After seven years of haggling over details and crafting regulations, California is about to become the first state to mandate how quickly HMO members see a doctor.

The California Department of Managed Health Care, the state agency that oversees health management organizations, is developing regulations establishing how long patients in managed care plans must wait to get appointments with primary care doctors and specialists. The regulations, which could go into effect as early as this year, stem from the Timely Access Law passed by the Legislature in 2002. The law was prompted by accusations that managed care plans were delaying access to care and contracting with too few physicians.

Appointments for non-urgent primary care will have to be made within 10 business days. Non-urgent appointments with specialists will have to be set within 15 business days. Guidelines also will be set for dentists who practice in managed care plans.

An estimated 20 million Californians are enrolled in managed care plans.

We asked several stakeholders how these new regulations would affect health care in California. Might these regulations have a broader impact beyond the HMO community? How might California’s new regulations affect the national health care reform debate?

We got responses from:

• Cindy Ehnes, director of the California Department of Managed Health Care
• Elizabeth Abbott, project director for Health Access, which sponsored the original timely access legislation
• Peter Schroeder, president of the Mental Health Association in California
• Patrick Johnston, president and CEO of the California Association of Health Plans, a trade organization representing 39 insurers
• William Barcellona, vice president of government affairs for the California Association of Physician Groups

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One of Most Important Efforts in DMHC History

Cindy Ehnes Director, California Department of Managed Health Care

One of the common consumer complaints received at the DMHC Help Center is not being able to see a doctor on a timely basis.  A recent study found that the average wait time for new patients to see a family practice physician in Los Angeles is 59 days. 

This is not just a California problem or unique to HMOs — patients across the country are literally sick of having to wait weeks to see an in-network doctor.  This is simply unacceptable, and California is poised to become the first state in the nation to provide patients with predictable wait times.

DMHC’s pending timely access regulations will make a significant difference for the approximately 21 million California HMO enrollees by ensuring that they have timely access to care that is appropriate for their conditions and consistent with good professional practice. 

In crafting these regulations, DMHC has worked countless hours with its health care partners to improve the entire system of care so that it is more responsive to enrollees’ needs, whether they are an HMO, PPO or government-sponsored plan patient.  The regulations will also ensure that robust networks are available to PPO patients so that they are not obliged to pay more for non-contracted specialists.

The development of these regulations has been one of the most extensive and important endeavors in DMHC history.  While it has been a challenge to incorporate so many diverse perspectives, the regulations have emerged with a strong, direct way to eliminate unnecessary delay for consumers while also taking into consideration the realities of today’s health care marketplace, such as geographic differences, provider shortages, and the rising costs of providing care. 

The physician community has been genuinely concerned that they will need to use stopwatches to meet the time standards, or that the regulations will potentially interfere with clinical judgment.  This is not the case. 

In reality, the regulations put the burden of providing time-specific standards on the health plan, not the individual provider.  That means that plans must have a strong and varied provider network to ensure that appointments can be made within the specified time frames. 

My commitment as director has always been to ensure that patients get the right care at the right time, and these regulations go a long way toward ensuring that.  I encourage consumers who have questions or concerns about timely access to care or other health care issues to contact DMHC’s Help Center at 1-888-466-2219 or online at www.healthhelp.ca.gov.

New Regs Could Influence National Debate

Elizabeth Abbott Project Director, Health Access

One of the most common complaints about health care is: “I can’t get in to see my doctor!” 

While urgent care is available, it often is delivered in our crowded emergency departments.  While the common view is that EDs are packed with the uninsured, recent studies show they are filled with people with health insurance. In order to provide timely access to care in a less expensive setting, California is about to embark on reforms that will enable people to get timely care from their physicians.  

In 2002, Health Access, a consumer coalition working for quality, affordable health care, sponsored legislation that directed the Department of Managed Health Care to set standards to guarantee timely access to health care.   While most plans and providers of services say they agree with the concept of timely access to care, patients do not always receive it. 

DMHC began its regulatory process in 2002.  Health plans argued that each individual HMO should define what constitutes “timely access.”  Health Access consistently supported specific time-elapsed standards and opposed less specific requirements and more vague standards.  We argued for meaningful enforcement.  Most plans and providers maintained they would be difficult and expensive to achieve. 

However, since the Knox-Keene Act was enacted in 1975, each HMO has filed timely access to care objectives that they believed they met.  It was these time-elapsed guidelines filed by the HMOs themselves that were used to create an industry standard by the state. 

The regulation spells out how quickly patients should be able to see a doctor in concrete, time-elapsed language based on type of provider and the urgency of the care needed. 

For example, this regulation enumerates that a consumer must be able to get an appointment for urgent primary care within 24 hours and an appointment for routine primary care within 10 days. 

When plans and providers do not provide timely access to care, it often masks other problems, such as inadequate provider networks and/or financial insolvency.

Health Access believes these time-specific, measurable, common sense regulations will help achieve better health outcomes for Californians who are enrolled in managed care. 

We hope the California regulatory language will be influential in setting clearer benchmark standards during the national debate on health care reform.   These timely access standards assure that those who have health insurance will be able to get the health care they need when they need it.

New Regulations Will Help Mental Health Community

Peter Schroeder President, Mental Health Association in California

Because mental illness is still so stigmatized in our society, administrative barriers to care that may seem reasonable for physical health can be insurmountable for a person seeking mental health treatment.

I applaud the Department of Managed Health Care for completing the very difficult task it was given with the passage of the timely access statute. The regulations that are going into effect will benefit so many.

With the federal Wellstone-Domenici Mental Health Parity and Addiction Equity Act of 2008 also becoming effective now, those people who do reach out for help should find it substantially easier to get the care they need.

That said, problems do persist.

Many people do not understand that their mental health benefits are, in many cases, provided by an entity other than the medical group or physician’s office that provides their physical health care.

Behavioral health carve-outs have become common in California. These carve-out situations create a gap between primary and mental health care. They also create confusion for consumers when they must call several phone numbers before finally reaching the carve-out responsible for their mental health care.

While the timely access regulations should apply in these situations, it is difficult to see how this will be monitored in a meaningful way. I hope that DMHC will be aggressive in this respect.

There is certainly a dearth of mental health providers participating in managed care, and the timely access statute will not fix this situation. Providers have been leaving managed care or reducing the amount of their practices given over to managed care because of low reimbursement rates and extraordinary administrative burdens placed on providers.

Levels of utilization review in mental health are much higher than in other types of care.

Some, but not all, of the health plans have indicated to their providers that they intend to lessen the utilization review burden to conform to the new federal parity law. If this comes to pass, this would be a huge victory for patients. It is often this utilization review process that leads a patient and provider to end treatment, even when that treatment may still be medically necessary.

It seems unlikely that these regulations will have an impact outside the HMO/PPO community in California, at least with respect to mental health. I suspect they will have a far greater impact in the broader medical community and could become a model for other states to use when crafting similar consumer protections.

As to whether they could play a role in the reform debate going on in Washington, D.C., well, I am skeptical. Appointment wait times do not seem to be central to the goings on in that debate.

Are There Enough Doctors in California?

Patrick Johnston President and CEO, California Association of Health Plans

The gestation period for developing timely access regulations is about to conclude.

As these new rules were developed, health plans worked cooperatively with the state, consumer advocates and physicians to come to a reasonable compromise.   Left unaddressed is the bigger question: are there enough doctors to see all the patients?

The California HealthCare Foundation recently published an assessment of physician supply in California.  The report looked at primary care physicians and specialists to see if our state had an adequate number of doctors.  The answer, in short, was no.

(Editor’s note: CHCF publishes California Healthline.)

The foundation found that California has only 59 PCPs per 100,000 people.  And that supply is poorly distributed, leaving some rural counties with far fewer primary care doctors than is recommended, per capita.

The assessment also found that while California has an abundant supply of specialists, they are concentrated in urban areas.  More than half of the state’s counties have a shortage of specialists.

No matter how many rules health plans or doctors have about how long patients should wait to be seen or have an e-mail or phone call returned, rules will not address the root problem of a low supply of physicians.

As CHCF’s report suggested, the state should boost reimbursement rates for Medi-Cal so more doctors are motivated to provide care to under-served populations. 

The federal and state governments should provide incentives to physicians and medical students to practice medicine in areas with shortages.

There is now a greater investment by the state in information technology that allows our existing supply of PCPs to treat patients in remote locations through telemedicine and other technologies.

California’s health plans will continue working with state regulators as new rules on timely access to care are implemented.   In addition, health plans are partnering with providers and foundations to bring needed medical expertise to communities that are short of physicians.

A Rule in Search of a Mission

William Barcellona Vice President of Government Affairs, California Association of Physician Groups

When it comes to timely access to primary care services, the Department of Managed Health Care, in many ways, has been faced with an impossible task of trying to keep relevant a solution to a problem that has since been significantly resolved. A concerning outcome of which will likely be putting health care coverage further from reach for more Californians.

The context of medical services delivery is very different today than it was in 2002, when Assembly member Rebecca Cohn successfully passed Assembly Bill 2179. The reality is that the timely access regulation has been a rule in search of a mission ever since. 

Around 2002, more than 110 medical groups had closed their doors, and four major health plans had been taken over by DMHC and shut down.  It was during this time that I worked at DMHC and oversaw the transfer of four million HMO patients.  

To help with this massive transition, we implemented financial solvency regulations (SB 260) to usher in better financial management in the delivery system, as well as a continuity of care law (SB 244) that specified how patients could be safely transferred from one provider to the next. 

These steps worked, the chaos abated and the system started to stabilize by the end of 2003.  The strength of the primary care system and the hundreds of medical groups that support it has been growing stronger every year. 

Timely access complaints now occur at a rate of .0046 of the total managed care population.  In fact, medical groups have grown much larger and more sophisticated each successive year and have introduced mechanisms — like same-day appointments, online secure e-mail communications with doctors, and online appointments — to vastly increase access. 

They’ve accomplished this in a marketplace that is flat or declining for HMO enrollment each year.  So timely access isn’t going to get worse, it’s getting better for the people who have health coverage. 

One of the troubling aspects of the AB 2179 process is that somewhere along the way advocates have twisted the original intent of the bill to claim that it requires 24/7 access to your physician. 

No one could ever realistically meet that standard for the 37 million people who live California.  What medical groups in California do provide are alternative mechanisms like after-hours clinics and nurse advice lines.  This is the kind of patient and physician-driven evolution that continues to take place and is the direction California should be headed.

This doesn’t come without cost. These services significantly add to the bottom-line administrative costs.  After-hours staffing costs are steep, and in this economy, we must balance the need between ensuring access when people need it without unnecessarily increasing medical cost inflation. 

Which leads to perhaps the most unfortunate aspect of this regulation:  it does absolutely nothing to increase access to care for the people who need it most — those without health insurance.  The uninsured will still have to queue up at the local emergency department because they don’t have a medical home. 

In some respects, this regulation worsens their plight.  The added administrative costs this regulation imposes for those with health insurance will make affordable health insurance even further beyond the reach of those who don’t.