New Calif. HMO rules call for better access in ’11
For HMO members in California, the wait to see a doctor could get a lot shorter next year. California regulators last week announced new so-called timely access rules, which aim to make sure managed-care plans have adequate provider networks to meet member appointment requests.
Believed to be the first such regulations in the nation, they stem from a 2002 state law and will take effect on Jan. 17, 2011.
HMO patients must be able to see a nonurgent primary-care or mental health provider within 10 business days, get an appointment with a specialist within 15 days and have access to urgent care that doesn’t require preauthorization within 48 hours, according to the rules.
“California patients are literally sick of having to wait weeks to see a doctor,” said Cindy Ehnes, director of the California Managed Health Care Department, which oversees HMOs in the state and crafted the rules.
The regulations apply to the state’s 21 million HMO members.
The rules also encompass dental care, laboratory tests and wait times for telephone triage.
Securing timely physician appointments has been an ongoing problem in California. In Los Angeles, new HMO and PPO members wait an average of 59 days to see a family practice physician, according to a 2009 study.
The California Medical Association supported the 2002 law and supports the final regulations, but cautioned that HMOs must have enough physicians in their networks to meet the rules. “We want to be sure that HMOs meet these requirements without forcing doctors to shorten patient visits or meet unrealistic quotas that would compromise the quality of care,” said Brennan Cassidy, president of CMA, in a written statement. The CMA also wants to make sure that the state is adequately monitoring the HMOs for compliance, and that health plans are demonstrating that they meet requirements on network adequacy, added a spokesman for the medical association.
The law specifies no set penalties for noncompliance, but the Managed Health Care Department has the authority to investigate health plans and issue fines at its discretion.
For their part, health plans in the state have until October to develop their specific plans on implementing the regulations. “The key is flexibility,” said Patrick Johnston, president and CEO of the California Association of Health Plans. “The rules allow the flexibility to prioritize the range of requests for appointments— from the urgent to the preventative.”
Cassidy, left, says he’s worried about shorter patient visits. Johnston says the rules allow for flexibility in prioritizing appointments.