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PRIMARY CARE CASE MANAGEMENTA PRIMER FOR PROVIDERSWHAT 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 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 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 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. Surveys from states with PCCM programs support 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. WHAT TYPES OF PROVIDERS PARTICIPATE IN PCCM?All twenty-nine states with PCCM programs include family practice physicians, pediatricians, internists, general practice physicians, OB/GYNs, group practices, outpatient hospital departments and community health clinics (FQHCs) as PCPs. Some also include nurse practitioners, nurse-midwives, physician assistants, osteopaths, and psychiatrists. Cardiologists, clinical social workers, general surgeons, oncologists, public health departments, hospitals, resident teaching clinics, urgent care centers and pulmonologists are also PCPs in at least one state. Most states allow a flexibility option in which a recipient can apply for assignment to a PCP not on the state's list, if that makes sense for their needs. 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. HOW COULD PCCM WORK FOR CONNECTICUT?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 care. The reduction in administrative burden has also allowed reassignment of current staff to case management functions. HMOs are not involved in PCCM; providers deal directly with the state or an administrative contractor. States vary in how they manage provider networks and recruit new providers. States also vary in whether PCPs are gatekeepers, meaning that consumers must secure a referral from their PCP to access most specialty services. In the absence of a gatekeeping role, it is imperative that PCPs receive timely, accurate information concerning services accessed by their consumers 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. 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. WHAT ARE 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 19, 2003 |