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Health Insurance & Managed Care
There are four main types of managed care plans. First, it helps to have a basic understanding of what managed health care is. Managed care "combines healthcare delivery with the financing of services provided" (Green & Rowell, Chapter 3). In a typical managed health care system, the payer restricts the patient with respect to what facilities and doctors the patient can use. The facilities reduce their fees in exchange for the promise of substantially more business from the managed health care organization. Managed health care takes six distinct forms, according to Green and Rowell (2013, Chapter 3).
The first of these is the exclusive provider organization (EPO), which "provides benefits to subscribers who are required to receive services from network providers." In this model, the patient coordinates care within this network, with the primary care physician. Under this plan, the EPO coordinates the network of providers, and the patients work within that network (Green & Rowell, Chapter 3).
The second type of managed care plan is the Integrated Delivery System (IDS), which is an organization of health care providers that join together to offer services to subscribers. An IDS is similar to an EPO except that the providers...
There are several types of IDS, depending on who organizes them.
The third type of managed care plan is the health maintenance organization (HMO). An HMO provides comprehensive health services to enrolled members on a prepaid basis (Green & Rowell, Chapter 3). The HMO pays a monthly capitation and tries to keep health care costs below that level. The subscriber still manages his/her own care with a primary care provider in this model, again within the network. HMOs typically provide preventative services as a means of controlling costs, require copayments. So for any given service, there will be a provider fee, a copayment and the insurance payment from the HMO (Green & Rowell, Chapter 3). There are several different sub-models of HMO, including both closed- and open-panel models.
The point of service plan (POS) "some HMOs and preferred provider organizations have implemented the POS, under which patients have the freedom to use the managed care panel of providers or to self-refer to out-of-network providers. If the primary care provider agrees, the patient can go out-of-network and only pay the usual copay (Green & Howell, Chapter…
References
Green, M. & Rowell, J. (2013) Understanding Health Insurance: A Guide to Billing and Reimbursement, 11th Edition. Delmar Cengage Learning.
Cox, T. (2010). Legal and ethical implications of health care provider insurance risk assumption. JONAS Healthcare Law, Ethics and Regulation. 12(4):106-116. How healthcare providers really feel about managed care and other forms of insurance is very important. If doctors and hospitals do not feel good about the payments they receive from specific managed care organizations, they may choose not to work with those organizations. That can leave a large number of
.. maybe finally it has come the time to be put into practice and not only be debated in Talk Shows and News Papers One thing remains certain... The larger the number of citizens covered by the health care plan, better for the nation itself, for its tax payers and for the health of its present and future generations. Annex 1 Source: http://www.factcheck.org/elections-2008/theyve_got_you_covered.html, retrievedonline April 17, 2008. Bibliography World Health Organization: Core Health Indicators, retrieved online
Heath Care Health Care Plans Health Care Types of Health Insurance Indemnity Insurance This type of insurance is also known as a traditional or fee-for-service plan. The benefit of an indemnity plan is the flexibility; this plan allows members to choose any doctor or hospital. However, members must pay an annual deductible and then a percentage of each medical bill. Although these plans offer the greatest freedom to select any doctor, they are usually the
Healthcare in the United States: Where We Have Been, Where We Are Going The current healthcare crisis in America is not one that happened over night. It is one that has been building for more than a quarter century. There was a time in America when healthcare was a stellar institution: research, cures, technological advances, and treatments. The focus of healthcare was maintaining and improving the quality of life. Then, during
(Menzel, 1990, p. 3) Fisher, Berwick, & Davis alude to the idea of integration in health care, with providers linking as well as creating networks of electronic medical records and other cost improvement tactics. The United States and other nations over the last twenty or so years, have begun a sweeping change in health care delivery, regarding the manner in which health information is input, stored and accessed. Computer use
A recent article touted the 6.1% growth of spending on medical care in 2007. The same article cautioned however that, "most experts know that no matter what the numbers say, there is still a great deal of work ahead to reform a healthcare system that is still fundamentally broken -- and is facing one of the worst economic recessions in decades" (Lubell, 2009, pg. 6). Government and industry officials have been