No More Wait for Access to HMO Ob-Gyns

Beginning this week, Ventura County doctors are notifying HMO-insured women who have had to wait days or weeks for referrals that they can now go directly to their obstetricians and gynecologists for treatment.

Under a new state law championed by women and consumer groups for years, health maintenance organizations must allow patients to bypass their primary care “gatekeeper” doctors if they need treatment for women’s health care.

With that in mind, Ventura business executive Iva Grant’s first appointment of the new year was with her longtime, trusted gynecologist. She’d delayed her annual exam with Dr. Patrick Diesfeld until 8:30 a.m. Monday to take advantage of the new law.

The law, Grant said, has caught up with common sense and patient loyalties.

“Finally, we have something that really looks at women and their unique needs,” said Grant, 36. “Dr. Diesfeld and I have had a relationship for almost 10 years. He delivered my second child. So this gives me continuity of care.”

The new state law allows patients to bypass their primary care doctors for women’s health problems and still be covered by their health maintenance organization insurance plans. The women’s care specialists, however, must be part of the network of doctors under contract with the patient’s HMO.

For example, Diesfeld is one of a panel of gynecologists paid to see patients covered by Grant’s HMO.

“It’s an improvement, thank God, that’s long overdue,” said Dr. Gary Nishida, head of California Women’s Health Care, whose 23 physicians control about 70% of the Ob-Gyn services in Ventura County.

“We’re passing the word along to our patients,” he said. “We know most women prefer it this way.”

Referrals for obstetric and gynecological care became a major issue in recent years as HMOs restricted women’s access to the doctors they had traditionally relied upon most. That led to a backlash that produced a 1998 bill that former Gov. Pete Wilson signed in September.

The new law recognizes “the unique, private and personal relationship between women patients and their obstetricians and gynecologists” and requires all health plans to allow patients direct access to women’s care specialists.

“This is a big step forward,” said 43-year-old Mary Nash of Oxnard. “But I’m going to have to find a new Ob-Gyn because the one I had left town. He was so tired of dealing with HMOs.”

Nash said that because of HMO restrictions, she had settled in recent years for annual examinations and gynecological tests by her family doctor, not a specialist.

“I don’t always make the annuals,” she said. “But now I’ll have to find a new Ob-Gyn. This is more encouraging, especially as I’m getting older and want to go more often.”

The new law has prompted a flurry of activity by Nishida’s group of women’s care specialists. Its contracts with local physician groups that coordinate HMO care had to be altered because more patients will now go to the specialists, he said.

“We’ve been negotiating to accommodate this open access,” Nishida said. “We have to get paid for it.”

But those new contracts are virtually in place, he said. And the changes are for the better, he said, because specialists can now diagnose patients immediately instead of wasting time with a referral system strewn with unnecessary paperwork.

“First they’d have to get an appointment with their primary care physician and be evaluated,” Nishida said. “That initial diagnosis and treatment would require one or two visits. Then the primary care physician would have to request a referral to us. That would take another week or two to get approved. So it would all take three or four weeks usually. Now we’re eliminating all those steps.”

For Nishida, that’s positive.

“Frankly, it’s a step back to the sort of access women had before HMOs, when patients could come in when they felt it was appropriate.”

Dr. David Mescher, medical director of the Seaview physicians group, the county’s largest with 60,000 patients, said his HMO-contracted organization has allowed women to self-refer to gynecologists for annual “well-woman” exams for two years.

And Dr. John Keats, medical director of the large Buenaventura Medical Group, said his organization has allowed gynecologists to act as women’s primary care physicians for 13 years.

“We were ahead of the curve on this by a lot,” Keats said. “We’ve always allowed unlimited access to Ob-Gyns within our group. I would say more than half of our [women] patients choose to do that. That leads to some duplication of services, but we know our patients want it.”

Buenaventura even used this ready access to gynecologists as a come-on in an advertising campaign a few years ago, Keats said.

But physicians say there are gray areas in the new law that need to be ironed out--and that could cause patients trouble in the future. Questions remain about what would happen if women refer themselves to gynecologists for routine illnesses that are not specific health problems experienced only by women.

“All of us are going to have to find out together just what are the borders of women’s care,” Mescher said. “I’m not clear at this point just what they are. The domains of health care are not always precise.”

Diesfeld, for one, is leery of provisions in the new law that require gynecologists to report back to “gatekeeper” physicians about treatment given to HMO patients and about planned treatment.

“Maybe that could be distorted so that we couldn’t see patients again until the gatekeeper agreed,” Diesfeld said. “That’s contrary to the whole idea that we would be primary care physicians for women’s problems--that the Ob-Gyn has a unique relationship with female patients. These restrictions are not placed on other specialists. Every time a pediatrician sees a baby, he doesn’t have to satisfy some sort of feedback provision for the gatekeeper.”

For now, however, patients say they like the new law.

Iva Grant said it will save her $200 to $300 a year for office visits, since she had chosen to see Diesfeld without going through her HMO’s referral system--paying from her own pocket for the privilege.

“For me, time is money. I don’t have the time to go from one physician to another when I know I want to go to Dr. Diesfeld,” she said. “I liked his style, I liked his staff. He had my history. So I was not going to change doctors.”