Health Maintenance Organzations

Running head : HEALTH MAINTENANCE ORGANIZATIONS

HMO

Student Name

Place

August 17 , 2006

Abstract

The article starts off with a brief history of HMO 's and proceeds describe various models . Further management of HMO 's is discussed followed by various benefits a member gets from HMO 's and SHMO 's also described

Health Maintenance Organizations

According to Answers .com the term Health Maintenance Organization was coined by father ' of HMO Dr . Paul Ellwood in early 1970 's and the U .S . Department of Health and Human Services endorsed

the Health Maintenance Organization Act in 1973 . The act consisted of three key provisions

Grants and loans were provided to plan , start , or expand an HMO

Certain state-imposed restrictions on HMOs were removed if the HMOs were federally certified

Employers with 25 or more employees were required to offer federally certified HMO options alongside indemnity upon request

Health Maintenance Organization is a type Managed Care Organization (MCO ) providing a wide range of prepaid medical services including hospitalization for a fixed monthly or annual fee . Since costs to patient are fixed in advance ' physicians work in groups and stress upon preventive medicines to avoid hospitalization . In to gain an upper hand over traditional insurance plans majority of HMO 's call for their patients to select a primary care physician (PCP ) such as internists pediatricians , family doctors or general practitioners to act as gatekeeper ' to health services . Thus in a typical HMO setup a patient first visits a PCP and if required the PCP refers and authorizes the patient to visit a specialist or other doctors . In emergencies a patient may directly approach the specialist without an authorization from PCP Most of the plans permit chronically ill patients to select a specialist of their choice as PCP and women to select a gynecologist /obstetrician in addition to a PCP

According to Wikipedia HMO 's carry out a utilization review and utilization expressed by keeping a count of number of visits or services or amount spent per member per month (PMPM

HMO 's may operate in one or a blend of two or more forms . Some of the models are explained as under

Staff Model : Physicians are employed and paid by the HMO 's and operate from the office premises of HMO buildings , thus the physicians may examine only the HMO patients . This is an example of closed panel HMO

Group Model : This is another example of closed panel model wherein the HMO pays to a group of physicians and the group in turn allocates and distributes the money amongst them

In open panel HMO , an Independent Practice Association (IPA ) consisting of contracted physicians may contract with the HMO . Thus the physician may maintain his own office and examine non-HMO members

Network Model : In this model an HMO may contract IPA 's , any combination of groups or even individual physicians

According to Mark Henricks benefits included unlimited visits to primary care doctors , no extra charges are levied for laboratory and radiology services rendered , Most HMO...