Question

Discuss managed care in terms of organization (MCOs, HMOs, PPOs, IPAs).

Describe the main characteristics of a health maintenance organization.

Discuss the utilization control methods of gatekeeping and the types of utilization review in terms of how they try to contain costs.

Answer 1

1) Managed Care Organizations ( MCOs) combine insurers and provider's functions into a single administrative organization.Main goal of MCO is to control cost without sacrificing quality because MCO assure financial risk for expenditures. They have strong incentives to control cost and utilisation of health services.

Different types of MCOs are HMOs(Health maintenance organizations), PPOs ( Preferred Provider Organizations) and IPAs( Independent Physician Association) . HMOs are the most common. With an HMO plan, you must choose a Primary Care Physicians ( PCP) from a network of local health providers who will refer you to in- network specialists or hospitals when necessary. All your care is coordinated through that primary care physician. PPOs do not require that beneficiaries use certain providers, however they offer financial incentives to encourage member to use providers that participate in the plan. PPOs is a managed care organisations of medical doctors, hospitals and other health care providers who have agreed with an insurer or a third party administrator to provide health care at reduced rate to the insurer's or administrator's clients. Independent Physicians Association ( IPA) consists of a list of independent healthcare providers that provide healthcare services to managed care organisations on flat fee, fee for service or per capita basis.