Primary care case management

Health care in the United States
Government Health Programs

Private health coverage

Health care reform law

State level reform
Municipal health coverage

Primary Care Case Management (PCCM) is a system of managed care used by state Medicaid agencies in which a primary care provider is responsible for approving and monitoring the care of enrolled Medicaid beneficiaries, typically for a small monthly case management fee in addition to fee-for-service reimbursement for treatment.[1] In the mid-1980s, states began enrolling beneficiaries in their PCCM programs in an attempt to increase access and reduce inappropriate emergency room and other high cost care. Use increased steadily through the 1990s.

History

In 1981, the 97th session of Congress enacted the Omnibus Budget Reconciliation Act (OBRA) which allowed state Medicaid programs to implement risk-based managed care programs as well as PCCM, pending HCFA(now known as CMS) waiver approval. The state had to meet two requirements in order to be granted HCFA approval.

In their earliest forms, PCCM programs closely resembled traditional fee-for-service Medicaid than managed care. Some states developed PCCM as a first step towards risk-based managed care and considered their MCO contracts as the main managed care system. As PCCM programs matured, state goals have expanded to improving quality of care provided. States have used strategies similar to network management principles used by MCOs.[3] PCCM programs have evolved over the past two decades through the addition of a variety of care management and care coordination features. These include payment innovations; increased care management resources; improved performance monitoring and reporting; increased resources for management of serious and complex medical conditions; and a variety of “medical home” innovations, including performance-based reimbursement, better use of information technology, increased contact with patients, and efforts to provide additional resources for physician offices.

Intent

By 1986, seven states had implemented PCCM programs.[4] By 1990, that number had grown to 19.[5] States were motivated to implement PCCM programs for several reasons.

Prevalence of PCCM

As of July 1, 2010, approximately 21% of the almost 39 million Medicaid enrollees who were enrolled in a comprehensive managed care plan were enrolled in a PCCM program.[6]

Organization of PCCM Programs

In most PCCM programs, PCPs are paid a per member per month fee for each Medicaid beneficiary or an increase in preventive service fees to pay for case management services. In addition, PCPs are paid on a fee-for-service reimbursement for all primary care services that he/she provides. HMOs are not involved. In return, the PCP is responsible for providing primary care and for prior authorizations to hospitals and specialty care providers.[8]

Physicians bear no financial risk for the services they provide or approve. State Medicaid agencies may include additional activities, such as medical management, network management or performance incentives, to improve outcomes and generate cost savings.[9]

States vary in how they manage provider networks, provider recruitment, data collection and analysis, monitoring, quality improvement, patient education, disease management programs and enrollment. Some states perform all these programs in-house using state employees; other states contract out all or some of these functions.[10]

Scientific Evidence

States that have tried implementing PCCM programs have encountered mostly positive results

See also

References

  1. Joanne Rawlings Sekunda, Deborah Curtis, and Neva Kaye. “Emerging Practices in Medicaid Primary Care Case Management Programs.” Prepared by the National Academy for State Health Policy for the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, June 2001
  2. Deborah A. Freund, Medicaid Reform: Four Studies of Case Management (Washington, DC: American Enterprise Institute, 1984).
  3. Joanne Rawlings Sekunda, Deborah Curtis, and Neva Kaye. “Emerging Practices in Medicaid Primary Care Case Management Programs.” Prepared by the National Academy for State Health Policy for the U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation, June 2001
  4. Maren D. Anderson, Peter D. Fox, "Lessons Learned from Medicaid Managed Care Approaches," Health Affairs 6, no. 1 (Spring 1987): 71-88.
  5. Horvath, J. and N. Kaye, Eds. Medicaid Managed Care: A Guide for States, 2nd Edition. Portland, Maine: National Academy for State Health Policy, 1995.
  6. Medicaid Enrollment in Comprehensive Managed Care Plans by Type. http://statehealthfacts.org. Accessed January 29, 2012
  7. VanLandeghem K and Brach C. Impact of primary care case management (PCCM) implementation on Medicaid and SCHIP. CHIRI™ Issue Brief No. 8. Rockville, MD: Agency for Healthcare Research and Quality. March 2009. AHRQ Pub. No. 090020.
  8. Complete information about the BBA and Medicaid managed care, including the actual text and a series of letter to states from HCFA(now known as CMS) regarding the BBA, is available at http://www.hcfa.gov/medicaid/bbahmpg.htm
  9. Neva Kaye, "PCCM Contracting and Quality Monitoring", Medicaid Managed Care: A Guide for States (Second Edition) (Portland, ME: National Academy for State Health Policy, 1995), 115-135
  10. Silberman P, Poley S, Slifkin R. Innovative Primary Care Case Management Programs Operating in Rural Communities: Case Studies of Three States. http://www.schsr.unc.edu/research_programs/rural_program/wp76.pdf. Accessed August 18, 2006
  11. Cotter JJ, McDonald KA, Parker DA, et al. Effect of different types of Medicaid managed care on childhood immunization rates. Eval Health Prof. Dec 2000;23(4):397-408
  12. Rossiter LF, Whitehurst-Cook MY, Small RE, et al. The impact of disease management on outcomes and cost of care: a study of low-income asthma patients. Inquiry. Summer 2000;37(2):188-202.
  13. Silberman P, Poley S, Slifkin R. Innovative Primary Care Case Management Programs Operating in Rural Communities: Case Studies of Three States. http://www.schsr.unc.edu/research_programs/rural_program/wp76.pdf. Accessed August 18, 2006
  14. Momany ET, Flach SD, Nelson FD, Damiano PC. A cost analysis of the Iowa Medicaid primary care case management program. Health Serv Res. Aug 2006;41(4 Pt 1):1357-1371
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