Calif. limits how long HMO patients wait for appointments

Primary care doctors in the state will have to see patients within 10 days. Physician organizations say some requirements in the new regulation are troublesome.

By — Posted Feb. 8, 2010

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In what they say is a first, California regulators have set maximum times for how long HMO patients must wait before receiving the medical attention of a physician in nonemergency settings.

The California Dept. of Managed Health Care regulation was adopted in January but will not take full effect until January 2011. Health maintenance organizations have until October to tell the department how they plan to make sure that patients have access to services such as 24-hour telephone triage, urgent care physician appointments within 48 hours, primary care doctor visits within 10 business days and specialist appointments within 15 business days.

The rules were formulated after extensive negotiations among regulators, HMOs and physician organizations pursuant to legislation enacted in 2002. About 16 million Californians were covered by HMOs as of July 2008, according to the nonprofit Kaiser Family Foundation.

Patients in San Diego typically wait 24 days for a nonurgent appointment with a family physician, and patients in Los Angeles wait nearly two months, according to a 2009 survey by the physician search and consulting firm Merritt Hawkins & Associates. The national average wait for a nonurgent appointment with a family physician is 20 days, based on the survey of physician practices in 15 cities.

The California Medical Assn. supported the 2002 legislation because it required HMOs to maintain adequate networks of physicians to care for their enrolled members. But the association's president, Brennan Cassidy, MD, said the specific wait timelines are problematic.

"We do not support the timelines and deadlines that the Dept. of Managed Health Care came up with because they're unnecessary, impractical and in some cases totally unworkable," said Dr. Cassidy, an emergency and family physician in Orange County, Calif.

Particularly troublesome, he said, is the requirement that patient phone calls be returned within 30 minutes.

"If a doctor is busy stabilizing an emergent patient or in the middle of an extended examination, the doctor may be tied up for more than 30 minutes and could not attend to that patient telephone call," Dr. Cassidy said.

HMOs could comply with the 30-minute phone triage requirement by setting up a 24-hour, plan-run phone service, but they also could farm out the duties to physician offices.

"The regulations are intended to improve access and theoretically improve quality," Dr. Cassidy said. "But if the result of the regulations is that patients have to be seen in a shortened period of time, that's not improving quality."

The California Assn. of Health Plans called the rules a "reasonable compromise." Kaiser Permanente, which insures more than 6.5 million Californians, did not respond to a request for comment by this article's deadline.

A chance to change

The California Academy of Family Physicians did not push for the new rules, but the organization's past president, Carla Kakutani, MD, said she sees them as an opportunity for physicians to change how they structure their practices.

"We've kind of emphasized this as a way to encourage doctors to make changes in how they schedule and how they staff their offices," said Dr. Kakutani, who practices in Winters, Calif. "Ultimately, those changes will benefit them and their patients and put pressure back on HMOs. ... The reason that patients can't get in sooner, it doesn't entirely rest on individual offices, but on whether health plans have gone to the trouble and expense of creating an adequate network to really take care of patients."

The statewide and national shortage of primary care physicians also must be addressed to get at the underlying source of excessive patient wait times, Dr. Kakutani said.

The California Assn. of Physician Groups represents 150 doctor groups practicing in the managed care model and opposed the 2002 legislation.

"The concern was over the unintended consequences that could arise from this law -- namely, that rigid, mechanistic standards would be imposed on doctors," said William J. Barcellona, the association's vice president of government affairs. "There is no evidence that such mechanisms will improve patient outcomes."

Barcellona said those concerns were allayed by an exception in the regulation that allows doctors to extend the waiting time for a particular appointment if the physician has determined that it will not adversely affect the patient's health.

This "clinical judgment exception," Barcellona said, "preserves the physician's ability to waive the time elapse standard in cases where it isn't medically appropriate."

The Dept. of Managed Health Care "will focus more upon patterns of noncompliance than isolated episodes of noncompliance" by HMOs, according to the regulation.

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Targeting wait times

New regulations in California that take effect in 2011 will require HMOs to ensure that their patients be seen without excessive delays.

Medical appointmentMaximum wait time
Urgent care (no prior authorization)48 hours
Urgent care (prior authorization required)96 hours
Nonurgent primary care10 business days
Nonurgent speciality care15 business days

Source: California Dept. of Managed Health Care (link)

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External links

California Dept. of Managed Health Care timely physician access regulation (link)

"2009 Survey of Physician Appointment Wait Times", Merritt Hawkins & Associates (link)

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