Guest Editorial by Paul Kasuba, M.D., Chief Medical Officer, Tufts Health Plan

From the Winter 2014 For Your Benefit pdf format of    Winter 2014 FYB   newsletter

Fifty-two year old Joe has been dealing with a persistent cough. After a week of sleepless nights and some encouragement from his wife, Joe contacted his Primary Care Provider (PCP). Because Joe has a relationship with his PCP and his provider knows that aside from his preventative appointments, Joe only calls him when he is truly ill, he told Joe to come in right away. Joe is seen by his PCP and the diagnosis is pneumonia.  Without treatment, Joe's situation could have gotten a lot worse in a short amount of time.

Joe’s story is not an uncommon one and it highlights the importance of having a PCP who knows you. Building that relationship creates a rapport with someone who understands not only your health care needs, but also you personally. Having continuity in your relationship with a clinician is an important part to maintaining your health.  They may guide you on age appropriate preventative screenings, treat your health conditions, and advise on lifestyle changes intended to keep you well.

Your PCP is a trusted resource capable of navigating the confusing world of health care, making this relationship critical. As a PCP myself, I have experienced the value of this relationship with my patients. Knowing the difference in how individuals react to stressful circumstances helps me to better understand my patient’s concerns and personal health needs.  It becomes easier to know when a headache is just a headache and when it may be something more. I am better able to pick up on subtle differences related to a patient’s symptoms when I have a connection with a patient over time.

Today, many PCPs use a team approach that centers on the patient to provide a higher level of quality, greater affordability and convenience. PCPs are usually physicians, but may also be nurse practitioners and physician assistants. They coordinate with other providers and get to know you as a person as well as a patient. The GIC’s Centered Care Program seeks to better coordinate care for patients, with PCPs as the focal point.

PCPs are taking a more active role in adding value to a patient’s overall health care experience. The traditional HMO plan is a “gated care” model, whereby the plan manages referrals by keeping care not only within the network at large, but typically within a home hospital.  A PPO plan is is more of a “guided care model”, and gives members more freedom of choice to go wherever and whenever they choose, with higher out of pocket expenses when going outside of the network. While it is not required in a PPO to have a PCP, it is strongly encouraged because “guided care” means better care for patients, with patients exercising informed decision making with the support of a PCP who knows them. A POS is somewhat of a compromise between the two requiring members to designate a PCP, but still giving you the ability to go out of network. Regardless of plan type, having a PCP that you trust and have confidence in will assure that you get the care that you need to keep or make you healthy.

Paul Kasuba, M.D., is the Chief Medical Officer of Tufts Health Plan and also serves as Vice Chairman of the Medical Directors Committee for the Alliance of Community Health Plans. A member of the American Medical Association and the Massachusetts Medical Society, Dr. Kasuba currently maintains a limited private internal medicine practice. He is a graduate of Tufts University School of Medicine and received his A.B. degree with honors in political science from Duke University.


This information provided by the Group Insurance Commission.