Many Americans who have private health coverage must wait to see their family doctor or a specialist, or to schedule surgery. California regulators say the problem is so bad that the state will soon set limits on how long those waits can be. It's the first such effort in the United States.
Under new state regulations that will take effect this fall, appointments for a nonurgent primary-care visit must be made available within 10 business days; a nonurgent appointment with a specialist, within 15 business days; and most urgent-care appointments must be available within two days. The rules say that all after-hour emergency calls to a doctor must be returned within 10 minutes. The new regulations apply only to patients in managed health care plans, or about 19 million Californians, but it's expected that all doctors in the state will adopt the wait-time limits.
"These are modern times; we are not in a feudal situation," says Cindy Ehnes, director of the California Department of Managed Health Care. "We are in a modern health care environment."
Years Of Negotiations
Ehnes says the new rules have been a long time coming. The state Legislature first passed the so-called Timely Access Law in 2002, in response to the widely held perception that HMOs were delaying necessary care for enrollees and lacked big enough networks of providers. It was only after years of negotiations with insurance companies, providers and consumer groups that the parties arrived at what all agreed was a reasonable time to wait.
Ehnes says this was done while not raising premiums to an incredible amount and by ensuring that physicians will not feel like they have a stopwatch on them at all times.
The regulations call on insurance companies to have enough doctors and hospitals in their networks to accommodate their customers. But it will also be the job of providers not to take on more patients than they can reasonably handle or retool their offices to be more efficient.
A Retooled Medical Practice
One office that has retooled is the Alliance Medical Group in Pinole, a working-class, bedroom community across the bay from San Francisco.
Dr. Michael Zimmerman, a family-practice doctor with the group, says patients were getting frustrated that calls weren't returned right away, especially if they thought they needed to get in quickly. Now that is changing.
Today, the office uses electronic medical records and e-mail. But just as important, Zimmerman says, the office anticipates the needs of patients who want what is called "same-day access."
Zimmerman displays a schedule of electronic medical records of all doctors in the office.
"About 10 to 25 percent of visits for each provider are reserved for same-day needs," he says.
Family doctors adjust the number of same-day appointments depending on the time of year.
"There's usually more same-day access in wintertime and on Mondays and certain holidays," Zimmerman says.
The doctors also guarantee to return after-hour calls within 20 minutes and better coordinate medical care with specialists.
Long Waits Nationwide
A recent survey by the Texas-based consulting firm Merritt, Hawkins found that nationwide, Americans wait an average of four weeks to see an OB-GYN and three weeks to see a family physician. The average wait to see a cardiologist was more than two weeks.
Another survey, by the nonpartisan Center for Studying Health System Change, found that wait times were among the top reasons people with insurance delay medical care or go without it altogether. The center's president, Paul Ginsburg, says long waits are no longer the fault of HMOs skimping on the number of doctors they allow because in most cases they have expanded their networks.
"Today, when you hear about wait times or inability to get into a practice, people tend to not blame the network but to say this is a systemwide problem and needs a systemwide solution," he says.
Ginsburg and other experts say they agree today's wait times are, in large part, due to low reimbursement rates for primary-care doctors and the nationwide shortage of primary-care physicians. Specialists are also in short supply in many areas.
The health care bills currently before Congress attempt to address doctor shortages. They would boost payments for primary care in government programs, in an effort to increase the number of doctors willing to practice primary care. Health experts say it's crucial to increase the numbers of doctors and nurses who do primary care, especially if the country does decide to expand coverage to the 46 million Americans who currently lack insurance.