Models of Managed Health Care-HMOs are organized healthcare systems that are

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.

Explanation & Answer

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