Preferred Provider Organization Research Paper

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

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.

There are various differences between managed care plans. With an HMO, the member would receive most or all healthcare from a provider within the network. Also, members are required to choose a PCP and would need a referral to see a specialist or another doctor. PPOs have contracts with a network of providers which they deem “preferred”. Furthermore, PCPs are not required by a PPO and members do not need a referral to see other providers in the network. The POS plan is a combination of both the HMO and PPO plans. With a POS plan, the member must pick a PCP and is allowed to see a provider that is not in the

2) Preferred Provider Organizations (PPOs), PPOs allow members to obtain care in network and out of network, but the member have to pay higher premium.

Health Maintenance Organizations (HMOs), that provides a wide-ranging option of services, over a period f time and at a fixed rate.

“…Paul Ellwood (along with the Nixon administration), a physician specializing in rehabilitation medicine, who through his Minnesota think tank InterStudy promoted the term HMO and saw it as the building block for an entirely different approach to health care reform” (Oliver, 2004). According to the National Library of Medicine, “managed care plans are health insurance plans that contract with health care providers and medical facilities to provide care for members at reduced costs” (www.nlm.nih.org). The categories of plans include Health Maintenance Organization (HMO), Preferred Provider Organizations (PPO), and Point of Service (POS). According to the American Heart Association the goals of managed health care ensure that “providers deliver high-quality care in an environment that manages or controls costs, the care delivered is medically necessary and appropriate for the patient’s condition, care is rendered by the most appropriate provider, and care is rendered in the most appropriate , least restrictive setting” (www.americanheart.org). Due to the customization ability of managed care plans individuals control their respective health coverage and allow cost reduction cooperation between health organizations and

Instead, customers are encouraged to use providers within the network through offering them reduced rates for service. When a customer uses a provider that participates with the program, they pay less in the form of out of pocket copayments. These discounts are available because the health care providers within the network have contracts with the PPO stating the agreed upon discounted rates the providers will be paid when they provide services for members of that particular PPO (Gapenski, 2013).

HMOs or Health Maintenance Organizations are health care plans that reduce health care cost. Members of an HMO are usually required to make a co-payment when seeing a physician. A lot of time members have a deductible they will have to pay before they are able to see their physician too. These are just some of the ways HMOs try to keep health care cost down.

Let’s take PPO’s and HMO’s plans and compare the difference. The word “preferred” means that the plan is designed to have contracts with doctors and medical facilities that perform services for their members at a lower rate than the non-members and a referral does not need to be obtained in order for the patient to see a specialist (Pearson 2015). This means that a consumer will not have to compromise between searching for the best physician and searching for what is affordable. Then we have the HMO plan which is the most affordable plan and has a lot more benefits to offer than the PPO plan, but it does come with restrictions for those patients with serious health conditions. HMO’s offer very limited and strict network of physicians and other healthcare professionals with limitations on what is covered by the plan and many patients have to pay out-of-pocket expenses if services are not within the network. Overall, this plan is lower than the PPO plan but it has many drawbacks. Before choosing a healthcare plan, be sure to

Nevertheless HMOs' fixed rates encourage them to offer outstanding coverage for health improvement as well as preventive care services. POS plans are comparable to HMOs on the aspect that their domain is healthcare networks. In case the insured primary care doctor refers him to a doctor outside the network, the insurance company will honor major part of the bill. Also, if the insured refers himself to a doctor outside his network, the

A PPO is when a managed care organization of medical doctors, hospitals, and other health care professionals provides health care at reduced costs to clients and patients. POS is a type of plan in which you pay reduced costs if you use medical doctors, hospitals, and other health care professionals that belong to the plan’s network. With POS plans patients and clients are required to get referrals from primary care doctors in order to see a specialist. Staff Model HMOs employs salaried physicians. The care patients are usually provided is in a facility owned by the HMO. There is a high degree of control over care delivered, and premium costs are often lower because the HMO usually owns the facility. The Physicians are on fixed

Is a managed health care plan that provides health services for insurance, self-funded health care benefit plans, individuals, and other entities in the United States. It acts as a liaison with health care providers (hospitals, doctors, etc.) on a prepaid basis. In most HMO Plans, you can only go to specific doctors or other health care provider within the hospital systems that are outlined in the plan with the exception of an emergency. The patient generally needs to get a referral from their primary care doctor who authorized what services or specialists the patient is allowed to see. This controls costs and manages unnecessary services that the plan will not pay for or the patient may have to pay for the full cost of the service.

The following market plans to research are Exclusive Provider Organization (EPO): This is also flexible, and do not need a referral for special services. The exception is hospital emergencies. Health Maintenance Organization (HMO): Providers that work through a HMO, the exception is emergencies. Point of Service (POS): One would pay less if using providers within the network. Preferred Provider Organization (PPO): More flexibility and use the physicians outside of the plan.

Preferred Provider Organization: With a Preferred Provider Organization (PPO), members pay less for care when they use in-network providers — doctors, hospitals, and pharmacies that are part of the PPO network. The plan also provides coverage when members go to out-of-network providers, but they will pay more. This plan doesn 't require referrals.

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.