State Health Commissioner Daines Announces Selective Medicaid Contracting for Breast Cancer Surgery

State Health Department Selects Hospitals to Provide Breast Cancer Surgery to Medicaid Patients

ALBANY, N.Y. (March 3, 2009) Starting March 1, 2009, New York Medicaid will pay for breast cancer surgery only at those hospitals and ambulatory surgery centers that perform at least 30 of these surgeries annually.

Given that recent medical peer-reviewed literature has cited the association between higher breast cancer surgery volume and higher rates of five-year survival, State Health Commissioner Richard F. Daines, M.D., said, "This action should help improve the lives of women on Medicaid who are diagnosed with breast cancer. In several types of surgery, practice does improve the surgeon, and we believe that tax dollars invested in Medicaid should be invested in high-quality health care for our patients."

The move comes as the Department of Health (DOH) continues to reform Medicaid to ensure it is buying high-quality, cost-effective care for Medicaid beneficiaries.

"For women to survive breast cancer, they need access to medical services and high quality care," said Dave Momrow, Sr. Vice President of Cancer Control, American Cancer Society of NY & NJ. "The state's decision to limit breast surgery for Medicaid patients from low volume to higher volume hospitals makes sense since research shows a strong connection between procedures done at high volume facilities and the five-year breast cancer survival rate."

Initially, 52 facilities will be affected by the new policy. The low-volume facilities to be excluded were identified by examining DOH's all-payer hospital and ambulatory surgery center data from 2005-07. Facilities that averaged fewer than 30 surgeries a year during that time will no longer be paid by Medicaid for conducting mastectomy or lumpectomy procedures.

Forty-six of the state's 62 counties have within them a facility that exceeds the minimum volume threshold, thereby reducing potential access issues for women who are faced with a breast cancer diagnosis. In addition, excluded facilities will still be able to conduct diagnostic tests for breast cancer and provide post-operative care such as reconstruction, chemotherapy and radiation.

The decision to exclude low-volume facilities will apply to both Medicaid-eligible women in fee-for-service as well as women enrolled in a managed care plan.

DOH will re-examine all-payer breast cancer surgery volume annually and modify accordingly its list of hospitals and ambulatory surgery centers with which Medicaid will contract with for such surgery.

In addition, DOH is seeking applications from hospitals who want to be designated as Medicaid providers of bariatric surgery. Like lumpectomies and mastectomies, gastric bypasses and in installation of lap bands are procedures where the data show improved results for patients at higher-volume hospitals. Applications are required by April 6; the Web site address for DOH's Request for Applications is at www.health.ny.gov/funding/rfa/0810300900/.

Governor David A. Paterson's Executive Budget includes the following quality improvements for New York Medicaid:

  • Enhanced payments for primary care providers who met primary care standards or achieve certification as a "medical home."
  • Coverage for cardiac rehabilitation, screening for persons at risk for substance abuse and smoking cessation for postpartum women and children age 10-19.
  • Quality of care incentives for nursing homes and home care providers.

A list of the hospitals that will continue to provide breast cancer surgery to New York Medicaid patients is listed on http://www.health.ny.gov/press/releases/2009/hospitals_and_ascs_approved_for_breast_cancer_surgery.htm