Bill BarcellonaCSHA Annual Conference

Monterey, April 9 2010

Timely Access Reg.

Health Care Reform

My Daughters’ Braces

The HMO backlash resulted from the failure of Managed Care Organizations to build patient trust and deliver satisfaction

Several notable business failures permeated the public consciousness

“Care delayed is care denied” became a universally accepted perception of HMOs

“Specifically the lack of timely access to care often conceals:• inadequate provider networks,

• insufficient financial resources devoted to providing care,

• insufficient accountability/oversight of providers,

• contracting imbalances by medical specialty or geographic area, and/or

• financial insolvency”

- Health Access, the Back Story, Abbot, 12/22/09

“This bill is sponsored by Health Access California to ensure that enrollees have access to needed health care services in a timely manner. HAC states that health plans enrollees cannot get care when they need it, resulting in emergency rooms filled with health plan enrollees who cannot get timely appointments with their physician, enrollees waiting for extended periods of time to get through on the telephone to providers and health plans, and enrollees unable to get referrals to specialists in a timely manner.”

- Bill analysis prepared by Scott Bain, August 26, 2002

Not to the same extent and degree:• Industry consolidation and shakeout occurred

• Since 2002, closures/disruptions are very slight

• SB 260 financial solvency requirements work

• HMO provider networks are broad/ PPO broader

• Providers created advanced access programs,

patient portals, secure email communications

Both CDI and DMHC required to write regulations adopting standards for timely access to care by 2004

Establish time-elapse, monitoring, compliance and enforcement standards

Regulators given the authority to permit alternative standards

Title 28, Section 1300.67.2.2Timely Access to Non-Emergency Health Care Services

A. ApplicationB. DefinitionsC. StandardsD. Quality Assurance ProcessesE. Enrollee Disclosure and EducationF. Alternative StandardsG. Filing Implementation and Reporting

Does not cover emergency services, but doescover hospital-based non-emergency services

Requirements can be delegated to providers via contract

Limited application to specialty health plans

“Advanced Access” was modified to included same day or next business day

“Appointment Waiting Time” was modified to exclude office waiting time

“Triage or Screening” was modified to focus on the assessment of a patient’s condition rather than diagnosis

The guiding principle:

Plans shall provide or arrange for the provision of covered health care services in a timely manner appropriate for the nature of the enrollee’s condition consistent with good professional practice. Plans shall establish and maintain provider networks, policies, procedures and quality assurance monitoring systems and processes sufficient to ensure compliance with this clinical appropriateness standard.

Request for Care Routine Urgent Standard

Primary Care visit √ 10 business days

Primary Care visit √ 48 hours

Specialist Referral √ 15 business days

Specialist Referral √ 96 hours

Mental Health Provider √ 10 business days

Ancillary services visit √ 15 business days

Preventive Care visit √ “Consistent with

professionally recognized

standards of practice”

Dental visit √ 36 business days

Dental visit √ 72 hours

Preventive Dental visit √ 40 business days

Telephone triage with a

health care professional

√ Waiting time cannot exceed 30

minutes

Compliance monitoring systems that include:

Tracking and documenting network capacity and availability with respect to the standards set forth in subsection (c);

(B) Conducting an annual enrollee experience survey, which shall be conducted in accordance with valid and reliable survey methodology and designed to ascertain compliance with the standards set forth at subsection (c);

(C) Conducting an annual provider survey

Evidence of Coverage and membership cards:

Plans shall disclose in all evidences of coverage the availability of triage or screening services and how to obtain those services. Plans shall disclose annually, in plan newsletters or comparable enrollee communications, the plan’s standards for timely access.

The telephone number at which enrollees can access triage and screening services shall be included on enrollee membership cards.

A plan may file a material modification for

approval of alternatives to time-elapse

standards or alternative time-elapse

standards Provider shortages

Development of evidence-based metrics

Deadline Requirement Content

10/17/10 Compliance Amendment Quality assurance policies and procedures, survey forms, subscriber

and enrollee disclosures, and amendments to provider contracts.

physician-to-enrollee ratios, including but not limited to updated

Exhibits I-1 and I-4 to the plan’s license application

1/17/11 Implementation Policies, procedures and systems necessary for compliance with the

requirements of Section 1367.03 of the Act and this section

3/31/12 &

Annually

Annual Compliance Report, pursuant to subsection (f)(2) of Section 1367.03 of the Act,

regarding compliance during the immediately preceding year. The first

reporting period shall be the calendar year ending December 31,

2011.

Section Content

Standards The Plan’s previously approved standards (if alternative)

Rate of

Compliance

Statistical survey data on provider compliance by county

Incident Reports Any incidents/patterns of non-compliance and response

Advanced Access A list of the providers offering advanced access

Technology A list of provider tech mechanisms to improve access

Survey Results The results of annual patient and provider surveys

Network Status Geo-access data by county of doctors and hospitals

Stakeholder work group meets frequently to resolve questions over the implementation of: Provider survey – crafted

question

Patient survey – determined data is already collected

Future issues…

I vote for an early lunch!

The Department of Insurance adopted its version sooner than the DMHC• No time-elapse standards

• Focus on geo-access and provider ratios

• The two regulations create incompatible standards for doctors who won’t know which regulation to follow

Physicians

Health Plans

Hospitals

Challenges for Doctors and their Physician Groups

Evaluating the risk of delegation of certain functions under the Regulation

Discerning which standard to apply to PPO patients (CDI or DMHC)

Documentation of exceptions to the time-elapsed standards

Tracking and monitoring of physician rate of compliance within IPAs

Improving referral patterns to specialists

Increasing advanced access programs and electronic patient portals

Coping with liability problems associated with consumer advocacy

Challenges for Health Plans

Delegation of obligations to downstream providers

Triage & screening phone lines (challenges with delegation)

Integration of non-English speaking language assistance requirements

Rate of compliance reporting – what’s the “rate?”

Implementation within a PPO network of independent physicians

Conflicts between CDI and DMHC requirements for PPOs

Plan Type Requirement

Dental Subsection (c) (6) sets forth the three time-elapse standards,

for urgent care appointments (within 72 hours), non-urgent

appointments (within 36 business days),

and preventive care (within 40 business days).

Mental Health The fifteen business day rule for specialist referral to

psychiatrists poses problems. Whether this time-elapse

standard applies to MFCCs remains an open issue, since the

term “specialist” is not defined in this instance.

For All Plans Challenges meeting the ten minute customer

service time-elapse standard under subsection (c) (10).

The 15 business day standard applies to

all non-emergent hospital-based ancillary

services and also applies to diagnostic

providers under contract with plans

The focus is on patterns of non-compliance rather than isolated incidents

A five-factor analysis that looks at referral patterns, clinical appropriateness and “other factors”

I’ve got my

eye on

you!

CHCF predicts 6 million

new covered patients

by 2014 from health

reform

We have 67,000 active

practice doctors for 38

million Californians

Enrollee, circa 2014

Bill BarcellonaVice President, CAPG

wbarcellona@capg.org

1215 K Street, Suite 1915

Sacramento, CA 95814

(916) 443-4152