Managed Care Essay Research Paper Chapter 3

Managed Care Essay, Research Paper

Chapter 3: Types of Managed Care Organization

. The distinction between health care providers and health care insurers have blurred substantially

. 10 Years ago managed care organizations were often referred to as alternative delivery systems

. Managed care is now the dominant form of health insurance coverage in the United States

. Managed care can mean managing the provider delivery system can be equivalent in its outcomes to managing the medical care delivered to the patient

. Managed care may not perfectly describe this current generation of financing vehicles, it provides a convenient shorthand description for the range of alternatives to traditional indemnity health insurance

. On one end of the continuum is managed indemnity with simple pre-certification of elective admission and large case management of catastrophic cases, superimposed on a traditional indemnity insurance plan

. Further along the continuum are PPOs, POSs, open-panel [individual practice association (IPA) type] HMOs, and closed-panel (group and staff model) HMOs

TYPES OF MANAGED CARE ORGANIZATIONS AND COMMON ACRONYMS

HMOs

. HMOs are organized health care systems that are responsible for both the financing are the delivery of a broad range of comprehensive health services to an enrolled population

. HMO health insurer and a health care delivery system

. HMOs are responsible for providing health care services to their covered members through affiliated providers, who are reimbursed under various methods

. HMOs must ensure that their members have access to covered health care services

. HMOs generally are responsible for ensuring the quality and appropriateness of the health services they provide to their members

. The five common models of HMOs are (1) staff, (2) group practice, (3) network, (4) IPA, and (5) direct contact

PPOs

. PPOs are entities through which employer health benefit plans and health insurance carriers contract to purchase health care services for covered beneficiaries from a selected group of participating providers

. PPOs often limit the size of their participating provider panels and provide incentives for their covered individuals to use participating providers instead of other providers

. In contrast to individuals with traditional HMO coverage individuals with PPO coverage are permitted to use non-PPO providers

. PPOs sometimes are described as preferred provider arrangements (PPAs)

. PPA is used to describe a less formal relationship than PPO

. The term PPO implies that an organization exists, whereas a PPA may achieve the same goals as a PPO through an informal arrangement among providers and payers

. Key common characteristics of a PPO include:

. Select provider panel

. Negotiated payment rates

. Rapid payment terms

. Utilization management

. Consumer choice

Exclusive Provider Organizations

. Exclusive provider organizations (EPOs) limit their beneficiaries to participating providers for any health care services

. The EPO generally does not cover services received from other providers, although their may be exceptions

. EPOs, like HMOs, require exclusive use of the EPO provider network and also use a gatekeeper approach to authorizing non-primary care services

. The difference between an HMO and an EPO is that the former is regulated by HMO laws and regulations, and the latter is regulated under insurance laws and regulations

. Employee Retirement Income Security Act of 1974

. EPOs usually are implemented by employers (b/c it.s cost efficient)

POS Plans

. Hybrids of HMO and PPO models

. Characteristics include:

. Primary care physician are reimbursed through capitation payments (i.e. Fixed payment per member per month)

. An amount is with held from physician compensation that is paid contingent upon achievement of utilization or cost targets

. The primary care physician acts as a gatekeeper for referral and institutional medical services

. The member retains some coverage for services rendered that either are not authorized by the primary care physician or are delivered by non-participating providers

Open Access or POS HMOs

. Provides some level of indemnity-type coverage along with the HMO coverage

. HMO members covered under these types of benefit plans may decide whether to use HMO benefits or indemnity-style benefits for each instance of care

. The member is allowed to make coverage choice at the point of service when medical care is needed

. Most POS plans experience between 65 percent and 85 percent in-network usage, thus retaining considerable cost control compared to indemnity-type plans

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

1) Via a single HMO license

a. HMO provides the out-of-network benefit using its HMO license

2) Via a duel-license approach

a. The health plan uses an HMP license to provide the in-network care and an indemnity license to provide the out-of-network coverage

b. More flexible

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