CHOOSING YOUR PHYSICIAN

How Should I Choose My Primary Care Provider (PCP)?

HMOs give you an opportunity to choose your own primary care provider (PCP). You will receive a list of participating providers when you first enroll. Some HMOs have their current provider lists on the internet (See For More Information). Check to see if your current PCP is already a participating provider. If so, you can designate him or her as your PCP. If not, you should call the HMO and your provider and tell them you would like your provider to enroll in the HMO’s network.

If your provider is not a participating provider or if you want to choose another provider, you will need to review the HMO’s list of participating providers. The list usually includes the names, addresses and phone numbers of the provider, as well as the provider’s specialty. The provider directory usually lists PCPs separately from other providers. Most HMOs require that you select a family physician, general pediatrician or general internist as your PCP. Some HMOs allow you to choose a nurse practitioner (NP) or physician’s assistant (PA). Some may also allow you to choose an obstetrician-gynecologist (OB-GYN) or other provider as your PCP. If you fail to choose a PCP, some HMOs will choose one for you.

Even though a physician or group practice may be listed in a provider directory it does not necessarily mean that new patients are being accepted. When a physician’s practice is full, he or she may stop taking new patients. It is important to call the physician’s office to see if new patients are being accepted. You should also ask the office how long it usually takes to get an appointment for both immediate needs and for general check-ups. Ask what hours the office is open. Calling the physician’s office will also give you a sense of how easy or difficult it is to reach the office by telephone.

There are other ways to check out prospective physicians. Talk to friends and neighbors about their experiences with a physician’s practice. Ask them how easy—or difficult—it is to reach the physician by phone or to schedule appointments, how much time the physician spends with them and how comfortable they feel talking with the physician.

The NC Board of Medical Examiners can tell you if a physician has had any action (including disciplinary action or restrictions) taken against his or her license. A doctor could have his or her license revoked or restricted because of malpractice or inappropriate behavior. Public Citizen Health Resource Group in Washington DC also keeps records of all physicians who have had a disciplinary action by a state Board of Medical Examiners.

How Can I Find the Best Physician if I Have a Special Health Care Need?

If you have a special health care need, such as a disability or chronic illness, or have a child with a disability, you may want to talk to an advocacy or self-help group to find out which physicians are best known for treating your (or your child’s) health condition. The HMO should also be able to give you information regarding the educational background and specific interests of in-network PCPs and specialists. It is particularly critical that you find a primary care physician who understands your disability and is willing to work with you in developing a long-term treatment plan. If you do not have specific recommendations for a physician, you may want to consider interviewing potential PCPs once you have selected your health care plan. Ideally, however, this interview process should take place prior to plan selection.

Once your have selected a PCP, it is important to set up an initial appointment or exam with him or her so that you can immediately begin developing a care plan. This appointment will also provide the opportunity to begin establishing a positive long-term relationship with your physician. You should try to meet with your PCP before an emergency situation arises. This will help to avoid some of the possible confusion over emergency care coverage and processes. Having a physician who personally knows you and your condition, will also increase your ability to obtain the care you need. Selecting a PCP who will advocate for your needs is crucial in managed care. The PCP can help you navigate the health care system in both emergent and non-emergent situations as well as assist you and your family in transitioning to another health care plan, should the need arise.

What Can I Do If I Don’t Like My Primary Care Provider (PCP)?

You do not have to stay with your physician if you do not like the care you receive. Most HMOs let you switch PCPs at least once a year. Some plans allow you to switch whenever you are dissatisfied. Check your member handbook (Evidence of Coverage) about the procedures to switch physicians. You may need to call the HMO to get a new provider directory since participating PCPs can change frequently. Call the PCP you are considering to make sure that he or she is accepting new patients. Once you have selected your new PCP, call the HMO again to change the name of your PCP in your records.

How Much Choice Do I Have in Choosing a Specialist?

If you are enrolled in an HMO, you will usually have to obtain care from network providers, including specialists, hospitals, home health, hospice and other health care providers. Sometimes, you will be given a choice of health care providers—for example, if you need to be referred to a cardiologist there is usually more than one cardiologist to whom you could be referred. At other times, the HMO may limit which health provider you can see. Most of the HMOs in North Carolina contract with specific hospitals for transplant services. If you need a transplant, you may be given no choice of where you can receive these services.

Sometimes your choice of providers may be limited to a subset of providers within the HMO’s network. Some HMOs contract with Independent Practice Associations (IPAs). An IPA is a network of providers who contract with the HMO. These IPAs effectively operate as “mini” networks within the HMOs larger network. If your PCP is part of an IPA, then he or she may only be able to refer you to specialists and other health providers within the IPA’s network (in contrast to the larger HMO network). Thus, when you enroll in an HMO, you may or may not have access to all the HMO’s network of providers. It is therefore very important to find out whether your physician is part of an IPA, and whether the IPA places restrictions on referrals.

How Is My Physician Paid? Does My Physician Receive Financial Incentives to Withhold Care?

Not all HMOs give providers a financial incentive to efficiently manage care. Some HMO pay providers on a fee-for-service basis and have other mechanisms to control costs. For example, most HMOs have quality assurance and utilization review systems to look at care that was provided to make sure it was appropriate. These systems are used to ensure that a health care provider does not authorize unnecessary services or withhold necessary care.

HMOs sometimes give physicians financial incentives to be cost conscious in the care they provide. They do this through one of three payment mechanisms: capitation, withholds or incentive payments.

A capitation payment is a fixed payment per month that a physician’s practice receives to cover a specified set of services. The practice gets a fixed regular payment from the HMO for each member who is served. Under capitation systems, the physician’s practice receives the payment whether or not patients receive services in that month. In return, the practice is responsible for providing all the specified services, even if the costs exceed the monthly capitation payment (See capitation Description).

Capitation Description

Dr. Jones’ practice receives $20 per member per month to cover the primary care needs of 100 of an HMO’s members, (or a total of $2,000 month). If none of the HMO members seek care in a particular month, Dr. Jones’ practice gets keeps the full $2,000. However, if the members’ health care costs actually exceed $2,000, then the practice will need to pay for those costs from other revenues. In theory, this type of payment system gives Dr. Jones an incentive to keep all the members healthy. If the members are healthy, they would have less need to obtain health care services and the physician’s practice would be able to keep more of the capitation payment. However, some people are afraid that a capitation system encourages physicians to withhold care in order to make money.

While some physicians receive capitation payments, other physicians have different payment arrangements. Some physicians receive a salary for their services. Other physicians are paid on a fee-for-service basis, that is, payment for each service provided. HMOs sometimes combine these payments with other methods to discourage unnecessary care. For example, HMOs may combine capitation, salary or fee-for-service payments with withholds or incentive payments.
Under a typical withholding arrangement, the HMO keeps a certain percentage of the physician’s regular payment to cover excess medical costs. The physician may receive a refund of the “withhold” at the end of a specified time period if health care services and spending are within allowable limits. Thus, the money a physician receives may depend on how often he or she refers members to specialists, admits members to hospitals or orders expensive tests and procedures.

Another similar system is an incentive payment. Incentive payments are in addition to a physician’s ordinary payment and are made on the basis of efficiency. A physician who orders fewer tests and procedures and makes fewer referrals or admissions may get an additional incentive payment or bonus. Both withholds and incentive payments encourage physicians to manage treatment efficiently. However, some people are concerned that these payments may also discourage physicians from referring or admitting members or ordering certain diagnostic tests or medical procedures, when they may be needed.

Withhold or incentive systems may also be based on quality of care measures in addition to efficiency. For example, HMOs may take into consideration patient satisfaction scores or the percentage of members who receive preventive services in paying physicians.

Each HMO and insurance company has different reimbursement rules and oversight systems. Ask your physician directly about your HMO’s payment arrangements or internal review mechanisms if you are concerned that the arrangement may affect the care your physician can provide to you.

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