California Prepares to Implement Timely Physician Access Regulations for Managed Care Plans

January 28, 2010 05:05 pm James Arvantes

California physicians are preparing for the effects of new regulations from the California Department of Managed Health Care, or DMHC, that will require physicians in managed care organizations to meet a series of timelines for providing care and services to patients seeking treatment.

[Stock photo of an analog clock face with hands at 12:00]

The timely access regulations will take effect next January, making California the first state in the country to set time limits for physicians to see patients, and possibly providing an example for other states to follow when trying to improve access to care.

Under the guidelines, primary care physicians in managed care plans will have to see patients in their networks who ask for an appointment within 10 days. Subspecialists will have 15 days to see in-network patients. The regulations also require all physicians in the plans to return phone calls from managed care patients within 30 minutes and to see those who are seeking urgent care that does not require prior authorization within 48 hours. There are exemptions from the timelines if the treating physician can show that longer wait times will have not have a detrimental effect on the health of the patient, according to the California AFP.

Managed care plan companies will be responsible for surveying physicians and for using the data so gathered to develop and submit plans to the DMHC to address problems, such as physician network shortages, said the California AFP. The companies are required to submit their plans by Sept. 1; the actual requirements take effect Jan. 17, 2011.

According to Tom Riley, director of government relations for the California AFP, about 11,000 family physicians practice in the state; roughly 80 percent of them take some form of managed care payment. Thus, Riley is concerned about the effect of the regulations on family physicians. "I think in the immediate future (the regulations) will create a lot of angst on the part of overworked, underpaid family physicians," he said.

Although Riley noted that many primary care physician practices are meeting and even beating the time limits spelled out in the regulations, he said there are physicians who will have to shorten the time they spend with patients to accommodate the new requirements.

Riley hopes, however, that the timeline standards in the legislation will induce health plans to create adequate networks of primary care physicians -- something that can be accomplished only by paying primary care physicians fairly.

According to Riley, the California AFP opposed the 2002 legislation that created the regulations because of fears it would result in more work and less pay for family physicians in the state. When the legislation became law, however, the chapter worked with regulators to ensure that physicians did not bear the brunt of implementing the regulations.

In addition, the California AFP will be monitoring implementation of the regulations carefully and holding lawmakers to the promise that ultimately the law will help primary care physicians negotiate fairer contracts with managed care plans, Riley said.

"We have told the (DMHC) we will scream loudly if this results in more abuse of primary care physicians in the state," Riley said.

Carla Kakutani, M.D., past president of the California AFP and a member of the Sutter West Medical Group in Winters, Calif., said the regulations "could be a good thing for patients."

"I am hoping that HMOs that have had notoriously skimpy network options for patients will have to go out of their way to attract both primary care and (sub)specialty physicians with good contracts so they will join the networks and provide more access for their patients," said Kakutani. "That would be good for everybody."

Like Riley, Kakutani is concerned the regulations could have a negative effect on physicians who are already overburdened. But, according to Kakutani and others, the regulations seem to put the onus for meeting the requirements on the health care plan companies, and not physicians.

"The HMOs are going to have to answer to the (DMHC) when their patients complain," said Kakutani.

Samuel Applebaum, M.D., of Rocklin, Calif., who also practices with the Sutter Medical Group, said the regulations are "coming from a very good place."

"I think whatever we can do to improve patient care, patient satisfaction and patient safety is a good thing," said Applebaum, who completed his residency in 2008. "Is this the 100 percent right way to approach it? I can't say that it is. But it is coming from the right direction."