In the United States, the healthcare organization ( HMO ) is a medical insurance group that provides healthcare at a fixed annual cost. It is an organization that provides or arranges managed care for health insurance, self-funded health care plans, individuals, and other entities, acts as a liaison with health care providers (hospitals, doctors, etc.). The Healthcare Organization Act of 1973 requires companies with 25 or more employees to offer federally certified HMO options if the company offers traditional health care options. Unlike traditional compensation insurance, HMOs include treatments provided by doctors and other professionals who have been approved by the contract to treat patients according to the HMO guidelines and restrictions in exchange for the flow of customers. HMOs include emergency care regardless of contracting status of health care providers.
Video Health maintenance organization
Operasi
HMOs often ask members to choose primary care physicians (PCP), doctors who act as "goalkeepers" for direct access to medical services but this is not always the case. PCP is usually an internist, pediatrician, family doctor, geriatrician, or general practitioner (GP). Except in a medical emergency, patients need referrals from PCP to see a specialist or other physician, and the gatekeeper can not authorize the referral unless the HMO guidelines consider it necessary. Some HMOs pay PCP goalkeepers charge a fee for any prescribed medical procedure that they provide for an insured (cost-for-service) patient and then an unexpected specialist (ie, paying a set of fees for each insured treatment, regardless of medical procedure which the specialist does to achieve the treatment), while others use inverted settings.
"Open access" and "POS" (service point) products are a combination of HMOs and traditional compensation plans. Members do not need to use a gatekeeper or get a referral before seeing a specialist. In this case, traditional benefits apply. If a member uses a gatekeeper, the benefits of HMO are applied. However, the distribution of beneficiary costs (eg, co-payments or coinsurance) may be higher for specialist care. HMO also manages treatment through utilization review. That means they monitor doctors to see if they are doing more services for their patients than other doctors, or fewer. HMOs often provide preventive care for lower or free copayments, to keep members from developing a preventable condition that will require a lot of medical services. When HMOs arise, the compensation plans often do not include prevention services, such as immunizations, infant examinations, mammograms, or physical. This is an inclusion of services intended to maintain the health of members who give HMO its name. Some services, such as outpatient mental health care, are limited, and more expensive forms of care, diagnosis or treatment may not be covered. Experimental treatments and elective services that are not medically required (such as elective plastic surgery) are almost never closed.
Another option for managing care is case management, in which patients with identified catastrophic cases, or disease management, in which patients with certain chronic diseases such as diabetes, asthma, or some form of cancer are identified. In both cases, HMOs take greater levels of involvement in patient care, assigning a case manager to a patient or group of patients to ensure that no two providers provide overlapping care, and to ensure that patients receive appropriate care, in order not worse than what could be helped.
Maps Health maintenance organization
Cost containment
Although businesses pursue the HMO model for alleged detention costs, several studies show that private HMO plans do not achieve significant cost savings over non-HMO plans. Although the out-of-pocket costs are reduced for the consumer, controlling for other factors, the plan does not affect the total expenses and payments by the insurance company. A possible reason for this failure is that consumers can increase utilization in response to lower cost sharing under HMO. Some people claim that HMOs (especially those pursuing profits) actually increase administrative costs and tend to choose healthier patients.
History
Although some form of "managed care" groups existed before the 1970s, in the United States they have emerged primarily through the influence of US President Richard Nixon and his friend Edgar Kaiser. In a discussion at the White House on 17 February 1971, Nixon expressed his support for the important philosophy of HMO, which John Ehrlichman described as follows: "All incentives lead to less medical care, because the less care is given to them, the more money they produce. "Kaiser Permanente debates the" second hand interpretation, inarticulation "of Ehrlichman, and presents a record of the summaries received by Ehrlichman and the White House.
The earliest forms of HMOs can be found on some pre-paid healthcare packages . In 1910, the Western Clinic in Tacoma, Washington offered timber mill owners and their employees certain medical services from its providers at a premium of $ 0.50 per member per month. This is considered by some to be the first example of HMO. However, Ross-Loos Medical Group, founded in 1929, is considered the first HMO in the United States; its headquarters are based in Los Angeles and initially provide services to Los Angeles County Waterworks and Electricity (DWP) employees and Los Angeles County.200 DWP registered employees at a cost of $ 1.5 per month. Within a year, the Los Angeles Fire Department registered, then the Los Angeles Police Department, then Southern California Telephone Company (now AT & T Inc), and more. In 1951, registration reached 35,000 and included teachers, districts and city employees. In 1982 through the incorporation of the North American Insurance Company (INA) established in 1792 and Connecticut General (CG) established in 1865 joined CIGNA. Also in 1929 Dr. Michael Shadid made a health plan in Elk City, Oklahoma where the farmers bought a $ 50 stake to raise money to build the hospital. The medical community disliked this arrangement and threatened to suspend the Shadid license. The Farmers Union took over the hospital and health plan in 1934. Also in 1929, Baylor Hospital provided about 1,500 teachers with prepaid care. This is the origin of Blue Cross. Around the year 1939, the state medical association made Blue Shield plan to close doctor services, as Blue Cross only covers hospital services. This prepaid plan grew during the Great Depression as a method for providers to ensure steady and stable income.
In 1970, the number of HMOs declined to less than 40. Paul M. Ellwood, Jr., often called the "father" of the HMO, began discussing with what is now the US Department of Health and Human Services leading to the enactment of the Health Care Organization Act in 1973. This law has three main provisions:
- Grants and loans are provided to plan, start or expand HMO
- Some restrictions imposed by the state on HMO are removed if HMO is federally certified
- Employers with 25 or more employees are required to offer a federally certified HMO option with compensation at the request
This last provision, called multiple choice provisions, is of the utmost importance, as it gives HMO access to critical business-based markets that have often been blocked in the past. The federal government was slow to issue regulations and endorsed plans until 1977, when the HMO began to grow rapidly. The multiple-choice provisions expire in 1995.
In 1971, Gordon K. MacLeod MD was developed and became the first director of the federal Health Maintenance Organization (HMO) program in the United States. He was recruited by Elliot Richardson, secretary of the US Department of Health, Education, and Welfare.
Type
HMO operates in various forms. Most HMOs today do not fit into one form; they can have multiple divisions, each operating under a different model, or combining two or more shared models. In the staff model , GPs are paid and have offices in the HMO building. In this case, the doctor is a direct employee of the HMO. This model is an example of a closed panel HMO, which means that the contracted physician can only see HMO patients. Previously this type of HMO is already common, although currently almost inactive. In the group model , HMOs do not hire physicians directly, but contract with the practice of a multi-specialty physician group. Individual doctors are employed by group practice, not by HMO. Group practices can be established by HMOs and serve only HMO (captive group model) members. Kaiser Permanente is an example of the HMO captive group model rather than the HMO staff model, as is commonly believed. HMOs can also contract with existing independent group practices ("independent group models"), which will generally continue to treat non-HMO patients. The HMO model group is also considered a closed panel, as doctors should be part of group practice to participate in HMO - closed HMO panels for other physicians in the community.
If not yet part of the group medical practice , doctors may contract with an independent practice association (IPA), which in turn contracts with HMO. This model is an example of an open panel HMO, where a doctor can maintain his own office and be able to view non-HMO members.
In the network model , HMO will contract with a combination of groups, IPA (Independent Practice Association), and individual doctors. Since 1990, most HMOs are run by managed care organizations with other business lines (such as PPO, POS, and compensation) using a network model.
Rule
HMOs in the US are set at the state and federal levels. They are licensed by the state, under a license known as an authority certificate (COA) rather than under an insurance license. State and federal regulators also issue mandates, requirements for health maintenance organizations to provide specific products. In 1972, the National Association of Insurance Commissioners adopted the HMO Model Act, which is intended to provide a model of regulatory structure for states to use in authorizing the establishment of HMOs and in monitoring their operations.
Legal responsibility
HMOs often have a negative public image due to their limited appearance. HMO has been the target lawsuit claiming that restrictions on HMOs prevent the necessary care. Whether an HMO can be responsible for physician negligence depends partly on the HMO screening process. If the HMO only contracts with the provider meeting certain quality criteria and advertises this to its members, the court may be more likely to find that the HMO is responsible, just as the hospital may be responsible for negligence in choosing a doctor. However, HMOs are often isolated from malpractice lawsuits. The Employees Pensione Revenue Act (ERISA) can be held to precede claims of negligence as well. In this case, the deciding factor is whether the damage is caused by the administration of the plan or the actions of the provider. ERISA does not precede or protect HMOs from breach of contract or state law claim as confirmed by a third party independent medical service provider143.
See also
- Category: Health-care organizations
- Exclusive provider network
- Substitute replacement
- Managed care
- Preferred provider organization
- Publicly funded health care
- Sicko , the Michael Moore documentary that criticized the HMO
- Single payer health care
References
External links
- Health Maintenance Organization in Nigeria: Marketing Place
- High costs for nonprofit care - an article that includes references to excesses from HMO Chief Executive Officer pay in the US.
- Doctor Salary in the US - A Photo
Source of the article : Wikipedia
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