It’s never time for HMO self-regulation…

Really important lead story by Jordan Rau in the California section of the Los Angeles Times today.

We’ve written before about pending rules at the Department of Managed Health Care on timely access to care, and how important they are for patients trying to get the care they need. They are based on a law, AB 2179 (Cohn) in 2002, that Health Access sponsored.

Well, right before the holidays, the DMHC drafted a new set of regulations that were significantly weaker, and they have already been submitted to the Office of Administrative Law for final review. The regulations are weak enough that we have asked the Governor and the DMHC to withdraw the regulations. Here’s the article:

HMO rules stuck in limbo
Three years past the deadline, the health plans are now writing their own standards for timely appointments for patients.

by Jordan Rau

SACRAMENTO — In 2002, California’s HMO czar, Daniel Zingale, declared, “The days are over when they could make patients wait and wait for healthcare.”

Zingale was heralding a new law that required his department to ensure that HMO patients received timely appointments with doctors. The law was spawned by the case of a 74-year-old woman who died from an aneurysm in a Kaiser Permanente waiting room while pleading to see her physician.

The Schwarzenegger administration’s enactment of the new rules, which the law required by January 2004, has not been prompt. The Department of Managed Health Care did not release its proposed rules until 2007. When HMOs and doctors groups objected to them, the department scrapped the rules in favor of ones that let health plans come up with their own methods of complying with the law. The plans have to submit their guidelines in October, and the department will review them.

Consumer advocates charge that the way the department is putting the law into action controverts the promise six years ago from Zingale, who is now a senior advisor to Gov. Arnold Schwarzenegger and chief of staff for Schwarzenegger’s wife, Maria Shriver.

“The pending rules are a betrayal of consumers and of the clear intent of the law,” said Anthony Wright, executive director of Health Access California, a consumer advocate group that sponsored and helped write the original legislation. “The department is letting the insurance companies set their own standards.”

The industry says they can’t meet timely access standards, or the sky will fall. But if that’s the case, they have been admitting that they haven’t been in compliance with the basic principle of timely access, which has been in the Knox/Keene law since the 1970s.

Imagine if we let the airline industry overbook their flights (or have too few planes) so people are routinely bumped for weeks or months onto other flights. Yet without strong standards, we are letting the HMOs do the same thing with our medical care!

For a good example of why this matters, here’s an example from the article:

Bobby Perry, a pharmacy clerk whose employer insures itself and uses Blue Shield of California’s provider network, said that for five weeks, Blue Shield could not provide a psychiatrist who would treat her 15-year-old son. He has psychosis that sometimes makes him violent.

Perry, who lives in a Sacramento suburb, said that because she couldn’t get an appointment for her son to obtain appropriate medication, she ended up having to call the police to have him institutionalized during an episode.

“Most of the doctors wouldn’t take adolescents,” she said, while the others “didn’t have appointments until one month later.””I asked them what happens in the meantime, and they said, ‘Just send him to the emergency room,’ ” she said….

But “why am I paying insurance,” Perry said, “if they’re not going to give me services?”

Health Access California promotes quality, affordable health care for all Californians.
VIEW THE FILE Timely Access

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