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Health Maintenance Organization Analysis

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Health Maintenance Organization (HMO)
There are four basic types of managed care plans that fall under the umbrella of a Managed Care Organization. The first type is a Health Maintenance Organization (HMO). An HMO is the most common type of MCO and it mainly focuses on wellness (Stark 2014). HMOs contract with different health care providers who become part of a network that provides health services to HMO patient members at a fixed, prepaid fee regardless of actual medical costs or the amount of times they are seen in the office (Stark 2014). In return, the HMO guarantees a steady flow of patients to the providers. The major goal of HMOs is to provide quality health care while reducing health care costs and administrative complications (Stark …show more content…

The first is the staff model. In this type of HMO, physicians are directly employed by the organization on a salary basis (2013). Since medical care is not reimbursed in a fee-for-service basis, physicians have very little personal financial incentives to over utilize medical service (2013). Then there is a group model. This type of HMO provides physicians services by contracting with group practice. Normally the group is compensated on a capitation basis. As a result, physicians in the group face a strong disincentive to over utilize medical services (2013). Next is the Network model. The only difference in between the group model and the network model is that in the network model, the HMO contracts with more than one group practice for physician services (2013). Also, similar to the group model, compensation is generally on a capitation basis. Finally, there is the Individual Practice Association (IPA) model. This form of HMO contracts with a number of independent physicians from various types of practice settings for medical services. In this situation, physicians generally provide care in a traditional office setting and are normally compensated in a fee-for-service basis, but at a discounted rate. In return, the HMO promises a large and continuous volume of patients …show more content…

The designation of POS refers to the fact that the amount of co-payment an insured pay is dependent upon the “point of service.” If an insured member goes outside of the plan network to receive care, the co-payment is higher, as network providers have agreed to accept a discounted rate for services in return for patient volume and patient

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In this case, members pay a monthly premium for their compensation to Health Maintenance Organization. Health Maintenance Organization is associated with rules where a member is required to see the doctor in a specific geographical region within a specific network. A member should pay for the medical cover for them to receive the medical services provided by Health Maintenance Organization. In America indemnity and traditional coverage is known as health insurance. An insurance company gives comprehensive coverage to the insured in exchange of a monthly premium.

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Links to specific plan websites allow patients to view all options for coverage from verified Medicare HMO providers.

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The front office staff that registers the patient begins this process. During registration the patient provides their demographic and insurance policy information. The insurance carrier and type of policy that the patient has, will determine what the cost per services will be based on the terms of the contract

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In an HMO, a patient pays a monthly premium and only has access to doctors, hospitals, and other healthcare providers that are within the HMO network. To participate in an HMO, the individual must pay a monthly premium,

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Some variability differs with the capability of providing out-of-network health providers and the services in which can be provided. By having a broad range of choices that can be provided, will cause a higher the cost for the individual that is paying. Most Medicare patients have received the managed care plans due to promises of a lower copayment amount and often medication benefits. Medicare post-acute spending has grown rapidly with the number of users between 1999 and 2007. The growth in Medicare short-term post-acute service use, in part, reflects short hospital stays and a growing demand for rehabilitation services.

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Health maintenance organizations have been in existence since the late 1800s. The government began to encourage the development of HMOs in the 1950s. The Health Maintenance Organization Act was enacted in 1973 and in 1978 a Congressional amendment increased federal aid for HMO development. In the 1990s 95% of private insurance companies used some form of managed care and was incorporated into Medicare and Medicaid plans. The primary intent of managed care is to reduce health care costs.

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A patient is going to have a different idea of how a health care should be managed. This in contrast to the way a physician may think the administration should be managed. Furthermore, each different stakeholder involved would have their own ideal reasons to why the health care administration

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The Managed Care Organizations it continues the expansion of the products. The MCO business models it changes the services in mixing and volume of the patients and the representation on the multi-year contracts. It provides profiling to the current

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A study by McKinsey in 2014 goes much further by defining a narrow network as one that includes 31% - 70% of all hospitals in a participating area and an ultra-narrow network is defined as having less than 30% of all hospitals in a particular area (McKinsey & Company, 2014). While the McKinsey & Company’s study evaluates hospital coverage, a study by Polsky & Weiner assesses physician participation in narrow network plans. Polsky and Weiner find that the majority, i.e. 41% of networks are small or extra small which by their definition means that they include less than 10% of office-based physicians in the area (Polsky & Weiner, 2015). Consumers are incentivized to seek care inside the limited network by the application of a generous in-network benefits in

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