California is seeking to reduce waiting time in HMOs by requiring that doctors treat patients within ten business days of requesting appointment. It will be 15 days in the case of specialists.
A health maintenance organization (HMO) is a type of managed care organization (MCO) that provides a form of health care coverage in the United States that is fulfilled through hospitals, doctors, and other providers with which the HMO has a contract.
New regulations will also say patients seeking urgent care that does not require prior authorization must be seen within 48 hours.
Telephone calls to doctors' offices will have to be returned within 30 minutes, and physicians or other health professionals will have to be available 24 hours a day.
Responding to pleas of shortage of physicians, especially in rural area, regulators say flexibility is built in. For example, doctors can use their professional judgment to extend the waiting time if they determine that a delay will "not have a detrimental impact on the health of the enrollee."
California says it is the first state to set time standards for HMOs, which serve nearly 21 million of its residents.
The managed healthcare department acted in response to a 2002 law that mandated more timely access to medical care. The law left it to state officials to work out the details, which became subject to protracted negotiations with HMOs, doctors, hospitals, consumer groups and other healthcare activists.
"It's been a long time coming," said Anthony Wright, executive director of Health Access California, a consumer group that pushed for the 2002 law. "These regulations . . . will not only get people access to care when they need it, but will reduce unnecessary use of the emergency room."
The rules will be unveiled Wednesday at Cedars-Sinai Medical Center in Los Angeles and phased in over the next year.
"We really feel the work we've done over the last several years has put us in a place to be in compliance," said Patti Harvey, Kaiser's vice president for quality in Southern California. She declined to specify the company's current wait times or to estimate potential costs.
The trade group representing California HMOs called the new rules a "reasonable compromise," but predicted higher costs as a result.
California consumers have long complained about delays in getting care from HMOs and other health insurers, Duke Helfand reported for Los Angeles Times.
One 2009 study that has been cited by state officials found that consumers in California's two largest cities, San Diego and Los Angeles, face extended delays, up to even 59 days, when trying to get medical services.
Hopefully the new rules could make life easier for consumers.
The rules also apply to HMO plans that provide dental, vision, chiropractic, acupuncture and mental health care -- but in some cases with different wait times.