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How to Select a Good Health Plan and a Great Doctor

ALL DOCTORS AND HEALTH PLANS ARE NOT CREATED EQUAL

By Pamela Armstrong, MPH, MBA

Most consumers don't understand how the healthcare system really works, and because of that, many choose their doctors in ways that don't yield the best results.

Wrong Reasons for Choosing Your Doctor

Right now, let's take a quick look at the ways in which many people choose their doctors. My goal is to point out how heavily most consumers rely on traditional methods that no longer make sense in the face of current evidence. I call these traditional ways "false starts," and millions of people use them.

1. The "What Do My Friends Do?" Method

"Dr. Smith is my golf buddy's doctor. If he's good enough for Larry, he's good enough for me." Without a better method for choosing a good physician, many of us simply rely on the recommendations of friends. Unfortunately, if our friends have not done their research, they may be making incorrect assumptions about the quality of care they are getting. By taking their advice, we end up making the same false assumptions.

2. The "Yellow Pages" Method

Man looking in phone book: "Let's see here ... which doctor should I choose? Adams, Abrahms, Ai, Bose, Brown, Crusoe, Diaz, Donley, Ellis? I’ll pick Dr. Ellis. His ad says he is one of the country's finest internists, and he's just down the block from my office!" Choosing a doctor from the phone book is as good a method as pulling a name out of a hat -- no assurance of quality, even if the doctor's ad in the phone book says there is.

3. The "Frills" Method

"I look for expensive furniture and quality magazines in the waiting room. I figure if he can afford nice furniture, he must be a good doctor." As you will see in the pages to come, neither cost of care nor waiting-room accessories are good measures of quality of care.

4. The "Nice Guy" Method

"He's really a nice guy. He reminds me of Dr. Welby." A good "bedside manner" is a great attribute for a physician to have, but it does not guarantee quality of care.

5. The "He Gives Me Whatever I Want" Method

"Every time I ask for antibiotics, he gives me a prescription -- no questions asked." This is a complex but important issue. Giving you whatever you want, especially antibiotics too often or other care that can cause problems later, is not high-quality care. It is merely a way to avoid saying "No" to you or to avoid taking the time and effort to explain why what you are asking for is not good for you.

Overuse of antibiotics, for example, happens all too often and contributes to the development of bacteria that are resistant to the remedy. If you or your family members take antibiotics when you don't really need them, they may not be effective when you do need them. For example, many people assume that they should get antibiotics whenever they have a bad cold. But, in fact, antibiotics have no effect whatsoever on colds because colds are caused by viruses, and antibiotics have no impact on viruses.

One person I read about had gotten her doctor to prescribe antibiotics every time she had a cold. Then she developed a very serious infection from a paper cut that, as a result of her taking too many antibiotics previously, was resistant to almost every antibiotic that was tried as a cure. She went through weeks of disabling illness that could have been avoided if her doctor had had the courage to say "No" to her earlier requests. The federal Centers for Disease Control reports that 70% of the bacteria that cause hospital-acquired infections are now resistant to at least one antibiotic.1

So, you can see that you must be wise about what you demand from your doctor. And your doctor should be wise about what he or she agrees to give you.

The Ideal Physician

When seeking a new physician, look for a Dr. Welby -- male or female -- who is either part of a highly rated, highly integrated medical group, or who specializes in the type of treatment you need for a particular diagnosis (e.g., diabetes, heart disease, etc.). Make sure that he or she has proven competency in that specialty. Look for a doctor who practices in a setting that gives him or her the best available staffing, quality control, and information support systems. Relatively few physicians have all of these support systems available to them.

What Does a Doc Want in a Doc?

Here is a list, given to me by a thoughtful, quality-minded physician, of the attributes she looks for when finding a physician for herself:

1. Keeps up with changing medical practice.

Scientific research continuously increases the medical knowledge base of what treatments work best for a given diagnosis. This knowledge base has grown exponentially over the last few decades and continues to expand at a mind- numbing pace, making it difficult for physicians to keep up. According to recent studies, only a minority of physicians actually incorporate the latest medical guidelines into their treatments for all diagnoses.

2. Makes wise decisions. Is moderately conservative in treatment -- not the first to use new treatments and not the last.

Only about 30% of all the medical care provided by doctors has been clearly proven effective through scientific evidence. Some would say that estimate is too high. An even smaller percentage of treatment regimens have been subjected to randomized controlled scientific trials, which some medical experts say are required to actually prove the value of a treatment.

Even when physicians think they have "evidence," for example, when the FDA approves a drug for a particular medical condition, problems still crop up when the use is extended from a carefully controlled clinical trial to the real world. Some very high-profile drug recalls bring that point home. Therefore, many doctors believe that unless the situation is desperate -- that is, unless there are no other options -- it is best to wait until a drug has been out for a while before incorporating it widely into their practice. Of course, you don't want a physician who never gets around to using a new therapy or who is the last one to use it either.

3. Uses information technology to manage his or her practice. Has all needed information easily accessible to make a good decision.

Ideally, every physician should have access to a fully electronic set of medical records for every patient. This technology is not yet widely available. Short of that, there are a number of electronic systems that are readily available and extremely helpful. They provide:

Electronic access to all diagnoses (including allergies), lab results, and prescriptions.

Access to a patient-maintained electronic history.

4. Builds in consultation with respected colleagues -- is not afraid to ask for help. This doctor knows the limits of his or her expertise.

5. Knows about me -- my life, my preferences, my work, etc. Works with me to make decisions about my care that fit my life.

6. Explains all of my conditions and the options for treatment-- the upsides and downsides of each -- and helps support me in making decisions that are right for me.

7. Is accountable to me and to society for high-quality, affordable care. This means being willing to publicly report the cost and quality of care he or she provides so consumers can use this information in decision-making.

8. Is nice. (Note that this is #8, not #1.)

Available Data for Wisely Choosing a Physician

The unfortunate truth is that there is not much physician-specific data available that can inform consumers about the level of quality a physician provides. We have few easy ways to find out whether a physician is up-to-date on the most effective therapies, or more importantly, if a physician actually applies this information, even if he or she knows it. Applying current medical information appropriately often requires using a database to track data about each patient.

To properly evaluate the level of quality a physician provides, we would need to know several important things:

1. What is the level of knowledge he or she has about the latest medical research?

2. Does he or she have access to good reminder systems for using this research?

3. Does he or she have access to-- and does he or she use -- good patient database systems?

In California, the Pacific Business Group on Health provides results to the public of a consumer survey rating the quality of care of 128 medical groups across the state. (See www.healthscope.org. Also available at www.opa.ca.gov.) Unfortunately, this type of information is not available in most other parts of the country. Even where information on the quality of medical groups is available, often that information does not compare the care of individual doctors. This is an important point, because even in high-performing medical groups, some doctors will be more diligent in quality practices than others.

"Best Doctors" lists are published annually by certain organizations. However, these lists usually only provide information about a doctor's training, location, and which hospitals and health plans he or she is affiliated with. Before relying on these types of lists, take the time to learn the basis of their rankings.

Five Good Ways to Find a Great Doctor

1. Provider Recognition Programs: The American Diabetes Association and the National Committee on Quality Assurance (NCQA) have a Provider Recognition Program that measures how well specific physicians and medical groups deliver high-quality diabetes care, based on the most up-to-date medical research. If you have, or a family member has, diabetes, contact one of the physicians on this list for care. You will find the list at www.ncqa.org. At that website, do a search for Diabetes Physician Recognition Program. The American Heart Association/American Stroke Association and NCQA are also developing a Heart/Stroke Recognition Program that will be designed in the same way to recognize physicians and medical groups delivering high-quality care for heart disease and stroke patients.

2. Board Certification: If a physician is Board Certified, it means that he or she has done additional training in and has passed tests on a medical specialty area. Tests are sponsored by an organization appropriate for that subject area, such as the American Academy of Pediatric Medicine. Therefore, physicians who are Board Certified are often better trained and more knowledgeable than those who are not. Look for a physician who is Board Certified in the specialty area of your needs. Many boards now require periodic recertification. Patients should ask if their doctor has recently been recertified in his or her specialty.

3. Interaction With Patients: The way a doctor interacts with patients is one key to the quality of care he or she gives. Doctors who communicate poorly or who don't take time to answer questions are not providing good patient care. Doctors who take the additional step of including the patient in decision-making are providing better care than those who don't.

Patient feedback on how well a physician communicates, answers questions, and is willing to work in partnership with a patient is available from a few sources. Look for descriptions of individual physician "practice style and philosophy." You can always make an initial visit with a doctor to determine his or her style and then switch to another physician if that doctor doesn't meet your needs.

4. Specialization in Specific Diagnoses or Treatments: Some physicians choose to specialize in specific diagnoses or procedures, such as heart transplants. If you have a specific diagnosis and need treatment, you may receive better care from a doctor experienced in treating your diagnosis. However, it would still benefit you to research for yourself what the most up-to-date medical information shows to be the best treatment. To find guidelines for treatment of your diagnosis that are based on the latest scientific evidence, go to www.guideline.gov. Use this information to check whether your physician or intended physician knows and uses these guidelines.

5. Participation in a Highly Rated Medical Group: If medical groups in your geographic area have been researched and rated for quality by a trustworthy organization using criteria based on parameters such as those established by the National Committee on Quality Assurance, choose a physician from one of the highly rated groups. These groups choose their physicians carefully, and they monitor and provide support to participating physicians in order to keep the quality of care high.

Use caution if you find an organization that seems to provide quality comparison information on individual physicians. For example, one Internet site, www.healthgrades.com, lists 70% of all physicians as "leading physicians," largely based on the fact that these physicians have been Board Certified. Board Certification shows that a physician has increased his or her knowledge in a specific medical area. However, it does not prove that he or she knows and uses the latest research on the best medical practices.

Three Things to Consider in Selecting a Health Plan

Beyond being able to find a good doctor on a health plan's list, what factors are important in choosing one plan over another? Three questions are key to ask yourself:

1) Will I stay healthy better with one health plan versus another? In other words, how well will I get the preventive care that sound medical research has proven to be effective?

A number of factors go into answering this question.

If you have a choice, the health plan you choose should cover all important preventive care at no or low out-of-pocket costs.

The right plan for you will cover the particular preventive screening tests you need based on your risk factors. Only by knowing your risk factors and which tests you need will you be able to tell if a plan properly covers your preventive care. (See Chapter 7 for further details.)

Next is whether you can find a doctor in the health plan who makes sure his or her patients get all appropriate preventive care.

Some health plans assist their doctors in various ways to encourage them to give all needed preventive care. Some plans also send reminders to members, through newsletters or otherwise, to encourage using proven preventive screening tests. The National Committee for Quality Assurance (NCQA) website at www.ncqa.org has comparative information on how well health plans are preventing certain major diseases.

2) When I am sick, will I get the best care possible?

Consider the following factors to answer this question.

Choosing your primary-care and specialist physicians is key here. You must read the rest of this book to see why. Many issues are involved, and not necessarily the ones you think.

Choosing a health plan should be based on how well the health plan gives you access to physicians, hospitals, and other providers who rate highly in valid quality comparison surveys. Beware of general public perceptions about the quality of a specific health plan, hospital, or any other provider. These perceptions can be wrong.

Some health plans do better than others in helping their doctors coordinate the care of chronically and seriously ill patients. Some case management and disease management programs are better than others. See the National Committee for Quality Assurance (NCQA) website at www.ncqa.org. It has comparative information on not only how well health plans are preventing certain major diseases but also how well their doctors treat certain diseases.

Your total costs for any care you may need are also important. You must understand and compare what your care will cost in each of your health plan options. Balance the projected costs against the level of quality you will receive. You must read the rest of this book to know the details of how to judge quality and cost-effectiveness in healthcare choices.

3) When I need medical care, either preventive care to stay well or care when I am sick, will I be able to get that care easily?

The following access-to-care factors should be considered in comparing health plans. If care is not convenient, you may be tempted to avoid getting needed care.

Is the location of the providers convenient for you, including laboratory and pharmacy?

Are the office hours of the providers and the health plan member assistance services convenient?

How easily can you get through by phone to your key providers and health plan member assistance?

If you and/or covered family members need to speak to physicians and other providers in a language other than English, how well does your health plan and the providers it offers accommodate your language needs?

Excerpted from Surviving Healthcare by Pamela Armstrong, MPH, MBA. Copyright © 2004 by Pamela Armstrong. All rights reserved. Reprinted with permission of Chestnut Ridge Books. $19.95. Available in local bookstores or call 866-202-9112 or click here.