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
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
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
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
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
2. Does he or she have access to good reminder systems for using
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
"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
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
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
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
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
Excerpted from Surviving Healthcare by Pamela
Armstrong, MPH, MBA. Copyright © 2004 by Pamela Armstrong.
All rights reserved. Reprinted with permission of Chestnut Ridge
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