Making Provider Choices in Managed Care
How to make the wise choice in a primary care physician.
Under managed care, a primary care provider (PCP) wields considerable power.
He or she is the gatekeeper who holds the keys to the specialized medical care
you may need. Above this doctor, though, is the managed care plan itself -- the
PCP's gatekeeper. The average consumers may think their most important health
care choice is picking the right PCP. But other factors, including the plan you
choose, have just as great an effect on your health care.
Choosing a PCP
Bob Blendon, PhD, professor of health studies at the Harvard School of
Public Health, believes consumers today select their PCPs the same way they've
always chosen doctors: Personal experience, a recommendation from a friend or
coworker, or how convenient the doctor's office and hours are.
This approach is sound, according to the American Medical Association, which
suggests similar criteria in its consumer publication, "Choosing a
Doctor." The AMA also recommends selecting a PCP who shares your values
about medical care, and interviewing the doctor before you make a final
Yet although advice like the AMA's is a common-sense approach to the
selection process, Blendon thinks it may give a false sense of security.
"It's not clear to me that people know the power of their primary care
provider, let alone the limitations their plans may have. People are
confused," he says.
Blendon thinks consumers should redirect their attention to the plan itself,
not necessarily the doctors who participate in the plan. "What matters more
is how restrictive the plan is about seeing specialists, what kind of
limitations are placed on prescriptions, and what incentives are paid to the
doctors to keep costs down."
To complicate the choice, any particular doctor probably appears on the PCP
lists of several different plans at once. Due to the multiple listings,
explains Blendon, physicians can become confused trying to distinguish between
plans. For instance, one plan may have more restrictions about medical testing,
which may lead to your undergoing tests that your plan won't cover.
The Government's Role
State legislatures and the federal government have both been trying to
regulate certain areas of health access. This is especially true where patient
choice is involved.
"Normally people don't want the government to be involved unless they
don't trust the health care system," says Les Zendle, MD, associate medical
director of Kaiser-Permanente in Southern California. "This is most often
the case for patients who have chronic diseases or special medical
The public's mistrust has lead to legislation in several states that allows
a consumer to select a medical specialist to serve as a PCP, says Molly
Stauffer, senior policy specialist with the National Conference of State
Legislatures (NCSL). In a study of medical access released in October of 1999,
NCSL reported that 18 states and the District of Columbia now require managed
care plans to allow a woman the option of choosing an obstetrician-gynecologist
as her PCP. A number of other states also allow a woman direct access to an
ob-gyn without first getting approval from her PCP.
Blendon believes the trend of specialized access may expand. For example,
laws may be put into place that let parents select a pediatrician PCP for
children. "In general, the managed care companies that grow the fastest
tend to be the ones that offer the most choice," he says.