What is a "PCP"?

What is a “Patient Advocate”?

By Martine G. Brousse (not AI!)

"The Medical Bill Whisperer"

Patient Advocate, Certified Mediator

AdvimedPro

June 17, 2024

The Primary Care Physician ("PCP") has a large and important role in healthcare, and also affects your wallet.

What is their role? Pros and cons? And how to make best use of their services? 

A.   What is a “PCP”?

1.     Stands for “Primary Care Physician”

·      The older-days “family Doctor” or “General Practitioner”

·      The Doctor you consult first for a medical question or issue

·      The physician supervising and managing your overall medical care and wellness

·      The physician attending to your “every day” medical concerns and needs

·      Depending on your State, a PCP can be a:

• MD (medical doctor)

• D.O (Dr of Osteopathy)

• NP (Nurse Practitioner)

• PA (Physician Assistant)

• CNS (Clinical Nurse Practitioner)

·      Usually Not a specialist, although in some cases, it can be:

• OB-GYN, especially if pregnant

• Pediatrician (for children under 18)

• Internist (for more serious conditions)

• Oncologist (during cancer treatment)

·      Medical professional who manages and handles:

• Minor medical issues or concerns
  

• General medical care

• Wellness screenings

• Preventive care
  

• Lifestyle advice and support

• Rx management

• Centralized medical records

• Minor emergencies
  

• Referral to specialists when appropriate

2.     For HMO members:

·      The physician you MUST be assigned to, and who you MUST consult first (except if a 911 emergency)

·      The medical professional who handles all of your care and needs

·      The medical professional who issues authorizations (“referrals”) for you to see a specialist or receive care he/she cannot provide

3.     For non-HMO members:

·      The medical professional you may choose to manage your medical care

·      The medical professional you would consult for basic medical care, preventive care, advice to specialists, and management of certain diseases or conditions

B.    Pros

1.     Clinical

·      Familiarity with your medical status allows for more focused and personalized care

·      In-depth knowledge of your conditions, lab and test results, Rx may lead to a reduced need for diagnostic measures

·      Centralized medical records allow for prompt sharing of info with other medical providers, especially in case of emergencies

·      Centralized medical records lower duplication of services and can help prevent Rx counter-indication or medical errors

·      Access to care can be

• Direct face-to-face office appointment

• Telehealth visits

• Communication through online patient portal for questions or less urgent/serious matters

• Easy portal access to: test results, appointment management, Rx refill requests

• Support Staff can handle minor requests, off-visits tasks, saving you time and efforts (and copays!)

2.   Financial

·      No need for authorization, so no risk of a denial for lack thereof

·      Lowest copay, so lowest cost to you

·      PCP is usually In Network, at lowest cost to you

·      Lower need for diagnostic tests, scans and labs save you $

C.     Cons

1.     Limited by:

·      PCP’s level of medical training, experience, expertise

·      Choices of PCPs in your plan

·      PCP’s level of decision authority: PCP’s employer’s guidelines may limit your access to specialists or outside care

·      PCP’s insurance requirements: must authorize every service outside of their practice (HMO)

·      PCP’s business model: If a PCP is "capitated" - meaning they get paid in advance a certain sum to manage your care, their income lowers the more services they render. In some

cases, they may have to pay if they refer you to a specialist.

2.     HMO members:

·      PCP must authorize every service outside of their scope of practice

·      Complaints over the years have included:

• limited or obstructed access to care, especially to specialists,

• delays in obtaining outside referrals, and then to obtain a timely appointment

• “gatekeeping” (PCPs prefer to treat everything themselves) that leads to misdiagnoses, delays in treatments, reluctance to transfer care to a more qualified physician
  

• Sometimes poor or sub-standard quality of care by more inexperienced practitioners
  

• Letting cost of care influence medical decisions

3.     Non-HMO members

·      Push by insurances to use PCPs rather than specialists

·      Although there is no requirement for an authorization to see a specialist, and access is open, copays are higher

·      More and more specialists are out of network, with reduced insurance payments

·      Many (if not most) “super” specialists are Out Of Network (those experts in one rare disease, or pioneers in their field)

·      Out Of Network services are always (much) more costly to patients

D.    Some Tips

1.     Always seek the (level of) care you need!

Your PCP can handle a certain level of care and emergency but 911 is your point of contact for life-threatening emergencies or times of crisis!

You and medical professionals are best able and suited to make all determinations regarding your need to access care, and where, how and when it is best rendered.

2.     Understand your PCP’s scope of practice

·      Preventive care

·      Treatment of common illnesses and conditions

·      Early detection of more serious medical issues

·      Management of chronic conditions

3.   Evaluate “side” benefits

·      Staff can handle “minor” tasks

·      Telehealth appointments

·      Support of lifestyle changes

·      Centralized medical records

4.  Know when to raise your level of care

PCP

·      More specialized care is needed

·      Condition is or has become unmanageable, or is worsening

·      More aggressive or specialized intervention/treatment is needed

·      PCP lacking expertise

5.   Pick well

·      A good relationship with the right PCP leads to better care and better health

·      Consider a PCP who can listen to your healthcare choices and support your decisions, while explaining and highlighting options, solutions and consequences

·      A two-way dialogue leads to trust and trust leads to best outcomes

Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.

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@martine brousse 2024 @ the medical bill whisperer 2024