing preventive health services, coordinating care, and acting as a gatekeeper to most specialty services. PCPs must provide 24-hour access to information, emergency referrals and treatment and are expected to provide all routine preventive care.
Providers bill the state under fee-for-service for the services they provide. PCPs also receive a flat per member per month fee to pay for case management services. Providers bear no financial risk for the services they provide or approve.
Yes, currently 28 states use some form of PCCM for their Medicaid programs. A few use PCCM to administer their General Assistance Medical programs; Massachusetts has included their general assistance population in PCCM with Medicaid recipients since 1992. Most states have both PCCM and HMO programs, often in the same area of the state serving the same population, offering providers and consumers a choice. Several states with both PCCM and HMOs maintain that parallel systems make both programs stronger as well as giving consumers more options. States with PCCM programs experienced a decrease in emergency room use, a decrease in specialty services and an increase in the use of preventive care over fee for service levels.
Providers in PCCM states are generally satisfied with the program and are far more positive about PCCM than HMOs. They have more control over medical decision-making and the administrative burden is far less than with HMOs. Texas physicians and providers are spearheading an effort to stop expansion of HMOs into Medicaid and revert back to PCCM for that state. Surveys report that consumers are far more satisfied with PCCM than HMOs. Massachusetts consumers, who have a choice between PCCM and HMOs, overwhelmingly choose PCCM.
Vermont recently lost all the HMOs from their Medicaid program and had to implement a PCCM program quickly. Since the switch, Vermont consumers have enjoyed an increase in available providers. Several other states are considering either instituting PCCM or expanding current PCCM programs in response to Medicaid HMO instability.
States vary in which types of providers can serve as PCPs, but all twenty-eight states with PCCM programs include community health clinics. PCPs agree to provide 24 hour, 7 day a week access to information and care for all their assigned recipients. PCPs are also required to assemble a referral network of specialists that take Medicaid. To encourage providers to participate in Medicaid, some states have systems in place to help with these functions.
The Hill Health Center has operated a PCCM-model system of care for New Haven's SAGA population for over a decade. The arrangement saves money for the state and improves access to care for consumers. Under the current proposal, clients would choose a community health center as their PCP. Community Health Network (CHN), Connecticut's Medicaid managed care health plan created and owned by the community health centers, would administer the program for the state. CHN now cares for 39,142 Medicaid members. Clients who live in an area not served by a clinic would have access to a PCP from the CHN statewide network. Clinics would deal directly with the state or CHN.
Under PCCM, providers contract directly with the state and bill for their services under fee for service. PCPs also receive compensation for case management, generally a flat per member per month fee. In many practices and clinics, this fee has allowed hiring new staff to manage cases. The reduction in administrative burden has also allowed reassignment of current staff to case management functions. States vary in which services require a referral from a PCP. It is imperative that PCPs receive timely, accurate information concerning services accessed by their consumers.
Consumers will benefit from assignment to a medical home. They will not have to search for a provider that takes SAGA. They will no longer have to figure out where to call with what problem - they should call their clinic or PCP. They will also benefit from care management services and disease management programs.
States vary in how they manage their provider networks, provider recruitment, data collection and analysis, monitoring, quality improvement, patient education, community relations, disease management programs, and enrollment. Most states monitor client and provider satisfaction annually through surveys.
Maine operates a PCP incentive payment program - essentially a pool of money beyond case management and service fees -- that is targeted to PCPs who provide quality care. The mechanism for judging quality was designed together with providers.
A clear key to success from other states' experience is to develop any program in an open process that includes meaningful input from consumers, providers, policymakers, researchers and advocates.
There are several important design questions for clinics: