Managed Care Essay, Research Paper

Chapter 3: Types of Managed Care Organization

? The differentiation between wellness attention suppliers and wellness attention insurance companies have blurred well

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? 10 Old ages ago managed attention organisations were frequently referred to as alternate bringing systems

? Managed attention is now the dominant signifier of wellness insurance coverage in the United States

? Managed attention can intend pull offing the supplier bringing system can be tantamount in its results to pull offing the medical attention delivered to the patient

? Managed attention may non absolutely depict this current coevals of funding vehicles, it provides a convenient stenography description for the scope of options to traditional insurance wellness insurance

? On one terminal of the continuum is managed insurance with simple pre-certification of elected admittance and big instance direction of ruinous instances, superimposed on a traditional insurance insurance program

? Further along the continuum are PPOs, POSs, open-panel [ single pattern association ( IPA ) type ] HMOs, and closed-panel ( group and staff theoretical account ) HMOs


Health maintenance organization

? HMOs are organized wellness attention systems that are responsible for both the funding are the bringing of a wide scope of comprehensive wellness services to an enrolled population

? HMO wellness insurance company and a wellness attention bringing system

? HMOs are responsible for supplying wellness attention services to their covered members through attached suppliers, who are reimbursed under assorted methods

? HMOs must guarantee that their members have entree to covered wellness attention services

? HMOs by and large are responsible for guaranting the quality and rightness of the wellness services they provide to their members

? The five common theoretical accounts of HMOs are ( 1 ) staff, ( 2 ) group pattern, ( 3 ) web, ( 4 ) IPA, and ( 5 ) direct contact


? PPOs are entities through which employer wellness benefit programs and wellness insurance bearers contract to buy wellness attention services for covered donees from a selected group of take parting suppliers

? PPOs frequently limit the size of their take parting supplier panels and supply inducements for their covered persons to utilize take parting suppliers alternatively of other suppliers

? In contrast to persons with traditional HMO coverage persons with PPO coverage are permitted to utilize non-PPO suppliers

? PPOs sometimes are described as preferable supplier agreements ( PPAs )

? PPA is used to depict a less formal relationship than PPO

? The term PPO implies that an organisation exists, whereas a PPA may accomplish the same ends as a PPO through an informal agreement among suppliers and remunerators

? Key common features of a PPO include:

? Choice supplier panel

? Negotiated payment rates

? Rapid payment footings

? Utilization direction

? Consumer pick

Exclusive Provider Organizations

? Exclusive supplier organisations ( EPOs ) limit their donees to take parting suppliers for any wellness attention services

? The EPO by and large does non cover services received from other suppliers, although their may be exclusions

? EPOs, like HMOs, require sole usage of the EPO supplier web and besides use a gatekeeper attack to authorising non-primary attention services

? The difference between an HMO and an EPO is that the former is regulated by HMO Torahs and ordinances, and the latter is regulated under insurance Torahs and ordinances

? Employee Retirement Income Security Act of 1974

? EPOs normally are implemented by employers ( b/c it? s cost efficient )

POS Plans

? Loanblends of HMO and PPO theoretical accounts

? Features include:

? Primary attention doctor are reimbursed through capitation payments ( i.e. Fixed payment per member per month )

? An sum is with held from physician compensation that is paid contingent upon accomplishment of use or cost marks

? The primary attention physician acts as a gatekeeper for referral and institutional medical services

? The member retains some coverage for services rendered that either are non authorized by the primary attention doctor or are delivered by non-participating suppliers

Open Access or POS HMOs

? Provides some degree of indemnity-type coverage along with the HMO coverage

? HMO members covered under these types of benefit programs may make up one’s mind whether to utilize HMO benefits or indemnity-style benefits for each case of attention

? The member is allowed to do coverage pick at the point of service when medical attention is needed

? Most POS plans experience between 65 per centum and 85 per centum in-network use, therefore retaining considerable cost control compared to indemnity-type programs

? There are two primary ways form an HMO to offer POS option

1 ) Via a individual HMO licence

a. HMO provides the out-of-network benefit utilizing its HMO licence

2 ) Via a duel-license attack

a. The wellness program uses an HMP licence to supply the in-network attention and an insurance licence to supply the out-of-network coverage

B. More flexible

? Coverage under HMO POS plans late has been the fastest turning section of wellness insurance

Self-Insured and Experience-Rated HMOs

? The federal HMO Act originally mandated community evaluation for all HMOs that decided to prosecute federal making

? Under a typical self-insured benefit option, an HMO receives a fixed monthly payment to cover administrative services ( and net income ) and variable payment that are based on the existent payments made by the HMO for wellness services

? Under experience-rated benefit options, an HMO receives monthly premium payments much as it would under traditional premium based programs

? The HMO ordinances of some provinces and federal HMO making ordinances preclude HMOs from offering self-insured or experience rated benefit programs

Forte HMOs

? Specialty HMOs functioning other wellness attention demands ( e.g. mental wellness ) have besides developed in certain stated where they are permitted under the insurance or HMO Torahs and ordinance

Managed Care Overlays to Indemnity Insurance

? Managed attention sheathings have developed that can be combined with traditional insurance insurance, service program insurance, or self-insurance

? The term insurance insurance is used to mention to all three signifiers of coverage in this context

? The undermentioned types of managed attention overlays presently exist

? General use direction? complete bill of fare of utilization direction activities selected by single employer or insurance companies

? Specialty Utilization direction

? Catastrophic or big instance direction? ( regardless of forte involved )

? Workers? compensation use direction? to turn to the alone demands of patients covered under workers? compensation benefits

Physician-Hospital Organizations

? Physician-hospital organisation ( PHOs ) are organisations that by and large are jointly owned and operated by infirmaries and their attached doctors

? A vehicle for infirmaries and doctors to contract together with other managed attention organisations to supply both physician and hospital service

? Physicians and one or more infirmaries are stockholders or members

? PHOs can offer several advantages for suppliers who develop them

? They may increase the negociating clout of their single members with managed attention organisations

? They provide a vehicle for doctors and infirmary to set up reimbursement and risk-sharing attacks that align inducements among all suppliers

? They can function as a clearinghouse for certain administrative activities, including credentialing and use direction, thereby cut downing the administrative load on their single doctor and infirmary members

? They provide an organized attack for doctors and infirmaries to work together on managed attention issues, including utilization direction and

quality betterment

? PHOs may besides offer advantages to some managed attention organisations:

? PHOs can supply a agency of quickly set uping a panel of take parting doctors and infirmaries

? PHOs can supply a agency of cut downing operating costs

? The deficiency of success of PHOs are:

? PHOs offer small or no benefit for inscribing big panels of take parting doctors and infirmaries

? PHOs, as of right now, wear? T assume fiscal hazard for presenting wellness services by accepting capitation-based payments


? The five normally recognized theoretical accounts of HMO? s are:

1 ) Staff

2 ) Group

3 ) Network

4 ) IPA

5 ) Direct contact

? The major differences among these theoretical accounts pertain to the relationship between the JHMO and its participating doctors

? Many HMOs can non easy be classified as a individual theoretical account type, although such programs are on occasion referred to as assorted theoretical accounts

Staff Models

? In a staff theoretical account HMO, the doctors who serve the HMO? s covered donees are employed by the HMO

? Doctors are normally paid on a salary footing and may besides have fillip or inducement payments that are based on their public presentation and productiveness

? Staff theoretical account HMOs must use doctors in all the common fortes to supply for the wellness attention demands of their members

? Staff theoretical account HMOs are besides known as closed panel HMOs because most active doctors are employees of the HMO, and community doctors are unable to take part

? Physicians in staff theoretical account HMOs normally pattern in one or more centralised ambulatory attention installations

? Staff theoretical account HMOs normally contract with infirmaries or inmate installations in the community to supply non-physician services for their members

? They have a greater grade of control over their pattern forms of their doctors

? Besides offer the convenience of one-stop shopping for their members because the HMO? s installations tend to be full service

? Disadvantages of the staff theoretical account:

? More dearly-won to develop and implement because of the little rank and the big fixed wage disbursals that the HMO must incur for staff doctors and support staff

? Supply a limited pick of take parting doctors for possible HMO members

? Productivity jobs with their staff doctors? raising costs for supplying attention

? Expensive to spread out services into new countries

Group Model

? The HMO contracts with a multi-specialty doctor group pattern to supply all physician services to the HMO? s members.

? Physicians in the group pattern are employees by the group pattern ( non by the HMO )

? Physicians in a group pattern portion installations, equipment, medical record, and support staff

Captive Group

? The doctor group pattern exists entirely to supply services to the HMO? s donees

? I.e. Kaiser Foundation Health Plan

Independent Group

? The HMO contracts with an bing, independent, multi-specialty doctor services to its members

? I.e. Geisinger Health Plan

? Continues to supply services to non-HMO patients while is participates in the HMO

Common Features of Group Models

? Advantages

? Both types of group theoretical account HMOs are besides referred to as closed-panel HMOs because doctors must be members of the group pattern to take part in the HMO

? Group pattern HMOs may hold lower capital demands than staff theoretical account HMOs

? Disadvantages

? Limited pick of take parting doctors from which possible HMO members can choose

? Limited figure of office locations for the take parting medical groups

? Restricts the geographic handiness of doctor for the HMO? s members

? Certain group patterns may be perceived by some possible HMO members as offering an unwanted clinic scene

Network Model

? In web theoretical account HMOs, the HMO contracts with more than one group pattern to supply doctor services to the HMO? s members

? The HMO compensates groups on an across-the-board physician capitation footing

? The group is responsible for supplying all physician services to the HMO? s members assigned to the group and may mention to other doctors as necessary

? Network modeled may be either closed- or open-panel

? Closed-panel program:

? Merely contracts with a limiter figure of bing group patterns

? Open-panel:

? Engagement in the group patterns will be unfastened to any doctor who meets the HMO? s and group? s certificates standards

? Broader physician engagement that? s normally identified with web theoretical account HMOs helps get the better of the selling disadvantage associated with the closed panel staff and group theoretical account programs

? This theoretical account normally have more limited doctor engagement than either IPA theoretical account or direct contract theoretical account programs

IPA Model ( Individual Practice Association )

? IPA theoretical account HMOs contract with an association of doctors? the IPA? to supply doctor services to their members

? IPA physicians continue to see their non-member HMO patients and keep their ain offices, medical records, and support staff

? IPA theoretical account HMOs are open-panel programs because engagement is unfastened to all community doctors who meet the HMO? s and IPA? s choice standards

? Broad physician engagement can assist do the IPA theoretical account HMO more attractive to possible HMO members

? Methods IPA theoretical account HMO establishes relationships with their IPAs:

? HMO contracts with IPA that has been independently established by community doctors

? These types of IPAs frequently have contracts with more than one HMO on a nonexclusive footing

? The HMO works with community doctors to make an IPA and to enroll doctors to take part in it

? The HMO contract is normally on an sole footing because of the HMO? s taking function in organizing IPA

? Most HMOs compensate their IPAs on an across-the-board physician capitation footing to supply services to the HMO? s members

? The IPA so compensates its engagement doctors on either a fee-for-service footing or a combination of fee-for-service and primary attention capitation

? IPA theoretical account HMOs overcome all the disadvantages associated with staff, group, and web theoretical account HMOs

? They require less capital to set up and run

? Supply a wide pick of take parting doctors who pattern in their private offices

? Two major disadvantages from an HMOs position:

1 ) The development of an IPA creates an organized forum for doctors to negociate and contract straight with managed attention programs

a. Individual members of an IPA retain their ability to negociate and contract straight with managed attention programs

b. IPA are immune from antimonopoly limitations on group activities

2 ) The procedure of use direction is more hard in an IPA theoretical account HMO than it is in staff and group theoretical account programs

a. Because doctors remain single practicians with small sense of being a portion of the HMO

Direct Contact Model

? Direct contact theoretical account HMOs contract daily with single doctors to supply doctor services to their members

? I.e. U.S. Healthcare and its subordinate Health maintenance organization

? Attempt to enroll wide panels of community doctors to supply physician services as take parting suppliers

? A.K.A. ? gatekeeper systems

? Compensate their doctors on either a fee-for-service footing or a primary attention capitation footing

? Direct theoretical account HMOs extinguish the potency of a physician bargaining unit by undertaking straight with single doctors

? Disadvantages

? HMO may presume extra fiscal hazard for physician services relative to an IPA theoretical account HMO

? This is expensive

? Difficult and clip devouring for a direct contract theoretical account HMO to enroll doctors because it lack the physician leading inherent in an Information science


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