Managed Care: Differences Between Managed Care

As far as insurance plans go, generally there are three plans a patient will have, they are Health Maintenance Organization (HM0), Preferred Provider Organization (PPO) and Point-of-Service (POS).

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

of the patient with controlling the costs of care, the issue of the uninsured began to grow. The concept of some sort of governmentally funded universal health care for all began over a century ago, however, never successfully implemented. From a historical viewpoint, individuals obtained health insurance by purchasing their own policy, as a benefit of employment, or through governmentally funded programs that required certain eligibility criteria be met in order to be eligible. If a person did not qualify for one of these types of health insurance, they generally were left without health insurance coverage.

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.

EPO’s vs PPO’s—PPO’s are more flexible when it comes to physician choices than EPO’s. EPO’s are less expensive than PPO’s. Neither plan require a primary care physician. EPO’s do not cover out-of-network where PPO’s do pay for out-of-coverage services. PPO’s have higher premiums and have a deductible.

Point-of-service (POS) health insurance combines several elements from both HMO and PPO plans. Similar to health maintenance organization plans, (HMO), a member is required to choose a primary care physician and seek referrals to network specialists. Like preferred provider organization insurance, (PPO), members have the choice to receive care from non-network providers but typically incur larger out-of-pocket costs for venturing outside the network.

The purpose of this paper is to thoroughly examine the similarities and differences of Medicare and Medicaid managed care plans by comparing and contrasting its strengths, weaknesses, incentives, commitment to access, and risks to the consumer. Medicaid and Medicare are both health insurance programs financed and administered by government entities and are both equivalent in terms of the number of beneficiaries and total expenditures (McCarthy, Schafermeyer, & Plake, 2011). These healthcare programs differ in terms of how they are funded and governed and who they cover. Medicare is an important source of coverage for 65 or older adults, for people under 65 with disabilities, and for people of all ages with End-Stage Renal Disease in the United States. It provides health insurance protection and enables access to medical care for 54 million beneficiaries.

The same is true of POS plans and indemnity plans. The first plan is a combination of HMO and PPO type plans, by requiring a primary physician whom must approve all coverage, but also allowing you to get coverage outside of your network.

The PPO gives discounts, with its doctors and hospitals that participation, and then pays a fee for services given. Patients have a list that they can pick from for a primary physician. The patient pays a set fee per office visit and the insurance provider pays the rest. It’s basically a co-payment which depends on what type of plan they have. However, like an HMO, the PPO has to choose a physician in that network, if they don’t they may be charged a penalty.

The United States has a unique system of healthcare delivery, it is complex and massive. Twenty-five years ago; American citizens had guaranteed insurance, meaning the patient could see any physician and the insurance companies and patients would share the cost. But today, 187.4 million Americans have private health insurance coverage (Medicaid, 2014). The subsystems of American health care delivery are Managed care, military, vulnerable populations and integrated delivery

The next difference that exists between the two is that one can see any specialist whenever you like, even though some practitioners prefer when referrals are done by the general practitioners. For the managed care plan, a patient is referred to a specialist only if the primary physician determines it as being very

Hello Carlo, I do agree with every statement you have pointed out regarding the traditional and managed care insurance. Like you have mentioned, traditional insurance is for individuals who are willing to pay high deductibles and co-payments. Even though the freedom of choice is a big advantage for the consumers there is a downside to it as well. Yes, the patient has the freedom to choose a health care provider, doctor or a hospital according to their will. But, this type of insurance mainly focuses on treatment expenses rather than encouraging preventive treatment options and yearly physical check-ups. People more likely prefer to get involved in preventive care measures.

PPO is a type of private insurance company which is a Medicare Advantage Plan. If you use health care providers, or in a hospital that belong to the plan, you will pay less then to locations who do not.The places that do not take the plans are known as out of network.HMO is a type of network that you are only able to access certain doctors and hospitals. These locations have accepted to lower there rate plans for these clients. Now with HMO you are unable to go out of network verses with a PPO plan, where you are able to go out of network.POS, also known as point of service plan, is a plan that is a mixture of the HMO and PPO plans. Therefore, with the POS plan you are able to be seen where ever you may like, in or out of network. However,

This paper provides an overview of the healthcare environment and its financing in the U.S. and define acute care and long term care. It addresses three important issues. First, it provides a snapshot of how health care is currently financed in the United States, including the differences and/or similarities between Managed Care Organizations. The second part of the paper examines the current federal government programs and various types of access to health care available to every citizen. The third part of paper examines the implications nurses have in

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.