One of the first things many managed care plans, especially
health maintenance organizations (HMOs), ask you to do is choose
a primary care doctor. Your primary care doctor is the doctor you
see for routine check-ups and when you are ill. This is your most
important partner in your health care. He or she coordinates your
health care and sends you to a specialist or hospital if you need
it.
For these reasons, it is important to trust your doctor and feel
comfortable talking with him or her about any health issues that
concern you.
Your primary care doctor is usually a "generalist." A
generalist can be a general practitioner, an internist, or a
family practice doctor. These doctors focus on the whole body.
If you want to have a specialist as your primary care doctor, ask
your plan. For example, some women prefer a gynecologist as their
primary doctor. Be sure to talk to your specialist about this.
Some specialists do not want to coordinate your health care
needs. They may not be comfortable working on medical problems
outside their area of expertise.
Choosing a Primary Care Doctor
Ask if you can interview the doctor, either by telephone or
in person. This gives you a sense of his or her style and whether
you feel comfortable with that person. Talk about what you want
from a doctor and what the doctor will expect from you. You might
have to pay for this interview with your own money, but it could
be worth it.
Talk to other health plan members about what they like and
don't like about different doctors.
Check the plan directory to see if it contains information
about doctors' education, training and special interests.
Find out if the doctors you are considering are "board
certified" in their field. "Board certified" means
that they have taken extra training and passed tests in certain
areas of medicine. You can also find out if your doctor is board
certified from the American Board of Medical Specialties.
Contact your state health department or medical board for
information on complaints or actions taken against doctors. You
can also search the web sites of several groups that collect
information on disciplines taken against doctors.
Ask whether the doctor is taking new patients. Some doctors
limit the number of new patients they will see.
Ask how long you must wait for an appointment. Some doctors
have waits of four to six weeks. The length of your wait might
depend on the kind of problem you have.
Find out how easy it is to reach the doctor during the
evening and on weekends in an emergency, or if your plan has a
special advice line when the office is closed.
Check out the doctor's office location, hours, parking
availability, whether you can get there by public transportation,
and if it has access for people with disabilities.
Staying With Your Current Doctor
Perhaps you have been going to the same doctor for many years. If
you joined a new health plan and want to stay with your current
doctor:
Check your plan's list of participating doctors to see if
your doctor is listed. Call your plan's member services
department if you need help or ask your doctor.
Ask if your doctor is seeing patients from your new managed
care plan. Sometimes doctors will take only so many patients from
managed care plans. Even though you have been going to your
doctor for many years under one health plan, there is no
guarantee that the same doctor will see you when you change plans
or that he or she will practice the same way you are used to.
If you can stay with your current doctor, ask what will change
when you see your doctor as part of your new plan. For example,
Your doctor might have to send you to different specialists
or hospitals that are part of the managed care plan's
network.
The amount of time your doctor spends with you may change.
Many managed care plans want doctors to see a certain number of
patients every hour.
The plan prescription drug benefit might determine what
medicines your doctor uses. Your doctor may need to switch your
prescription drugs to those approved by the plan.
Your doctor might have to use the plan's laboratory to
process your tests.
Changing Your Primary Care Doctor
It takes time to build a good relationship with your doctor, so
that he or she knows all about your health and medical history.
There may be a time, however, when you need to change your
primary care doctor because:
You are unhappy with the care you are getting.
Your doctor is no longer part of your plan.
Your plan drops the doctor from its network.
Most managed care plans let you change your primary care doctor.
Be sure to follow plan rules regarding the change. Remember to
ask your former doctor to send copies of your medical records to
your new doctor. You may be charged a fee for copying your
records.
Getting a Referral to a Specialist
Many people see their primary care doctor for most of their
health care needs. But sometimes it's necessary to see a
specialist. Here's how you can see a specialist when you are
in a managed care plan:
Referrals Inside Your Managed Care Plan
In many managed care plans, especially HMOs, your primary care
doctor must give you a written referral before you can see a
specialist in your plan's network. The referral tells you
how many times you can see the specialist.
Referrals Outside Your Managed Care Plan
Learn your plan's rules for seeing specialists who are not
part of your plan. Find out how much you will pay for the visit
and how much your plan will pay. Know if your plan will pay
your hospital bills if you are admitted to the hospital by an
out-of-network specialist. You don't want to be faced with
large hospital bills if you don't follow the plan's
rules.
