Today, many of us can choose the physician who will provide our medical
care, including, importantly, the surgeon who will perform any operation
we may need. It's one way we can ensure that we'll have the best possible
result from any medical treatment or procedure. But Americans may not have
this choice much longer. Change is coming to our nation's health care system,
and changes now under consideration could limit your right to consult with
the qualified specialist of your choice.
The American College of Surgeons believes that maintaining patient choice
is crucial to maintaining high standards of care. That's why we think you
should be fully informed about all of the implications that these proposed
changes could have on the health care provided to you and your family.
To help you understand this issue, we've developed this brochure to answer
some of the questions that you might have about retaining the right of
patient choice.
Q-1 Why is it important that I be able to choose
the physician or surgeon who will provide my medical or surgical care?
Not being able to choose your physician can pose some problems for you
as a patient. You need to feel comfortable in talking with your doctor,
and if you have a good doctor/patient relationship, you can more easily
communicate with each other. Having good rapport with your doctor is a
vitally important and reassuring experience for you as a patient, and will
help you to feel confident about the treatment that your doctor recommends.
In addition, if you have a medical problem that is worrisome, painful,
or not yet diagnosed, it is only natural that you might wish to seek care
from a physician specialist or a medical facility that is known to have
special expertise in your problem. In these types of situations, you may
become displeased and unhappy if limits are placed on your ability to select
the physician of your choice.
Q-2 Will reforming our country's health care
system limit my ability to choose my doctor?
Well, that's certainly something to think about. Right now, even without
a national health care reform plan being enacted, the current trend is
for health care coverage to be purchased by individuals or their employers
through what are known as managed care plans. Some managed care plans allow
patients some choice in selecting their primary care physician. This physician
is the patient's first "point of contact" with the system whenever
he or she becomes ill. However, it appears that most managed care plans
allow considerably less choice for patients when they need to see a medical
or surgical specialist. These plans also limit the patient's ability to
decide independently when it is time to seek care from a medical or surgical
specialist.
Q-3 What, exactly, is "managed care"?
Managed care is a system of providing patients with health care service
at prices that tend to be somewhat lower than those of traditional health
insurance plans. Since under a managed care plan, the medical insurance
premiums charged to patients or their employer are generally lower, the
costs of health care services that are provided under these plans must
be kept as low as possible
To keep costs low, specific health care practitioners within the plan--who
are often called "gatekeepers"--"manage" the amount
and type of health care that is provided to patients. Sometimes these practitioners
are primary care physicians; other times they are health care professionals
who are not physicians, such as nurse practitioners. These managed care
practitioners may be required by the plan to limit the number of times
that patients with special medical problems may be referred to specialists.
Managed care plans also may require specialists to get approval from the
managed care practitioners before they hospitalize a patient or order expensive
diagnostic services--a process that is referred to as "preauthorization."
Some managed care plans also differ from traditional insurance plans
in that they will pay for certain physical examinations and preventive
health care services, such as immunizations. This policy is based on the
belief that in the long run, it's more effective to spend money "up
front" to prevent an illness than it is to provide more expensive
services after a patient becomes sick.
Q-4 How can managed care affect my ability
to choose my physician or surgeon?
Typically, a patient's choice of physicians is limited by the managed
care plan's gatekeepers who try to refer patients only to health care facilities
and physicians who are members of the plan's network. Often, these gatekeepeers
are offered financial incentives to limit a patient's access to expensive
medical services. For example, some gatekeepeers receive a bonus at the
end of the year from their managed care plans if they keep the number of
patients who are hospitalized or who are sent to specialists below a certain
number that has been set as a limit for that year. So, a gatekeeper might
not be willing to allow you to see a specialist when you want to.
Q-5 Do all physicians practice in managed care
plans?
Today, physicians can choose to join a managed care network or remain
in a medical practice where they see patients who have private insurance
coverage or privately pay for a physician's services. Some physicians see
both types of patients. However, due to the increasing cost of private
medical insurance, many companies now favor a managed care system for their
employees. As a result, more employers are only offering their employees
managed care plans for their health care needs. Therefore, the number of
managed care networks is growing, and more physicians are looking to participate
in these networks in order to maintain an active practice.
Q-6 Why might a particular doctor not be a
member of a managed care network?
Doctors can be left out of managed care networks for a number of reasons.
Many networks start out actively recruiting physicians to participate in
their plans. Later, when the networks have enough medical and surgical
specialists in their plans, these networks can become difficult for other
physicians to join. For example, physicians are usually more in demand
than are doctors who are specialists. Therefore, a doctor's specialty may
affect his or her chances of being accepted into the network. It may simply
depend on whether the group believes it has enough physicians of various
specialties to meet the needs of the patients who are enrolled in the network.
How much money the plan has to spend for the care a doctor orders in
treating patients--or even how much time a doctor typically spends with
patients--may also be taken into consideration by the managed care network.
Some networks may evaluate doctors by looking at how many and what kinds
of tests they order for their patients, whether tests or procedures are
performed on an inpatient or outpatient basis, and if a patient is hospitalized,
how much time he or she spends in the hospital. This practice of evaluating
physicians based on the cost of the care they provide is called economic
credentialing. However, some physicians take care of more elderly or high-risk
patients than other doctors do. Such patients may require additional days
in the hospital or more extensive medical treatment in order to receive
the best possible care. Economic credentialing does not always take special
factors like these into consideration in evaluating the cost of the care
physicians provide.
Finally, on relatively rare occasions, a physician may even be excluded
or dropped from a managed care network for failure to meet the networks
quality of care standards.
Q-7 If I'm a patient in a managed care network,
I'm pretty much limited to seeing only doctors who participate in the plan.
But what happens if I need to seek care from a surgical or other medical
specialist who is not a member of the plan?
A managed care network is set up so that patients with most medical
problems can find a network doctor who has the proper skills and training
to treat them. Nonetheless, there are times when a patient's illness may
be uncommon or difficult to diagnose and a suitable specialist cannot be
found within the network. If that happens, the primary care physician or
the plan's gatekeeper may need to negotiate with the person(s) who manage
the plan to get authorization to refer the patient to a medical or surgical
specialist who is not a member of the managed care network.
Q-8 So, if my problem is unusual, arrangements
can be made for me to get the care I need from a special physician who
is not a member of the plan. But what happens if my plan has doctors who
can provide the care I need, but, for some reason, I would rather see someone
else?
The limits placed on your ability to see a physician who is not in the
network may vary and will depend on the rules of the managed care plan
you have. Even the most restrictive plans cannot prohibit you from seeing
the physician or surgeon of your choice, but they can refuse to pay for
it. Many plans will simply make you pay more to see a doctor who is not
in the network. If for example, a patient is usually required to pay $10
for every visit to the plan's doctors regardless of the service provided,
he or she may have to pay a percentage of what the physician or surgeon
who is not in the network charges for the service. If the problem is one
that is expensive to treat, this extra charge can amount to a sum of money
that is more than the patient can afford.
Q-9 It appears, than, that the more "managed"
a managed care plan is, the less likely it will be that a patient can choose
a physician or health care facility. Yet, most health care reform proposals
are promoting managed care as the way to offer universal health care coverage
in the United States. What can I do to make sure that I will be abe to
retain the right to choose my own physician or surgeon under a reformed
health care system?
Although managed care plans typically do restrict patient choice to
one degree or another, many of them appear to be effective in keeping the
cost of health care services low. That's why managed care plans are so
attractive to many promoters of health care reform. However, some experts
believe that at least some managed care plans only appear to be less expensive,
in part because they include healthier-than-average people. Other observers
even worry that some managed care plans could keep costs low by skimping
on needed health care services.
In any event, if you want to retain the right to choose your own physician
or surgeon, you need to make sure that your your insurance plan--whether
government or private--will safeguard your right to choose. Let your elected
officials and your employer know that you are concerned about the changes
that are coming to our nation's health care system. Explain that you are
worried about the changes now being considered that could limit your right
to consult with the qualified medical or surgical specialist of your choice.
Urge them to preserve your right to choose. After all, your health and
well-being are of the utmost importance, and you must be able to see the
physician or surgeon whom you think has the best skills and experience
to take care of you and your family.
Remember, today it's your choice. Make sure it will still be
yours tomorrow.
