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Sacramento Business Journal

February 2, 2009

Proposed state regulations require more timely care

Patients with severe mental illness frustrated by ‘phantom panels’

By Kathy Robertson

Timely access is a long time coming.

State regulators have released the sixth version of draft rules required by state law to ensure patients get timely access to health care services.

The issue hits patients with severe mental illness especially hard. Most have to navigate two systems - one for medical care and the other for mental health care. State law requires equal coverage but a shortage of psychiatrists and other mental health providers makes that difficult to achieve.

By one estimate, there are 700 child psychiatrists to serve the more than 9.2 million children in California.

The fix on timely treatment remains controversial but agreement is getting closer.

There's little dispute that a psychotic patient in crisis is as urgent as an accident victim in an emergency room. The problem is how to ensure patients of all kinds get treatment in the right place at the right time from someone who knows how to treat them.

That means fixing the chronic problem of "phantom panels," the lists of specialists provided by health plans that might - or might not - be accepting patients or practicing medicine. The situation leaves patients frustrated and treatment delayed.

"It's a huge issue," said Randall Hagar, governmental affairs director for the Association in Sacramento. "One plan declared it had more psychiatrists on its panel than the entire number of psychiatrists in the state."

Timely access to care is required by Assembly Bill 2179. Approved in 2002, it took effect Jan. 1, 2003. The California Department of Managed Health Care has been working to develop standards such as maximum wait times for an appointment or phone response. The rules take a novel approach that puts responsibility for timely response by providers in the hands of health plans.

"We're heartened. They've done their best to make sure plans don't just pass it through," Hagar said. "It's causing plans to revisit how they treat providers, how they pay them - and how much baloney (patients) have to go through."

The latest version, released for public comment from Dec. 30 through Feb. 23, would require health plans to have enough providers to ensure patients get:

  • Urgent-care appointments for services that don't require prior authorization within 48 hours of the request
  • Urgent-care appointments with specialists within 96 hours
  • Non-urgent appointments for primary care and non-physician mental health providers within 10 business days
  • Non-urgent appointments with specialists within 15 business days

Access to screening and triage services 24 hours a day, seven days a week, with 10-minute waits standard. The number to call must be included on each patient's health plan identification card.

The proposed regulations say the waiting time for a particular appointment may be extended if the provider or person providing triage determines that a longer wait time will not have a detrimental effect on the patient.

It would also require health plans to monitor medical groups for compliance. The idea is to track trends rather than focus on individual incidents unless they cause serious harm to a patient.

"It is up to the plans to provide access," said Maureen McKennan Strumpfer, chief of the licensing division at the Department of Managed Health Care.

When it comes to mental health, the problem is compounded by a severe national shortage of psychiatrists.

"There is definitely a work force shortage in some areas," said Marcy Gallagher, an attorney at the agency's HMO help center. Then, it is up to health plans to consider each patient's condition and make a decision on a case-by-case basis. Sometimes that may mean sending the patient out of the regular network, Gallagher said.

Health plans bristle at time limits and reporting rules.

"We want to make sure everybody has access to the doctors they need but we don't want the government to make a decision about when a patient should be seen," said Nicole Kasabian Evans, a spokeswoman at the California Association of Health Plans, an industry trade group.

Time-lapsed standards interfere with providers' ability to use their own judgment to meet patient needs, Kasabian Evans said. If regulators are going that way, the trade group wants language that gives the provider discretion that may outweigh government-imposed standards.

The 10-minute standard is "very excessive, intrusive and unnecessary," the association says, and doesn't take into account providers with small staffs. Health plans do not triage patients, providers do, the association says.

"(Rules) have to be realistic; otherwise, they are just punitive," Kasabian Evans said. "If there isn't a specialist available in the specified time, there may not be a specialist available outside of it either. There simply aren't enough of them around."

Mental health advocates say the version released for public comment is not as strong as earlier versions and they want some changes.

"Weasel language," Hagar said. "It's a lot more generic."

The psychiatric association wants the regulations to require a specific phone line manned by a mental health specialist who understands the special needs of mental health clients. The group also wants health plans to have designated space on their Web sites that address mental health issues, and stricter rules that require plans to post the Department of Managed Health Care's complaint hotline "everywhere you look," Hagar said, "not buried in piles of documents."

For other stories in this special report, click here:

Mental health care steps up

State rules for autism care remain as murky as the science

Drug choices and costs for mental health disorders

  • $6.40 to $12 per month for generic equivalents for antidepressants such as Prozac, Paxil and Zoloft
  • $10 per month for the generic form of Xanax, sometimes used to treat panic disorders and social phobia
  • $125 per month or more for newer antidepressants such as Cymbalta and Effexor-XR, depending on dosage
  • $300 to $400 per month, depending on dosage, for antipsychotics such as Abilify, Zyprexa and Seroquel
  • Source: Envision Pharmaceutical Services