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How to Select a Medical Group

 

What is a medical group?

When you enroll in an HMO — your HMO is responsible for seeing that you can get needed care from physicians and other practitioners. HMOs arrange for health services through doctors that are hired by the HMO or by contracting with groups of physicians to provide services.

Physicians who decide to work together to contract with health plans can form a variety of legal entities such as a medical group or an independent practice association (IPA). Physicians form medical groups for several reasons. One reason is that it is easier for a group of physicians to arrange contracts with HMOs than it is for individual physicians. It also is easier for HMOs to deal with a single group of doctors than hundreds or thousands of individual physicians. The other reason that is more important for you as a patient is that no one physician can handle every medical problem you may encounter. Physicians work together in medical groups to make sure that you and your HMO have access to both primary care and specialty physician services (see below).

It can be confusing to understand the differences between medical groups and HMOs. HMOs tend to be large regional or multi-state organizations, medical groups are smaller and are usually limited to physicians in a single community or geographic region. Consequently, there are 5 HMOs in California with about 90% of commercial HMO enrollees, but there are hundreds of medical groups throughout the state. Medical groups may contract with more than one HMO just as HMOs may contract with more than one medical group.

Another important distinction between medical groups and HMOs is how they determine the health care you receive. While HMOs decide which insurance benefits to cover and how much they will cost the member, HMOs try to leave individual medical care decisions to members and their doctors. Because your doctor belongs to a medical group, and the medical group has contracted with the HMO for the health care you receive, the medical group plays a very important role in your health care. Often it is your medical group or IPA, not your HMO that:

  • Has checks to safeguard the quality of care you get
  • Sets guidelines for “getting an ok” to see specialists and get other care
  • Adopts standard steps for doctors to follow in diagnosing and treating health problems
  • Checks the qualifications and history of new doctors
  • Schedules when and how long you see your doctor or other staff
  • Decides where you go for hospital, specialty or other medical services.


Primary Care and Specialist Physicians

Most HMOs require members to select a personal doctor from a list of doctors who work with the HMO. Personal doctors are physicians with special training in one of the four primary care specialties; pediatrics, family medicine, obstetrics and gynecology, and internal medicine. Primary care physicians have the responsibility for providing initial and primary care to patients, maintaining the continuity of patient care, and initiating referrals for specialist care. This means providing care for the majority of health care problems, including, but not limited to, preventive services, acute and chronic conditions, and psychosocial issues. Your primary care physician should be aware of and coordinate the range of health care services you are receiving even if the primary care physician does not provide these services themselves. If you want to continue seeing your personal doctor be sure to check with the HMO to see if your doctor is part of that plan.

In contrast to primary care physicians, specialty physicians have in-depth training in a specific aspect of health care. Examples of specialists include surgeons, urologists, radiologists, cardiologists, and dermatologists. Unlike primary care physicians, specialists are not expected to know about or coordinate all aspects of your health care. However, they are expected to have expertise in their field of training and be able to treat a particular condition or health problem. Specialists may provide ongoing care to a patient for a particular health care need, such as continuing check ups or testing with a cardiologist for a heart condition, or an oncologist for management of breast cancer. Specialists may also provide feedback to your personal primary care physician in the form of recommendations for care such as when a neurosurgeon examines a patient for low back pain and suggests physical therapy rather than surgery.


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How do I choose a medical group?

Some medical groups — and their doctors — provide excellent care and service. Others don’t. This web site rates a number of the largest medical groups and IPAs in California. Check out these Medical Group Ratings to learn about the medical groups and IPAs in your area. If you already have a doctor, use this web site’s Directory of doctors to find the medical group he or she belongs to and check the quality of that medical group. For additional help, see the What Medical Group Quality Means. Use this checklist to size up the medical groups in your area:

  • Compare Medical Group Ratings
  • Which medical groups belong to the health plans that are available to you?
  • Which hospitals do the doctors in the medical group use?
  • Who in the group is an expert in your health problem or concern?
  • Call today, how long is the wait for a routine check-up, how long for an appointment to treat an ongoing illness?
  • What does the medical group do to safeguard the quality of its patients' care?
  • Does the group see that you are quickly told about all your test results whether the finding is normal or not?
  • Are the medical office business hours and locations convenient?
  • Who is available if you need help or advice after hours?
  • Does the group provide information and services online?
  • How do you get your medical record information — like your medication history — if you need it?
  • What are the fees for the services that you pay for directly?


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