Guidelines for Medical Residents as Primary and Specialty Care Providers -
NYS DPP - 2003
Primary Care
MCOs may utilize Medical residents as participants (but not as
designated 'primary care providers') in the care of enrollees as long as all
of the following conditions are met:
• Residents are a part of patient care teams headed by fully licensed
and MCO credentialed attending physicians serving patients in one or more
training sites in an "up weighted" or "designated priority" residency
program. Residents in a training program which was disapproved as a
designated priority program solely due to the outcome measurement requirement
for graduates may be eligible to participate in such patient care teams.
• Only the attending physicians and nurse practitioners on the
training team, NOT RESIDENTS, may be credentialed to the MCO and may be
empanelled with enrollees. Enrollees must be assigned an attending physician
or nurse practitioner to act as their PCP, though residents on the team may
perform all or many of the visits to the enrollee as long as the majority of
these visits are under the direct supervision of the enrollee's designated
PCP. Enrollees have the right to request care by their PCP in addition or
instead of being seen by a resident.
• Residents may work with attending physicians and nurse
practitioners to provide continuity of care to patients under the supervision
of the patient's PCP. Patients must be made aware of the resident/attending
relationship and be informed of their rights to be cared for directly by
their PCP.
• Residents eligible to be involved in a continuity relationship with
patients must be available at least 20% of the total training time in the
continuity of care setting and no less than 10% of training time in any
training year must be in the continuity setting and no fewer than 9 months a
year must be spent in the continuity care setting (NYS DPP interprets 20% as
288 continuity sessions in 3 years).
• Residents meeting these criteria provide increased capacity for
enrollment to their team according to the following formula:
PGY-1 300 per FTE
PGY-2 750 per FTE
PGY-3 1125 per FTE
PGY-4 1500 per FTE
Only hours spent routinely scheduled for patient care in the continuity
training site may count as providing capacity and are based on 1.0 FTE=40
hours.
• In order for a resident to provide continuity of care to an enrollee,
both the resident and the attending PCP must have regular hours in the
continuity site and must be scheduled to be in the site together the majority
of the time.
• A preceptor/attending is required to be present a minimum of 16 hours
of combined precepting and direct patient care in the primary care setting to
be counted as a team supervising PCP and accept an increased number of
enrollees based upon the residents working on his/her team. Time spent in
patient care activities at other clinical sites or in other activities off-
site is not counted toward this requirement.
• A 16-hour per week attending may have no more than 4 residents on
their team. Attendings spending 24-hours per week in patient
care/supervisory activity at the continuity site can have 6 residents per
team. Attendings spending 32-hours per week can have 8 residents on their
team. Two or more attendings may join together to form a larger team as long
as the ratio of attending to residents does not exceed 1:4 and all attendings
comply with the 16-hour minimum.
• Specialty consults must be performed or directly
supervised by the MCO credentialed specialist. The specialist may be
assisted by a resident or fellow.
• Responsibility for the care of the enrollee remains with the
attending physician. All attending/resident teams must provide adequate
continuity of care, 24-hour 7-day coverage and appointment and availability
access which meets RFP standards.
• Residents who do not qualify to act as continuity providers as part
of an attending/resident team may still participate in the episodic care of
enrollees as long as that care is under the supervision of an attending
physician credentialed to the MCO. Such residents will not add to the
capacity of that attending to empanel enrollees, however.
• Nurse practitioners may not act as attending preceptors for
resident physicians.
Specialty Care
Residents may participate in the specialty care of Medicaid managed care
patients in all settings supervised by fully licensed and MCO credentialed
specialty attending physicians.
• Only the attending physicians, not residents or fellows, may be
credentialed by the MCO. Each attending must be credentialed by each MCO
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 MCO 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’s coverage group in order to
insure ongoing responsibility for the patient by his/her MCO 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’s 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 agency.
• All sites in which residents train must produce legible (preferably
typewritten) consultation reports. Reports must be transmitted so 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.
