California’s new HMO rules

After members of health maintenance organizations complained about long waits for appointments -- up to 50 days or more for routine physicals -- the Legislature passed a bill in 2002 that called for strict limits on waiting times. In crafting the new standards, the California Department of Managed Health Care has done a careful and in ways masterful job of balancing the requirements of the legislation, a shortage of doctors and the desires of patients. It also has forged new paths in encouraging the use of technology to give patients better access to doctors.

To meet its goals for appointment times, the agency drew up new ways of delivering healthcare to make the deadlines work. Everyone ends up sacrificing something for this -- HMOs, doctors and even patients, who are likely to pay higher prices, visit more doctors who are not their regular physicians, and be “seen” more often via e-mail or videoconference.

Under the rules announced last week, if a patient’s regular doctor can’t set an appointment within the allotted time frame, the patient calls the HMO, which must find another doctor among its contracting physicians. If none is available, it must set up an appointment with an out-of-network doctor at no extra cost to the patient. A patient with an urgent medical problem must be seen within 48 hours; for routine care such as checkups, the time frame is 10 working days or, in the case of a specialist, 15 days.

The urgent-care rules are the best devised and should be a real help. People who feel ill or who find a frightening lump are unlikely to insist on seeing their regular doctor as long as they are seen soon. By using computers to take advantage of openings in network doctors’ schedules, HMOs will at minimum improve their record on waits for appointments. Some issues, such as medication changes, can and will be handled by e-mail. People with chronic problems such as diabetes might have regular appointments in groups, via videoconference.

The regulations on routine appointments are less useful. Many of these doctor visits can be anticipated. If a student needs a vaccination for the start of school in September, parents shouldn’t be waiting until Aug. 15 to call for an appointment. Forcing HMOs to schedule routine appointments within 10 or 15 days diminishes their ability to fit in the urgent cases. Nor do the new regulations solve the underlying problem of the state’s doctor shortage.

If HMOs have to pay out-of-network doctors to meet the appointment deadlines, premiums or co-payments might rise. But it’s more likely that network doctors will be pushed to see more patients, which would mean being rushed through office visits even more quickly than HMO patients complain they are now.