Question

Who opposed health maintenance organizations and what were their reasons? Describe the roles of government and the insurance industry in promoting managed care plans.

Answer 1

1) In the United States, a health maintenance organization (HMO) is a medical insurance group that provides health services for a fixed annual fee.It is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals, and other entities, acting as a liaison with health care providers(hospitals, doctors, etc.) on a prepaid basis. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options if the employer offers traditional healthcare options.Unlike traditional indemnity insurance, an HMO covers care rendered by those doctors and other professionals who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers. HMOs cover emergency care regardless of the health care provider's contracted status. HMOs often require members to select a primary care physician (PCP), a doctor who acts as a gatekeeper to direct access to medical services but this is not always the case. PCPs are usually internists, pediatricians, family doctors, geriatricians, or general practitioners (GPs). Except in medical emergency situations, patients need a referral from the PCP in order to see a specialist or other doctor, and the gatekeeper cannot authorize that referral unless the HMO guidelines deem it necessary. Some HMOs pay gatekeeper PCPs set fees for each defined medical procedure they provide to insured patients (fee-for-service) and then capitate specialists (that is, pay a set fee for each insured person's care, irrespective of which medical procedures the specialists performs to achieve that care), while others use the reverse arrangement.Open-access and point-of-service (POS) products are a combination of an HMO and traditional indemnity plan. The member(s) are not required to use a gatekeeper or obtain a referral before seeing a specialist. In that case, the traditional benefits are applicable. If the member uses a gatekeeper, the HMO benefits are applied. However, the beneficiary cost sharing (e.g., co-payment or coinsurance) may be higher for specialist care. HMOs also manage care through utilization review. That means they monitor doctors to see if they are performing more services for their patients than other doctors, or fewer. HMOs often provide preventive care for a lower copayment or for free, in order to keep members from developing a preventable condition that would require a great deal of medical services. When HMOs were coming into existence, indemnity plans often did not cover preventive services, such as immunizations, well-baby checkups, mammograms, or physicals. It is this inclusion of services intended to maintain a member's health that gave the HMO its name. Some services, such as outpatient mental health care, are limited, and more costly forms of care, diagnosis, or treatment may not be covered. Experimental treatments and elective services that are not medically necessary (such as elective plastic surgery) are almost never covered.Other choices for managing care are case management, in which patients with catastrophic cases are identified, or disease management, in which patients with certain chronic diseases like diabetes, asthma, or some forms of cancer are identified. In either case, the HMO takes a greater level of involvement in the patient's care, assigning a case manager to the patient or a group of patients to ensure that no two providers provide overlapping care, and to ensure that the patient is receiving appropriate treatment, so that the condition does not worsen beyond what can be helped.HMOs operate in a variety of forms. Most HMOs today do not fit neatly into one form; they can have multiple divisions, each operating under a different model, or blend two or more models together. In the staff model, physicians are salaried and have offices in HMO buildings. In this case, physicians are direct employees of the HMOs. This model is an example of a closed-panel HMO, meaning that contracted physicians may only see HMO patients. Previously this type of HMO was common, although currently it is nearly inactive.In the group model, the HMO does not employ the physicians directly, but contracts with a multi-specialty physician group practice. Individual physicians are employed by the group practice, rather than by the HMO. The group practice may be established by the HMO and only serve HMO members ("captive group model"). Kaiser Permanente is an example of a captive group model HMO rather than a staff model HMO, as is commonly believed. An HMO may also contract with an existing, independent group practice ("independent group model"), which will generally continue to treat non-HMO patients. Group model HMOs are also considered closed-panel, because doctors must be part of the group practice to participate in the HMO - the HMO panel is closed to other physicians in the community.
If not already part of a group medical practice, physicians may contract with an independent practice association (IPA), which in turn contracts with the HMO. This model is an example of an open-panel HMO, where a physician may maintain their own office and may see non-HMO members.In the network model, an HMO will contract with any combination of groups, IPAs (Independent Practice Associations), and individual physicians. Since 1990, most HMOs run by managed care organizations with other lines of business (such as PPO, POS and indemnity) use the network model.

2) PPO plan can be a betterchoice compared with an HMO if you need flexibility in which health care providers you see. More flexibility to use providers both in-network and out-of-network. You can usually visit specialists without a referral, including out-of-network specialists.

3) Role of government: Three levels of government are collectively responsible for providing universal health care: They contribute their own funding in addition to that provided by federal government. States are also responsible for regulating private hospitals, the location of pharmacies, and the health care workforce.

4) Managed Care is a way for health insurers to help control costs by managing the healthcare services people use. Today, nearly all health insurance plans include a managed care component to control costs. One such component is pre-authorization: Members may need to receive approval from the insurance company before being admitted to a hospital or having a major procedure.Over the years, managed care has given birth to several types of health plans, all in an effort to balance quality care with lower costs. Here are a few of the prevalent ones you’ll encounter: Preferred Provider Organizations (PPO) plans are similar to Fee For Service, with one wrinkle: They use a network of contracted medical “preferred providers” (doctors, hospitals, etc.). When members see doctors in the PPO network, they present a card and don’t have to fill out and submit claim forms. PPO members can visit any provider they choose without a referral even doctors, specialists and hospitals outside the network. However, they will pay more for services outside the network than they will if they use in-network providers.Point of Service (POS) plans revolve around a “primary care physician” who makes referrals to specialists as needed. Members who see providers in the POS plan network generally pay a small fraction of the service fee. Members can see providers outside the plan network only if they receive a referral from their primary care physician, plus they’ll generally pay a much larger percentage of the cost for out-of-network provider services.Health Maintenance Organizations (HMO) plans are generally less expensive (lower premiums, copayments and deductibles), and member costs are more predictable, than with other types of plans. But they also offer the least amount of choice within their network of doctors, hospitals and other providers. And HMOs offer no coverage to members who see providers outside the network. (Exceptions may be made in emergencies or when necessary for other medical reasons.) Additionally, the smaller network can mean that members may have to wait longer for a doctor’s appointment.