HMO Model Paper

PPO- This plan contracts with physicians and facilities to perform services and a specified rate. Its to ensure that PPO members are charged less than nonmembers

The types of managed care are differentiated by definition, operation, structure, and information needs. `HMOs were the most common type of MCO until commercial insurance companies developed PPOs to compete with HMOs' (Douglas, 2003, p.331). `HMOs are business entities that either arrange for or provide health services to an enrolled population after prepayment of a fixed sum of money, called a premium' (Peden, 1998, p.78). There are three characteristics that an HMO must have. The first is a health care financing and delivery system that provides services for members in a particular geographic area. Second, is ensured access to a complete range of health care services, health maintenance, treatment, and routine checkups. Last, health care must be obtained from voluntary personnel that participate in the HMO. The five HMO models related to the participating physicians are the Staff

The Counseling Model is the most appropriate model to employ in health care organization, under this model, HR is the advocate for the employees, provides resources to managers for people problems to help resolve disputes. This is important in health care organization, because the total cost of employees represents a large portion of the budget. Happy employee’s produces excellent service, and excellent service produce revenue for the health care organization.

Another type of managed care program that was introduced is the Preferred Provider Organization (PPO). A PPO is comprised of a group of physicians, hospitals and other medical service providers who contract with employers, insurance companies or other plan sponsors. The PPO offers discounted pricing to these contracted organizations due to the high volume of business received. PPO’s typically have up-front cost sharing in the form of deductibles and/or co-insurance, which vary depending upon the actual plan chosen.

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).

Group Model HMOs are centered around multi-specialty medical groups that focus on the performance of the group as a whole; they tend to be a bit less structured than the Staff Model HMOs. Many Group Model HMOs have ties to hospitals in the areas in which they practice, but are legally independent of those hospitals. New physicians to group practices must sign a Non-Compete Clause to prevent stealing of patients and often face an entry barrier due to the reverence given to senior members of the HMO.

Because each type of managed care organization has certain unique characteristics, network strategies must be chosen to fit these characteristics. An organization that offers more than one type of health plan may choose to coordinate provider networks through a network-within-a-network approach. This is done by including the providers from one product's panel in the network of another panel. Provider network strategies are also found to vary with the geographic scope and market focus of the plan. A growing number of managed care organizations are attempting to build national provider

New England Health Maintenance Organization (HMO) is a regional not for profit managed care company that has its headquarters in Boston, MA, with over 500,000 enrollees within 25 different plans including Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont. A consortium of employers has shown interest in bidding on a managed care contract to be offered to the consortium’s 75,000 employees whom are locate in and around Nashua, New Hampshire. The consortium of employers includes companies such as IBM, Ford, and Prudential Insurance.

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.

Today, there are several types of managed care plans including Preferred Provider Organizations (PPOs), HMOs, and Point-of-Service (POS) plans. There are many types of HMOs that offer members a variety of health benefits. An HMO plan requires the member to use health care providers and facilities within the HMO network in order receive coverage, unless it is an emergency (Andrews, 2014, p. 1). A PPO is a form of managed care that most resembles a fee-for-service type situation. The plan members can generally refer themselves to doctors, including doctors outside the plan, although they typically will pay a higher percentage of the cost if the doctor is out of the network (Andrews, 2014, p. 1). A POS plan allows members to refer themselves outside the HMO network and still get some coverage (Andrews, 2014, p. 1). While these

(POS). There are over half of Americans with health insurance are enrolled in managed care

“An Integrated Physician Model is the result of a series of partnership between hospitals and physician develop overtime” (Harrison, 2016). Primarily, it is a joint venture that has become many joint ventures. In addition, all of this joint ventures are connected through congruent goals, and that is to provide different level of care to all the patients. Integrated physician model also organizing themselves to improve the cost and quality by operating under a clinical guideline. This could include acute care hospital, home care, nursing homes, affiliated medical group, primary care clinics, employed physician and any independent medical groups.

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.

of the physicians can be defined. MGOA can then start to assign cost requirements to each physician

The United States being referred for specialties depends on the insurance plan (Mossialos, Wenzel, Osborn, Sarnak, 2016, pp. 171-177). Health Maintenance Organization (HMO) plans give access to certain healthcare organizations and physician within their network that have agreed to lower rates for their services. The individual must agree to these services to have services covered. All services will be coordinated by the primary care physician PCP. Medicaid coverage is also based on these principles. Preferred Provider Organization (PPO) plan have higher premiums but give more flexibility. PPO allows the individual to see any physician they choose but cost is less if the individual stays within the network. PPO does not require that the individual have a PCP. No referrals for specialist are needed.