Primary care case management

Health care in the United States
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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. 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.

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. 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.

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

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.

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.

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.

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Wikipedia