Gatekeeping Research Paper

HMO- Is the most popular of the plans and is a group of providers that provides services to subscribers with a very small or even co copay when services are rendered. There actually are various types of HMO's that link providers to create a healthcare delivery system, they are Group Model HMO, Individual Practice Association HMO, Network Model HMO, Staff Model HMO, and Open Access HMO.

Managed care dominates health care in the United States. It is any health care delivery system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by methods such as gatekeeping, case management, and utilization review. Different types of managed care plans came into development by three major factors. These factors include choice of providers, different ways of arranging the delivery of services, and payment and risk sharing. Types of managed care organizations include Health Maintenance Organizations (HMOs) which consist of five common models that differ according to how the HMO is related to the participating physicians, Preferred Provider Organizations

The HMO’s stress wellness and preventive care, therefore its focus is more on health maintenance rather than just the treatment itself. Because of this, HMO’s offer much richer benefits than the traditional plans. HMO’s have little to no upfront costs in an effort to encourage maintenance, while comprehensive and major medical plans have up-front cost sharing so as to discourage over utilization.

HMOs have the strictest access structure, called a gatekeeper model, where patients must have a primary care physician (PCP) through whom all care is routed. PCPs decide which diagnostic tests are needed and control access to specialists through referrals, deciding when it is necessary for a patient to seek more expensive specialty care (Barsukiewicz, Raffel, & Raffel, 2010).

Patients could be attracted to Staff Model HMOs for a variety of reasons as well; because Staff Model HMOs are practiced in comprehensive medical facilities, all necessary resources are located in one place. Unlike the Group Model, new physicians would be salaried and would therefore not feel the pressure to “push,” patients

Throughout the last half of the 20th century, employers have acted on their own to regulate health costs by requiring employees to join health maintenance organizations (HMOs). More than 100 million Americans are under managed care. However, many patients and doctors complain that HMOs impose too many regulations and sacrifice healthcare quality. HMOs are undergoing a high level of scrutiny due to criticisms that the network is controlling and jeopardizing the healthcare system of the nation.

Under the HMO, each patient is appointed to a primary care physician (PCP), who is essentially accountable for the long-term care of the members that she/he has been assigned and any specialists that a patient needs to see should be referred by their PCP. Some examples of HMOs are Kaiser Permanente and Humana. HMOs have been licensed at the state level, under a license that is known as a certificate of authority. A pro of an HMO is that treatment for a patient can begin prior to their insurance being authorized; A member may benefit from this because there would be little to no treatment delays. A con of an HMO is that in order to save cost, most HMOs provide narrow provider networks; A member may not benefit if in an emergency because their “in-network” emergency room might be far or there are “quick-care” in their area.

Health care systems are made to improve and provide quality, efficient care, work in a more collective fashion to improve patient care and reduce overall healthcare cost. They must be mindful of wasteful spending and become more accountable to a diverse patient population.

of gag clauses in contracts amongst the MCOs and their providers. These clauses limit providers

Managed care reduces cost by keeping a pool of doctors and specialist to a minimum, and at the same time keeping the volume of patients high. This often means that a patient may not receive the same amount of attention and care as they should, or were accustomed to. Consumers have long grumbled that HMO's have done too much too keep health costs down by stinting on patient care.(1).

The relationship of an HMO and its physician member is to help provide a wider range health care for its patients and a wide area of services available for its physician members. A patient must choose a primary care physician from a list of providers. The relationship with the physician provided from the HMO is in a contract that is to deliver services to their patients for a fee. There can also be a group plan which is a HMOs contract with a group of physicians to deliver services. The HMO organization compared to PPOs, a PPO is a variation of an HMO, and it features traditional insurance and managed care.

The health care industry is one of the most dynamic and delicate industries in the U.S. having experienced healthy and substantial changes for the last thirty years most of which have aimed to improve health care management and services delivery to the patients. The changes have enabled the integration of technology into the industry such as in the area of informatics, science and research and payment services and clinical treatments. The health care sector has introduced various changes to address disease and health care management such as the Modernization Act of 2003, the Patient Protection Act and Affordable Act, which aim at improving health provision and most

The goal in healthcare today is to achieve better patient outcomes. Technology is changing daily that affects how patient care is provided. As the world around us continues to move into a more advanced technology based healthcare system incentives are offered to qualifying healthcare entities, provided they are utilizing approved health information technology (IT) to comply with standards set by the Centers for Medicare & Medicaid Services (CMS) (Jones, Rudin, Perry, & Shekelle, 2014). Standards such as meaningful use help ensure with the use of electronic health records (EHR) that patients are receiving quality care (Centers for Disease Control and Prevention [CDC], n.d.). This paper will define and discuss the importance and implications of meaningful use relating to healthcare. Several key points will be discussed including an overview of meaningful use, analysis, further recommendations and a conclusion.

HMOs multiplied rapidly with the new federal giveaways. Managed care, now including PPOs, mushroomed. Employers initially perceived managed care plans as cheaper than traditional fee-for-service insurance. Gradually, they stopped offering a choice of health plans, making individual policies more expensive. HMOs' penetration of the industry had been subsidized into existence. Government had instituted managed care. Today, while overall quality of patient care remains the best in the world, doctors practice medicine in an increasingly intricate web of rationing and regulations: Physicians are stripped of professional autonomy. As patients wander the maze of managed bureaucracy, costs rise and quality deteriorates. Every American dependent on a third party for health coverage is a potential victim of managed care. And state sponsored management of medicine

As defined by Bodenheimer & Grumbach (2009), in the healthcare system, gatekeeping refers to the process of determining whether individuals require healthcare beyond the primary level and if so, referring individuals to the specific health services that they require. Primary care involves the basic treatment of common illnesses/medical issues, and is usually performed by an individual’s general practitioner (GP). Uncomplicated but less common illnesses or injuries are treated by specialists at the secondary level (usually in hospitals), and very rare, complicated diseases are treated by subspecialists at the tertiary level. Gatekeeping is done by the first point of contact within the health system and is used in many countries in an attempt to provide structure to the healthcare system and the flow of patients through it (Bodenheimer & Grumbach).