Calfornia HMOs must provide care within 10 days under new law

March 1, 2010

Timely access to treatment for HMO patients in California has been a long time in coming as HMOs, physicians, hospitals, and consumer groups battled it out.

"The new rules on timely access represent a compromise," says Patrick Johnston, president and CEO of the California Association of Health Plans, a statewide trade association representing 39 full-service health plans. "Health plans felt it was important to strike a balance between ensuring patients don't face unnecessary delays for care and leaving room for doctors to use their professional judgment in prioritizing patient care."

A first-of-its-kind regulation by the California Department of Managed Health Care requires that patients be treated by HMO doctors within 10 days of making an appointment and by specialists within 15 days. In addition, the law provides for urgent care appointments that don't require prior authorization within 48 hours of a request and within 96 hours for urgent care appointments that do require a prior authorization.

California HMOs will have until January 2011 to comply with new rules, which apply to 21 million HMO policyholders.

WEEKS OF WAITING

Merritt Hawkins & Associates' 2009 Survey of Physician Appointment Wait Times indicates that the highest average appointment waiting times in select major cities in 2009 were as high as 63 days around the Boston area and 59 days around Los Angeles. The study also showed a low of seven days of waiting time in Miami.

There is some flexibility in the California law, however. The regulation says the waiting time for a particular appointment may be extended if the provider or person providing triage determines that a longer wait time will not have a detrimental effect on the patient.

The rules allow the flexibility to prioritize the range of requests for appointments-from the urgent to the preventive.

"At the end of the day, we don't want to get in the way of doctors doing their jobs," Johnston says.

Besides untimely treatment of patients, long waiting times often create avoidable and expensive trips to the emergency room.

The new law, which required the department to create specific waiting times, took seven years to come to fruition, Wright says that the law invited some resistance from insurers, but has resulted in one set of standards helping HMOs and physicians meet consumer expectations.

After the January 2011 compliance date, HMOs will face penalties for failing to provide timely care. Responsibility for prompt attention falls on the shoulders of HMOs, thus making them the change agents and leveraging their influence over provider practices.

Physicians, however, believe a bigger problem lies in the shortage of physicians to care for the population. Costs could possibly increase as a result of the demand for timely service.

Of particular concern is the growing scarcity of specialty physicians in California, particularly in areas such as pediatrics, geriatrics and vascular surgery. The new law calls for plans to have sufficient numbers of contracted providers to maintain compliance with the standards. It will become the plan's responsibility to ensure their networks are adequate to meet the needs of their enrollees.

California has only 59 primary care physicians (PCPs) per 100,000 people, according to the California HealthCare Foundation. This compares to 248 PCPs per 100,000 people in Washington, for example.

"We all-health plans included-share the goal of making sure patients get the care they need when the need it. And, we all share the responsibility to help make that happen," CAHP's Johnston says.