Models of Managed Health Care
What are pros and cons for each model?
What are some suggestions to strengthen the weaknesses of the each model?
1. Health Maintenance Organizations
HMOs are organized healthcare systems that are responsible for both the financing and the delivery of a broad range of comprehensive health services to an enrolled population. HMOs act both as insurer and provider of healthcare services. They charge employers a fixed premium for each subscriber. An independent practice association (IPA)-model HMO provides medical care to its subscribers through contracts it establishes with independent physicians. In a staff-model HMO, the physicians would normally be full-time employees of the HMO. Individuals who subscribe to an HMO are often limited to the panel of physicians who have contracted with the HMO to provide services to its subscribers
2...Preferred Provider Organizations
Preferred provider organizations (PPOs) are entities through which employer health benefit plans and health insurance carriers contract to purchase healthcare services for covered beneficiaries from a selected group of participating providers. Most states have specific PPO laws that directly regulate such entities. Common characteristics of PPOs include:
â?¢ Select provider panel
â?¢ Negotiated payment rates
â?¢ Rapid payment terms
â?¢ Utilization management (programs to control the utilization and cost)
â?¢ Consumer choice (allows covered beneficiaries to use non-PPO providers for an additional out-of-pocket charge [point-of-service option])
In PPOs, a payer, such as an insurance company, provides incentives to its enrollees to obtain medical care from a panel of providers with whom the payer has contracted a discounted rate.
3..... Management Service Organizations
A management service organization (MSO) is an entity that provides administrative and management services to physicians. The organization performs services, such as practice management, marketing, managed care contracting, accounting, billing, and personnel management. The MSO can be hospital affiliated, a hospital-physician joint venture, physician owned, or investor owned.
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One of the pros to the HMO healthcare system, includes the fact that this system provides a mechanism by which healthcare services are financed for individuals that enroll within the system, and the financing of the healthcare for these individuals makes it much more convenient and less costly for individuals enrolled in these programs to receive a high level of care from a variety of different physicians, who specialize in a variety of different areas of medicine, which will be highly effective in treating a variety of different healthcare conditions within the enrolled population. In addition, the premiums for this high level of healthcare are much less than would be the cost incurred by these individuals if they independently sought out private healthcare services. A major con to this healthcare ...