MEDICAL CARE;

You asked for a description of primary care case management, how it evolved, and its history in Connecticut.

SUMMARY

Primary care case management (PCCM) is a medical care model in which patients are assigned to a primary care physician who is responsible for managing the quality, appropriateness, and efficiency of the care they receive. PCCM emerged in the 1980s as one model for improving Medicaid fee-for-service systems that were viewed as costly and lacking in quality management. The other model that emerged at that time was managed care. Today, many states use PCCM in their Medicaid programs, either as the sole delivery system or in conjunction with managed care systems.

Connecticut has taken the managed care approach and does not currently use PCCM, although it briefly considered it earlier in this decade. In 2000, the Department of Social Services (DSS) contracted with the Mercer Group as part of a legislatively mandated study of the state’s Medicaid managed care system, including the PCCM option. Mercer’s report identified three PCCM models—basic, enhanced, and premium. These models differed with respect to (1) the level of responsibility given to the primary care provider, which ranged from simply managing referrals to specialists and hospitals to responsibility for quality of outcomes and (2) the level of financial risk the provider was expected to assume, which ranged from none (providers received a small monthly per client administrative fee) to performance-based contracts.

Mercer identified several factors for policy makers to consider in deciding whether to establish a PCCM program and how to design it: provider support, available state staffing and management information system capacity, and the criteria for determining success—cost savings, increased access to care, and improved quality of care.

Mercer recommended beginning with a pilot program either in an area unserved by managed care plans or with a population that was not served by managed care. The legislature in 2001 authorized DSS to establish a pilot program for State and Town Administered General Assistance populations, but it rescinded this authorization in 2002, before DSS initiated any pilot program.

PRIMARY CARE CASE MANAGEMENT

PCCM is a medical care model in which patients are assigned to a primary care physician who is responsible for managing the quality, appropriateness, and efficiency of their care. It is typically implemented as part of a state’s Medicaid program, where it falls between the traditional fee-for-service model and the newer managed care model.

PCCM Evolution

Medicaid services were originally provided only through fee-for-service arrangements; that is patients went to whatever Medicaid participating physician, hospital, or other provider they chose. The provider was paid a fee set by the state Medicaid agency for each service provided. The fee-for-service system had few cost control mechanisms and few checks on the quality of services patients received. In the early 1980s, states began to look for other models with the goal of (1) providing a single primary medical caregiver for each client, (2) promoting preventive care, and (3) implementing some management control over the care provided. PCCM emerged as one approach, managed care plans emerged as another. In some ways the two are similar; the principal difference is that most PCCM programs operate within a fee-for-service structure while managed care plans typically pay providers a fixed monthly fee for each client (capitation fee) regardless of the amount of services they receive.

PCCM Models

The Mercer Group’s study of PCCMs in 2000 for DSS identified three models that states were using in some form or another.

The first, or basic, PCCM model assigns each Medicaid client to a primary care physician (PCP). The PCP provides or authorizes primary or specialty and hospital care, but is usually not responsible for emergency, behavioral health, vision, hearing, or dental care. PCPs receive a monthly case management fee for each client (typically $ 2 to $ 4), regardless of the amount of service they receive, plus the normal fee for each medical service they provided.

A second-stage, or enhanced, PCCM model builds on the basic model and emphasizes cost-effectiveness, improved patient outcomes, and greater state Medicaid agency participation. It uses some of the techniques of managed care. Some of the features of this approach are: patient education and disease management; state and provider collaboration to effectively management service utilization; network management, including provider profiling and access determination; and performance incentives, that is, higher reimbursements based on agreed-upon quality indicators such as vaccination rates.

In the third, or premium, model, the state takes on the role of the managed care plan, either by directly contracting with providers or through an administrative service organization (ASO). In addition to the two previous model’s features, this one involves comprehensive use of managed care practices, use of performance-based contracting for providers, and possible use of risk-based (partial capitation) financial arrangements for providers. In 2001, Mercer said that these models had been employed infrequently, primarily because clients and providers had a negative perception of managed care, providers were not interested, and states saw limited potential for savings beyond the enhanced PCCM model.

Factors for Successful PCCM Development and Implementation

Mercer identified several factors for policy makers to consider in deciding whether to establish a PCCM program and how to design it. These are:

1. a management information system with capacity to handle the scope of the program (Mercer stated that Connecticut’s system at the time was not adequate to do this);

2.

state Medicaid agency staffing levels, which would determine whether the state could administer the program directly or should contract for services;

3. provider support and participation, which was dependent on (a) who is eligible to be a PCP, (b) what medical and administrative functions they would have to fulfill, (c) how much they would be reimbursed, and (d) how their performance would be measured; and

4. the criteria used for determining whether the program is successful, which could be cost containment, increased access to care, improved quality of care, or a combination of these factors.

Mercer also stated that, in developing a PCCM system, the state must consider its effects on the existing healthcare delivery system, including managed care plans, and the potentially adverse effect on existing rate structures.

Because of the complexity and challenges associated with implementing a new health care delivery model, Mercer recommended beginning with a pilot project. It recommended that the pilot either be conducted (1) in a specific geographic region where it would not compete with an existing managed care system or (2) with a population that was not currently served by managed care. The selected population could also be in a limited geographic area for the pilot program. Mercer identified as potential unserved populations (1) the Medicaid-Medicare dually eligible population aged 65 and above, (2) blind and disabled people, and (3) people on State-Administered General Assistance (SAGA).

CONNECTICUT PCCM HISTORY

PA 00-1, June Special Session (§ 31) required DSS to study ways to operate the Medicaid managed care program, including the existing HMO and fee-for-service systems and PCCM. The study was to compare probable costs and quality under each system, including provider and client participation; client access to care and their ease of access; preventive care; treatment referrals; outreach; disincentives to providing care; public ownership of program information and data; and the administrative burdens on providers, clients, and the state. The report, Mercer’s “Assessment of Medicaid Health Care Delivery and Primary Care Case Management,” was completed in spring 2001.

In 2001, the legislature authorized DSS to implement a mandatory PCCM program for both SAGA and town-administered general assistance (Norwich) clients. It permitted the commissioner to contract for both medical services and program management (PA 01-02, June Special Session § 20). The following year, the legislature repealed this authorization, which DSS had not yet implemented, and, instead, permitted DSS to contract with federally qualified health centers to provide medical services to the SAGA and town GA populations (PA 02-7, May Special Session).

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