Medicaid Develops Primary Care Standards for Clinicians

Avoiding Hospitalization Through Better Primary Care

ALBANY, N.Y. (June 12, 2008) – As part of its multi-year initiative to enhance the quality of primary and preventive care, improve the health status of New Yorkers and reduce avoidable hospitalizations and emergency department visits, the Department of Health today announced that all primary care clinicians and programs participating in New York Medicaid will be required to meet a comprehensive set of practice standards beginning in January 2009. Draft standards have been released for public comment at www.nyhealth.gov/health_care/medicaid/standards/.

A team of experienced clinicians and Medicaid analysts in the Department has drafted these primary care standards to provide guidance on the Health Department's expectations of primary care clinicians and programs that contract with Medicaid. The team is led by James J. Figge, M.D., and Foster C. Gesten, M.D., the Medical Directors of New York Medicaid.

"Practices and hospital clinics should put refinement and implementation of these quality standards at the top of their agendas," said state Health Commissioner Richard F. Daines, M.D. "Medicaid patients receive their primary care in settings ranging from private offices to freestanding health centers to the outpatient departments of teaching hospitals. Development of explicit standards will ensure that in each of these settings, patients will receive the same high quality of care and will have an ongoing relationship with a team of clinicians who knows them and their medical history."

The draft standards include the following:

  • Patients should be offered the opportunity to select or change their own primary care clinician;
  • Patients will know the name of their primary care clinician and be given every opportunity to develop an ongoing relationship with that clinician, who will provide continuous, comprehensive care, and when necessary, arrange for inpatient care and consultations with specialists;
  • Primary care clinicians will be expected to coordinate findings and recommendations of specialists, and interpret findings to the patient and patient's family as appropriate and allowable under confidentiality rules;
  • Practices must provide 24 hours a day/seven days a week coverage, reminders to patients who require routine and follow-up services, and referrals for patients who need assistance maintaining or obtaining public or private health insurance.

Commissioner Daines added, "The primary care clinics of our great teaching hospitals are critically important. Not only do many Medicaid patients receive their care in those settings, the standards of care demanded and the attention given to the professional development of trainees will define the primary care environment and create the professional workforce of the future. New York training programs are already national leaders in achieving many of these objectives."

Draft standards applicable to primary care training programs include:

  • One full-time supervising faculty attending for every four residents working at the clinic;
  • Full-time ambulatory training sites must operate at least 40 hours per week, including at least eight hours during evenings/weekends;
  • Where a resident is designated as the primary care clinician, that resident must be part of a stable team including at least one permanent attending clinician.
  • Residents in primary care training must be available to patients several times each week and throughout most of the academic year regardless of other assignments and rotations.
  • Medicaid patients should have the right to request and receive direct care and contact from the supervising attending physician in addition to the resident.
  • Hospitals must measure and report to the Department of Health the percentage of visits in which patients see their assigned primary care clinician.
  • When the designated physician is not available, the primary care team must have a regular coverage arrangement and means to communicate important patient information back to the regular primary care physician.

In recent weeks the Health Department also announced other initiatives as part of its continuous strategy to improve health care quality, ensure patient safety, and avoid unnecessary Medicaid costs. They include:

  • In October 2008 Medicaid will cease reimbursement for hospital care that results from "never events" – which are hospital system failures, such as objects left in the patient during surgery or incompatible blood transfusions.
  • Starting in 2009, Medicaid will use its contracting authority to limit the hospitals with which it will contract for bariatric surgery and breast cancer surgery based on quality.
  • Issuance of a Request for Proposals for a contractor to perform retrospective utilization review of medical services. The selected contractor will review Medicaid claims to identify practice patterns that do not conform to evidence-based standards and/or inappropriate resource utilization and notify medical providers.