Enhanced Primary Care Case Management Program
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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.[1]
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. [2]
- These 8 million consumers participate in PCCM programs in 31 states.
- There are 11 states which offer PCCM as the only managed care option.
- Illinois, North Carolina, Texas and Louisiana have the largest PCCM programs, each with over 700,000 enrollees.
Organization of PCCM Programs In traditional PCCM programs, providers bill the state directly under fee-for-service for the services they provide. HMOs are not involved. PCPs also receive a flat per member per month fee or an increase in preventive service fees to pay for case management services. 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. 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.
Scientific Evidence
Enhanced Primary Care Case Management a managed care initiative designed to control healthcare costs in hospitals across the United States. It is a systematic approach to healthcare for members experiencing high utilization/high costs with chronic or episodic health concerns. EPCCM supports the role of the primary care provider (PCP) through case management coordination that enhances collaboration and communication among providers and with the member.[3]
References
- ^ 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
- ^ Medicaid Enrollment in Comprehensive Managed Care Plans by Type. http://statehealthfacts.org. Accessed January 29, 2012
- ^ Iowa Foundation for Medical Care, IMFC Response to the Iowa Department of Human Services - RFP #MED-04-034; Tab 9, pg 85, March 26, 2004