Health Care System Evolution 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.

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

Expansion of the MCO model occurred with the enactment of the Health Maintenance Organization Act of 1973. This Act provided the foundation for managed health care and required employers with greater than 25 employees to provide and HMO offering. The Act served to counter Democratic efforts to nationalize U.S. health care and to stimulate competition within the health care market. HMO’s also began the concept of for profit health care operations. While most health care providers are not for profit (Phelps, 2011) and number operate under a for profit model. Non-profit dominates the healthcare sector based on their tax exempt status.

HMOs are usually the least expensive health plans, offer predictable costs for health care, the least administrative paperwork, and cover preventive care (Barsukiewicz, Raffel, & Raffel, 2010). However, HMOs also restrict direct access to specialists by requiring referrals by a PCP, requiring patients to see a provider in the HMO network, and often not covering more costly procedures or care options, because care is managed to control excessive or unnecessary care. Providers gain if they provide less care (Austin & Wetle, 2012). This incentive could affect patient-provider trust.

People are aware that managed care has caused patient free will to be lost in the sprint to cut price. Insurance companies in this sense control patients rather than self-monitoring or by a physician. One wants to make their choices. Managed care -whether in the form of HMOs, PPOs, etc., or limits on service- is an attempt by the payers (insurance companies, federal agencies or self-funded groups) to restrict payment for services and procedures the payers consider to be unnecessary

Many people are concerned about rising health care costs. In reaction to this, some individuals and companies are gravitating toward the assumed lower prices of Health Maintenance Organization (HMO) health plans. HMOs spend billions of dollars each year advertising their low cost services. While these savings look good on paper, there are many pages of small print. The explanation after the asterisk indicates that not only do the HMOs lack lower costs, but they also short-change the patient in quality care. Much of the money spent on premiums goes directly into the pockets of stockholders and less is then available for

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.

Unlike insurers, HMOs provide care directly to patients; HMOs were viewed as low-cost alternatives to hospitals and private doctors. In 1997 approximately 651 HMOs provided care to 66.8 million people.

An HMO provides comprehensive health-care services to the insured for a fixed periodic payment. There may also be a nominal fee paid for each visit to a health-care provider. Unlike traditional insurance, HMOs actually provide the health care rather than just making payments to health-care providers. HMOs can have a variety of relationships with hospitals and physicians. Plan physicians may be salaried employees, members of an independent multi-specialty group, of a network of independent multi-specialty groups, or part of an individual practice association.

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

The Health Maintenance Organizations, well-known as HMO, has made healthcare a reasonably priced for numerous people here in America. What is an HMO? An HMO is an organization where the patient or subscriber is able to choose a medical provider from a list of doctors in a certain medical group. Every medical doctor has signed an agreement to see patients at a reduced rate. This kind of

A preferred provider organization (PPO) plan gives patients the flexibility to see providers and specialists within or outside the network of care; it will typically cost less to receive care from an in-network provider (U.S. Centers for Medicare & Medicaid Services, n.d.). In most cases, referrals for specialists and designating one physician as a primary care provider is not required of a PPO plan. (U.S. Centers for Medicare & Medicaid Services, n.d.). Alternatively, a health maintenance organization (HMO) limits patients to receive care from doctors, specialists, and hospitals covered under the health plan (U.S. Centers for Medicare & Medicaid Services, n.d.). With the exception of emergency can and out-of-area urgent care, all care providers

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.

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