Background: Many states have operated PCCM programs to provide services to the majority of Medicaid recipients for several years. Such programs typically lock-in recipients to a single PCP who manages medical care by providing authorization for hospital and specialty physician services. In addition to regular fee-for-service reimbursement, PCPs are paid nominal monthly case management fees (approximately $2 to $3 PMPM). The population of high-cost Medicaid recipients is one that is typically included in most PCCM programs, yet may not receive the level of service that would most benefit them from both a quality of care and a cost effectiveness standpoint.
Methods: A population of Georgia PCCM participants was analyzed for a period of twenty-four quarters (1/94 to 12/99). This population remained in the upper quintile for total medical costs for each of these quarters. Average annual visits to PCPs were calculated in order to determine the level of involvement of the PCP.
Results: While these individuals utilized medical services at extensive levels, the majority (58%) saw PCPs less than once per quarter. Of this group 29% saw PCPs less than once per year and 15% never saw a PCP for the entire period they were in the PCCM program.
Conclusions: It is recommended that states adopt more intensive, disease specific, case management approaches that more effectively manage the care provided to high-cost recipients. Such care should not only benefit the state in controlling costs but should provide better care and better outcomes to this vulnerable population.
Learning Objectives: To focus attention on important sub-populations such as high-cost recipients who may not be adequately managed by traditional primary care case management (PCCM) plans administered by many state Medicaid programs.
Keywords: Disease Management, Case Management
Presenting author's disclosure statement:
Organization/institution whose products or services will be discussed: Georgia Department of Community Health, Division of Medical Assistance
I do not have any significant financial interest/arrangement or affiliation with any organization/institution whose products or services are being discussed in this session.