Primary care case management programs demand state-of-the-art quality measures

As states focus on evaluating the quality of health maintenance organizations (HMOs), the performance of their cousins—primary care case management (PCCM) programs—often gets overlooked.

That’s a shame, say the administrators of Massachusetts’ Primary Care Clinical Plan, because PCCM programs deserve and demand the kind of quality assessment typically given exclusively to HMOs.

"Primary care case management programs can be molded to what the state needs and wants," asserted Massachusetts plan director Beth Tortolani. "They can be more than managed care lite.’"

Massachusetts’ strategy to promote quality in its primary care case management plan is centered around Health Plan Employer Data and Information Set and in-house data collection, quality improvement projects and provider profiling.

Quality assessment functions are kept almost completely separate from audit functions and provider relations functions. Occasionally, a problem noticed during a quality assurance visit may be referred to an auditor. More often, a quality assurance official may be called upon to resolve a provider relations issue before quality improvement can be tackled.

"There was no way you were getting into a doctor’s office if they had a billing issue or a provider relations issue. There’s no way they’re talking quality," Ms. Tortolani said.

PCCM programs are compared head-to-head with HMOs in the publication of quality report cards, although administrators admit some limitations in the presentation. For example, even though about 80% of the state’s disabled Medicaid population has chosen primary care case management over an HMO, no risk adjustment is made to account for the difference in the clinical status of patients in the two types of plans. In addition, there are few reliable external benchmarks against which to measure the quality of a Medicaid PCCM program, said Anthony Asciutto, the plan’s assistant director for quality management.

Ms. Tortolani attributed much of the success of Massachusetts’ approach to treating primary care case management providers collectively as a managed care plan. Every six months, Massachusetts’ Medicaid officials use data from paid claims to profile the PCCM plans in five broad areas: well-child care, breast cancer screening, cervical cancer screening, asthma care, and emergency department utilization. Plan and state officials jointly develop an individualized "action plan" to improve the PCCM program’s performance in one or more of the five targeted areas.

The next challenge for the PCCM programs will be to develop carve-outs for specific services and integrate medical care more effectively with behavioral health services, Ms. Tortolani said.