What is a Medical Group?

Health plans contract with groups of doctors to provide your health care. These groups of doctors are called medical groups. Medical groups can range from small practices with several doctors to very large organizations with hundreds of doctors. While a small number of health plans – fewer than twenty – insure most people in California, there are hundreds of medical groups in the State.

The difference between a medical group and a health plan sometimes isn’t clear. The medical group’s job is to care for patients – this work is done by the doctors, nurses, therapists and other professionals in the medical group. The health plan is responsible for seeing that its members get care easily by contracting with enough medical groups and their doctors in a local area so it is convenient for members to get care nearby. The health plan pays for the care and typically makes the rules to determine the types of care that are covered.

The job of a health plan and its contracted medical groups can vary depending upon the type of health plan. In a PPO plan, the doctors’ and medical groups’ main responsibility is to care for patients. In an HMO plan, the doctors and medical group often have a bigger job – in addition to providing patient care, the medical group is responsible for the patient’s overall health – including steps to avoid future health problems. Because of these added responsibilities for HMO members, the Report Card’s medical group ratings concern the care and services for HMO members. The medical group and its doctors’ care and service for HMO members is explained below.

How Are Medical Groups Important to Me?

There are two main reasons why medical groups are important to you, as an HMO member. First, it is usually the medical group or one of its doctors, not the HMO, that decides what care you receive and how you receive it. For example, the medical group:

  • Checks that its doctors give care that’s been proven to work.
  • Sets the rules for you to “get an ok” (a referral) to see specialists and get other care.
  • Decides the steps doctors must follow to diagnose and treat health problems.
  • Checks the training and experience of new doctors.
  • Schedules when and how long you see your doctor or other staff.
  • Decides where you go for hospital care and other medical services.

Second, one doctor cannot take care of every medical problem that you may have. The doctors in a medical group work together to make sure that you get all the care you need. These doctors include your main (primary care) doctor and other doctors who are specialists.

How Do I See the Doctors In the Medical Group?

Most HMOs require that their members choose a main doctor. This doctor is called a Primary Care Physician, or PCP. You can choose your PCP from a list of doctors who work with the HMO.

PCPs are doctors with special training in one of the four primary care specialties. These specialties are pediatrics (children’s medicine), family medicine, obstetrics and gynecology (women’s medicine), and internal medicine.

You may see your PCP for most of your health care. This can include preventive services and care for acute and chronic conditions, psychosocial issues, and more. Your PCP also coordinates the other health care services that you may need. For example, if you need to see a specialist to treat a problem, your PCP refers you to a specialist in the medical group.

A specialist has training in a special area of health care. Surgeons, urologists, radiologists, cardiologists, and dermatologists are among the more familiar specialists. Specialists treat particular conditions or health problems. Depending upon the patient’s illness, a specialist may care for the patient over a long period of time.