Subcommittee on Health Care Reform / Managed Care Recommendations for the Role of Specialty Graduate Medical Education Programs in Medicaid Managed Care
Adopted by the Council on June 8, 1998
The New York State Department of Health is committed to the transition of the current Medicaid financing system to one which is based largely on managed care. The recent approval by HCFA of the State's 1115 Waiver request indicates that over the next few years the vast majority of Medicaid recipients will receive their care through the auspices of one of the licensed managed care plans in New York State. The Health Reform / Managed Care subcommittee views this transition to managed care as an opportunity to develop a one-class and first-class system of medical care in New York State.
Residents in graduate training programs have played a major role in caring for persons enrolled in Medicaid and for the medically uninsured. Over the past year the New York State Council on Graduate Medical Education, through its Health Reform / Managed Care Subcommittee, has developed a set of standards for the involvement of primary care residents in Medicaid Managed Care. These recommendations are now being incorporated into managed care plan contracts by the New York State Department of Health.
This document is an initiative by the Council to establish the standards for the involvement of specialty residents in Medicaid Managed Care1. The following three objectives are prominent in this endeavor:
- the need to protect the rights/needs of patients and to provide a single standard of care for all patients, including commercially insured and Medicaid HMO/PHSP clients,
- the need to bring training program capacity to the aid of Medicaid recipients,
- the need for residents training in specialty care to have experiences caring for people who receive Medicaid and the medically uninsured.
The Council discussed at least four phenomena that will affect residency training as care of Medicaid recipients moves into a managed care setting.
- Specialty care delivered through panels of HMO credentialed specialists is likely to move to private practices or faculty practices of specialists rather than remain in the traditional specialty clinic setting. Primary care physicians, having the choice of referring their patients to specialists in patient-friendly private settings, may increasingly choose this option over referring patients to specialty clinics. Some specialty training programs will likely adapt to this new system of health care delivery and follow the transition of specialty care into the community. For example, surgical training may be advantaged by increasingly moving into ambulatory surgical centers while medical specialty training moves into non-hospital-based medical group practices.
- Some specialty training, like primary care training, requires the ability of a resident to take ongoing care of a patient in a specialty care setting. This requires the development of a schedule that provides the resident and attending the ability to reappoint patients to their own follow-up care. For the patient, this provides an essential level of accountability and responsibility that has not been regularly provided in traditional clinic settings. For the resident this provides the opportunity for learning achieved only by being able to follow acute and chronic problems longitudinally.
- It has been a tradition within many training institutions to encourage specialty consultation in order to enhance the training opportunities of housestaff. This has been used to share the care of interesting problems between specialty services as well as between primary care physicians and specialists. Concern over length-of-stay, the use of clinical guidelines, financial incentives and utilization review criteria which are part of the managed care delivery model may foster a decrease in the utilization of specialty consultation, in both inpatient and outpatient settings.
- Consortia are predicted to play an increasing role in the organization of residency training programs as specialized procedures are regionalized into particular institutions through resource reallocations and managed care market forces.
Proposed Standards of Care for Specialty Graduate Medical Education Programs in Medicaid Managed Care
- Residents may participate in the specialty care of Medicaid managed care patients in all settings supervised by fully licensed and HMO/ PHSP credentialed specialty attending physicians.
Only the attending physicians, not residents or fellows, may be credentialed by the HMO/PHSP. Each attending must be credentialed by each HMO /PHSP with which they will participate. Residents may perform all or many of the clinical services for the enrollee as long as these clinical services are under the supervision of an appropriately credentialed specialty physician. Even when residents are credentialed by their program in particular procedures, certifying their competence to perform and teach those procedures, the overall care of each enrollee remains the responsibility of the supervising, HMO credentialed attending.
It is understood that many enrollees will identify the resident as their specialty provider but the responsibility for all clinical decision-making remains with the attending physician of record.
- Enrollees must be given the name of the responsible attending physician in writing and be told how they may contact their attending physician or covering physician, if needed. This allows enrollees to assist in the communication between their primary care provider and specialty attending and enables them to reach the specialty attending if an emergency arises in the course of their care. Enrollees must be made aware of the resident /attending relationship and must have a right to be cared for directly by the responsible attending physician, if requested.
- Enrollees requiring ongoing specialty care must be cared for in a continuity setting. This requires the ability to make follow-up appointments with a particular resident/attending physician, or if that provider team is not available, with a member of the provider coverage group in order to insure ongoing responsibility for the patient by his/her HMO credentialed specialist. The responsible specialist and his/her specialty coverage group must be identifiable to the patient as well as to the referring primary care provider.
- Attending specialists must be available for emergency consultation and care during non clinic hours. Emergency coverage may be provided by residents under adequate supervision. The attending or a member of the attending coverage group must be available for telephone and/or in-person consultation when necessary.
- All training programs participating in Medicaid managed care must be accredited by the appropriate academic accrediting agency2.
- All sites in which residents train must produce legible (preferably typewritten) consultation reports. Reports must be transmitted such that they are received in a time frame consistent with the clinical condition of the patient, the urgency of the problem and the need for follow-up by the primary care physician. At a minimum, reports should be transmitted so that they are received no later than two weeks from the date of the specialty visit.
Written reports are required at the time of initial consultation and again with the receipt of all major significant diagnostic information or changes in therapy. In addition, specialists must promptly report to the referring primary care physician any significant findings or urgent changes in therapy which result from the specialty consultation.
- All training sites must deliver the same standard of care to all patients irrespective of payor.Training sites must integrate the care of Medicaid, uninsured and private patients in the same settings.
- Many aspects of these guidelines are not applicable to training programs in pathology, radiology, nuclear medicine, and anesthesiology.
- It is recognized that some training programs are not eligible for accreditation and are thus not required to meet this provision. It is also recognized that provisionally accredited programs and those on probation may participate in the Medicaid managed care program as long as they continue to seek full accreditation status.