When you imagine yourself at the doctor’s office, you probably picture an exam room with a provider asking you about your health. What you’re imagining as you picture this scene is a routine visit with a primary care provider (PCP).
Regular visits with a PCP might not feel important, particularly if you’re in good health. But they are an essential tool in your personal health care toolkit. And for Medicare-eligible individuals, choosing a PCP may be required. This article will break down what a PCP is and does, and why they’re essential for many on Medicare.
What is a primary care provider?
A PCP is a doctor, nurse practitioner, or physician assistant who provides comprehensive care and coordinates with specialists on behalf of patients. If you regularly see a health care professional for wellness checks, vaccines and treatment for chronic conditions, then you’ve likely already been seeing a PCP.
The term “primary care provider” is sometimes used interchangeably with “primary care physician.” Primary care physicians are also primary care providers, but are specifically Doctors of Medicine (MD) or Doctor of Osteopathic Medicine (DO). All physicians are providers, but not all primary care providers are physicians.
Regardless of whether your primary care provider is a doctor, nurse practitioner, or physician assistant, they’ll help take care of you and your health.
Why visit a primary care provider?
As we age, our health care needs often increase. Visits with a PCP aren’t just for when you’re not feeling well. Regularly seeing your PCP can also help prevent illness and enable you to better manage chronic conditions.
Think of your PCP as the quarterback of your care. They evaluate your health needs and call plays to help guide your care. And when needed, they’ll hand you off to specialists to help carry your health forward.
Essential health care services offered by PCPs include:
- Preventive care and screenings. Preventive care is intended to help you avoid certain health conditions and maintain your overall wellbeing. Vaccines and routine wellness visits are common preventive care services offered by PCPs. Health screenings and many lab tests are also considered preventive care services.
- Chronic condition management. Certain chronic conditions, such as diabetes, can be managed with the help of a PCP. Through regular visits, your provider can monitor your condition and develop a treatment plan. Your PCP will also be able to prescribe and help manage your prescription medications.
- Care coordination. Should you need to see a specialist, your PCP will be able to help guide you to an appropriate provider. This is what’s known as a referral. Your PCP can then lead your health care team and coordinate care between providers.
In addition to these services, having a PCP that you see regularly allows for continuity of care. This means that even if your health care needs change or you need to see a specialist, you’ll have a PCP that knows you and your health well.
Why are primary care providers important for those on Medicare?
No matter your age or current health, building a relationship with your PCP will help ensure you have support along your health journey. Over time, your PCP will get to know you and have greater knowledge of your health care needs. Primary care providers also watch for changes in your health. This can help them spot the warning signs of potential health concerns earlier.
Beyond the reasons you should regularly see a PCP, certain Medicare plans require you to pick an in-network provider to serve as your PCP.
Do you need to pick a primary care provider if you select a Medicare HMO plan?
When you enroll in a Medicare Advantage HMO plan, you will be required to select a PCP from the plan’s network. You’ll also need a referral from your PCP to see a specialist. Think of your PCP as your dedicated "care quarterback," guiding you through your health care journey.
Your PCP will take a holistic approach to your care, helping make sure all your care works together. This is what sets HMO plans apart from other types of health care coverage, including PPO plans. Learn more about the difference between Medicare HMO and PPO plans.
What is a referral and why would you need one?
A referral is an official request from your PCP that lays out the rationale for seeing a specialist. Some Medicare plans require that you get a referral from your PCP before you can see a specialist or receive certain medical services.
Often, your PCP will recommend you see an in-network specialist to help manage certain conditions. You can also request a referral from your PCP for certain health care services. Having a PCP submit an in-network specialist referral will help make sure your visit is covered by your plan.
As an example of care led by your PCP, imagine you’re experiencing pain in an elbow joint. Your first call should be to your PCP. They can look at your elbow to determine your care needs. If your PCP thinks additional expertise is needed, they may submit a referral to an orthopedic specialist. From then on, your PCP and specialist will be in contact to coordinate care for your elbow.
Even if you don’t need to select a PCP for your health plan, it’s a good idea to have one. Need help finding a primary care provider? Here are some tips to get you started.
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Medicare Made Clear brought to you by UnitedHealthcare provides Medicare education so you can make informed decisions about your health and Medicare coverage.