Keeping You Healthy While Controlling Costs

If you belong to a managed care plan, your primary care provider has two important roles: keeping you healthy and controlling costs. Sometimes these roles can conflict with each other.

Your primary care provider(PCP) provides the health care services that you need. Your PCP will see you for physical exams and immunizations, as well as when you are sick or injured. Your PCP will manage most long-term "chronic" medical problems over time. For example, you may see your PCP regularly for the treatment of hypertension, diabetes, asthma, migraines, or other chronic medical conditions. The primary care provider also plays an important role in coordinating your care by making sure you don't get lost in the health care maze. If you need to see a number of specialists, your PCP can make sure they're all working together.

In most plans your primary care provider will be a physician, but in some plans it might be a nurse practitioner or physician's assistant. They are well trained to provide 80-90% of the care that you need and to know when to call in a physician.

Your primary care provider also plays a role in reducing costs. Controlling costs is important to you, because it will keep your premiums down and allow you and your employer to afford quality medical care. In some managed care plans, this involves your PCP acting as a gatekeeper. As the gatekeeper, your PCP controls your access to the rest of the health care system-making sure you get the referrals to specialists that you need, but also making sure that you don't see a specialist unless it's really necessary.

However, in many plans, your primary care provider may have a financial incentive to restrict your care. This can occur in two ways: The PCP may get a bonus if the number of referrals in kept below a budgeted number, or the doctor may be "capitated." (In the American medical care system, capitation is when a health- care provider is paid a flat rate for each person served.)

A bonus for "efficient care" can be paid in two ways. It may be an amount paid quarterly or annually, or a percentage (usually around 10-20%) of a fee that is held back from providers by managed care organizations, known as a "withhold." It is only given to providers if the amount of care they provide costs less than what has been budgeted for each quarter or for the entire year.

Capitation means that your primary care provider gets a fixed payment each month whether or not you use services. If patients use very few services, the PCP will have extra money. The money may be used up in caring for other patients, or some may remain at the end of the year. If so, it will then belong to the PCP. If patients use a lot of services, PCPs can actually lose money.

Both bonuses and capitation can cause a conflict between your PCP's financial interests and your own health needs.

Good communication is a good way to protect yourself.

Find out how your PCP is paid. Your PCP may belong to many different managed care plans. Your PCP will be paid differently depending on your particular managed care plan. Find out if- under the plan that covers you-they are capitated or if they get a bonus to keep their referrals or total care below a budgeted amount. If you're reluctant to ask your provider directly, try checking with your plan's marketing or member services department. If the PCP can earn a bonus or is capitated, the next step is very important.

Speak up for what you want. If you believe you need to see a specialist, say so. If your doctor disagrees, ask why. If you're not convinced, insist, or speak to your plan's member services department. As a last resort, you can switch doctors or switch to another plan. You should be aware, however, that most physicians now practice under the same constraints. It is possible that your new doctor will also be reluctant to refer you to a specialist.


Most physicians are genuinely concerned about their patients and will make the decision that is in the patient's best interest-- even if it hurts them financially. However, not all doctors operate in this manner, so make sure you communicate your questions and needs.

Your health is a product of what your physician does and what you do. The better you communicate and the more you speak up, the better this health care partnership and your health are likely to be.



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