New Calif. Rules Cut Wait Times For Medical Care Regulations that take effect this fall outline how soon appointments must be made available to patients in managed health care plans. The rules call on insurance companies to have enough doctors and hospitals in their networks to accommodate patients, and on providers to not take on more patients than they can handle.
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New Calif. Rules Cut Wait Times For Medical Care

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New Calif. Rules Cut Wait Times For Medical Care

New Calif. Rules Cut Wait Times For Medical Care

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Now to one of the many obstacles to passing a health care overhaul. Some critics say a government-run insurance plan would mean longer waiting times to see doctors and to get procedures. But studies show that many Americans who have private insurance already face long waits.

California is trying to change that. The state is setting limits on how long waits can be and they go into effect soon. It's the first such effort in the U.S., as Sarah Varney of member station KQED reports.

SARAH VARNEY: Under new state regulations that will take effect in California this fall, appointments for a non-urgent primary care visit must be made available within 10 business days; a non-urgent 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.

Ms. CINDY EHNES (Director, California Department of Managed Healthcare): These are modern times. We are not in a feudal situation. We are in a modern environment for health care.

VARNEY: That's Cindy Ehnes, director of the California Department of Managed Health Care. She 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 they arrived at what all agreed was a reasonable time to wait.

Ms. EHNES: While at the same time, not raising premiums in an incredible amount, and also to ensure that physicians do not feel that they have a stopwatch on them at all times.

VARNEY: 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.

JODY(ph): Alliance Medical Group. This is Jody. May I help you?

VARNEY: 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 is a family practice doctor here. He says patients were getting very frustrated that calls weren't returned right away, especially if they thought they needed to get in quickly. Now, that's changing.

Today, the office uses electronic medical records and email. But just as important, says Dr. Zimmerman, the office anticipates the needs of patients who want what's called same-day access.

Dr. MICHAEL ZIMMERMAN (Family Practice, Alliance Medical Group): We're looking here at a schedule on the electronic medical record of all the doctors. And anywhere from 10 to 25 percent of the visits for any individual provider are reserved for same-day needs.

VARNEY: And the family doctors here adjust the number of same-day appointments depending on the time of year.

Dr. ZIMMERMAN: There's usually more same-day access in the wintertime, on Mondays, we know that as a big day, and then certain holidays.

VARNEY: The doctors also guarantee to return calls after-hours within 20 minutes and better coordinate medical care with specialists.

Nationwide, a recent survey by the Texas-based consulting firm Merritt Hawkins found that Americans wait an average of four weeks to see an OB-GYN and three weeks to see a family physician.

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.

Center President Paul Ginsburg says long waits are no longer the fault of HMOs skimping on the number of doctors they allow.

Dr. PAUL GINSBURG (President, Center for Studying Health System Change): Today, when you hear about wait times or inability to get into a practice, people tend not to blame the network, but really to say, oh, this is a system-wide problem and it's going to need a system-wide solution.

VARNEY: Ginsburg and other experts 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 boost the number 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.

For NPR News, I'm Sarah Varney in San Francisco.

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