My Coverage Explained

Let me introduce you to your doctor.

Do you have a doctor you call your own? If not, let me introduce you to someone – a primary care physician.

I grew up in a small town. Our town was lucky enough to have our own doctor.  A lot of people called him the “town doctor.” . If you heard someone say  “I can’t shake this cold,” you would very often hear someone reply “Well, go see the town doctor. He’ll fix you right up.”

Our town’s doctor was Dr. Sanders, and he was my doctor. Dr. Sanders took care of my whole family – from grandparents to sisters and cousins. Even if we were never sick, we still went to him for sports and school physicals in the fall. But he also spent a lot of time taking care of patients with stomach aches or  colds. He’s also the man behind the stitches in my chin, the result of falling and taking  out the corner of the coffee table with my chin when I was young. He took care of all that, times hundreds, every day until he retired at age 70.

My family referred to Dr. Sanders as our “family” doctor rather than the town doctor. Today, we would  also call him a primary care physician, or PCP. A PCP may be a family doctor, general medicine practitioner, or in this case, a rural medicine physician.

Then or now, the primary care physician’s role hasn’t changed much. He or she would still be the one  you would call first when you had a health problem. If you said “I need to call the doctor,” this is “the doctor” you would call.

While the web is a good place for information about a health problem you know you have, it isn’t the best place to go if you have symptoms and want to know what the real problem is, if you should see a doctor, or which kind of doctor you should see. A statistic from the Pew Research Center says  1 out of 3 adult Americans in our modern day go to the web first for health information. So much so, it’s been labeled the “cough and click culture.”

Here’s an example of why going to the web to diagnose yourself isn’t a good idea. Fatigue and joint pain are some of the symptoms of Lupus, a chronic and devastating disease. But they can also be caused by stress, lack of sleep, and certain meds. A doctor can find out what is really happening, based on his or her medical training, tests and follow up treatment.

If you already had “your” doctor, or PCP, you would know  what to do. You would know that the first step is to call your doctor. If you do nothing else, the single most important thing you can do for your health is to have your own personal doctor. . It means you’ll have someone in your corner making sure you get the care you need.

  • Your PCP can help you make informed choices about your care based on your health history, what health problems you have, and what meds you take. Your PCP will be there when you need care right away, such as with colds and the flu, but can also handle your routine health care needs like physicals and annual exams..
  • Your doctor becomes your health coach, showing you better ways to stay healthy and live longer. Your PCP can help you focus more on staying healthy, instead of only seeking help when you are sick or hurt.
  • Your PCP will coordinate your care when seeing specialists or going to the hospital, and can guide you to the best place to go when you need more care. This keeps your care on track can help you avoid unnecessary visits.
  • Your PCP manage your care also means problems can be caught before they become serious. For example, getting high blood pressure under control could prevent you from having a stroke later on.
  • If you happen to have a chronic health problem like diabetes, asthma, or a heart problem, your PCP can make sure you  get the care you need to keep it from getting worse.

Do You Have an HMO Plan?
At the center of an HMO,  or Health Maintenance Organization, is the doctor-patient relationship that starts with having a primary care physician (PCP).  Your PCP will be part of a Medical Group, a group of doctors that can address many of your health care issues.

To make the most of your relationship with your PCP and get the most out of your HMO, keep these tips in mind:

  • If you are new to an HMO or are choosing a new personal doctor as your PCP, make your first appointment as soon as possible. This will help you avoid delays when you’re sick or hurt.   
  • Your PCP’s name and contact information will be listed on your member ID card. Each person on your plan can pick their own PCP. You can change your PCP choice if you later decide your PCP isn’t right for you.
  • Always call or go to your PCP first when you need care. Your PCP will be able to make informed choices about the care you need. That may mean going in to see your PCP, going to a retail health clinic or urgent care center, or heading to an emergency room.
  • If you need to be seen by someone else, start with your PCP (unless it’s an emergency). Your PCP will make sure you have a  referral to a network specialist or facility, so that your care is covered by your HMO plan.
  • It’s important you get all your care from providers in your HMO network. This will help you have fewer out-of-pocket expenses and ensure you go to the right provider. You could end up paying the full cost of your care if you get care from a provider who is not in your HMO plan’s network.

So, What's the Difference Between a PCP and an HCP?

According to UC Berkely, a Health Care Practitioner (HCP) is a person who has been trained in a specific kind of medicine to help target health issues. These can be doctors, nurses or specialists.

Most often a doctor (MD), a primary care provider (PCP) is a health care practitioner who manages a patient’s health over a long period of time. This is a care provider who sees people that have common medical concerns or are seeing preventive care. A PCP can also be a physician assistant or a nurse practitioner.

Both will file claims with your insurance provider. Long story short, a PCP is a type of HCP, but an HCP might not be a PCP. It is always a good idea to talk to your doctor—by that we mean your PCP-- about any other treatments that you receive from a specialist or other provider or HCP. Make sense?

To get information about your health plan or need help finding a PCP, log on to Blue Access for Members and use our  Provider Finder, a search tool that will show you all the providers in your HMO plan’s network.

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