Pros And Cons Of Health Insurance

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.

People monthly premium can be a lot lower based on people income. No matter which health insurance plan people choose. They can save a lot money on their monthly insurance based on their income. The difference between HMO Health Maintenance Organization and PPO Preferred Provider Organization. These two health plans help people compare plans to get the right coverage for them and their family. A HMO health plan is a type of plan where people can pick one primary care Physician acts as the gateway between you, family, and your care. It also plans often offer the best pricing and least flexibility. They have lower prices by limiting your care to the doctors, clinics and hospital within the HMO a network. It require to choose primary care physician

Through the use of managed care, HMOs and PPOs are able to reduce the costs of hospitals and physicians. Managed care is a set of incentives and disincentives for physicians to limit what the HMOs and PPOs consider

Perferred providers orginaztion asl known as PPO is an advanced-based medical care. The membership allows a dicount below the regularly charge of rates to the asigned professionals grouped together with the organizations. Ppo themselves earn more money by charging cilents for the acess of the insurance company. PPO have plans that provide a lot of flexibility when choosing a physician or hospital. The features also have a network that physicians; are some restrictions to seeing a non-network physician. Your PPO will pay if you see a physician that isnt in the network. It can be a smaller rate. Here are some bennefits that you can see a specialist first without having to being seen to by your physician. You can go to any hospital outside your network and still be covered for. You’ll have more benefits if you stay in your plan. Premiums are usually higher, and more common for there discount.

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 book discuss about three major types of managed care organization: health maintenance organizations (HMO), preferred provider organizations(PPO), and point of service plans(POS). Managed care has been around for minute. This organization has been around since 1930s. The three managed care organizations are require an agreement between the insurer and a network of health care providers. Policy holders are encouraged to use the providers in the network by the fact a percentage will pay the cost of care if received outside the network.

In chapter 4, I learned about managed care organizations (MCOs), preferred provider organization (PPOs), and health maintenance organizations (HMOs). In PPO there is a list of in-network providers that patients are allowed to see but pay a lot more if they see a physician that is not on the list. In a HMO patients are only allowed to see physicians that are employed by them and may not see anyone else. There are a variety of methods to pay providers for healthcare services. Two of them are widely known as capitation and per diagnosis. Under capitation, organizations receive a fixed amount of money each month regardless of use. In per diagnosis, organizations are paid based on the diagnosis of the patient. The chapter also explained cost shifting

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

HMOs are a type of MCO that requires a PCP and the patient can only see their PCP, no care is covered including specialist care if it is outside the network. These thing help keep cost down. HMOs have two sub groups, the staff model and the group model. The staff model were the HMO owns the health care facility and pays the providers a salary, all care under this plan must be done in network (all owned by the HMO). The group model In the HMO system has a contract with a health care facility and the facilities providers and there is an agreement that the providers in the network that will only see the HMO’s patients. Then, there is the open panel where in this system providers agree to be PCP providers for a HMO and can also see other patients. The network model is when there is an agreement with healthcare facilities to accept the insurance and see the patients. The final type of HMO plan is the Independent Physician Association (IPA), the provider is paid an agreed price for the services and they see a high number of patients. Now to look at the PPO plans, for these plans contracts are made with providers for them to provide care to the patients as a preferred provider in the network. The providers agree to see the patients at their own office and are paid the agreed upon price for their services. There is no PCP or

The uninsured and underinsured populations create a burden on society. Due to the high cost of health care services, many bills remain unpaid. Health care providers must absorb this expense and there is often a spillover of the cost to the insured population, usually in the form of increased fees for service. A study by the Institute of Medicine Committee found that there are several other costs consequent to uninsurance. The workforce faces diminished productivity due to people not seeking preventative and palliative care, which could lead to missing shifts, leaving the job, or retiring early for health purposes.

Managed Care is a complex health care system in which physicians, hospitals, and other healthcare professionals organize in an interrelated system of people and facilities that communicate with one another and work together as a unit, commonly referred to as a network. This network coordinates and arranges health care services and benefits for a specific group of individuals, referred as enrollees, for the purpose of managing costs, quality, and access to health care. The Managed care program may be provided in a variety of settings, such as Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO). In Health Maintenance Organization, the insurance company will only pay for care within the network. The member will pick a primary care provider who coordinates most of their care. Preferred Provider Organization (PPO) usually pays more if the member will get care within the network, but they still pay a portion if the member will go outside. And Point of Service (POS) plans let you choose between an HMO and a PPO each time you need care (Merrick, 2013).

Managed care dominates health care in the United States. It is any health care delivery system that combines the functions of health insurance and the actual delivery of care, where costs and utilization of services are controlled by methods such as gatekeeping, case management, and utilization review. Different types of managed care plans came into development by three major factors. These factors include choice of providers, different ways of arranging the delivery of services, and payment and risk sharing. Types of managed care organizations include Health Maintenance Organizations (HMOs) which consist of five common models that differ according to how the HMO is related to the participating physicians, Preferred Provider Organizations

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.

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.

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.