Hmo Influence On Health Care

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 Iron triangle for healthcare consists of cost, quality, and access; these three characteristics when balanced create great healthcare. Managed Care Organizations combine the three to offer consumers with care that is appropriate for their individual needs. Our book describes managed care organizations as “the cost management of healthcare services by controlling who the consumer sees and how much the service cost” (Basics of the U.S Healthcare System, Niles). Taking a look at the history prior to the Health Maintenance Organization Act of 1973 (HMO ACT of 1973) the implementation has been significant in balancing cost, and quality control. Before this Act was signed in to law by President Nixon healthcare costs were determined by fee for service. A fee for service or indemnity plan is a plan that allows the provider to determine the cost of service, this fee for service plan caused for healthcare costs to increase rapidly. An example of this would be going to the doctor with neck pain, being told to stretch then receiving a bill for 25,000 dollars. As could be understood the cost of healthcare had became a problem.

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.

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 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.

In this country there are numerous concerns about health care economics. Several factors contribute to the increase of health care costs. One area of concern is the impact of managed care on health care finances. Managed care has been around since the early 1970s. The definition of managed care is a set of contractual and management methods implemented to manage the financing and delivery of health care services. Initial implementation of managed care was for health care cost saving (Getzen & Moore, 2007, p. 203, para. 1). Though Managed care initially addressed several health care finance issues, there are still problems with the current

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.

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.

It is “designed to screen out unnecessary and inappropriate care and to reduce costs (Gerdes et al., 2013). Different forms of managed care exist and we still use them to this day, including the health maintenance organization (HMO) and the preferred provider organization (PPO). The HMO structure requires a person to have a primary care physician and the individual can only go to a specialist after getting referred by this physician (Gerdes et al., 2013). The PPO structure offers clients a list of health care providers to choose from that are in their preferred network. If the individual decides to go out of network, the cost is either reimbursed at a lower rate or not covered at all (Gerdes et al., 2013). Managed care changed the health care system drastically, which lead to a “fundamental shift in the role of the social workers in acute health care” (NASW, date?). More emphasis was placed on discharge planning and transitioning the person to a different level of care or home (NASW, date?).

An HMO is an organization whereby the subscriber, or patient, is allowed to choose a medical provider from a list of doctors within a certain medical group. Each physician

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.

Less than a hundred years ago, in the late 1920’s and 30’s, almost 90% of Americans did not have health insurance (Fall of HMO’s 4). They used a variety of home remedies and when medical assistance was truly needed, they paid for it out of pocket, even incurring vast amounts of debt. This had been the case throughout history, and it changed due to an important factor, medical equipment. The industrial revolution finally caught up with the medical industry and the country saw a vast change in the scientific instruments used by physicians. These instruments required a lot of money to make and care for which caused prices to rise. Due to this massive problem, a committee was formed of health care professionals and after a 5 year study, the Committee on the Cost of Medical Care suggested that health insurance co-operatives start. These corporate medical practices became known as Health Maintenance Organizations (HMO’s) and preferred provider organizations (PPO’s), and up until the 1970’s, were an experiment to regions across the U.S. Factors that hindered health care included bullying of “money politics” from both sides of the isle as well as Presidential views and tactics as well. President Nixon first

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

Overall, the role of health insurance as a financial channel will be mentioned. Monetary business objectives will be contrasted with the altruistic goals of health care as a humanitarian service. The benefits of shifting health care management altogether to the government will be discussed, emphasizing its positive effects on the businesses of the employers and the performances of the employees in the United States.