Making Provider Choices in Managed Care

How to make the wise choice in a primary care physician.

3 min read

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.

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 choice.

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.

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 needs."

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.

In selecting a PCP, you should consider how well he or she communicates with you. Ray Werntz, president of the Consumer Health Education Council in Washington, thinks openness is the base of a good doctor-patient relationship.

"Consumers can go online when selecting a PCP and find out where that doctor graduated from medical school or how they did academically, but the PCP who listens well may be much better than the one who graduated at the top of the class," he says. "What happens between the doctor and patient isn't always medical. It's also about relationships."

Werntz believes that whenever a patient is denied access to the doctor he or she wants, frustration and mistrust in the entire system is sure to follow. "That's why consumer demand for choice is so huge," he says.