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Proposal Would Require Health Plans, Doctors to Cut Appointment Wait Times

Cheryl Clark, for HealthLeaders Media, May 22, 2009

California soon may become the first state in the nation to set a maximum number of hours a health plan enrollee may wait before getting in to see a doctor.

Under the proposed regulations that are six years in the making, a patient needing an "urgent" appointment for a service not requiring prior authorization must be seen within 48 hours. For urgent appointments requiring prior authorization, they must be seen within 96 hours.

Patients would be allowed to speak with a doctor on the phone or receive a "triage" call back from a health professional–not answering service personnel–within 10 minutes, no matter what time of the day or night they call.

"We're trying to improve the entire system of care so that it's more responsive to the enrollees' needs," says Cindy Ehnes,  director of the California Department of Managed Health Care, which was given authority to write such regulations with a law passed in 2002.

Health plans and physicians remain opposed. But Ehnes says that for six years, their objections have been under discussion, and the proposed regulations have been re-written nearly six times. "We've been working very closely with the stakeholders to minimize their concerns," Ehnes says. Now, she says, the regulations must be set.

Ehnes says the proposed regulations must resolve the numerous complaints from health plan enrollees who "all too often, can't find a doctor who is listed as part of the network, is open, and accepting patients. Our response to this is to require health plans to have an adequate panel of physicians," both primary care practitioners as well as specialists. "That goes for rural areas as well."

According to the proposed regulations, non-urgent visits for primary care must be allowed within 10 business days of the appointment request. Non-urgent visits with specialist physicians should take place within 15 business days of the request.

And urgent visits within a dental plan network provider should occur within 72 hours of the request, while non-urgent dental visits should take place within 36 business days of the request.

The most recent version of the proposed regulations may include some modifications when the final version is released before the end of this month, Ehnes says. But she does not anticipate major changes.

"We believe we have genuinely addressed the real concerns from the physician community that they're going to have to wear stop watches, or that this will impose a situation that will potentially interfere with their clinical judgment," she says.

The new rules will apply to about 39 plans within her purview, covering about 17 million lives. Under state law, the rules must be promulgated by the end of the year or else new legislation will have to be written and passed, with the regulatory process starting all over again. Ehnes does not think that will happen.

The department has the authority to impose fines, with previous penalties up to $10 million assessed against the state's largest for-profit health insurer, Anthem Blue Cross, last year for dropping more than 1,000 patients after they became ill.  The department also can require corrective action.

The proposed regulations say penalties would be considered because of "patterns" of non-compliance rather than isolated episodes.

But health plan and physician groups say they still have concerns.

"We agree with the idea that everybody needs to see and have access to the doctors they need," says Charles Bacchi, president of the California Association of Health Plans. "But our view is that when it comes to making decisions about which patients get seen first, in a doctor's office or group practice or a clinic, it's really the doctor's call."

Besides, he says, it's unfair to hold health plans responsible for a standard that the physicians who contract with those plans must enforce.

"Throwing these new requirements into our contracts is not going to be easy. Secondly, we're the ones who will get fined," Bacchi says.

The California Medical Association in February issued a nine-page summary of its objections. A primary concern is that physicians will be blamed for something that is the health plans' responsibility.

"This will definitely add more tension between doctors and HMOs," says CMA attorney Armand Feliciano.

The physician group's concern, he says, is that historically, health plans have not had enough doctors in their plan networks, especially in rural and underserved parts of the state. "If you're going to have a time standard of 48 hours, you've already set it up for failure if you don't have enough doctors in the networks," he says.

"These requirements impose a 'stop watch' mentality. You don't want your doctor looking at you saying 'Sorry, I've got to go to the next patient.' That's not quality of care."

In the objection summary, he wrote, "In truth, the proposed regulation may have the unintended consequence of compromising current patient care. Specific time standards ... may shorten the time doctors are able to spend with individual patients, or worse, they may be forced to turn away patients just to comply."

Ehnes says the regulations do not put a stop watch on doctors. "What's the foremost concern to the department is this notion of what you might call triaging the patient," she explains. "The system must provide a way to assess the individual's condition and provide a timely response to what their needs are."

For example, she says, all too often, patients get an answering service when they call their doctor.

"It's 12:01 p.m. You call them up and say 'My daughter's really sick.' You hear that they're all at lunch. And the voice on the phone says 'We'll have someone call you back this afternoon.'"

Under the new regulations, she says, "That's no longer an acceptable response."

Anthony Wright of Health Access, an advocacy group that helped write the original 2002 bill, says that while the most egregious problems were publicized seven years ago, "we continue to hear stories of people who aren't able to see a doctor in a reasonable amount of time.

"At some level, the long waits almost become so routine, people don't know it's wrong that they can't get in to see a pediatric neurologist for two or three months."

Wright added that many studies over the years have attributed increases in emergency room visits to people who have insurance, "but who could get an appointment with their doctor in time."


Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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