Finding the right health care professional to provide
primary care can be a challenge–we’re all looking for the right balance of
expertise, compassion, communication skills, and availability. So no one
likes it when an insurance company steps in to limit our choice when it comes
to picking an available primary care provider. One of the new protections
added by the Affordable Care Act, and going into effect for new plans this month,
aims to ensure choice of providers–and it includes special safeguards for
Some health plans require enrollees to choose a primary
care provider (PCP) who serves as a gatekeeper for other types of care; to see
a specialist or get certain tests, enrollees need to get the approval of the
PCP. Under the new law, new plans (though not grandfathered plans) that
have this requirement must allow enrollees to choose any PCP who participates
in the plan and who is available to take new patients. Under the Patients’
Bill of Rights regulations, plans must notify enrollees of this right.
This prevents insurance companies from limiting the choice of PCP to a subset
of their network providers.
For children, all participating pediatricians (who are
taking new patients) must be available as choices for a child’s PCP. This
is an important provision for children as regular pediatric care has been
proven to improve child health outcomes, avert preventable health care costs,
and limit delays in care. Moreover, parents want to be able to choose a
pediatrician they trust. A way to take this important advance one step
further would be to include pediatric subspecialists in the definition of
pediatricians that can be designated as a primary care provider.
For some children with serious chronic conditions,
pediatric subspecialists can provide children with their routine and ongoing
care as well as needed specialty treatment. This improves continuity of care
for the child and the ease of receiving treatment for the family. A
family with a child who is receiving cancer treatment, for example, could
designate their pediatric oncologist as the PCP for their child.
Families should be afforded the ability to designate these kinds of clinicians
as the primary care provider if they choose.
The choice of health care professionals helps to shift
control over care to consumers and away from insurance companies.
Together with the other provisions that take effect September 23, it adds
valuable protections that will benefit millions of Americans immediately and
millions more as health care reform is fully phased in over the next four