New York to Nail Down the Facts About Medicaid Services to Ensure High Quality Care Based on Good Science and Good Practice

ALBANY, N.Y. (May 8, 2008) – Do Medicaid patients receive appropriate medical care, based on scientific evidence and best practices? The state Department of Health is undertaking a comprehensive review to answer that question as part of its strategy to improve health care quality, ensure patient safety, and rein in unnecessary Medicaid costs.

The Department has issued 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.

"We're working hard to enroll eligible New Yorkers in Medicaid and Child Health Plus to ensure access to health care," Commissioner Richard F. Daines, M.D., said. "We also must make sure that appropriate care is given. And, like any other insurer, we want to pay for quality care, and ensure that providers do not order excessive tests or medications that could react badly with other medications a patient is taking. This helps increases patient safety."

The Department is also revising Medicaid's current utilization threshold program. Enacted nearly 20 years ago, the system has assigned each patient the same number of services, regardless of his or her medical condition. The revised program will use clinical evidence to establish patient-specific threshold limits based on diagnoses and severity of illness. Patients who are sicker, or who have multiple chronic conditions, will have access to more services because they need more services than healthy enrollees. This will reduce paperwork and costs for both the taxpayers and Medicaid care providers. Providers will still be able to ask for increased services for a patient, providing appropriate justification.

In addition, Medicaid is expanding its retrospective drug utilization review (DUR). The review identifies over- and under-utilization of prescription drugs and alerts prescribers to avoid adverse drug reactions. Prescribers will receive clinical educational intervention letters describing the best prescribing practices.

"We want to work with Medicaid providers on the same goal – better care and, ultimately, better health of our Medicaid patients," Dr. Daines said.

Starting January 1, 2009, the fees paid to physicians will increase by an average of 46 percent. For example, the fee paid for a physician office visit for a new patient will increase from $30 to $55. Physicians will receive an additional payment for scheduled evening and weekend appointments; physicians practicing in health professional shortage areas will receive a 10 percent payment enhancement. Fees for other providers, including nurse practitioners, midwives, psychologists and physical and occupational therapists, will also be increased.

Responses to the RFP are due Aug. 15. The documents can be viewed at the Department's Web site: