Preferred Provider Organization Research 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.

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 vs HMO-- EPO contracts solely with specific specialists, clinics, hospitals and other health care providers to form a network. EPO clients know they don't have many options when it comes to providers, but they do have the comfort of knowing they'll always be reimbursed for any in-network expenses. HMO’s requires a co-payment on each visit while EPO’s have no co-pays. Both EPO’s and HMO’s keep costs low. EPO’s do not require a referral while HMO’s must confirm that specialized care is required before they will issue a referral

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.

Group Model HMO is the type of HMO plan that is based around a multi-specialty medical group that may include all types of specialists including obstetricians, gynecologists, cardiac and oncology specialists and surgeons contracting exclusively with the HMO to provide services. Care is delivered in facilities owned either by the physician groups, such as clinics, or the HMO, such as a hospital. Network Model is an HMO that contracts with many medical provider groups. Care can be provided in a larger geographic service area than would be possible with only one physician group. The network model offers the patients a choice of physicians and managed costs. Independent Practice Association Model HMO is an association of independent physicians or small groups of physicians formed for the purpose of contracting with one or more managed health care organizations. Physicians that are members of the IPA provide medical services for HMO patients in their own

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).

They require members to select a primary care physician and a referral is required to see specialist or for some more expensive testing. Before receiving care from a specialist or other physician. HMOs pay only for care within the provider network.

“…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

Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

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

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

Health Maintenance Organization (HMO) is medical insurance group that provides health services for a set annual fee. The primary reason of managed care is to reduce health care costs among Americans. The belief behind managed care programs was to maintain good health that will be accomplish by preventing diseases and providing quality care. By having good health the cost in health care can be controlled and lowered. Managed health care organizations became contracted with groups of health care providers such as HMOs and PPOs. HMOs covers care provided by physicians and other professionals who have agreed by contract to treat patients in following with the HMOs guidelines and rules in exchange for patients. PPOs are known as preferred provider organizations where individuals can only receive care from providers in contract with PPO. Payment arrangements between managed health care organizations and care providers are made in advance.

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 three major types of health insurance available in the US are "Health Maintenance Organizations--HMOs, Point of Service plans--POS, Preferred Provider Organizations --PPOs." (Health Insurance Coverage, 2010) All the three coverage options come under managed care plans wherein the health insurers collaborate with healthcare providers to build networks. HMOs offer the most economical health insurance coverage, however their plans are not always flexible. As they come under HMO purview the insured has to pay monthly premium while the co-payments are relatively low for hospital and subsequent office visits. When an insured belongs to an HMO, there is a restriction to visit doctors within his network only and any failure will entail footing the bill by the insured himself. Prior to visiting Specialist Doctors, HMOs often need the insured to get referrals. Even visiting the Emergency Room needs approval if one belongs to an HMO. (Health Insurance Coverage, 2010)

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.