Mandatory second surgical opinion (44 percent). No single source of information on HMO model type exists that is universally recognized as accurately depicting the current HMO organizational structure. A Synthesis of research findings on the operations and performance of health maintenance organizations. HMOs increased in popularity following the passage of the HMO Act in 1973, which sought to increase the usage of HMOs to improve patient care, decrease health care costs, and put a greater emphasis on preventative health care. they increase administrative complexity if an employer offers more than one type of medical expense coverage. Exam 1 Flashcards | Quizlet Prior authorization for inpatient care (88 percent). When using these physicians, the HMO enrollee is subject to traditional insurance arrangements, including possibly a deductible and coinsurance of some fixed percentage. 133-137 This protection may involve two different . If youre someone who visits the doctor frequently, you may find that an HMO doesnt offer enough coverage for your needs. 71 percent were nonprofit compared with 48 percent of all HMOs. 16. Federal government websites often end in .gov or .mil. The relationship between chain affiliation and HMO financial and operational performance has not been examined in detail. Even though it is seldom possible to obtain information on detailed financial incentives or specific utilization controls in place in every HMO, the HMO model type often is a reasonable proxy for these arrangements. If the HMO owns the facilities in which the medical group practices and/or a hospital, it is likely that the HMO will have greater control over the medical practice styles of its providers. The organizational characteristics that were associated with a particularly low ratio of HMO hospital-use-to-market-area-hospital-use were: Group Model HMOs were found to have the lowest hospital use ratios, IPA Model HMOs had the second lowest ratios, and Staff Model HMOs had the highest utilization relative to area rates. In 1980, 236 HMOs served 9 million members. Physician characteristics and training emphasis considered desirable by leaders of HMOs. Which of the following statements about vision-care benefits is correct? Which concerning utilization management by managed care plans is correct? In addition, PPOs recruit and offer a network of preferred providers who are selected on the basis of practice style and willingness to follow the utilization management and review requirements of PPOs. Effect of surveillance on the number of hysterectomies in the province of Saskatchewan. they often have pre-certification requirements for many types of hospitalizations, outpatient procedures, and medical supplies. Gruber, Shadle, and Glaser (1989) report that 7.5 percent of all HMOs offered an open-ended option as of June 30, 1988. Copays and deductibles are cost-sharing strategies where patients are potentially responsible for paying a portion of the cost of seeing a provider. 19. A health maintenance organization (HMO) is a type of plan that requires members to get care within the plans network of providers. It is evident from this brief examination of research on utilization management, financial incentives, and HMO performance that much additional analysis, requiring data on a larger number of HMOs and on the characteristics of HMO enrollees, will be needed if the impact of utilization management techniques and financial incentives on utilization patterns and on HMO performance are to be determined. [2]The motivation for the emergence of HMOs was a desire to align financial and care-quality incentives. HMOs aredesigned to accomplish these goals by integrating health insurance and health care delivery within the same organization and thus aligning the incentives of the health care payer and provider. It is seldom required by large employers who can do their own analysis of managed care plan. HMOs cover a wide variety of medical services, including doctor visits, urgent care, hospitalization, lab tests, imaging, and prescriptions, says Decker. How do financial incentives affect physicians' clinical decisions and the financial performance of health maintenance organizations? Correct Response. The Medicare risk HMOs were less likely to report using primary care gatekeepers (81 percent versus 93 percent of GHAA respondents) and retrospective inpatient review (56 percent versus 89 percent of GHAA respondents) and were more likely to report using physician practice profiles as a management tool (59 percent versus 44 percent of GHAA respondents). Group Health Association of America (1989) reports that in 1988 37 percent of those HMOs in existence for more than 3 years were Mixed Model HMOs. These providers are commonly solo practitioners and will see patients both inside and outside of the HMO. Cerne F, Traska MR. However, it is unclear whether the association with profitability is caused by chain affiliation or by other correlated organizational characteristics. HMOs feature a variety of payment processes and structures but generally collect payment from their enrolled patients through methods such as premiums, copays, and deductibles. This is of particular concern as the Health Care Financing Administration considers the further expansion of managed care options available to Medicare and Medicaid beneficiaries. Each of the organizations that monitors HMOs on a continuing basis uses a slightly different definition of HMO model for classifying reported HMOs. By 1989, there were 591 HMOs with over 34 million enrollees. Correct Response: 17 percent employed physicians on salary. The average employer-sponsored HMO plan costs $1,212 per year or $101 per month, based on Kaiser Family Foundation (KFF) data. Commonly recognized types of HMOs include all but: a. IPAs b. Direct-contract plans c. PHOs d. Staff and group c. PHO s 12. Here are some of the biggest HMO advantages and disadvantages: PPO plans, which stands for preferred provider organization, are the most common employer-sponsored health plan. Which of the following is NOT a reason why an employee might elect medical expense coverage under a managed care plan? Structure and performance of health maintenance organizations: A review Organizational and operational characteristics of TEFRA HMOs/CMPsdraft report. Barr JK, et al. C. Managed care plans offer an unrestricted use of medical care providers. Most of this change has come about because new HMOs are distributed differently by organizational characteristics than are older HMOs. All of these reasons combined have led the profit status of the industry to change so that a majority of HMOs are now for-profit entities. ( TEFRA risk contracting HMOs were reported by Brown et al. The rapid growth in the number of HMOs occurred primarily through the development of new IPAs and HMOs that contracted with medical groups that serve both fee-for-service and prepaid patients. Chain-affiliated HMOs were more likely than were independent HMOs to use each of the utilization control methods. Employer Group Benefits Plans are a form of Entitlement Benefits Programs. Choi Y. Larkin (1989) recognizes that despite the decline in HMO profitability in the late 1980s, conversions of nonprofit HMOs to for-profit status have continued. A federal government website managed and paid for by the U.S. Centers for Medicare & Medicaid Services. I participating providers are paid on a fee for service basis as their services are used II. Advantages of an IPA include: [TRUE/FALSE] An IDS may NOT operate primarily as a vehicle for negotiating termswith private payers. First annual report: National evaluation of Medicare competition demonstrations. Physicians are offered financial incentives that are intended to increase their awareness of the impact of their practice patterns on costs of care. The rapid expansion of HMOs and PPOs in the health care market has resulted in the enrollment of a much larger number of persons into managed care organizations that are very different from the set of HMOs that were available in the 1960s and 1970s. If you were to apply their views to, 1.) Inclusion in an NLM database does not imply endorsement of, or agreement with, In this article, the author reviews evidence on the relationship between HMO organizational arrangements and performance, and the trends within the HMO industry toward new organizational structures. HHS Vulnerability Disclosure, Help Even though some limited evidence exists that managed care, particularly HMOs, may have an impact on utilization of services and the overall level of costs, most of this evidence is based on data from older, well-established HMOs that were operating in the 1970s and earlier. CIOs are the commercial counterpart of ACOs, as ACOs were designed, strictly speaking, to contract with Medicare only. The defining feature of a direct contract model is the HMO contracting directly with a hospital to provide acute services to its members. the contents by NLM or the National Institutes of Health. The main difference between an HMO and PPO is the network of doctors that a member has access to under their insurance. As mentioned above, human milk oligosaccharides are resistant to enzymatic hydrolysis by brush border intestinal lactase 121,122 and therefore the major part enters the colon, probably in an intact state. The principal reasons for choosing nonprofit arrangements had declined, and competitive pressures to seek for-profit status had increased substantially during the 1980s. 15 percent were mixed in their payment methods, owing to mergers of different types of HMO physician structures. Houck and Mueller (1988) suggest that the historical prevalence of nonprofit HMOs was attributable to legal prohibitions against the corporate practice of medicine and the availability of Federal grants and loans only to nonprofit HMOs. An HMO plan with a network model is the most flexible in terms of provider options. When the type of utilization review mechanisms is examined by the characteristics of HMOs, there appears to be an interaction of organizational type and utilization controls. The main reason why someone would choose a PPO plan over an HMO plan is to assess a larger network of doctors and hospitals. Health insurance plan & network types: HMOs, PPOs, and more a. For family coverage, the rate is $5,289 per year or $440 per month.

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