It’s Time for Standards…

HEALTH ACCESS UPDATE
Thursday, September 20, 2007

TIMELY ACCESS TO CARE STANDARDS DEBATED
* Tuesday DMHC Hearing Brings Insurer and Provider Opposition to Consumer Protections
* Consumer Groups Say Delayed Care is Denied Care; Seek Stronger Regulations
* ACTION ALERT: Deadline for Consumer Comments is Friday, September 21st!

New on the Health Access WeBlog: SPECIAL SESSION SPECIAL! What’s Next in the Special Session?; Negotiation Next Steps; California and the National Debate; How Many Experience Uninsurance?; Rising Health Care Costs; Governor, Read the Bill!; Lessons from Healthy San Francisco; Assembly Workgroups for the Special Session; More Fallout from the Budget Cuts

The Department of Managed Health Care (DMHC) held another hearing this Tuesday, September 18, 2007 in Sacramento to seek public comment on their second proposed revision to the new regulation governing timely access to care.

This long-delayed regulation is based on AB2179(Cohn) sponsored by Health Access California and passed in 2002. The inability of *insured* patients to get in to see a doctor or specialist is one of the most common complaints that consumer groups get. The lack of ability to get a medical appointment also leads people to unnecessarily go to the emergency room, leading to ER overcrowding and increased medical expenses. The law and regulation are intended to remedy these problems, and protect the value of the coverage for which people are paying.

DMHC wrote these regulations to require that consumers must be able to see a physician within certain prescribed time frames. Some examples specified in the regulation require that consumers see a primary care physician for urgent care within 24 hours, get an appointment for routine care with a primary care physician within 8 business days, or be referred to a specialist for urgent care within 72 hours. DMHC also outlined procedures for measuring performance, tracking compliance, and potential enforcement mechanisms.

INDUSTRY OPPOSITION: Health plans, providers, and their associations spoke against the Department’s regulation as written. They emphatically expressed their clear dislike for any time-elapsed standards. Some in provider community emphasized that this would result in “chaos in the delivery of health care in California ” and would be “very burdensome to administer.” Many medical groups said this regulation would continue to drive doctors to retire or move to other states to practice. Many plan representatives asserted that the implementation of this regulation would be extremely costly and would actually make timely access to care less available. Many providers objected to any tracking or monitoring of whether they actually met even the plan’s own internal standards for timely access and they objected to the imposition of any administrative sanctions or penalties for repeated failure to achieve this minimal performance standard.

There was testimony given that DMHC should drop this regulation entirely, after five years of work, and form a work group of plans, providers, and DMHC staff to formulate alternative standards. Despite the Department’s repeated specific requests, neither plans or providers presented any proposals which included outlines of meaningful alternative standards in place of the Department’s specific time elapsed standards.

CONSUMER RESPONSE: Consumer advocates, including Health Access California, Western Center on Law and Poverty, Health Care Rights Hotline, several mental health advocates, countered these claims at the hearing. They emphasized that this law was passed five years ago and, because of the delay in drafting the regulation, plans and providers had plenty of time to prepare for their implementation.

They argued that the best way to ensure that consumers were afforded timely access to care was to measure how long it took to get a necessary health care appointment. Often the requirement to provide timely access to care uncovers the inadequacy of the provider network, or even so-called “phantom networks” which list more providers as available for appointments than actually are.

Advocates emphasized how the failure to receive timely access to care affects consumers by describing several actual experiences. For example, one patient who had a medical emergency, had to make 19 calls before being able to secure an appointment. Although the plan insisted their network was sufficient, this consumer found many problems. The obstacles she encountered included the listed providers were on vacation, they no longer belonged to the plan, they were no longer taking new patients, they did not have any appointments available for at least 30 days, they had their telephone number disconnected, their voicemail was full, or they did not return phone call messages.

Advocates urged that it was now time to move forward and were generally supportive of the regulation as written. They have asked for some changes, including wanting to close gaps that would have allowed insurers to get out from timely access standards if they declared there was a provider shortage.

The issue was raised again regarding whether it would be acceptable for consumers if they had to forego any entitlement to timely access to care if they required language assistance. This is especially troublesome since the Department finalized their Cultural and Linguistic Access to Care regulation earlier this year, on February 23. This landmark regulation guaranteed low English proficient consumers the right to have health care delivered in a language they understood and written documents provided in multiple languages. Consumer advocates stated unequivocally at the hearing that consumers should not be required to make a “choice” between receiving health care in a language they understood and receiving health care on a timely basis (nor should providers be permitted to make that choice for their patients.) The impact of being forced to make such a decision would be clearly discriminatory.

Action: Consumer advocates are awaiting the Department’s decision whether to make the regulation final as written, to revise the regulation, to invite another round of comments, or to begin the process all over again.

All interested parties should immediately indicate their support of time-elapsed standards by sending comments on Timely Access to Health Care Services (Control No. 2005-0203) by 5:00 pm on Friday, September 21, 2007.

This can be done by email to regulations@dmhc.ca.gov, or by fax to (916) 322-3968 to the attention of the Regulations Coordinator. More information is available on the Department’s website at http://click.icptrack.com/icp/relay.php?r=1019412729&msgid=3702720&act=XQ9M&c=5484&admin=0&destination=http%3A%2F%2Fwww.dmhc.ca.gov%2F&l=3.

For more information, contact Health Access Project Director Elizabeth Abbott, the author of this report, at 916-497-0923, or eabbott@health-access.org.

Health Access California promotes quality, affordable health care for all Californians.

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