New Limits on HMO Wait Times Could Alter Health Care Delivery Statewide

State officials say California's health care system could undergo major changes as it adjusts to new regulations requiring HMOs to provide more timely access to medical care, the Sacramento Bee reports.

New Regulations

This week, the California Department of Managed Health Care rolled out new rules giving HMO patients the right to obtain:

• A physician appointment within 10 business days of a request;
• A specialist appointment within 15 business days of a request;
• An urgent care visit within 48 hours of a request; and
• Telephone access to a health care professional at all times.

Health plans will have one year to comply with the new rules. After January 2011, the state will have the authority to fine non-compliant HMOs (Calvan, Sacramento Bee, 1/20).

DMHC said it will draw on consumer complaints to determine when to audit an HMO over the new rules. The department also indicated that it does not plan to investigate every individual complaint (Archibold, New York Times, 1/20).

Potential Benefits

DMHC Director Cindy Ehnes said the new rules could transform health care delivery in California and across the nation (Sacramento Bee, 1/20).  She predicted that the regulations would motivate health care providers statewide to reduce appointment wait times, which could benefit HMO members and non-HMO members alike.

Other stakeholders said the rules could ease emergency department crowding because more patients would be able to obtain appointments for urgent conditions (Colliver, San Francisco Chronicle, 1/20).

Possible Trade-Offs

Critics say the new wait time requirements could compel HMOs to hire more physicians, which could drive up premiums. Others say the rules might encourage health care providers to spend less time with each patient (Kleffman, San Jose Mercury News, 1/19).

Ehnes acknowledged that HMOs could face difficulty complying with the new rules, particularly in regions that already suffer from a shortage of primary care physicians.

In addition, California physicians might struggle to keep up with demand if national health care reform efforts succeed in extending coverage to millions of uninsured U.S. residents.