It’s about time…

Tuesday, January 27, 2009

* CA Department of Managed Health Care Prepares to Finalize Important New Regulation on Timely Access to Health Care
* Public Comments Solicited on Newest Version of Regulation that Establishes Time Limits for Consumers to Receive Primary and Specialty Care in California
* ACTION ALERT: Letters Needed To Support Key Consumer Protections

New on the Health Access WeBlog: The Senate Stimulus; New Assembly Committees; The Reinvestment and Recovery Act in the House; Jump-Starting the Economy and Health Reform; Healthy Families Cuts Implemented; Health Wonk Review; President Obama’s First Health Care Actions; Bush’s Record; Do Bi-Partisan Efforts Help or Hurt Reform?; Federal Decisions Will Dramatically Impact Help to California.

Consumer and health advocacy groups may be close to witnessing the final regulation by the Department of Managed Health Care (DMHC) to write the “rules of the road” on timely access to health care. One of the most common complaints from consumers is that they cannot get in to see their doctor on a timely basis. These regulations will put in place requirements and establish expectations for concrete, time-elapsed standards based on type of service needed and degree of medical urgency. These rules stipulate that consumers should be able to:
* See a primary care physician for urgent care in less than 48 hours,
* Consult with a specialist within 96 hours of an urgent referral,
* Obtain a non-urgent appointment for primary care within ten business days, or
* Receive advice from a health care professional 24/7 regarding whether a symptom indicates an emergency or the consumer can safely wait until regular business hours on the next workday.
* Have interpreter services coordinated with scheduled appointments.

Research shows that Californians often obtain medical care from emergency rooms, the most expensive place to get medical care, because they cannot get in to see their doctor on a timely basis. It is also true that because consumers do not have clinical training, it is difficult for them to judge whether they are facing a true emergency and they need immediate care or whether they can safely wait.

A Long Road

This seemingly basic health care right to timely access to care has been a long time in coming. Health Access first sponsored legislation in this area in 1997, when we sponsored AB497 by then-Assemblymber member Scott Wildman. In 2002, AB2179 was carried by Assemblymember Rebecca Cohn (D-Saratoga), passed the legislature, and was signed by Governor Davis.

In 2002, many in the advocacy community thought California would soon usher in “a new era” where consumers and patients would have a clearly-defined right to timely access to health care for all those who were enrolled in managed care plans (HMOs). Those in favor of the statute anticipated a drop in health care costs (because of a decrease in people seeking care in emergency rooms) and an increase in quality of health care because it would be dispensed in a much more timely fashion resulting in better health care outcomes for patients.

Regulations Matter

However, some would say the battle over issue of timely access to care was just beginning. The statute laid the groundwork in the law (like an architect’s design for the building). However, many realized that the regulations written by the responsible state agency represented the actual detailed instructions about how the law would operate and resemble the general contractor’s plan for the building. This is where the phrase “the devil is in the details” comes from. The requirement to write detailed rules about how the law is supposed to work, what planning, measurement, reporting and auditing offered all stakeholders another opportunity to discuss (and disagree!) on the principles underlying the law and the key provisions of how it should operate. In many cases, legislation prescribes specific standards. However, Health Access took a different approach in AB2179: the legislation directed DMHC to develop the standards for timely access. It is no coincidence that almost seven years have elapsed since the legislation was signed into law.

Not surprisingly, HMOs and providers have fought over these years not only to delay the regulations but to make them meaningless. Health Access opposed earlier versions of the regulations that were no better than the inadequate procedures in place since 1975 when the Knox-Keene Act was created.

We now are at a major juncture in the road and consumer advocates eagerly await the finalization of this important regulation. After numerous consumer advisory panels, stakeholders’ meetings, public hearings, informal comments, formal written comments to the Department of Managed Health Care, withdrawal and reissuance of previous versions of this regulation, we now may be close to this regulation being enacted.

Support Needed for Specific Standards

Health Access and other members of our health care coalition generally agree that the language of the regulation, while not perfect, provides reasonable protections and specific time-elapsed standards for consumers to obtain timely access to health care. It also outlines reporting responsibilities of the plans, appeals actions available to consumers, and oversight duties to be performed by DMHC.

In our role as advocates, we have offered pages and pages of specific comments over the years: DMHC has not adopted every comment we have ever offered but the regulations provide basic consumer protections along with mechanisms for monitoring HMO compliance with those protections.

The Department has formally issued this regulation and they are soliciting comments on it from the public through February 23, 2009.
Action Needed Now
Consumer advocates need to act now to support these regulations. We need to make our voice heard so that consumers can get the care they need when they need it.
Key Points to Make:
* Consumers need care in a timely manner.
* Specific time-elapsed standards are reasonable minimums, getting urgent care within 48 hours and non-urgent care within 10 days are standards consumers should be able to expect.
* Being able to get triage and advice 24/7 from a qualified professional is an important consumer protection.
* Interpreter services should be coordinated with the appointment.
* Providing timely access will mean consumers get care from their doctor, rather than being forced to go to an emergency room to get care quickly.

Comments should be addressed to Department of Managed Health Care, Office of Legal Services, Attn: Regulations Coordinator, 980 9th Street , Sacramento , CA 95814 or you may comment on DMHC’s website at Your comments should reference Timely Access to Non-Emergency Health Care Services, Control No. 2008-1579 and must be received by DMHC no later than 5:00 pm on Monday, February 23, 2009. Health Access can make available draft comment letters including model language for you or your organization to use if requested.

Please feel free to contact Elizabeth Abbott at Health Access if you have questions or need further information. She may be reached at (916) 497-0923, ext. 201 or at

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

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