Primary-care physicians are the gatekeepers to the health care
system. Choose carefully.

Choosing a primary care doctor is as important as choosing an HMO

By KELLEY BOUCHARD and MARY K. FITCH

News staff

It took three days in the hospital and two months on intravenous antibiotics for Carol Daigle to learn how crucial it is to find the right primary-care physician.

A lupus sufferer for many years, Daigle knew she needed special care. But when she signed up with her HMO a year ago, she hastily picked a general internist who she says knew little about her disease.

When she cut her foot, Daigle says the doctor overlooked the possibility that her lupus and its medications could lead to serious complications. The cut turned into a full-blown infection.

"I just think the doctor had no clue as to how dangerous lupus is," says Daigle, 47, of Melrose. "I'm on some dangerous drugs because of lupus and she didn't seem to care about that."

She has since found a primary-care physician who specializes in treating lupus.

Daigle's case shows how important it is these days to be a partner in your own health care. That means the two most vital decisions you have to make — finding the right HMO and a good primary-care physician — should be considered long before you get sick. Don't choose a doctor just because he's in your neighborhood or an insurance plan simply because it's the cheapest.

Compare HMO benefit plans in detail and interview the people who will be making decisions about your health care. This is especially important in choosing your primary-care physician, your gatekeeper to the managed care system. He will decide whether you see a specialist, get a blood test, or undergo an operation.

Even critics say managed care is here to stay, so it's up to us to learn to work within the system. That requires the same kind of effort you'd put into any major purchase, like buying a house or a car. The more research you do up front, the more confident you can be that you'll choose the right doctor or HMO.

"With managed care, you have to be an assertive, aggressive and educated consumer," says Barbara Anthony, chief of the state attorney general's Public Protection Bureau.

Choosing a

primary-care physician

Dr. Joseph Heyman, a West Newbury obstetrician/gynecologist, says he's the kind of doctor who is willing to fight HMOs when they try to restrict patients' care.

Maybe his patient needs to spend more than 48 hours in the hospital after giving birth or having a hysterectomy. Maybe a woman wants to see him and he's not in her network of doctors.

Sometimes Heyman wins the battle, sometimes he loses. But he says he always makes the effort to ensure his patients get the best health care possible, because that's what he expects for himself.

"I'd want my doctor to be my advocate to make sure I get my fair share. I want to know that the physician is working for the patient above all others," says Heyman, who is president of the Massachusetts Medical Society.

To guarantee you get that level of dedication, experts like Heyman say you should take your time in picking a primary-care physician.

This is the person who will direct your care when you've got painful tendinitis, a persistent ear infection, or a suspicious lump in your breast.

As you begin your search for a primary caregiver, ask friends, relatives and people you know in the medical community to recommend respected doctors. Then set up interviews with a few doctors to see if they'll fit your needs. You might have to pay for these visits yourself, but it's well worth the cost, which could range from $30 to $100 depending on the length of the meeting.

"I see more people in their 30s and 40s, people with families, coming in and wanting to check me out and see what I do," says Dr. Steven Barrett, a family practitioner in Manchester-by-the-Sea. "It's the consumer movement going on in medicine. I think it's healthy. It's good."

During the interview, try to find out whose side the doctor is on. Is he working for you or the HMO? What's his patient load? Can you make same-day appointments? Will you always see him or a physician's assistant or nurse?

It's also important to ask how the doctor gets paid because many HMOs give doctors incentives to limit care. Certain questions will give you a feel for his philosophy: Would he check your cholesterol if you were concerned about a family history? Would he put you on antibiotics if that nagging cough won't go away? Would he phone in a prescription refill without a visit?

"People should know if their doctors are being paid more to do less," says Rebecca Derby with the statewide advocacy group Health Care For All.

While physicians should clearly explain how they get paid, don't get bogged down with the financial details of your doctor's practice. Just be sure that his money concerns won't determine his medical decisions.

"Finding a physician you can put your trust in is much more important than how they're paid," Heyman says.

While you're talking, it's also important to notice if the doctor is responsive to your questions. If not, keep shopping around. If you can't ask a doctor how he conducts business, imagine talking to him about an embarrassing medical condition.

"It's good to ask those questions in an interview-type format," says Dr. Gregory Bazylewicz, a family doctor in Manchester-by-the-Sea. "A brief, face-to-face encounter tells you a lot about whether you'll be comfortable with that doctor."

If you have a particular health problem, such as heart disease or diabetes, find out if the doctor has experience treating the problem or can refer you to the specialists you want.

When Karin Martin of Marblehead chose her primary-care physician, she made sure she would be able see a cardiologist for regular checkups because she had a heart attack two years ago. She also has had no problem getting referrals when other problems cropped up. She recently saw an orthopedic surgeon for a bunion and an oncologist for a suspicious lump on her leg.

Choosing an HMO

While there are many similarities among HMOs, there are dozens of different policies available in Massachusetts. The subtle variations in coverage and cost make a difference in the care you get.

That's why Martin, the Marblehead resident, carefully studied her choices before selecting her HMO.

Martin, 65, met with representatives from Harvard Pilgrim, Tufts and U.S. Healthcare at a health fair held at a Lynn restaurant.

Specifically, Martin wanted to find out what she would get for her money. She asked about what each plan covered, the availability of doctors, and the ease of getting referrals to specialists. She says the HMO reps were more than willing to give her the answers.

"They went out of their way to show me what avenues and options were open to me," Martin says. "Every representative was wonderful and there was no pressure."

HMOs will provide policy information to anyone who requests it or offer representatives to talk with prospective customers.

But don't settle for a glossy PR pitch. Ask to see what is known as the "evidence of coverage" booklet or "subscriber agreement," which outlines benefits in detail. HMOs usually provide this after you sign up, but if they want your business, they should give it to you ahead of time.

If your employer offers a few plans to choose from, don't simply pick the cheapest one. Think about the level of health care you want and how much you're willing to pay for it.

Then ask HMO representatives about each plan you're considering. Is it accredited with the National Committee for Quality Assurance? Does it cover pre-existing conditions? Does it cover prescriptions, cancer treatment, maternity care, chiropractic services, or any other special treatment you might need?

Consider how important choice is to you, too. Some plans cover a limited network of doctors and hospitals, while others have thousands of physicians. HMOs can tell you what practices, hospitals and treatment facilities are within their networks.

Less expensive plans tend to have fewer choices, while more expensive plans offer more flexibility and coverage even if you want to see doctors outside the HMO network.

"You can get anything you want — if you want to pay for it," says Dr. Curtis Prout of Manchester-by-the-Sea, a senior physician and instructor at Brigham and Women's Hospital in Boston.

Even if you pay for membership in a far-reaching HMO, some primary-care physicians sign additional contracts that require them to refer to a limited group of specialists. Ask about such restrictions before you pick any one primary-care physician.

The public library is another great resource. Check out back issues of Consumer Reports and other magazines that have rated HMOs throughout the country.

Check in with your doctor, too. He can often recommend which plans offer the best coverage for you. Your personnel manager at work often reviews plans in depth and may also help.

"There are some plans out there that are better than others," says Derby, from Health Care for All. "So make sure you get all the information you need to make an informed choice."