Task of the day: Insurance choice focusing on your priorities for being able to acquire quality health care requires accessibility, affordability, quality, tactics--AAQT. Consider your own views about Primary Care Providers, known less favorably as gate-keepers. If you have or intend to use an HMO or POS insurance, you will likely be dealing with the requirement that you choose a primary care physician. POS, marketed as a blend of the HMO product and the PPO product usually require use of a Primary Care Physician to utilize in-network benefits.
Policy consideration: The requirement of having a primary care physician is not offensive on its face, treatment by your own doctor and referrals to specialists when needed is benign on its face. If you aren't a doctor, having the go to guy for your medical issues is not necessarily bad. The issues arise in two ways with Primary Care Providers:
Issues: 1) Lag time in making an appointment with a primary care physician: How long you might have to wait to see your primary care physician and 2) Obtaining referrals: There have been complaints that primary care physicians do not make referrals, keeping the treatment of a patient in their office when the patient and the circumstances warrants referral to another physician.
Reforming the idea of Primary Care Providers in order to Revitalize the insurance model:
To address the real world problems cited with Primary Care Providers, insurance plans should include the real risk to consumers that they will encounter one of the above issues. These issues are currently NOT addressed. If a plan requires use of a primary care physician, possible reforms to such plans would include provision that if the insured cannot get an appointment with his/her primary care physician within a certain number of days then the insured is automatically covered to schedule an appointment with any doctor he/she chooses for in network cost. Proof of such delay in obtaining an appointment would be provided to consumer on the day he/she tries to schedule an appointment with his/her primary care provider. If I call my doctor on Wednesday to schedule an appointment and he/she cannot see me until the following month, his office sends me a piece of paper documenting my call on x date and the next available appointment date. Penalties for doctor offices that do not follow this protocol is between them and the insurance company.
For the second issue: If the insured requests a referral and it is denied, the appeal form is filed by the insured to the insurance company and resolution is provided within ten days. If the insured seeks treatment by an out of network specialist because of such denial, the specialist's treatment is prima facie proof that such specialty treatment was medically necessary and the fees for this specialist will be covered by the insurance company.
For now, choice of HMO or POS typically requires that in order to get the economic benefit of the network, an insured use a Primary Care Physician.
