PRIMARY CARE CASE MANAGEMENT:

AN ALTERNATIVE FOR MEDICAID IN CONNECTICUT

By: Yale University School of Nursing Graduate Students

• Emily Barey, RN
• Eva Gallegos, RN
• Vanessa Morgan, RN
• Patrick Whalen, RN

December 2000

TABLE OF CONTENTS

• Acknowledgements
• Executive Summary
• Introduction
• Methodology
• Results
• Implications
• Conclusion
• Appendix
• References
• Resources

ACKNOWLEDGEMENTS

This study would not have been possible without the assistance of the following persons. Regina F. McNamara, President, Kelsco Consulting Group, LLC, YSN Courtesy Faculty, who shared with us her wisdom and expertise regarding health care consulting. We thank her for all the guidance, support and encouragement given to us this semester. We also thank Ellen Andrews, Executive Director of Connecticut Health Policy Project for making this study possible. Her vision and enthusiasm for exploring alternative strategies to improve access to care for the Medicaid population in Connecticut provided us with the tools necessary for seeing this project through to completion. Her advice, experience, and knowledge on Primary Care Case Management (PCCM) programs was invaluable. Kathleen Bauer, Yale University Medical Librarian, provided additional advice and assistance for our research.

We are especially appreciative of the assistance from local and national state officials who generously shared the data and knowledge about their respective programs. The resource list located in this study has the names of the various state officials we interviewed.

We recognize and thank Yale University School of Nursing for the opportunity to participate in the planning process of this program.

EXECUTIVE SUMMARY

The purpose of this report is to explore policy alternatives for Connecticut's Medicaid Managed Care program. The focus will be on states and their agencies, which administer Primary Care Case Management (PCCM) as a mechanism for implementing managed care within the Medicaid population.

PCCM programs offer the attractive promise of improved access to care while promoting cost efficiency and quality control. This is accomplished by channeling access to care for Medicaid enrollees through a primary care provider (PCP), also known as a "gatekeeper." The PCP is usually not at financial risk, but is responsible for providing primary care with around the clock availability, care coordination and authorization for services.

This report examines 22 states that administer a PCCM program. Most of these states have a combination of PCCM program and a Managed Care Organization (MCO) for delivering Medicaid managed care. In addition to improved access to care, cost efficiency and quality control, study results indicate that some of the states report better continuity of care, improved provider and enrollee satisfaction, and increased provider participation.

The experience of PCCM in the states reviewed lends support to the fact that alternative strategies are necessary for the operation of the current Medicaid Managed care system in Connecticut. It is beyond the scope of this study to exhaustively describe all intricacies of the state PCCM programs. What it does offer, is an overview of how geographically diverse state Medicaid programs have dealt with the challenges of implementing the PCCM program in their states in order to improve access to services and promote cost effectiveness.

Paper | Acknowledgements | Executive Summary | Introduction | Methodology | Results | Implications | Conclusion | Appendix | References | Resources