Hello again eestudent-ga!
You ask interesting questions and I?m glad to be able to answer one
again. (And by the way, I grew up in ?Taxachusetts.?) As I?ve
mentioned before, my husband is a family physician so I have a great
resource right here in my own home. Here?s my standard disclaimer:
this answer is not intended to substitute for the opinion of a
qualified health professional that you trust. If you have any specific
concerns or questions you should discuss them with him or her. Here is
what I?ve come up with for you.
- - - - - - - - - - - - - - - - - - - -
CHOOSING A PERSONAL PHYSICIAN
Most people will choose to have one physician as a ?primary care
physician,? or PCP. These are generally family physicians or general
internists. In the case of a child or adolescent, a pediatrician can
serve as a PCP. (An OB-GYN is not a PCP in the truest sense, but can
function as one for routine annual exams for women). The PCP takes
care of the routine problems, such as physical exams, immunizations,
coughs and colds, aches and pains, and whatever else he or she cares
to see in the office. Insurance companies generally dictate which
physician subscribers can see. These doctors have contracts with the
individual insurance companies in exchange for the company directing
patients their way. Most companies have both ?in-network? and
?out-of-network? providers. When seeing an ?in-network? provider, the
patient may pay a small co-pay, say $10, and then have the rest of the
visit paid by the insurance company. When seeing an
?out-of-network?physician, the patient may be responsible for paying
20% of the total cost of the visit, and the insurance company will
cover the remaining 80%.
Health Maintenance Organizations (HMOs) are generally the strictest
insurance plans. Some HMOs employ physicians and many have contracts
with physicians. In any case, HMOs subscribers choose one of the
physicians in their network to be their physician and agree to see him
or her for all of their medical needs. As long as the PCP is still
taking patients with that particular health plan, the patient now
?belongs? to him or her. If a specialist needs to be seen, then the
PCP will order the referral, and if the HMO approves the referral the
patient then arranges with a specialist contracted with his or her
HMO.
?Typical? insurance companies will function similarly to an HMO, but
they will not usually be as strict. You may not need a referral to see
a specialist, and you may have more flexibility in the types of tests
that may be ordered. You will likely still need to identify one PCP
and see him or her for your routine issues.
Patients without insurance, or those with ?catastrophic plans? (i.e.,
plans that cover emergencies and hospitalizations but not routine
physicals and other simple issues) usually are left to pay cash for
their medical expenses, and securing a physician is at times a bit
simpler. You simply select a PCP in your area and call the office. If
he or she is accepting new patients, voila! You have a new PCP.
Hospitals themselves do not usually provide PCPs for people who
request them. Their staff physicians generally provide hospital care
only. Many times a hospital will have physician offices on site even
though they do not directly refer patients to their offices. This
arrangement is a convenience to the doctors who provide other hospital
services, and to the patients who may choose to have testing done at
the hospital. Ultimately it is a financial benefit to the hospital to
provide these offices as the physicians will lease the space and the
patients will utilize the hospital?s services.
The cost of seeing a PCP varies greatly depending upon the services he
or she provides and the relative cost of services in your area. A
typical visit to a PCP for a routine problem may run anywhere from $50
to $100. Insurance companies will usually pay for all of this after a
co-pay. Cash-paying patients are responsible for the full cost.
- - - - - - - - - - - - - - - - - - - -
SPECIALISTS
Specialists can loosely be defined as those physicians that do not
provide primary care. In most cases, insurance companies will require
a PCP?s referral for the specialist to see the patient. These
companies reserve the right to deny access if they deem the service to
be ?unnecessary.? OB-GYNs do not usually require a referral for
providing prenatal care or annual exams (i.e., Pap smears) but to see
patients for other issues (like vaginal bleeding, pelvic pain, etc.)
the patients will probably need referrals from their PCPs.
Cash-paying patients can choose to directly contact specialists if
they think that they need to see one, but many specialists will still
require a referral for these patients as well. This is so that they
can avoid seeing problems that really could be handled by a PCP.
When my husband was in medical school and residency, specialists would
always tell him the things that they never wanted to see in their
offices because the PCP can handle them. It was amazing to hear how
many things there were like this.
You could probably call a hospital to find out which specialists in
your area are on the hospital?s staff, but the hospital does not
usually arrange for patients to see these specialists, even if they
lease office space at the hospital.
Specialists charge significantly more than PCPs, even as high as
double the rates. This varies widely as I?ve mentioned above.
- - - - - - - - - - - - - - - - - - - -
URGENT CARE AND EMERGENCY DEPARTMENTS
When someone does not have a PCP or is ill after usual office hours,
they can choose to visit an Urgent Care or Emergency Department (ED).
Both of these take ?walk-in? patients by design. Urgent Cares may be a
part of a hospital ED or may be a freestanding building that operates
independently. EDs prefer to treat patients that have, well,
emergencies. It sounds simple enough, but many people choose to come
to the ED with things such as runny noses and earaches. Some insurance
companies have chosen to require patients to call their PCPs before
going to the ED. This is to prevent people with problems that can
easily be treated in the office from using the ED as emergency
services are quite a bit more expensive, even for a runny nose. My
husband received lots of calls in residency from people who had
figured this out and wanted to be treated at 3 am!
Here is a list of probable emergencies:
*Chest pain
*Worsening difficulty breathing
*Head injury
*Loss of consciousness
*Drug overdose
*Poisoning
*Possible fractures (although many can be evaluated and treated in a
PCPs office if he or she is comfortable with it)
*Changes in ?mental status? (i.e., people acting ?strange? or ?weird?)
*The ?worst headache of my life?
*Eye injuries
*Babies with most problems (don?t mess around with this)
*Major accidents
This is, of course, not a complete list of appropriate problems for
the ED, but it gives you an idea of the kinds of things the doctors
there would rather take care of. If you have any doubt, many EDs will
do triage over the phone. You call in to the hospital, request to
speak with someone in the ED, and then explain your situation. They
can then help you know where you should be evaluated. An Urgent Care
center will take care of most simple problems, and then refer people
with more significant concerns to an ED if necessary.
A visit to an ED or Urgent Care center is quite expensive, costing as
much as $50 or $75 even with insurance. Cash-paying patients may pay
hundreds of dollars, depending upon which tests and procedures you
have performed.
- - - - - - - - - - - - - - - - - - - -
HOSPITALIZATIONS
In order to be admitted to a hospital, you need a physician to admit
you there. This is usually your PCP, but there is always some
physician with the responsibility to admit patients to the hospital
without a PCP on staff. This rotates at most hospitals among various
staff physicians, but hospitals are increasingly contracting with
hospitalists that take care of all of these types of patients. In
teaching institutions, residents frequently care for patients without
PCPs in the area.
Admissions usually work one of two ways: you are seen in the ED and it
is determined that you need hospitalization, so your PCP is contacted
and you are admitted to the hospital. The other way is that your PCP
sees you in the office and then determines that you need to be
hospitalized. Then he or she sends you to the hospital.
Insurance companies will need to authorize your hospitalization, but
in the case of emergencies, you can receive this authorization after
the fact. There is usually a case manager or similar hospital employee
who helps to arrange this. If you do not have insurance, as long as a
physician on staff admits you, you can stay. Of course, you are
entirely responsible for the bill in these cases.
I won?t even attempt to tell you what a hospitalization costs as it
depends greatly on the exact nature of the services provided. Suffice
it to say, it can take years for someone without insurance to finally
pay off a bill for a hospitalization.
- - - - - - - - - - - - - - - - - - - -
WALK-INS
Each physician handles walk-ins quite differently. As I?ve mentioned,
Urgent Care centers and EDs, by nature, accept walk-in patients
without exception. Many PCPs will accept walk-ins, but many will not.
You will need to call the doctor first and ask how he or she handles
this. Most specialists do not accept walk-ins, but will agree to see
their established patients on the same day if they call. The vast
majority of specialists will say that if you need to be seen the same
day, maybe you should go to the ED. Again, this is highly individual
and varies widely from specialist to specialist.
- - - - - - - - - - - - - - - - - - - -
AN ILLUSTRATIVE EXAMPLE
Here is an example of how this may all work.
Mr. X has a heart condition and wakes up with severe chest pain. He
calls his PCP?s office and asks to be seen. A nurse takes his call,
asks him his symptoms, and then runs them by a doctor in the office.
The doctor says that Mr. X needs to go to the ED for evaluation. The
nurse relays this message to Mr. X who promptly calls an ambulance.
The ambulance arrives at the city hospital where Mr. X is promptly
evaluated by an ED physician. This physician determines that Mr. X
will likely need to be admitted in order to rule out a heart attack
and perform further testing. The ED physician calls the physician who
happens to be taking care of patient in the hospital that day for his
or her practice.
The PCP goes to the ED and evaluate Mr. X. After reviewing his medical
chart and tests, and then performing a physical examination, he or she
agrees that Mr. X needs to be hospitalized. The PCP writes the orders
and Mr. X is moved from a terribly uncomfortable cot with wheels in
the ED hallway to a moderately uncomfortable bed with wheels in a
shared room upstairs.
After arriving in his room, Mr. X is greeted by innumerable hospital
employees, including a nursing assistant, nurse, dietary staff worker,
chaplain, case manager, and anyone else milling around who wants to
chat. The case manager handles the authorization and paperwork so that
his insurance will pay for the whole affair (or begins scrambling to
figure out how Mr. X is going to pay for all this), and the other
employees explain the wonderful and exciting things for which each one
of them is responsible. Nestled in his bed, Mr. X leans back and waits
for modern medicine to do its thing, and hopes that his insurance will
pay its part. Either way, he won?t be getting much sleep tonight.
Well, I did editorialize a bit, but that should give you an idea of
what happens. I hope you enjoyed the story.
- - - - - - - - - - - - - - - - - - - -
I hope that you find this information useful! Again, it?s a pleasure
to answer another one of your questions. It?s kind of a fun diversion
from the norm to write answers that don?t require ?Geegle searches.?
You may well become one of my favorite Google Answers customers! If
you have any need of further clarification, please let me know how I
can help.
Sincerely,
Boquinha-ga |
