PRIMARY CARE CASE MANAGEMENT

A PRIMER FOR CONSUMERS

WHAT IS PRIMARY CARE CASE MANAGEMENT?

Primary Care Case Management (PCCM) is a way of running Medicaid Managed Care - HUSKY or Connecticut Access. Under PCCM, consumers are not members of health plans or HMOs - Anthem/Blue Care, Health Net, Community Health Network or Preferred One/FirstChoice. Consumers choose a doctor, clinic or other provider to be their Primary Care Provider (PCP). That PCP is responsible for routine checkups and health care, to coordinate care, and to guide clients to any other care they need. Providers do not lose or gain money based on the treatments they provide or recommend.

IS PCCM USED IN ANY OTHER STATES?

Yes, twenty-nine other states use PCCM. Surveys show that consumers are very satisfied with PCCM. Most states with PCCM also have HMOs, so many consumers have a choice between the two programs; states report that having two programs makes both work better. Consumers in states with both programs overwhelmingly choose PCCM.

Many states are looking at starting PCCM programs or expanding the programs they have because HMOs are leaving Medicaid. Vermont recently lost all their HMOs and had to start a PCCM program very quickly.

HOW WOULD IT WORK FOR MY FAMILY? HOW WOULD PCCM BE DIFFERENT FROM WHAT WE HAVE NOW?

Right now, after you enroll in the program you choose a health plan. After you've chosen a plan, you choose a doctor or other health care provider to be your PCP. You must choose a PCP that participates in the health plan you chose. You see your PCP for basic, regular health care needs, like check ups, and when you feel sick. If you need tests or to see a specialist, you have to get your PCP's permission (a referral).

The only change you would see under PCCM is that you wouldn't choose a health plan. As soon as you enrolled in the program, you would choose a PCP. You would probably have a choice of more providers for your PCP, as you could choose any that take HUSKY regardless of what health plans they work with.

Under PCCM, you would still see your PCP for most regular health care. You may also have to get their permission to see a specialist. Your PCP would be responsible for finding a specialist who takes Medicaid or HUSKY.

Under PCCM, for urgent problems you would call your PCP (or another number they give you) for help. In a true emergency you should go to the emergency room, in either system.

WHAT ARE THE IMPORTANT QUESTIONS IN DESIGNING THE PROGRAM FOR MY FAMILY?

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 -

• Should PCPs be gatekeepers?
• How to ensure that the program is designed and evolves with effective public input?
• How to design adequate quality monitoring and improvement process that are in place from the beginning?
• How to provide effective training/education for consumers, providers, contractors, state agencies, collaborating community resources and other stakeholders?
• If the state runs a PCCM program parallel to the current HMO system, how to fairly inform new and continuing clients so they enroll in the right program to meet the needs of their family?
• How to ensure that clients with special needs get the care they deserve?

March 19, 2003