Less wait­ing

New Calif. HMO rules call for bet­ter ac­cess in ’11

Modern Healthcare - - The Week In Healthcare - Re­becca Ve­sely

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.

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