Primary Care Physician

Managed care plans are written with a focus on delivering the best care while managing health care costs.

A Primary Care Physician is another of the ways that a health insurance carrier will seek to control costs. A Primary Care Physician (PCP) can be thought of as a gate keeper in that they hold the keys to the kingdom, so to speak.

Real world example

A patient, new to an HMO plan, schedules a visit with his Primary Care Physician requesting a referral to a chiropractor for his back pain. He has had this problem occasionally off and on for years. It is usually no big deal, it flares up and after a few chiropractic visits, he is good as new. Because he has always had a PPO plan, he never had to get “permission” in the form of a referral before; he could just see any doctor he wanted to.

His Primary Care Physician requests a back x-ray. The patient knows this is not going to yield anything more than a soft tissue injury. The x-ray is negative for anything serious, so his Primary Care Physician diagnoses him with a soft tissue injury of some sort, writes him a prescription for muscle relaxants and pain pills, and tells him to come back in 4 weeks if it has not improved. No referral to a Chiropractor is given at this stage. It takes the patient two more trips before he can convince the PCP to issue the referral.    

The role of the Primary Care Provider

This example, loosely, describes the Primary Care Providers role. A PCP is tasked with deciding what medical services should be allowed, if a referral to a specialist is warranted and what is deemed necessary to treat the current condition. All services must be approved by the PCP. 

The PCP’s will try to manage the level of care that each patient needs based on their current condition. The goal is to try to start with the lowest, most inexpensive level of care and move up to higher, more expensive and extensive, levels of care as needed.

Of course, any patient that exhibits any severe, life threating, serious or concerning injuries or illnesses will immediately be elevated to the highest  level of care and stepped down to a lower level of care as needed.

Keep in mind that most patients can be easily managed in a lower level of care. Colds, minor illnesses, some chronic or controlled conditions and even certain injuries may not require numerous visits, a specialist or admittance to a hospital. Their condition may easily be remedied with medication and time.

The PCP is tasked with understanding and treating a patient in the best possible way to ensure the overall well-being of the patient. But this does not mean that they are always right; all plans have a method to dispute or complain about the treatment or care that was received. 

Managed care plans usually will have you select a Primary Care Provider upon enrollment and you will have the option to change this PCP if he leaves or if you become unsatisfied with the care that is provided.


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