PRIMARY CARE CASE MANAGEMENT:

AN ALTERNATIVE FOR MEDICAID IN CONNECTICUT

RESULTS

Driving Forces

The reasons for the adoption the Primary Care Case Management (PCCM) model varies by state, but only slightly. Reports of its use as a method of reducing overall health care costs for Medicaid recipients is unanimous. For example, Maine's program started out as a three county program and was expanded over a four-year period because it showed such impressive cost savings. Georgia's model started out as pilot project and eventually expanded statewide over a three-year period. Massachusetts adopted its PCC model mainly because costs were out of control, as Massachusetts was considered one of the 'easier' states in which to receive Medicaid assistance. In Pennsylvania, the state adopted the model to reduce costs it recognized were largely from the use of the emergency room as a treatment of choice.

Another reason for the adoption of PCCM was the lack of alternatives that existed in some states. Managed Care Organizations (MCOs) were either scarce or non-existent in many locales such as reported by New York and Indiana. In "frontier" states like Kansas, Iowa, and South Dakota, MCOs were unable to sustain operations in light of low population density in large, rural areas of the states. A smaller, individual primary care provider practice, federally supported rural health clinic or Indian Health Service clinic was more suited to serve these areas.

Some states reported having a less than ideal relationship with some MCOs and thus developed PCCM models for that reason. Access to a PCP was also a great motivator in the adoption of the PCCM model. All states report increasing consumer access to a PCP (medical home) in as cost effective a manner as possible, as a major goal in PCCM implementation.

Overall, the states feel their Primary Care Case Management programs are working well and as expected. Massachusetts has a Primary Care Clinician (PCC) program and they report that it is successful and growing year after year. In addition to its PCCM Medicaid model, New York utilizes a PCMP or Physician Case Management Program that is similar to its PCCM program but slightly larger. Through customer satisfaction surveys, Tennessee has demonstrated greater satisfaction among beneficiaries in its' PCCM model when compared to the former straight FFS model. This improvement was seen in three successive surveys. Florida, Virginia, and Indiana specifically report favorable patient satisfaction ratings as being in the 80th to 90th percentile.

Most of the PCCM models have been in existence since the early 1990's with the exception of New York whose 1915(b) waiver originates from 1987 and Kentucky whose waiver originates from 1985. Maine, Massachusetts, Indiana, Georgia, Louisiana, North Carolina, West Virginia, and Iowa use the PCCM model for 50% or more of their total Medicaid populations. (PCCM in both Pennsylvania and New York consist of much smaller percentages of Medicaid recipients at 12% and .4% respectively.) In the study, the largest PCCM models exist in Georgia and North Carolina with 675,000 and 579,119 enrollees respectively. Massachusetts with its PCC program consists of 500,000 enrollees, and 3,000 physicians in 1600 sites. The smallest programs exist in Washington which consists of 4,065 Native Americans, and New York with 5,182 in its' PCCM program and 7,000 in its' PCMP program.

Legislation

The state legislatures have had differing roles in the evolution of the various PCCM programs. The majority of states report solid legislative support for PCCM. For instance, Maine was mandated by its legislature to start the PCCM model because it couldn't attract HMOs to participate in Medicaid. The state feels that the PCCM model is much easier to oversee than MCOs/HMOs because data and feedback is much easier to obtain. Strong legislative support, affecting development of the PCCM model was present and greatly needed as reported by Idaho, Montana, Oklahoma, and Mississippi. New York reportedly likes PCCM/PCMP because unlike the HMO model, local control is maintained. Indiana on the other hand, reports continued lack of solid legislative support. The state is not known as a 'managed care friendly state' and subsequently had to struggle in order to develop a managed care model.

Eligibility and Access

Generally speaking, the Primary Care Case Management programs are mandatory for Medicaid recipients who do not choose capitated managed care programs. This includes those who receive TANF or Temporary Aid for Needy Families, CHIP or Children's Health Insurance Program, pregnant women and children at or slightly above the poverty level, foster children, SSI or Social Security Income recipients not receiving Medicare, and blind and disabled individuals. Among those usually included in PCCM programs are not people receiving Long Term Care (LTC), Medicare, residents of institutions, as well as hospice and medically needy populations. Interestingly, Tennessee reports that it "insures nearly everybody".

PCCM is available countywide in Maine, Pennsylvania, New York, Idaho, Mississippi, Oklahoma, Louisiana, North Carolina, and Iowa with plans to expand statewide in Maine. The remaining states operate statewide programs. Most states report that growing or expanding their current PCCM programs are priorities, except for New York who encourages expansion only in rural areas, which have limited Medicaid penetration. Indiana, Idaho, Mississippi, Oklahoma, Washington, Florida, Georgia, Kentucky, Louisiana, Tennessee, Virginia, West Virginia, Iowa, Kansas, Texas, and South Dakota describe their programs as stable. Pennsylvania reports the phasing in of its' PCCM model in some counties and the phasing out of it in other counties as a result of the expansion of capitated managed care models.

Who is can be a Primary Care Physician (PCP) within the different PCCM programs varies only slightly. Most states recognize general and family practitioners, internists, pediatricians, obstetricians, gynecologists, and nurse practitioners as PCP's. Not only may individual caregivers serve as PCPs, but physician groups, community health centers, community hospitals, out patient departments, rural health clinics, and other federally qualified health centers may participate. Physician assistants are recognized as PCPs in Maine, Florida, Louisiana, North Carolina, Oklahoma, Tennessee, Washington, Virginia, and West Virginia. In many cases this is due to the lack of alternatives. In states with large Native American populations, provider selection is tailored to the needs of the population. This is clearly evident in Washington, where only Native Americans are eligible for PCCM.

The ratio of provider to patients is an important indicator of access to care. Estimated average ratios within these states range from 1 to 53 in Montana, to 1 to 2,000 in North Carolina, Tennessee, and Virginia. The average provider to patient ratio for New York and Mississippi is not known. Provider flexibility within the PCCM Medicaid model is granted as long as certain guidelines/protocols are abided by, such as around the clock availability and ongoing communications with appropriate state agencies. Providers are mandated to stay in touch with the various state agencies that administer each program. This is accomplished in several ways. There is heavy use of monthly/quarterly reports, report cards, and patient/provider satisfaction surveys. Massachusetts utilizes a Network Management Services Department whose only job is to communicate with PCPs very closely. Indiana stresses its use of provider relations representatives as well as the states extensive website. Louisiana utilizes random sampling in its mailing of surveys to recipients and evaluation of their program is based upon survey results.

Costs

Primary care physicians in PCCM are reimbursed on a fee-for-service basis with an additional monthly case management fee. The average fee among the various states is $3 per member per month (PMPM). Interestingly, Maine pays its' PCPs a quarterly bonus (based on performance) in addition to the management fee. Whatever the arrangement, the PCCM model has suppressed PMPM costs. For instance, Indiana, which has reported a large cost savings, has saved approximately 20% PMPM in its PCCM program in comparison to straight FFS for the year 1998. For the same time period, Maine has reportedly decreased PMPM costs by 3.5% in PCCM versus non-PCCM models. Maine mentions PCCM costs as growing considerably less than they would if there was no physician oversight. South Dakota estimates it has saved $16.5 million for fiscal year 1998 with its' PCCM model. In an assessment of its PCCM model, Virginia has shown a 9% cost savings over their former FFS program. Florida reports cost savings ranging from 8.5 % to 19 % over a 27-month period between its PCCM model and straight FFS model. Massachusetts estimates for 1999, its PCC (FFS gatekeeper) model and its capitated MCO model have shown a 3% cost savings PMPM over the straight FFS model. Pennsylvania with its countywide PCCM model has evidently saved 13.7% in 1996 as compared to 1995.

Utilization

The popularity and extensive use of the PCCM models across the states is due in large part to the savings that each state has achieved. These savings are a result of closely managing utilization rates that appear to be decreasing. Most states report emergency room (ER) use has decreased since the adoption of PCCM. Maine, for example, has reduced ER costs by 9% PMPM as compared to straight FFS. Georgia reports that PCCM has dramatically cut back on "ER abuse". Louisiana stresses the importance PCPs have in educating recipients and discouraging unnecessary ER use. Prior to the implementation of PCCM, Tennessee's ER utilization rates were double what they were in 1997. However, Massachusetts and Indiana report continuing struggles with the management of their ER utilization in this population. Similar struggles are reported in Florida, with 73% of recipients continuing to use the ER for inappropriate reasons. Interestingly, in Indiana, 68% of patients report better health since joining PCCM, another 85% report their medical care as either very good or good.

As a result of the PCP acting as the case manager, not only has access to care increased but the use of preventative medicine has as well. For many Medicaid recipients, the PCP is a new concept that allows them to take advantage of information and services aimed at prevention. Many states stress the relationship with one's primary doctor as essential, and it is highly encouraged. With the continuity of care fostered by PCCM, PCPs are able to increase both patient education, and the use of important services/projects that target various diseases and ailments such as asthma, diabetes, and cancers. Maine reports that PCCM has decreased the utilization rates of specialist services because diseases are diagnosed earlier and thus treated more effectively.

Challenges

The challenges inherent in the PCCM model as seen by the states, differ somewhat. While some states express more than others, most challenges are not directly related to the model itself, but related to other issues. For example, Massachusetts reports that a disadvantage to its' PCC model is that it sometimes frustrates clinicians. Many times unassigned patients appear at provider offices randomly. The clinician is then responsible for contacting the patient's assigned physician for direction as to the level of care (if any) to be given. Other problems in the state are the lack of availability of providers in certain areas, and the fact that some members still do not show up for appointments or follow treatment plans. Georgia mentions operational challenges. For example, some PCPs complain that they do not have enough Medicaid patients while others state they have too many. Therefore, there is competition among providers for patients. Pennsylvania reports that PCPs may not possess the wealth of knowledge nor the resources to case manage. They stress that PCPs devote much of their time establishing resources to ensure patients are placed with available services. In essence, it requires them to make changes in behavior as reported by Louisiana. In New York, some feel PCCM is a "pain in the neck" to administer. They report that under this model the clinician is forced to construct his/her own network (who to refer to, who accepts Medicaid, etc), has lots of paperwork, must be available 24 hours a day 7 days per week, and that reimbursement is "God awful". Availability of PCPs was a big challenge in Florida. Providers originally were not complying with the 'around the clock availability' rule until the state began stringent enforcement of this requirement. The state reports that it is in a better position to be more selective of PCPs. The most frequently cited challenges in Tennessee were access to needed medications, inadequate reimbursement, and confusing or complex rules. Indiana clinicians complain of low reimbursement rates, but little else.

Paper | Acknowledgements | Executive Summary | Introduction | Methodology | Results | Implications | Conclusion | Appendix | References | Resources