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The Dr. Will See You Now! CA Regulates HMO Wait Times

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By Tanya Roth, Esq. on January 22, 2010 2:11 PM

More than seven years in the making, the California Department of Managed Health Care announced this week that over the next year, it will begin implementing new rules governing how long HMO patients in the state will wait to see a physician. A law passed in 2002 mandated timely access to health care for Californians served by HMOs, but the actual nuts and bolts were up to the regulators to decide, through lengthy negotiations with hospitals, doctors, HMOs and managed health care advocates. California says it is the first state to set such standards for HMOs, which serve nearly 21 million patients statewide.

The new rules include the following requirements applicable only to patients under the care of HMOs:

  • patients must be seen by doctors within 10 business days of requesting an appointment, and by specialists within 15
  • patients seeking urgent care that does not require prior authorization must be seen within 48 hours
  • telephone calls to doctors' offices must be returned within 30 minutes, and physicians or other health professionals must be available 24 hours a day

The legislation that prompted the regulations was spurred by complaints from HMO members about access and wait times for heath care. According to the Los Angeles Times, a 2009 study showed patients in San Diego wait an average of 24 days for a routine physical with a family practitioner. In Los Angeles, patients wait 59 days on average, the study found.

Doctors themselves believe the real problem lies in the need for more doctors. To prevent physicians from having to rush care to comply with time restrictions, the plans need to ensure there are enough to go around. "The pressure should be on health plans to have adequate networks of doctors," said Dr. Richard Frankenstein, a Riverside internist and former president of the California Medical Assn.

The regulations that have emerged from this process have been called a "reasonable compromise" by the trade group representing the HMOs, but that does not preclude them issuing the typical warnings of higher costs to consumers.

HMOs will be given until January 2011 to comply; after that, Dept. of Managed Heath Care will have the authority to penalize HMOs that fail to ensure timely care. People will be able to complain to the Department about delays.

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