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Characteristics of various popular managed care models

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Outline the characteristics of various popular managed care models (i.e., HMO staff model, HMO group model, IPA, PPO, EPO, etc.) and compare with traditional indemnity insurance plans. Identify all the differences you can think of.

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This solution outlines characteristics of various popular managed care models and compares with traditional indemnity insurance plans. APA formatted references included.

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Managed care plans:

Although there are important differences between the different types of managed care plans there are similarities. All managed care plans involve an arrangement between the insurer and a selected network of healthcare providers. All HMOs offer policyholders significant financial incentives to use providers within the network. Typically, there are specific standards for selecting providers and steps outlined to ensure quality care is delivered.

Health maintenance organizations (HMOs) proved medical treatment to members on a prepaid basis with members paying a set amount monthly. This fee is fixed, regardless of the amount of service the patient receives each month. In return, the HMO provides medical services, from routine physician visits to hospital care. Typically, HMO members receive medical treatment from physicians and facilities within the HMO network. HMOs have low out of pocket costs, there is no lifetime maximum payout, and there is an emphasis on wellness and preventative care. This encourages patients to seek care early before health problems become severe.
A disadvantage of HMOs is tight controls, which can make it more difficult to get specialized care. Also, care from non-HMO providers is generally not covered.

Closed panel HMO: managed care plan that involves exclusive contracts with physicians, and does not allow physicians to see patients from another managed care organization. An example of this model is the staff and group model HMOs.

Staff model: physicians in this HMO are salaried employees of HMO. All medical services are delivered in HMO owned medical facilities and are typically open to the HMO members only. The HMO, health plan, ...

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Sally Baldwin, Ed.D
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  • MSS, United States Sports Academy
  • Ed.D, Boise State University
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