Managed Care Models

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School

Rasmussen College, Minneapolis *

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3110

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Health Science

Date

Feb 20, 2024

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docx

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5

Uploaded by CaptainOstrich3506

1 Managed Care Models Shelly Standley Rasmussen University H310/HSA3109: Foundations of Managed Care Professor Sandi Moore-Foggey 11/13/2023
2 Managed Care Models The term managed care or managed healthcare is a group of activities intended to reduce the cost of providing healthcare while improving the quality of that care (Wikipedia (1), 2023). There are multiple managed care models across the country. There are private models, such as Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Exclusive Provider Organization (EPO), and Point of Service (POS). There are also models associated with government plans, such as Medicare Advantage. The primary focus is to compare two models, HMO and PPO, and discuss the advantages and disadvantages of each model. A Health Maintenance Organization (HMO) is a type of medical insurance group that pays a fixed monthly fee for various medical services. These plans often cover only doctors, hospitals, labs, and others within the organization. However, the care range is complete, and the prices are usually low. Many drugs are also covered. Most HMOs require that you choose a primary care doctor. This doctor will give you a referral so you can see a specialist or enter a hospital (EBSCO, 2023) . HMO plans generally require patients to see physicians within their network and need referrals to specialists. They have contracts with provider offices that ensure quality care at a reduced rate. Even though these plans are backed by the government and afforded to low-income families, consumers can still enroll in the pursuit of their choosing once per year during open enrollment. Medicaid-managed care plans are ideal for those with a fixed income, children, and elderly patients with pre-existing conditions. The Preferred Provider Organization (PPO) is a managed care organization of medical doctors, hospitals, and other healthcare providers who have agreed with an insurer or third-party administrator to provide healthcare at a reduced rate to the insurer or administrator’s clients (Wikipedia (2), 2023). Plans will negotiate fees and schedules for services rendered with healthcare professionals and facilities. Often, the rate is lower than what the provider would charge. The insurer will pay the PPO fee to access the network in exchange for the lower rates.
3 HMO and PPO plans are opposite of each other. HMO plans require patients to be seen by an assigned primary care physician and direct referrals to specialists, but they are lower in cost than most other models. HMO Plans will have lower co-payments and deductibles for services. These plans often cover most services at a fixed price to consumers. Meanwhile, PPO Plans have a set deductible that has to be met before the start of coverage, and then a higher co-payment is required for many of the services. They offer the clients a choice of providers and facilities but are more costly in the long term. Financial burdens may arise when enrolling in an HMO plan, so consumers should understand the in-depth details of the plan's cost. Most Medicaid HMO plans typically do not have a monthly premium due to their availability only to low-income persons. A disadvantage is that Medicaid HMO plans are only available to a small percentage of the population; they are the best option for those with pre-existing conditions requiring specialist visits, testing, and prescriptions that need to be filled monthly or quarterly. However, other HMO plans can have high premium costs. On top of this cost are the copays for services and medications. All prescriptions must be on the plan's list of covered drugs, and those not are subject to high co-payment after authorization or noncoverage. There are several costs associated with PPOs, and premiums tend to be higher than other types of insurance plans. PPO plans tend to charge higher premiums because they are costlier to administer and manage. Participants are generally responsible for co-payments paid directly to the provider at each visit. There are also deductibles that patients must meet before the plans start paying claims in full (Grant, 2023). A disadvantage of the PPO model is the high cost associated with the plan. PPO plans are best suited for those who only visit the doctor occasionally or want the capability to choose a doctor within the network without authorizations or referrals. I have had many insurance plans in my life. I prefer the lower monthly premiums and higher deductibles when looking at insurance coverage. Currently, my employer offers two insurance plans, an HMO and a POS. The HMO plan has an out-of-pocket maximum and covers most healthcare services.
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