In Selecting Doctor, the Group’s the Thing
This is the time of year when people who purchase health insurance through their employers get to choose new health plans, or make changes to their existing coverage.
But the choice that could impact your health care the most isn’t likely to be explained in any of the glossy packets put out by health plans.
It has to do with the choice of a primary care doctor, and the medical group to which that doctor belongs. Most people don’t know it, but the seemingly simple choice of a physician to handle routine visits and referrals actually determines far more about your benefits than the choice of a health plan.
Why?
Because in California--where 23 million people are covered by HMOs or other forms of managed health care--it’s not really your insurance company that makes the day-to-day decisions about your care. It’s groups of doctors. Your health plan pays doctors money every month to take care of you--and they’re the ones who decide whether you get to see a specialist, who the specialist might be, and even which hospital you have to use.
By signing up for a doctor, you’re really signing up for his or her medical group. So it’s for you to decide which doctor group you want even before you pick a health plan.
There are roughly 300 doctor groups in California--some small, comprising just a few doctors, and some quite large, with thousands of them. As employers and insurers have continued to push for medical cost-cutting, many of these California groups have struggled to stay financially afloat. So far this year, 15 physician groups have declared bankruptcy or gone out of business, according to the California Medical Assn.
Most people barely know that these groups exist, much less the impact that they have on care.
Why does it matter?
The most immediate reason is that unless the specialists you like--whether its your eye doctor, dermatologist or cardiologist--are affiliated with the same group as your primary care doctor, you won’t be able to get a referral. (A primary care doctor is typically a family doctor or internist who oversees your care--for women, this may be their obstetrician-gynecologist; for children, their pediatrician.)
Erem Oganian found this out the hard way. One day last spring, Oganian was in Glendale when he tripped and fell, breaking his leg so severely that the bone protruded from the skin.
Paramedics rushed him to Glendale Memorial Hospital, where an orthopedist he liked very much set the wound.
But when he tried to see that orthopedist for a follow-up visit, his medical group referred him to another doctor because the orthopedist was not part of the group. Oganian, a North Hollywood resident who, like many people, did not even realize that he was in a medical group--couldn’t understand what was happening.
“I feel like a basketball,” bounced from doctor to doctor, he said gloomily. After switching health plans did not resolve his problems, he finally discovered that he needed to first see which medical groups his favorite doctors were in, then find a health plan that included those groups.
Group’s Financial State May Affect Patients
Besides choice of specialists, the shaky financial state of many groups could impact patients. If a group goes broke or is sold, for example, patients may be unable to see their specialists--at least for a period of time. In a worst-case scenario, a doctors’ group may be so strapped financially that it cannot pay for needed treatment, resulting in medical care that is delayed or denied.
But how does a consumer go about researching physician groups?
For members of the Kaiser HMO, the question is somewhat moot: Kaiser Foundation Health plan has exclusive contracts with its affiliated Permanente Medical Groups. These groups are very large and organized according to region, and members may choose fairly freely among thousands of doctors and dozens of clinics and hospitals.
But for everybody else, unfortunately, there is no simple approach. Most medical groups are completely unregulated now, making it virtually impossible for anyone who wishes to do so to investigate a group’s financial health. But legislation that is awaiting signing by Gov. Gray Davis would allow state officials to set financial standards for physician groups.
Still, there are ways for consumers to make informed choices.
Here are some questions to consider:
* What type of medical group does your doctor belong to?
Is it a small group with just a few specialists or no specialists? Ask the doctor why she is affiliated with the group, and whether she likes it. Is the doctor part of more than one group and, if so, what are the characteristics of each group? Find out which insurance plans the group accepts.
* How will the group treat me?
What are the rules for referrals to specialists? Do patients need to wait until a referral arrives in the mail, or can their doctor approve a visit to a specialist on the spot? How long does it take to get an appointment with a doctor? Some health plans publish report cards on their physician members, based on consumer surveys and complaints. Ask your health plan or medical group for this information. You may also check with the California Medical Board in Sacramento to see if a doctor’s license is in good standing.
Betsy Imholz, director of operations for Consumers Union’s West Coast office in San Francisco, suggests asking if the group has a customer service department and, if so, calling them. “You can learn a lot by calling customer service and asking questions,” Imholz said. “If you’re on hold for 15 minutes, if you get evasive answers, you should take that into consideration because, when push comes to shove, those are the folks that you’re going to have to deal with.”
* Does the group have enough doctors in different specialties to meet my needs?
Find out whether there are enough primary care doctors in the group to provide round-the-clock coverage in case of emergencies, says Peter Boland, a health care consultant based in Berkeley.
If the group only has primary care doctors, find out which specialists they would refer you to. If the group has its own specialists--and you or someone in your family needs to see a specialist regularly--find out the names of the doctors to which you would be referred. Also find out which hospital the group is affiliated with. Is the hospital close to your home? Is it a small community hospital or a larger facility affiliated with a university or where a lot of medical research is done?
* Is the group in good financial shape?
This is the most difficult area to assess. One way to check is to ask the administrator if the group has a license from the state, called a limited Knox-Keene license. About 30 of the larger groups have these permits. These groups must report their financial status to the California Department of Corporations, which has offices in Los Angeles, San Francisco, Sacramento and San Diego. This information as well as data on consumer complaints is available on the agency’s Web site at https://www.corp.ca.gov or by calling the agency. The phone number for the Los Angeles office is (213) 576-7500.
However, most of the state’s 300 groups are private companies that do not have to file financial reports with the state. One way to get around this problem, suggests Michael Eberhard, who runs a Cerritos consulting company that works with medical groups, is to ask your doctor if he likes working with the medical group you are thinking of joining. This is presuming, of course, that the doctor will be candid about sharing this information.
“I would go to my doctor and ask, ‘Which group do you like working with?’ ” said Eberhard, president of Medical Pathways Management Corp. “Which group pays its claims right and doesn’t hassle you? . . . Patients should go where the doctors are happy about how it’s all being handled.
Once you’ve narrowed your choices of groups, find out which ones are affiliated with the health plans your company offers. At open enrollment, choose the whole package together--health plan, primary physician and medical group. Most important, be prepared to switch if it turns out that you don’t like the group you’ve chosen. Most health plans allow patients to change groups over the phone.
“Patients,” said Eberhard, of Medical Pathways, “should vote with their feet.”
