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Health Care cont...
HMOs * PPOs * POSs * EPOs

Page 1 - Page 2

Four Basic HMO Model Types

The Staff Model HMO: Staff Model HMOs employ health care providers directly. The providers are employees of the HMO, and deal exclusively with HMO members. This is an organization like Kaiser Permanente. It is referred to as a Staff Model, because all of the physicians and facilities are owned by the HMO. They are not independent.

The Individual Practice Association HMO: With these IPA models, an HMO contracts with providers and facilities at specific rates to provide medical care to its members. Independent Practice Association (IPA) model HMOs contract with physicians in solo practice, or with associations of physicians which in turn contract with their member physicians, to provide health care services to members. Most physicians in IPA model HMOs are in solo practice, and in many cases have a significant number of patients who are not HMO members.   Some HMOs combine two or more of the four basic model types, that is, some of their members are in options or components that function as one model type (for example, a group model) and others are in plans that function as another model type (for example, a network model), although all belong to the same HMO. Many publications and reports call those "mixed model" HMOs. This is the more popular form of HMO, and includes most of the HMO's that are sold throughout the country. Their costs are lower than typical insured plans, because they negotiate their contracts on a capitated basis. Capitation means that the provider is paid a certain amount of dollars per member in the HMO. This payment is made to the provider whether they see the members or not. Obviously, there is some risk for the provider, because if they see every member that is enrolled, they will not have enough money to pay their expenses. However, on the other hand, if they limit the care, and see only a percentage of the members, then they can make a profit on a capitated contract. The upside to an HMO plan is, it is usually competitively priced, and offers a great deal of benefits to employees with very little out of pocket expense. The downside to an HMO is, it requires the employee to go through many cost containment procedures before getting care. The most prominent of which is what is referred to as the "gate keeper" provision. Here is how it works, a Primary Care Physician is assigned to each member and that physician has to control all care for that member. In order to get care, an employee must first get permission from that gate keeper. The other downside to HMO's is, they are built upon a financial model, that provides a dis-incentive for care and some individuals are not receiving proper testing, or the highest level of quality care available. Before you make a decision to enter into an HMO, these are things you should know.

The Group Model HMO contracts with one or more group practices to provide health care services, and each group primarily treats the HMO's members.

The Network Model HMO contracts with one or more group practices to provide health care services, and some or all of the groups provide care to a substantial number of patients who are not the HMO's members.

A Medicare Health Care Prepayment Plan (HCPP) is much like a cost contractor in the way it provides care, in that beneficiaries may receive care outside the provider panel. HCPPs do not, however, have to provide all Medicare benefits, and do not have to follow the same requirements that cost and risk contractors do. HCPPs can screen for health risks, and are only governed by Medicare's Part B payment rules; they can provide Part A services under contract with the individual, but that contract is not governed by Medicare rules (HCFA, 1995). Medicare cost contracts are available to federally qualified HMOs, or to Competitive Medical Plans (CMPs, which operate much like HMOs) to provide both Part A and Part B Medicare services to beneficiaries. The health plan receives a prepaid monthly sum per beneficiary from the Health Care Financing Administration (HCFA) plus the part B premiums. At the end of the year the contract is audited to determine the final payment to the plan, which is adjusted for actual costs. Beneficiaries in cost contracts may seek care from providers not on the plan's panel and simply pay as they would in fee-for-service Medicare.

Medicare risk contracts are available to federally qualified HMOs, or to Competitive Medical Plans (CMPs, which operate much like HMOs) to provide both Part A and Part B Medicare services to beneficiaries. The health plan receives a prepaid monthly sum per beneficiary from the Health Care Financing Administration (HCFA) plus the Medicare Part B premiums. This sum, or capitation payment, must cover all of the Medicare risk member's health needs. If the costs of the care exceed their capitation payments, the health plan takes a loss; hence the term "risk." The risk contractor may agree to provide more than the usual Part A and Part B services for the prepaid sum, such as greater prescription drug coverage, more preventive care, greater eye and dental coverage, etc. Some risk contractors charge added premiums beyond the standard Medicare Part B premium, just as a supplementary policy might. As of September 1995, however, according to HCFA data, approximately half (49.7 percent) of risk contractors added nothing to the standard Part B premium.

Medicare SELECT is a Federally approved Medigap (supplemental or Part B) policy with a managed health care component that offers seniors lower-cost coverage in exchange for the use of preferred providers. The Medicare SELECT program was initially a pilot program available in only fifteen states. On July 7, 1995, the program was extended until June 30, 1998, and expanded to all states.

Medicare supplementary (or Medigap) insurance supplements Medicare benefits. By HCFA regulations, to qualify as Medigap insurance, a policy can only pay (within specified limits) for services not covered at all, or not fully covered, by Medicare (HCFA, 1994). The Federal Government has approved only 10 standard Medigap plan designs.

Peer review organizations (PROs) "are groups of practicing doctors and other health care professionals paid by the federal government to monitor the care given to Medicare patients. Each state has a PRO that has the authority to decide whether care given to Medicare patients is reasonable, necessary, provided in the most appropriate setting, and meets standards of quality generally accepted by the medical profession" (HCFA, 1995). The Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA) established the PRO program, and these organizationsfunction much like UROs, including the goal of containing unnecessary costs. PROs also investigate beneficiary complaints.

Point-of-service (POS) options or products may be offered by managed care organizations or indemnity insurers. They combine HMO features and out-of-network coverage, with economic incentives (for example, a fixed copayment instead of a 20 or 30 percent coinsurance rate) for using network providers. When an HMO offers a POS option, its availability is arranged between the HMO and the purchaser. Out-of-network usage under such options generally has a per-person cap, and that usage is insured as fee-for-service coverage.

A preferred provider organization (PPO) is a health care benefit arrangement designed to supply services at an affordable cost by providing incentives to use designated health care providers (who contract with the PPO at a discount), while also providing coverage for services rendered by health care providers who are not part of the PPO network. Financial incentives for individuals to use preferred providers include lower copayments or coinsurance and maximum limits on out-of-pocket costs for in-network use. The typical PPO differs from the typical HMO in that visits to specialists usually do not require authorization by a primary care provider. Also, unlike most HMOs, out-of-network usage is allowed by PPOs, though at a higher cost to the patient. Most PPOs involve an arrangement between a panel of providers (physicians, hospitals and other health care professionals) and the purchasers of care, e.g., employers or insurance companies. The panel of preferred providers agrees to a specified fee schedule in return for preferred status, and is required to comply with certain utilization review (UR) guidelines. Moreover, PPOs are not insurers; they generally do not assume any financial risk for arranging medical services. In many cases, the risk is assumed by self-insured employers, or by another underwriter. Some PPOs are sponsored by providers, employers, or other entities, and many insurance companies also own PPOs. Some of the largest insurers have developed their own PPO networks, while others lease networks from fellow insurers or form cooperative ventures with independent PPOs.

Specialty HMOs provide their members with one or more limited health care benefits or services--e.g., pharmacy, vision, dental, or mental health services--and are based upon any of the four HMO model types.

Specialty PPOs are designed similarly to regular health coverage PPOs, but provide only one or more limited benefits, e.g., pharmacy, vision, dental, mental health, or Workers' Compensation.

Utilization review organizations (UROs) are external reviewers who assess the medical appropriateness of a suggested course of treatment for a particular patient, thereby providing the patient and payer increased assurance of the appropriateness, value, and quality of health care services being provided. The most common form of UR, preadmission certification, is requested by the patient's physician for approval of any non-emergency admission to an inpatient facility. Other techniques include concurrent review, second surgical opinion, discharge planning, outpatient certification, case management, etc. URO services are purchased by employers, insurers, HMOs, PPOs, IPAs, or other entities responsible for all or most of the cost of the care. Utilization review and utilization management comprise a set of procedures used by purchasers of health benefits to contain health care costs through assessment of the appropriateness of care, usually before the care is provided. Utilization review or management may be performed in-house by the managed care entity (HMO, PPO, etc.), or by an external reviewer

Helpful Information Links

The American Accreditation HealthCare Commission/URAC

Health Care Financing Administration (HCFA), HCFA operates regional Medicare and Medicaid offices throughout the country–check with directory assistance for the telephone number of your regional office

Joint Commission on Accreditation of Health Care Organizations (JCAHO) (630) 792-5600

National Committee for Quality Assurance (NCQA)
(202) 955-3200



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