PUBLIC LAW 99-509—OCT. 21, 1986
100 STAT. 2067
(A) the identity of those procedures which are high volume or high cost procedures among patients who are covered under the State medicaid plan, (B) the payment rates under those plans for such procedures, and the aggregate annual payment amounts made under such plans for such procedures (including the Federal share of such payment amounts), (C) the rate at which each such procedure is performed on medicaid patients and (to the extent that data are available) comparisons to the rate at which such procedure is performed on patients of comparable age who are not medicaid patients, (D) with respect to each such procedure— (i) the number of board certified or board eligible " physicians in the State who provide care and services to medicaid patients and who perform the procedure, and -¥#i*l (ii) in the case of a State with a mandatory second surgical opinion program in operation, the number of physicians described in clause (i) who provide second opinions (of the type described in section 1164 of the Social Security Act) for the procedure at prevailing payment rates under the State medicaid plan, and (E) in the case of a State with a mandatory second ' surgical opinion program or a program of inpatient hospital preadmission review in operation, a description of— (i) the extent to which such program impedes access to necessary care and services, and (ii) the measures that the State has taken to address such impediments, particularly in rural areas. (2) Such report shall also include a list of those surgical procedures which the Secretary believes meet the following criteria and for which a mandatory second opinion program under medicaid plans may be appropriate: (A) The procedure is one which generally can be postponed without undue risk to the patient. (B) The procedure is a high volume procedure among patients who are covered under State medicaid plans or is a high cost procedure. (C) The procedure has a comparatively high rate of cri,£ • nonconfirmation upon examination by another qualified physician, there is substantial geographic variation in the rates of performance of the procedure, or there are other ws,o reasons why requiring second opinions for 100 percent of such procedures would be cost effective. (3) The representative sample of States required to be included in the report shall include States with mandatory second surgical opinion programs in operation, States with programs of inpatient hospital preadmission review in operation, and States with neither such program in operation. (4) In this subsection, the term "medicaid plan ' means a State plan approved under title XIX of the Social Security Act. (c) STUDY.—
(1) The Secretary shall conduct a study of the utilization of selected medical treatments and surgical procedures by medicaid beneficiaries in order to assess the appropriateness, necessity, and effectiveness of such treatments and procedures. (2) The study shall analyze the extent to which there is significant variation in the rate of utilization by medicaid bene-
Health care professionals.
Ante, p. 196. Health care facilities.
Rural areas.
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Health care professionals.
Health care facilities.
42 USC 1396.
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