Covered California Certified Enroller Practice Exam

What role does a PCP play in an HMO?

1. Acts as the primary care provider without referrals

2. Issues referrals for members to specialists

3. Only provides preventive care

4. Handles all emergency cases independently

The correct answer is: Issues referrals for members to specialists

The role of a primary care physician (PCP) in a health maintenance organization (HMO) is vital in coordinating patient care. A PCP not only manages the overall health of a member but is also responsible for issuing referrals to specialists when necessary. In an HMO model, members typically must go through their PCP to access specialized services, ensuring that care is managed efficiently and that all aspects of a member's health are considered before moving on to more specialized treatment. This referral process helps to streamline care and often reduces unnecessary services, as the PCP evaluates the patient's condition and determines the appropriate course of action. The focus of the HMO is on integrated care and managing costs while ensuring that members receive appropriate treatments, which is why the function of the PCP in providing those referrals is essential to the overall structure of the HMO system. In contrast to the other options, which either suggest a lack of coordination (the first choice) or limit the role of the PCP to specific types of care (the third and fourth choices), the referral process embodies the PCP's critical role in navigating the healthcare system within an HMO, highlighting the importance of primary care in maintaining the continuity of care for patients.