Question

What is a weakness of Open-Panel Model HMO?

Answer 1

Ans) Managed Care:

- It is a system of health care delivery that influences utilization of services, cost of services and that measures performance

- HMO, PPO, POS are forms of managed care.

- HMO (Health Maintenance Organization): Thiis form of managed care is typically considered the most managed form of health care.

* Features that differentiate HMOs from health insurers:

1. Licensed under different laws than health insurers.
2. Must provide adequate access to providers w/in their service areas.
3. Must require 'no balance billing' clauses in all provider

contracts that are stronger than those found in non-HMOs.
4. Must allow direct access to PCPs & OB/GYNs.
5. Must have written policies & procedures for physician credentialing, UM, & quality management.
6. Must maintain defined minimum levels of capital reserves.
7. Usually share some financial risk with physicians.
8. Most require members to see a PCP for routine services & to access specialty care.
9. Most are accredited by an accrediting organization.

* Types of HMOs:

1. Open panel - The HMO contracts w/ private physicians who agree to its terms & conditions & who meet its credentialing criteria
a) Independent practice association (IPA) model - the HMO contracts w/ an IPA. Physicians are not employees of the HMO or the IPA & continue to see their non-HMO patients
b) Direct contract model - the HMO contracts directly w/ independent physicians or medical groups.

2. Closed-panel - Most of the care is provided through either a single medical group associated w/ the HMO or through physicians employed by the HMO. Closed to private physicians
a) Group model - the HMO contracts w/ a multi-specialty medical group practice to provide all physician services to the HMO's members. The physicians are employed by the group practice.
b) Staff model - physicians are employed by the HMO & are paid by salary plus bonus or incentives.

3. True network model - The HMO contracts w/ more than one large medical group or physician Organization.

4. Mixed model HMOs - most commonly occurs when a closed-panel HMO adds open panel components.

5. Open-access HMOs - the member selects a PCP & gets the most benefits by using the HMO system. Can bypass the PCP to get in-network specialty care directly, but with less coverage. Only services provided in network are covered.

Open-panel HMOs:

Strength-
1. More easily marketed & sold due to large panel of private physicians.
2. Easier for members to find a participating physician that is conveniently located.
3. In IPA models, routine medical mgmt functions may be delegated to the IPA.
4. Easier & less costly to set up & maintain.

Weakness-
1. Because the HMO is not providing medical care itself, it has little ability to manage care
2. Premiums are often higher than those of closed panels