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OLR Research Report


February 2, 2010

 

2010-R-0037

HUSKY PRIMARY CARE

By: Robin K. Cohen, Principal Analyst

You asked for information on the state's Medicaid primary care case management pilot program (PCCM), HUSKY Primary Care.

SUMMARY

PCCM is a Medicaid health care delivery model that lets Medicaid recipients choose a primary care provider (PCP) to manager their health care. The state pays participating PCPs a monthly per patient fee (typically less than $10) in addition to reimbursing them for services they render to patients. Many states have adopted the PCCM model as an alternative to the traditional “full risk” care offered by managed care organizations (MCOs).

In 2007, the Connecticut legislature directed the Department of Social Services (DSS) to establish a PCCM pilot program. The program (named HUKSY Primary Care), has been available to HUSKY A recipients living in the Waterbury and Windham areas since early 2009. The legislature expanded the pilot program to include the Hartford and New Haven areas beginning on January 1, 2010. As of January 1, 2010, 243 HUSKY A recipients were enrolled in the program, and 223 PCPs had signed on to participate. Most of the PCPs are in the New Haven area.

The state has a federal waiver that enables it to run a Medicaid managed care program, including PCCM. A legislative amendment to the waiver requires DSS to evaluate the PCCM program by July 1, 2010 to determine whether to extend it statewide.

HUSKY PRIMARY CARE

What is Medicaid PCCM?

Two of the most common types of Medicaid managed care service delivery models are risk-based MCOs and PCCM, which is a non-risk managed care model. Under a risk-based model, the state Medicaid program pays an MCO a flat per member per month fee to cover all of the member's health care needs (including any case management that may occur). The MCO assumes full financial risk for doing so.

The Medicaid recipient in a PCCM program chooses a provider to coordinate his or her care, including referrals to specialists. The PCP can be any number of providers, including pediatricians and advanced practice registered nurses. For performing this function, the provider receives from the state a flat monthly amount for each Medicaid patient whose care he or she manages. This is in addition to the reimbursement from the state's Medicaid program for any medical services he or she provides. More than 30 states are using the PCCM model to deliver health care services in their Medicaid programs.

HUSKY Primary Care Pilot Program

PCCM Plan. In response to criticisms that the managed care model was costly and did not provide adequate care management, the legislature directed DSS to develop a plan to begin a PCCM pilot program for at least 1,000 HUSKY A beneficiaries, starting enrollment by April 1, 2008 (PA 07-2, JSS). DSS submitted the plan to the Human Services and Appropriations committees and, in October 2008, the department released a request for applications. The program did not get underway until February 1, 2009, in part because of the time needed to educate and enroll both patients and providers. DSS chose to begin the program in the Waterbury and Windham areas because of their relatively small size.

Managed Care Waiver. In April 2009, DSS applied for a new Medicaid managed care waiver to address many changes the Medicaid program had undergone, including the introduction of PCCM. The Human Services and Appropriations committees amended the waiver to extend the program to HUSKY A recipients in Hartford and New Haven counties starting January 1, 2010. The amendment also calls for extending the program to additional areas that the DSS commissioner approves provided (1) an independent evaluation (see below) finds that PCCM contains costs and improves quality and access to healthcare and (2) an adequate number of PCPs for both children and adult have applied to participate in the program.

Implementation. The HUSKY Primary Care program allows families a fourth option when signing up for HUSKY A benefits. In addition to the three MCOs (Aetna Better Health, Americhoice, and Community Health Network), clients can enroll in the pilot program and choose a PCP who has signed up with DSS to participate. DSS pays the PCP $7.50 for each HUSKY A patient whose care he or she coordinates. DSS encourages families to enroll their child with a pediatrician and the parent or adult caretaker relative with an internal medicine doctor. Other possible PCPs include family medicine practitioners; OB-GYNs; advanced practice registered nurses; physician's assistants; hospital clinics; nurse midwives; and, with prior approval in individual cases, specialists.

Oversight/Evaluation

The Medicaid Managed Care Council is charged with advising the legislature on the HUSKY program, including the HUSKY Primary Care program. It includes a subcommittee devoted exclusively to PCCM. At the subcommittee's November meeting, members suggested that it was too soon to draw conclusions about PCCM because only about 60 members had been enrolled continuously since the February 1, 2009 start of the program. DSS (1) announced that Mercer (a nationally recognized consulting firm that helps state Medicaid programs, including performing program evaluations) would be performing the evaluation called for in the Medicaid waiver amendment and (2) agreed to delay the evaluation deadline to account for the program's slow start. It is not clear that this can occur given that the waiver document requires the evaluation to be done by July 1, 2010.

HUSKY Primary Care Geographic Areas and Enrollment

Table 1 shows cities and towns for the four areas participating in HUSKY Primary Care.

Table 1: HUSKY Primary Care—Geographic Areas (January 2010)

Area

Contiguous Towns

Waterbury

Cheshire, Middlebury, Naugatuck, Plymouth, Prospect, Thomaston, Waterbury, Watertown, Wolcott

Windham

Chaplin, Columbia, Coventry, Franklin, Lebanon, Mansfield, Scotland, Sprague, Windham

Hartford

Bloomfield, East Hartford, Hartford, Newington, Wethersfield, Windsor

New Haven

Hamden, New Haven, North Haven, Orange, Woodbridge

Source: Department of Social Services

Table 2 shows that nearly 150,000 HUSKY A recipients could potentially enroll in HUSKY Primary Care. Of that number, 243 were enrolled as of January 1, 2010.

Table 2: HUSKY Primary Care Enrollment

Area of State

HUSKY A Population (based on November 2009 Enrollment)

% Statewide HUSKY Enrollment for November 2009

PCCM Enrollment as of Januray 1, 2010

Windham/Willimantic

8,158

2.3

31

Waterbury

36,659

10.2

202

New Haven

44,406

12.4

8

Hartford

57,681

16.1

2

Total

146,904

41.0

243

Source: Department of Social Services

Table 3 shows that 223 PCPs had signed up to participate in the program as of January 1, 2010. More than half of them are in the New Haven area.

Table 3: HUSKY Primary Care Provider Enrollment

(as of January 1, 2010)

Area of State

HPC PCPs

New Haven

122

Hartford

47

Waterbury

41

Windham

13

Total

223

Source: Department of Social Services

OTHER RESOURCES

For information on other states' PCCM programs, please see OLR report 2009-R-0216. For a more detailed description and history of PCCM, see OLR report 2003-R-0339.

Additional resources:

1. Medicaid Managed Care Council website, www.cga.ct.gov/ph

2. Connecticut Health Policy Project website, www.cthealthpolicy.org

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