health maintenance organizations (hmo’s) sandy h. yoo may 5, 2006
TRANSCRIPT
Health Maintenance Organizations
(HMO’s)Sandy H. YooMay 5, 2006
The Rise of Managed Care Organizations
(MCO)• The cost of healthcare has
skyrocketed in the last few decades • The components of healthcare have
become increasingly complex• Hence, the rise of MCOs to control
costs and coordinate healthcare delivery
MCOs • Health care systems that
coordinate the financing and delivery of health care services to covered individuals
• The goal is to control cost without sacrificing quality
• In 2004, over 177 million Americans were enrolled in a MCO
Healthcare Choices
•Individual Health Insurance
•Group Health Insurance**
Health Plan Choices• Government sponsored plans
– Medicare– Medicaid
• Indemnity (fee-for-service) • Managed Care Plans
Major Types of MCOs
•Health Maintenance Organizations (HMO)
•Preferred Provider Organizations (PPO)
•Point-of-Service (POS) Plans
Features of an HMO• HMO’s contract directly with
physicians, hospitals, and other healthcare providers
• “Network Providers” offer their services at a discounted rate
• In exchange, HMO’s offer referrals• HMOs emphasize preventative care
Capitation• HMO’s spread risk with network
providers• Physicians and hospitals receive a
fixed amount per member per month (PMPM)
• If the cost of care is more expensive than the fixed PMPM, then providers must absorb the losses
Utilization Review• Utilization is expressed as a number
of visits or services or a dollar amount per member per month (PMPM)
• Intended to identify providers providing an unusually high amount of services
• Cost-control and efficiency measure
HMO Members• Members pay a monthly premium,
but little to no copay (~$5-10)• Members select a primary care
physician (PCP)• Members can only see providers in
the HMO network• Members can only see a specialist if
authorized by their PCP
The Gatekeeper• PCPs are generally:
– family doctors, internal medicine docs, pediatricians and general practitioners
• PCPs are the gatekeepers that provide, coordinate, authorize all aspects of a member’s health-care
• Members generally must see PCP first
HMO Pros and ConsPROS• Comprehensive
range of health benefits for lowest out-of-pocket expenses
• Little to no copay
CONS• Most restrictive
health plan• Can only see in
provides in the network
• Can only see a specialist if referred by PCP
Rules & Regulations
• State-licensed MCOs are regulated under state law
• Self-funded (employer) health plans are covered under federal laws
• Currently, there is a lack of clarity, federal vs. state, as to who regulates MCOs and HMOs
State Laws• Each state has laws that require
state-licensed MCOs to offer or include coverage for certain benefits or services
• Health plans are covered under the rules and regulations of each state’s Department of Insurance (DOI)
Federal Laws• Employee Retirement Income
Security Act of 1974 (ERISA)• Health Insurance Portability and
Accountability Act of 1996 (HIPAA)• Consolidated Omnibus Budget
Reconciliation Act of 1985 (COBRA)• Mental Health Parity Act of 1996
(MPHA)
Federal Laws• Newborn’s and Mothers’ Health
Protection Act of 1996 (NMPHA)• Family and Medical Leave Act (FMLA)• Pregnancy Discrimination Act (PDA)• Age Discrimination in Employment Act
(ADEA)• Omnibus Budget Reconciliation Act of
1993 (OBRA ’93)• Women’s Health and Cancer Rights Act
(WHCRA)
ERISA• Written to ensure uniformity in the
administration of pension plans and retirement benefits
• ERISA does not require employers to provide health insurance
• However, ERISA regulates health plans already established
HMO vs. PPO• Similar to HMO, PPOs make contracts with
providers• Members do not have a PCP• Members do not have to use in-network
provider, but they receive financial incentives if they do
• Financial incentives are lower deductible and copays
• More flexible, but higher out-of-pocket expenses
HMO vs. POS
• Members can choose either HMO or PPO at the time of service
• PCPs are encouraged but not required• Members who use PCPs receive lower
copays and/or deductibles• Members can see out of network
providers • Ultimate flexibility, but higher
out-of-pocket expenses
References1. Rich RF, Erb CT, Gale LJ. Judicial Interpretation of
Managed Care Policy. The Elder Law Journal vol 13. 2005 Sept 13: 86-89.
2. Stern C. The Fundamentals of Healthcare Benefits – The Employer Perspective. 2005 Jan. [Pending publication]
3. American Heart Association, Managed Care Plans. Available at: http://www.americanheart.org/presenter.jhtml?identifier=4663
4. Wikipedia Encyclopedia. Search terms: Health Maintenance Organization, ERISA. Available at: http://en.wikipedia.org/wiki/Main_Page