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What is a Medical Group?

Your HMO is in charge of making sure that you can get the health care you need. It contracts with groups of doctors to provide you with your health care. These groups of doctors are called medical groups.

It can be confusing to understand the differences between an HMO and a medical group. An HMO is usually a large organization. An HMO offers health care in a region, such as Los Angeles or Northern California. Some HMOs cover all of California. The HMO decides which benefits to cover and how much you will have to pay.

A medical group is smaller. There are hundreds of medical groups in California. A medical group is usually made up of doctors in one community or area. The medical group includes many kinds of doctors. An HMO contracts with one or more medical groups in an area. A medical group may contract with more than one HMO in its area. That is why one doctor may see patients from more than one HMO.

How Are Medical Groups Important to Me?

There are two main reasons why medical groups are important to you, as an HMO member. First, it is usually the medical group or one of its doctors, not the HMO, that decides what care you receive and how you receive it. For example, the medical group:

  • Checks that its doctors give care that’s been proven to work.
  • Sets the rules for you to “get an ok” (a referral) to see specialists and get other care.
  • Decides the steps doctors must follow to diagnose and treat health problems.
  • Checks the training and experience of new doctors.
  • Schedules when and how long you see your doctor or other staff.
  • Decides where you go for hospital care and other medical services.

Second, one doctor cannot take care of every medical problem that you may have. The doctors in a medical group work together to make sure that you get all the care you need. These doctors include your main (primary care) doctor and other doctors who are specialists.

How Do I See the Doctors In the Medical Group?

Most HMOs require that their members choose a main doctor. This doctor is called a Primary Care Physician, or PCP. You can choose your PCP from a list of doctors who work with the HMO. (If you change HMOs and you want to keep your PCP, check to make sure that your doctor is part of the new HMO.)

PCPs are doctors with special training in one of the four primary care specialties. These specialties are pediatrics (children’s medicine), family medicine, obstetrics and gynecology (women’s medicine), and internal medicine.

You may see your PCP for most of your health care. This can include preventive services and care for acute and chronic conditions, psychosocial issues, and more. Your PCP also coordinates the other health care services that you may need. For example, if you need to see a specialist to treat a problem, your PCP refers you to a specialist in the medical group.

A specialist has in-depth training in a special area of health care. Surgeons, urologists, radiologists, cardiologists, and dermatologists are among the more familiar specialists. Specialists treat a particular condition or health problem. They may also provide ongoing care to a patient for a particular health care need. For example, if you have a heart condition, your cardiologist may give you ongoing care. A specialist may also tell your PCP about specific care you need.