To keep 21 million Californians from waiting and waiting and waiting to see a doctor, state regulators are implementing standards on how long it should take to receive care.
Aimed primarily at people covered by HMOs, the first-in-the-nation mandates will take effect Jan. 17. They say it should take no more than 10 days to see a doctor in most routine cases and no more than 48 hours in many urgent care situations.
The new rules administered by the California Department of Managed Health Care also dictate that health plans provide a system of screening the severity of illnesses and injuries. That triage system should respond to initial phone calls from a patient within 30 minutes regardless of when the call is made.
"It's not a cure-all for what ails healthcare, but it's a big step forward in improving quality of care and patient satisfaction," said Cindy Ehnes, director of the state's managed care department.
Announced a year ago, the regulations come out of seven years of negotiations among state officials, insurers, patient advocates and medical groups. And while the focus for the first year will be to make sure the new rules are implemented across the state, health plans that repeatedly keep people waiting could face penalties and fines.
Ehnes said that insurers -- not doctors -- will be held ultimately responsible. Doctors who need to postpone one appointment so they can see patients who absolutely can't wait can waive the new requirements. But they must provide medical reasons for delays in care, and their offices still must meet the 30-minute obligation for an initial assessment of a health problem.
"One concern that doctors have is that they were being put on a stopwatch," said Ehnes. "Doctors remain in control of the care of the patients."
Ehnes said she expects health plans will have to expand doctor's networks at least in some regions to meet the new regulations. Jim Anderson, spokesman for Kaiser Permanente, said the HMO has been boosting its networks for several years and had to make only minor adjustments to gear up for the new standards.
"We're confident that we're going to be able to meet or exceed the new rules when they take effect," he said.
In addition to HMOs, the new rules cover people in Blue Cross and Blue Shield PPOs. The rules break down maximum wait times in several categories:
-- 48 hours for most urgent care appointments.
-- 96 hours for urgent care that requires prior authorization.
-- 10 business days for regular primary care.
-- 15 business days for a specialist.
-- 10 business days for a mental health specialist.
Many providers say the mandates are reasonable and, in many cases, already met. The mandates for specialists sound too lenient to Dr. Robert Lum, a radiation oncologist who envisioned a cancer patient waiting 15 days or even 96 hours to see one of a series of specialists. It's too long.
"I don't think rules like this should have to exist," Lum said. "But the unfortunate thing is if they didn't have these rules in place, someone might make someone wait over a month. ... It's a sad state of affairs."
(Tom Kisken is a reporter for the Ventura County Star in California)
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