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Shorter Waits To See a Doctor Coming Soon to California

Here’s a bit of irony: One of the standard arguments against government-run health care is long wait times to see a doctor. But in California, a government bureaucracy will soon begin regulating wait times in private managed care health plans.

Almost seven years in the making, new state regulations will go into effect this fall governing the amount of time members of HMOs have to wait to see a doctor. Stemming from accusations that managed care plans were delaying access to care and contracting with too few physicians, the Legislature passed the Timely Access Law in 2002.

A little more irony: It’s taken seven years to define and deal with “timely access.”

“This has definitely taken longer than pretty much any other regulation we’ve dealt with,” said Cindy Ehnes, director of the California Department of Managed Health Care, which wrote the new rules with input from insurers, physicians and consumer rights groups.

“These have been very complicated and very contentious regulations to develop,” Ehnes said. “Opposing sides have been very strong and unrelenting. We had some false starts, and then we decided we didn’t just need new regulations, we needed a new process. We pulled the stakeholders together and hammered things out and came up with a much better process. I’m very proud of our staff and I think we’ve developed truly consensus regulation,” Ehnes said.

Nicole Kasabian Evans, spokesperson for the California Association of Health Plans and a veteran of the Schwarzenegger administration, said insurers appreciate the extra time and effort state regulators made on these new regulations, but some issues still need to be ironed out.

“We want to make sure we minimize unnecessary red tape for providers. We’re also concerned with some of the requirements related to health plans doing triage and screening,” Kasabian Evans said. “We’re concerned about some of the language that may put the onus on health plans — that could be a big cost item,” she added.

New Maximum Wait Times

When California’s new regulations go into effect, the 19 million Californians covered by managed care plans can expect these new levels of service:

  • Most urgent care appointments must be available within two days;
  • Appointments for non-urgent primary care visits must be made available within 10 business days;
  • Non-urgent appointments with a specialist must be available within 15 business days;
  • After-hour emergency calls to a doctor must be returned within 10 minutes.

Although the new regulations apply only to managed health care plans, industry experts believe most California physicians and insurers will adopt similar wait-time guidelines.

Insurers will be expected to contract with enough physicians and hospitals to accommodate their customers. Part of that equation may be setting limits to ensure that HMOs don’t take on more customers than they can handle.

And, of course, new regulations might be accompanied by price increases.

“That is an implicit threat every time you talk about new regulations,” said Ehnes. “In this instance those costs are potentially impacts of local negotiations — additional costs in physician offices as well as new costs at the health plan level.”

“It would be disingenuous to presume that there are no costs from adding new requirements,” Ehnes said.

First Wait-Time Regulations in Country

California has the highest degree of managed care penetration in the country. It’s also the only state with its own government agency dedicated to overseeing HMOs.

When California’s new timely-visit regulations take effect later this year, they’ll be the first in the country, but if managed care continues to grow and spread, they won’t be the last.

Richard Cauchi, health program director at the National Conference of State Legislatures, said other states may take an interest as wait times grow longer. 

“There’s data that shows wait times to see a doctor have grown, and they continue to grow in some parts of the country,” Cauchi said.

A national survey earlier this year showed appointment wait times increased by more than a week since the last survey was conducted in 2004.

Merritt Hawkins and Associates, a consulting firm specializing in recruiting physicians and other health care professionals, surveyed more than 1,150 medical offices in 15 cities.

The survey found wait times increased by an average of 8.6 days over the past four years.  Los Angeles had the third highest wait — 24.2 days.

Boston had the longest wait, averaging 49.6 days, followed by Philadelphia with 27. Atlanta had the shortest wait — 11.2 days.

The study measured average wait times for appointments in family practice offices as well as four specialties: cardiology, dermatology,  obstetrics/gynecology and orthopedic surgery.

Overall, in all 15 cities and five practice areas the average wait was 20.5 days.

Americans wait an average of four weeks to see an OB-GYN and three weeks to see a family physician. The average wait to see a cardiologist was more than two weeks.

A survey by the Center for Studying Health System Change found that wait times were one of the main reasons people with insurance delay medical care or avoid it altogether.

Model for National Reform Efforts?

Once final issues are resolved — a process that could take the rest of the year — California’s timely-access regulations could become a model for other states or for national regulations if a national health care effort ever gets that far.

“What we’ve done I think is potentially very valuable, and I’d love for all of our suffering to count for something,” Ehnes said.

“This is hard stuff. There are a lot of competing interests that come into play. It really does require a different approach to regulation development where individual interests have to come together and work together,” Ehnes said.

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