Follow us on Twitter  Like the Connecticut Health Policy Project on Facebook  Read the CT Health Notes Blog  Subscribe to the CT Health Notes Newsletter
Connecticut Health Policy Project
  Improving Connecticut's Health Through Information

PCCM Primer for Policymakers

WHAT IS PRIMARY CARE CASE MANAGEMENT?

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 in some states, acting as a gatekeeper to specialty services. PCPs must provide 24-hour access to information, emergency treatment and referrals and are expected to provide all routine preventive care. PCPs include primary care physicians, clinics, group practices, and nurse practitioners, among others.

Providers bill the state under fee-for-service for the services they provide. PCPs also receive a flat per member per month fee or an increase in their preventive service fees to pay for case management services. Providers bear no financial risk for the services they provide or approve.

IS PCCM USED IN OTHER STATES?

Yes, currently 29 states use some form of PCCM; the majority have both PCCM and HMO programs, often in the same area of the state. Several states with both PCCM and HMOs maintain that parallel systems make both programs stronger, promote accountability, give the state more options in negotiations, and offer consumers more choice.

States with PCCM programs report savings similar to full-risk HMO programs. States see 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 their administrative burden is far less. PCCM in Connecticut could significantly increase the number of providers willing to care for Medicaid and HUSKY patients.

Surveys from states with PCCM programs find greater satisfaction among consumers with PCCM. 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.

HOW COULD PCCM WORK FOR CONNECTICUT?

Consumers may not notice much change at all. They now choose a PCP after they choose a health plan, and must get approval from the PCP for referrals. They should notice an increase in the number of available providers, both because more providers may be attracted to the program, and because they can choose any provider who takes Medicaid, not just one from their health plan's network. They will no longer have to figure out where to call with what problem - they should call their PCP.

States vary in how they manage their provider networks, provider recruitment, data collection and analysis, monitoring, quality improvement, patient education (including toll-free lines), disease management programs, and enrollment. Some states perform all these functions in-house by state employees, other states contract out some functions and Texas contracts out all these functions to one company. Most states monitor client and provider satisfaction annually through surveys.

Under PCCM, the state "owns" the program data and any best practices identified by monitoring. All recipients benefit from effective disease management programs, not just those in one HMO. Under PCCM the state has more control over providers and the quality of services delivered to clients, as the state is paying for them directly.

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 higher quality care. The mechanism for judging quality was designed together with providers.

WHAT ARE THE IMPORTANT QUESTIONS IN DESIGNING THE PROGRAM?

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 -

March 2003