By Hayley Kappes
Killeen Daily Herald
Knowing when to see a primary care physician versus a specialist can be a daunting task, and it is largely dictated by health insurance plans.
If one has an earache, for instance, one can see a general practitioner or schedule an appointment with an otolaryngologist, more commonly known as an ear, nose and throat specialist, to treat the problem.
For some, it's not so easy to book an appointment with a specialist.
Under a Health Maintenance Organization plan (HMO), insurance companies usually will not cover specialist visits without a referral from a primary care physician.
A Preferred Provider Organization plan (PPO) will generally cover appointments scheduled with specialists without a referral.
"As long as someone with a PPO sees a specialist in their network, they're not going to pay an outrageous amount of money," said Ross McClaren, media relations manager with Humana. "If they choose to go directly to a specialist, but don't have a PPO, they'll pay a higher cost for the visit."
Humana calls it an increased share on the member's behalf if they have an HMO, or visiting a doctor out of their network.
McClaren said it's always best to see primary care physicians first. They will provide a referral if the need is there.
Kristy Anderson, M.D., runs a general practice in Copperas Cove. She handles a wide diversity of patients, from infants to senior citizens, and gets to know families personally. She said going through a general practitioner should be the first step for non-emergency medical problems.
"You have more immediate access with a primary care doctor," Anderson said. "If I feel like their care needs further elevation with a specialist, a second opinion or a more specialized procedure than what I can do in the office, I will refer them to another doctor."
Anderson said a general practitioner used to not be required to complete a three-year residency like specialist doctors. Now more are moving toward that endeavor after medical school and becoming certified by the American Board of Medical Specialties.
The number of primary care doctors dropped 6 percent in the United States from 2001 to 2005, according to the Center for Studying Health System Change.
The Medical Group Management Association released a study showing that specialists saw a near 7 percent increase in the amount they were paid in 2006 over general practitioners.
A problem patients may run into if they bypass seeing a primary care physician is figuring out what kind of specialist will properly diagnose their problem.
"Patients don't always know who to schedule appointments with," said Dr. Rory Lewis, who runs an orthopedic clinic in Killeen. "If a patient has a nasal fracture, they may try to get an appointment with me, but I wouldn't be the right doctor for that type of injury."
There's also an issue of availability.
Generally it's easier to book a more immediate appointment with a primary care physician as opposed to a specialist.
Lewis said he has encountered cases of specialists who are booked out four or five months.
Lewis also has dealt with patients who will jump the gun and book an appointment with a specialist before considering other options.
"For instance, they'll come in with a shoulder pain they've had for two days when they could have tried an anti-inflammatory medication or a general practitioner first," he said. "There was no need to see a specialist as of yet."
Angie Coplin, southwest regional director of communication for Aetna, said it's crucial for patients to be fully aware of what their health insurance plan will and will not provide for them prior to scheduling doctor's appointments.
Become familiar with how to search which doctors are in the network, what the co-pay is and if a referral is needed to affordably see a specialist.
"The health insurance industry is so large and there are so many different plans. It really gets complicated," Coplin said. "When the first of the year rolls around, it will be prudent for people to know what their benefits are, especially since the economy has taken a downturn."
Contact Hayley Kappes at email@example.com or (254) 501-7559.